Every finding on record at Silverado Hospice, Inc.

Based on observation, interview, 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 Condition of Participation regarding Initial and Comprehensive 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 of the patient) of the Patient was met as follows: --- Based on observation, interview 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 Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The hospice agency failed to ensure the patient's eligibility for hospice services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions were accurately assessed, for two of 19 sampled patients (Patient 1 and Patient 9). (Refer to L524) 2. The hospice staff failed to accurately assess one of 19 sampled patients (Patient 9). For Patient 9, the hospice skilled nurse did not fully assess the patient for signs and symptoms of heart failure. (Refer to L525) 3. The hospice agency failed to maintain an accurate, current medication profile for one of 19 sampled patients (Patient 9). (Refer to L530) These systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits. Based on observation, interview and record review, the hospice staff failed to accurately assess two of 19 sampled patients (Patients 5 and 9). For Patient 5, the SN (skilled nurse) did not assess the patient's existing portacath (is a small chamber that sits under the skin. It's attached to a long plastic tube that goes into a large vein close to the heart) during initial and consecutive SN visits.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to conduct and document a comprehensive 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 of the patient) that reflected the patients current health status and identify the patients' needs for hospice care and services related to hospice eligibility and management of terminal illness for one of 19 sampled patients (Patient 9). This deficient practice had the potential for Patient 9s needs not to be met. --- Findings: During a review of Patient 9s General Patient Details form, the General Patient Details form indicated a start of care (SOC) date of 8/22/2023 with a terminal diagnosis of chronic systolic heart failure (a condition in which the heart does not pump blood as well as it should). The General Patient Details form indicated the frequency of visits by the agencys skilled nurse (SN) to one visit weekly and three times prn (as needed) visits every 90 days. During a review of Patient 9's Comprehensive Assessment visit, dated 12/7/2023, the Comprehensive Assessment indicated Patient 9 was alert, oriented to person and place, able to make her needs known, easily dyspneic (one who is suffering from shortness of breath) with simple exertion (effort). The Comprehensive Assessment indicated Patient 9 would ambulate (walk) using an assistive, and was on NYHA Class IV level for heart failure (New York Heart Association Class IV: Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). During a review of Patient 9's Hospice Certification of Terminal Illness (or CTI, physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the benefit period 11, from 12/20/2023 to 2/17/2024, the CTI indicated the hospices Medical Director certified Patient 9 was terminally ill with a life expectancy of six months or less if the terminal illness runs it normal course. The CTI indicated the hospice's Medical Director did not communicate with Patient 9s primary physician to certify Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. The CTIs "Brief Narrative Statement and Attestation," section indicated there was no supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results prior to the SOC to support Patient 9s terminal illness diagnosis. The CTIs ";Face to Face Visit Details," dated 12/2/2023, indicated the Medical Directors nurse practitioner (NP 1) documented Patient 9 had a regular heart rhythm, was comfortable at rest, no edema (swelling caused by too much fluid trapped in the body's tissues), and was on NYHA Class III level for heart failure (New York Heart Association Class III – comfortable at rest; less than ordinary physical activity causes fatigue, dyspnea, palpitations, or angina). During a review of Patient 9s Local Coverage Determination (LCD, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) worksheets for Heart Disease indicated Patient 9 was eligible per LCD guidelines. The LCD worksheet indicated Patient 9 was optimally treated for heart disease, was either not a candidate or had declined surgical procedures or had symptoms of heart failure at rest. The LCD Guidelines for heart disease indicated patients should meet the criteria for NYHA Class IV level and not NYHA Class III to qualify for hospice eligibility. During an observation on 6/6/2024, at 12:05 p.m., at Patient 9s residence, with Licensed Vocational Nurse 1 (LVN1), Patient 9 was sitting on a sofa awake, alert, oriented but hard of hearing. Patient 9 walked using an assistive device accompanied by a family member (FM 1). During an interview on 6/6/2024, at 12:22 p.m., with FM 1, FM 1 stated Patient 9 was doing good, eating well, would walk around the house using a walker (assistive device), and did not complain of any chest pain. FM1 stated Patient 9s blood pressure was within normal levels every time the HAs SN (in general) would check during their visits. During an interview on 6/7/2024, at 11:20 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 9 had declined surgical procedures or any documentation prior to hospice admission or that Patient 9 was on complete rest or confined to bed or chair or was optimally treated for heart disease with medications. During a review of the hospice agencys policy and procedure titled, ";Admission Criteria", revised June 19, 2023, indicated the hospice only admits patients who meet the admission criteria. In reaching a decision to certify that the patient is terminally ill, the hospice physician must consider at least the following information: a. Diagnosis of the terminal condition of the patient; b. Other health conditions, whether related or unrelated to the terminal condition; c. clinically relevant information supporting all diagnoses; d. Current medication and treatment orders; e. Information about the medical management of the patients conditions unrelated to the terminal condition; f. Following Medicare LCD guidelines.

Based on observation, interview and record review, the hospice agency (agency providing care to terminally ill patients who has six months or less to live) failed to assess the health status of two of 19 sampled patients (Patients 5 and Patient 9) during the initial and consecutive Skilled Nurse (SN) visits. a. For Patient 5, the HA licensed nurses (in general) did not assess Patient 5s existing Portacath (is an implanted device that gives access to the veins) during initial and consecutive SN visits. b. For Patient 9 who had a diagnosis of heart failure (a condition that develops when your heart does not pump enough blood for the body's needs), the HA licensed nurses (in general) did not assess Patient 5 for signs and symptoms of edema (swelling caused by too much fluid). These deficient practices placed Patient 5 and Patient 9 at risk for harm and complications. (Refer to L525) --- Findings: During a review of Patient 9s General Patient Details form indicated a start of care (SOC) date of 8/22/2023 with a terminal diagnosis of chronic systolic heart failure (a condition in which the heart does not pump blood as well as it should). The form further indicated the frequency of visits by the agencys skilled nurse (SN) to one visit weekly and 3 prn (pro re nata, or as needed) visits every 90 days. During a review of Current Care Plan Problem, initiated on 12/14/2023, indicated Patient 9 was at risk for lower extremity (is everything from your hip to your toes) edema (swelling due to fluid retention) related to heart disease. The goal indicated patient will have less than +2 edema to lower extremities in next 2 months. The care plan interventions indicated to for the agency SN to assess grade of edema to lower extremities, collaborate with physician with increased edema, educate on causes of increased edema, educate on diet modifications that could help manage edema, educate to elevate lower extremities whenever sitting or lying, and to monitor effectiveness of diuretic (medications that help the body get rid of extra fluid) therapy. During a joint home visit, on 6/6/2024 at 12:05 p.m. with the licensed vocational nurse (LVN 1) at Patient 9s residence, Patient 9 was observed sitting in a sofa awake, alert, oriented, and ambulatory using an assistive device. During an observation, on 6/6/2024 at 12:16 p.m., LVN 1 assessed Patient 9 but did not remove the patient's socks to assess for pedal edema (foot and ankle swelling). During an interview with LVN 1, on 6/6/2024 at 12:38 p.m., LVN 1 stated, "I did not fully assess for pedal edema. I should have removed the patients socks." According to the American Heart Association (organization dedicated to fighting heart disease and stroke [damage to the brain from interruption of its blood supply]), signs and symptoms of heart failure include swelling in the feet, ankles, legs, fingers, abdomen and in other tissues and organs, shortness of breath, and increased heart rate. During an interview on 6/7/2024 at 11:20 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated the agencys skilled nurse should be checking for pedal edema for patient that have heart failure including checking patients foot for any swelling. During a review of the hospice agencys undated policy and procedure titled, ";Initial and Comprehensive Assessment", indicated hospice conducts and documents a patient specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional and spiritual care. This includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. Assessments are made at each visit/contact with the patient/family or caregiver. A review of Patient 5's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated she was admitted to the hospice agency on 4/19/2024, with a terminal diagnosis of malignant neoplasm of the ovary (a cancer that begins in the female organs that produce eggs). The form further indicated the frequency of visits by the agencys skilled nurse (SN) to two visits weekly and 3 prn (pro re nata, or as needed) visits every 60 days. A review of Patient 5's Physician's order dated 4/19/2024, indicated to administer Sodium Chloride 0.9 percent to administer 80 ml (milliliters) per hr (hour) via portacath for 12 hours once weekly every Monday as needed for dehydration. During a review of Patient 5's Initial comprehensive assessment dated 4/19/2024, indicated no documented evidence of an assessment for an existing portacath device, of it's location and skin condition around the area. A further review of Patient 5's SN Clinical Visit Chart from dates 4/19/2024 to 5/26/2024, indicated no entry of an existing portacath device, of the location and the skin condition of the area. During an interview on 6/7/2024 at 1 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated Patient 5 has a portacath with one port huber needle at right upper chest. The DPCS further stated the visiting nurse should have assessed and document the existing portacath and skin surrounding in their nursing notes on every visits.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to maintain a current medication profile (a written summary of all the medicines a person takes regularly, including over the counter) for one of 19 sampled patients (Patient 9). This deficient practice had the potential to place Patient 9 at risk for medication errors and adverse drug reactions (a harmful, unintended result caused by taking medication). --- Findings: During a review of Patient 9s General Patient Details form indicated a start of care (SOC) date of 8/22/2023 with a terminal diagnosis of chronic systolic heart failure (a condition in which the heart does not pump blood as well as it should). The General Patient Details form indicated the frequency of visits by the agencys skilled nurse (SN) to one visit weekly and three prn (as needed) visits every 90 days. During a review of Patient 9's Current Care Plan Problems, the Current Care Plan Problems indicated for the HA skilled nurses (in general) to assess for safety, educate regarding medications that increase fall risk, to frequently monitor patient for status change, and to consult with pharmacy for medication review. During an observation on 6/6/2024, at 12:05 p.m., at Patient 9s residence, with Licensed Vocational Nurse1 (LVN 1) Patient 9 was sitting on a sofa awake, alert, and oriented. During a review and interview of Patient 9s current medication, on 6/6/2024, at 12:35 p.m., with LVN 1, and Patient 9s family member (FM 1), a bottle of hyoscyamine sulfate (used to treat many different stomach and intestinal disorders) 0.125 milligram (mg, a unit of measure) one tablet oral every four hours as needed for excess secretions could not be found. Patient 9s current medication list provided by the HA indicated Patient 9 was taking the medication. During the concurrent observation and interview, FM 1 stated Patient 9 did not use the medication and was not aware if the HA provided them with the medication bottle since the SOC. During an interview on 6/7/2024, at 11:20 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated nursing staff (in general) needed to review patients current medication on every visit and update the medication list in the patients clinical record. During a review of the hospice agencys policy and procedure titled, ";Medication, Medical Supplies and DME (durable medical equipment) Management", revised June 19, 2023, indicated adequate patient care medications and supplies are made available to provide quality care at all times. An ongoing, updated list of all medication the patient is taking, including over the counter drugs, is maintained in the patients clinical record and reviewed by Medical Director / hospice physician at scheduled interdisciplinary group (IDG) meetings.

Based on interview 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 Condition of Participation 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 Hospice agency failed to ensure to assess the vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) of one of 19 sampled patients (patient 17) and document in Patient 17s clinical record. This deficient practice had the potential to affect the care of Patient 17. (Refer to L543). 2. The hospice agency failed to ensure to develop a plan of care for three of 19 sampled patients (Patient 1, Patient 5, and Patient 12). This deficient practice had the potential not to meet the health care needs and goals of Patient 1, Patient 5, and Patient 12 (Refer to L545). 3. The HA failed to ensure to implement physician orders for one of 19 sampled patients (Patient 2) who had an elbow skin tear. (Refer to L549). This deficient practice had the potential for Patient 2 to develop a skin infection. These systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Interdisciplinary Group, Care Planning, and Coordination of Services to ensure the quality of care are being provided to patients certified to receive hospice benefits.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has 6 months or less to live) failed to ensure to assess the vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) of one of 19 sampled patients (patient 17) and document in Patient 17s clinical record. This deficient practice had the potential to affect the care of Patient 17. --- Findings: During a review of Patient 17's untitled admission record indicated a start of care date of 11/28/2022, with a terminal diagnosis Alzheimers disease, (progressive disease with mild memory loss) unspecified. During a review of Patient 17s Skilled Nurse (SN) notes dated 5/23/2024, the SN notes indicated the HA did not check Patient 17s blood pressure, apical pulse (a pulse point on the chest), and temperature. During an interview on 6/7/2024, at 11 a.m., with Registered Nurse2 (RN 2), RN2 stated the importance of checking and documenting the vital signs was to stablish the baseline of a patient (in general). RN 2 stated she did not document on Patient 17s SN notes that Patient 17 refused vital signs on 5/23/2024. During a concurrent interview and record review, on 6/7/2024, at 11 am, with the Director of Patient Care Services (DPCS), Patient 17s SN notes dated 5/23/2024 were reviewed. The DPCS stated there was no documentation for Patient 17s blood pressure, apical pulse, temperature, and no other documented evidence. The DPCS stated the importance of checking Patient 17s vital signs were to assess for any decline. The DPCS stated that taking the vital signs was a standard nursing practice (in general). During a review of the hospice agency's policy and procedure titled, ";Plan of Care-Revised," dated June 19, 2023, indicated revised plan of care must include information from the patients updated comprehensive assessment and must note the patients progress towards outcomes and goals as specified in the plan of care.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has 6 months or less to live) failed to failed to ensure to develop a plan of care for three of 19 sampled patients (Patient 1, Patient 5, and Patient 12). This deficient practice had the potential not to meet the health care needs and goals of Patient 1, Patient 5, and Patient 12. --- Findings: During a review of Patient 12s General Patient Details form indicated a start of care (SOC) date of 5/18/2024 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of the lungs. The form further indicated the frequency of visits by the agencys skilled nurse (SN) to three visits weekly and 3 prn (pro re nata, or as needed) visits every 60 days. During a review of Patient 12's Initial comprehensive assessment dated 5/18/2024, indicated Patient 12 had a gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach). During a review of Patient 12s Current Care Plan for the certification period starting on 5/18/2024, indicated it did not contain goals and specific interventions for care of the patients G-tube site. During a concurrent interview and record review, on 6/7/2024 at 11:20 a.m., with the Director of Patient Care Services (DPCS), the DPCS confirmed Patient 12s plan of care did not have specific interventions for care of G-tube site. During a review of the hospice agency's policy and procedure titled, ";Plan of Care-Revised", dated June 19, 2023, indicated the IDG (Interdisciplinary Group, a group composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness), in consultation with the attending physician, develops a plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familys specific needs identified in the comprehensive assessment. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated she was admitted to the hospice agency on 6/27/2023, with a terminal diagnosis of senile degeneration of the brain (loss of intellectual ability that is associated with or the characteristics of old age). The form further indicated the frequency of visits by the agencys skilled nurse (SN) to three visits weekly and 3 prn (pro re nata, or as needed) visits every 60 days. A review of Patient 1's Physician's order dated 11/1/2023, indicated to administer Seroquel (psychotropic medication [any drug that affects mental function, behavior, and mood]) 25 mg (milligrams, a unit of measurement) one tablet two times a day for hallucinations. A further review of Patient 1s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for psychotropic medication management (Seroquel) for Patient 1. On 6/7/2024, at 12 p.m., during an interview with the Director of Patient Care Services (DPCS), when she was asked if the Seroquel medication dosages were safe to give to Patient 1, she stated yes, that it was safe to help control Patient 1s disease process. She further stated that there was no plan of care developed for psychotropic medication management for Patient 1. Findings: a. During a review of Patient 1's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA on 6/27/2023, with a terminal diagnosis of senile degeneration of the brain (loss of intellectual ability that is associated with or the characteristics of old age). The Demographics indicated the frequency of visits by the agencys skilled nurse (SN) for three visits weekly and three prn (as needed) visits every 60 days. During a review of Patient 1's Physician's order dated 11/1/2023, indicated for Patient 1 to receive Seroquel (psychotropic medication [any drug that affects mental function, behavior, and mood]) 25 milligrams (mg, a unit of measurement) one tablet two times a day for hallucinations (an experience involving the apparent perception of something not present). During a concurrent interview and record review, on 6/7/2024, at 12 p.m., with the Director of Patient Care Services (DPCS), Patient 1s clinical record was reviewed. The DPCS stated the HA did not develop a plan of care for psychotropic medication management (Seroquel). b. A review of Patient 5's Demographics indicated the HA admitted Patient 5 on 4/19/2024, with a terminal diagnosis of malignant neoplasm of the ovary (a cancer that begins in the female organs that produce eggs). The Demographics indicated the frequency of visits by the agencys SN to two visits weekly and three prn visits every 60 days. During a review of Patient 5's Physician's order dated 4/19/2024, the Physician Order indicated for Patient 5 to receive Sodium Chloride 0.9 percent (is an electrolyte that regulates the amount of water in the body) 80 ml (milliliters, a measure of volume) per hour via Patient 5s portacath (is an implanted device that gives access to the veins) for 12 hours once weekly every Monday as needed for dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally). During a concurrent interview and record review, on 6/7/2024 at 1 p.m., with DPCS), Patient 5s clinical record was reviewed. The DPCS stated the HA did not develop a plan of care for Patient 5 and did not have specific interventions for the nursing care of the portacath device. c. During a review of Patient 12s General Patient Details form indicated a start of care (SOC) date of 5/18/2024 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of the lungs. The General Patient Details indicated the frequency of visits by the agencys SN to three visits weekly and three prn visits every 60 days. During a review of Patient 12's Initial comprehensive assessment dated 5/18/2024, the Initial comprehensive assessment indicated Patient 12 had a gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach). During a review of Patient 12s Current Care Plan for the certification period starting on 5/18/2024, the Current Care Plan for the certification indicated there were no goals and specific interventions for the nursing care of Patient 12s G-tube site. During a concurrent interview and record review, on 6/7/2024, at 11:20 a.m., with the DPCS, Patient 12s clinical record was reviewed. The DPCS stated Patient 12s plan of care did not have specific goals and interventions for the nursing care of Patient 12s G-tube site. During a review of the hospice agency's policy and procedure titled, ";Plan of Care-Revised," dated June 19, 2023, indicated the IDG (Interdisciplinary Group, a group composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness), in consultation with the attending physician, develops a plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familys specific needs identified in the comprehensive assessment.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has 6 months or less to live) failed to ensure to implement physician orders for one of 19 sampled patients (Patient 2) who had an elbow skin tear. physician orders were implemented for 1 of 19 sampled patients (Patient 2). This deficient practice had the potential for Patient 2 to develop a skin infection. --- Findings: During a review of Patient 2's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 2 on 11/16/2023, with a terminal diagnosis of senile degeneration of the brain (loss of intellectual ability that is associated with or the characteristics of old age). The Demographics indicated the frequency of visits by the agencys skilled nurse (SN) to one visit weekly and three prn (as needed) visits every 60 days. During a review of Patient 2's Physician's Order dated 3/23/2024, the Physician's Order indicated for Patient 2 to receive a wound treatment for the right elbow skin tear as follows: to clean wound with wound cleanser, pat dry, apply triple antibiotic, and cover with dry dressing. During a concurrent interview and record review, on 6/7/2024, at 12 p.m., with the Director of Patient Care Services (DPCS), Patient 2s SN Visit Notes dated 3/26/2024, 3/26/2024, 4/3/2024, and 4/10/2024, were reviewed. The DPCS stated she could not find any documentation by the visiting nurse that wound care was provided for Patient 2. During a review of the HA's undated policy and procedure titled, "Physician Orders Communications and Implementation," indicated the nursing staff should be implementing orders received and updating the plan of care.

Observed in Surveyor review but corrected onsite pending acceptable Evidence of Standards Compliance. In 5 of 14 patient records reviewed, the organization did not assess the patient according to defined timeframes. In RRHV#1, the MSW did not complete the initial assessment within five (5) days of the election of hospice care. It was documented the Social Worker was unavailable for the assessment visit due to time off. In RRNHV#10, the initial MSW assessment was not completed within five days of the patient's election of hospice, with no documentation as to the reason for the delay. In RRHV#3, RRNHV#4, and RRNHV#5, the initial bereavement assessment was not completed/documented within five days of the patient's election of hospice care. This was reviewed and verified with the Director of Patient Care Services.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization did not plan the patient's care by ensuring the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. In RRHV#2, the patient was assessed at high risk for falls based on the fall risk assessment, but fall prevention/safety was not included in the plan of care. In RRNHV#1, the patient was on Oxygen at 2-4 liters per nasal cannula and assessed at high risk for falls. Care interventions and goals related to the oxygen safety and fall prevention was not included in the patient's plan of care. In RRNHV#4, the patient's diagnoses included Alzheimer's Disease and Dysphagia. It was also documented the patient was on a pureed diet. There was no interventions/goals related to the Dysphagia included in patient's plan of care. This was reviewed and verified with the Director of Patient Care Services

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. In RRNHV#6, the patient's plan of included an evaluation for volunteer services. There was no documentation that the evaluation had been completed or that volunteer services were provided. It was confirmed by the Volunteer Coordinator that the evaluation for services had been missed. This was reviewed and verified with the Director of Patient Care Services.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not plan the patient's care by ensuring a registered nurse prepared written patient care instructions for the hospice aide. In RRNHV#4, the most recent plan of care review completed by the RN indicated a bed bath only for the patient to ensure safety. It was documented on the hospice aide care plan that the aide was to provide a shower every visit. This was reviewed and verified with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not provide care, treatment, or services in accordance with the orders as required by law/regulation. In RRHV#4, the hospice aide did not provided services consistent with the plan of care. The aide removed and then reapplied the same three over-the-counter Lidocaine patches to the patient's back before/after the shower per the patient's request. This task was not assigned on the aide plan of care. This was reviewed and verified with the Director of Patient Care Services.

Observed in Patient Home. In 4 of 4 home visits conducted, the organization did not provide patient education and training based on each patient's needs and abilities, including procedures to follow if care, treatment, or services were disrupted by a natural disaster or an emergency. In RRHV#1, RRHV#2, RRHV#3, and RRHV#4, there was no individual emergency preparedness plan/education based on the patient's specific needs and abilities in the home. This was reviewed and verified with the Administrator.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not implement the infection prevention and control activities it had planned to minimize reduce, or eliminate the risk of infection. In RRHV#2, the RN did not follow the organization's bag technique policy. Upon entry to the patient's residence, the main compartment of the RN's canvas field bag, where care equipment and other items were stored, was open to the outside environment. Upon completion of the visit and exiting the patient's room, the RN's backpack field bag remained open. This was reviewed and verified with the Director of Patient Care Services.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, the Hospice Care plans did not have measurable goals. RR#1 & RR#2 had issues related to pain, were high risk for falls, oxygen dependent, and the initial care plan did not reflect a target date to achieve goals. RR#3 had a stage 4 decubiti, oxygen dependent, had a Foley and gastrostomy tube and there were no specific goals for these problems or target dates to achieve goals. Per the manager, patient goals are reviewed every two weeks during IDG.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the hospice record did not reflect clear and or accurate orders related to medications. RR#1 was on two different narcotics for pain and one topical agent. The medication orders did not reflect the sequence of medication the patient should take based on pain level. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the plan of care did not reflect complete orders. RR#3 had a Foley and the plan of care only reflected the Foley size not the balloon size. Nor did it specify the frequency of change of the Foley it only indicated change prn without further qualification. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 2 patient records reviewed, the hospice aide care plan did not reflect precautions as required by the patient assessment. RR#1 was oxygen dependent and the HHA Care plan did not reflect oxygen precautions. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, there was inaccurate documentation. RR#1 oxygen dependent and the RN documented no SOB in the respiratory portion of the assessment. The narrative associated with this note however reflected that the patient was SOB on rest and was dependent on oxygen. This observation was discussed with the director.

Based on observation, interview and record review, the Condition of Participation for Patients Rights were not met as follows: 1. The hospice agency, prior to providing hospice care, failed to ensure the patient representative was informed regarding the formulation of an advance directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), failed to notify the family representative for the patient's change in condition and the patients death, for one of five patients, (Patient 1). This deficient practice resulted to the violation of one of the patients rights and wishes for her medical care. (Refer to L503). 2. The agency failed to ensure the current medications and the medication profiles were reviewed and updated, and the expired medications were destroyed for one of 5 sampled patients, (Patient 3). This deficient practice placed the patient at risk for medication errors and adverse drug reactions that could affect the health and safety of the patients. (Refer to L 530) The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to ensure highest quality of patient care is provided to patients certified to receive the Hospice benefits. --- .

Based on interview and record review, the hospice agency, prior to providing hospice care, failed to ensure the patient representative was informed regarding the formulation of an advance directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), failed to notify the family representative for the patient's change in condition and the patients death, for one of five patients, (Patient 1) This deficient practice resulted to the violation of one of the patients rights and wishes for her medical care. --- On 2/9/2023, an unannounced Complaint Validation survey was conducted at the agency with the following allegations: Patient 1 did not have a physicians order for life sustaining treatment ([POLST] a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) created before the start of Patient 1s care. Family was not notified by the hospice skilled nurse regarding a change in her condition on 11/1/2021. Patient 1s change of condition was not re-assessed and was not sent to the hospital. Patient 1 expired on 11/3/2021. Family members were not informed by the skilled nurse, until social workers notification over an hour after. During an entrance conference with the new Administrator, Vice President (VP) of Clinical Operation, and QAPI (Quality Assurance/ Performance Improvement) Manager on 2/9/2023, at 11:45 a.m., the QAPI Manager stated, the hospice agency did not have a POLST for Patient 1 and whenever there is no POLST for a patient, the patient is treated as a full code (which allows medical personnel to provide all interventions needed to restore breathing or heart functioning). On 2/10/23, a review of Patient 1s electronic clinical record indicated a start of care date of 10/29/2021, with terminal diagnosis of Parkinsons Disease (a disorder of the central nervous system that affects movement , often including tremors), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), pressure ulcer on right elbow Stage 4 (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones), Stage 2 (skin that breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure ulcer on the left elbow. A review of Patient 1's ";Patient Information Report" indicated a referral date of 10/22/2021 and Patient 1 was a full code. A review of Patient 1's ";Physicians Certification for Hospice Benefit" for the first 90-day period from 10/29/2021 to 1/26/2022, indicated Patient 1s terminal diagnosis was Parkinsons Disease. A review of the general acute care hospital (GACH) history and physical documentation dated 10/22/2021, indicated, ";life sustaining treatment desired per next of kin request with a start date of 9/17/21, continue, stop after 1,000 days, renewable." A review of Patient 1's initial Nursing Assessment by the Registered Nurse (RN) dated 10/29/2021, indicated Patient 1 was bedbound, obtunded (reduced level of alertness), unable able to make her needs known, does not respond to stimuli, all extremities contracted, with stage 4 pressure ulcer to right elbow, stage 2 pressure ulcer to left elbow, and required maximum assistance. The RN documented the POLST was left at the General Acute Care Hospital (GACH), however, the clinical record did not indicate a follow up call was made to GACH in regards to obtaining the POLST. A review of the Licensed Vocational Nurse (LVN) 1s Visit Note Report dated 10/30/21, indicated Patient 1 had a temperature of 97.2 and a respiratory rate of 24 breaths per minute (shallow) and was on 2 liters per minute (LPM) of oxygen (O2) per nasal canula. LVN 2s narrative visit note report dated 10/30/2021, indicated Patient 1 had "end stage parkinsons disease, sepsis of stage 4 wound, not verbally responsive, extremely lethargic, on oxygen 3 liters per minute via nasal cannula, wet cough, bilateral lungs clear with crackles at base. Instructed facility nurse on patient's condition, new physicians order, proper medication administration, hand hygiene, infection control, comfort and safety measures, hospice philosophy and when and how to call hospice with any change of condition or concern rather than calling 911 (medical emergency phone number)." LVN 1s visit note report dated 11/1/2021, indicated Patient 1 had a temperature of 101.3, with labored respirations of 32 breaths per minute. In the narrative section, LVN 1 indicated, ";Patient breathing is labored 32 breaths per minute on O2 at 2LPM via nasal cannula. Skin is cool to touch, clammy, sweating noted, checks reddened, flushed. Temp 101.3, cooling measures applied. Increased O2 to 4 LPM, no relief of labored breathing or shortness of breath". There was no documentation Patient 1s family members were informed of Patient 1s change in condition. During an interview with the QAPI Regional Manager on 2/10/2021, at 12:10 p.m. in the hospice agencys conference room, he stated the LVN should have notified the family regarding the change in condition, so the POLST status could have been re-evaluated and possibly changed if the family wanted to keep Patient 1 a full code, then the patient should have been sent to the hospital. The QAPI Regional Manager also stated the LVN should have notified the hospice and Patient 1 should have been re-assessed within 24 hours of her change in condition. The Regional QAPI Manager stated Patient 1 should have been visited on 11/2/2021. During a telephone interview on 2/10/2023, at 12:20 p.m. in the hospice conference room, LVN 2 stated, usually when a change of condition happens and if its a routine visit, she has to let the RN at hospice agency know and call the doctor. LVN 2 could not recall if she informed the hospice RN or Patient 1s family members. During a telephone interview with Family member 1 on 2/10/2021, at 6:48 p.m., via telephone, he stated the hospice agency never notified him of the change in condition of Patient 1 on 11/1/2021. Patient 1 was a full code who should have been sent out to the hospital when she had a change of condition. Family member 1 stated the LVN never called and informed him on 11/3/2021 that Patient 1 had expired. He was only called and informed by the Social worker. During a telephone interview with Family Member 2 on 2/11/2021, at 10:00 a.m., she stated she was never notified by the hospice agency of Patient 1's change in condition on 11/1/2021, and the LVN never called her to inform her Patient 1 had expired on 11/3/2021. During a telephone interview with the hospice Medical Doctor on 2/11/2023, he stated the family members of Patient 1 should have been notified of her change in condition and the POLST should have been discussed/re-evaluated with the family members. If they still wanted Patient 1 to remain a full code, she should have been sent out to the hospital. A review of the hospice agencys policy and procedure titled," Patient Rights #301 Advanced Directives", dated September 3, 2019, indicated, "Prior to or upon admission, Hospice provides written information to patients regarding Out-of-Hospital Do Not Resuscitate (OOH-DNR) order as appropriate, hospice policies regarding the implementation of such rights."

Based on observation, interview, and record review, the hospice agency failed to ensure the current medications and the medication profiles were reviewed and updated, and the expired medications were destroyed for one of 5 sampled patients, (Patient 3). This deficient practice placed the patient at risk for medication errors and adverse drug reactions that could affect the health and safety of the patients. --- During a review of Patient 3's Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) dated 8/1/2022, the CTI indicated the Patient 3 was admitted to the hospice agency on 8/1/2022, with primary diagnosis of end stage heart failure (failure of the heart to function properly). During a review of Patient 3's "POC Summary" dated 2/9/2023, the Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) summary indicated the Skilled Nurse (SN) visit was once a week, Medical Social Worker (MSW) will visit twice a month, and the hospice aid (HA) will visit twice a week for eight weeks, then once a week for a week. During a review of Patient 3s ";Client Medication Report" dated 2/9/23, the medication profile listed an order for Robitussin (cough medicine) 5 milligrams (mg). The concentration was 50 mg in 5 milliliters (ml) and 10 ml to be given every six (6) hours as needed by mouth for cough. On 2/10/2023, at 10:40 a.m., joint visit was made with Registered Nurse (RN) 1 to the Assisted Living facility where Patient 3 resided. During an observation on 2/10/2023, at 11:03 a.m., with RN 1 in the Assisted Living medication room, the medication available for Robitussin was Guaifenesin 100 mg per 5 ml and the dose to take was 10 ml to be taken every 6 hours as needed for cough. During an interview on 2/10/2023, at 11:04 a.m., RN 1 stated, ";I see where there is a discrepancy between the dose that was ordered by the doctor and the dose that was supplied by the pharmacy. The concentration ordered by the doctor is 50 mg per 5ml, but the bottle that was sent by pharmacy was 100 mg per 5 ml, yet the label stated to take 10 ml. This would be double the dose. This discrepancy should have been verified by the nurse with the doctor and the pharmacist." During an observation on 2/10/2023, at 11:11a.m. with RN 1 in the Assisted Living medication room, there was 1 box of Hyoscyamine (medication to dry out oral secretions) 0.125 mg to be taken 1 tablet by mouth every 4 hours as needed for excessive oral secretions with an expiration date of 1/2023, and 1 box of Ativan 0.5mg to be taken 1 tablet by mouth every 4 hours as needed for anxiety or shortness of breath, with an expiration date of 1/2023. During an interview on 2/10/2023, at 11:12 a.m., RN 1 stated, ";I am not the regular nurse for Patient 3. This is my first time seeing this patient. The regular nurse is on vacation. I can tell you that yes, these two medications are expired. What my process is with my other patients, I go through all their medications every time I go visit them to make sure all dosages are correct, all medications match the med profile and there are no expired meds." During an interview on 2/10/2023, at 11:14 a.m., with the Assisted Living care coordinator, she stated, ";the nurses usually go through all the medications every time they come and if there are any medications that are expired, they will tell us, and we will destroy it. This was not communicated to us in this case." During a review of the agency's undated policy titled, " Initial and Comprehensive Assessment", it indicated that ";the comprehensive assessment identifies the physical, medical, psychological, emotional, and spiritual needs related to the terminal illness and takes into consideration the following factors: a review of all the patients prescription and over-the-counter drugs and alternative treatments that could affect drug therapy".

Based on interview and record review, the hospice agency failed to ensure the Conditions of Participation for IDG, Care Planning and Coordination of Services was met as follows: 1. The hospice agency failed to: Ensure education regarding its responsibilities for the care and services of the hospice patient were provided to the primary caregivers at the skilled nursing facility. Ensure instructions were given to the primary caregivers at the skilled nursing facility, for Patient 1, who was treated as a full code (which allows medical personnel to provide all interventions needed to restore breathing or heart functioning), to be sent out to General Acute Care Hospital (GACH) for further care and interventions. This deficient practice resulted in Patient 1 not provided with the interventions according to his wishes when the significant change of the condition was manifested which led to Patient 1s death. (Refer to L544) 2. The hospice agency failed to ensure the license professionals providing direct patient care participates the interdisciplinary group meeting (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) to coordinate aspects of care, for one of 5 sampled patients, (Patient 1). This deficient practice resulted in the hospice staff not aware of the code status of the patient and did not have the guidance on how to provide care according to the patient and family members wishes during a change in condition. (Refer to L585) The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for IDG, Care Planning and Coordination of Services to ensure highest quality of patient care is provided to patients certified to receive the Hospice benefits. --- .

Based on interview and record review, for one of 5 sampled patients, (Patient 1), the hospice agency failed to: 1. Ensure education regarding its responsibilities for the care and services of the hospice patient were provided to the primary caregivers at the skilled nursing facility. 2. Ensure instructions were given to the primary caregivers at the skilled nursing facility, for Patient 1, who was treated as a full code (which allows medical personnel to provide all interventions needed to restore breathing or heart functioning), to be sent out to General Acute Care Hospital (GACH) for further care and interventions. This deficient practice resulted in Patient 1 not provided with the interventions according to his wishes when the significant change of the condition was manifested which led to Patient 1s death. --- On 2/10/23, a review of Patient 1s electronic clinical record indicated a start of care date of 10/29/2021, with terminal diagnosis of Parkinsons Disease (a disorder of the central nervous system that affects movement , often including tremors), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), pressure ulcer on right elbow Stage 4 (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones), Stage 2 (skin that breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure ulcer on the left elbow. A review of Patient 1's ";Patient Information Report" indicated a referral date of 10/22/2021 and Patient 1 was a full code (which allows medical personnel to provide all interventions needed to restore breathing or heart functioning). A review of Patient 1's ";Physicians Certification for Hospice Benefit" for the first 90-day period from 10/29/2021 to 1/26/2022, indicated Patient 1s terminal diagnosis was Parkinsons Disease. A review of Patient 1's initial Nursing Assessment by the Registered Nurse (RN) dated 10/29/2021, indicated Patient 1 was bedbound, obtunded (reduced level of alertness), unable able to make her needs known, does not respond to stimuli, all extremities contracted, with stage 4 pressure ulcer to right elbow, stage 2 pressure ulcer to left elbow, and required maximum assistance. The RN documented the physicians order for life sustaining treatment [(POLST), a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was left at the General Acute Care Hospital (GACH). The clinical record did not indicate a follow up call was made to GACH in regards to obtaining the POLST. A review of Patient 1s ";Initial order and Plan of Care" dated 10/29/2021, indicated the skilled nurse (SN) visit frequency for Patient 1 was two times a week for two weeks, 1 time a week for 12 weeks, 3 as needed RN visits for agitation, shortness of breath (SOB) or any other change in condition. A review of Licensed Vocational Nurse (LVN) 1s Visit Note Report dated 10/30/21, indicated Patient 1 had a temperature of 97.2 degrees fahrenheit and a respiratory rate of 24 breaths per minute (shallow) and was on 2 liters per minute (LPM) of oxygen (O2) per nasal canula. LVN 2s narrative visit note report dated 10/30/2021, indicated Patient 1 had end stage parkinsons disease, sepsis of stage 4 wound, not verbally responsive, extremely lethargic, on O2 3 liters per minute via nasal cannula, wet cough, bilateral lungs clear with crackles at base. Instructed facility nurse on patient's condition, new physicians order, proper medication administration, hand hygiene, infection control, comfort and safety measures, hospice philosophy. The notes also indicated that family member appears not on board for hospice are and the conversation was more regarding rehabilitation care. The notes also indicated LVN 2 instructed the facility nurse on when and how to call hospice with any change of condition or concern rather than calling 911 (medical emergency phone number)." LVN 1s visit note report dated 11/1/2021, indicated Patient 1 had a temperature of 101.3, with labored respirations of 32 breaths per minute. In the narrative section, LVN 1 indicated, ";Patient breathing is labored 32 breaths per minute on O2 at 2LPM via nasal cannula. Skin is cool to touch, clammy, sweating noted, checks reddened, flushed. Temp 101.3, cooling measures applied. Increased O2 to 4 LPM, no relief of labored breathing or shortness of breath". During an interview with the hospice QAPI (Quality Assurance/Performance Improvement) Regional Manager in the agency conference room on 2/10/23, at 12:10 p.m., he stated the skilled nursing facility (SNF) staff should have informed the family members of the change in condition on 11/1/21, called 911 to have Patient 1 sent out to the General Acute Care Hospital (GACH). During a telephone interview on 2/10/23, at 1:20 p.m. in the agencys conference room, LVN 2 stated she was notified by SNF staff on 11/3/21 that Patient 1 had expired and went to assess/confirm patients death after receiving the call from the SNF. During a telephone interview with Family member 1(FM) on 2/10/2021, at 6:48 p.m., he stated the skilled nursing facility (SNF) did not inform him of the change of condition of Patient 1 on 11/1/21. He also stated, Patient 1 was a full code (which allows medical personnel to provide all interventions needed to restore breathing or heart functioning) who should have been sent out to the hospital when she had a change of condition. FM 1 also stated the SNF never called and informed him on 11/3/21, Patient 1 had expired. He was called and informed by the social worker of the hospice agency over an hour after Patient 1 had died. During a telephone interview with FM 2 on 2/11/21, at 10:00 AM., she stated she was never notified by the SNF of Patient 1's change in condition on 11/1/21, or about Patient 1's death on 11/3/21. A review of the hospice agencys policy and procedure, titled, ";Patient Care-General Policy # 808 Coordination of Services not dated under Policy", indicated the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services are provided according to the plan of care whether provided directly or under arrangement." It also indicated, the IDG members facilitate the coordination of care by frequent written and oral communication among each other and other non-hospice care providers and care provided under arrangement. Documentation of any communication is included in the clinical record."

Based on interview and record review, the hospice agency failed to ensure the license professionals providing direct patient care participate in the interdisciplinary group meetings (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) to coordinate aspects of care, for one of 5 sampled patients, (Patient 1). This deficient practice resulted in the hospice staff not aware of the code status (the level of medical interventions a patient wish to have started if their heart or breathing stops) of the patient and did not have the guidance on how to provide care according to the patient and family members wishes during a change in condition. --- During an entrance conference on 2/9/2023, at 11:45 a.m. with the new Administrator, Vice President (VP) of Clinical Operation, and QAPI (Quality Assurance/ Performance Improvement) Manager, the QAPI Manager stated the hospice agency did not have a physicians order for life sustaining treatment [(POLST), a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) for Patient 1 and when there is no POLST the patient is a full code (which allows medical personnel to provide all interventions needed to restore breathing or heart functioning). On 2/10/23, a review of Patient 1s electronic clinical record indicated a start of care date of 10/29/2021, with terminal diagnosis of Parkinsons Disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), pressure ulcer on right elbow Stage 4 (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones), Stage 2 (skin that breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure ulcer on the left elbow. A review of Patient 1's ";Patient Information Report" indicated a referral date of 10/22/2021 and Patient 1 was a full code. A review of the ";Physicians Certification for Hospice Benefit, ";for the first 90-day period from 10/29/2021 to 1/26/2022, indicated Patient 1s terminal diagnosis was Parkinsons Disease. A review of the General Acute Hospital (GACH) history and physical documentation dated 10/22/2021, indicated, ";Life sustaining treatment desired per next of kin request with a start date of 9/17/21, continue, stop after 1,000 days, renewable." A review of Patient 1's initial Nursing Assessment by the RN dated 10/29/2021, indicated Patient 1 was bedbound, obtunded (reduced level of alertness), unable able to make her needs known, does not respond to stimuli, all extremities contracted, with stage 4 pressure ulcer to right elbow, stage 2 pressure ulcer to left elbow, and required maximum assistance. The Registered Nurse (RN) documented the POLST was left at the GACH. The clinical record did not indicate a follow up call was made to GACH in regards to obtaining the POLST. A review of Patient 1s ";Initial order and Plan of Care" dated 10/29/2021, indicated the skilled nurse (SN) visit frequency for Patient 1 was two times a week for two weeks, 1 time a week for 12 weeks, 3 as needed Registered Nurse (RN) visits for agitation, shortness of breath (SOB) or any other change in condition. A review of Licensed Vocational Nurse (LVN) 1s Visit Note Report dated 10/30/21, indicated Patient 1 had a temperature of 97.2 degrees fahrenheit and a respiratory rate of 24 breaths per minute (shallow) and was on 2 liters per minute (LPM) of oxygen (O2) per nasal canula Review of LVN 1s Visit Note Report dated 10/30/2021 in the narrative, indicated Patient 1 has "end stage parkinsons disease, sepsis of stage 4 wound, not verbally responsive, extremely lethargic, on oxygen at 3 liters per minute via nasal cannula, wet cough, lungs clear with crackles at base bilaterally. Instructed facility Nurse on patient's condition, new physicians order, proper medication administration, hand hygiene, infection control, comfort and safety measures, hospice philosophy and when and how to call hospice with any change of condition or concern rather than calling 911 (medical emergency phone number)." LVN 2s visit note report dated 11/1/2021, indicated Patient 1 had a temperature of 101.3, with labored respirations of 32 breaths per minute. In the narrative section, LVN 1 indicated, ";Patient breathing is labored 32 breaths per minute on O2 at 2LPM via nasal cannula. Skin is cool to touch, clammy, sweating noted, checks reddened, flushed. Temp 101.3, cooling measures applied. Increased O2 to 4 LPM, no relief of labored breathing or shortness of breath". There was no documentation Patient 1s family members were informed of Patient 1s change in condition. During an interview on 2/10/23, at 12 p.m. in hospice agency's conference room, Registered Nurse (RN) 1 stated she was the RN who did the initial comprehensive assessment for Patient 1 and other new admission for the hospice patients in the past however, she is a RN case manager at this time. RN 1 stated she never attended or was involved in interdisciplinary group meeting (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) as an admitting RN and that admitting nurses do not attend IDG. RN 1 also stated in her new position as an RN case manager, she was not involved /participated in the IDG meetings. During an interview on 2/10/2021, at 12:10 p.m., in the hospice agencys conference room, the Regional QAPI Manager stated the admitting nurse and most licensed staff providing direct care do not participate in the IDG's. The RN case managers, administrator, DPCS, medical doctor along with the social worker and chaplain attend the IDG meetings and the RN case managers reports back to her team regarding what was discussed or their concerns. During a telephone interview on 2/10/2023, at 12:20 p.m., in the hospice conference room, LVN 2 stated she does not attend/participate in the IDG and could not recall Patient 1 being a full code. A review of the agency's undated policy and procedure titled, "Patient Care- General policy # 819 Interdisciplinary Group", indicated that hospice designates an interdisciplinary Group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The IDG members provide the care and services offered by the hospice, and the IDG supervises the care and services. The Hospice designates a registered nurse to coordinate care and the implementation of the POC for each patient. It also indicated, documentation in the clinical record reflects that the plan of care was reviewed and revised. At a minimum, the review incudes: a) advance directives and code status; b) implementation of IDG plan of care in all setting; c) documentation of IDG findings and decisions about care plan revisions and actions.

Based on record review and interview, the hospice agency failed to ensure entries in the clinical record were correct and readily available to the patient's physician and staff for one of five patients (Patient 1). This deficient practice resulted in the patient's care records not being validated for the care received. --- A review of Patient 1's clinical record revealed the following discrepancies of patient information as follows: a. A review of Patient 1 electronic clinical record indicated a start of hospice care date of 10/29/2021, with a terminal diagnosis of Parkinsons Disease,( A disorder of the central nervous system that affects movement , often including tremors) Dementia,( a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking.) pressure ulcer ( injury to the skin and underlying tissue very deep reaching into muscle and bone resulting from prolonged pressure on the skin) on right elbow, stage 4, pressure ulcer left elbow stage 2. b. A review of the initial Nursing Assessment by the RN dated 10/29/2021, indicated Patient 1 was bedbound, obtunded (Reduced level of alertness), unable able to make her need known, does not respond to stimuli, all extremities contracted, with stage 4 pressure ulcer to right elbow, stage 2 pressure ulcer to left elbow, and Patient 1 required maximum assistance. The RN documented the Physician Order for Life-Sustaining Treatment (POLST) was left at the General Acute Care Hospital (GACH). c. A review of the Patient 1's IDG Comprehensive Assessment and Plan of Care Update Report with the IDG date of 11/4/21, page 1 of 9 , indicated Patient 1 was a 90 year old female who was admitted to the HA on 10/29/21, a full code with diagnoses of Parkinson's disease, dementia , dysphagia ( difficulty swallowing food or liquids), Chronic Obstructive Pulmonary Disease, (COPD a condition involving constriction of the airways and difficulty /discomfort breathing) heart failure, ( a chronic condition in which the heart does not pump blood as well as it should) contracture( a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and pressure ulcer of right elbow, stage 4 on routine care. d. A review of Patient 1's Hospice IDG Comprehensive Assessment and Plan of Care Update Report with the IDG, page 3 of 9 electronically signed by RN 2 indicated the following," IDG clinical notes: Patient continues to meet hospice criteria as evidence by PT is 74 YO Female with a terminal diagnosis of CAD, and comorbidities of HTN, AFI, COPD, cervical disectomy, Thoracic lumbar cord compression, hypothyroidism, HX of stage 3 left buttock decubitus ulcer, Anemia, protein calorie malnutrition, spinal stenosis. e. Patient is oriented to self, place, and time, make needs known appropriately, with some confusion at times. Patient is able to feed self, requires moderate assist with turning to her side in bed but requires moderate to max assist with all other ADL's. The diagnosis was End stage CAD (coronary artery disease). f. Review of IDG Comprehensive Assessment and Plan of Care Update Report page 4 of 9 electronically signed by RN 2 indicated the plan of care reviewed with IDG team/Family member 1 (FM1- the full name of FM1 is incorrect) and BC owner. g. A review of page 5 of 9, of the IDG Comprehensive Assessment and Plan of Care Update Report electronically signs by RN 2 indicated " PT is in Board and Care (BC) and facility owner to administer meds. h. Continued review of page 5 of 9, electronically signed by hospice Social worker stipulates, " IDG admit Clinical Note: Patient is an 88 year old female . Initial eval completed, Code status: DNR. However, MSW to follow up with son at later time regarding completing POLST form. i. A review of LVN 2, Visit Note Report and Patient information report dated 11/3/21 indicated, "Patient 1 is absent of life evident by absence of vital signs under routine level of care. FM1 grieving appropriately, emotional support provided. Confirmed mortuary." j. A review of patient 1's Patient Information Report dated 11/3/21, electronically signed by the MSW indicates," MSW make telephone call to FM1 regarding follow-up of mortuary information as patient passed away. FM1 was not aware that patient had passed away this morning and was emotional and tearful throughout phone call. MSW allowed patient to vent sadness as FM1 was hopefully that patient would live longer. FM1 reports that there is no mortuary arrangements in place at this time." k. A review of the Patient Information Report, indicated Patient 1 was a 90 year old female that resided in a skilled nursing facility. During an interview with Family member 1 (FM1) on 2/10/21, at 6:48 pm., he stated Patient 1 was 90 years old, bedbound, unresponsive to anything, and had a feeding tube to feed her. He stated he reviewed Patient 1's clinical records sent to him by the agency which had a lot of inconsistencies. FM 1 stated he was not informed by LVN2 of Patient 1's passing and was informed by the social worker who called later. A review of the agency's policy and procedure titled Clinical Records Policy #701 Contents and Authentication revised October 17, 2022, indicates," A clinical record containing past and current findings is maintained for each patient. The clinical record contains correct clinical information that is available to the patient's attending physician and hospice staff."

Based on record review and interview, the hospice failed to ensure there was a physician's order for the second dose administration of Morphine sulfate to be administered to one of 5 sample patients. (Patient 1), and failed to clearly identify the route in which the medication was to be delivered. This deficient practice resulted in the LVN giving the medication without a physician's order. --- Findings: On 2/10/23, a review of Patient 1 electronic clinical record indicated a start of hospice care date of 10/29/2021, with a terminal diagnosis of Parkinsons Disease,( A disorder of the central nervous system that affects movement , often including tremors) Dementia,( a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking.) pressure ulcer ( injury to the skin and underlying tissue very deep reaching into muscle and bone resulting from prolonged pressure on the skin) on right elbow, stage 4, pressure ulcer left elbow stage 2. A review of Patient 1's ";Patient Information Report" on page one indicated a referral date for patient 1 of 10/22/2021. On page 3 of the agencys ";Patient Information Report", indicated Patient 1 was a full code A review of Patient 1's ";Physicians Certification for Hospice Benefit, ";for the first 90-day period from 10/29/2021 to 1/26/2022,indicated Patient 1s terminal diagnosis was Parkinsons Disease. A review of Patient 1s ";Initial order and Plan of Care dated 10/29/2021, indicated the SN visit frequency for Patient 1 was two times a week for two weeks, 1 time a week for 12 weeks 3 as needed RN visits for agitation, shortness of breath (SOB) or any other change in condition. Review of LVN 2 Visit Note Report dated 11/1/2021, indicated Patient 1 had a temperature (temporal) of 101.3, with labored respirations of 32 breaths per minute. Continued review of patient 1s Visit Note report in the narrative section indicated, "; Patient breathing is labored 32 breaths per minute on O2@ 2LPM via nasal cannula. Skin is cool to touch, clammy, sweating noted, checks redenned, flushed. Temp 101.3, cooling measures applied. Increased o2 to 4 LPM, no relief of labored breathing or shortness of breath. Morphine 0.25ML administered per LNV sublingually and Acetaminophen 650 mg., suppository administered rectally, at 12:30 pm.,1:00 PM., patient continues with labored breathing, no decrease in breathing ,32. Ativan 0.5 mg. tab provided via G-Tube. 1:52 pm., no relief of shortness of breath, Temp decreased to 100.1 continued cooling measures. Remains on 4LPM o2 via nasal cannula. Communicated with Medical Director with orders to administer 0.25 ML of Morphine sublingually X 1. 2:15 PM., patients respiration have decreased to 22 relief of shortness of breath noted. Wound care provided per treatment nurse at facility. Assisted with care, tolerated well. Review of the IDG Summary report and Client Medication report indicated a physician ordered, Morphine concentrated 100mg/5 5-20 mg ML( 20 MG/ML) Oral solution for pain and dyspnea( Shortness of breath) with special instructions as follows: Give 5 MG (0.25 ML) for mild pain 1-3 or mild dyspnea, Give 10 MG(0.5ML) for Moderate 4-6 pain or moderate dyspnea. Give 20 MG(1ML) for severe pain 7-10 or severe dyspnea. Give via G Tube if PO is compromised every 4 hours.. During an interview with the VP of clinical operations and the QAPI Managerin the agency conference room on 2/10/23, at 2:29 pm.they both were asked what method of medication deliver is PO. One said by mouth and the other said sublingual. Concurrent review of LVN 2's Visit notes dated 11/1/21, indicated she gave the morphine medication sublingually and twice within a 2 hour period. The VP of clinical operations stated the order should have specified if PO is by mouth or suglingual and that there should have been another order pf Morphine on top of the prior order to specify with in 2 hours/ The agency could not provide documented evidence of the physician's order for the second administration of morphine Policy and Procedure on Patient Care- General #822 Medication, Medical Supplies & DME Management undated, indicates, " all medication must be administered within acceptable standards of practice.

Based on observation, interview, and record review, the hospice agency staff failed to ensure coordination of care with the assisted living facility and updating IDG pertaining to ongoing use of a discontinued medication, review of all current medications, and inputting a new verbal medication order for one of 5 sample patients (Patient 3). This deficient practice placed the patient at a potential risk for medication error which could affect the overall health status and resulted in patient not receiving medications prescribed by physician, and receiving a medication discontinued by the physician. Findings: During a review of Patient 3's Certification of Terminal Illness (CTI) dated 8/1/2022, the CTI indicated the patient was admitted to the hospice agency on 8/01/2022, with primary diagnosis of end stage heart failure. During a review of Patient 3's "POC Summary" dated 2/9/2023, the POC Summary indicated the Skilled Nurse (SN) visit was once a week, the Medical Social Worker (MSW) will visit twice a month, and the hospice aid (HA) will visit twice a week for eight weeks, then once a week for a week. During a review of Patient 3s ";Client Medication Report" dated 2/9/23, the medication profile listed a discontinued order for Losartan potassium (medication to lower blood pressure) 50mg 1 tablet to be taken by mouth twice a day. The medication was discontinued on 12/1/2022. On 2/10/2023, at 10:40 a.m., joint visit was made with Registered Nurse 1 to the Assisted Living facility where Patient 3 resided. During an observation on 2/10/2023 at 10:53 a.m. with Registered Nurse 1 (RN1) in the Assisted Living medication room, the medication Losartan was observed in Patient 3s medications. During an interview on 2/10/2023, at 10:54 a.m., with RN 1, RN 1 stated, ";I see how this medication was discontinues on 12/1/2022. The nurse should have been communication with the assisted facility staff to stop this medication." During an interview on 2/10/2023 at 10:55 a.m. with assisted living care coordinator, she stated, ";if a medication is discontinued, this should be communicated by the hospice nurse to us. Patient 3 received a dose of Losartan this morning. It was never communicated, and we even received a refill on 1/18/2023 of this medication. Why would we receive another box of the medication more than a month after it was discontinued. Apparently, there is no communication with the pharmacy either. Had we received communication we would have destroyed the medication." During a review of Patient 3s ";Client Medication Report" dated 2/9/2023, a medication profile indicated an order for Aspirin 81 mg (blood thinning medication) to be taken 1 tablet by mouth daily. During an observation on 2/10/2023 at 11:05 a.m. there was no Aspirin 81mg in Patient 3s medications provided by assisted living med tech 1. During an interview on 2/10/2023 at 11:06 am with assisted living care coordinator, she stated, ";we dont have Aspirin 81mg in our records. We never got it." During an interview on 2/10/2022 at 11:08 a.m. with RN 1, RN 1 stated, ";I dont know what happened here. I see the Aspirin 81mg on Patient 3s medication profile and an active order. The nurse should have reviewed the medications with the assisted living facility to see what they have versus what medications are listed in our medication profile." During a record review of ";physicians orders" in the assisted living facility hospice binder, there was a carbon copy of a physician order dated 2/2/2023 for Gabapentin (medication for peripheral nerve pain) 100mg to be taken once a day at bedtime for neuropathic pain (nerve pain). During a review of ";Visit Note Report" dated 2/2/2023, indicated ";Patient complain of new shooting pain that worsens at nights in right hand for about a month, MD add gabapentin at bedtime." During a review of ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 2/9/2023, there was no mention of the new pain or medication by nurse. During a review of ";Client Medication Report" dated 2/9/2023, Gabapentin was not listed on the medication profile. During an interview on 2/10/2023, at 2: 45p.m., with Vice President of Clinical Operations, she stated, ";we reviewed the whole chart for Patient 3 and we were unable to find an order for Gabapentin. There is mention about it in the visit note dated 2/2/2023 but not in the IDG and Plan of Care or the medication profile. Our process is any time there is a verbal MD order given, the nurse writes it in a form and then inputs it in the system so it will be in the electronic file and go to pharmacy. We then discuss it in IDG as it is a change. What must have happened is the nurse didnt input the order in the system after receiving it from the physician. We were not able to find the first page to the carbon copy that was in the hospice binder either." During a review of the agency's policy titled " Initial and Comprehensive Assessment" (undated), the policy indicated "; 5). the comprehensive assessment identifies the physical, medical, psychological, emotional, and spiritual needs related to the terminal illness and takes into consideration the following factors.. m). a review if all the patients prescription and over-the-counter drugs and alternative treatments that could effect drug therapy..." During a review of the agencys policy titled ";Coordination of Services" (undated), the policy indicated ";7. IDG members facilitate the coordination of care by frequent written and oral communication among each other and other non-hospice care providers and care provided under arrangements. 8. Documentation if any communications is included in the clinical record. The regular meetings of the interdisciplinary group include a review of the continuity, coordination of care, and effectiveness of care for each patient on service....11. Ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions are facilitated through written and oral communications."

Observed in Document Review. In 6 of 7 complaint reports reviewed, the organization did not follow their policy regarding grievances and complaints. According to organizational policy Grievance and Complaints No. 307, complaints will be investigated, and every effort will be made to resolve the issue. Complaints, the investigation, and responses to patients/families will be documented, maintained, and included as part of the Quality Assessment Performance Improvement Program. For example, on review of RR#8, it was noted the spouse called with a complaint regarding poor communication from staff. On review of the clinical record, the documentation reflected the communication issues had been addressed and resolved; however, there was no documentation as part of their grievance process to validate the investigation, resolution, and follow through was completed. This was validated with the Vice President of Clinical Operations and the Regional QAPI Manager.

Observed in Patient Home. In 3 of 3 home visits conducted, standard precautions were not used to reduce the risk of infection. According to organizational policy No.9-014 Bag Technique, hand hygiene will be performed prior to entering the bag. During all home visits, the clinicians were observed entering their bag on multiple occasions without first performing hand hygiene. This was validated with the Vice President of Clinical Operations who was present during the visits. Observed in Patient Home. In 3 of 3 home visits conducted, standard precautions were not used to reduce the risk of infection related to disinfection of equipment. According to organizational protocol Bag Technique No. 7.04, reusable equipment should be allowed to air dry after disinfection prior to returning to the bag. During HV#1, the clinician was observed disinfecting their vital sign equipment with an alcohol wipe and placed the equipment immediately back into their bag without allowing the equipment to air dry. During HV#2 and HV#3, the clinician was observed cleaning their vital sign equipment with a Sani-cloth disinfecting wipe and placing the equipment immediately back into their bag without observing the manufacturer's guidelines of a 2-minute contact time. This was validated with the Vice President of Clinical Operations who was present during the visits.

Observed in Record Review. In 1 of 3 home visits conducted in which medications were reviewed, the medication list in the record was inaccurate. During HV#2, it was noted Seroquel was listed on the patient’s medication profile in the record; however, in discussion with the nurse from the facility, the patient does not have an order for Seroquel and is not receiving this medication. This was validated with the hospice nurse and Vice President of Clinical Operations during the visit.