Every finding on record at Sierra Hospice Care, Inc.

Observed in Record Review. In 3 of 10 patient records reviewed, Confirmed by the Administrator/DON. The plan of care had not developed measurable goals . Example: During review of HOSrr#4 the integumentary goals had not been updated to include a measurable goal for the skin tears being treated. During review of HOSrr#5 a problem had been documented for loose stools with documented interventions, however a goal had not been documented. It remained blank. Observed in Record Review. During record review HOSRR#2, surveyor found the following: integumentary care plan did not contain measurable goals. Example: The genitourinary goal stated for a stage 2 ulcer that there would be no excoriation or skin breakdown. This was confirmed by Administrator/DON.

Observed in Record Review. In 1 of 10 active patient records reviewed. PRN medication orders had not identified specific indications for use. Example.: HOSv#1 medication orders had duplicate prn medications to include Morphine 5mg po prn for breakthrough pain and Norco 5 mg po prn for breakthrough pain. It had not indicated which to use first. This was confirmed by the Administrator /DON. Observed in Record Review. In 3 of 10 patient records reviewed, Confirmed by the administrator/DON. The plan of care had not been updated to reflect the care being provided. Example: During review of patient HOSv#2 visit notes, it had been identified that the patient suffered two skin tears during care and had treatment being provided to them. During review of HOSrr#4 it had been reviewed that Calmoseptine had been ordered for a hip rash, but the plan of care had not been updated to reflect the treatment to the rash on the hip.

Observed in Individual Tracer. In 2 of 3 Hospice visits observed and confirmed by the Administrator/DON. The infection control plan agency procedures or CDC guidelines had not been implemented. Example: During observation of HOSv#2 the RN had removed his gloves after patient care and preceded to clean his equipment. He had not cleansed his hands after removal of the gloves. During observation of HOSv#3 the HHA had removed her gloves and donned another pair without cleansing her hands.

Observed in HR File Review. In 1 of 2 Director of Nursing records reviewed and confirmed by the Administrator/DON. It had been identified a competence/evaluation/ assessment had not been completed for the responsibilities of the DON. Only an RN competence and evaluation had been completed.

Based on interview, and record review, the hospice agency (HA) failed to ensure all staff members had attended the annual training for emergency and disaster preparedness drills. This failure had the potential for the staff to lack the knowledge to respond effectively during an emergency/disaster situation. --- Findings: During a concurrent interview and record review on 3/3/2023, at 10 am, with the Administrator (ADM)/Director of Patient Care Services (DPCS), the Emergency Preparedness binder was reviewed. There was no documented evidence that all staffs had attended the emergency preparedness training/disaster drill conducted on 5/10/2019, 2/10/20, 3/10/21, and 12/5/22. The ADM/DPCS also stated that not all staffs were able to be trained and unsure why the other staff failed to attend the drill. ADM/DPCS stated that she provided the materials discussed in the emergency preparedness to the staff but there was no documented evidence it was given. ADM/ DPCS stated that it was important for all staffs to be present so they could be aware of what to do during a disaster. A review of the Hospice agency's policy and procedure titled, Emergency Management Plan, dated 12/2017, indicated that the training and testing program is reviewed and updated at least annually and includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement and volunteers if applicable, organization leadership will provide for orientation and annually thereafter of all personnel regarding participation in the emergency management plan.

Based on interview and record review, the hospice agency failed to ensure the hospice licensed nurse performed a comprehensive pain re-assessment for one of 14 sampled patients (Patient 2). This deficient practice placed the patient at a potential risk of ineffective pain management that could lead unrelieved pain and discomfort. --- Findings: A review of Patient 2's clinical records indicated a start of care (SOC) date of 9/15/2022, with diagnoses that included cachexia (weakness and wasting of the body due to severe chronic illness), and dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 2's Plan of Care (POC) order, dated 9/15/2022, included an order for the Skilled nurse (SN) to visit the patient once a week to provide a direct care for the patient, reviewing all the aspects for the patient, and to closely coordinate any notable changes observed for appropriate interventions. A review of Patient 2's POC identified alteration in comfort related to pain developed 9/15/2022. The POC also indicated the patient care goal for the pain level of 4/10 (moderate) or above will be relieved within 30 minutes to 1 hour of intervention. The care plan indicated for the SN to assess pain every visit, to administer pain medication per MD (physician) order, to educate patient/patient caregiver (PCG) for pain management, and to notify MD if interventions are ineffective. The physician ordered Norco oral tablet 5/325 milligram (mg) one tablet by mouth every 6 hours as needed for pain, Ibuprofen oral tablet 600 mg 1 tablet by mouth two times a day as needed for pain and Diclofenac 2% cream/gel apply 2 grams to affected area (right knee) 4 times a day as needed for pain. A review of the "RN- Skilled nursing visit", dated 1/31/2023, indicated Patient 2 experienced right knee pain at a pain level of 3/10 (mild or noticeable) pain. SN applied Diclofenac 2% cream/gel, 2 grams to patients right knee. There was no documentation if the pain was relieved or what the pain level was after the intervention. During an interview with the Director of Patient Care Services (DPCS), on 03/03/2023, at 11:45 a.m., the DPCS stated Patient 2s quantified pain level and effectiveness of the pain interventions should have been assessed. A review of the agency's policy and procedure titled "Pain Assessment", undated, indicated when the patient or the clinician identified pain, the following in-depth pain assessment information will be obtained whenever possible: Pain intensity using a rating scale (on a scale of 0-10; 0=no pain, 10=unbearable pain). The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain.

Based on interview and record review, the hospice agency failed to ensure the patients' comprehensive assessment (describes in detail a patient's medical, physical, and psychosocial condition and needs) was completed within five days after the election of hospice care for two of 14 sampled patients (Patient 2 and Patient 3). The patients' initial psychosocial assessment were not conducted within 5 days from the start of care date. This deficient practice had the potential to cause the patient and family's psychosocial and emotional needs will not be met --- Findings: A review of Patient 2's clinical records indicated a start of care (SOC) date of 9/15/2022, with diagnoses that included cachexia (weakness and wasting of the body due to severe chronic illness), and dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 3's clinical records indicated a SOC date of 12/14/2022, with diagnoses that included Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and hypertension (high blood pressure). During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 03/03/2023, at 11:45 a.m., the DPCS stated an initial psychosocial assessment was conducted on 9/30/2022 for Patient 2, and 12/26/2022 for Patient 3. The DPCS stated that an initial psychosocial assessment should have been done as part of the comprehensive assessment within 5 days from SOC for Patient 2. DPCS stated there was a delay in conducting Patient 2 and Patient 3 initial psychosocial assessment. A review of the hospice agencys policy and procedure titled, ";Comprehensive Assessment" (undated), indicated a comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record. A review of the hospice agencys policy and procedure titled, ";Psychosocial Services" (undated), indicated the purpose of the policy and procedure is to ensure that appropriate psychosocial services are provided to hospice patients and family/caregivers. The social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.

Based on observation, interview, and record review, the Hospice Agency failed to conduct an accurate comprehensive assessment of the skin integrity (skin is damaged, vulnerable to infection, injury or unable to heal normally) and failed to reflect in the clinical record of the Foley catheter care/assessment for one of 14 sampled patients (Patient 9). The deficient practice has the potential to result in the hospice agency's inability to ensure the provision of quality health. --- Findings: A review of Patient 9's clinical record indicated a start of care (SOC) dated 2/8/23, with a terminal diagnosis of end stage Alzheimers disease (The final stage of the disease, which symptoms are severe including lost of ability to respond to the environment, to carry on a conversation and, eventually, to control movement). A review of Patient 9s Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 2/15/23 indicated and order for frequency visit of Skilled Nurse (SN) to once a week, medical social worker (MSW) to once to twice for three months and hospice aide (CHHA) to once a month. It also indicated that SN will monitor for the foley catheter (is a common type of indwelling catheter, it has soft, plastic or rubber tube that is inserted into the bladder to drain the urine) patency every visit, signs/symptoms of infection, foley catheter care/peri care, change of catheter tubing/drainage bags if needed, secure the catheter to facilitate flow of urine during every visit, to provide/educate the patient/caregiver on proper cleaning and care, to observe skin condition every visit, to report to hospice agency of any changes in skin condition and to provide teaching to patients caregiver/facility staff regarding perineal skin care and repositioning every 2 hours. A review of Patient 9s physicians order dated 2/8/23, indicated that patient has a foley catheter that was inserted in the hospital and redness/fragile skin in both heels with orders for Foley catheter care, change foley catheter monthly and apply heel protectors. A review of Patient 9's comprehensive nursing assessment dated 2/8/23 and SN notes dated 2/14/23 and 2/21/23 with no indication of skin assessments of both heels and Foley catheter. During a joint home visit with the Registered Nurse (RN 1) on 3/1/23 at 10:30 am, Patient 9 was comfortably resting on her bed and in no apparent distress. RN 1 performed hand hygiene and started his assessment and took patient 9s vital signs. Patient 9 has no Foley catheter in placed and wears dry incontinence underwear. RN 1 stated that the Foley catheter was removed already. RN 1 stated that he performed catheter care on every visit and checked its patency but for some reason he forgot to document it. During an interview with the Director of Patient Care Services (DPCS) on 3/3/23, at 10:30 am, she was not able to provide the documented evidence that assessment was performed for Patient 9s bilateral heels and presence/condition of Foley catheter on dates of 2/8/23, 2/14/23 and 2/21/23 and stated that SN should perform a complete and thorough skin assessment with the patient on every visit including any devices that are currently use by them. A review of the agencys policy titled ";Client/Patient Care of the Foley Catheter", revised 3/2013, indicated that the skilled nurse will monitor the integrity of the foley catheter of any patient that is being care for by the agency on each visit. A review of the agency's policy titled " Comprehensive Assessment", undated, indicated that all baseline data and other relevant information will be documented in the patient's clinical record including at least a physical assessment, including blood pressure, temperature, pulse, respiration skin, and other relevant data related to pertinent physical findings and the patient's terminal illness. A review of the agency's policy titled "Ongoing Comprehensive Assessment", undated, indicated the nurse will assess the patient on each visit, for vital signs appropriate to the patient's condition.

Based on interview and record review, the hospice agency failed to provide education and training on interventions identified in the Plan of Care (POC) for two of 14 sampled patients (Patients 4 and 9). This failure had the potential to create the risk of not providing appropriate instructions to address the care needs of the patient. --- A review of Patient 9's clinical record indicated a start of care (SOC) dated 2/8/23, with a terminal diagnosis of end stage Alzheimers disease (The final stage of the disease, which symptoms are severe including lost of ability to respond to the environment, to carry on a conversation and, eventually, to control movement). A review of Patient 9s Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 2/15/23 indicated and order for frequency visit of Skilled Nurse (SN) to once a week, medical social worker (MSW) to once to twice for three months and hospice aide (CHHA) to once a month. It also indicated that SN would monitor for the foley catheter (is a common type of indwelling catheter, it has soft, plastic or rubber tube that is inserted into the bladder to drain the urine) patency and wound treatment to stage II pressure sore on sacrum (When a pressure ulcer reaches the second stage, the sore has broken through the top layer of the skin and part of the layer below. This typically results in a shallow, open wound. It may appear as a shallow, crater-like wound or a blister containing a clear or yellow fluid located on a large, flat triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra) on every visit, signs/symptoms of infection, foley catheter care/peri care, change of catheter tubing/drainage bags if needed, secure the catheter to facilitate flow of urine during every visit, to provide/educate the patient/caregiver on proper cleaning and care, to observe skin condition every visit, to report to hospice agency of any changes in skin condition and to provide teaching to patients caregiver/facility staff regarding perineal skin care, wound treatment and repositioning every 2 hours. A review of Patient 9s clinical records indicated no documented evidence that skilled nurse provided teaching/education to patients caregiver/facility staff regarding foley catheter care and wound treatment. During an interview with the Registered Nurse (RN 1), on 3/1/23 at 11:00 am, he stated that he provided teaching and education to facility staff but did not document it in his skilled nursing notes. During an interview with the Director of Patient Care Services (DPCS) on 3/3/23 at 1:00 pm, she stated that the nurses documentation must be accurate so that there will be no miscommunication between staff. She also stated that SN should document if teaching was provided to patient/caregiver/facility staff regarding a particular task to validate that it was done. A review of the hospice agencys policy and procedure titled ";Contents of Clinical Records", undated, indicated that a clinical record will be maintained for each patient receiving care, the clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate the continuity of care among hospice interdisciplinary group members and contract personnel, information will eb available in the clinical record as applicable to care, services and documentation which include educational needs of patient and family/caregiver, patient and family education provided, summary of care/coordination of care provided and progress toward goals/outcomes of care. Findings: a. A review of Patient 4's clinical record indicated he was admitted to the hospice agency on 1/11/2023, with a diagnosis including congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 4's Plan of Care (POC) Order, dated 1/11/2023, included an order for the Skilled nurse (SN) to visit the patient once a week to establish plan of care, continuous review of all aspect of patient and supervisory visit. The POC indicated for the SN would provide the following education and training to Patient 4 and/or to his care giver (PCG) during the home visits: a) educate patient and/or caregiver(s) on oxygen safety and equipment maintenance b) educate patient and/or caregiver(s) on aspiration precautions c) educate on measures to reduce respiratory distress d) instruct patient and/or caregiver(s) on energy conservation techniques During an interview and clinical record review with the director of patient care services (DPCS), on 3/03/2023 at 11:45 a.m., the clinical visit notes from 1/24/2023 to 2/21/2023 were reviewed. The DPCS concurred there were no clinical notes found with documentation of education and training on the above topics provided to Patient 4 and/or his PCG. DPCS stated education and training to patient and/or PCG should be done on every skilled nursing visit and be documented on the patient clinical record. A review of the agency's policy and procedure titled "The Plan of Care", undated, indicated the plan of care will identify the patient's needs and services to meet those needs, including patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching.

Based on interview and record review, the hospice staff failed to ensure the plan of care (POC) includes the frequency of home visit and services provided for two out of 14 sampled patients (Patients 2 and 3). This deficient practice placed the patients at risk of not being cared for by the hospice staff and has the potential to negatively affect the patient's quality of life. --- Findings: a. A review of Patient 2's clinical records indicated a start of care (SOC) date of 9/15/2022, with diagnoses that included cachexia (weakness and wasting of the body due to severe chronic illness), and dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning). A review of the history of Psychosocial Assessment indicated the Social Worker (MSW) visited Patient 2/patient caregiver at least once a month from 9/30/2022 to 2/28/2023. A review of the History of Spiritual Assessment indicated the Spiritual Counselor (SC) visited or called Patient 2/patient caregiver at least once a month from 9/19/2022 to 2/28/2023. A review of Patient 2s initial POC (Plan of Care) order, and IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 9/28/2028, did not indicate the frequency of visits and/or assessment by MSW and SC. Subsequent IDG form from 10/2022 to 02/2023 was reviewed and did not indicate the frequency of visit and/or assessment by MSW and SC. b. A review of Patient 3's clinical records indicated a SOC date of 12/14/2022, with diagnoses that included Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and hypertension (high blood pressure). A review of the history of Psychosocial Assessment indicated the MSW visited Patient 3/patient caregiver at least monthly from the start of care. A review of Patient 3s initial POC order, and IDG form dated 12/21/2022, did not indicate the frequency of visits and/or assessment by MSW. Subsequent IDG forms from 01/2023 to 02/2023 was reviewed and did not indicate the frequency of visit and/or assessment by MSW. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 03/03/2023, at 11:45 a.m., the DPCS was not able to provide the documented evidence that the frequency of visits of MSW and SC services was included in the POC for Patient 2 and Patient 3. The DPCS stated the frequency of visits of all hospice discipline including MSW and SC should have been included in the POC. A review of the agency's policy and procedure titled "The Plan of Care", undated, indicated the plan of care will identify the patient's needs and services to meet those needs. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs.

Based on interview and record review, the hospice agency (HA) failed to provide the Foley catheter care as ordered by the physician for one of 14 sampled patients (Patient 9). This deficient practice placed the patient at a potential risk for urinary infection that could lead to pain and discomfort of the patient. --- Findings: A review of Patient 9's clinical record indicated a start of care (SOC) dated 2/8/23, with a terminal diagnosis of end stage Alzheimers disease (The final stage of the disease, which symptoms are severe including loss of ability to respond to the environment, to carry on a conversation and, eventually, to control movement). A review of Patient 9s Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 2/15/23 indicated and order for frequency visit of Skilled Nurse (SN) to once a week, medical social worker (MSW) to once to twice for three months and hospice aide (CHHA) to once a month. It also indicated that SN will monitor for the Foley catheter (is a common type of indwelling catheter, it has soft, plastic or rubber tube that is inserted into the bladder to drain the urine) patency every visit, signs/symptoms of infection, foley catheter care/peri care, change of catheter tubing/drainage bags if needed, secure the catheter to facilitate flow of urine during every visit, to provide/educate the patient/caregiver on proper cleaning and care, to observe skin condition every visit, to report to hospice agency of any changes in skin condition and to provide teaching to patients caregiver/facility staff regarding perineal skin care and repositioning every 2 hours. A review of Patient 9s physicians order dated 2/8/23, indicated patient has a Foley catheter that was inserted in the hospital and redness/fragile skin in both heels with orders for Foley catheter care, change Foley catheter monthly and apply heel protectors. A review of Patient 9's comprehensive nursing assessment dated 2/8/23 and SN notes dated 2/14/23 and 2/21/23 with no documented evidence of Foley catheter care performed as indicated in the plan of care (POC). During a joint home visit with the Registered Nurse (RN 1) on 3/1/23 at 10:30am, Patient 9 was comfortably resting on her bed and in no apparent distress. RN 1 performed hand hygiene and started his assessment and took Patient 9s vital signs. Patient 9 has no Foley catheter in placed and wears dry incontinence underwear. RN 1 stated that the foley catheter was removed already. RN 1 stated that he performs Foley catheter care on every visit and check its patency but for some reason he forgot to document it. During an interview with the Director of Patient Care Services (DPCS) on 3/3/23, at 10:30 am, she was not able to provide the documented evidence that Foley catheter care was performed on 2/8/23, 2/14/23 and 2/21/23 and stated that SN should document that Foley catheter care was performed on each visit to validate that it was completed. DCPCS also stated that SN must accurately perform an assessment of the Foley catheter to ensure it is free from infection and flows freely without any obstruction. A review of the agencys policy titled ";Client/Patient Care of the Foley Catheter", revised 3/2013, indicated that the skilled nurse will monitor the integrity of the Foley catheter of any patient that is being care for by the agency on each visit. A review of the agencys policy titled ";Contents of Clinical Record", undated, indicated that a clinical record will be maintained for each patient receiving care, will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.

Based on interview and record review, the hospice agency failed to ensure bereavement assessment was updated and the family/caregiver's needs were discussed and documented after the patient's death for one of 4 closed record sampled patients (Patient 7) as indicated in their policy. This deficient practice placed the family at a potential risk for not receiving support and preparation for what to expect after the patients' death. --- Findings: A review of Patient 7's closed clinical record indicated a start of care date (SOC) of 5/17/2022, with diagnoses which included malignant melanoma of skin, unspecified (a type of skin cancer). A review of Patient 7's Discharge Summary indicated hospice services ended on 7/03/2022, due to patient's death. A review of the closed clinical record indicated there was no documented evidence that bereavement assessment was updated, and the family/caregiver's needs were discussed after Patient 7's death. During a concurrent interview and record review of Patient 7s electronic medical record with the Director of Patient Care Services (DPCS), on 3/03/2023 at 11:45 a.m., the DPCS was unable to provide the updated bereavement assessment or the post death bereavement assessment after the patients death. A review of the agency's policy and procedure titled "Bereavement Services", undated, indicated within three to five weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. This assessment will note and observe the bereaved for symptoms related to grief. The bereavement counselor will render a professional judgement as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction.

Based on interview and record review, the hospice agency failed to ensure the contents in the clinical record are accurately documented for one of 14 sampled patients (Patient 9). For Patient 9, the skilled nurse documented stage II pressure ulcer on bilateral heels inconsistent with the documented report of bilateral heel redness to hospice doctor. This deficient practice can prevent communication properly between the agency staff and can prevent facilitating highest quality of care among interdisciplinary group members. --- Findings: A review of Patient 9's clinical record indicated a start of care (SOC) dated 2/8/23, with a terminal diagnosis of end stage Alzheimers disease (The final stage of the disease, which symptoms are severe including loss of ability to respond to the environment, to carry on a conversation and, eventually, to control movement). A review of Patient 9s Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 2/15/23 indicated an order for frequency visit of Skilled Nurse (SN) to once a week, medical social worker (MSW) to once to twice for three months and hospice aide (CHHA) to once a month. It also indicated that SN will monitor for the Foley catheter (is a common type of indwelling catheter, it has soft, plastic or rubber tube that is inserted into the bladder to drain the urine) patency every visit, signs/symptoms of infection, Foley catheter care/peri care, change of catheter tubing/drainage bags if needed, secure the catheter to facilitate flow of urine during every visit, to provide/educate the patient/caregiver on proper cleaning and care, to observe skin condition every visit, to report to hospice agency of any changes in skin condition and to provide teaching to patients caregiver/facility staff regarding perineal skin care and repositioning every 2 hours. A review of Patient 9s physicians order dated 2/8/23, indicated that patient has a Foley catheter that was inserted in the hospital and redness/fragile skin in both heels with orders for Foley catheter care, change Foley catheter monthly and apply heel protectors. A review of Patient 9s clinical record indicated a physicians order dated 2/8/23 identified Patient 9 had some redness and fragile skin in both heels and Hospice doctor has been informed and new order was given to apply heel protector. A review of the Comprehensive Nursing Assessment dated 2/8/23 indicated that Patient 9 has stage II pressure ulcer on the sacrum and bilateral heels on summary/comment section. A review of the Skilled Nursing Visit Notes dated 2/14/23 and 2/21/23 indicated Patient 9 has stage II pressure ulcer on the sacrum and bilateral heels on summary/comment section. The IDG (interdisciplinary Group) meeting dated 2/15/23 indicated Patient 9 has stage II pressure ulcer on the sacrum and bilateral heels on summary/comment section. During a joint home visit with the Registered Nurse (RN 1) on 3/1/23, at 10:30am, Patient 9 was comfortably resting on her bed, in no apparent distress and wore heels protectors. RN 1 performed hand hygiene and started the skin assessment Patient 9 and noted to have a healing stage II pressure sore on sacrum (When a pressure ulcer reaches the second stage, the sore has broken through the top layer of the skin and part of the layer below. This typically results in a shallow, open wound. It may appear as a shallow, crater-like wound or a blister containing a clear or yellow fluid located on a large, flat triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra) and bilateral heels redness. RN 1 performed wound treatment appropriately as ordered by physician and followed infection control measures. During an interview with the Director of Patient Care Services (DPCS) on 3/3/23, at 12:30 pm, she stated that the nurses documentation must be accurate so that there will be no miscommunication between staff. DPCS also stated that it was an error in documentation and that Patient 9 has no pressure wound on both heels but rather it was a redness and dry skin. A review of the hospice agencys policy and procedure titled ";Contents of Clinical Records", undated, indicated that a clinical record will be maintained for each patient receiving care, the clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate the continuity of care among hospice interdisciplinary group members and contract personnel, information will eb available in the clinical record as applicable to care, services and documentation which include educational needs of patient and family/caregiver, patient and family education provided, summary of care/coordination of care provided and progress toward goals/outcomes of care.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of the Patient was met as follows: a. The hospice agency failed to accurately assess the patient's eligibility (the quality or state of being eligible) for hospice services related to the palliation and management of the terminal illness (an illness or condition which cannot be cured and is likely to lead to someone's death) and related conditions for two of six sampled patients (Patients 1 and 3). (Refer to L521) b. The hospice agency skilled nurse failed to assess the pressure ulcer wound (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of six (6) sampled patients (Patient 5). (Refer to L524) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Initial and Comprehensive Assessment of Patients to ensure the highest quality of care is provided to the patients assessed for eligibility to receive hospice care and services. --- 1

Based on observation, interview, and record review, the hospice agency (HA) failed to accurately assess the patient's eligibility (the quality or state of being eligible) for hospice services related to the palliation and management of the terminal illness (an illness or condition which cannot be cured and is likely to lead to someone's death) and related conditions for two of six sampled patients (Patients 1 and 3). This deficient practice had the potential to result in the misuse of the provision of the hospice services benefits that could affect the patients highest practicable mental, physical, and psychosocial well-being and quality of life. --- Findings: a. A review of Patient 1's clinical record indicated a Start of Care (SOC) date of 6/23/22, with a terminal diagnosis of cerebral infarction, unspecified (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area). A review of Patient 1's "Plan of Care (POC) Order" dated 6/23/22, indicated the skilled nurse (SN) was to visit Patient 1, one to two times a week. The chaplain and medical social worker was to visit Patient 1, one to three visits per quarter and the Hospice aide and volunteer was to visit only as needed. A review of Patient 1's Physician ";Written Certification" (form used to document the clinical reason a person is admitted to hospice) dated 6/23/22, indicated the Medical Director documented, the patient (Patient 1) was currently bedbound and relied heavily on assistance with her ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Given the patients current rate of decline and poor state of health, the patients life expectancy was less than six months. A review of Patient 1's RN (Registered Nurse) Initial Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 6/23/22, indicated Patient 1 was alert, oriented to person, forgetful, confused but responsive to verbal and tactile stimuli (warming, drying, and rubbing the back or the soles of the feet). Patient 1 was not in pain, had no shortness of breath, and was able to swallow some solid foods. The RN Assessment also indicated Patient 1 has been reported to have lost 20 pounds in the past four months. The Hospice Agency was not able to provide documented evidence showing Patient 1 had lost 20 pounds in the past 4 months. During a phone interview with Patient 1s family member (FM 1), on 1/18/23 at 2:55 p.m., he stated no physician, nurses, or any clinician told him that Patient 1 has 6 months to live or less. He stated Patient 1 should not have been admitted to hospice and her Attending physician did not make the referral to hospice care. During the complaint validation survey on 1/18/23 at 3:50 p.m., attempts to contact Patient 1s attending physician (Physician 1) by telephone was unsuccessful. During the complaint investigation under the State process, a telephone interview on 8/15/2022 at 12:05 p.m., was conducted with Physician 1, and stated he was Patient 1s attending physician while Patient 1 was admitted at a skilled nursing facility (SNF 1). When asked if he (Physician 1) referred Patient 1 to hospice care, Physician 1 stated he did not. When asked if the hospice Medical Director (MD) discussed Patient 1's medical history and diagnosis with him, Physician 1 stated he did not and did not know the Medical Director. A review of Patient 1's clinical record indicated there was no documented evidence showing Patient 1 had a weight loss greater than 10% in the last 6 months, or greater than 7.5% in the last three months, or was severely disabled, very sick or totally bedbound, and had severe dysphagia (swallowing difficulties). b. A review of Patient 3's clinical record indicated a Start of Care date on 8/5/22, with a primary diagnosis of chronic obstructive pulmonary disease unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Plan of Care (POC) Order" dated 8/5/22, indicated the skilled nurse (SN) was to visit Patient 3 once a week. The chaplain was to visit 1-3 times every quarter, and the volunteer was to visit twice a week. The frequency of visit for both medical social worker (MSW) and hospice aide was left blank. A review of Patient 3's Physician ";Written Certification", dated 8/5/22, indicated the Medical Director documented, patient (Patient 3) was alert, responsive, ambulatory but often prefers to either be seated or remains in bed due to her weakness, has poor appetite, and highly dependent for assistance with all her ADLs. Given the patients current rate of decline and poor state of health, the patients life expectancy is less than six months. A review of Patient 3's RN Initial Assessment, dated 8/5/22, indicated Patient 3 was alert, oriented (to person and place), forgetful, confused, and verbally responsive. Patient 3 was ambulatory but preferred to remain seated or laid in bed, and dependent on assistance with her ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). The RN assessment further indicated Patient 3 was breathing evenly, and signs of SOB (shortness of breath) were noted with moderate exertion. Patient 3s O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood) was 93% on room air (Normal range will be around 95–100%). On 1/18/23, at 11:40 a.m., a home visit was conducted for Patient 3 with the Registered Nurse (RN 1) at the patients residence (ALF 1). Patient 3 was observed lying in bed sleeping, not on oxygen, and not showing any signs and symptoms of pulmonary disease. During a concurrent interview with the patients caregiver (PCG 1), PCG 1 stated she helped Patient 1 walk during the day and Patient 1 would only have intermittent shortness of breath. PCG 1 stated when patient 1 is in bed or in chair, she does not have any shortness of breath. On 1/18/23, at 3:30 p.m., during a phone interview with Patient 3 family member (FM 2), she stated Patient 3 walked regularly using a walker with assistance and she had not seen her having shortness of breath. FM 2 stated she was not aware that Patient 3 was placed in hospice care. On 1/18/223, at 4:10 p.m., during a phone interview with Patient 3s Attending Physician (Physician 2), he stated he did not refer Patient 3 to hospice care and did not have any discussion about Patient 3's medical diagnosis with the HA Medical Director. A review of Patient 3's clinical record indicated there was no documented evidence Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, and/or had O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) of 88% or less. On 1/19/23 at 11:00 a.m., during a phone interview with the Medical Director (MD), he stated he certified Patients 1 and 3 had terminal illness and admitted both to hospice care by reviewing each patients medical history, prior medical record, and the registered nurse initial assessment. When asked if he (MD) was the attending physician of Patient 1 and 3, the MD stated he was not. When asked if he (MD) contacted Patient 1 and Patient 3s attending physician for any patient records, or to discuss the patient's diagnosis or eligibility for hospice, the MD stated he did not. On 1/19/23 at 1:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS could not provide supporting evidence, such as labs, records and/or referral from the primary physician, diagnostic results that the MD stated he reviewed for Patient 1 and Patient 3. A review of the hospice agencys (undated) policy and procedure titled, ";Admission Criteria and Process" , indicated the purpose of the policy is to establish standards and a process by which a patient can be evaluated and accepted for admission. the facility will admit any patient with a life-limiting illness that meets the admission criteria. The patient must meet the eligibility criteria for Medicare, Medicaid, or private insurance hospice benefit reimbursement.

Based on interview and record review, the hospice agency skilled nurse failed to assess the pressure wound (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of six sampled patients (Patient 5). This deficient practice resulted in the inability to ensure the provision of quality health for patients and did not promote the wellbeing, comfort, and dignity of the patients. --- A review of Patient 5's electronic clinical record indicated a Start of Hospice care date of 5/9/22, with a terminal diagnosis of malignant neoplasm of the colon (Cancer that forms in the tissues of the colon (the longest part of the large intestine). A review of Patient 5s physicians order dated 6/13/22, indicated to cleanse the pressure wound on Patient 5's gluteal area (are a grouping of muscles that make up the buttock area) with normal saline 0.9%, pat to dry, then apply the wound compound cream once daily and as needed for soiled dressing until healed for skin management. A review of Patient 5s skilled nurse (SN) visits notes dated 6/7/22, 6/14/22, 6/21/22, 6/22/22 and 6/28/22 did not note an assessment of Patient 5's wound, skin impairment or skin issues located on Patient 5s gluteal area. A review of Patient 5s Plan of Care/Interdisciplinary Group Meeting (POC/IDG) dated 6/8/22, indicated the SN assessed Patient 5's skin was generally intact, with no signs of any cuts or injuries noted. The intervention indicated the SN would observe Patient 5's skin every visit, staff to report to hospice nurse any changes in patient's skin and signs and symptoms of infection and the facility staff to was change Patient 5's diaper and provide perineal/skin care upon diaper change. On 1/18/23 at 10:00 am, a joint home visit was conducted with Registered Nurse (RN 1) at Patient 5s Assisted Living Facility (ALF) assigned room. Patient 5 was lying on her bed resting, awake but confused at times. RN1 performed hand hygiene then proceeded to check Patient 5s vital signs and performed a head-to-toe assessment and found no pressure wounds or skin problems. During interview with RN 1, he stated he assessed Patient 5s skin on each of his visits. RN 1 stated he is aware of Patient 5s pressure wound on the gluteal area, but it was already healed for a long time. RN1 stated during the time he saw the wound on Patient 5s gluteal area, he immediately notified the office and the Medical Doctor. RN 1 stated he did not document it since he already informed the MD, he stated he should have documented the wound, so it was closely monitored. On 1/19/23, at 10:30 a.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence that Patient 5s pressure wound on the gluteal area was identified or discussed during IDG meetings. The DPCS stated the SN should have documented the pressure wound for proper staging with measurements, appearance, and odor to provide a proper treatment. A review of the agency's policy and procedure titled, "Ongoing Assessments", indicated the purpose of the policy is to provide guidelines for assessments of patients during ongoing care and to ensure the nurse will assess each patient on each visit which includes skin integrity.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as evidenced by: 1. The hospice agency failed to ensure an individualized plan of care for risk of falls, the patient's use of Eliquis (an anticoagulant [blood thinner] medication but can cause serious bleeding), and a wound care ordered by the physician that included problems, interventions and goals were developed for two of six sampled patients (Patients 2 and 5). (Refer to L545) 2 The hospice agency skilled nurse (SN) failed to provide a wound care treatment as ordered by the physician for one of six sampled patients (Patient 5). (Refer to L549) 3. The hospice agency failed to ensure services were provided in accordance with the Plan of Care (POC), for three of six sampled patients (Patient 1,2 and 3). The hospice agency skilled nurses (SN) failed to assess the patients for oral intake during SN visit. (Refer to L555) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services. --- .

Based on observation, interview, and record review, the hospice agency (HA) failed to develop a comprehensive, patient-centered care plan for two of six sampled patients (Patient 2 and 5). a. For Patient 2, the HA did not develop an individualized plan of care for risk of falls and for Patient 2's use of Eliquis (an anticoagulant [blood thinner] medication but can cause serious bleeding). b. For Patient 5, the HA did not develop a plan of care for wound care ordered by the physician that included problems, interventions and goals. These deficient practices had the potential to result in the patients to not have patient-centered interventions to address the patients specific needs, potentially resulting in a decline in emotional, physical, psychosocial well-being, and quality of life. --- b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 5/9/22, with a terminal diagnosis of malignant neoplasm of colon (Cancer that forms in the tissues of the colon (the longest part of the large intestine). A review of Patient 5s Plan of Care (POC) Order, dated 6/8/22, indicated an order for the skilled nurse (SN) frequency of visit of once a week. A review of Patient 5s physicians order dated 6/13/22, indicated a skin treatment order on wound pressure on gluteal area (are a grouping of muscles that make up the buttock area) to cleanse with normal saline 0.9%, pat to dry then apply wound compound cream once daily and as needed for soiled dressing until healing for skin management. A review of Patient 5's clinical record indicated there was no documented evidence the HA developed a plan of care for pressure wound on gluteal area. On 1/19/23, at 1:30 p.m., during an interview with the DPCS, she stated she could not provide plans for Patient 5s wound care. She stated the HA should have develop care plans immediately after the discovery or assessment of patients wound so it could be address and treat appropriately and in timely manner. A review of the agencys policy and procedure titled, "Interdisciplinary Group Plan of Care", undated, indicated a comprehensive patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan. The plan of care will be based on comprehensive assessments by members of the interdisciplinary group and will be reviewed on a regular basis. The plan will focus on identified problems, goals, and interventions. Findings: a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 5/12/22, with a terminal diagnosis of cachexia (weakness and wasting of the body due to severe chronic illness). A review of Patient 2s Plan of Care (POC) Order, dated 5/12/22, indicated an order for the skilled nurse (SN) frequency of visit of once a week, medical social worker (MSW) and hospice aide 1 to 3 visits every quarter. The POC order indicated a physician order to provide Eliquis oral tablet 2.5 milligrams (mg) 1 tablet by mouth twice a day indicated for CVA (cerebrovascular accident, a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain) prophylaxis. A review of Patient 2's Registered Nurse (RN) Initial Assessment, dated 5/12/22, indicated Patient 2 was alert, oriented to person and place, forgetful and lethargic. Patient 2 was highly dependent for assistance with all her ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), and at high risk for falls due to her noticeable weakness. A review of Patient 2's Fall Assessment, dated 5/12/22, indicated Patient 2 had a total score of 5 (a score of 4 or greater is considered at risk for falling). On 1/18/23, at 11:10 a.m., a home visit was conducted at Patient 2's residence (ALF 1). Patient 2 was observed lying in a hospital bed with two upper siderails up, alert, confused, and lethargic. During a concurrent interview with the registered nurse (RN 1), he stated Patient 2 was bedbound, total assist with all her ADLs, and at risk for falling. A review of Patient 2's clinical record indicated there was no documented evidence the HA developed a plan of care for patients risk of falling and used of Eliquis medication. On 1/19/23, at 1:00 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated she could not locate care plans for fall risk and the use of Eliquis medication for Patient 2. DPCS stated the HA should have develop care plans on admission for fall risk patient to provide interventions for fall prevention, and to establish goals for the use of Eliquis and implement interventions in the event the patient experience unusual bleeding, a side-effect of the medication.

Based on interview and record review, the hospice agency (HA) failed to provide a wound care treatment as ordered by the physician for one of six patients (Patient 5). For Patient 5, the patient had an open pressure wound (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the gluteal area (gluteal area (are a grouping of muscles that make up the buttock area) but the visiting nurse failed to perform wound treatment documentation on each visits. This deficient practice placed the patient at a potential risk for delayed wound healing, a decline in the condition of the wound, and possible risk for wound infection. --- A review of Patient 5's electronic clinical record indicated a Start of Hospice Care date of 5/9/22, with a terminal diagnosis of malignant neoplasm of colon (Cancer that forms in the tissues of the colon (the longest part of the large intestine). A review of Patient 5s physicians order dated 6/13/22, indicated a skin treatment order to cleanse Patient 5's gluteal (a grouping of muscles that make up the buttock area) pressure wound with normal saline 0.9%, pat to dry, then apply wound compound cream once daily and as needed for soiled dressing until healed for skin management. A review of Patient 5s clinical records indicated no documented evidence that wound treatments and patient/caregiver education were done. On 1/18/23 at 10:00 am, a joint home visit conducted with Registered Nurse (RN 1) at Patient 5s Assisted Living Facility assigned room. Patient 5 was lying on her bed resting, awake but confused at times. RN1 performed hand hygiene then proceeded to check Patient 5s vital signs and performed a head-to-toe assessment and found no pressure wounds or skin problems. During an interview with RN 1, he stated he assessed and performed a wound treatment on Patient 5s skin on each of his visits. RN 1 stated that he is aware of Patient 5s wound pressure on the gluteal area, but it was already healed for a long time. RN1 stated he also provided teaching on how to perform wound care treatment to Patient 5s facility staff caregiver since he only sees the patient once a week and as needed. RN 1 stated he did not document since the treatment was mostly done by the caregiver. RN1 stated he should document the wound care treatment and teaching so it could validate that it was done. On 1/19/23, at 10:30 a.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence that Patient 5s wound pressure on the gluteal area was treated as ordered by the physician. DPCS stated the SN should have documented the pressure wound treatment and the caregiver education to validate that it was done and for proper tracking of wound healing process. A review of the hospice agencys undated policy and procedure titled ";Contents of Clinical Records", indicated that a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate the continuity of care among hospice interdisciplinary group members and contract personnel. Information will be available in the clinical record as applicable to care, services and documentation which includes educational needs of patient and family/caregiver, patient and family education provided, summary of care/coordination of care provided and progress toward goals/outcomes of care.

Based on interview and record review, the hospice agency (HA) Skilled Nurse (SN) failed to follow the written plan of care to assess the oral intake during the nurse visit for for three of six sampled patients (Patient 1, 2 and 3). This deficient practice had the potential to result in poor meal intake and undetected weight loss. --- Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 6/23/22, with a terminal diagnosis of cerebral infarction, unspecified (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area). A review of Patient 1s Physician Initial Admit Order, dated 6/23/22, indicated an order for the SN frequency of visit of once a week. A review of Patient 1s Plan of Care (POC) Order, for the benefit period starting from 6/23/22 to 9/20/22, indicated a POC of Alteration in nutritional status due to terminal illness, unintentional weight loss manifested by poor appetite, decreased oral intake, and cachexia (a general state of ill health involving marked weight loss and muscle loss). The goal was for the patient will experience no discomfort during the expected unintentional weight loss. One of the interventions was for the SN to assess patient for oral intake on every visit. A review of Patient 1s Skilled Nursing Visit, dated 6/28/22 and 7/05/22, indicated no documentation that Patient 1s oral intake was assessed and/or recorded. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 5/12/22, with a terminal diagnosis of cachexia (a general state of ill health involving marked weight loss and muscle loss). A review of Patient 2's "Plan of Care (POC) Order" dated 5/12/22, indicated the SN visit was once a week, the chaplain and medical social worker (MSW) visit was 1-3 visit every quarter. A review of Patient 2s IDG Meeting, dated 11/23/22, indicated a POC of Alteration in nutritional status due to terminal illness, unintentional weight loss manifested by poor appetite, decreased oral intake, and cachexia. The goal was for the patient will experience no discomfort during the expected unintentional weight loss. One of the interventions was for the SN to assess patient for oral intake on every visit. A review of Patient 2s Skilled Nursing Visit, dated 12/06/22, 12/13/22, 12/20/22, 12/29/22 and 1/10/23, indicated no documentation that Patient 2s oral intake was assessed and/or recorded. c. A review of Patient 3's clinical record indicated start of care date on 8/05/22, with primary diagnosis of chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Plan of Care (POC) Order" dated 8/05/22, indicated the skilled nurse (SN) visit was once a week, the chaplain visit was 1-3 visit every quarter, and volunteer twice a week. A review of Patient 3s IDG (Interdisciplinary Group) Meeting, dated 12/07/22, indicated a POC of Alteration in nutritional status due to terminal illness, unintentional weight loss manifested by poor appetite, decreased oral intake, and cachexia. The goal was for the patient will experience no discomfort during the expected unintentional weight loss. One of the interventions was for the SN to assess patient for oral intake on every visit. A review of Patient 3s Skilled Nursing Visit, dated 12/13/22, 12/20/22, 12/29/22, 1/03/23 and 1/10/23, indicated no documentation that Patient 3s oral intake was assessed and/or recorded. On 1/19/23, at 1:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS cannot provide any documented evidence that meal intake was recorded for Patient 1, 2 and 3 during SN visit. DPCS stated SN should have assessed and documented patients meal intake on the skilled nurse visit form on every visit. A review of the hospice agencys policy and procedure titled, "The Initial Plan of Care" (undated), indicated the initial plan of care will be developed by the case manager or admitting registered nurse at the time of the initial visit. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Core Services was met as evidenced by: a. The hospice agency (HA) failed to maintain accurate records for the receipt and disposition of all controlled drugs for one out of six sampled patients (Patient 3). (Refer to L591) b. The HA failed to ensure medical social services (MSW) was provided, for four of six sampled patients (Patient 3, 4, 5, and 6). (Refer to L594) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Federal regulations for Core Services to ensure the highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on observation, interview and record review, the hospice agency (HA) failed to maintain accurate records for the receipt and disposition of all controlled drugs for one of six patients (Patient 3). The HA registered nurse failed to record the date and amount of medication administered on the narcotic sheet. This deficient practice had a potential to result in poor outcomes for the patient, and liability issues for the agency. --- Findings: A review of Patient 3's clinical record indicated a Start of Care date (SOC) on 8/5/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD), unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Plan of Care (POC) Order" dated 8/5/22, indicated the skilled nurse (SN) was to visit once a week. The chaplain was to visit one to three times every quarter, and the volunteer twice a week. There was a physician's order to administer Alprazolam oral tablet 0.5 milligram (mg),one tablet by mouth two times a day for anxiety. A review of a physicians order, dated 9/29/22, indicated to start Ambien oral tablet 10 mg, one capsule by mouth once at bedtime for insomnia (persistent problems falling and staying asleep). On 1/18/23, at 11:40 a.m., a home visit was conducted at Patient 3's residence. Patient 3 was observed lying in bed sleeping. On 1/18/23, at 12:10 p.m., during an observation and a concurrent medication reconciliation with the registered nurse (RN 1), he showed the bottles of medications and medication bubble packs the patient was currently taking. There was an Ambien 10 mg bubble pack x 2 packs. The first Ambien bubble pack medication had a label stating there were 30 tablets with a filled date of 12/16/22. A total of 30 tablets were dispensed from the bubble pack and there were 0 tablets remaining. The second Ambien bubble pack had a label stating there were 30 tablets with a filled date of 1/16/23. There were 30 tablets remaining, and 0 tablet was dispensed. A review of Patient 3's Ambien 10 mg Controlled Medication Record sheet indicated no such record existed. There was an Alprazolam 0.5 mg tablet bubble pack medication with a label stating there were 30 tablets with a filled date of 1/16/23. A total of 0 tablet was dispensed from the bubble pack and there were 30 tablets remaining in the bubble pack. A review of Patient 3's Alprazolam 0.5 mg medication Controlled Medication Record sheet indicated no record existed. On 1/18/23, at 12:15 p.m., during an interview with RN 1, he stated Patient 3 was taking Ambien 10 mg tablet every night and Alprazolam 0.5 mg tablet twice a day. RN 1 stated the HA does not have a Controlled Medication Record sheet and he does not reconcile controlled medication on every patient visit. On 1/19/23, at 1:00 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated that the skilled nurse should always document administered narcotic medications in the narcotic sheet. The DPCS was not able to provide documented evidence that Patient 3 had a narcotic count sheet in the clinical record. A review of the agency's undated policy and procedure titled, ";Home Use and Disposal Of Controlled Substances" indicated controlled drugs will be accounted for on a narcotic count record, which will be maintained as a part of the clinical record.

Based on interview and record review, the hospice agency (HA) failed to ensure medical social services was provided, for four of six patients reviewed (Patients 3, 4, 5, and 6). This failure had the potential for Patients 3, 4, 5, and 6, to not receive information regarding supportive services for terminal illness, the dying process, and community resources. --- b. A review of Patient 4's clinical record indicated start of care date on 5/23/22, with primary diagnosis of chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 4's "Plan of Care (POC) Order" dated 5/23/22, indicated the skilled nurse (SN) visit was once a week, the chaplain, hospice aid, volunteer and medical social worker (MSW) services were refused by Patient 4 and her family. A review of Patient 4s clinical record indicated there was no documented evidence MSW conducted an initial encounter or visit with the patient and/or the patients family/caregiver. c. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 5/9/22, with a terminal diagnosis of malignant neoplasm of colon (Cancer that forms in the tissues of the colon (the longest part of the large intestine). A review of Patient 5s Plan of Care (POC) Order, dated 6/8/22, indicated an order for the skilled nurse (SN) frequency of visit of once a week, the chaplain, hospice aid, volunteer and medical social worker (MSW) services were refused by Patient 5 and her family. A review of Patient 5s clinical record indicated there was no documented evidence MSW conducted an initial encounter or visit with the patient and/or the patients family/caregiver. d. A review of Patient 6's electronic clinical record indicated a start of hospice care date of 1/3/23, with a terminal diagnosis of Cachexia (Loss of body weight and muscle mass, and weakness that may occur in patients with terminal, or other chronic diseases). A review of Patient 6's "Plan of Care (POC) Order" dated 1/3/23, indicated the skilled nurse (SN) visit was once a week, the chaplain, hospice aid, volunteer and medical social worker (MSW) services were refused by Patient 6 and her family. A review of Patient 6s clinical record indicated there was no documented evidence MSW conducted an initial encounter or visit with the patient and/or the patients family/caregiver. On 1/19/23, at 12:00 p.m., during a concurrent interview and record review with the DPCS (Director of Patient Care Services), she stated during the initial SN assessment of patient 4,5 and 6, the patients and their respective families refused MSW visit but MSW still needs to have an initial assessment in the patients clinical record of the services that was offered and the reason for refusal. DPCS acknowledged there was no MSW assessment in the patients clinical record. At 12:30 p.m., during an interview with the MSW, he stated that if patients refused the service, he took it as their final answer, he stated he does not offer it again, stated the patients or their families need to contact the agency if they change their mind. MSW stated that if patients wish to have MSW services, the patients or family members need to initiate, or they can tell the visiting nurse so it can be arranged. MSW stated that he does not document when patients refused his service. MSW stated he agreed that it must be documented so it proved that he tried to contact patient, explain the nature of his services and if patient refused. A review of the hospice agencys medical social worker job description, undated, indicated that the medical social worker, contracted or employed through the organization is responsible for the implementation of standards of care for medical social work services and for adherence to all conditions in the service agreement. The essential job functions/responsibilities which include to maintain clinical records on all patients referred to social work. A review of the hospice agencys policy and procedure titled ";Contents of Clinical Records", undated, indicated that a clinical record will be maintained for each patient receiving care, the clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate the continuity of care among hospice interdisciplinary group members and contract personnel. Findings: a. A review of Patient 3's clinical record indicated start of care date on 8/05/22, with primary diagnosis of chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Plan of Care (POC) Order" dated 8/05/22, indicated the skilled nurse (SN) visit was once a week, the chaplain visit was 1-3 visit every quarter, and volunteer twice a week. The frequency of visit for both medical social worker (MSW) and hospice aide was left blank. A review of Patient 3s clinical record indicated there was no documented evidence MSW conducted an initial encounter or visit with the patient and/or with the patients family/caregiver. On 1/19/23, at 1:00 p.m., during a concurrent interview and record review with the DPCS (Director of Patient Care Services), she stated during the initial SN assessment of patient, the patient refused MSW visit but MSW still needs to have an initial assessment in the patients clinical record of the services that was offered and the reason for refusal. DPCS acknowledged there was no MSW assessment in the patients clinical record.

Based on observation, interview, and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The hospice agency failed to ensure the medical director had responsibility for the medical component of the hospice patients care program, including initial certification of terminal illness for two of six sampled patients (Patients 1 and 3). (Refer to L667) 2. The hospice agency failed to ensure the medical director conducted a review and verified the patients clinical information to determine the patient needs of recertification of terminal illness for continued hospice care and services for one of six sampled patients (Patient 3). (Refer to L668) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Medical Director services to ensure the highest quality of patient care is provided to the patients certified to receive hospice services. --- .

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the hospices Medical Director provided accurate initial certification of terminal illness to validate the diagnoses and life limited prognoses for two out of six sampled patients (Patient 1 and 3). For the initial certification of terminal illness for Patient 1 and 3, there was no supportive evidence, and no attending physician signatures to support the diagnoses of terminal illnesses. This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice services. --- Findings: a. A review of Patient 1's clinical record indicated a Start of Care (SOC) date of 6/23/22, with a terminal diagnosis of cerebral infarction, unspecified (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area). A review of Patient 1's "Plan of Care (POC) Order" dated 6/23/22, indicated the skilled nurse (SN) was to visit one to two times a week, the chaplain and medical social worker was to visit one to three times per quarter. The Hospice aide and volunteer was to visit only as needed. A review of the Physician's ";Written Certification" (form used to document the clinical reason a person is admitted to hospice) dated 6/23/22, indicated the Medical Director documented, Patient 1 was currently bedbound and relied heavily on assistance with her ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Given the patients current rate of decline and poor state of health, Patient 1's life expectancy was less than six months. During a telephone interview with Patient 1s family member (FM 1), on 1/18/23 at 2:55 p.m., he stated the physician, nurses, nor any clinician told him that Patient 1 had six months to live or less. He stated Patient 1 should not have been admitted to hospice and her attending physician did not make the referral to hospice care. During the complaint validation survey on 1/18/23 at 3:50 p.m., Patient 1s attending physician (Physician 1) was contacted by telephone and was unsuccessful. During a telephone interview on 8/15/2022 at 12:05 p.m., Physician 1 stated he was Patient 1s attending physician while Patient 1 was admitted at a skilled nursing facility (SNF 1). When asked if he (Physician 1) referred Patient 1 to hospice care, Physician 1 stated he did not. When asked if the hospice Medical Director (MD) discussed Patient 1's medical history and diagnosis with him, Physician 1 stated he did not and did not know the Medical Director. A review of Patient 1's clinical record indicated there was no documented evidence Patient 1 had a weight loss greater than 10% in the last six months or greater than 7.5% in the last 3 months, was severely disabled, very sick or totally bedbound, and had severe dysphagia (swallowing difficulties). b. A review of Patient 3's clinical record indicated a Start of Care date of 8/5/22, with a primary diagnosis of chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Plan of Care (POC) Order" dated 8/5/22, indicated the skilled nurse (SN) was to visit once a week. The chaplain visit was to visit one to three times every quarter, and the volunteer was to visit twice a week. The frequency of visit for both medical social worker (MSW) and the hospice aide was left blank. A review of Physician ";Written Certification", dated 8/5/22, indicated the Medical Director documented, that Patient 3 was alert, responsive, ambulatory but often prefers to either be seated or remains in bed due to her weakness, has poor appetite, and highly dependent on assistance with all her ADLs. Given the patients current rate of decline and poor state of health, Patient 3's life expectancy is less than six months. On 1/18/23, at 11:40 a.m., a home visit was conducted for Patient 3 with the Registered Nurse (RN 1) at the patients residence (ALF 1). Patient 3 was observed lying in bed sleeping, not on oxygen, and not showing any signs and symptoms of pulmonary disease. During a concurrent interview with the patients caregiver (PCG 1), PCG 1 stated she helped the patient walked during the day and will only have intermittent shortness of breath. PCG 1 stated when patient is in bed or in chair, she does not have any shortness of breath. On 1/18/23, at 3:30 p.m., during a telephone interview with Patient 3 family member (FM 2), she stated Patient 3 walked regularly using a walker with assistance and has not seen her having shortness of breath. FM 2 stated she was not aware that Patient 3 was placed in hospice care. On 1/18/223, at 4:10 p.m., during a telephone interview with Patient 3s Attending Physician (Physician 2), he stated he did not refer Patient 3 to hospice care and did not have any discussion about Patient 3 medical diagnosis with the HA Medical Director. A review of Patient 3's clinical record indicated there was no documented evidence Patient 3 had a disabling dyspnea (shortness of breath) at rest, was poorly responsive or unresponsive to bronchodilators, and/or had O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) of 88% or less. On 1/19/23 at 11:00 a.m., during a telephone interview with the Medical Director (MD), he stated he certified Patients 1 and 3 had terminal illness and admitted to hospice care by reviewing patients medical history/prior records, patients diagnosis, and the registered nurse initial assessment. When asked if he (MD) was the attending physician of Patient 1 and 3, the MD stated he was not. When asked if he (MD) contacted Patient 1 and Patient 3s attending physician for any patient records, or to discuss the patient's diagnosis or eligibility for hospice, the MD stated he did not. On 1/19/23 at 1:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS could not provide supporting evidence, such as labs, records and or referral from the primary physician, diagnostic results that the MD stated he reviewed for the sample patients. A review of the hospice agencys policy and procedure titled, "Certification of Terminal Illness" (undated), indicated "at the time a patient and family/caregiver choose hospice care, the hospice Medical Director and the patients attending physician will certify the patients terminal illness and program of hospice care. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less to live by the attending physician and the hospice Medical Director." A review of the hospice agencys policy and procedure titled, ";Admission Criteria and Process" (undated), indicated the purpose of the policy is to establish standards and a process by which a patient can be evaluated and accepted for admission. Sierra Hospice Care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patient must meet the eligibility criteria for Medicare, Medicaid, or private insurance hospice benefit reimbursement.

Based on observation, interview and record review, the hospice agency failed to ensure the hospice services were provided by a physician who reviewed the patient's clinical information prior to approving another 60 days of hospice service to obtain justification for continuing hospice services for one out of six sampled patients (Patient 3). This deficient practice resulted in providing hospice care to a patient who did not meet readmission criteria and did not qualify for the Medicare hospice benefit. --- Findings: A review of Patient 3's clinical record indicated a Start of Care date of 8/5/22, with a primary diagnosis of chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's Registered Nurse (RN) Recertification assessment, dated 11/1/22, indicated Patient 3 was alert, oriented (to person and place), forgetful, confused, and verbally responsive. Patient 3 was ambulatory but preferred to sit or lay in bed, and was dependent on assistance with her ADLs (activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Patient 3 was breathing evenly, and had signs of SOB (shortness of breath) with moderate exertion. Patient 3s O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) was 97% on room air. A review of the Physician's Written Recertification, dated 11/01/22, indicated the Medical Director certified Patient 3 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The Medical Director documented Patient 3 was alert, responsive, and relied heavily on assistance with almost all her ADLs. Given the patients current rate of decline and poor state of health, patients life expectancy is less than six months and will be recertified for comfort care and symptom management. A review of Patient 3's IDG (Interdisciplinary Group) Meeting, dated 11/9/22, indicated the skilled nurse (SN) was to visit once a week. The chaplain was to visit one to three times every quarter, and volunteer twice a week. The frequency of visit for both medical social worker (MSW) and hospice aide was left blank. On 1/18/23, at 11:40 a.m., a home visit was conducted for Patient 3 with Registered Nurse (RN 1) at Patient 3's residence (ALF 1). Patient 3 was observed lying in bed sleeping, with no oxygen, and not showing any signs and symptoms of pulmonary disease. During a concurrent interview with the patients caregiver (PCG 1), PCG 1 stated she helped the patient walk during the day and will only have intermittent shortness of breath. PCG 1 stated when Patient 1 is in bed or sitting in a chair, she does not have any shortness of breath. On 1/18/23, at 3:30 p.m., during a phone interview with Patient 3's family member (FM 2), she stated Patient 3 walked regularly using a walker with assistance and had not seen her having shortness of breath. FM 2 stated she was not aware that Patient 3 was placed in hospice care. A review of Patient 3's clinical record indicated there was no documented evidence Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and/or had O2 saturation of 88% or less. On 1/19/23 at 11:00 a.m., during a telephone interview with the Medical Director (MD), he stated he certified Patient 3 had terminal illness and admitted to hospice care by reviewing patients medical history and prior records, patients diagnosis, and the registered nurse reassessment. When asked if the (MD) contacted Patient 3s attending physician for any patient records, or to discuss the patient's diagnosis or eligibility for hospice, the MD stated he did not. On 1/19/23, at 1:00 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated she was not able to find the documented evidence Patient 3 was poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity, had a disabling dyspnea at rest, or had an oxygen saturation 88% or less. A review of the hospice agencys (undated), policy and procedure titled, ";Admission Criteria and Process" indicated the purpose of the policy is to establish standards and a process by which a patient can be evaluated and accepted for admission. Sierra Hospice Care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patient must meet the eligibility criteria for Medicare, Medicaid, or private insurance hospice benefit reimbursement. Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care. A review of the agency's undated policy and procedure titled "Physician Services - Medical Director", indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to, overall responsibility for the medical component of hospice patient care program and reviewing patients medical eligibility for hospice services in accordance with hospice program policies and procedures and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness.

Based on interview and record review, the hospice agency (HA) failed to ensure one of six sampled patients (Patient 6) that was discharged from the hospice agency had a discharge summary that included a summary of the patients stay, treatments, symptoms, current plan of care, pain management and any other documents. This deficient practice had the potential to result in a lack of providing continuity of care after the patient was discharged. --- A review of Patient 6's electronic clinical record indicated a start of hospice care date of 11/21/22 (3rd benefit period), with a terminal diagnosis of cachexia (loss of body weight and muscle mass, and weakness that may occur in patients with terminal, or other chronic diseases). A review of Patient 6's "Plan of Care (POC) Order" dated 11/21/22, indicated the skilled nurse (SN) was to visit once a week. The chaplain, hospice aid, volunteer and medical social worker (MSW) services were refused by Patient 6 and her family. A review of Patient 6's "Initial orders and Plan of Care" dated 11/21/22, indicated the skilled nurse (SN) visit frequency for Patient 6 was once a week for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/care plan/intervention in collaboration with interdisciplinary team (IDT). A review of Patient 6s clinical records indicated a physicians order dated 12/5/22 , to discharge Patient 6 from hospice services as of 12/5/22 for aggressive treatment per familys request. On 1/19/23, at 1:30 p.m., during a concurrent interview and record review with the DPCS (Director of Patient Care Services), there was no documented discharge summary in Patient 6s clinical record. DPCS stated that she was not aware that discharge summary was not completed yet and it should be completed at least 72 hours from the time the patient was discharge from hospice services. DPCS acknowledged there was no discharge summary in the patients clinical record. A review of the hospice agency's undated policy and procedure titled ";Discharge Summary", stipulates that all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued and the discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from the service.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate record of the receipt and disposition of all controlled drugs for one of six patients (Patient 3). The HA registered nurse failed to record the date and amount of medication administered on the narcotic sheet. This deficient practice had the potential to result in risk that the accuracy and accountability of the controlled drugs will not be maintained and monitored which could result in unauthorized use of these drugs by the hospice staff and other healthcare personnel. --- Findings: A review of Patient 3's clinical record indicated a Start of Care date (SOC) of 8/5/22, with a primary diagnosis of chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Plan of Care (POC) Order" dated 8/5/22, indicated the skilled nurse (SN) was to visit Patient 3 once a week. The chaplain was to visit one to three times every quarter, and the volunteer was to visit twice a week. There was a physician's order to administer Alprazolam oral tablet 0.5 milligram (mg), one tablet by mouth two times a day indicated for anxiety. A review of Patient 3's physicians order, dated 9/29/22, indicated to start Ambien oral tablet 10 mg, one capsule by mouth once at bedtime for insomnia (persistent problems falling and staying asleep). On 1/18/23, at 11:40 a.m., a home visit was conducted at Patient 3's residence. Patient 3 was observed lying in bed sleeping. On 1/18/23, at 12:10 p.m., during an observation and a concurrent medication reconciliation with the registered nurse (RN 1), he showed the bottles of medications and medication bubble packs the patient was currently taking. There was an Ambien 10 mg bubble pack x 2 packs. The first Ambien bubble pack medication had a label stating there were 30 tablets with a filled date of 12/16/22. A total of 30 tablets were dispensed from the bubble pack and there were 0 tablets remaining. The second Ambien bubble pack had a label stating there were 30 tablets with a filled date of 1/16/23. There were 30 tablets remaining, and 0 tablet was dispensed. A review of Patient 3's Ambien 10 mg Controlled Medication Record sheet indicated no such record existed. There was an Alprazolam 0.5 mg tablet bubble pack medication with a label stating there were 30 tablets with a filled date of 1/16/23. A total of 0 tablet was dispensed from the bubble pack and there were 30 tablets remaining in the bubble pack. A review of Patient 3's Alprazolam 0.5 mg medication Controlled Medication Record sheet indicated no record existed. On 1/18/23, at 12:15 p.m., during an interview with RN 1, he stated Patient 3 was taking Ambien 10 mg tablet every night and Alprazolam 0.5 mg tablet twice a day. RN 1 stated the HA does not have a Controlled Medication Record sheet and he does not reconcile controlled medication on every patient visit. On 1/19/23, at 1:00 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated the skilled nurse should always be documenting administered narcotic medications in the narcotic sheet. The DPCS was not able to provide documented evidence that Patient 3 had a narcotic count sheet in the clinical record. A review of the agency's undated policy and procedure titled, ";Home Use and Disposal Of Controlled Substances", indicated controlled drugs will be accounted for on a narcotic count record, which will be maintained as a part of the clinical record.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the organization did not ensure the plan of care included all required information. For example, a review of the medical record for RR#3, revealed that during week 3 of the 1st benefit period the patient was assessed to have a new symptom of back pain. The plan of care did not include a goal statement to evaluate the effectiveness of pain management interventions. This observation was reviewed with the Care Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the organization did not ensure the plan of care included all required information. For example, a review of the medical record for RR#3 revealed that during week 3 of the 1st benefit period, the patient was assessed to have a new symptom of back pain. A new order for Salonpas Pain Relief Patch External Patch, 1 patch to the lower back three times a day as needed for Pain management was documented. The plan of care was not updated to include a problem statement related to lower back pain, and interventions for pain management strategies.