Every finding on record at St Joseph Hospice of Acadiana, LLC

Based on record review and interview, the Hospice agency failed to ensure an initial bereavement assessment was completed for 1 (#7) out of 19 (#1-19) records reviewed. --- Findings: Review of the patients electronic clinical record revealed SOC (start of care) date was 04/08/2024 and the admitting diagnosis was End-Stage COPD (Chronic Obstructive Pulmonary Disease). The benefit period reviewed was 12/04/2024 to 02/01/2025. Further review of the clinical record revealed no documented evidence that an initial bereavement assessment was conducted. On 12/17/2024 at 10:45 AM, S2SED (Senior Executive Director) and S1ED (Executive Director) both confirmed that the patients initial bereavement was not conducted and it should have been completed within 5 days after the patient was admitted.

Condition of participation: Interdisciplinary group, care planning, and coordination of services Condition of Participation for Interdisciplinary Group, Care Planning and Coordination of Services was not met as evidenced by: --- 1.Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure the SN (skilled nurse), MSW (Medical Social Worker), and CH (Chaplain) followed the POC for visits as ordered for 12 (#1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #14) out of 19 sampled patients. 2. Based on record review and interview, the agency failed to coordinate care as evidenced by failing to provide an ongoing sharing of information with the patients non-hospice provider for 1 (#1) out of 19 (#1-#19) sampled patients.

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure the SN (skilled nurse), MSW (Medical Social Worker), and CH (Chaplain) followed the POC for visits as ordered for 12 (#1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #14) out of 19 sampled patients. --- 1. Patient #1. Review of the patients electronic clinical record revealed the start of care date was 08/16/2024. The patients admitting diagnosis was Senile Degeneration of Brain. The benefit period reviewed was 11/14/2024 to 02/11/2025. Review of the patient's POC for benefit period 11/14/2024 to 02/11/2025 revealed an order for SN effective 11/14/2024 2wk1, 4wk5, 3wk7, 1wk1, 4 SN prn visits for symptom management (skilled nurse visits effective the week of 11/14/2024 two visits a week for one week, four visits a week for five weeks, three visits a week for seven weeks, one visit a week a for one week, and four skilled nurse visits as needed for symptom management). Review of the physician orders dated 11/18/2024 revealed a change in the SN visit frequency. The changed order was SN effective 11/17/2024 3wk2, 4wk3, 3wk7, 1wk1 (skilled nurse visits effective the week of 11/17/2024 three visits a week for two weeks, four visits a week for three weeks, three visits a week for seven weeks, and one visit a week for one week). Review of the physician orders dated 11/20/2024 revealed a change in the SN visit frequency. The changed order was SN effective 11/24/2024 2wk1, 4wk3, 3wk7, 1wk1 (skilled nurse visits effective the week of 11/24/2024 two visits a week for one week, four visits a week for three weeks, three visits a week for seven weeks, one visit a week for one week). Further review of the POC revealed an order for MSW effective 11/14/2024 4M1, 5M1, 2M1, 1M1 (Medical Social Worker visit effective the week of 11/14/2024 four visits a month for one month, five visits a month for one month, two visits a month for one month, one visit a month for one month). The POC revealed an order for CH effective 11/14/2024 4M2, 1M2 (Chaplain visit effective the week of 11/14/2024 four visits a month for two months, one visit a month for two months). Review of the patients SN visit notes for the week of 11/14/2024 revealed no evidence that 2 skilled nurse visits were made for that week as ordered. Review of the SN visit notes for the week of 11/17/2024 revealed no evidence that 3 skilled nurse visits were made for that week as ordered. Review of the SN visit notes for the week of 11/24/2024 revealed no evidence that 2 skilled nurse visits were made for that week as ordered. Review of the patients MSW visit notes and CH visit notes for the month between 11/14/2024 to 12/14/2024 revealed no evidence that 4 visits were made for the month as ordered. On 12/16/2024 at 4:30 p.m., an interview was conducted with S2SED (Senior Executive Director) after she reviewed the patients electronic clinical record. S2SED confirmed that the SN, MSW, and CH visits were not made as ordered per the patients benefit period POC dated 11/14/2024 to 02/11/2025. 2. Patient #2. Review of the patients electronic clinical record revealed the start of care date was 11/22/2023. The patients admitting diagnosis was Malignant Neoplasm of Liver and Anus. The benefit period reviewed was 11/16/2024 to 01/14/2025. Review of the patient's POC for benefit period 11/16/2024 to 01/14/2025 revealed an order for SN effective 11/16/2024 1wk1, 2wk4, 1wk5, 4 SN prn visits for symptom management (skilled nurse visits effective the week of 11/16/2024 one visit a week for one week, two visits a week for four weeks, one visit a week for five weeks, and four skilled nurse visits as needed for symptom management). Further review of the POC revealed an order for MSW effective 11/16/2024 4M2, 1M1 (Medical Social Worker visit effective the week of 11/16/2024 four visits a month for two months, one visit a month for one month). The POC revealed an order for CH effective 11/16/2024 4M2, 1M1 (Chaplain visit effective the week of 11/16/2024 four visits a month for two months, one visit a month for one month). Review of the patients SN visit notes for the week of 11/16/2024 revealed no evidence that a skilled nurse visit was made for that week as ordered. Review of the SN visit notes for the weeks of 11/17/2024, 11/24/2024, 12/01/2024, and 12/08/2024 revealed no evidence that 2 skilled nurse visits were made for those weeks as ordered. Review of the patients MSW visit notes and CH visit notes for the month between 11/16/2024 to 12/16/2024 revealed no evidence that 4 visits were made for the month as ordered. On 12/18/2024 at 10:45 a.m., an interview was conducted with S1ED (Executive Director) after she reviewed the patients electronic clinical record. S1ED confirmed that the SN, MSW, and CH visits were not made as ordered per the patients benefit period POC dated 11/16/2024 to 01/14/2025. On 12/18/2024 at 10:55 a.m., an interview was conducted with S3RNED (Registered Nurse Executive Director) S3RNED confirmed that the SN, MSW, and CH visits were not made as ordered per the patients benefit period POC dated 11/16/2024 to 01/14/2025. 3. Patient #10. Review of the patients electronic clinical record revealed the start of care date was 11/27/2024. The patients admitting diagnoses included Heart Failure and Cardiomyopathy. The benefit period reviewed was 11/27/2024 to 02/24/2025. Review of the patient's POC for benefit period 11/27/2024 to 02/24/2025 revealed an order for SN 6wk1, 3wk1, 2wk11, 4 SN prn visits for symptom management (skilled nurse visits six visits a week for one week, three visits a week for one week, two visits a week for eleven weeks, and four skilled nurse visits as needed for symptom management). Review of the patients SN visit notes for the week of 11/27/2024 revealed no evidence that 6 skilled nurse visits were made for that week as ordered. Review of the SN visit notes for the week of 12/01/2024 revealed no evidence that 3 skilled nurse visits were made for that week as ordered. On 12/18/2024 at 10:45 a.m., an interview was conducted with S1ED (Executive Director) after she reviewed the patients electronic clinical record. S1ED confirmed that the SN visits were not made as ordered per the patients benefit period POC dated 11/27/2024 to 02/24/2025. On 12/18/2024 at 10:55 a.m., an interview was conducted with S3RNED (Registered Nurse Executive Director) S3RNED confirmed that the SN visits were not made as ordered per the patients benefit period POC dated 11/27/2024 to 02/24/2025. 4. Patient #14. Review of the patients electronic clinical record revealed the start of care date was 12/04/2024. The patients admitting diagnosis was Malignant Neoplasm of Lower Lobe, Right Bronchus or Lung. The benefit period reviewed was 12/04/2024 to 03/03/2025. Review of the patient's POC for benefit period 12/04/2024 to 03/03/2025 revealed an order for SN 6wk1, 2wk12, 1wk1, 4 SN prn visits for symptom management (skilled nurse visits six visits a week for one week, two visits a week for twelve weeks, one visit a week for one week, and four skilled nurse visits as needed for symptom management). Review of the patients SN visit notes for the week of 12/04/2024 revealed no evidence that 6 skilled nurse visits were made for that week as ordered. On 12/18/2024 at 10:45 a.m., an interview was conducted with S1ED (Executive Director) after she reviewed the patients electronic clinical record. S1ED confirmed that the SN visits were not made as ordered per the patients benefit period POC dated 12/04/2024 to 03/03/2025. S1ED confirmed that the order for the frequency of visits was not followed. S1ED stated that the frequency of visits was added in the schedule incorrectly and confirmed that the error should have been identified at the IDG (Interdisciplinary Group) meeting. On 12/18/2024 at 10:55 a.m., an interview was conducted with S3RNED (Registered Nurse Executive Director) S3RNED confirmed that the SN visits were not made as ordered per the patients benefit period POC dated 12/04/2024 to 03/03/2025. S3RNED confirmed that the orders for frequency of visits were not followed. S3RNED confirmed that the frequency of visits was added in the schedule incorrectly and that the error should have been identified at the IDG meeting. On 12/18/2024 at 3:50 p.m. during the IDG (Interdisciplinary Group) meeting, an interview was conducted with S4MD (Medical Doctor). S4MD stated that he was not aware that the orders for frequency of visits were not being followed. S4MD stated that he was not aware of any missed visits. Patient #5 Review of the patients electronic clinical record revealed a start of care date of 08/31/2024. The patients diagnoses included hypertensive heart disease, and chronic kidney disease with heart failure. The benefit period reviewed was 11/29/2024 to 02/26/2025. Review of the patients POC (Plan of Care) revealed an order for SN (skilled nurse), effective 11/29/2024: 1wk1, 3wk12, 1wk1 (1 time a week for 1 week, 3 times a week for 12 weeks, 1 time a week for 1 week). Review of the skilled nurse visits revealed during the week of 12/01/2024, 2 SN visits were conducted. During the week of 12/08/2024, 2 SN visits were conducted. On 12/17/2024 at 9:40 a.m., S2SED (Senior Executive Director) confirmed patient #5s orders stated that SN visits were to be conducted 3 times a week, and the patient received SN visits 2 times a week. She denied the patient had any missed visits and reported it was an error when entering the orders that should have read as 2wk12 (2 times a week for 12 weeks). She was unable to provide documentation that the order should have entered as 2 times per week. Patient #6 Review of the patients electronic clinical record revealed a start of care date of 10/02/2024. The patients admission diagnosis was of malignant neoplasm of unspecified site of unspecified breast. The benefit period reviewed was 12/01/2024 to 01/29/2025. Review of the patients POC revealed an order for SN (skilled nurse), effective 12/01/2024: 6wk1, 2wk8 (6 times a week for 1 week, 2 times a week for 8 weeks) Review of the skilled nurse visits revealed during the week of 12/01/2024, 2 SN visits were conducted. On 12/17/2024 at 9:40 a.m., S2SED (Senior Executive Director) confirmed patient #6s orders stated that SN visits were to be conducted 6 times a week, and the patient received SN visits 2 times a week. She denied the patient had any missed visits and reported it was an error when entering the orders that should have read as 2wk1 (2 times a week for 1 week). She was unable to provide documentation that the order should have entered as 2 times per week. Patient #9 Review of the patients electronic clinical record revealed a start of care date of 02/09/2024. The patients admission diagnosis was neurocognitive disorder with Lewy bodies. The benefit period reviewed was 12/05/2024 to 02/02/2025. Review of the patients POC revealed an order for SN (skilled nurse), effective 12/05/2024: 1wk1, 2wk4, 1wk4 (1 time week for 1 week, 2 times a week for 4 weeks, 1 time week for 4 weeks) Review of the skilled nurse visits revealed during the week of 12/05/2024, no SN visits were conducted. During the week of 12/08/2024, 1SN visit was conducted On 12/18/2024 at 11.10 a.m., during an interview and record review with S1ED (Executive Director), she confirmed patient #9s visits were not conducted as ordered. She verified patient #9 did not have a visit for week 1, and had 1 visit conducted for week 2. Patient #11 Review of the patients electronic clinical record revealed a start of care date of 06/06/2024. The patients admission diagnosis was malignant neoplasm of the mouth, basal cell carcinoma of the skin of the nose. The benefit period reviewed was 12/03/2024 to 01/31/2025. Review of the patients POC revealed an order for SN (skilled nurse), effective 12/03/2024: 5wk1, 2wk8 (5 times a week for 1 week, 2 times a week for 8 weeks) Review of the skilled nurse visits revealed during the week of 12/03/2024, 2 SN visits were conducted. On 12/18/2024 at 11.10 a.m., during an interview and record review with S1ED (Executive Director), she confirmed patient #11s visits were not conducted as ordered. She verified Patient #11 received 2 SN visits and not 5 as ordered. Patient #3. Review of the patients electronic clinical record revealed a start of care date 07/03/2024. The patients admitting diagnosis was renal cancer. The benefit period reviewed was 10/24/2024 to 01/21/2025. Review of the patient's POC (Plan of Care) for benefit period 10/24/2024 to 01/21/2025 revealed the following orders for: 1. SN effective 10/24/2024 5wk1, 2wk12, 1wk1 and 4 prn visits for symptom management (skilled nurse visits five times a week for one weeks, two times a week for twelve weeks, one time a week for one week and four visits as needed for symptom management). 2. CH effective 10/24/2024 1M4 (Chaplin visits one time a month for four months) Review of the patients October 2024 visit calendar and visit time report revealed one SN visit was made on 10/24/2024, in the first week of the benefit period (10/24/2024 to 10/26/2024), instead of five visits, and there were no Chaplin visits made in the month of October and November 2024. Further review of the patients clinical records revealed no physicians order to change the frequency of the visits. Patient #7. Review of the patients electronic clinical record revealed a start of care date 04/08/2024. The patients admitting diagnosis was End-stage COPD (Chronic Obstructive Pulmonary Disease). The benefit period reviewed was 12/04/2024 to 02/01/2025. Review of the patients POC for benefit period 12/04/2024 to 02/01/2025 revealed an order for SN effective 12/04/2024 2wk1, 3wk8, and 4 prn visits for symptom management (skilled nurse visit two times a week for one week, three times a week for eight weeks, and four as needed visits for symptom management.) Review of the patients visit December 2024 calendar and visit time report revealed that one SN visit was made on 12/04/2024, in the first week of the benefit period (12/04/2024 to 12/07/2024), instead of two visits. A review of the patients previous POC, with a benefit period from 10/05/2024 to 12/03/2024, revealed the following orders: 1. SN effective 10/05/2024 1wk1, 3wk8, 1wk1 and 4 PRN visits for symptom management (skilled nurse visit one time a week for one week, three times a week for eight weeks, one time a week for one week and four as needed visits for symptom management) 2. MSW effective 10/05/24 5M1, 6M1 and 1M1 (master social worker visits five times a month for one month, six times a month for one month and one time a month for one month) 3. CH effective 10/05/24 6M2, 1M1 (Chaplin visits six times a month for one month and one time a month for one month) A review of the patients October 2024 to December 2024 visit calendar and visit report revealed there was no SN visit made for the week of 10/05/2024 and 2 SN visits were made each week from 10/06/2024 to 11/30/2024 (eight weeks), instead of 3 visits per week. The MSW made two visit in October 2024, instead of five visits and one visit in November 2024. Further review revealed there was no Chaplin visits mad in October and November 2024. Patient # 8. Review of the patients electronic clinical record revealed a start of care date 04/07/2024. The patients admitting diagnosis was heart failure. The benefit period reviewed was 12/03/2024 to 01/31/2024. Review of the patients POC for benefit period 12/03/2024 to 01/31//2025 revealed the an order for SN effective 12/03/2024 1wk1, 2wk7, 1wk1 and 4 PRN visits for symptom management (skilled nurse visits one time a week for one week, two times a week for seven weeks and one time a week for one week and four as needed visits for symptom management) Review of the patients December 2024 visit calendar and visit time report revealed that no SN visit made during the first week of the benefit period (12/03/2024 to 12/07/2024) and one SN visit, instead of two visits a week were made the week of 12/08/2024 to 12/14/2024. A review of the patients previous POC, with a benefit period from 10/05/2024 to 12/03/2024, revealed an order for SN effective 10/04/2024 4wk1, 1wk9, and 4 PRN visits for symptom management (skilled nurse visits four times a week for one week, one time a week for nine weeks and four as needed visits for symptom management) Review of the patients October 2024 to December 2024 visit calendar and visit time report revealed that no SN visit made during the first week of the benefit period (10/05/2024 to 10/06/2024). Further review of the patients clinical records revealed no physicians order to change the frequency of the visits. Patient #12. Review of the patients electronic clinical record revealed a start of care date 09/06/2024. The patients admitting diagnosis was atherosclerotic heart disease. The benefit period reviewed was 12/05/2024 to 03/04/2025. A review of the patients POC, with a benefit period from 12/05/2024 to 03/04/2025 revealed an order for SN effective 12/05/24 5wk1, 2wk12, and 4 SN PRN visits for symptom management. (skilled nurse visits five times a week for one week, two times a week for twelve weeks and four as needed visits for symptom management.) Review of the patients December 2024 visit calendar and visit time report revealed one SN visit was made in the first week of the benefit period (12/05/2024-12/07/2024) instead of five visits and one SN visit was conducted, instead of 2 visits the week of Week of 12/08/24 to 12/14/2024. Further review of the patients clinical records revealed no physicians order to change the frequency of the visits.

Based on record review and interview, the agency failed to coordinate care as evidenced by failing to provide an ongoing sharing of information with the patients non-hospice provider for 1 (#1) out of 19 (#1-#19) sampled patients. --- Review of the agencys document titled, Coordination of Patient Care with a revised date of June 2019, read in part... 5. Care will be coordinated with other involved external organizations, e.g., home medical equipment providers, infusion therapy/pharmacy companies and community agencies. Staff will: Share relevant information to facilitate appropriate continuity and care coordination. Review of Patient #1s electronic clinical record revealed the start of care date was 08/16/2024. The patients admitting diagnosis was Senile Degeneration of Brain. The benefit period reviewed was 11/14/2024 to 02/11/2025. On 12/16/2024 at 10:30 a.m., a home visit was conducted at Patient #1s place of residence at an assisted living facility. During the home visit, the surveyor asked the nurse for the information that the hospice agency provide to them regarding the patients services being provided by hospice. The nurse stated that the Director of Wellness would have that information. On 12/16/2024 at 10:55 a.m., an interview was conducted with the Director of Wellness at Patient #1s place of residence. The Director of Wellness stated that the hospice agency has not provided them with any documents regarding the patient since he has been residing there.

Based on record review and interview, the hospice agency failed to ensure a RN (Registered Nurse) made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide to ensure that services ordered meet the patients needs for 1 (#5) out of a total sample of 19 patients. --- Review of patient #5s electronic clinical record revealed the start of care date was 08/31/2024 with diagnoses that included hypertensive heart and chronic kidney disease with heart failure. The certification period reviewed was from 11/29/2024 to 02/26/2025. Review of the patients plan of care revealed orders for the hospice aide ,effective 11/29/2024, 1wk1,5wk12,3wk1 (1 time a week for 1 week, 5 times a week for 12 weeks,3 times a week for 1 week). Review of the hospice aide visit notes revealed visits were made daily 12/02/2024 thru 12/06/2024, 12/09/2024 thru 12/11/2024, 12/13/2024, and 12/16/2024 thru 12/17/2024. Review of the RN visit notes revealed visits were made on 12/02/2024 and 12/09/2024. There was no indication that the RN conducted an assessment of the quality of care and services provided by the hospice aide to ensure that services provided by the hospice aide met the patients needs. On 12/17/2024 at 9:40 a.m., an interview and electronic record review was conducted with S2SED (Senior Executive Director). She reviewed the RN visit notes from 11/29/2024 to 12/17/2024, and confirmed there was no documentation that the RN conducted an assessment of the quality of care and services provided by the hospice aide in the patients home. She confirmed the RN visit for supervision was not scheduled until 12/26/2024, which was greater than every 14 days.

Based on review of policy, observation, and interview, the agency failed to store food in a sanitary manner in the agency's inpatient kitchen. This deficient practice has the potential to affect a census of 2 inpatients. --- Review of the agencys document titled, Patient Food Service with a revised date of 12/18/2024 read in part... F. If food is found to be expired or without date it will be discarded. On 12/18/2024 at 10:05 a.m., an observation of the inpatient unit was conducted with S5RN (Registered Nurse). The kitchen/food prep area was observed. During this observation, the inside of the refrigerator was observed. There was an opened gallon of juice that was not dated. There was an observation of a burrito in a zip lock bag that was not labeled and not dated. There was an observation of an open bag of chicken breasts and chicken nuggets that was not dated. An observation was made of an open container of cranapple juice that was dated August of 2024 in the refrigerator. These items were all confirmed by S5RN and she stated that all items should have been labeled and dated and expired items should been discarded.

Based on record review and interview, the agency failed to provide evidence the patient/family/responsible party were involved in the development of the patients POC (plan of care) for identifying the pain medication and anxiety/agitation medication used in the patients care for 1 (#2) out of 5 sampled patients. --- Review of the agencys policy and procedure for the Plan of Care revealed, ";Purpose: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy: ...The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group...This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. Procedure: ...4. The plan of care will identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail... services needed to meet the patients and family/caregivers needs..." Patient #2. Review of the patients electronic clinical record revealed a SOC (Start of Care) date 7/26/2023. The patients admitting diagnosis was Sepsis. The benefit period reviewed was 7/26/2023 to 10/23/2023. Review of the patient's POC for benefit period 7/26/2023 to 10/23/2023 revealed an order, ";Admit... service for GIP (General in Patient) symptom management of pain... Meds: Morphine 4mg/ml (milligrams/milliliter) 1ml IVP (intravenous push) q 2h prn (every two hours as needed) pain, SOB (Shortness of Breath); Ativan 2mg/ml 1ml IVP q 2h prn anxiety..." Review of the patients POC for benefit period 7/26/2023 to 10/23/2023 revealed that there was no evidence the skilled nurse identified the medications that were ordered for pain management and agitation. Further review of the POC under orders of discipline and treatment section revealed, ";Hospice nurse to monitor patients pain level and report ineffective pain control to the physician..." The plan of care did not identify the medications ordered for pain management and anxiety/agitation. Review of the patients Hospice POC Report pathway for Hospice Skilled Nursing revealed, ";...Need for skilled teaching regarding pain/altered comfort-Hospice; Instructed regarding pain control measures; Instructed patient/caregiver to notify hospice nurse of any significant change in pain intensity or if pain medication is not adequately controlling pain; Patient/caregiver will verbalize/demonstrate understanding of pain management measures; Patient/caregiver understands need to report changes in pain level to hospice staff; Anxiety/Terminal Agitation-Hospice; Instructed regarding cause of anxiety/terminal agitation; Instructed regarding measures to manage anxiety/agitation; Patient/caregiver verbalizes understanding of origin/cause of anxiety/terminal agitation; Patient/caregiver verbalizes/demonstrates appropriate measures to minimize/control anxiety/agitation..." There was no evidence of the medications that were ordered for pain management and control of anxiety/agitation. Review of the patients SN (Skilled Nurse) visit note dated 7/27/2023 at 7:00 a.m., revealed the patient received Morphine 2 mg, 1 dose for pain over the past 24 hours. Also, Ativan 2 mg was administered IVP for restlessness and agitation." Review of the patients SN visit note dated 7/27/2023 at 7:00 p.m., revealed the patient received Morphine 2 mg, 2 doses for pain over the past 24 hours. Review of the patients MAR (Medication Administration Record) for benefit period 7/26/2023 to 10/23/2023 revealed the patient was administered Morphine 4 mg intravenously on 7/26/2023 at 9:20 p.m., on 7/27/2023 at 10:20 p.m., on 7/28/2023 at 12 midnight, on 7/29/2023 at 5:05 a.m., and on 8/1/2023 at 3:05 a.m. Further review of the MAR revealed the patient was administered Ativan 2 mg injection on 7/27/2023 at 4:44 p.m., on 7/29/2023 at 5:05 a.m., on 7/29/2023 at 9:35 p.m., and on 8/1/2023 at 3:05 a.m. Review of the patients Complaint Report dated 8/5/2023 at 8:27 a.m. revealed, ";Description: On August 5, 2023, a complaint was received regarding patient being given morphine when caregiver did not want this given..." On 8/29/2023 at 8:25 a.m., an interview was conducted with S2DON (Director of Nurses). S2DON stated the patients daughter made a complaint because she did not want the patient to receive Morphine. S2DON stated that S3CLPC, (Clinical Liaison of Patient Care) was the person responsible for explaining and providing the information for the inpatient admitting process and explaining the different levels and services provided for hospice. On 8/29/2023 at 8:35 a.m., an interview was conducted with S4RN (Registered Nurse). S4RN stated the patient was admitted for GIP. She stated the patient was admitted for pain management and agitation control with Morphine and Ativan. S4RN stated that Morphine and Ativan were standard protocol for pain and agitation. S4RN verified that she was informed the patients daughter did not want the patient to have morphine. S4RN could not recall the date she became aware of the patients daughters request for the patient not to receive Morphine. On 8/29/2023 at 9:20 a.m., an interview was conducted with S5RN. S5RN stated that Morphine and Ativan were standard protocol for pain and agitation. S5RN stated the patient was admitted for GIP. S5RN confirmed the patients daughter did not want the patient to receive Morphine. S5RN could not recall the date she became aware of the patients daughters request for the patient not to receive Morphine. On 8/29/2023 at 9:52 a.m., an interview was conducted with S3CLPC (Clinical Liaison of Patient Care). S3CLPC stated the patient was admitted for GIP services for symptom management because he was admitted from the hospital. S3CLPC stated that she met with the patients daughter after she was contacted by the hospital case manager. S3CLPC stated that she explained to the patients daughter the patient qualified for GIP services for symptom management which included IV medication to manage pain and SOB. S3CLPC stated that she was only aware that the patients daughter did not want any controlled substances in the patients home and that she did not think that it was in reference to the inpatient GIP nursing staff administering Morphine and Ativan. On 8/29/2023 at 11:57 a.m., an interview was conducted with S1ED (Executive Director). She stated that to her knowledge, the patients daughter told the nursing staff that she did not want the patient to have Morphine on 7/31/2023 or 8/1/2023. On 8/29/2023 at 1:00 p.m., an interview was conducted with S2DON. S2DON stated that the admission process was not conducted following standard protocol. S2DON stated that because of that, the care planning was not conducted face to face with the patients daughter. S2DON stated that she did not know when the patients daughter voiced she did not want the patient to have morphine. S2DON stated that Morphine and Ativan were standard protocol for pain and agitation management regardless if patient was respite or GIP. S2DON stated she did not know what was discussed with the patients daughter during the care planning process. After review of the patients POC, S2DON agreed that the patients POC did not specify what pain medications would be used to control the patients pain and that the POC should identify the specific pain medication used to control a patients pain.

Based on record and policy and procedure review and interview, the agency failed to ensure the patient/family right to be informed of the patients condition when patient #2 had a fall for 1 out of 2 (#1, #2) patients with falls out of a total sample of 5 patients. --- Review of the agencys policy and procedure for Rights and Responsibilities revealed, ";Purpose: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. Policy: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. A patient may designate someone to act as his/her representative in accordance with state law. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by (Hospice Agency)... To assist with fully understanding patient rights and responsibilities, all policies are available to organization personnel, the patient, and his/her representatives as well as other organizations and the interested public. Procedure: 1. G. The right to be informed of his/her condition...." Patient #2. Review of the patients electronic clinical record revealed SOC (start of care) date was 9/29/2022 and the admitting diagnosis was Malignant Neoplasm of Colon. The patient was admitted for GIP (General Inpatient care). The benefit period reviewed was 9/29/2022 to 12/27/2022. Review of the patient's POC for benefit period 9/29/2022 to 12/27/2022 revealed an order for SN 7wk1, 12wk1 ( skilled nurse visits seven times a week for one week, skilled nurse visits 12 times a week for one week). Review of the patients Coordination Notes dated 10/1/2022 at 5:11 p.m. revealed, ";...2:00 p.m. up to chair after walking about 50 feet. Sat in chair and offered some ice cream was eating it and went to grab his (drink) knocking over (drink) and bed side table... Stood up and fell back losing balance and falling on floor onto his buttock using left hand to block fall... 5:30 p.m. c/o (complain) pain now to back and neck MSIR (Morphine Sulfate Immediate Release) 15 mg given po (by mouth) for c/o of pain at 6 (6/10 pain scale).... There was no evidence in the clinical record the patients representative was informed the patient had a fall. On 4/3/2023 at 2:05 p.m. a telephone interview was conducted with S3RN (Registered Nurse). S3RN stated that she was on duty on 10/1/2022 when the patient had a fall. S3RN confirmed that she did not notify the patients son concerning the fall. She stated that she did not report the fall to the patients son because the patient did not have an injury. She stated that she remembered the patients son being upset about not being notified about the fall. S3RN stated that she should have notified the patients son concerning the fall. On 4/3/2023 at 2:50 p.m., an interview was conducted with S1ED (Executive Director). She stated that if a patient had a fall in the GIP setting that the nursing staff should have notified the patients representative concerning falls. On 4/4/2023 at 8:47 a.m., an interview was conducted with S2RCS (Regional Clinical Supervisor). She stated if the patients family was not present in the GIP setting when the patient had a fall that the patients representative should have been notified when the patient had a fall.

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure HA (hospice aide) visits were made as ordered per the POC for 1 (#2) out of 13 sampled patients. Findings: Patient #2. Review of the patient's electronic clinical record revealed a start of care date 3/17/2021. The patient's admitting diagnoses included Chronic Kidney Disease Stage 3. The benefit period reviewed was 11/12/2021 to 1/10/2022. Review of the patient's POC for the benefit period 11/12/2021 to 1/10/2022 revealed an order for HA visits effective 11/14/2021 4wk1, 5wk7, 1wk1 (hospice aide visits effective week of 11/14/2021 four times a week for one week, hospice aide visits five times a week for seven weeks, hospice aide visit one time a week for one week). Review of the patient's HA visit notes revealed that there was no evidence that 4 HA visits were made for the week of 11/14/2021. On 1/12/2022 at 12:10 pm, S1DON (Director of Nurses) reviewed the patient's electronic clinical records and confirmed that there was no evidence that 4 HA visits were made for the week of 11/14/2021.

Based on record review and interview, the agency failed to ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including the frequency of services necessary to meet the specific patient and family needs as evidenced by documentation of incorrect frequencies for SN (Skilled Nurse) on the patient's plan of care for 3 (#5, #6, #9) and for CH (Chaplain) visits for 1 (#6) out of a total sample of 13 sampled patients. Findings: Patient #5. Review of the patient's electronic clinical record revealed a start of care date of 12/2/2021. The patient's admitting diagnoses included Active Breast Cancer and Acute Kidney Failure. The benefit period reviewed was 12/2/2021 to 3/1/2022. Review of the patient's POC for the benefit period 12/2/2021 to 3/1/2022 revealed an order for SN visits 6wk1, 2wk12, 1wk1 (skilled nurse visits six times a week for one week, two visits a week for twelve weeks and one visit a week for one week). Review of the patient's SN visit notes revealed that there was no evidence that 6 SN visits were conducted the week of 12/2/2021. Patient #6. Review of the patient's electronic clinical record revealed a start of care date of 4/15/2021. The patient's admitting diagnoses included Acute Myeloid Leukemia and Atherosclerotic Heart Disease. The benefit period reviewed was 12/11/2021 to 2/8/2022. Review of the patient's POC for the benefit period 12/11/2021 to 2/8/2022 revealed an order for SN effective 12/11/21 4wk1, 2wk8 (skilled nurse visits four a week for one week, two visits a week for eight weeks) and CH 4m1, 2m1 (chaplain four visits for one month, two visits for one month). Review of the patient's SN visit notes revealed that there was no evidence that 4 SN visits were conducted the week of 12/11/2021. Review of the patient's chaplain visit notes revealed that only 2 visits were conducted for the month of December 2021 instead of 4 as ordered per the patient's POC. Patient #9. Review of the patient's electronic clinical record revealed a start of care date 12/14/2021. The patient's admitting diagnoses included Dissection of Abdominal Aorta. The benefit period reviewed was 12/14/2021 to 3/13/2022. Review of the patient's POC for the benefit period 12/14/2021 to 3/13/2022 revealed an order for SN visits 6wk1, 2wk3, 1wk1, 2wk6, 3wk1, 2wk1 (skilled nurse visits six times a week for one week, two visits a week for three weeks, one visit a week for one week, two visits a week for six weeks, three visits a week for one week, two visits a one week). Review of the patient's SN visit notes revealed that there was no evidence that 6 SN visits were made for the week of 12/14/2021 and there was no evidence that 2 SN visits were made for the week of 12/19/2021. On 1/13/2022 at 10:40 am, S1DON reviewed the patient's electronic clinical record and stated that the frequency visits on the POC included prn (as needed) visits. S1DON stated that the frequency for SN and CH visits was written incorrectly on the POC.

Based on record review and interview, the agency failed to ensure it develop and maintain a system of communication and integration to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement as evidenced by failing to have the patient's POC and updated IDG (Interdisciplinary Group) notes available during visit at patient's residence (nursing home) for 1 (#3) out of 4 (#1-#4) home visits made out of a total sample of 13 patients. (#3) Findings: Patient #3. Review of the patient's electronic clinical record revealed a start of care date 12/9/2021. The patient's admitting diagnoses included Pulmonary Heart Disease. The benefit period reviewed was 12/9/2021 to 3/8/2022. On 1/11/2022 at 12:58 pm, a visit was made to the patient's residence (nursing home). S3RN (Registered Nurse) was present during the visit. During the visit, the surveyor requested to review the patient's POC and IDG notes. S3RN stated that the patient's hospice binder that contained all those documents was not in the nursing home. The patient's nurse in the nursing home confirmed that the patient's hospice binder was not available. On 1/12/2022 at 9:05 am, an interview was conducted with S1DON (Director of Nurses). S1DON stated to ensure that coordination of care and services were provided that all current notes for the last 2 weeks from IDG meetings and POC were kept in a hospice binder at the nursing home. S1DON stated that the hospice binder should have been in the nursing home facility.

Based on observations, interview and policy review, the agency failed to store food in a sanitary manner in the agency's inpatient kitchen. This deficient practice has the potential to affect a census of 14 inpatients. Findings: On 1/13/22 at 12:05 pm, an observation of the inpatient kitchen was conducted with S2RNDirIP. An opened gallon of whole milk with an expiration date of 1/9/22; an unlabeled and undated plastic storage container of food; and an opened, unlabeled and undated package of sliced ham were observed inside of the kitchen's refrigerator. Further observation of the kitchen, revealed an opened, undated/unlabeled jar of peanut butter with lid resting loosely on top and not screwed shut. On 1/13/22 at 12:10 pm, S2RNDirIP stated that all food items should be labeled and dated. He further stated that the expired milk should have been disposed of on 1/9/22. Review of the facility's policy for food storage provided by the agency revealed the following: ...all items placed in the refrigerator or freezer must be labeled and dated ...inpatient staff disposed of items left in the refrigerator longer than one week ...