Every finding on record at Solace Hospice LLC

Based on observation, record review, and interview, the agency failed to ensure the patient was treated with respect and dignity for 1 of 2 home visits of patients residing in a nursing facility (Patient #2). Findings include: --- 1. Review of an agency document titled ";Hospice Patient Rights and Responsibilities" indicated the patient had the right to have their person treated with respect and dignity. 2. Record review included the POC for benefit period 09/16/2024 – 12/14/2024 that indicated Patient #2 had an alteration in neurological status with chronic confusion related to cognitive changes from late effects of a stroke. During a home visit on 10/16/2024 beginning at 9:00 AM, the director of clinical services was observed providing personal care to Patient #2. Patient #2 was lying in a hospital bed in a private room at Entity 2 with open window blinds in the room. The director of clinical services was observed removing Patients sweatshirt and disposable brief, rolled Patient to the right side, cleaned buttocks, and applied barrier cream to buttocks, rolled patient to the left side, and secured a clean disposable brief with tape. During an interview on 10/16/2024 at 1:42 PM, when asked what privacy measures should be put into place when providing personal care to Patient #2, the director of clinical services indicated should have closed the window blinds.

Based on interview and record review, the IDG failed to ensure goals were individualized based on the patients current needs for 1 of 3 patients observed at a home visit (Patient #3). Findings include: --- 1. A review of Patient #3s POC dated 9/19/2024 indicated a diagnosis of Alzheimers Disease. The POC evidenced a goal ";Patient will establish a realistic therapeutic regimen that is congruent with their self- determined goals with validation from caregivers." 2. During a home visit with Patient #3 on 10/16/2024 at 8:30 AM, observed Patient #3 and CNA 1 complete a shower. Patient #3 followed simple commands, such as move your hand. Patient #3 did not initiate conversation, and verbal responses were single word answers. Patient #3 often required repeated commands or questions before responding. During an interview on 10/16/2024 at 8:20 AM, CNA 1 indicated Patient #3 declined after a recent bout with COVID and functioning had not returned to baseline. During an interview on 10/17/2024 at 3:29 PM, the Director of Clinical Services indicated the goal was not appropriate for Patient #3s current level of functioning and the goal should have been for the family members, not the patient. The Director of Clinical Services indicated the goal was not individualized to Patient #3s current functional status.

Based on record review and interview, the agency failed to ensure the POC was individualized to include patient interventions based on patient problems identified in the comprehensive assessment for 1 of 2 active records reviewed of patients residing in own home (Patient #5). Findings include: --- 1. Review of an agency policy titled ";The Plan of Care" indicated the POC will be based on the comprehensive assessments and will include individualized interventions. 2. A review of the IDG Summary/Comprehensive Assessment Update for Patient #5 and dated 10/04/2024 included a nursing update entered by the administrator that indicated the RN prefilled the medication box for the next week. Review of the POC for benefit period 09/25/2024 – 11/23/2024 failed to evidence skilled nurse intervention for prefilling the medication box. During an interview on 10/17/2024 at 10:44 AM, the administrator indicated prefills the pillbox for Patient #5. When asked where the intervention for refilling the pillbox could be found, the administrator indicated there was no intervention.

Based on record review and interview, the agency failed to ensure it developed individualized POCs which included measurable outcomes for 3 of 4 active clinical records reviewed of patients residing in nursing facilities (Patient #2,3,6) and for 1 of 2 discharged records reviewed (Patient #7). Findings include: --- 1. The POC policy indicated measurable outcomes (goals) would be included on the POC as a means to determine progress based on the interventions the agency provided. 3. Patient #3s POC, dated 9/19/2024 included a goal of ";Incontinence of bowel and bladder will be managed by caregivers." During an interview on 10/17/2024 at 3:29 PM, the Director of Clinical Services indicated the goal was measurable because Entity 1 had a ";changing schedule" to ensure briefs were changed at consistent times. They did not know what the schedule was or where it was tracked. When asked, the Director of Clinical Services indicated they expected an absence of urinary tract infections and no skin breakdown. They indicated those were measurable indicators. 4. A review of Patient #6s POC dated 9/29/2024 indicated a terminal diagnosis of sequelae of cerebral infarction (after effects of a stroke). The POC included goals of ";Patient will have symptoms of fluid volume overload ... controlled within the disease limits" and ";Patient will maintain maximum safety and independence in ADLs [activities of daily living] within the limits of disease process." During an interview on 10/17/2024 starting at 3:29 PM, the Director of Clinical Services indicated the EMR has a set of goals to choose from which limited their ability to identify measurable goals. 5. A review of the POC for Patient #7 dated 9/7/2024 identified a terminal diagnosis of congestive heart failure (the heart does not pump blood as effectively as it should). The POC included a goal of ";Patient will have optimal symptom management through end of life." During an interview on 10/17/2024 starting at 3:29 PM, the Director of Clinical Services indicated this was an issue with the EMR they need to fix. Review of the POC for Patient #2 for benefit period 09/16/2024 – 12/14/2024 identified a terminal diagnosis of sequelae of cerebral infarction (aftereffects of a stroke) and a comorbidity diagnosis of adult failure to thrive (a syndrome of weight loss, poor nutrition and inactivity). The POC evidenced a goal of Skin will heal to maximum potential. During an interview on 10/16/2024 at 1:42 PM, when asked how to measure the goal, skin will heal to maximum potential, the director of clinical services indicated it was not a measurable goal.

Based on record review and interview, the agency failed to ensure the RN provided specific instructions regarding feeding and aspiration precautions for 1 of 1 patient with a home visit observation with an aide (Patient #3). Findings include: --- 1. The aide care plan for Patient #3 included a section for safety precautions. The safety precautions did not include aspiration precautions. A review of the POC dated 9/19/2024 evidenced a nursing intervention of ";... while feeding patient, monitor for delayed coughing or coughing during intake, pocketing of food, wet sounding voice, sneezing when eating, delay of more than 1 second in swallowing, or spitting food. If any of these signs of dysphagia and/ or aspiration is present, remove all food from the oral cavity, and stop feeding." During an interview on 10/16/2024 at 8:20 AM, CNA 1 indicated they had just finished feeding Patient #3 breakfast. During an interview on 10/16/2024 at 9:25 AM, CNA 1 indicated Patient #3 had no safety precautions. During an interview on 10/17/2024 starting at 3:29 PM, the Director of Clinical Services indicated they were unsure if CNA 1 fed Patient #3. The Director of Clinical Services indicated the care plan failed to include the task of feeding Patient #3 and specific aspiration precautions.

Based on observation, record review, and interview, the agency failed to ensure the CNA provided services identified on the care plan and consistent with training for 1 of 1 home visit observations with an aide (Patient #3). Findings include: --- 1. Patient #3s care plan included a nutrition task list which indicated the aide was to encourage fluids. The care plan did not indicate the aide should assist with feeding the patient. During an interview on 10/16/2024 at 8:20 AM, CNA 1 indicated they had just finished feeding Patient #3 breakfast. CNA 1 indicated Patient #3s functional status declined after a diagnosis of COVID and the patient was no longer able to feed him/ herself. During an interview on 10/17/2024 starting at 3:29 PM, the Director of Clinical Services indicated they were unsure if CNA 1 fed Patient #3. They indicated the care plan failed to include feeding the patient and should have included it if CNA 1 was feeding the patient. During a home visit observation on 10/16/2024 at 8:30 AM, observed CNA 1 shower and dress Patient #3. After dressing the patient, CNA 1 transferred the patient into the wheelchair. The wheelchair was unlocked, which allowed it to move during the transfer. During an interview on 10/16/2024 at 9:25 AM, CNA 1 described the process to transfer a patient to a wheelchair. CNA 1 indicated locking the wheelchair as the first step of the transfer.

Based on record review and interview, the agency failed to provide a copy of the discharge summary to the patients attending physician for 2 of 2 discharged records reviewed of patients who revoked the hospice benefit (Patient 4,7). Findings include: --- 1. The policy on Discharge indicated the discharge summary would be completed within 72 hours and sent to the attending physician. 2. The clinical record for Patient #7 evidenced a revocation of the hospice benefit signed and dated by Patient #7 on 10/14/2024. The record failed to evidence a discharge summary. During an interview on 10/17/2024 at 2:50 PM, the Administrator indicated there was no discharge summary. The Administrator indicated a discharge summary was not completed as the patient chose the Medical Director as the attending physician. The Administrator indicated they believed Patient #7 intended to return to the agency after hospital treatment following a fall. Since the patient would return, the Administrator indicated they did not believe a discharge summary was required. Review of the clinical record for Patient #4 evidenced a revocation of the hospice benefit document was signed and dated by Person 4 on 09/11/2024. During an interview on 10/17/2024 at 11:10 AM, when asked to provide evidence of confirmation that the discharge summary was sent to the attending physician, the administrator indicated there was no documentation that the discharge summary had been sent to the attending physician.

Based on record review and interview, the agency failed to ensure a hospice discharge summary was completed for 1 of 2 discharged records reviewed (Patient #7) and failed to ensure the discharge summary included a summary of patients care, current POC, and most recent physician orders for 1 of 2 discharged records reviewed (Patient #4). Findings include: --- 1. The agency discharge policy indicated the agency will send a discharge summary to the attending physician. The summary should include the reason for transfer or discharge, the patients physical and psychosocial status at the time of discharge, including problems requiring follow – up; a summary of the care provided, progress, and response to interventions; the current POC, a copy of the medication profile with active and discontinued medications; physician orders; continuing symptom management needs; follow – up that an IDG team member will provide during the transfer process; pertinent laboratory results; a summary of patient education and understanding of the education; instructions and referrals provided to the patient; existence of Advance Directives (if any); and the date of discharge. 2. Patient #7s clinical record evidenced a Discharge Visit document dated 10/14/2024, completed by the Director of Clinical Services. The visit form indicated ";Accepting Provider Agreed to Assume Primary Care of Patient." The narrative section of the note indicated the Director of Clinical Services called Entity 3, a hospital, and reviewed the medication list, medical history, and the patients involvement with hospice. During an interview on 10/17/2024 at 2:50 PM, the Administrator indicated there was no discharge report and no attending physician other than the hospice Medical Director. The Administrator was unable to identify Patient #7s medical provider prior to hospice care. During an interview on 10/17/2024 starting at 3:29 PM, the Director of Clinical Services indicated they did not know who the patients medical provider was now or when Patient #7 started hospice services. 2 Review of clinical record of Patient #4 included a document titled ";Unattended Discharge Note" dated 09/11/2024 and completed by the director of clinical services. The note included sections with check boxes for notification of discharge and for discharge readiness. The narrative section indicated the reason for revocation and transport of patient to the hospital. The document failed to evidence a summary of patients care, current POC, and most recent physician orders During an interview on 10/17/2024 at 11:10 AM, when asked if the POC, current orders, and care provided would be included with the discharge summary, the administrator indicated no.

Based on record review and interview, the agency failed to coordinate medication orders for 2 of 2 active patients (Patient #2, #3) residing in a nursing or skilled nursing facility. Findings include: --- 1. After the home visit with Patient #3 on 10/16/2024 at 8:30 AM, Entity 1 provided a copy of Patient #3s current orders. Among other medications, the orders included Acetaminophen 500 mg (milligrams). 2. A review of the agency medication list included medications which included but were not limited to Acetaminophen 325 mg. During an interview on 10/17/2024 at 3:29 PM, the Director of Clinical Services indicated Patient #3 received 500 mg of Acetaminophen, not 325 mg. They indicated they corrected the discrepancy that day. When asked, the Director of Clinical Services indicated they would need a printed copy of Entity #1s orders to verify no discrepancies existed. The Director of Clinical Services indicated they did not want to be disruptive to Entity 1 by requesting printed orders. Review of an agency policy titled ";Provision of Care to Residents of Skilled Nursing Facility (SNF)/Nursing Facility (NF) or Intermediate Care Facility (ICF)/Intermediate Care Facility for Individuals with Intellectual Disabilities (IID), indicated hospice will provide medication information to the facility. During the home visit with Patient #2 at Entity 2 on 10/16/2024 at 9:50 AM, Person 5 provided a copy of Patient #2s current medications which included the following medications, but not limited to, Jardiance 10 mg once a day (used to control blood sugar), and Lispro insulin 100 units before meals with sliding scale (progressive increase in pre-meal insulin dose based on blood sugar ranges). Review of the agency medication list included the following, but not limited to, Jardiance 10 mg twice daily, Colace 100 mg daily as needed (stool softener for constipation), and MiraLAX packet daily as needed (laxative for constipation). During an interview on 10/16/2024 at 1:42 PM, when asked what the frequency of Jardiance should be, the director of clinical services indicated once a day and the medication records of hospice and Entity 2 should be the same. When asked where the insulin sliding scale was in the hospice record, the director of clinical services indicated was not in the hospice medication records. When asked why Colace and MiraLAX were in the hospice record and not found in the Entity 2 record, the director of clinical services indicated the records should be the same. 1. Review of an agency policy titled ";Provision of Care to Residents of Skilled Nursing Facility (SNF)/Nursing Facility (NF) or Intermediate Care Facility (ICF)/Intermediate Care Facility for Individuals with Intellectual Disabilities (IID), indicated hospice will provide medication information to the facility. 2. During the home visit with Patient #2 at Entity 2 on 10/16/2024 at 9:50 AM, Person 5 provided a copy of Patient #2s current medications which included the following medications, but not limited to, Jardiance 10 mg once a day (used to control blood sugar), and Lispro insulin 100 units before meals with sliding scale (progressive increase in pre-meal insulin dose based on blood sugar ranges). Review of the agency medication list included the following, but not limited to, Jardiance 10 mg twice daily, Colace 100 mg daily as needed (stool softener for constipation), and MiraLAX packet daily as needed (laxative for constipation). During an interview on 10/16/2024 at 1:42 PM, when asked what the frequency of Jardiance should be, the director of clinical services indicated once a day and the medication records of hospice and Entity 2 should be the same. When asked where the insulin sliding scale was in the hospice record, the director of clinical services indicated was not in the hospice medication records. When asked why Colace and MiraLAX were in the hospice record and not found in the Entity 2 record, the director of clinical services indicated the records should be the same. 3. After the home visit with Patient #3 on 10/16/2024 at 8:30 AM, Entity 1 provided a copy of Patient #3s current orders. Among other medications, the orders included Acetaminophen 500 mg (milligrams). A review of the agency medication list included medications which included but were not limited to Acetaminophen 325 mg. During an interview on 10/17/2024 at 3:29 PM, the Director of Clinical Services indicated Patient #3 received 500 mg of Acetaminophen, not 325 mg. They indicated they corrected the discrepancy that day. When asked, the Director of Clinical Services indicated they would need a printed copy of Entity #1s orders to verify no discrepancies existed.

Based on record review and interview, the hospice failed to ensure hospice orientation and training had been provided to skilled nursing facility (SNF) staff providing care to hospice patients for 2 of 2 SNF agreements reviewed for 2 active patients (Entity 1, 2). Findings include: --- 1. Review of an agency policy titled ";Provision of Care to Residents of SNF/Nursing Facility (NF) or Intermediate Care Facility (ICF)/Intermediate Care Facility for Individuals with Intellectual Disabilities (IID), indicated the hospice will arrange for orientation and training of SNF staff furnishing care to hospice patients. 2. Review of the nursing facility agreements with Entity 1 and Entity 2 indicated the hospice would provide orientation and training to SNF staff providing care to hospice patients. During an interview on 10/17/2024 at 3:25 PM, when asked to see documentation of the hospice training provided to Entity 1 and Entity 2, the administrator indicated gave an agency document titled ";Guide for Facilities Partnering in Hospice Care" to the point of contact at the SNF. When asked who the point of contact was at each SNF, the administrator could not. When asked to see documentation of confirmation the SNF staff received hospice orientation, the administrator indicated there was no documentation to confirm.