Every finding on record at Seasons Hospice & Palliative Care of Delaware, LLC

Observed in Record Review. In 4 of 24 active patient records revviewed, the organization failed to conduct and document a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. In record RRNHV#5 the patient was admitted for osteomyelitis of the knee and the nurse wrote only in the note that there was purulent drainage. In records RRIP#3, RRNHV#2 a comprehensive spiritual assessment was not documented. In record RRNHV#10 both comprehensive spiritual and social work initial comprehensive assessments were not documented. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations. Observed in Record Review. In 1 of 24 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services. On review of RRHV#5 the patient had documentation of a laceration with significant bruising of the face and forehead that happened days prior to admission yet there was no wound assessment documented on initial comprehensive assessment nor subsequent nursing visits as required by organization policy. One nursing visit noted there was a wound but no description further. During conversation with the RN and patient husband on home observation the wound and bruising was present during time of admission. This observation was reviewed with the Director of Clinical Operations.

Observed in Record Review. In 5 of 24 activate patient records reviewed, the organization failed to ensure that the patient record was accurate. In record RRIP#1 the aide plan of care indicated that a bed bath was to be completed daily, but the visit frequency was twice a week. In record RRIP#2 the initial comprehensive nursing assessment documented that current hydration was regular liquids, however the patient was NPO. The medical social work assessment only included that the patient would return to the assisted livening facility which is an addiction treatment center. In record RRIP#3 a nurse wrote that the patient had an unstageable wound to the right buttock, however measurements were documented at 1x2x0.1 cm and 1x2.5x0.5 cm on two different days. In that same record an order was written for 14-16 French foley catheter. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.

Observed in Record Review. In 17 of 24 active patient records reviewed, the organization failed to create plan of care goals that were individualized and measurable. Examples include: Patient/family/caregiver will have a patient defined good death by end of life AEB documented opportunities to verbalize final wishes, explore closure, and define a good death during visits by IDG members with a focus on SOC, sudden changes in condition and recertification visits. Patient's nutritional needs will be managed within the context of their expected decline and expressed desires throughout hospice care. Patient/family/caregiver will report that patient's urinary incontinence has been brought to/maintained at a level that the patient/family/caregiver expresses acceptable within the context of the disease process while on IPC AEB no urinary retention or incontinence present. Family will verbalize understanding of EOL education on symptoms of imminent death and POC to achieve a comfortable death by the end of the visit or call when imminent death is identified. Patient's nutritional needs will be managed within the context of their expected decline and expressed desires throughout hospice care. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.

Observed in Record Review. In 6 of 24 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 the patient was diabetic with insulin administration that noted to hold with blood glucose <140. On conversation with the patient daughter she confirmed that they were monitoring the patient's blood glucose daily however diabetes and blood glucose monitoring were not reflected in the plan of care. On admission the initial assessment documented the patient with a Pure Wick catheter yet the catheter was not reflected in the plan of care. In RRHV#3 the patient's primary diagnosis was interstitial lung disease with continuous oxygen use but there was no care plan established for respiratory. On home observation the RN specified that constipation was an ongoing issue but was not reflected on the plan of care. In RRHV#4 pain was an ongoing issue where morphine was scheduled 3 times a day with morphine also being utilized for breakthrough pain yet there was no care plan for pain to guide the care. On review of RRHV#5 the patient had documentation of a laceration and significant bruising to the face/forehead yet there was no care plan or orders reflected on the plan of care to guide the care. The patient also had documented in the record, and per conversation at home observation, issues with agitation and sleep requiring medication changes yet the issues were not reflected on the care plans. In RRHV#6 the documentation noted the patient with a upper respiratory infection with use of antibiotics but no care plan for infection to guide the care. There was also documentation of significant weight loss and a diet of thickened liquids yet no nutritional care plan open. IN RRNHV#14 there was documentation of multiple medication changes to control the patient's pain yet none of the changes were reflected in the plan of care. These observations were reviewed with the Director of Clinical Operations.

Observed in Record Review. In 1 of 24 active patient records reviwed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. In the record of RRNHV#6 a nurse documented that the patent was using oxygen at 3 lpm per cannula, however there was no order for it. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations. Observed in Record Review. In 1 of 24 patient records reviewed, the organization failed to ensure the plan of care contain all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#2 the patient was receiving Oxycodone and Morphine as needed for pain however there were no specific instructions to guide the user as to when to use which medication. This observation was reviewed with the Director of Clinical Operations.

Observed in Record Review. In 1 of 24 patient records reviewed, the organization failed to ensure the plan of care was revised with progress toward goals based on the updated comprehensive assessment. On review of RRHV#5 the current plan of care remained unchanged since admission in June through recertification. All goals remained current without documented progress to goals to include the goal: complete SOC physical assessment and initiate hospice plan of care by end of admission visit. This observation was reviewed with the Director of Clinical Operations. Observed in Record Review. the organization failed to ensure the plan of care was revised with progress toward goals based on the updated comprehensive assessment. In almost every active patient record reviewed the following goals were created. Care coordination services will be initiated within 5 days of request. Complete start of care physical assessment and initiate hospice plan of care by end of admission visit. None were identified as completed in the time frames stated. Complete start of care physical assessment and initiate hospice plan of care by end of admission visit. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.

Observed in Record Review. In 1 of 24 active patient records reviewed, the organization failed to provide the patient with treatment according to the plan of care. In record RRIP#3 a daily wound dressing change was not documented every day as ordered. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.

Observed in Patient Home. In 3 of 6 home visits conducted, the organization failed to ensure accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions were followed per policy. On home observation for RRHV#2 the spiritual counselor was observed to place his bag, 2 phones and tablet on the patient's room floor and did not sanitize the equipment when retrieved after the visit was concluded. In RRHV#4 and RRHV#5 the RN was observed to cleanse reusable equipment with Santi cloth wipe but did not allow a 2 minute contact time for disinfection as required by manufacturers guidelines as the nurses immediately placed back in the bag after wiping the equipment. These observation were reviewed with the Director of Clinical Operations Leadership Team.

Observed in Patient Home. In 3 of 24 patient records reviewed, with hospice aide services, the organization failed to ensure written patient care instructions for a hospice aide were prepared by a registered nurse. On review of RRHV#1 the patient was on oxygen continuously yet the Aide plan of care did not specify if the oxygen could be removed for providing care or should be left in place. Further, the patient had a wound dressing on the right forearm and great toe yet there were no specific instructions on how the aide was to handle the dressing while completing tasks. In RRHV#4 the patient was on 2 lts oxygen per nasal cannula yet there were no oxygen precautions or instructions on how to handle the oxygen on the aide plan of care. On review of RRHV#6 the patient was on oxygen yet there were no oxygen precautions noted on the aide plan of care. The patient also required assistance with transfers yet the aide plan of care did not provide instruction on the level of assistance for patient transfers. These observations were reviewed with the Director of Clinical Operations and Leadership team. Observed in Record Review. In 5 of 24 active patient records reviewed, with hospice aide services, the organization failed to ensure written patient care instructions for a hospice aide were prepared by a registered nurse. In records RRIP#2, RRIP#3 the patient was using oxygen continuously however the aide plan of care did not specify that it was to remain on during bathing. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.

Observed in Patient Home. In 4 of 6 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On home observation of the medication reconciliation for RRHV#3 there were discrepancies from the medication in the patient home to the orders per the plan of care. There was Tylenol 500mg tablets noted in use in the home but the medication orders showed Tylenol suppositories 650 mg. The daughter showed the surveyor ondansetron ODT bottle for nausea and vomiting but the medication was not found on the medication profile. Further, the med profile had gabapentin 300mg capsules but the daughter noted they had been giving the gabapentin liquid form and not capsules. In RRHV#4 on medication reconciliation with the facility medication list the Acetaminophen 650 mg was every 4 hours as needed in the facility but every 6 hours as needed on the hospice orders. Also, prochlorperazine maleate 10 mg tabs were noted on the hospice medication profile but was not included on the facility med profile. In RRHV#5 the patient was in a facility and on medication reconciliation there were several discrepancies as the Bisacodyl was being given as scheduled per the facility since June but the hospice orders were for as needed. The melatonin was 10 mg and Senna was daily on the hospice med profile but the melatonin was changed to 5 mg gummies and Senna moved to as needed per the facility back in Mid-August. The guaifenesin was noted as needed starting in July per the facility but scheduled per the hospice orders. Further, the facility medication profile had Seroquel that started 5 days prior to survey but was not reflected on the hospice medication profile. There were vitamins B-1, Vitamin C, and Atorvastatin that were on the hospice medication orders but were not on the facility orders. In RRHV#1 the patient daughter pointed out the patient's medications on home observation and noted they were giving supplements Ocuvite and a Multivitamin, yet they were not included on hospice medication orders. These observations were reviewed with the Director of Clinical Operations and the Leadership Team.

Observed in Record Review. In 5 of 24 active patient records reviewed, the organization failed to maintain accurate records. In record RRIP#3 the patient signed the visit note with an X. In records RRIP#4, RRNHV#1 the patient drew a line. In each record clinicians failed to follow the necessary steps for this type of documentation in Policy C2.5.6 entitled Documenting in the Electronic Medical Record. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.

Observed in Proficiency Testing. In 1 of 24 active patient records reviewed, the organization failed to maintain accurate records. In a telephone order in record RRIP#1 a registered nurse wrote an order for IV valium 5 mg ever 4 hours and changed it to every 6 hours by writing over the first number without completing the actions outlined for correcting the error in Policy C2.5. entitled 1 Clinical Patient Care Records, Timeliness, Corrections. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.

Observed in Record Review. In 2 of 3 live discharge records reviewed, the organization did not have evidence that the discharge summary was sent to the accepting facility or physician.

Observed in Building Tour. The Soiled Utility Room (3N13B) had a neutral pressure relationship to the adjacent corridor versus (vs.) the required negative pressure relationship to the adjacent corridor. This was confirmed by the Facilities Manager & Associate Executive Director.

Observed in Building Tour. The Third (3rd) floor stairwell door (equipped with delayed egress locking) near near Room (3N09) was missing the required fifteen (15) second delayed egress signage on the door. This was confirmed by the Facilities Manager & Associate Executive Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Based on staff (EMP) interviews and document review, the Agency failed to ensure that orientation and training regarding hospice philosophy were performed for all staff providing care to the patients residing at 1 of 1 skilled nursing facilities (SNF1) sampled. Findings include: --- A review of the Agency document titled "Nursing Facility Service Agreement" between ChristianaCare-AccentCare Hospice & Palliative Care of Delaware and Nursing Facility #1 dated 11/1/2024 revealed, "...Hospice Care Training. Hospice shall provide orientation and ongoing hospice care training to Facility's personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control and symptom management as well as principles about death and dying, individual responses to death, patient rights, appropriate forms and recordkeeping requirements..." During an interview on 12/20/24 at 9:10 AM, EMP1 revealed the Agency does not provide overall education to SNFs. EMP#11 meets with SNF1 staff 1:1 and with SNFEMP1 to review patient plans of care and emergency planning. During an interview on 12/20/24 between 10:40 and 10:50 AM, SNFEMP1 revealed he/she is not aware of in-services being provided by the Agency. He/She stated the hospice nurse educates the SNF nurse caring for the hospice patient and the Agency does let him/her know that education is available if requested. During an interview on 12/20/24 at 2:12 PM, EMP1 revealed the Agency has designated employees (Hospice Care Consultants) that regularly meet with staff of SNFs where patients reside that can include educational information. A review of the Agency document titled "Call Summary Report" dated 9/1/24 to 12/20/24 revealed that Hospice Care Consultants visited SNF#1 26 times, with notes documenting the visits included "...rounds to check on any hospice needs or concerns..." There is no evidence of hospice care education or orientation being provided to SNF staff during these visits. On 12/20/24 at 2:45 PM, EMP1 acknowledged that there is no evidence the Agency provided hospice orientation or philosophy education to SNF1 staff caring for their hospice patients. A review of the Agency document titled "Nursing Facility Service Agreement" between ChristianaCare-AccentCare Hospice & Palliative Care of Delaware and SNF1 (Skilled Nursing Facility) dated 11/1/2024 revealed, "...Hospice Care Training. Hospice shall provide orientation and ongoing hospice care training to Facility's personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control and symptom management as well as principles about death and dying, individual responses to death, patient rights, appropriate forms and recordkeeping requirements..." During an interview on 12/20/24 at 9:10 AM, EMP1 revealed the Agency does not provide overall education to SNFs. EMP11 meets with SNF1 staff 1:1 (one to one) and with SNF1 EMP1 to review patient plans of care and emergency planning. During an interview on 12/20/24 between 10:40 and 10:50 AM, SNF1 EMP1 revealed he/she is not aware of in-services being provided by the Agency. He/She stated the hospice nurse educates the SNF nurse caring for the hospice patient and the Agency does let him/her know that education is available if requested. During an interview on 12/20/24 at 2:12 PM, EMP1 revealed the Agency has designated employees (Hospice Care Consultants) that regularly meet with staff of SNFs where patients reside that can include educational information. A review of the Agency document titled "Call Summary Report" dated 9/1/24 to 12/20/24 revealed that Hospice Care Consultants visited SNF1 twenty-six times during the time period, with notes documenting that the visits included "...rounds to check on any hospice needs or concerns..." There is no evidence of hospice care education or orientation being provided to SNF staff during these visits. On 12/20/24 at 2:45 PM, EMP1 acknowledged that there is no evidence the Agency provided hospice orientation or philosophy education to SNF1 staff caring for their hospice patients.

Based on medical record review, staff interview and policy and procedure review, it was determined that the Hospice agency failed to ensure that 1 out of 6 patients in the sample (Patient #1) were free from neglect and injury. Findings include: --- Agency policy titled ";In-Patient Services" revised 5/15/21, stated, ";...Provide 24-hour services including...Provision of care in accordance with the patients plan of care established by hospice for treatments...as prescribed...A focus on insuring that the patient is kept comfortable...and protected from accident, injury..." Agency policy titled ";IPC [inpatient care unit] Fall Prevention" revised 10/31/23, stated, ";...Assess patients risk of falling...on admission to IPC...High Fall Risk, Red, 4-10...Perform hourly safety rounds...every two hours during the night...Use a chair or bed alarm, if needed..." Review of the medical record for Patient #1 revealed: 1) Patient #1 was admitted to service on 7/19/2023. Review of document titled ";Hospice Certification and Plan of Care" revealed, ";Activities Permitted: Up as tolerated, walker...Mental Statuses: Forgetful, disoriented... Physician Narratives: This patient is a 91-year-old female admitted to hospice with late effects of cerebrovascular disease...the patient has fallen numerous times...The patient is also more confused, and confusion worsens at night. She seems to have increased levels of agitation and paranoia..." 2) Patient #1 was transferred to Wilmington Inpatient Unit on 9/3/2023 at 4:55 PM. Review of document titled, ";Provider Visit Note" dated 9/3/2023 revealed, ";Nurse sent out this morning to Straight Cath patient, as patient had not voided overnight. Patient confused, climbed on top of dining room table to use the bathroom. Taken to bathroom and unable to void. Confusion worse. Sustained a fall on Thursday 8/31/2023 with a quarter sized bump in the Right occipital region of skull. Will work up for a UTI [urinary tract infection] and brain bleed. Transferred to Bayhealth Sussex. UA [urinalysis] positive for UTI. CT [computerized tomography] of head was negative for a brain bleed." 3) Review of document titled ";Hospice Plan of Care Report" revealed, ";... 9/5/2023 Initiated/Reinforced Fall Precautions to Minimize Incidence of Falls..." 4) Review of document titled ";Visit Note Report" dated 9/5/2023 at 4:26 PM revealed, ";...Pain Assessment...2 doses of Morphine in 24 hours...Which of the following factors contributing to fall risk are present? Mobility, Mentation, Elimination, History of Falls, regularly administered antipsychotic/antianxiety/or narcotic meds...Mentation findings: Periodic confusion, restlessness...Needs Assistance with Toileting...Fall Potential Score: 7...Indicate Fall Potential Interventions: Safety Checks on, Bed/Chair Alarm on..." 5) Review of document titled ";Hospice Daily Encounter Report" revealed the following: 9/6/2023 4:45 AM. Patient found in middle of room in an upright position. Patient assisted up and returned to bed. Cut above right eyebrow, Puffy with blood from orbital area. Bruising at eye area cleaned and covered. Bruise noted on underside of chin right side of face. Reclining chair had a pool of blood next to it. Patient reported having to go to the bathroom, no urine on the floor, sheets are dry. Patient complaint of pain when cleaning wound above eye. Denies pain anywhere else. Full range of motion in all extremities. 6) Review of document titled ";Client Occurrence Report" for Patient # 1 revealed, ";Patient got out of bed and fell. Patient hit her head on the chair resulting in a laceration and bruising around right eye. Alarm was not set on patients bed. She was found sitting on the floor near the recliner and doorway with obvious trauma. Patient was sent to ER [emergency room] for follow-up and X-ray showed a right orbital fracture and laceration requiring stitches..." Interview conducted with Employee #1 on 1/24/2024 between 12:40-12:50PM. Employee #1 confirmed that Patient #1s bed alarm was not on at the time of this fall. Patient sustained an injury, a laceration requiring stitches and a right orbital fracture.

Based on record review, policy review, and staff interview, it was determined that the hospice failed to update the comprehensive assessment as frequently as the condition of the patient required for 1 out of 2 patients in the sample who experienced a fall (Patient #5). Findings include: --- Record review revealed: A Clinical Occurrence Report dated 3/31/23 at 2:34 PM stated, ";Patients wife called to follow up on supply request and mentioned to this TD [Team Director] that patient rolled out of bed last night. No injuries." Under the ";Follow-up Comments" section of the report ";Fall mats ordered through Medcare" is listed. A Coordination Note dated 4/1/23 5:19 PM stated, ";...Caller spouse [name & contact number] requesting a visit for swollen red right eye. No pain, itching, burning or drainage noted. Redness is around the eye not on the actual eye." A Visit Note dated 4/1/23 at 7:40 PM completed by an RN revealed a fall risk assessment denying a history of falls within 3 months. The assessment narrative stated, ";Unscheduled visit for c/o [complaint of] per spouse of swelling and redness around (not in) right eye. Wife not with Pt [patient] at time of visit. Pt very confused, but denied SNAP [shortness of breath, nausea/vomiting, agitation/anxiety, and pain]. No s/sx [signs and symptoms of] distress noted. Pt refused VS [vital signs] and full assessment, but did allow quick check of eye with flashlight. No discharge noted, no c//o pain or burning. Suggested to nurse that they try warm compress. Phone call to update wife." There is no evidence that the patients eye was assessed for possible injury. There is no evidence of a post fall assessment done for this patient. The finding above was confirmed by Employee #1 on 1/24/24 at 11:35 AM. Facility policy titled ";Fall Prevention 2017 Protocol" with an effective date of 12/15/2005 stated, ";...When the patient has fallen (refer to Protocol 2037 for visit guidelines when a fall has occurred)..." When Protocol 2037 was requested, facility policy titled ";Triage 2037 Protocol" with an effective date of 4/24/23 was provided to surveyors. This policy stated, ";...When a fall is reported by a family, patient, or facility/residence caregiver, it is considered a significant event and require a hospice nurse assessment visit including evaluation of patient status, any need for DME [durable medical equipment] equipment changes, any need for diagnostic x-rays, fall risk rating, evaluation of safety of environment, and determine any plan of care changes, including need for hospitalization, level of care, transfer, etc... If no reported injury, a Hospice Nurse visit will occur within 24 hours. The local team is aware through Coordination Note Report – Call Center Notes..." In an interview on 1/24/24 at 11:35 AM, Employee #1 confirmed that the agencys fall protocols were not initiated correctly. The patient should have been seen within 24 hours post fall by a nurse to conduct a post fall assessment, which was not done. The visit to evaluate the patients right eye on 4/1/23 did not include assessing if the symptoms were related to the fall.

Based on medical record review, document review, and staff interview, it was determined that the agency failed to track 1 out of 3 falls included in the sample (Patient #5) as part of their QAPI program. Findings include: --- Agency policy titled ";Quality Assurance and performance Improvement" revised 4/01/22, stated, ";...The Hospice agencys performance improvement activities shall.... Focus on...adverse patient events...Measures, analyzes, and tracks quality indicators to monitor program effectiveness, patient safety, and quality of care...Performance improvement results are tracked, trended, analyzed, and used by the hospice agency to address problem issues, improve the quality of care and patient safety, and shall be incorporated into program planning and process design..." A Clinical Occurrence Report for Patient #5 dated 3/31/23 at 2:34 PM stated, ";Patients wife called to follow up on supply request and mentioned to this TD [Team Director] that patient rolled out of bed last night. No injuries." Under the section heading ";Nature of Occurrence", ";Other" was listed. In an interview on 1/24/24 at 12:37 PM with Employee #1 indicated that on the Occurrence Report the information under ";Nature" is how falls are tracked and that an occurrence put in as ";other" would not have been tracked as a fall. Employee #1 confirmed that the fall reported for Patient #5 on 3/31/23 was not tracked as a fall.

Based on medical record review, Quality Assurance Performance Improvement [QAPI] document review, internal investigation reports review, staff interview, and policy and procedure review, the Hospice Agency failed to identify opportunities for improvement and failed to monitor quality-of-care related incidents that occurred for 2 out of 2 patients (Patient #1 and Patient #5) that experienced a fall. Findings include: --- Agency policy titled ";Quality Assurance and Performance Improvement" revised 4/01/22, stated, ";...The Hospice agencys performance improvement activities shall.... Focus on...adverse patient events...Measures, analyzes, and tracks quality indicators to monitor program effectiveness, patient safety, and quality of care...Performance improvement results are tracked, trended, analyzed, and used by the hospice agency to address problem issues, improve the quality of care and patient safety, and shall be incorporated into program planning and process design..." Agency policy titled ";Fall Prevention, 2017 Protocol" revised 10/31/2023, stated, ";...A Quality Incident (QI) will be documented in the EMR [electronic medical record] for each patient fall including the unwitnessed ones reported between nursing visits. An Adverse Event (AE) will be documented for each fall with injury. A patient falls report will be aggregated and presented at the QAPI meeting each quarter. Any trends will be discussed and analyzed for improved patient outcomes and fall prevention strategies." Agency policy titled ";Incident and Adverse Event Reporting" revised 9/20/23, stated, ";Adverse event: Injury or unintended harm to a patient resulting from an act of commission or omission rather than by the underlying disease or condition of the patient...Adverse events include, but are not limited to...Falls, witnessed and un-witnessed...As Part of the agencys Quality Assurance Performance Improvement (QAPI) process, adverse patient events are analyzed to determine causes and preventive actions to be implemented that lead to an immediate correction of any identified problem that directly or potentially threatens the health and safety of any patient.." Review of document titled ";Client Occurrence Report" for Patient #1 revealed, ";Patient got out of bed and fell. Patient hit her head on the chair resulting in a laceration and bruising around right eye. Alarm was not set on patients bed. She was found sitting on the floor near the recliner and doorway with obvious trauma. Patient was sent to ER [emergency room] for follow-up and X-ray showed a right orbital fracture and laceration requiring stitches..." Review of document titled ";Client Occurrence Report" for Patient #5 dated 4/3/23 revealed, ";...Facility contacted office to inform patient found on floor in room c/o [complain of] right leg pain. BP [blood pressure] 70/50. 911 called and pt [patient] to be sent to...ED [emergency department] ..." Review of the agencys ";QAPI Quarterly Report and Professional Advisory Committee Meeting Minutes" dated 10/24/2023, revealed there was no documentation that the hospice agency had completed an analysis or review of processes of care that lead up to the adverse events for Patients #1 and # 5. Review of agencys internal investigation reports for Patients # 1 and # 5 revealed no documentation that the agency identified opportunities for improvement and failed to monitor the quality-of-care related incidents. These findings were confirmed by Employee #1 in an interview conducted on 1/24/2024 from 12:40PM –12:55 PM. In an interview on 1/24/24 at 1:49 PM with Employee #1, they stated that they were unable to provide data analysis for QAPI related to falls. The employee stated that the agency tracks the number of falls and compares month to month and quarter to quarter. The employee reports that no further analysis of falls was done as part of QAPI for 2023.

Based on patient record reviews, interviews, and policy and procedure review the Hospice Agency failed to ensure that patients' rights were protected, promoted and patients and/or caregivers were able to exercise their patient rights for effective symptom management for three (Patient (P) 1, P3, and P6) of eight patient records reviewed. This deficient practice has the potential to affect all 171 patients receiving care from the agency. Findings include: --- The Hospice Agency failed to ensure that effective pain management, effective management for anxiety, agitation and depression, or effective dyspnea (shortness of breath) management were provided to three (Patient (P) 1, P3, and P6) of eight patient records reviewed. (See findings in tag L512).

Based on medical record reviews, patient's family interview, staff interview, and policy and procedure review, the Hospice Agency failed to ensure that effective pain management, effective management for anxiety, agitation, and depression, or effective dyspnea (shortness of breath) management were provided to three (Patient (P) 1, P3, and P6) of eight patient records reviewed. This deficient practice has the potential to affect all 171 patients receiving care from the agency. Findings include: --- Based on medical record reviews, patient's family interview, staff interview, and policy and procedure review, the Hospice Agency failed to ensure that effective pain management, effective management for anxiety, agitation and depression, or effective dyspnea (shortness of breath) management were provided to three (Patient (P) 1, P3, and P6) of eight patient records reviewed. This deficient practice has the potential to affect all 171 patients receiving care from the agency. Findings include: 1. Review of P1's electronic medical record (EMR), from revealed the following: a. The document titled "Hospice Certification and Plan of Care" dated 06/27/23 and signed by the certifying physicians revealed that P1 started service on 06/27/23, and one of the goals of care was "pain will be managed at a level acceptable to the patient within 7 days." The patient was ordered pain medications consisting of acetaminophen (Tylenol) as needed for mild pain, hydromorphone (Dilaudid) scheduled doses three times a day, morphine as needed for pain, and morphine sulfate controlled-release tablets (MS Contin) scheduled doses two times a day. b. During a Registered Nurse (RN) visit on 06/27/23, under the "Visit Note Report", the RN failed to perform a pain assessment for P1 per policy. On 06/29/23, a "Visit Note Addendum" was completed by a different RN and indicated that the patient's pain was "mild" with no numeric value; however, the assessment did not include the location of pain, severity of pain, character of pain, duration of pain, frequency of pain, what relieves/worsens the pain, and how it affected the quality of life for P1. The addendum visit note was not signed by the RN. c. During an RN visit on 06/28/23, under the "Visit Note Report", the RN documented that P1 rated his/her pain level a six on a pain scale of zero to 10. Zero indicates no pain, and 10 indicates the highest intensity of pain. The RN documented that P1 described the pain as "constant", reported that the pain occurred with "all activity", and the highest intensity of pain in the last 24 hours was eight on a pain scale of zero to 10. P1's pain goal (the acceptable pain level) was documented as three on a pain scale of zero to 10. The RN failed to determine how often P1 was taking the pain medications and failed to notify the physician of the patient's increased pain or that P1 was not meeting their pain goal on the current medication regime. d. During an on-call RN visit on 07/04/23 for increased anxiety, under the "Visit Note Report", the RN documented that P1 rated his/her pain level a seven on a pain scale of zero to 10, described the pain as "frequent", reported that the pain occurred with "all activity", and the highest intensity of pain in the last 24 hours was a nine on a pain scale of zero to 10. The RN documented that the patient took a dose of Dilaudid (hydromorphone) during the visit; however, the RN failed to reassess the patient's pain level after taking the pain medication. The patient's caregiver reported to the RN that P1 was "significantly affected" by anxiety and depression, rated the highest intensity of anxiety for the past 24 hours a six on an anxiety scale of zero to 10, and rated the highest intensity of depression for the past 24 hours a five on a depression scale of zero to 10. Zero indicates no anxiety/depression and 10 indicates the highest intensity of anxiety/depression. The intervention documented by the RN for anxiety and depression was to "continue currents medications" and for the RNCM [Registered Nurse Case Manager]" to "follow-up for a possible dosage increase." The RN failed to determine how often P1 was taking the pain and anxiety medications and failed to notify the physician of the patient's increased pain and anxiety. e. During an RN visit on 07/10/23, under the "Visit Note Report", the RN documented that P1's pain level was a four on a pain scale of zero to 10 and reported that the pain occurred with "all activity". The patient's pain goal was documented as two on a pain scale of zero to 10. The patient's caregiver stated to the RN that P1was "significantly affected" by anxiety and depression, rated the highest intensity of anxiety for the past 24 hours an eight on an anxiety scale of zero to 10, and rated the highest intensity of depression for the past 24 hours a six on a depression scale of zero to 10. The RN failed to determine how often P1 was taking the pain and anxiety medications and failed to notify the physician of the patient's increased pain and anxiety. The only intervention documented by the RN for anxiety and depression was to "continue currents medications. f. During an RN visit on 07/18/23, under the "Visit Note Report", the RN documented that P1's pain level was a six out of 10, described the pain as "constant", reported that the pain occurred with "all activity", and the highest intensity of pain for the past 24 hours was 10 out of 10. The patient's pain goal was documented as four on a pain scale of zero to 10. The patient stated (with caregiver assistance) that he/she was "significantly affected" by anxiety and depression, rated the highest intensity of anxiety for the past 24 hours an eight on an anxiety scale of zero to 10, and rated the highest intensity of depression for the past 24 hours a six on a depression scale of zero to 10. The RN failed to determine how often P1 was taking pain and anxiety medications and failed to notify the physician of the patient's increased pain, anxiety, and depression. The only intervention documented by the RN for anxiety and depression was to "continue currents medications." Review of P1's "Medication List", no changes were made to the patient's medications. g. Telephone calls received from P1's caregiver on 07/23/23 were documented by a Triage RN under the "Patient Information Report" as follows: 8:35 AM, P1's caregiver called and stated that the patient "pulled out his/her chest drain tube during the night [caregiver] reconnected it;" 3:30 PM, P1's caregiver called and stated, "he/she is anxious, states [he/she] is having trouble breathing, caregiver gave Ativan [a medication used for anxiety] 15 minutes ago;" 4:20 PM, P1's caregiver called to report that the patient "disconnected his drain box, took morphine and Ativan." The Triage RN instructed the caregiver to place oxygen on the patient. After placing the oxygen on the caregiver stated "[he's/she's] not better." The Triage RN documented that he/she made a phone call to the on-call nurse requesting that he/she make phone contact with the caregiver; and 4:41 PM, the on-call nurse documented that he/she called the caregiver and there was no answer. The nurse left a voice message. There was no documentation that the on-call nurse attempted to call the caregiver again. There was no documentation that a nursing visit was made on 07/23/23. h. During an RN visit on 07/25/23, under the "Visit Note Report", the RN documented that the P1 stated (with caregiver assistance) that he/she was "significantly affected" by anxiety and rated the highest intensity of anxiety for the past 24 hours an eight on an anxiety scale of zero to 10. The RN failed to determine how often P1 was taking anxiety medications. The intervention documented by the RN for anxiety was to "continue current medications". Review of P1's "Medication List", no were changes made to the patient's medications. i. During an RN visit on 07/28/23, under the "Visit Note Report", the RN documented that P1 "is a high risk for terminal agitation and dislodgement of tube." The RN failed to determine how often P1 was taking pain and anxiety medications. The intervention documented by the RN for agitation and anxiety was to "continue current medications." Review of P1's "Medication List", no changes were made to the patient's medications. j. Review of the "Patient Information Report" the Triage RN documented that P1's caregiver called the hospice agency on 07/29/23 at 8:36 AM to report that "[The patient] left the house in the middle of the night and was picked up by the state police and taken to [the hospital]. [P1] reported to the police that [he/she] was kidnapped and shot in the neck." 2. Review of P3's electronic medical record (EMR) revealed a document titled "Hospice Certification and Plan of Care" dated and signed by the certifying physicians stated that P3 started hospice service as general inpatient level of care (GIP) at a local hospital. Review of the agency's intra-office electronic mail document, dated 09/21/23, revealed the subject of the e-mail "Complaint Investigation", and included documentation of the events that occurred leading up to P3 not receiving medications timely for symptom management. The document revealed, "An ... (sic)after-hours registered nurse completed a visit with the patient at [the hospital] at 8:43pm on 04/21/23 (Friday)." A medical record entry by the after-hours registered nurse indicates that [he/she] (1) "... (sic) sent a request to the on-call provider to fax orders for comfort medication to the facility..." and (2) "advised a [skilled nursing facility (SNF)] nurse to "...be on the lookout for the orders via fax..."; On 04/21/2123 (Saturday), between 12:30-12:40 AM, a [hospice agency] nurse practitioner faxed a prescription/order for Morphine [for pain], Ativan [for anxiety], and Levsin [for anti-tremor] to [SNF] ... On 04/22/23 (Saturday), at approximately noon, a [hospice agency] registered nurse visiting the patient learned that [SNF] never received the faxed order/prescription (which, as noted above, had previously been faxed to [SNF] shortly after midnight). Upon learning that [SNF] never received the earlier fax, the [hospice agency] registered nurse requested that a new order/prescription be faxed to [SNF]; A second order/prescription for the same medications was faxed to [SNF] the afternoon of 04/22/23 (Saturday). During an interview on 09/21/23 at 3:00 PM, a family member of P3 confirmed that he/she delivered the comfort pack (a box containing medications including morphine for pain, lorazepam for anxiety, and haloperidol for agitation) as requested by the hospice agency's hospice nurse to the skilled nursing facility (SNF) that the patient was being transferred to; however, was later told by the SNF staff that they were unable to administer the medications because there were no orders sent from the hospice agency. The family member advised that the patient did not have any medications administered for the management of agitation and pain for at least 24 hours. The family member further stated that the "patient really suffered and had skin tears all over needing steri-strips (a type of bandage) applied from thrashing around in the bed." 3. Review of P6's EMR revealed the following: a. The document titled "Client Medication Report" revealed that the patient was ordered morphine on the day of admission, 04/11/23, for shortness of breath. b. During an RN visit on 09/14/23, under the "Visit Note Report", the RN documented that the "patient is more SOB", and that the patient is "currently under treatment" for dyspnea. The only intervention documented was for oxygen use. The RN failed to educate the patient on the use of morphine for shortness of breath. c. During an RN visit on 09/07/23, under the "Visit Note Report", the RN documented that the "patient reports being more SOB and needing frequent rest periods," and that the patient is "currently under treatment" for dyspnea. The only intervention documented was for oxygen use. The RN failed to educate the patient on the use of morphine for shortness of breath. d. During an RN visit on 08/31/23, under the "Visit Note Report" the RN documented that the "patient reports that it's taking [him/her] a little longer to catch [his/her] breath." and that the patient is "currently under treatment" for dyspnea (shortness of breath). The only intervention documented was for oxygen use. There was no documentation of education provided to the patient on the use of morphine for shortness of breath. e. During an RN visit on 08/17/23, under the "Visit Note Report" the RN documented that the "patient continues with [SOB] shortness of breath after ambulation [name of patient] takes frequent rest periods, and that the patient is "currently under treatment" for dyspnea. The only intervention documented was for oxygen use. There was no documentation of education provided to the patient on the use of morphine for shortness of breath. f. During an RN visit on 08/02/23, under the "Visit Note Report" the RN documented that the "patient's [family member] observed that patient is taking longer to catch [his/her] breath ... takes 8-10 minutes after ambulating where a week ago it was 3-5 minutes to catch [his/her] breath, and that the patient is "currently under treatment" for dyspnea. The only intervention documented was for oxygen use. There was no documentation of education provided to the patient on the use of morphine for shortness of breath. g. During an RN visit on 07/27/23, under the "Visit Note Report" the RN documented that the "patient reports that in the last week [he/she] has been more SOB with picking up items from the floor and changing position on couch, and that the patient is "currently under treatment" for dyspnea. The only intervention documented was for oxygen use. There was no documentation of education provided to the patient on the use of morphine for shortness of breath. During an interview on 09/22/23 at 9:00 AM, the Executive Director confirmed that the RN's did not follow the hospice agency's policy for symptom management for P1, P3 and P6. Review of the agency's protocol, effective 04/26/23, titled "Pain Management 2082 Protocol" indicated "Hospice staff will respect each patient's rights to rapid assessment and management of pain ... The pain rating for >6 timely follow up is required and must be documented in the EMR ... Pain management assessments, reassessments, plans, interventions, and responses to treatments will be documented in the Hospice electronic medical record and appropriate information will be exchanged with physicians, call center staff, on-call staff, contracted facilities, and other appropriate persons involved in patient care." Review of the agency's policy, revised 11/01/22, titled "Pain Assessment and Management" indicated " ... If the patient has pain on admission, a re-assessment of pain will be completed no later than 24 hours after admission to evaluate the interventions implemented. The goal is to reduce the patient's pain to a comfort level within 48 hours of admission. ... The patient and caregiver will be instructed on the benefits of keeping a pain diary, if able." Review of the agency's policy, revised 02/15/23, titled "The Plan of Care" indicated " ... The written care plan shall contain, but will not be limited, to the following: ... Individual interventions to assist with end-of-life care ... pain and symptom management interventions." J

Based on medical record review, patient's family interview, staff interview, and policy and procedure review, the Hospice Agency failed to ensure that an on-call nursing visit was provided to one of one patient (Patient (P) 1) records reviewed requiring a home visit. The total universe was eight. This deficient practice has the potential to affect all 171 patients receiving care from the hospice agency. Findings include: --- A review of P1's medical record revealed a "Patient Information Report" containing the following phone calls made on 07/23/23 to the hospice agency's triage nurse by the patient's caregiver: At 8:35 AM, the caregiver stated that the patient "pulled out his/her chest drain tube during the night [caregiver] reconnected it." At 3:30 PM, the caregiver stated, "[he/she] is anxious, states [he/she] is having trouble breathing, caller gave Ativan [a medication used for anxiety] 15 minutes ago." At 4:20 PM, the caregiver called to report that the patient "disconnected his drain box", and took morphine and Ativan. The Triage Registered Nurse (RN) instructed the caregiver to place oxygen on the patient. After placing the oxygen on P1 the caregiver stated "[he/she's] not better." The Triage RN documented that he/she made a phone call to the on-call nurse requesting that he/she make phone contact with the caregiver. At 4:41 PM, the on-call nurse documented that he/she called the caregiver and there was no answer. The nurse left a voice message. A review of P1's medical record revealed no documentation that the nurse attempted to call the patient again or that a nursing visit was made on 07/23/23. During an interview, after completion of the survey on 09/25/23 at 11:00 AM, a family member of P1 revealed that he/she was unable to get anyone from the hospice agency to help after the patient pulled out the chest tube and he/she had to contact the manufacturer of the chest tube to obtain assistance with the dislodged tube. During an interview on 09/22/23 at 9:50 AM, the Executive Director confirmed that there was no documentation that an RN visit was made on 07/23/23 after P1's caregiver contacted the Hospice Agency four times about P1's anxiety and pulling out his/her chest tube. A review of the agency's protocol revised 04/24/23 titled "Triage" indicated "If unresolved symptoms/problem or additional interventions or orders needed, Call Center will contact site on-call nurse or Patient Experience (PE) staff to visit the patient. On-call nurse will be contacted for a visit if: 1. The caregiver is unable, reluctant, or unwilling to provide interventions based on existing orders for symptomatic patient. 2. If patients/caregivers have called 2 or more times with symptom management questions/needs within a l2-hour period. ..."

Based on interviews and reviews of medical records, Quality Assurance Performance Improvement (QAPI) documents, internal investigation reports, and policy and procedures, the Hospice Agency failed to ensure it had an effective QAPI program when it failed to analyze, review processes of care, identify opportunities and monitor quality-of-care related incidents for improvement for three (Patient (P) 1, P3, and P7) of three adverse patient events reviewed. Failure to have an effective QAPI program has the potential to affect all 171 patients receiving care from the agency. Findings include: 1. The Hospice Agency failed to analyze and review processes of care related to three (Patient (P) 1, P3, and P7) of three adverse patient events reviewed. (See findings in tag L562) 2. The Hospice Agency failed to identify opportunities for improvement and failed to monitor quality-of-care related incidents that occurred for three (Patient (P) 1, P3, and P7) of three adverse patient events reviewed. (See findings in tag L564)

Based on interview, review of the medical records, the Quality Assurance Performance Improvement (QAPI) documents, the internal investigation reports, policy, and procedure, the Hospice Agency failed to analyze and review processes of care for three (Patient (P) 1, P3, and P7) of three adverse patient events reviewed. This failure in the QAPI process has the potential to affect all 171 patients receiving care from the agency. Findings include: Review of the agency's QAPI documents for 2023 revealed no documentation that an analysis or a review of processes of care leading up the adverse patient events for P1, P3, and P7 had been completed. 1. Review of P1's medical record revealed a document titled "Patient Information Report" and stated that on 07/29/23 at 8:36 AM the patient's caregiver called the hospice agency to report that "the patient left the house in the middle of the night and was picked up by the State police and taken to the hospital." According to the family member, the patient reported to the police that he/she was kidnapped and shot in the neck. On 07/29/23 at 9:45 AM, a Registered Nurse (RN) from the hospital called the hospice agency to report that the "patient was brought in by ambulance last night after being found in a ditch [patient's name] was hallucinating so they admitted with altered mental status." Review of the agency's internal investigation report for P1 for the incident that occurred on 07/29/23 was dated 08/21/23, revealed, there was no documentation that The Hospice Agency had analyzed or reviewed the process of care for P1. 2. Review of the Hospice Agency's intra-office electronic mail document, dated 09/21/23, revealed the subject of the e-mail "Complaint Investigation" and included documentation of the events that occurred on 04/21/23 leading up to P3 not receiving medications timely for symptom management. The document revealed, "An ... (sic) after-hours registered nurse completed a visit with the patient at [the hospital] at 8:43pm on 04/21/23 (Friday). A medical record entry by that after-hours registered nurse indicates that [he/she] (1) sent a request to the on-call provider to fax orders for comfort medication to the facility and (2) advised a [skilled nursing facility (SNF)] nurse to be on the lookout for the orders via fax; On 04/21/2123 (Saturday), between approximately 12:30-12:40 AM, an (sic) [hospice agency] nurse practitioner faxed a prescription/order for Morphine, Ativan, and Levsin to [SNF] ... On 04/22/23 (Saturday), at approximately noon, an [hospice agency] registered nurse visiting the patient learned that [SNF] never received the faxed order/prescription (which, as noted above, had previously been faxed to [SNF] shortly after midnight). Upon learning that [SNF] never received the earlier fax, the [hospice agency] registered nurse requested that a new order/prescription be faxed to [SNF]; A second order/prescription for the same medications was faxed to [SNF] the afternoon of 04/22/23 (Saturday)." Review of the agency's complaint investigation for P3, dated 09/01/23 (132 days after the event), revealed the Hospice Agency had no documentation that it analyzed or reviewed the process of care regarding the adverse event for P3. 3. Review of the Hospice Agency's internal investigation report for P7, dated 06/01/23, revealed the "[Patient's name] was admitted 5/26. [He/she] lives at [assisted living facility (ALF)] and the call center was made aware of a fall on 05/28/23. Investigation and Timeline: The facility sent [him/her] 911 to the hospital where it was determined that [he/she] had a wrist fracture. [He/she] was seen today by his/her RNCM [Registered Nurse Case Manager] and [he/she] was notified that the patient complained of hip pain while at the hospital, [P7] was x-rayed and found to have a fractured hip as well. Event Outcome: Patient will be coming off of (sic) service today for pin placement to [P7's] hip." Review of the Hospice Agency's internal investigation report for P7, dated 06/01/23, revealed there was no documentation that the Hospice Agency analyzed or reviewed the process of care regarding the adverse event for P7. During an interview on 09/22/23 at 1:00 PM, the Executive Director confirmed that the internal investigations for P1, P3 and P7 were incomplete and did not include an analysis or review of process of care for the patients' adverse events. Review of the Hospice Agency's policy titled "Quality Assurance and Performance Improvement" revised 04/01/22 indicated "... Identify and set specific outcomes/priorities for improvement, adjusting priorities in response to unusual or urgent events."

Based on medical record review, Quality Assurance Performance Improvement (QAPI) document review, internal investigation reports review, staff interview, and policy and procedure review, the Hospice Agency failed to identify opportunities for improvement and failed to monitor quality-of-care related incidents that occurred for three (Patient (P) 1, P3, and P7) of three adverse patient events reviewed. This failure in the QAPI process has the potential to affect all 171 patients receiving care from the agency. Findings include: Review of the agency's QAPI documents for 2023 revealed there was no documentation that the Hospice Agency had completed and an analysis or review of processes of care leading up the adverse patient events for P1, P3, and P7. 1. Review of P1's medical record revealed a document titled "Patient Information Report" and revealed that on 07/29/23 at 8:36 AM the P1's caregiver called the hospice agency to report that "the patient left the house in the middle of the night and was picked up by the State police and taken to the hospital." According to the family member, the patient reported to the police that he/she was kidnapped and shot in the neck. On 07/29/23 at 9:45 AM, a Registered Nurse (RN) from the hospital called the hospice agency to report that the "patient was brought in by ambulance last night after being found in a ditch ... [patient] was hallucinating so they admitted with altered mental status." Review of the agency's internal investigation report for P1's adverse patient event, dated 08/21/23, revealed there was no documentation that the agency identified opportunities for improvement or to monitor the quality-of-care related to the incident that occurred 07/29/23 while under the Hospice Agency's care when P1 left his/her home in the middle of the night, and was found in a ditch. 2. Review of the agency's intra-office electronic mail document, dated 09/21/23, revealed the subject "Complaint Investigation" and included documentation of the events that occurred on 04/12/23, 04/21/23 and 04/22/23, leading up to P3 not receiving medications timely for symptom management. The agency's intra-office electronic mail document stated, "An ... after-hours registered nurse completed a visit with the patient at [the hospital] at 8:43pm on 04/21/23 (Friday). A medical record entry by that after-hours registered nurse indicates that [he/she] (1) "...sent a request to the on-call provider to fax orders for comfort medication to the facility..." and (2) advised a [skilled nursing facility (SNF)] nurse to "...be on the lookout for the orders via fax..."; On 04/12/2123 (Saturday), between approximately 12:30-12:40am, an [hospice agency] nurse practitioner faxed a prescription/order for Morphine [pain medication], Ativan [anti-anxiety medication], and Levsin [anti-tremor medication] to [SNF] ... On 04/22/23 (Saturday), at approximately noon, an [hospice agency] registered nurse visiting the patient learned that [SNF] never received the faxed order/prescription (which, as noted above, had previously been faxed to [SNF] shortly after midnight). Upon learning that [SNF] never received the earlier fax, the [hospice agency] registered nurse requested that a new order/prescription be faxed to [SNF]; A second order/prescription for the same medications was faxed to [SNF] the afternoon of 04/22/23 (Saturday). Review of the agency's complaint investigation for P3's adverse patient event, dated 09/01/23, revealed no documentation that the agency identified opportunities for improvement, and failed to monitor the quality-of-care related incident. 3. Review of the agency's internal investigation report for P7, dated 06/01/23, revealed the "Patient ... was admitted 5/26. [He/she] lives at [name of assisted living facility] and the call center was made aware of a fall on 05/28/23. Investigation and Timeline: The facility sent [him/her] 911 to the hospital where it was determined that [he/she] had a wrist fracture. [He/she] was seen today by her RNCM [Registered Nurse Case Manager] and [he/she] was notified that the patient complained of hip pain while at the hospital, [he/she] was x-rayed and found to have a fractured hip as well. Event Outcome: Patient will be coming off of service today for pin placement to [his/her] hip." Review of the agency's internal investigation report for P7's adverse patient event, dated 06/01/23, revealed no documentation that the agency identified opportunities for improvement, and failed to monitor the quality-of-care related incident. During an interview on 09/22/23 at 1:00 PM, the Executive Director confirmed that the internal investigations were incomplete for P1, P3 and P7, and did not identify opportunities for improvement, and did not contain documentation that monitoring of the quality-of-care related to the three incidents was performed. Review of the agency's policy revised 04/01/22 titled "Quality Assurance and Performance Improvement" indicated " ... Identify and set specific outcomes/priorities for improvement, adjusting priorities in response to unusual or urgent events."

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure the Registered Nurse (RN) 1 followed proper infection control practices during patient care for one (Patient (P) 5) of two patients observed. This deficient practice has the potential to affect all 171 patients receiving care from the agency. Findings include: During an observation on 09/22/23 at 11:40 AM, Registered Nurse (RN) 1 performed incontinent care on P5 with gloved hands. After the incontinent care was completed, RN1 did not remove the soiled gloves or perform hand hygiene. With the soiled gloves still on RN1 removed clean several sanitary wipes from a container, wiped down the patient equipment including a blood pressure cuff, a stethoscope, and a pulse-oximeter (used to measure blood oxygenation rate), and placed the equipment into a bag. During an interview on 09/22/23 at 12:20 PM, RN1 and the Clinical Supervisor confirmed that RN1's gloves were not changed, and hand hygiene was not performed after completing incontinent care and before cleaning P5's patient care equipment. The Clinical Supervisor was present during the patient observation.

Based on medical record review, interviews, and policy and procedure review, the Hospice Agency failed to ensure that counseling services were offered to assist a patient and family with a terminal illness diagnosis related issue for one (Patient (P) 1) of eight patient records reviewed. This deficient practice has the potential to affect all 171 patients receiving care from the hospice agency. The findings include: Review of P1's electronic medical record (EMR) revealed that the "Client Coordination Note Report" for 06/29/23 indicated that P1 declined a social work visit and the "social worker should call back in three weeks." There was no documentation indicating that the social worker called or visited P1 three weeks after the 06/29/23 visit or while the patient was on service with the hospice agency. During an interview on 09/22/23 at 9:00 AM, the Executive Director confirmed that a social work visit had not been performed three weeks after the 06/29/23 visit or while the patient was on service with the hospice agency. Review of the agency's policy revised 02/15/23 titled "Plan of Care" indicated "This agency designates an interdisciplinary group, that in consultation with the patient's hospice physician and the attending community physician (if any), prepares a written plan of care (POC) for each patient that is regularly reviewed ... Purpose: To develop a plan of care that specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment relative to the terminal illness and associated conditions." During a telephone interview on 09/25/23 at 11:00 AM, P1's family member stated, "we really needed a social work visit, but did not get one."

Based on medical record review, staff interview, and policy and procedure review the Hospice Agency failed to provide coordination of care for hospice services for two (Patient (P) 1, and P3) of two records reviewed for patient transfers. This deficient practice has the potential to affect all 171 patients receiving care from the agency. Findings include: Review of P1's medical record revealed there was no documentation of a transfer summary sent to the receiving facility for a transfer that occurred on 07/29/23 when P1 was sent to an acute care hospital. Review of P3's medical record revealed there was no documentation of a transfer summary sent to the receiving facility for a transfer that occurred on 04/21/23 when P3 was sent to a Skilled Nursing Facility (SNF). During an interview on 09/21/23 at 9:23 AM, the Executive Director confirmed that transfer summaries were not provided to the receiving facilities for P1 and P3. Review of the agency's policy titled "Transfer Information" revised 05/15/21, indicated " ... The transferring clinician will complete a transfer summary that may include the following information: A summary of the patient's stay including treatment, symptoms, and symptom management; B. The patient's latest physician orders ... 5. Completed Discharge /Transfer Summaries will be sent to the receiving organization and tiled in the original in the clinical record. ..."

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient's condition changed. For example, during a review of the medical record for HV#2, it was noted that the patient experienced a fall during week 5 of the 7th benefit period. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to measure the effectiveness of interventions. This observation was reviewed with the Executive Director, Director of Clinical Operations – North, and Director of Clinical Operations – South.

Observed in Tracer Visit. In 1 of 5 Home Visit observations, it was noted that the organization did not ensure standard precautions were implemented during patient care activities. For example, the surveyor observation of HV#2, revealed that during hand hygiene activity the clinician did not use a paper towel to turn the faucet off. This observation was reviewed with the Director of Clinical Operations - North. Observed in Tracer Visit. In 2 of 5 Home Visit observations, it was noted that the organization did not ensure its bag technique policy was implemented. For example, the surveyor observation of HV#2 and HV#3, revealed that during patient care activities the clinician placed a blood pressure cuff and stethoscope directly on the floor. The blood pressure cuff, and stethoscope were cleaned by placing hand gel on the clinician's hand and then rubbing the equipment. This observation was reviewed with the Director of Clinical Operations - North.

Observed in Document Review. Example #2: During inpatient #2 tracer activities, it was noted that required signatures were not documented. For example, during a review of the Schedule II medication sheet for Diazepam 5mg a second nurse signature was not present at shift change on 9/25/22 – 7:30pm. During a review of the Schedule II medication sheet for Dilaudid CADD 250 ml a second nurse signature was not present at shift change on 9/25/22 - 7:30pm and 9/26/22 – 7:30pm. This observation was reviewed with the Director of Clinical Operations – Northern. Observed in Document Review. The organization did not ensure that its policy related to the control and accountability of all medications was implemented. For example, during a review of the policy titled: Medications in The Inpatient Center, the following information was noted: (2) All medications are to be stored in a secure area suitable for product stability. Schedule II medications will be stored in a separated double-locked compartment and counted by two skilled nurses at the end of each shift. During inpatient unit #1 tracer activities, it was noted that required signatures were not documented. On the following date(s) and times in 2022 there were no signatures recorded at shift change: 2/19 - 7am and 7pm; 5/20 - 7pm; and 9/9 - 7pm. On the following date(s) and times in 2022 a second nurse signature was not present: 2/18 - 7am and 7pm; 2/20 - 7am; 2/27 - 7am; 3/20 - 7am; 4/1 - 7pm; 4/2 - 7am and 7pm; 5/10 – 7p; and 5/18 – 7pm. This observation was reviewed with the Director of Clinical Operations – North and IPC Shift Lead RN.

Observed in Document Review. The individual named on the CLIA certificate was not updated within 30 days of that person leaving the company. This observation was confirmed with the Director of Business Operations.