Every finding on record at Shalom Hospice

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop an individualized plan of care (POC), four of five full records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's undated policy titled, ";Plan of Care," showed the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 12/27/2024 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and resided in a LTCF (Long-Term Care Facility). Review of the IDG (Interdisciplinary Group) Update POC, dated 01/22/2025, showed in part: - A problem of incontinence (involuntary loss of bladder or bowel control), a problem description of incontinent of bowel and bladder, and interventions/outcomes that included in part, foley catheter (a thin, flexible tube inserted into the bladder to drain urine); and - The patient did not have a foley catheter (A pull-up brief was worn for incontinence). RECORD/PATIENT #3: Review of the IDG (Interdisciplinary Group) Update POC, dated 01/22/2025, showed in part: - A problem of skin breakdown, a problem description monitoring skin each visit r/t (related to) increased incontinence of bowel and bladder, and interventions/outcomes that included in part, patient education handout(s) for stomach tube (a thin, flexible tube inserted directly into the stomach to provide nutrition, medication, or drainage) care, anal fissures (a small tear in the lining of the anus), colostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the large intestine is diverted and collected in a bag), ileostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the small intestine is diverted and collected in a bag); and - The patient did not have a stomach tube, anal fissure, colostomy, and/or ileostomy (A pull-up brief was worn for incontinence and barrier cream was used to prevent skin breakdown). During an interview, on 01/29/2025 at 11:15 AM, the administrator stated that: - The problem description section of the plan of care allows the staff to make interventions and goals patient-specific; - The plan of care showed interventions that did not apply to the patients because the staff were just checking the box on those interventions instead of selecting the ones that applied to that patient specifically; and - He/she would expect the POC to show patient-specific interventions and goals in the problem description section of the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors) and resided at a private residence. Review of the IDG (Interdisciplinary Group) Update POC, dated 01/22/2025, showed in part: -A problem of anxiety (a common emotional state characterized by feelings of unease, worry, fear or apprehension) and agitation (a feeling or irritability, mental distress or severe restlessness), the goal stated the patient would report understanding of the causes and treatment of anxiety; -A problem with pain (physical suffering or discomfort caused by illness or injury), the goal stated the patient would report that pain is reduced to a desired level, which was not indicated; -A problem with decline in activities of daily living (basic self-care tasks for well-being and independence), the goal stated the patient would report comfort and understanding of assistive devices, which the facility did not name in the plan; -A problem with anticipatory grief (the feeling of grief or loss that occurs before a death), the goal stated the patient would express and share grief and concerns, assist patient in identifying strengths; -A problem with nutrition (obtaining food necessary for health and growth), the goal stated the patient would be in control of what, how much and when to eat, caregiver must feed him/her and give fluids; -A problem with communication (sending or receiving information to express needs and wants), the goal stated the family will verbalize ways to effectively communicate with the patient, assist in methods of communication with no plan; and -The IDG narrative stated the patient was ";alert to self only and unable to voice his/her needs," and was unable to feed his/herself. Observation on 01/28/2025 at 1:20 PM showed the patient was unable to have a conversation and was unable to answer questions when asked. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a primary diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the IDG (Interdisciplinary Group) Update POC, dated 12/24/2024, showed in part: - A problem with fatigue or weakness, the goal stated the patient would participate in desired activities, patient would report comfort and understanding of assistive devices. The patients activities and assistive devices were not listed; - A problem with pain (physical suffering or discomfort caused by illness or injury), the goal stated the patient would report that pain is reduced to a desired level, the pain level was not indicated; and - The IDG Narrative indicated the patient is bedbound. Observation on 01/27/2025 at 1:45 PM showed the patient was not able to speak. He/she was able to nod in response to some questions. Findings included: Review of the provider's undated policy titled, ";Plan of Care," showed the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a terminal diagnosis of end stage heart failure (a decrease in the ability of the heart to pump blood) and Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and resided at a private residence. Review of the comprehensive assessment, dated 12/27/2024, showed in part: -According to the onset, progression of symptoms, functional status and response to treatment section: The interview with the patient/family/representative indicated the patient had increased mental status changes; - The patient was in need of total care and unable to make his/her needs known;- In the diagnosis and prognosis assessment: The patient was nonverbal;- In the pain and comfort assessment: The patient was unable to describe pain;- In the neurological status assessment: The patients behavior was hampered by Sundowners syndrome (a complex neurobehavioral disorder that affects people with dementia that worsens in the late afternoon, evening or night) and his/her speech was characterized as garbled (speech that was unclear or confusing making it difficult to understand);- The mental status assessment stated: The patient was confused at all times; - The immediate needs for problem and symptom management indicated a decline in the patients ADL (activities of daily living) and self-care; and- The communication section stated the representative was educated on diet, nutrition, feeding, and fluids. Review of the interdisciplinary group (IDG) update POC, dated 01/22/2025, showed in part: -A problem of anxiety (a common emotional state characterized by feelings of unease, worry, fear or apprehension) and agitation (a feeling or irritability, mental distress or severe restlessness). The goal showed, the patient would report understanding of the causes and treatment of anxiety; -A problem with pain (physical suffering or discomfort caused by illness or injury). The goal showed the patient would report that pain was reduced to a desired level. The POC failed to show the patient's acceptable level of pain; -A problem with decline in activities of daily living (basic self-care tasks for well-being and independence). The goal showed the patient would report comfort and understanding of assistive devices. The POC failed to show what assistive devices the patient was using); -A problem with anticipatory grief (the feeling of grief or loss that occurs before a death). The goal showed the patient would express and share grief and concerns. Staff would assist the patient in identifying strengths; -A problem with nutrition (obtaining food necessary for health and growth). The goal showed the patient would be in control of what, how much and when to eat. The caregiver must feed him/her and give him/her fluids; -A problem with communication (sending or receiving information to express needs and wants). The goal showed the family would verbalize ways to effectively communicate with the patient and assist in methods of communication. The POC failed to identify the communication methods used; and -The IDG narrative showed, the patient was ";alert to self only and unable to voice his/her needs," and was unable to feed him/herself. Observation on 01/28/2025 at 1:20 PM, showed the patient was unable to have a conversation and was unable to answer questions when asked. The POC failed to be individualized regarding:-The patient being unable voice his/her needs;-Acceptable level of pain;-Goal of grief (since the patient was unable to have a conversation);-Goal of nutrition (since the patient was unable to have a conversation, how would he/she be in control of what, how much, and when to eat); and-Communication methods. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 12/27/2024 with a terminal diagnosis of end stage heart failure and resided in a long-term care facility (LTCF). Review of the IDG update POC, dated 01/22/2025, showed in part, a problem of incontinence (involuntary loss of bladder or bowel control), a problem description of incontinent of bowel and bladder, and interventions/outcomes that included in part, foley catheter (a sterile tube placed in the bladder to drain urine). During observation on 01/27/2025 at 1:00 PM showed the patient did not have a urinary catheter. The POC failed to be individualized and accurate when it showed the patient had a urinary catheter and the patient did not have a catheter. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 03/01/2024 with a terminal diagnosis of malignant neoplasm of prostate (prostate cancer) and resided in a LTCF. Review of the IDG update POC, dated 01/22/2025, showed in part, a problem of skin breakdown, a problem description monitoring skin each visit related to r/t increased incontinence of bowel and bladder, and interventions/outcomes that included in part, patient education handout(s) for enternal feeding tube (a tube placed surgically through the abdominal wall into the stomach for the administration of foods, fluids, and medication) care, anal fissures (a small tear in the lining of the anus), colostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the large intestine is diverted and collected in a bag), ileostomy (a surgical procedure that creates an opening in the abdominal wall through which waste from the small intestine is diverted and collected in a bag). During observation on 01/28/2025 at 9:00 AM showed the patient did not have an enternal feeding tube, anal fissure, colostomy, and/or ileostomy. The POC failed to be individualized and accurate when it showed the patient had an enternal feeding tube, anal fissure, colostomy, and/or ileostomy and the patient did not have any of those. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a terminal diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the comprehensive assessment, dated 12/14/2024, showed in part: -According to the cardiopulmonary assessment: The patient used oxygen and experienced decreased activity; - The pain and comfort assessment indicated: Generalized pain/undefined location;- The patient was confined to the bed or a chair;- The medical condition impaired the patients ability to ambulate, or move independently; and- The environment assessment stated the patient was non-ambulatory. Review of the IDG update POC, dated 12/24/2024, showed in part:- A problem with fatigue or weakness. The goal showed the patient would participate in desired activities, the patient would report comfort and understanding of assistive devices. The POC failed to include the patients activities and assistive devices.- A problem with pain. The goal showed the patient would report that pain was reduced to a desired level. The POC failed to include the patients acceptable pain level; and- The IDG narrative indicated the patient was bedbound. Observation on 01/27/2025 at 1:45 PM, showed the patient was not able to speak. He/she was able to nod in response to some questions. The POC failed to be individualized and include:-The patients activities and assistive devices;-The patients acceptable pain level;-The patients bedbound status;-The patient being non-verbal; and -How to communicate. During an interview on 01/29/2025 at 11:15 AM, the administrator stated that: - The problem description section of the plan of care allowed the staff to make interventions and goals patient-specific; - The plan of care showed interventions that did not apply to the patients because the staff were just checking the box on those interventions instead of selecting the ones that applied to that patient specifically; and - He/she would expect the POC to show patient-specific interventions and goals in the problem description section of the plan of care.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop measurable outcomes in the implemented individualized plan of care (POC) that measured the goals for two of five patients (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's undated policy titled, ";Plan of Care, Policy Number: PC, P50," showed in part, the POC is written by members of the Interdisciplinary Team with measurable goals and outcomes for plans interventions. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a terminal diagnosis of end stage heart failure (a decrease in the ability of the heart to pump blood) and Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and resided at a private residence. Review of the interdisciplinary group (IDG) update POC, dated 01/22/2025, showed in part, the facility failed to incorporate measurable data in the plan of care, for reporting pain, comfort, and nourishment, based on the patient's inability to speak: -A problem of anxiety (a common emotional state characterized by feelings of unease, worry, fear or apprehension) and agitation (a feeling or irritability, mental distress or severe restlessness). The goal showed the patient would report understanding of the causes and treatment of anxiety; -A problem with decline in activities of daily living (basic self-care tasks for well-being and independence). The goal showed the patient would report comfort and understanding of assistive devices; -A problem with incontinence (involuntary loss of bladder or bowel control). The goal showed the patient would report comfort; -A problem with constipation (infrequent or difficult bowel movements). The goal showed the patient would report soft, formed stools; -A problem with anticipatory grief (the feeling of grief or loss that occurs before a death). The goal showed the patient would express and share grief and concerns; -A problem with nutrition (obtaining food necessary for health and growth). The goal showed the patient would be in control of what, how much, and when to eat; -A problem with communication (sending or receiving information to express needs and wants). The goal showed the family would verbalize ways to effectively communicate with the patient; and -The IDG narrative showed in part, the patient was ";alert to self only and unable to voice (his/her) needs" and was unable to self-feed. Observation on 01/27/2025 at 1:45 PM, showed the patient was not able to speak. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a terminal diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the IDG update POC, dated 12/24/2024, showed in part, the facility failed to include measurable data in the goals for the patient, for activity and pain relief, based on the patient's inability to move without assistance and being nonverbal: - A problem with fatigue or weakness. The goal showed the patient would participate in desired activities, the patient would report comfort and understanding of assistive devices; - A problem with pain (physical suffering or discomfort caused by illness or injury). The goal showed the patient would report that pain was reduced to a desired level. The POC failed to indicate the patient's acceptable pain level; and - The IDG narrative indicated the patient was bedbound. The narrative failed to include the pain criteria for when to notify the registered nurse case manager. Observation on 01/27/2025 at 1:45 PM, showed the patient was bedbound and was not able to speak. He/she was able to nod in response to some questions. During an interview on 01/29/2025 at 11:00 AM, the administrator stated that, the goals should be captured in the hospice tools in the problem description. That section was where the nurses should add the personal goals and the measurable data. He/she thought the nurses were leaving it off the plans.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the hospice aide written instructions included patient-specific instructions for patient care in four of five records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's undated policy titled, ";Hospice Aide/Personal Care Services," showed that the hospice RN (registered nurse) develops a written hospice aide plan of care that provides instructions to the hospice aide of the patient-specific care to be provided. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 12/27/2024 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and resided in a LTCF (Long-Term Care Facility). Review of the hospice aide care plan, dated 12/27/2024, showed in part: - Functional limitations: OOB (out of bed) with assist, two-person assist to transfer, poor endurance, and floor mat in place when in bed; - Safety precautions: safety precautions assigned (No further documentation of the safety precautions); and - The hospice aide care plan failed to show patient-specific instructions on how the hospice aide was to conduct the two-person transfer. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 03/01/2024 with a primary diagnosis of malignant neoplasm of prostate (prostate cancer) and resided in a LTCF (Long-Term Care Facility). Review of the hospice aide care plan, dated 01/27/2025, showed in part: - Assistive Devices/Equipment Used During Patient Care: Wheelchair; - Senses: Language barrier (Primary language was Spanish); and - The hospice aide care plan failed to show patient-specific instructions on safety precautions, how the hospice aide was to transfer the patient from the wheelchair for showers, and how the hospice aide was to communicate with the patient. During an interview, on 01/29/2025 at 11:00 AM, the administrator stated that: - The functional limitations were care planned by the nurse selecting the task box; and - The aide instructions should have included additional details with patient-specific instructions on how the hospice aide should perform the selected task. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 12/27/2023 with a primary diagnosis of end stage heart failure (the most advanced stage of heart failure, where the heart is severely weakened and unable to pump blood effectively throughout the body) and Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors) and resided at a private residence. Review of the hospice aide care plan update, dated 06/13/2024, showed in part: - Functional limitations: OOB (out of bed) with assist, two-person assist to transfer, Hoyer assist with two persons (a machine that mechanically lifts a person from one area in a sling device, and allows two people to move the patient to another area, while in mid-air), poor endurance, and side rails up on bed; - Safety precautions: safety precautions assigned (no further documentation of the safety precautions); and - The hospice aide care plan failed to show patient-specific instructions on how the hospice aide was to conduct the two-person transfer. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/14/2024 with a primary diagnosis of malignant neoplasm of body of pancreas (cancer with tumors that begins in the organ lying behind the lower part of the stomach and spreads to other parts of the body) and resided in a family residence. Review of the hospice aide care plan update, dated 12/14/2024, showed in part: -Functional limitations: bed bound, Hoyer assist with two persons, poor endurance and side rails up on bed; - Safety precautions: safety precautions assigned (no further documentation of the safety precautions); and - The hospice aide care plan failed to show patient-specific instructions on how the hospice aide was to conduct the two-person transfer with the Hoyer lift.

Based on policy review, employee file review, and interview, the hospice provider failed to ensure that a criminal background check (CBC) was conducted prior to patient contact in, one of five employee files reviewed (Employee #3). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's undated policy titled, ";Personnel Records," showed in part: - Personnel records are maintained for job applicants, employees, and past employees in accordance with laws and regulations and in order to maintain documentation of the hospices hiring practices and employment related matters; and - Personnel records contain criminal background checks in accordance with organizational policy and procedures and local and/or state law. EMPLOYEE #3: Review of employee #3's personnel file, showed in part: - Date of hire: 12/18/2024; and - Date of CBC: 01/28/2025 (during the recertification survey). During an interview on 01/28/2025 at 2:30 PM, the administrator stated that: - He/she thought that he/she submitted a Family Care Safety Registry (FCSR) request that checked for the CBC, but he/she did not receive any results back; and - He/she must have overlooked it.

Based on policy review, grievance file review, and interview, the agency failed to document the investigation of all alleged violations in accordance with established procedures in one (Complaint #1) of three complaint records reviewed. This deficient practice has the potential to affect the investigation of complaints and/or grievances of all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Patient Rights and Responsibilities," showed in part that the patient had the right to receive an investigation by the organization of complaints made by the patient or the patient's family or guardian regarding treatment or care and that the organization will document the existence of the complaint and the resolution of the complaint. Complaint #1: Review of complaint #1 with report date of 07/08/2022 showed the complaint form failed to contain documentation of: - The description of the complaint; - Resolution of the complaint (action taken); - Follow up needed; and - Signature, title and date of person reviewing and ensuring the implementation related to this complaint including any follow up that was needed. During an interview on 07/14/2022 at 12:40 PM, the administrator stated that the complaint form should have been completed. That he/she is busy and wears many hats and it just got missed. She did investigate via calling other patient's the staff member was caring for at that time and there was no other patients with problems with that staff member.

Based on policy review, record review, and interview, the agency failed to ensure the initial nursing assessment included an assessment of the patient's immediate psychosocial and spiritual needs in, but not limited to, one (Record/Patient #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, "Comprehensive Assessment," showed in part: - An initial assessment to determine the patient's immediate care and support needs is conducted by a hospice registered nurse (RN) within 48 of the patient's election of hospice care; - A thorough psychosocial assessment is initiated at the time of admission and continued throughout the course of care; and - The psychosocial assessment includes an evaluation of the patient's preferred style of communication, including expressing emotions, thoughts, and needs. An evaluation of mental health needs and identification of substance abuse symptoms. RECORD/PATIENT #5: Review of the patient's current medication profile showed an order dated 06/21/2022, for Lantus insulin daily. The order failed to include how many units of insulin the patient was to take. Review of the initial RN assessment dated 06/21/2022, showed the patient's blood sugars were to be monitored two times a day and as needed. The assessment failed to identify the patient's diabetic history, the patient's ability to check his/her blood sugars, ability of the patient to take his/her insulin, clarification of the amount of insulin the patient was to take, or whether there was a caregiver available to assist the patient if needed. The assessment also failed to identify whether there were any immediate spiritual needs. Review of the patient's clinical review for support of hospice eligibility signed by the RN on 06/21/2022, showed the section for psychosocial/spiritual changes was blank. Review of the POC dated 06/21/2022 showed to assess, perform and instruct on diabetic care, signs and symptoms of high and low blood sugars, medication administration, glucometer testing, and check blood sugars twice a day and as needed. Staff wrote in CG (unsure if this meant caregiver) check blood sugar as directed safely. During an interview on 07/13/2022, beginning at 2:10 PM, the administrator stated that he/she would expect the nurse to provide diabetic teaching with return demonstrations to assure the patient could safely check his/her blood sugar.

Based on policy review, record review, and interview, the agency failed to maintain an accurate/updated medication profile and complete the drug regimen review within five days of election in, but not limited to, one (Record/Patient #1) 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, "Admission to Hospice Care and Initial Assessment," showed in part that the hospice interdisciplinary group must complete the comprehensive assessment no later than five calendar days after the election of hospice care and will include a drug profile, including prescriptions, over-the-counter drugs, herbal remedies and alternative treatments which includes identification of effectiveness of drug therapy, drug side effects, actual/potential interactions, duplicate drug therapy, and drug therapy related to laboratory monitoring. Review of the agency's undated policy titled, "Medications - Profile," showed in part: - A medication profile is maintained for each patient and reviewed, at a minimum every fifteen days; - The patient's medication profile review includes, but is not limited to, determine accuracy and completeness of the profile, monitoring medication effectiveness, actual or potential medication related effects and untoward interactions, determining if there are medications that have been or may be discontinued, identifying duplicate drug therapy and drug therapy associated with laboratory monitoring RECORD/PATIENT #1: Review of the record showed the patient's election of hospice care was 05/19/2022. Review of the initial nursing assessment dated 05/19/2022 showed the patient resided in a long term care facility (LTCF). Review of the current LTCF physician orders listed the patient's allergies as codeine (pain medication), hydrocodone (pain medication), lorazepam (anti-anxiety), morphine (pain medication), oxycodone (pain medication), and quetiapine (anti-psychotic). Review of the current medication profile listed the patient's allergies as codeine, morphine, and Seroquel (quetiapine). The medication profile failed to list the hydrocodone, oxycodone, and lorazepam. The medication profile included orders for morphine and lorazepam. The clinical pharmacist review dated 05/31/2022 (12 days after admission) showed no known drug allergies. The review failed to address the discrepancies regarding the patient's drug allergies. Review of the current LTCF medication orders showed the following discrepancies with the hospice medication profile: - The LTCF orders showed an order dated 06/21/2022 for acetaminophen (Tylenol) 1000 milligrams (mg) every eight hours for pain. The hospice medication profile showed an order for acetaminophen 500 mg two tablets every eight hours as needed for pain; and - The LTCF orders showed an order dated 05/24/2022 for venlafaxine HCI extended release 37.5 mg one time daily for depression. The hospice medication profile showed an order dated 05/19/2022 for venlafaxine 75 mg one time daily for depression. During an interview on 07/13/2022, at 1:00 PM, the administrator stated that he/she could not find a pharmacy review completed during the first five days of admission. During an interview on 07/13/2022, beginning at 1:50 PM, the director of clinical services stated that the process for medication reconciliation was to monthly compare the physician order sheet from the LTCF with the hospice orders. The administrator stated that they had been doing this more frequently. The administrator stated that he/she would expect the pharmacy review to address the medication allergies. He/she stated that typically, the pharmacy review would "flag" that.

Based on policy review, record review, and interview, the agency failed to incorporate the bereavement assessment into the plan of care (POC), in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all bereaved individuals served by the agency. Findings included: Review of the agency's undated policy titled, "Comprehensive Assessment - Content," showed in part that it addresses an initial assessment of the bereavement needs of the patient's family and other involved individuals. Review of the agency's policy titled, "Bereavement - Care Planning," showed in part that the bereavement POC is developed based on an assessment of the patient/family needs at the time of admission and during the provision of hospice care. During the initial bereavement assessment, the IDG (interdisciplinary group) identifies family members, caregivers, or significant others who may be significantly impacted by the patient's death. The initial bereavement assessment is updated during IDG meetings throughout the course of the patient's care. RECORD/PATIENT #1: Review of the initial social worker progress note dated 05/19/2022, the bereavement section of the assessment showed that the family/caregiver has coping challenges. Interventions included providing emotional support and validation and that he/she would provide and assist with any community socialization, active listening and feeling validation with a goal that the caregiver would feel supported by the hospice team. Review of the POC dated 05/19/2022 showed a check mark beside grief management and to assess, perform and instruct but failed to include specific interventions and goals related to bereavement. During an interview on 07/13/2022 beginning at 10:25 AM, the social worker stated that he/she developed the POC in coordination with the spiritual counselor. They talk about bereavement in the IDG meetings but his/her interventions were not incorporated into the POC.

Based on policy review, record review, and interview the agency failed to follow an individualized plan of care (POC) in, but not limited to, one (Record/Patient #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: - An individual written POC is established and maintained for each patient and family; and - Care provided to an individual patient is in accordance with the POC. RECORD/PATIENT #5: Review of the initial nursing assessment dated 06/21/2022 showed the patient's blood sugars were to be monitored two times a day and as needed. Review of the POC dated 06/21/2022 showed to assess, perform and instruct on diabetic care, signs and symptoms of high and low blood sugars, medication administration, glucometer testing, and check blood sugars twice a day and as needed. Staff wrote in CG (unsure if this meant caregiver) check blood sugar as directed safely. Review of the skilled nurse (SN) visit notes from 06/21/2022 through 07/08/2022 showed no documentation of assessment of the patient's blood sugar readings or education regarding diabetic care. During an interview on 07/13/2022, beginning at 2:10 PM, the administrator stated that he/she would expect the nurse to provide diabetic teaching with return demonstrations to assure the patient could safely check his/her blood sugar and education regarding reporting high and low blood sugars. This should be documented in the nursing notes and included on the POC. The nurse should have the patient document their blood sugars and the nurse should assess the patient's blood sugar history.

Based on policy review, record review and interview the agency failed to develop an individualized plan of care (POC) in, but not limited to, three (Records/Patients #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," showed in part that the care and services provided to patients and their families are in accordance with an individualized, written POC. The interdisciplinary POC is based on initial and updated patient-specific comprehensive assessments by members of the IDG (interdisciplinary group). The patient's POC 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. The interdisciplinary POC is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated assessments and includes all services necessary for palliation and management of the terminal illness and related conditions including treatments, drugs, and interventions to manage pain and symptom and medical supplies and appliances necessary to meet the needs of the patient. RECORD/PATIENT #3: Review of the skilled nurse (SN) comprehensive assessment dated 05/24/2022, showed in part, the following was completed by registered nurse (RN) B (director of clinical services): - Patient was diagnosed with multiple sclerosis (disabling disease of the brain and spinal cord); - Genitourinary/Reproductive - Nurse: * Urine continence: Incontinent; * Issue: Patient is incontinent of bladder; and * Issue Description: Patient has incontinence of bladder and decreased mobility for improvement and wears briefs. Review of the POC, dated 05/14/2022 to 07/12/2022, showed no intervention or supplies listed for the incontinence. RECORD/PATIENT #4: Review of the SN initial assessment dated 06/22/2022, showed in part, the following was completed by RN B: - Patient was diagnosed with malignant neoplasm of prostate (cancer cells form in the tissue of the prostate); - Genitourinary/Reproductive - Nurse: * Urine continence: Continent; Incontinent; * Issue: Patient is incontinent of bladder; and * Issue Description: Bladder incontinence. Review of the POC, dated 06/22/2022 to 08/20/2022, showed no intervention or supplies listed for the incontinence. During an interview on 07/13/2022 at 02:35 P.M., the administrator stated that incontinent supplies should be listed on the plan of care. RECORD/PATIENT #5: The patient was admitted to hospice service on 06/21/2022. The POC dated 06/21/2022, showed pain management interventions included to assess pain status, response to medications, and non-pharmacological pain control measures. The goal was for the patient's pain to be at a comfortable level but failed to include what a comfortable level of pain was for the patient. During an interview on 07/13/2022, beginning at 2:10 PM, the administrator stated that the RN completes the initial assessment and determines what problems,interventions, and goals are included on the POC.

Based on home health standards, policy review, observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections was followed in one (Record/Patient #1) 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: [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; - After contact with blood, body fluid, or contaminated surfaces; and - Immediately after glove removal. Review of the agency's undated policy titled, "Infection Control - Hand Hygiene and Bag Technique," showed in part that staff must wash their hands before and after wearing gloves. RECORD/PATIENT #1: Observation on 07/12/2022, beginning at 10:00 AM, during the patient's home visit at a long term care facility (LTCF), showed registered nurse (RN) B (director of clinical services) provided wound care for the patient. RN B removed the patient's soiled dressing, removed his/her gloves, and applied clean gloves without washing his/her hands or using hand sanitizer. During an interview on 07/13/2022, beginning at 1:50 PM, the administrator stated that he/she would expect the nurse to use hand sanitizer when they changed their gloves.

Based on policy review, record review, and interview the social worker failed to provide care according to the plan of care and/or coordinate care with the hospice interdisciplinary group (IDG) in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect the quality of licensed professional social worker care and coordination of hospice care provided to all patients. Findings included: Review of the agency's undated policy titled, "Coordination of Services," showed in part that coordination of services and continuity of care is facilitated by established formal and informal communication mechanisms between all disciplines providing care. RECORD/PATIENT #3: The initial and ongoing physician orders and the plan of care, developed by the RN case manager with other members of the IDG, dated 05/14/2022 to 07/12/2022 showed: Patient will achieve optimal sleep/rest. Review of the clinical record showed the masters of social work, documented on 06/23/2022 in his her assessment in the Neuro/Mental/Emotional - Social Worker Comments: Patient reports he/she cannot sleep at night. Review of the Hospice Interdisciplinary group (IDG) Meeting and Care Plan Updates, dated 06/29/2022 showed no changes and to continue the plan of care. (There was no documentation about patient can't sleep). Review of the clinical record showed the masters of social work, documented on 07/07/2022 in his her assessment in the Neuro/Mental/Emotional - Social Worker Comments: Patient reports he/she cannot sleep at night. During an interview on 07/13/2022 at 02:35 P.M., the administrator stated that any changes should be reported to the nurse

Based on policy review, record review, observation, and interview, the agency failed to ensure the nursing needs of the patients were met in two (Records/Patients #1 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, "Nursing Services," showed in part: - Nursing services are directed and staffed to assure that the nursing needs of all patients are met as identified in the patient's comprehensive and updated assessments and plan of care (POC); - Professional nursing service is provided by a registered nurse (RN) and includes assessment, planning and provision of nursing services shall be the responsibility of the RN including initial and ongoing assessment of the impact of the terminal diagnosis on the patient's physical needs, implementing the individualized POC, informing the physician and other personnel of changes in the patient's needs and outcomes of intervention; - Professional nursing service may also include seeing, treating and writing orders for hospice patients; - When nursing services are delegated to an LPN (licensed practical nurse), the LPN is supervised by an RN, and the RN makes at least monthly home visits and documents that the LPN is routinely providing nursing services in accordance with the patient's POC and the LPN's scope of practice. RECORD/PATIENT #1: Review of the skilled nurse (SN) visit notes dated 06/07/2022 through 06/30/2022 showed the patient had wounds to the right and left heel. The nurses documented they assessed and provided wound treatments. The record showed no physician orders for the treatment to the right heel until 07/01/2022. The record showed no physician orders for treatment to the left heel. Review of the IDG (interdisciplinary group) meeting/care plan updates from 06/15/2022 through 06/29/2022 failed to show updates to the POC regarding the heel wounds. Observation on 07/12/2022, beginning at 10:00 AM, during the patient's home visit, showed the director of clinical services (DCS) provided wound care to the right heel and assessed the patient's left heel. The right heel wound measured 4.0 x 4.0 x 0.0 cm and appeared clean with dark reddish purple colored tissue in the center of the wound. The DCS stated that the facility had a wound care team that also saw the patient. Review of the hospice record showed a physician order dated 07/01/2022 for treatment of the right heel wound to cleanse the right heel with wound cleanser/normal saline (a salt solution with healing properties), apply Silvadene (antimicrobial) and Xeroform (occlusive dressing that keeps the wound clean), cover with a dry dressing and ABD (large, absorbent) pad, and wrap with Kerlix (gauze wrap) and ACE (elastic) bandage. The order failed to include a frequency. Review of the current long term care facility (LTCF) physician orders showed an order dated 07/01/2022 to cleanse the right heel with wound cleanser/normal saline, apply Silvadene and Xeroform, cover with a dry dressing and ABD pad, and wrap with Kerlix and ACE bandage every day shift. During an interview on 07/13/2022 beginning at 1:50 PM, with the administrator and DCS, the DCS stated that the patient did not have a wound on the left heel. The administrator stated that he/she would have expected a treatment order to be obtained and documented. He/she would expect the POC to be updated with interventions and goals for wound care. RECORD/PATIENT #5: Review of the POC dated 06/21/2022, showed to change the LVAD (left ventricular assist device, helps the heart to pump) dressing three times a week and as needed and report signs and symptoms of complications and infection to include increased pain and odor. Wound care included cleaning the incision site with wound cleanser, pat dry, apply dressing, and secure with tape. Review of the SN visit note dated 06/30/2022, showed the patient continued to have excessive bleeding from the incision/suture site. The RN/DCS was present during the visit, no concerns. There was no documentation that the physician was notified of the bleeding. Review of the SN visit notes showed from 06/22/2022 through 07/01/2022 the LPNs documented they performed dressing changes using sterile technique (the record showed no order for sterile dressing changes). Review of a SN visit note dated 07/06/2022, showed the nurse spoke with the physician and obtained an order to place calcium alginate over the sternal (chest) site for three dressing changes (the record showed no order for this). Review of a LPN supervisory visit dated 07/03/2022, the DCS documented the LPNs followed the LPN assignment. The supervisory visit failed to address the documentation of using sterile technique for dressing changes. During an interview on 07/13/2022, beginning at 2:10 PM, the administrator stated that he/she would expect the excessive drainage to be reported to the physician. The administrator stated that when a new order was received, the order should be written and carried over to the POC. The DCS stated that there was no order for sterile dressing changes.

Based on policy review, record review, and interview, the agency failed to ensure the registered nurse (RN) prepared complete written care instructions for the hospice aide in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients who receive aide services from the agency. Findings included: Review of the agency's undated policy titled, "Hospice Aide Assignment and Duties," showed in part that the aides are assigned to specific patients by an RN and follow written patient care instruction in providing care to assigned patients. The RN is responsible in preparing written patient care instructions that are patient-specific. RECORD/PATIENT #1: Review of the skilled nurse (SN) visit notes dated 06/07/2022 through 07/07/2022 showed the patient had wounds to the right and left heel and the nurses provided wound treatments. Review of the aide assignment established on 05/19/2022 and updated on 06/13/2022 showed no information regarding the patients wounds. During an interview on 07/14/2022, at 9:55 AM, the director of clinical services stated that the aide assignment should have been updated with information on the patient's wounds.

Based on policy review and record review the agency failed to ensure the hospice aide supervisory visits included all the required components in, but not limited to, one (Record/Patient #1) of five full records reviewed. 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 Supervision," showed in part that the supervising registered nurse (RN) assesses an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria in, but not limited to: - Following the patient's plan of care (POC) for completion of assigned tasks; - Creating successful interpersonal relationships with the patient and family; - Demonstrating competency with assigned tasks; - Complying with infection control practices; and - Reporting changes in the patient's condition. RECORD/PATIENT #1: Review of the aide supervision notes from 05/27/2022 through 06/28/2022 failed to address the components of creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, and reporting changes in the patient's condition. During an interview on 07/13/2022, beginning at 2:10 PM, the administrator stated that the aide supervisory visits did not include all the required information. It was a software issue, and did not realize the information was missing.

Based on policy review, employee file review and interview, the hospice provider failed to ensure that the skills and competence were assessed of all staff furnishing care/services to hospice patients in one of six employee files reviewed (Employee licensed practical nurse (LPN) D). This deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the agency's undated policy titled, "Competency Assessment," showed in part that clinical competency evaluations are performed at the time of hire and annually to assess employee basic skill levels for all staff/employees providing patient/family care. The competency of staff and volunteers is assessed through self-evaluations and checklists, supervised visits, interviews, simulated practice, and written tests. Employee LPN D: Review of the employee file showed the following: - Date of hire: 05/26/2022; - The employee was a current direct clinical staff of the hospice provider; and - No evidence that the employee had skills and competence assessed. On 07/12/2022 at 4:25 PM, the surveyor witnessed LPN D completing his/her competency sheet and dating it as 05/27/2022. LPN D stated that he/she could not find the original document. The findings were reviewed with the agency administrator on 07/14/2022, beginning at 12:40 PM. The administrator stated that the employee file was missing the required components and he/she should not have completed the requested missing form.

Based on policy review, record review and interview, the agency failed to provide accurate patient documentation of the patient's advance directive (right to make and direct decisions concerning medical care to accept and/or refuse care) for one patient (Record/Patient #3), failed to ensure documentation was accurate and/or timely and ensure staff signatures included their title and/or credentials in, but not limited to, two (Records/Patients #3 and #4) 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, "Documentation Requirements," showed in part that all documentation must be timely and is signed using credentials and title. Review of the agency's undated policy titled, "Advance Directives," showed in part that if available, a copy of any advance directive is placed in the patient's clinical record and the patient's wishes including his or her DNR (do not resuscitate) status and is communicated to members of the hospice IDG (interdisciplinary group) to be included in care planning for the patient. RECORD/PATIENT #3: Review of the Outside The Hospital Do-Not-Resuscitate (OHDNR) signed and dated 11/15/2021 at the start of care showed Code Status - Do Not Resuscitate (DNR) [authorize emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation in the event I suffer cardiac or respiratory arrest. Cardiac arrest means my heart stops beating and respiratory arrest means I stop breathing). The DNR will take effect and no medical procedure to restart breathing or heart functioning will be instituted. Review of the Hospice Physician Initial Orders dated 05/14/2022 to 07/12/2022 showed, Is the patient DNR? ("Do Not Resuscitate")? With the box marked "no". Review of the social worker progress notes, dated 06/07/2022, and 06/23/2022 both showed patient as a DNR in the basic patient information but documented, "patient also is a full code," in the visit summary. During an interview on 07/13 2022 at 4:45 PM, the MSW (masters of social work) stated that the patient is a full code. The patient's spouse died and the daughter of the patient was upset when she found out the patient's spouse was a DNR and the patient revoked DNR status. MSW could not provide a signed revoked advanced directive form. During an interview on 07/13/2022 at 2:35 PM, the administrator stated the advance directive should match the POC and nurses notes/MSW notes. Review of the skilled nurse (SN) comprehensive assessment visit note dated 06/04/2022 showed an electronic staff signature dated and timed 06/08/2022 01:43 PM (four business days later). The signature failed to include the staff members title and/or credentials. Review of the SN visit note dated 06/07/2022 showed an electronic staff signature dated and timed 06/09/2022 at 08:37 AM (two business days later). The signature failed to include the staff members title and/or credentials. Review of the SN comprehensive assessment visit note dated 06/15/2022 showed an electronic staff signature dated and timed 06/21/2022 12:51 AM (six business days later). The signature failed to include the staff members title and/or credentials. Review of the SN visit note dated 06/17/2022 showed an electronic staff signature dated and timed 06/21/2022 at 09:01 AM (four business days later). The signature failed to include the staff members title and/or credentials. Review of the hospice aide visit note dated 06/21/2022 showed an electronic staff signature dated and timed 06/23/2022 08:10 AM (two business days later). The signature failed to include the staff members title and/or credentials. Review of the SN visit note dated 06/28/2022 showed an electronic staff signature dated and timed 07/01/2022 08:32 AM (three business days later). The signature failed to include the staff members title and/or credentials. During an interview on 07/13/2022, beginning at 2:10 PM, the administrator stated that he/she expected staff to do their documentation at the bedside. If they were unable to complete at the bedside, he/she expected the documentation to be completed the same day. RECORD/PATIENT #4: Review of the clinical record initial plan of care, showed start of care 06/22/2022 and certification period of 06/22/2022 to 08/20/2022. The RN signature and physician signature were both hand dated 06/29/2022 (seven days after start of care). Review of the SN comprehensive assessment note, dated 07/05/2022 showed the patient was alert and orientated (A & O) toward person and place (A & O times two) and the summary of visit showed A & O times three with increased forgetfulness. Review of the SN routine visit note, dated 07/08/2022 showed the patient was A & O toward person and place (A & O times two) and the summary of visit showed A & O times three, did not have some confusion with timeline questions. During an interview on 07/13/2022, at 2:35 PM, the administrator stated that the nursing assessment and summary should match.

Based on policy review, review of the written agreement for respite services, record review, and interview, the agency failed to obtain a discharge summary from the skilled nursing facility (SNF) that provided respite services for one (Record/Patient #8) of one patient record reviewed for respite care (inpatient care for caregiver relief). This deficient practice has the potential to affect coordination of care for hospice patients who receive respite care. Findings included: Review of the agency's undated policy titled, "Written Agreements - Inpatient Care," showed in part that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; and a copy of the discharge summary be provided to the hospice at the time of discharge. Review of the written agreement for respite services with the SNF that provided Patient #8's respite care, showed the facility must provide the hospice a copy of the clinical record including a discharge summary, upon request. RECORD/PATIENT #8: Record review showed the patient received respite care from 03/11/2022 to 03/15/2022. The record failed to include a discharge summary for the respite stay. During an interview on 07/13/2022, at 2:25 PM, the administrator stated that they did not have a discharge summary from the facility.

Based on policy review, review of a written agreement for general inpatient care (GIP, short term care for symptom management)/inpatient respite services (inpatient care for caregiver relief), and interview the agency failed to ensure the agreement with the skilled nursing facility (SNF) included the requirement that the inpatient provider has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement in one (Contract A) of one inpatient contracts reviewed. This deficient practice has the potential to affect all inpatient/respite patients served by the agency. Findings included: Review of the agency's undated policy titled, "Written Agreements - Inpatient Care," showed in part that the contract for inpatient care would include the provision that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. CONTRACT A: Review of a written agreement for GIP/inpatient respite with a LTCF dated 03/11/2022, failed to include the provision that the inpatient provider has identified an individual within the facility who is responsible for the provisions of the agreement. During an interview on 07/13/2022, beginning at 1:50 PM, the findings were reviewed with the administrator. The administrator acknowledged the findings and no further information was provided.

Based on policy review, record review, and interview, the agency failed to ensure the coordinated task plan of care (POC) with the long term care facility (LTCF) included the frequency of visits for the social worker and failed to show accurate coordination of wound care management in one (Record/Patient #1) of two records reviewed of patients that resided in a LTCF. Findings included: Review of the agency's undated policy titled, "Hospice Care for Nursing Facility Residents - Hospice Plan of Care," showed in part: - The plan of care for the facility patient identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon and included in the POC; and - There shall be a coordinated single POC in the nursing facility which may be multiple documents that reflects coordination and input from both the hospice and nursing facility, identifies the care and services which each shall provide, and is updated to reflect changes in patient/family condition, needs, and care. RECORD/PATIENT #1: Review of the skilled nurse (SN) visit notes dated 06/07/2022 through 06/30/2022 showed the patient had wounds to the right and left heel. The nurses documented they assessed and provided wound treatments. Review of the hospice record showed a physician order dated 07/01/2022 for treatment of the right heel wound to cleanse the right heel with wound cleanser/normal saline (a salt solution with healing properties), apply Silvadene (antimicrobial) and Xeroform (occlusive dressing that keeps the wound clean), cover with a dry dressing and ABD (large, absorbent) pad, and wrap with Kerlix (gauze wrap) and ACE (elastic) bandage. Review of the current long term care facility (LTCF) physician orders showed an order dated 07/01/2022 to cleanse the right heel with wound cleanser/normal saline, apply Silvadene and Xeroform, cover with a dry dressing and ABD pad, and wrap with Kerlix and ACE bandage every day shift. Review of the hospice/long term care coordinated task plan of care maintained in the hospice binder at the LTCF (first date was 05/20/2022) failed to include the frequency of the social worker visits. There was no coordination of wound care documented until 07/01/2022 which showed Monday, Wednesday, and Friday wound care. Review of the nursing visits showed the hospice nurses visited the patient two times a week on Tuesdays and Thursdays. During an interview on 07/13/2022, beginning at 1:50 PM, the director of clinical services stated that the nurses do the wound care on their visits. The wound schedule should not have been Monday, Wednesday, and Friday. The administrator stated that he/she would expect the social worker visit frequency to be included.

Based on policy review, record review, home visit observation, and interview the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in, but not limited to, one (Record/Patient #1) of two applicable record of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Review of the agency's undated policy titled, "Hospice Care for Nursing Facility Residents - Coordination of Services," showed in part that the following information is provided to the facility: - Physician certification and recertification of the terminal illness; - Hospice physician and attending physician orders; and - Any advance directives specific to each patient. RECORD/PATIENT #1: Review of the hospice record maintained at the LTCF, during a home visit observation on 07/12/2022 beginning at 10:00 AM, showed it failed to contain the following required information: - Physician certification of terminal illness; - Hospice physician and attending physician orders; and - Advance directive. During an interview on 07/12/2022, at approximately 11:30 AM, the director of clinical services stated that the patient had an advance directive, but it was not in the LTCF record. They do no keep the physician certifications and physician orders in the facility record. During an interview on 07/13/2022, beginning at 1:50 PM, the administrator stated that the required information should be in the facility record.