Every finding on record at Shield Hospice & Palliative Care Inc

Based on interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Patient Rights was met as follows: 1. The Hospice Agency (HA) failed to report a suspected neglect to appropriate agencies and/or local enforcement authority in a timely manner for one of 14 sampled patients (Patient 7). (Refer to L508). The cumulative effect of this practice resulted in the hospice agency's failure to protect the rights of admitted patient to be free and protected from suspected neglect, mistreatments, and receive an appropriate and reasonable timely care.

Based on interview and record review, the Hospice Agency (HA) failed to report a suspected neglect to appropriate agencies and/or local enforcement authority in a timely manner for one of 14 sampled patients (Patient 7). This deficient practice resulted in the HA not implementing its policy and procedures on neglect identification and reporting that had the potential for the patient to experience psychological/emotional discomfort and harm and will jeopardize patient safety. --- A review of Patient 7's Face Sheet indicated Patient 7 was admitted to the agency on 10/17/2023 and was discharged on 12/14/2023, with the primary diagnosis of Alzheimers Disease (It is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). A review of Patient 7's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/25/2023, indicated the frequency of visits of the licensed vocational nurse (LVN) to two times per week plus 1 prn (pro re nata, which means ";as needed") visits, hospice aide visit to three times per week, the registered nurse (RN) supervisory visits every fourteen days, spiritual counselor (SC) and the social worker (MSW) to one visit for initial assessment within 5 days from admission then every recertification. During a telephone interview with the Licensed Vocational Nurse (LVN 3) on 3/1/2024, at 2:30 p.m., LVN 3 stated that she visited Patient 7 several times when she was under hospice care, stated Patient 7 is awake, not alert, and unable to verbalize her needs, bed bound and total dependent from care. LVN 3 stated that on occasions, during her visits, she observed that Patient 7 was left unchanged with her incontinence pads (are thin, absorbent pads designed to manage light urine leakage) likely overnight as her pads were saturated from her urine and feces were dried and was sticking to her buttocks area. LVN 3 stated she observed Patient 7 on this condition several times but unable to remember which dates, she stated that she does not know how long she was left unchanged and stated that Patient 7 did not develop any skin rashes or skin abnormalities from her groin and buttocks areas. LVN 3 stated she notified the office and the Director of Patient Care Services (DPCS) regarding suspected neglect to Patient 7. LVN 3 stated she asked Patient 7s son (Patient 7s Caregiver/Son/PCG1) regarding patient was left unchanged of her continence pad but he stated he does not know about it. LVN 3 stated she did not document her observations to her visit notes, and she did not call to report the suspected neglect to responsible agencies, she stated that she was unable to remember when the last time she had an abuse/neglect in services from the agency had but she does remember she had the abuse/neglect training during her orientation. LVN 3 stated that she should have reported it to the appropriate agency for further investigation. LVN 3 stated she was unaware of the process of reporting for suspected abuse/neglect although she is a mandated reporter. During an interview with the DPCS on 3/1/2024, at 3:10 p.m., DPCS stated that LVN 3 reported regarding Patient 7s suspected neglect from last December 2023. DPCS stated the agency did not conduct any internal investigation and did not report to the responsible agencies or local authorities. DPCS stated that she was occupied with assisting Patient 7 to have a state paid and provided caregiver. DPCS stated that the agency should have reported the suspected neglect to appropriate agency, conduct an internal investigation to determine if it occurred and protect the affected patient. DPCS was unable to provide documented evidence of Abuse/Neglect In-Services to all agencys staff. On 2/28/2024 at 10:30 a.m., 2/29/2024 at 11:00 a.m. and 3/1/2024 at 12:45 p.m., telephone calls were made to contact Patient Care Giver 1 (PCG1)but were unsuccessful. A review of Patient 7s ";Visit Note LVN" dated from 10/17/2023 to 12/14/2023, indicated no documentation that the appropriate agencies and/or local enforcement agency was immediately informed of the suspected neglect. A review of the agencys policy and procedure titled ";Assessment of Possible Abuse/Neglect", undated, indicated that the organization will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations, any clinicians who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor, the clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident.

Based on observation, interview, and record review, the hospice agency (HA) staff failed to review all the medications and update the medication profile with currently used medications for two of 14 sampled patients (Patient 8 and Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- a. A review of Patient 8s admission record indicated Patient 8 was admitted on 2/18/2023 with a primary diagnosis of hemiplegia (total or nearly complete paralysis [inability to make voluntary muscle movement] on one side of the body following cerebral infarction [stroke – when the blood supply to part of the brain is blocked or reduced, preventing brain tissue from getting oxygen and nutrients; brain cells die as a result]. A review of Patient 8's Plan of Care/Interdisciplinary Group Review (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 2/14/2024, indicated that a skilled nurse (SN, a licensed nurse in general), was to monitor/assess effectiveness of current and new medication/treatment for the cardiovascular (circulatory system that consists of the heart and a closed system of vessels called arteries, veins, and capillaries), endocrine (consists of glands that produces hormones), gastrointestinal (a network of organs that digest and absorb nutrition from food; the gastrointestinal system includes the mouth, pharynx [throat], esophagus, stomach, small intestine, large intestine, rectum, and anus), neurological (a organ system that sends messages back and forth between the brain and the body), and pain. A review of Patient 8s ";Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living) List" indicated that Patient 8 was on insulin Lispro 100 units/ml, inject 10 units subcutaneously before meals. During a joint home visit with Licensed Vocational 2 (LVN 2) on 2/29/2024 at 9 a.m., observed Patient 8 observed lying in bed, awake. Patient 8 was non-verbal. During medication review with LVN 2 on 2/29/2024 at 9:55 a.m., insulin Lispro 100 units/ml were available at Patient 8s home. During an interview on 2/29/2024 at 10:15 a.m. with PCG 1, who acted as the primary caregiver for Patient 8, PCG 1 stated she checked Patient 8s blood sugar before breakfast, before lunch, before dinner, and at bedtime. PCG 1 stated that Patient 8s blood sugar that morning, before breakfast, was 160 mg/dL. When PCG 1 was asked if she had been administering 10 units of insulin Lispro 100 units/ml before each meal as ordered, PCG 1 stated the amount of insulin Lispro that she administered would depend on Patient 8s blood sugar reading. PCG 1 stated, ";If the blood sugar is 150 or less, I dont give him insulin. If the blood sugar is 155, I will give 3 units. If its 160 to 170, I will give 5 units, and if its 180 to 200, I will give 10 units." PCG 1 stated that LVN 1, who is the visiting nurse that has been visiting Patient 8 once per week, instructed her to follow a list that had the unit of insulin to be given based on the blood sugar reading (known as sliding scale; a sliding scale varies the dose of insulin based on blood glucose level). PCG 1 was not able to show the surveyor a sliding scale for insulin Lispro. PCG 1 stated, ";I used to have it, but I dont have it anymore." During a telephone interview with LVN 1 on 2/29/24 at 12:09 p.m., LVN 1 stated that PCG 1 had been following the sliding scale to administer the insulin Lispro. LVN 1 stated that he believed the sliding scale was provided to Patient 8 by a home health agency which Patient 8 was a patient of before he was admitted to the HA. LVN 1 further stated he instructed PCG 1 to follow the sliding scale for insulin Lispro. LVN 1 stated he was supposed to check the medication list every visit and report it to the HAs office if there was any discrepancy between the physicians order and the dose taken by patient. The office would verify with the physician about the discrepancy. During a concurrent record review and interview with the DPCS on 3/1/2024 at 10:15 a.m., the DPCS reviewed Patient 8s medication list and POC/IDG Review, dated 2/14/2024. The DPCS stated that Patient 8 was on a sliding scale for insulin Lispro. However, the DPCS acknowledged the order for insulin Lispro was 10 units before meals. The DPCS was not able to provide the survey team with the physicians order for the sliding scale. During an interview with the DPCS on 3/2/2024 at 1:20 p.m., the DPCS stated that she was aware that insulin was a high-risk medication that could cause serious adverse events when not given in the correct dose. The DPCS stated that the visiting nurse was supposed to check patients medications with every visit and perform medication reconciliation. b. A review of Patient 9s admission record indicated Patient 9 was admitted on 10/4/2023 with a primary diagnosis of end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life). A review of Patient 9s ";Comprehensive Nursing Assessment," dated 10/4/2023, indicated that Patient 9 was alert, oriented, and able to verbalize pain. The ";Comprehensive Nursing Assessment" indicated Patient 9 denied pain during assessment, but the primary caregiver for Patient 9 (PCG 3) reported that Patient 9 had had episodes of pain. The ";Comprehensive Nursing Assessment indicated that the Director of Patient Care Services (DPCS), who conducted the comprehensive assessment, instructed PCG 3 to give prescribed pain medication as needed. A review of Patient 9s ";Current Treatment/Medication/DME List," indicated there was no pain medication ordered upon Patient 9s admission on 10/4/2023. During an interview with the DPCS on 3/1/2023 at 10:15 a.m., the DPCS stated Patient 9 denied pain during her visit. When asked what pain medication she instructed PCG 3 to give to Patient 9, the DPCS stated, ";It was over-the-counter medication. I believe it was Tylenol (medication to treat minor aches and pain)." The DPCS stated all medications taken by patient needed to be included in ";Current Treatment/Medication/DME List," including over-the-counter ones. The DPCS stated it was important to list all of patients medications to monitor effectiveness, side effects, and possible drug interactions. A policy for medication reconciliation was not provided upon request. A review of the HAs policy, titled ";Initial Assessment," revised November 2021, indicated the admitting registered nurse will gather the following information: F. Medications: dose/frequency/route

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: 1. The HA failed to ensure to follow the physicians order for one of 14 sampled patients (Patient 8). Patient 8 physicians order on 2/18/2023, indicated to administer 10 units of Lispro insulin (fast acting insulin used to control high blood sugar) subcutaneous (the insertion of medications beneath the skin by injection) before each meal. 2. The Skilled Nurse (SN) did not check Patient 8s blood sugar by glucometer (a device for measuring the concentration of glucose [sugar] in the blood) and conduct medication reconciliation (a process of comparing medications) during the home visits. These deficient practices resulted in Patient 8 received the incorrect units of Lispro from 2/18/2023 to 3/2/2024 and unmonitored blood sugar level, that could place Patient 8 at risk for hypoglycemia (low blood sugar levels), confusion (lack of understanding), and unresponsiveness (loss of consciousness [the state of being aware]) or hyperglycemia (high blood sugar levels, headache, blurred vision, confusion, and loss of consciousness). (Refer to L543) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.

Based on observation, interview, and record review, the Hospice Agency (HA, providing care to terminally ill patients who have six months or less to live) failed to ensure to follow physicians order for one of 14 sampled patients (Patient 8) by failing to: 1. Ensure the Licensed Vocational Nurse 1 (LVN 1) and Skilled Nurses (SNs, in general) checked Patient 8s blood sugar levels using a glucometer (a device for measuring the concentration of glucose [sugar] in the blood) and conduct medication reconciliation (a process of comparing medications) during the home visits. 2. Ensure Patient 8s caregiver (PCG 1) administered the correct doses of insulin. Patient 8 physicians order on 2/18/2023, indicated to administer 10 units of Lispro insulin (fast acting insulin used to control high blood sugar) subcutaneously (the insertion of medications beneath the skin by injection) before each meal. These deficient practices resulted in Patient 8 to receive the incorrect doses of Lispro insulin from 2/18/2023 to 3/2/2024 and unmonitored blood sugar levels that could place Patient 8 at risk for hypoglycemia (low blood sugar levels, confusion (lack of understanding), and unresponsiveness (loss of consciousness [the state of being aware]) or hyperglycemia (high blood sugar levels, headache, blurred vision, confusion, and loss of consciousness. On 3/2/2024, at 3 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Director of Patient Services (DPCS) and Administrator (ADM) related to the agencys failure to follow the physicians order for Patient 8's insulin medication. LVN 1 and SN (in general) failed to check Patient 8s blood sugar levels during home visits, conduct medication reconciliation, and provide teaching to Patient 8 on the administration insulin medication. On 3/2/24 at 4: 30 p.m., the agency was unable to submit an IJ removal plan, the survey team completed the survey tasks, and exited with the IJ not removed. --- Findings: During a review of Patient 8s untitled admission record indicated the HA admitted Patient 8 on 2/18/2023 with a primary diagnosis of hemiplegia (type of paralysis [immobility] that affects one side of the body). During a review of Patient 8s ";Visit Note LVN," completed by LVN 1, dated 2/5/2024, 2/12/2024, and 2/19/2024, indicated LVN 1 did not provide instructions and/or teaching related to blood sugar reading log, glucometer calibration, and insulin administration. During a review of Patient 8's Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness) dated 2/14/2024, the POC/IDG Review indicated a skilled nurse (SN) was to check blood sugar levels for any signs and symptoms of hypo/hyperglycemia and report if the blood sugar was below 70 milligrams (mg) per deciliter (dL) or above 351 mg/dL, instruct Patient 8s Caregiver (PCG) regarding signs and symptoms of hyperglycemia/hypoglycemia, and instruct the PCG on insulin Lispro 10 units ";intravenous (into the vein)" before meals. The POC/IDG Review indicated for the SN to ensure PCG was able/willing and competent with weekly glucometer calibration (a procedure to ensure accurate readings of blood sugar levels) and to have the PCG do a return demonstration, and monitor/assess effectiveness of current and new medication/treatment. During a review of Patient 8s POC/IDG Review, dated 2/14/2024, indicated SN visit frequency for Patient 8 was once per week and as needed for changes in condition. During review of Patient 8s undated ";Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)" indicated Patient 8 was on insulin Glargine (long acting) inject 10 units subcutaneous daily at bedtime and insulin Lispro inject 10 units subcutaneous before meals. During a joint home visit observation on 2/29/2024 at 9 a.m., with Licensed Vocational 2 (LVN 2), Patient 8 was lying in bed, awake. Patient 8 was non-verbal. During an observation and a review of Patient 8s medication on 2/29/2024 at 9:55 a.m., with LVN 2, Patient 8s Glargine 100 units/ml and Lispro insulins 100 units/ml were observed and available at Patient 8s home. During a interview, on 2/29/2024, at 10:15 a.m., with PCG 1, PCG 1 stated she checked Patient 8s blood sugar before breakfast, before lunch, before dinner, and at bedtime. PCG 1 stated Patient 8s blood sugar on 2/29/2024 morning, before breakfast, was 160 mg/dL. PCG 1 stated she did not record Patient 8s blood sugar readings. PCG 1 stated the HA did not instruct her regarding the recording of Patient 8s blood sugar levels. PCG 1 stated the HA did not provide a log to record Patient 8s blood sugar readings. PCG 1 stated she would administer the Lispro insulin depending on Patient 8s blood sugar readings. PCG 1 stated, ";If the blood sugar is 150 or less, I do not give him insulin. If the blood sugar is 155, I will give three units. If it is 160 to 170, I will give five units, and if its 180 to 200, I will give 10 units." PCG 1 stated LVN 1 visited Patient 8 once per week and instructed her to follow a sliding scale (varies the dose of insulin based on blood glucose level). PCG 1 stated she did not have a sliding scale. During an interview with LVN 2 on 2/29/2024, at 10:10 a.m., LVN 2 stated she was not the regular nurse for Patient 8, and she only saw Patient 8 once. LVN 2 stated she thought Patient 8 was on a sliding scale for insulin Lispro. During a telephone interview with LVN 1 on 2/29/2024, at 12:09 p.m., LVN 1 stated for insulin Lispro, Patient 8 had a sliding scale that was taped to the wall in his bedroom, and PCG 1 followed the sliding scale to administer the insulin Lispro. LVN 1 stated he last saw the sliding scale either in December 2023 or January 2024. LVN 1 stated he did not see the sliding scale on the wall during his last visit on 2/27/2024. LVN 1 stated a previous home health agency (HHA) provided the sliding scale to Patient 8 before he was admitted to the HA. LVN 1 stated PCG 1 would be the one who checked Patient 8s blood sugar. LVN 1 stated he instructed PCG 1 to follow the sliding scale for Lispro insulin. LVN 1 stated he was supposed to check the medication list every visit and report it to the HAs office if there was any discrepancy between the physicians order and the dose taken by patient. LVN 1 stated the office would verify with the physician about the discrepancy. During a telephone interview with PCG 1 on 3/2/2024, at 1:47 p.m., when asked the last time she calibrated Patient 8s glucometer PCG 1 stated she did not know what calibrating meant. During a concurrent record review, and interview on 3/1/2024, at 10:15 a.m., with the DPCS, the DPCS reviewed Patient 8s medication list and POC/IDG Review, dated 2/14/2024. The DPCS stated the order for Lispro insulin was 10 units before meals. The DPCS was not able to provide Patient 8s physicians order for the sliding scale. During an interview on 3/2/24 at 1:20 p.m., with the DPCS, the DPCS stated the HA did not have records of Patient 8s hemoglobin A1c test (a blood test that measures the average blood sugar levels over the past 3 months) or blood sugar log before meals. The DPCS stated she was aware that insulin was a high-risk medication that could cause serious adverse events (undesirable, and usually unanticipated event that causes death or serious injury) when not given in the correct dose. The DPCS stated LVN 1 was supposed to check Patient 8s medications with every visit and perform medication reconciliation. The DPCS stated it was important to educate Patient 8s caregiver regarding the importance of recording the blood sugar readings, calibrating the glucometer, and giving the right dose of insulin. The DPCS stated calibration was important to ensure the blood sugar readings were accurate. The DPCS verified that insulin Lispro was to be given subcutaneously and not intravenously. Per DPCS, the intravenously instruction in Patient 8s POC/IDG Review was a typing error. The DPCS stated the HA did not have a policy and procedure on insulin management. A review of the HAs policy titled ";The Plan of Care," revised November 2021, indicated that care provided to the patient will be in accordance with the plan of care. A review of the HAs undated policy, titled ";Home Glucose Monitoring (HGM)/Diabetic Patients," indicated that: If the nurse is using a home glucose monitoring device owned by the patient to provide care according to the plan of care, the nurse must ensure that the machine is in proper operating condition and that the nurse is trained on the machine. Calibration performance control solution checks are required when a nurse uses patient-owned HGM devices. Recording of calibration and control tests will be recorded in the nurses notes. Calibration and control tests will be performed per manufacturers instructions for the patient-owned meter. Calibration and control test results will be recorded on a log form entitled, ";Quality control for home glucose monitoring devices." The nurse will maintain this log with the device. Completed logs will be turned into and reviewed by the Clinical Supervisor or designee and will be retained by the organization.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure to provide education and training to the primary caregiver about their responsibilities for the care and services identified in the plan of care for one of 14 sampled patients (Patient 8). This deficient practice resulted Patient 8 to receive incorrect dose of insulin Lispro (an injectable medication to manage diabetes (high blood sugar in the blood) which may result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) crisis that could lead to a serious harm, hospitalization and/or death. --- A review of Patient 8s admission record indicated Patient 8 was admitted on 2/18/2023 with a primary diagnosis of hemiplegia (total or nearly complete paralysis [inability to make voluntary muscle movement] on one side of the body following cerebral infarction [stroke, when the blood supply to part of the brain is blocked or reduced, preventing brain tissue from getting oxygen and nutrients; as a result brain cells die]. A review of Patient 8's Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 2/14/2024, indicated that a skilled nurse (SN, a licensed nurse in general) was to instruct primary caregiver (PCG) regarding signs and symptoms of hyperglycemia/hypoglycemia, instruct PCG on insulin Glargine (an injectable medication to treat diabetes) 10 units subcutaneously (the insertion of medications beneath the skin by injection) daily at bedtime, and instruct the PCG on insulin Lispro (fast-acting insulin to control high blood sugar levels, an injectable medication) 100 unit/mL, 10 units before meals. The POC/IDG Review also indicated that SN was to ensure that PCG was able/willing and was competent with weekly glucometer calibration and SN to have the PCG to do a return demonstration. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 2/29/2024 at 9:00 a.m., observed Patient 8 lying in bed and was awake. Patient 8 was non-verbal. During an interview on 2/29/2024 at 10:15 a.m. with PCG 1, who acted as the primary caregiver for Patient 8, PCG 1 stated that she checked Patient 8s blood sugar before breakfast, before lunch, before dinner, and at bedtime. PCG 1 stated that Patient 8s blood sugar that morning, before breakfast, was 160 mg/dL (milligram/deciliter, a measurement of the blood sugar test). During an interview on 2/29/2024 at 10:15 a.m. with PCG 1, PCG 1 stated that LVN 1, who was the visiting nurse and who has been visiting Patient 8 once per week, instructed her to follow a list that had the unit of insulin to be given based on the blood sugar reading (known as sliding scale; a sliding scale varies the dose of insulin based on blood glucose level). PCG 1 was not able to show the surveyor a sliding scale for insulin Lispro. PCG 1 stated, ";I used to have it, but I dont have it anymore." During a telephone interview with LVN 1 on 2/29/2024 at 12:09 p.m., LVN 1 stated that PCG 1 had been following the sliding scale to administer the insulin Lispro. LVN 1 stated that he believed the sliding scale was provided to Patient 8 by the home health agency in which Patient 8 was a patient before prior getting admitted to HA. LVN 1 further stated he instructed PCG 1 to follow the sliding scale for insulin Lispro. During a concurrent record review and interview with the DPCS on 3/1/2024 at 10:15 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 8s medication list and POC/IDG Review, dated 2/14/2024. The DPCS stated the order for insulin Lispro was 10 units before meals. During an interview with the DPCS on 3/2/2024 at 1:20 p.m., the DPCS stated that she was aware that insulin was a high-risk medication that could cause serious adverse events when not given in the correct dose. The DPCS stated the visiting nurse was supposed to give education to the caregiver to follow the order for medication, including insulin. Per DPCS, if the caregiver did not understand the teaching, then the visiting nurse needed to reeducate the caregiver with each visit. A review of the HAs policy and procedure titled ";The Plan of Care," revised November 2021, indicated that care provided to the patient will be in accordance with the plan of care. The policy further indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program, the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. The policy indicated this plan will focus on identified problems, goals, and interventions.

Based on observation and interview, the Hospice Agency (HA) failed to provide one of 14 sampled patients (Patient 8) with necessary medical supplies (sharps container, a special container to waste used needles and other sharps). This deficient practice resulted in the patients caregiver unable to dispose the used needles and syringes in a safe manner, which could cause injury and spread of infection. --- A review of Patient 8s admission record indicated Patient 8 was admitted on 2/18/2023 with a primary diagnosis of hemiplegia (total or nearly complete paralysis [inability to make voluntary muscle movement] on one side of the body following cerebral infarction [stroke, when the blood supply to part of the brain is blocked or reduced, preventing brain tissue from getting oxygen and nutrients; as a result brain cells die]. A review of Patient 8s ";Current Treatment/Medication/DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) List" indicated the HA was to provide the following supplies: no rinse shampoo, diapers (large), Glucerna (meal or snack replacement designed for people with diabetes), needles for Insulin Lispro (an injectable medication for diabetes) syringe, wet wipes, Insulin Lispro syringe, and alcohol swabs. Sharps container was not listed in the ";Current Treatment/Medication/DME List." During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 2/29/2024 at 9:00 a.m., observed Patient 8 was lying in bed and was awake. Patient 8 was non-verbal. During an interview on 2/29/2024 at 10:15 a.m. with primary caregiver (PCG 1), who acted as the primary caregiver for Patient 8, PCG 1 stated she checked Patient 8s blood sugar before breakfast, before lunch, before dinner, and at bedtime. PCG 1 stated she administered all of Patient 8s medications, including insulin (an injection to manage blood sugar levels in people with diabetes). During an interview on 2/29/2024 at 10:15 a.m. with PCG 1, when asked PCG 1 where did she dispose the used lancets (a small needle used to prick the tip of the finger and quickly draw a drop of blood), needles, and syringes (a small hollow tube used for injecting or withdrawing liquids), PCG 1 opened a drawer in Patient 8s bedroom. Observed multiple orange-capped syringes in the drawer. PCG 1 then uncapped the syringes, and observed the needles on the syringes were bent. According to PCG 1, the sharps container was full, and she brought it to the pharmacy to be disposed. PCG 1 further stated, she had been keeping the syringes in the drawer since. During an interview with LVN 2 on 2/29/2024 at 10:30 a.m., LVN 2 stated syringes and needles must be disposed into a sharps container. LVN 2 stated that storing used needles and syringes in a drawer put PCG 1 at risk for injury and infection caused by the blood-borne pathogens. During an interview with the Director of Patient Care Services (DPCS) on 3/1/2024 at 10:25 a.m., the DPCS stated it was very important to use a sharps container for disposal of needles and syringes. The DPCS stated bending and recapping needles could injure the caregiver and spread infection. The DPCS stated the HA was responsible to provide Patient 8 with the sharps container since he required blood sugar checks and insulin injection. Per DPCS, it was the visiting nurses responsibility to check with the patient or caregiver if the sharps container was ¾ (represent part) full and if the patient needed a new one. A policy for medical supplies was not provided by the HA.

Based on interview, observation, and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the plan of care was revised to reflect a patient's refusal of medications for one of seven sampled patients (Patient 2). This deficient practice had the potential for not providing appropriate patient care services to maintain the patient's highest practicable well-being. --- A review of Patient 2's Face Sheet indicated a start of care (SOC) date of 6/13/2023, with the primary diagnosis of Atherosclerosis Heart Disease of Native Coronary Artery (thickening or hardening of the arteries, caused by a buildup of plaque in the inner lining of an artery which is a major blood vessel that carries the blood away from the heart). A review of Patient 2s ";Current Treatment/Medication/Durable Medical Equipment List", indicated prescribed medications as follow: - Alfuzosin 10 milligrams (mg) Extended-Release Tablet for BPH (Benign Prostatic Hyperplasia, a condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine). - Gabapentin 300 mg Tablet for Neuropathic (Nerve) Pain. - Losartan Potassium/Hydrochlorothiazide 100mg-25mg Tablet for Hypertension (a condition in which the blood vessels have persistently raised pressure). - Metformin Hydrochlorothiazide 500 mg Tablet for Diabetes Mellitus (a condition in which the body has trouble controlling blood sugar). - Senna 8.6 mg Tablet for Constipation. - Benadryl Allergy Ultratab 25 mg tablet for Seasonal Allergy. - Hydrocortisone 2.5 % (percent) Topical Cream for Itchiness. - Omeprazole 20 mg Delayed-Release Capsule for GERD (Gastroesophageal Reflux Disease, a common condition in which the stomach contents move up into the esophagus). - Acetaminophen 500 mg Tablet for Pain. On 2/29/2024 at 11:00 a.m., during a concurrent home visit and interview with the Licensed Vocational Nurse (LVN 1) and the Director of Patient Care Services (DPCS) to Patient 2s residence, Patient 2 was sitting on his bed, was alert and awake but was irritated for no apparent reason. Patient 2 denied any pain and refused to have LVN 1 to take his vital signs multiple times after explaining the benefits and risks of not doing it. Patient 2 stated, ";I do not take my medications and I do not need to take it". During medication reconciliation/review with LVN 1 of Patient 2s medications at home, bottles were still full of tablets and appeared that they were not used. LVN 1 stated that whenever there is a patients refusal to take medications and treatments, she reported it to the office so it could be discussed with the Physician on what measures can be done. LVN 1 further stated she does not attend IDG (IDG, Inter Disciplinary Group, a team responsible for the holistic care of the hospice beneficiary) meetings. During an interview on 2/29/2024 at 11:00 a.m. with DPCS, the DPCS stated she was aware of Patient 2s frequent refusal of his medications and that it was not discussed during IDG meetings. DPCS stated that it should have been discussed to ensure an appropriate care planning and to address the issue. DPCS further stated she reported it to the physician and there was no order given. A review of Patient 2s ";Communication Log" documented by the DPCS, indicated the following in the comment section: - Dated 10/31/2023 – ";Meds are not taken properly, SN explained the importance of taking medications on time as prescribed by the doctor. Patient refuses to comply." - Dated 12/26/2023 – ";Yet the patient refuses to take medications properly. Hospice doctor and patients family are aware of the situation." - 1/23/2024 – ";Patient still not taking all his meds. Refuses the nurse to explain the importance of properly taking the medications." - 2/20/2024 – ";Per RN, patient still not compliant. He is not taking the medications." A review of Patient 2's Plan of Care (POC)/IDG Review dated 12/20/2023, 1/3/2024, 1/17/2024, 1/31/2024, and 2/14/2024, indicated no care plan formulated nor discussions done to address Patient 2s refusal of his medications. A review of Patient 2s ";Updated Assessment" documented by the DPCS, indicated the following in the narrative section: - Dated 12/26/2023 – ";Patient refuses to take his medications." - Dated 2/20/2024 – ";Patient is not compliant and doesnt take his medications." A review of Patient 2s ";Visit Note LVN" documented by the DPCS, indicated the following in the narrative section: - Dated 12/6/2023 – ";Patient refuses to take his medications." - Dated 1/23/2024 – ";No medications were taken by him today." A review of the agencys policy and procedure titled ";The Plan of Care", revised November 2021, indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program, the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. The policy indicated this plan will focus on identified problems, goals, and interventions.

Based on observation and interview, the Hospice Agency (HA) failed to educate the patients caregiver on infection control practices, such as the safe disposal of sharps, for one of 14 sampled patients (Patient 8). This deficient practice had the potential to expose the patient and/or caregiver to infection caused by bloodborne pathogens. --- A review of Patient 8s admission record indicated Patient 8 was admitted on 2/18/2023 with a primary diagnosis of hemiplegia (total or nearly complete paralysis [inability to make voluntary muscle movement] on one side of the body following cerebral infarction [stroke, when the blood supply to part of the brain is blocked or reduced, preventing brain tissue from getting oxygen and nutrients; as a result brain cells die]. A review of Patient 8s ";Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living) List" indicated the HA was to provide the following supplies: no rinse shampoo, diapers (large), Glucerna (meal or snack replacement designed for people with diabetes), needles for Insulin Lispro syringe, wet wipes, Insulin Lispro syringe, and alcohol swabs. Sharps container was not listed in the ";Current Treatment/Medication/DME List." During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 2/29/2024 at 9:00 a.m., observed Patient 8 was lying in bed and was awake. Patient 8 was non-verbal. During an interview on 2/29/2024 at 10:15 a.m. with PCG 1, who acted as the primary caregiver for Patient 8, PCG 1 stated she checked Patient 8s blood sugar before breakfast, before lunch, before dinner, and at bedtime. PCG 1 stated she administered all of Patient 8s medications, including insulin (an injectable medication to manage blood sugar levels in people with diabetes). During an interview on 2/29/2024 at 10:15 a.m. with PCG 1, when asked PCG 1 where did she dispose the used lancets (a small needle used to prick the tip of the finger and quickly draw a drop of blood), needles, and syringes (a small hollow tube used for injecting or withdrawing liquids), PCG 1 opened a drawer in Patient 8s bedroom. Observed multiple orange-capped syringes in the drawer. PCG 1 then uncapped the syringes, and observed the needles on the syringes were bent. According to PCG 1, the sharps container was full, and she brought it to the pharmacy to be disposed. PCG 1 further stated, she had been keeping the syringes in the drawer since. During an interview with LVN 2 on 2/29/2024 at 10:30 a.m., LVN 2 stated syringes and needles must be disposed into a sharps container. LVN 2 stated that storing used needles and syringes in a drawer put PCG 1 at risk for injury and infection caused by blood-borne pathogens. During an interview with the Director of Patient Care Services (DPCS) on 3/1/2024 at 10:25 a.m., the DPCS stated it was very important to use a sharps container for disposal of needles and syringes. The DPCS stated bending and recapping needles could injure the caregiver and spread infection. Per DPCS, it was the visiting nurses responsibility to check with the patient or caregiver if the sharps container was ¾ full and if the patient needed a new one. A review of the HAs undated policy, titled ";Sharps Disposal," indicated in the home setting, a sharps disposal container will be available for use by the clinician and family/caregiver. The uncapped needle will be placed directly into the disposal container. When ¾ full, the disposal container will be sealed and transported to the dirty supply area located in the office. A new container should be provided to the patient for any future use.

Upon patient record review, 4 of 14 (Patient 2, 4, 5 & 7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2 medication profile includes "Miralax Powder for Solution 17gm oral Pwd F/Recon once a day with no dosage and no diluent instructions" Patient 4 medication profile includes "Voltaren 1% topical gel apply thin layer on affected areas 2-3 times daily with no location identified". Patient 5 medication profile includes "Triple Antibiotic First Aid Ointment 3.5mg/1gm apply thin layer on affected area 2-3 times a day with no location identified" and "Nystop 100,000 units/g topical powder apply on affected area twice a day with no location identified". Patient 7 medication profile includes "Oxygen 2-9 LPM via NC as needed for SOB; unclear dosage-range too wide".

Upon patient record review, 4 of 14 (Patient 2, 4, 5 & 7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2 plan of care includes "Miralax Powder for Solution 17gm oral Pwd F/Recon once a day with no dosage and no diluent instructions" Patient 4 plan of care includes "Voltaren 1% topical gel apply thin layer on affected areas 2-3 times daily with no location identified". Patient 5 plan of care includes "Triple Antibiotic First Aid Ointment 3.5mg/1gm apply thin layer on affected area 2-3 times a day with no location identified" and "Nystop 100,000 units/g topical powder apply on affected area twice a day with no location identified". Patient 7 plan of care includes "Oxygen 2-9 LPM via NC as needed for SOB; unclear dosage-range too wide".

Upon client record review, 2 of 14 (Patient #4, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4 & 6 plan of care included "Refer patient to PT" with no evidence of PT eval conducted.

Upon patient record review 5 of 14 (Patient 4, 5, 7, 13 & 14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 4 CHHA 2 x week effective 1/11/24, week of 1/7/24-1/13/24 only 1 visit made No evidence of HHA visits since 1/30/24 with no updated orders. Patient 5 CHHA ordered 2 x w, week of 1/7/24-1/13/24 there were no visits made. Patient 7 CHHA ordered 2 x w effective 12/17/23; week of 12/17/23-12/23/23 only 1 visit made. Week of 12/24/23-12/30/23 only 1 CHHA visit made. Patient 13 CHHA ordered 2 x w eff 7/26/23; week of 7/23/23-7/29/23 no visits made. Week of 11/5/23-11/11/23 only 1 visit made. Patient 14 CHHA ordered 2 x w, Week of 10/3/23-10/09/23 seen 4 times.

Based on interview, and record review, the hospice agency (HA) failed to provide one of 14 patients (Patient 2) information of their rights as a hospice patient in a language that would be understood, and the right to decline services before admission for hospice care. This deficient practice has the potential to result in the patient's lack of knowledge and understanding of their care and responsibilities as a patient certified to receive the hospice benefits. --- Findings: A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) of 2/10/2023 with a primary diagnosis of heart disease. Patient 2s primary language was listed as Spanish. A review of Patient 2s Informed Consent forms and Bill of Rights, dated 2/10/2023 were in English language and was signed by Patient 2. On 8/16/2023, at 3:30 pm., a joint home visit with Licensed Vocation Nurse (LVN 1) was conducted at Patient 2s home residence. Family Member (FM 3) provided assistance to translate the interview in Spanish. During an interview on 8/16/2023, at 3:45 pm., Patient 2 stated that he was not aware of what hospice meant and was not aware that he had a terminal illness. During an interview, Patient 2 was asked if he had heart disease. Patient 2 stated, he did not have any problems with his heart. During a telephone interview on 8/17/2023, at 12:38 pm., Family Member (FM 1) stated Patient 2 was not enrolled in hospice and that Patient 2 did not have a terminal illness. FM 1 stated that Patient 8 was enrolled with GACH 1 and did not know the hospice Medical Director. During an interview on 8/17/2023, at 11:45 am., FM 2 stated that Patient 2 did not have a terminal illness and that Patient 2s Primary Physician (PP 1) was from GACH 1 and just visited by PP 1 about two weeks ago. A review of Patient 2s Statement of Consent and Election Benefits, Patient Acknowledgement form, dated 2/10/2023, revealed all the documents provided to the patient were in English language instead of Spanish. A review of the Hospice Agencys Policy titled, ";Patient Bill of Rights/Responsibilities," dated 11/2021, indicated that the Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organizational services. This explanation will be in a language and manner he/she can reasonably be expected to understand. The policy indicated that written information will be provided to patients in the predominant languages of the population served.

Based on observation, interview, and record review, the hospice agency (HA) failed to maintain the current medication profiles for three of 14 sampled patients, (Patient 1, 2, and 9). The deficient practice has the potential to put patients at risk for medication errors and adverse drug reactions which can be life threatening. --- Findings: a. A review of Patient 1's Patient Information Sheet indicated a start of care date (SOC) of 9/14/2022 with diagnosis of hemiplegia (paralysis to one side of body) following cerebral infarction (stroke) affecting the right dominant side. On 8/16/2023, at 2:00 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 1s residence. LVN 1 performed skilled assessment of Patient 1 and medication review. During an observation and interview with LVN 1 on 8/16/2023 at 2:30 p.m., the following medications were observed: Quetiapine Fumarate, 25 milligram (mg, unit of measure) tablet, take one daily, Fill date 8/2/2023. Natrol, Melatonin, 10 mg, two gummies by mouth. The PCG 1 stated that the doctor prescribed the Quetiapine Fumarate medication for Patient 1 a couple of weeks ago and that Patient 1 started taking the gummy melatonin in April 2023. During an interview and record review on 8/16/2023 at 3:32 p.m. with LVN 1, Patient 1s Medication Profile was reviewed. LVN 1 stated Quetiapine Fumarate or the Melatonin gummies were not on the medication list. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) of 2/10/2023 with a primary diagnosis of heart disease. A review of Patient 2s Medication Profile indicated the following: Finasteride 5 mg tablet, 5 mg, one tablet by mouth once a day for benign prostrate hyperplasia (BPH, a condition in men in which the prostate gland is enlarged and not cancerous). Gabapentin 100 mg, one tablet by mouth twice a day for neuropathy (nerve pain). Oxygen, 2-5 liters per minute (LPM), 2 LPM nasal canula, as needed for shortness of breath. On 8/16/2023, at 3:45 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 2s residence. LVN 1 performed skilled assessment of Patient 2 and medication review. During an observation and interview with LVN 1 on 8/16/2023 at 4:00 p.m., the following medication bottles were observed at Patient 2s residence: Myrbetiq (medication used to treat overactive bladder), 50 mg, tablet, extended release, Take one tablet by mouth daily, date filled 6/11/2023 Doxazosin (medication used to treat urinary problems caused by an enlarged prostate (benign prostatic hyperplasia), 4 mg, tablet, Take one tablet by mouth at bedtime, date filled 05/12/2023 LVN 1 confirmed that Myrbetiq and Doxazosin were not listed on Patient 2s Medication list and that Finasteride, Gabapentin, and oxygen were not in Patient 2s home. During an interview on 8/17/2023 at 2:58 p.m., the Director of Patient Care Services (DPCS) stated that the visiting nurse should check medications every week for quantity, if the medication order and the medication label are correct and ask the patient if there are updates with medications. The DPCS stated that it was important to update the medication profile, so the hospice agency was aware of the current medications the patient was taking. A review of agencys undated policy and procedure titled, ";Medication Profile", indicated that medication profile will be updated for each change to reflect current medications and new and/or discontinued medications. c. A review of Patient 9's clinical record indicated she was admitted to the hospice agency on 6/7/2023, with a terminal diagnosis of heart disease (chronic obstructive pulmonary disease (damage from the brain from interruption of its blood supply). A review of Patient 9s POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 6/7 /2023, indicated skilled nurse (SN) visits once per week. The SN was to assess pain and symptoms management. The SN was to instruct the patient and/or caregiver regarding new medications or treatments, monitor for side effects, to monitor and assess effectiveness of the current and any new medications or treatments. The plan of care (POC) also indicated for the hospice aid to visit two times a week. On 8/15/2023, at 11:45 a.m., a joint home visit was conducted at Patient 9's residence, with the License Vocational Nurse (LVN 1). During the home visit Patient 9 was observed awake, alert, oriented, and ambulatory with cane without any assistance from family members. On 8/15/2023, at 12:10 p.m., during a review of Patient 9s current medications, indicated Oxygen 2-5 liters per minute (LPM- unit of measure) via nasal cannula as needed for mild dyspnea (difficulty breathing). However, there was no Oxygen found at the home visit. A review of Patient 9 's current medication profile indicated Patient 9 was receiving Oxygen 2-5 LPM. During an interview with Patient 9, stated she had never used Oxygen for breathing. A review of the POC indicated no documented evidence that the physician ordered to discontinue this medication. During an interview on 8/17/23, at 1:30 p.m., the Administrator (ADM) stated the visiting nurse needs to review patients current medication and should ask the patient or caregiver when and how they administer the prescribed medications every visit and update changes in the medication profile in the patient's clinical record.

Based on observation, interview, and record review, the hospice failed to ensure a qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operation of the hospice, and failed to ensure the administrator must be a hospice employee and possess education and experience required by the hospice's governing body. The deficient practice has resulted in the Administrator's to not fulfill his duties and responsibilities in accordance with the hospice established policies and procedures, day to day operation of the hospice, and continuous quality and performance improvement that could negatively impact the provision of the highest quality of care to patients certified to receive the hospice benefits. --- Findings: A complaint validation survey conducted was on 8/14/2023 to 8/17/2023. On 8/14/23, at 10 AM, during the entrance conference, the survey team requested the hospice agency's organizational chart, employee files, and other documents including policy and procedure from the administrator to be reviewed. During a concurrent interview with the Administrator stated she had to call someone who has access to send the requested documents to the survey team. However, the Administrator was unable to provide the documents requested. On 8/16/2023, at 12:22 PM, during a concurrent observation and interview with the administrator stated she was the only one who "runs" the hospice agency, and that the Administrator designee has a full-time job elsewhere and was not involved in the day-to-day operation of the hospice agency. It was further observed the Administrator was looking for the hospice regulations online and was unable to locate the correct regulations. The Administrator stated she did not know the guidelines or regulations that govern hospice agencies. During the complaint validation survey conducted from 8/14/2023 to 8/17/2023, the Administrator designee (ADMD) was unable to be reached for an interview. A review of the agencys undated job description titled ";Executive Director/Administrator" indicated that the Executive Director/Administrator is responsible for the overall direction of the day-to-day operations of the hospice services. The job description further indicated they are responsible for establishing standards of care to comply with federal and state regulations and guidelines.

Based on observation, interview, and record review, the hospice agency's medical director failed to coordinate with the patient's attending physicians to review the patient's clinical information to determine certification for eligibility for admission to the hospice program for one of 14 sampled patients (Patients 2).This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months or less to the patient who was not clinically eligible to receive hospice services. --- Findings: A review of Patient 2's Patient Information Sheet indicated a Start of Care (SOC) date on 2/10/2023, with primary diagnosis of heart disease. A review of Patient 2's Plan of Care (POC) dated 8/15/2023, indicated a Licensed Vocational Nurse (LVN) visit once per week for changes in condition and a Registered Nurse (RN) visits every 14 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention. A review of Patient 2s Hospice Referral dated 2/10/2023 written by the hospice Medical Director (MD 1) indicated ";I submit this referral/order for hospice. Please admit if appropriate. Diagnosis: Heart Disease." A review of Patient 2's Physician's Certification of Terminal Illness (CTI), dated 2/10/2023, Certification #1 for first 90 day period indicated the patient was admitted with a diagnosis of heart disease and that the patient Functioning Assessment Staging (FAST, a reliable measure commonly used to assess functional status in patients with dementia) score was 7A (ability to speak is limited to have a dozen intelligible different words or fewer in a course of an average day) and New York Heart Association (NYHA, a simple way to classify stages of heart failure) Class IV (severe symptoms such as fatigue, palpitations (tremors or shivers), chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest; severe limitation of functional status and mostly bed bound). The CTI indicated that the hospice philosophy and services were discussed in detail with the patient caregiver and verbalized understanding. The CTI was signed by the MD 1. The MD 1 signed as the Referring Physician to indicate Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 8/16/2023, at 3:30 pm, a joint home visit with Licensed Vocation Nurse (LVN 1) was conducted at Patient 2s home residence. Patient 2 was alert and oriented, and able to ambulate slowly and independently from the living room to the kitchen (about 10-15 steps). During an interview on 8/16/2023, at 3:45 pm, Patient 2 stated that he was not aware of what hospice meant and was not aware that he had a terminal illness. Patient 2 stated he did not have dementia and did not have heart problems with his heart. Patient 2 stated that when his blood sugar was low, he experienced heart palpitations, sweating, and shaking. During an interview on 8/17/2023, at 11:45 am, FM 2 stated that Patient 2 did not have a terminal illness and that Patient 2s Primary Physician (PP 1) was from GACH 1 and just visited PP 1 about two weeks ago. During an interview on 8/17/2023 at 12:38 pm, Family Member (FM 1) stated that Patient 2 was not enrolled in hospice and that Patient 2 did not have a terminal illness. FM 1 stated that Patient 2 was enrolled with GACH 1 and did not know the hospice Medical Director. A review of the HAs (undated) policy, Admission Criteria and Process, indicated that the HA will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any. The policy indicated that the patients physician (or other authorized independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patients resuscitation status with the patient and family/caregiver.

Based on observation, interview and record review, the hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, assuring continuity of hospice medical services when the medical director was on vacation, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness, and ensuring that competent physician services are routinely available for one of 14 sampled patients (Patient 2). This deficient practice resulted in the hospice medical director and/or the hospice attending physicians not available for medical services for patient continuity of care. --- Findings: a. A review of Patient 2's Patient Information Sheet indicated a Start of Care (SOC) date on 2/10/2023, with primary diagnosis of heart disease. A review of Patient 2's Plan of Care (POC) dated 8/15/2023, indicated a Licensed Vocational Nurse (LVN) visit once per week for changes in condition and a Registered Nurse (RN) visits every 14 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention. A review of Patient 2s Hospice Referral dated 2/10/2023 written by the hospice Medical Director (MD 1) indicated ";I submit this referral/order for hospice. Please admit if appropriate. Diagnosis: Heart Disease." A review of Patient 2's Physician's Certification of Terminal Illness (CTI), dated 2/10/2023, Certification #1 for first 90 day period indicated the patient was admitted with a diagnosis of heart disease and that the patient Functioning Assessment Staging (FAST, a reliable measure commonly used to assess functional status in patients with dementia) score was 7A (ability to speak is limited to have a dozen intelligible different words or fewer in a course of an average day) and New York Heart Association (NYHA, a simple way to classify stages of heart failure) Class IV (severe symptoms such as fatigue, palpitations (tremors or shivers), chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest; severe limitation of functional status and mostly bed bound). The CTI indicated that the hospice philosophy and services were discussed in detail with the patient caregiver and verbalized understanding. The CTI was signed by the MD 1. The MD 1 signed as the Referring Physician to indicate Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. During an interview on 8/16/2023 at 12:00 pm, MD 1 stated that he was on vacation and did not have access to patient records to be able to answer surveyor questions. MD 1 stated he did not remember if he referred Patient 2 for hospice or if Patient 2 was referred by another physician. When asked who the hospice physician designee is while he was on vacation, MD 1 stated that he could not remember the name or phone number of the physician designee and that MD 1 had not yet met him. A review of the hospice agencys policy titled ";Professional Services Agreement for Medical Director," dated 11/2021 indicated the policys purpose is to ensure qualified medical direction and consultation for the delivery of hospice services and programs. The policy further indicated the policys purpose is to demonstrate that the medical director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with attending physician as necessary for appropriate care.

Based on interview, and record review, the hospice agency (HA) failed to ensure the patient's clinical record contained the staff's completed clinical notes submitted in a timely manner for one of 14 sample patients (Patient 5). The deficient practice resulted in patient not having a complete clinical record that could affect the continuity and coordination of care services. --- Findings: A review of Patient 5's Patient Information Sheet indicated a start of care date (SOC) of 6/13/2023 with primary diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 5s Visit Notes dated 8/1/2023, 8/4/2023, and 8/8/2023 indicated the nurses' notes were signed late on 8/16/2023. During an interview on 8/17/2023 at 2:25 p.m., the ADM/DPCS stated, the nurses' notes should be entered and completed in seven days of visit. A review of the Hospice Agencys (undated) policy, ";Contents of Clinical Record," indicated that Staff notes will be submitted within seven days of the clinical visit date with the patient.