Every finding on record at St Liz Hospice, Inc

Observed in Patient Home. In 1 of 1 home visits conducted, the Hospice surveyor noted that the organization had not assessed potential medication-related problems. During HV#1 the nurse performed an incomplete medication assessment during the visit. She reviewed the routine medications only and when I asked about the other medications on the medication list she had the caregiver pull medications out of fridge and closet but did not review the hyoscyamine and DuoNeb. This finding was reviewed with the agency leadership.

Observed in Patient Home. In 1 of 1 home visits, the Hospice surveyor noted that the nurse stated that the board and care staff were trained and educated to do the ordered wound care on the days that the nurse was not there. During HV #1, the patient had wound care orders for every other day but the visit frequency for SN visits was weekly. When I asked the nurse who was doing the wound care on the days she was not there she stated that the board and care staff have been trained to do this. On review of the record, there is not documentation to show that training for board and care staff occurred. This was reviewed with agency leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, the Hospice surveyor noted the goals in patient records were not specific to the intervention and care needs of the patient. For example, in HV#1, the patient had an active wound and there was no goals for the management of the wound. On review of RR #2, the patient has a fall risk score of 14 but no goals to address the fall risk for the patient. This finding was reviewed with organization leadership.

Observed in Patient Home. On 1 of 1 home visits conducted, the Hospice surveyor noted that care was not provided according to the individualized hospice plan of care. During HV#1 the hospice nurse did not follow orders for the wound care to the back. Orders were to clean site with normal saline and pat dry, the nurse cleaned the site with wound cleaner which was not ordered. This was reviewed and discussed with the agency leadership.

Observed in Patient Home. In 1 of 1 home visits conducted the hospice surveyor noted that the organization had not followed accepted standards in performing disinfection of medical supplies and devices. During HV#1 the nurse used Lysol to clean equipment. She wiped down the equipment one time and left it out to dry but it did not remain wet for the 4 minute wet time per manufacturer guidelines, it was dry by 2 minutes after wiping. Agency policy 9.114.1 also states equipment will be cleaned with alcohol or soap and water after use and nurse did not follow the agency policy for cleaning. This was discussed with the agency leadership.

Observed in Patient Home. In 1 of 1 home visits conducted, the medication profile had not been reassessed. Agency policy states that the medication profile will be updated as changes occur. During HV#1, the medication list in the home had not been updated since July 2022 and did not reflect changes that have occurred in the medications. For example, patient had been started on Pepcid and triple antibiotic ointment and these were not reflected on the medication list. This finding was reviewed with agency leadership.

The hospice agency failed to ensure that patient rights and responsibilities were verbally explained to the patient's representative for one of 13 sampled patients (Patient 1), who accepted care prior to admission. This deficient practice resulted in the patient's representative not verbally informed about patient's rights and did not know he could have called 911 (medical telephone emergency) when Patient 1 had a change of condition. (refer to L502) The cumulative effect of these systemic practice resulted in the patient's representative lack of knowledge to revoke hospice service when calling 911 (medical telephone emergency) due to the patient's condition changed. --- .

Based on interview and record review, the hospice agency failed to ensure that patient rights and responsibilities were verbally explained to the patient's representative for one of 13 sampled patients (Patient 1) who accepted for care prior to admission and throughout her care. This deficient practice resulted in the patient's representative not verbally informed about patient's rights and did not know he could have called 911 (medical telephone emergency) when Patient 1 had a change of condition. --- On 1/10/23, a review of Patient 1s electronic clinical record indicated a start of care date of 4/7/22, with a terminal diagnosis of Heart Disease( a type of disease that affects the heart and blood vessel.) A review of Patient 1's Physicians Certification for Hospice Benefit for the fist 90-day period from 4/7/22 to 7/622 indicated patient 1s terminal diagnosis was heart disease. A review of Patient 1's Initial Nursing Assessment visit by the Registered Nurse (RN) dated 4/8/22, indicated Patient 1 was awake, confused, verbally responsive with slurred speech, who does not have the capacity to understand and follow commands or instructions. Patient 1 has dysphagia (difficulty swallowing) and was currently on a Mechanical soft diet with thin liquids as tolerated with aspiration precautions, and patient 1 was total care due to resent hip fracture with no surgery. Patient 1 required maximum assistance from staff from bed/chair transfer. A review of the RNs initial assessment under CPR (cardio-pulmonary resuscitation) Preference (DNR (do not resuscitate)/code status) indicated, ";Attempt CPR/Full code." A review of the Physician Orders for Life Sustaining Treatment (POLST) dated 4/7/22 and signed by Patient 1s representative and the hospice physician indicated Patient 1 was a Full Treatment with attempt to resuscitation. A review of Patient 1's Initial order and Plan of Care dated 4/7/22, indicated the skilled nurse (SN) visit frequency for patient 1 once a week and two visits as needed for symptom management, nursing assessment of caregiver needs, pain management. During a telephone interview with Patient 1s representative on 1/11/22, he stated he was never verbally informed about the patient's right and did not know he could have called 911 (medical telephone emergency) while he watched Patient 1 in rapid change of condition and waited for six hours for a hospice nurse to arrive at the assisted living facility to provide care/treatment to Patient 1. Patient 1's representative stated all consents for hospice and the POLST document were signed via email. Patient 1's representative stated because of this incident he has had to seek therapy due to post traumatic stress and the guilt he did not call 911. During a telephone interview with the agency's intake coordinator on 1/12/23, she stated she sent all consents and documents for Patient 1 to her representative via email and that the licensed nurse doing the assessment should have explained the hospice to the patient's representative. The intake coordinator stated if the licensed nurse did not then the social worker is responsible for explaining the hospice protocol to the patient's representative. A review of the agency's policy and procedure on Comprehensive Assessment revised November 2021 indicated "A comprehensive patient assessment will be performed by the hospice IDG (interdisciplinary group) no later than 5 calendar days after the election of hospice care in consultation with the attending physician." The agency's policy and procedure also indicated "During the comprehensive patient assessment, all baseline data and other relevant information will be discussed in the patient's clinical record including at least the following information as relevant: Presence of any Advanced Directive for care and/or discussions with the patient and family/caregiver regarding the withholding of resuscitative services or the withdrawal of life -sustaining treatment."

Based on observation, interview, and record review, the agency failed to update the medication profile for one of 13 sampled patients (Patient 8). This failure had the potential to increase for medication errors which could impact the patient's health condition. --- On 1-11-23, a review of Patient 8s clinical record indicated Patient 8 was admitted to the hospice agency on 9-17-21 with a primary diagnosis of Congestive Heart failure (a build up of fluid in the lungs and surrounding body tissues). A review of Patient 8's Plan of Care dated 1-9-23 indicated Skilled Nurse visits 1-3 times per week, the Hospice Aide visits two times per week, the social worker visit 1 time per month, and the spiritual counselor visit 1 time per month. On 1-12-23 at 10:50 a.m., during home visit at Patient 8's residence, two medications were identified as being incorrect on the medication profile. 1) Banophen 25mg 1 tab PO q 8hrs PRN (not documented on the medication profile, but medication was present during the home visit) 2) Benadryl 25mg 1 tab q 8hrs PRN (on documented on the medication profile but medication was not present during the home visit) On 1-2-23 at 11:00 a.m., in an interview with Licensed Vocational Nurse 1 (LVN 1), she stated the medication profile was not updated for these (2) medications. LVN 1 stated medication profiles should always be updated and current to reflect exactly what the physician orders for the patient. A review of the agencys policy entitled, ";Medication Profile" with a revised date of 11/2021indicated Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on interview and record review, the hospice agency failed to ensure the Conditions of Participation, regarding IDG, Care Planning and Coordination of Services was met. The hospice agency failed to designate an interdisciplinary group composed of individuals who work together to meet the physical, medical, psychosocial, emotional and spiritual needs of the hospice patient and families facing terminal illness in consultation with the patients attending physician, and failed to provide care and services for one of 13 sampled patients, (Patient 1). This deficient practice resulted in lack and delayed care and services to the patients. Refer (L539). The hospice agency failed ensure a registered nurse who was a member of the interdisciplinary group coordinated care and ensures continuous assessment of each patient's needs for one of 13 sampled patients ( Patient 1). This deficient practice resulted in the agency staff not aware of patient 1's full code status and failed to providing the necessary treatment when she had a change in condition, that resulted in delay in providing emergency treatment to the patient. (Refer L540) The hospice agency failed to ensure the hospice agency staff and the assisted living facility (ALF) staff providing care to the patient were inform and educated regarding "Full Code" status (a patient who has indicated via advance directive or instruction to their provider that all resuscitative measures should be taken if their heartbeat or breathing stops) and educated on what to do if the patient had change of condition for one of 13 sampled patients (Patient 1). This deficient practice resulted in a delay of emergency care and services for the patient change of condition. (Refer L544) The cumulative effect of these systemic practice resulted in the hospice agency's inability to ensure the provision of quality care and services in a safe and dignity manner, to the patients and their families. --- .

Based on interview and record review, the agency failed to ensure a registered nurse who was a member of the interdisciplinary group coordinated care and ensures continuous assessment of each patient's needs for one of 13 sampled patients ( Patient 1). This deficient practice resulted in the agency staff not aware of patient 1's full code status and failed to providing the necessary treatment when she had a change in condition, that resulted in delay in providing emergency treatment to the patient. --- On 1/9/23, during the entrance conference with the director of patient care services and the administrator. They both stated that patient 1 was a full code. The administrator stated there was no skilled nurse sent out to visit patient one after LVN 5 visited in the morning on 5/29/22, due to patient 1 being in transition by her gurgling. The administrator and DPCS stated, prior to that day, patient 1 had been un-arousable and not eating . On 1/10/23, a review of Patient 1s electronic clinical record indicated a start of care date of 4/7/22, with a terminal diagnosis of Heart Disease( a type of disease that affects the heart and blood vessel.) A review of the Physicians Certification for Hospice Benefit "; for the fist 90-day period from 4/7/22 to 7/622 indicated patient 1s terminal diagnosis was Heart disease. A review of the initial Nursing Assessment visit by the Registered Nurse (RN) dated 4/8/22, indicated patient 1 was awake, confused, verbally responsive with slurred speech, who does not have the capacity t understand and follow commands or instructions. Patient 1 has dysphagia and is currently on a Mechanical soft diet with thin liquids as tolerated with aspiration precautions, and patient 1 was total care due to resent hip fracture with no surgery. A review of the RNs initial assessment under CPR Preference (DNR/code Status) indicated, ";Attempt CPR/Full code." Review of the Physician Orders for Life Sustaining Treatment (POLST) dated 4/7/22 and signed by patient 1s representative and the hospice physician indicated patient 1 was a Full Treatment with attempt to resuscitation. A review of Patient 1s medical record indicated a start of care (SOC) date of 4/7/22, with a terminal diagnosis of heart disease (a type of disease that affects the heart and blood vessel). A review of the Physicians Certification for Hospice Benefit for the first 90-day period from 4/7/22 to 7/622 indicated, the patients terminal diagnosis was heart disease. A review of Patient1s Initial Nursing Assessment visit by the Registered Nurse (RN) dated 4/8/22, indicated, Patient 1 was awake, confused, verbally responsive with slurred speech, did not have the capacity to understand and follow commands or instructions. Patient 1 has dysphagia (a condition of difficulty of swallowing foods and liquids). Patient 1 was on a mechanical soft diet with thin liquids as tolerated with aspiration (when food, liquids, and other material enters the airway or lungs) precautions. Patient 1 was total dependent with care. A review of the RNs initial assessment under Cardiopulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest (sudden loss of all heart activity) Preference, Do not Resuscitate (DNR), code status indicated, ";Attempt CPR/Full code" (medical personal would do everything possible to save life in a medical emergency). A review of the Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated and signed on 4/7/22 by Patient 1s Representative and the hospice agencys physician, indicated Patient 1 was a full treatment with attempt to resuscitation. On 1/9/23, during the entrance conference with the director of patient care services (DPCS) and the administrator, both stated, Patient 1 was a full code. The administrator stated there was no skilled nurse sent out to visit Patient 1 after LVN 5 visited in the morning on 5/29/22, due to Patient 1s Representative concern of gurgling sounds on breathing. The administrator and DPCS stated, prior to that day, Patient 1 had been not arousable and was not eating . During a telephone interview with Patient 1s Representative (PR) on 1/11/22 stated, Patient 1 had been un-arousable for a few days due to the methadone (a strong drug used to relieve severe pain) the hospice agency had provided for the patients pain due to broken hip from a fall at the assisted living facility. Patient1s Representative stated, when the patient did not receive the methadone, the patient was able to get up and was awake to eat breakfast. The PR stated on 5/28/22, the family requested and notified the hospice agency to stop the methadone. During an interview with LVN 5 via telephone on 1/12/23, at the agency, she stated she was instructed to visit Patient 1 on 5/29/22, to see if she still needed the routine methadone medication ordered. LVN 5 stated Patient 1 was awake and she informed the hospice agency office to continue holding the methadone. LVN 5 stated, she only visits patients with a change of condition and was not aware of Patient 1 was full code. During an interview with the DPCS, on 1/12/23, she could not state the reason, that all licensed disciplines providing care to Patient 1 including the medical director where not aware Patient 1 was a full code with attempted treatment. The DPCS said nothing.

Based on interview and record review, the hospice agency failed to ensure the hospice agency staff and the assisted living facility (ALF) staff providing care to the patient were inform and educated regarding "Full Code" status (a patient who has indicated via advance directive or instruction to their provider that all resuscitative measures should be taken if their heartbeat or breathing stops) and educated on what to do if the patient had change of condition for one of 13 sampled patients (Patient 1). This deficient practice resulted in a delay of emergency care and services for the patient change of condition. --- A review of Patient 1s electronic clinical record indicated a start of care date of 4/7/22, with a terminal diagnosis of heart disease (a type of disease that affects the heart and blood vessel.) A review of Patient 1's Physicians Certification for Hospice Benefit "; for the fist 90-day period from 4/7/22 to 7/622 indicated patient 1s terminal diagnosis was heart disease. A review of Patient 1's the Initial Nursing Assessment visit by the Registered Nurse (RN) dated 4/8/22, indicated patient 1 was awake, confused, verbally responsive with slurred speech, who does not have the capacity t understand and follow commands or instructions. Patient 1 has dysphagia (difficulty of swallowing foods and liquids) and was on a mechanical soft diet with thin liquids as tolerated, with aspiration ((when food, liquids, and other material enters the airway or lungs) precautions. A review of the RNs initial assessment under Cardiopulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest (sudden loss of all heart activity) Preference, Do not Resuscitate (DNR), code status indicated, ";Attempt CPR/Full code" (medical personal would do everything possible to save life in a medical emergency). A review of the Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated and signed on 4/7/22 by Patient 1s Representative and the hospice agencys physician, indicated Patient 1 was a full treatment with attempt to resuscitation. A review of the initial order and Plan of Care dated 4/7/22, indicated the skilled nurse (SN) visit frequency for patient 1 once a week and two visits as needed symptom management, nursing assessment of caregiver needs, pain management. During a telephone interview on 1/12/23, at 11:00am with LVN 1, he stated he works registry with the hospice and gets his information regarding the patients via text. LVN 1 stated he did not know Patient 1 was a full code and he was the nurse assigned to provide continuous care to patient on 5/30/22. LVN 1 stated when he arrive at the facility patient 1 was in distress with high respiration at 52 breaths/minutes and medicated the patient. LVN 1 stated, he could not get a blood pressure, staff helped clean and change her and she passed away around 9:50 am During an telephone interview with LVN 2 on 1/12/23 at 11:15 a.m., via telephone in the agency office, she stated she has cared for patient 1 a few times and was not aware she was a full code. During a telephone interview with LVN 5, on 1/12/23 at 11;30 a.m., in the conference room of the agency she stated on 5/30/22, she was called to the ALF to see if patient 1 still needed her Methadone which was a routine medication, she stated patient 1 was awake a fine. She did not know Patient 1 was a full code. During an interview on 1/12/23 at 11:40 a.m., via telephone with LVN 4, she stated when she arrived at the ALF on 5/29/22 at 9 p.m., Patient 1 was in respiratory distress, she called the medical director, suctioned Patient 1, gave her morphine, stabilized her and informed family of continuous care in the morning. LVN 4 stated she was not aware Patient 4 was a full code or she would have called 911. During a telephone interview with the Medical Director on 1/12/23, she stated she did not know patient 1 was a full code, and that Patient 1 should have been nothing by mouth and she would never have accepted the patient for hospice services, if she knew that Patient 1 was a full code.

Based on interview and record review, the hospice agency failed to ensure that the interdisciplinary group (IDG, groups composed of individuals who work together to meet the physical, medical, psychosocial needs of hospice patient) meet, discussed, and documented, Patient 1's Representatives understanding of hospices agency's services provided to the patient, and agreement with the hospices plan of care for one of 13 sampled patients (Patient 1). This deficient practice resulted in Patient 1's Representative not fully understood the hospice care and services and patient's plan of care. --- A review of Patient 1s medical record indicated a start of care (SOC) date of 4/7/22, with a terminal diagnosis of heart disease (a type of disease that affects the heart and blood vessel). A review of the Physicians Certification for Hospice Benefit for the first 90-day period from 4/7/22 to 7/622 indicated, the patients terminal diagnosis was heart disease. A review of Patient1s Initial Nursing Assessment visit by the Registered Nurse (RN) dated 4/8/22, indicated, Patient 1 was awake, confused, verbally responsive with slurred speech, did not have the capacity to understand and follow commands or instructions. Patient 1 has dysphagia (a condition of difficulty of swallowing foods and liquids). Patient 1 was on a mechanical soft diet with thin liquids as tolerated with aspiration (when food, liquids, and other material enters the airway or lungs) precautions. Patient 1 was total dependent with care. A review of the RNs initial assessment under Cardiopulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest (sudden loss of all heart activity) Preference, Do not Resuscitate (DNR), code status indicated, ";Attempt CPR/Full code" (medical personal would do everything possible to save life in a medical emergency). A review of the Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated and signed on 4/7/22 by Patient 1s Representative and the hospice agencys physician, indicated Patient 1 was a full treatment with attempt to resuscitation. A review of the Initial order and Plan of Care (POC) dated 4/7/22, indicated the skilled nurse (SN) visit frequency for Patient 1 once a week and two visits as needed symptom management, nursing assessment of caregiver needs, pain management. During a telephone interview with patient 1s representative on 1/11/22, stated, he was never verbally informed about the patients right and no one from the hospice agency explained to him nor did he know that he could revoke hospice services at any time. Patient 1's representative stated all consent for hospice and the (POLST) was sign via email through docu-sign . During an interview with the intake coordination via telephone on 1/12/23, stated she sent all consents and document for Patient 1 to the Patient 1's Representative via email and the social worker was responsible for explaining the hospice protocol.

This Condition is not met as evidence by: Base on interviews and record review, the hospice agency failed to ensure that the Condition of Participation regarding Organization and Administration Services was met as follows: The hospice agency failed to ensure nursing services were made routinely available on a 24-hour basis 7 days a week when reasonable necessary to meet the needs of the patient and family for one of 13 sampled patients (Patient 1) as indicated in the agency's policy on On-Call/Weekend Service. For Patient 1, while visiting the patient, the patients representative had observed Patient 1 had gurgling sound, from 3:30 p.m. to 9:00 p.m. on 5/29/22 and when contacted the hospice agency, he was informed the nurse was busy with a patient. (L653) The cumulative effect of this systemic practice resulted in the the hospice agency's delay in sending out a licensed nurse to assess the patient's condition. --- .

Based on interview and record review, the hospice agency failed to ensure nursing services were available on a 24-hour basis for one of 13 sampled patients (Patient 1) necessary to meet the needs of the patient and family as indicated in the agency's policy on On-Call/Weekend Service. For Patient 1, while visiting the patient, the patients representative had observed Patient 1 had gurgling sound, from 3:30 p.m. to 9:00 p.m. on 5/29/22 and when contacted the hospice agency, he was informed the nurse was busy with a patient. This deficient practice resulted in the patient continued decline while the hospice agency was unable to find staff to provide immediate assistance. --- A review of Patient 1's Physicians Certification for Hospice Benefit for the first 90-day period from 4/7/22 to 7/6/22 indicated Patient 1s terminal diagnosis was Heart disease. A review of Patient 1's initial Nursing Assessment visit by the Registered Nurse (RN) dated 4/8/22, indicated Patient 1 was awake, confused, verbally responsive with slurred speech, who does not have the capacity to understand and follow commands or instructions. Patient 1 had dysphagia (difficulty swallowing) and was currently on a mechanical soft diet with thin liquids as tolerated with aspiration ( foods or fluids get into the airway) precautions, and was a total care due to recent hip fracture with no surgery. A review of Patient 1's Physician Orders for Life Sustaining Treatment (POLST) dated 4/7/22, and signed by the hospice physician and by Patient 1s representative indicated Patient 1 was a Full Treatment (primary goal of prolonging life by all medically effective means) with attempt to resuscitation. The directions for health care provider included that when comfort cannot be achieved in the current setting, the patient should be transferred to a setting able to provide comfort. A review of Patient 1's Initial Order and Plan of Care dated 4/7/22, indicated the skilled nurse (SN) visit frequency for patient 1 once a week and two visits as needed symptom management, nursing assessment of caregiver needs, pain management. A review of Patient 1's Plan of Care dated 5/25/22 indicated the patient had an alteration in nutritional status related to disease progression and poor intake. Interventions included educating the patient's family on aspiration precaution. The Plan of Care dated 5/25/22 also indicated the patient had an alteration in comfort and anticipatory respiratory distress during end of life. Interventions included assessing pain every visit, monitoring effectiveness of current medications treatment, educating the family or caregiver to call Hospice 24 hours number for concern, administering oxygen as ordered, and educating the family to notify the hospice agency regarding changes in patient condition. During a telephone interview with Patient 1s representative on 1/11/23, he stated while visiting Patient 1 on 5/29/22, he gave Patient 1 some water to drink at which time she started making a gurgling sound. Patient 1's representative stated he contacted the hospice agency on numerous calls and the staff at the assisted living facility (ALF) in which the patient resided and was answered by the director of patient care services (DPCS) who was the on-call staff. Patient 1s representative stated the DPCS stated she was trying to get a nurse to come to the ALF, however, the nurse was busy with a patient and that DPCS told him that 911 (medical emergency telephone number) could not be called due to violation of hospice agency. Patient 1s representative stated this went on for 6 hours as he and family members watched Patient 1 continued gurgling and had multiple calls to the DPCS and asked for help for a nurse to see Patient 1. Patient 1s representative stated this ordeal went on from 3:30 p.m. until about 9:00 pm. on 5/29/22, when a licensed nurse finally came to the facility and gave medication to Patient 1. During a telephone interview with Licensed Vocational Nurse (LVN 4) on 1/12/23, at 11:45 a.m., via telephone in the agencys conference room, she stated she was licensed nurse, who goes out to see the patient when there was a change in patient's condition. LVN 4 stated her shift starts at 8:30 p.m. LVN 4 stated when she arrived at the ALF at 9:00 a.m., she was informed Patient 1 had a change of condition. LVN 4 stated Patient 1 was in respiratory distress, at which time, she notified the hospice medical director, who gave the order for medication, suctioned the patient, stabilized the patient and through conversation with the physician and DPCS informed the representative and family that patient will start continuous care in the morning. During an interview with LVN 5, via telephone on 1/12/23, at 3:00 p.m., in the agency's office, she stated she is supposed to visit a patient with a change of condition. LVN 4 stated she visited Patient 1 in the morning of 5/29/22, to see if she still needed her routine medication of methadone. LVN 5 stated she called the office to inform them to keep medication on hold because she noticed Patient 1 was lethargic. During an interview in the office with the DPCS Designee on 1/12/23, at 2:00 p.m., she stated she was never notified by the DPCS of Patient 1's change in condition. DPCS Designee stated she could have visited Patient 1. During an interview in the office with the DPCS on 1/12/23, at 2:00 p.m. she stated, she thought about visiting patient 1 but was on-call. The DPCS stated she did not know the reason she did not call/notify the DPCS designee or Administrator of patient 1 needing a nurse visit that day. A review of the agency's policy and procedure titled, " On-Call/Weekend Services revised November 2021, indicated," on-call staff will respond to a call within 15 minutes and must be able to call back within (1) hour. If warrants a visits by a nurse, patients will be seen within 2 to 4 hours. A review of Patient 1's Visit Note (LVN) dated 5/29/22 at 9:00 p.m. indicated Patient 1 was awake, moaning and groaning, had respiratory distress, and was trying to speak but unable. Patient 1's physician was notified of the patient's respiratory distress and ordered to increase oxygen to 5 liters per minute, start morphine sulfate (medication used to treat moderate to severe pain) every 4 hours as needed for respiratory distress. A review of Patient 1's Continuous Care Documentation Note (LVN) dated 5/30/22 at 8:00 a.m. indicated the patient was unresponsive, breathing was rapid, short and shallow. The patient was given morphine sulfate 0.5 milliliters. At 9:50 a.m., the patient has stopped breathing and no heartbeat. The patient's family was notified. The Discharge Summary dated 5/30/22, indicated the physician had pronounced Patient 1 expired at 9:50 a.m. on 5/30/22.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows:1. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for one of 13 sampled patients (Patient 1). (Refer L 669)The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on record review and interview, the hospice agency failed to ensure the agency's medical director assumed the responsibility for the medical component of the hospice's patient care program that included, conducting an assessment, review, and verify patient clinical information necessary for initial certification and recertification of terminal illness for one of 13 sampled patients (Patient 1). For Patient 9, the hospice agency's medical director failed to assess Patient 1s Full Treatment /attempt CPR status of the Physician Order for Life sustaining Treatment (POLST) when the patient's condition changed.This deficient practice resulted in the hospice medical director being unaware of Patient 1s Full Treatment when notified by the skilled nurse of Patient 1s change in condition. --- A review of Patient 1's Physicians Certification for Hospice Benefit for the first 90-day period from 4/7/22 to 7/6/22 indicated Patient 1s terminal diagnosis was Heart disease. A review of Patient 1's initial Nursing Assessment visit by the Registered Nurse (RN) dated 4/8/22, indicated Patient 1 was awake, confused, verbally responsive with slurred speech, who does not have the capacity to understand and follow commands or instructions. Patient 1 had dysphagia (difficulty swallowing) and was currently on a mechanical soft diet with thin liquids as tolerated with aspiration ( foods or fluids get into the airway) precautions, and was a total care due to recent hip fracture with no surgery. A review of Patient 1's Physician Orders for Life Sustaining Treatment (POLST) dated 4/7/22, and signed by the hospice physician and by Patient 1s representative indicated Patient 1 was a Full Treatment (primary goal of prolonging life by all medically effective means) with attempt to resuscitation. The directions for health care provider included that when comfort cannot be achieved in the current setting, the patient should be transferred to a setting able to provide comfort. A review of Patient 1's Plan of Care dated 5/25/22 indicated the patient had an alteration in nutritional status related to disease progression and poor intake. Interventions included educating the patient's family on aspiration precaution. The Plan of Care dated 5/25/22 also indicated the patient had an alteration in comfort and anticipatory respiratory distress during end of life. Interventions included assessing pain every visit, monitoring effectiveness of current medications treatment, educating the family or caregiver to call Hospice 24 hours number for concern, administering oxygen as ordered, and educating the family to notify the hospice agency regarding changes in patient condition. During a telephone interview with Patient 1s representative on 1/11/23, he stated while visiting Patient 1 on 5/29/22, he gave Patient 1 some water to drink at which time she started making a gurgling sound. Patient 1's representative stated he contacted the hospice agency on numerous calls and the staff at the assisted living facility (ALF) in which the patient resided and was answered by the director of patient care services (DPCS) who was the on-call staff. Patient 1s representative stated the DPCS stated she was trying to get a nurse to come to the ALF, however, the nurse was busy with the patient and that 911 (medical emergency telephone number) could not be called due to violation of hospice agency. Patient 1s representative stated this went on for 6 hours as he and family members watched Patient 1 continued gurgling and had multiple calls to the DPCS and asked for help for a nurse to see Patient 1. Patient 1s representative stated this ordeal went on from 3:30 p.m. until about 9:00 pm. on 5/29/22, when a licensed nurse finally came to the facility and gave medication to Patient 1. During a telephone interview with Licensed Vocational Nurse (LVN 4) on 1/12/23, via telephone in the agencys conference room, she stated she was licensed nurse, who goes out to see the patient when there was a change in patient's condition. LVN 4 stated her shift starts at 8:30 p.m. LVN 4 stated when she arrived at the ALF at 9:00 a.m., she was informed Patient 1 had a change of condition. LVN 4 stated Patient 1 was in respiratory distress, at which time, she notified the hospice medical director, who gave the order for medication, suctioned the patient, stabilized the patient and through conversation with the physician and DPCS informed the representative and family that patient will start continuous care in the morning. LVN 4 stated she was not aware Patient 1 was a full code and if she had known she should have called 911. During a telephone interview with the Medical Director in the conference room of the agency on 1/12/23, she stated she did not know Patient 1 was a full code status and she would have sent the patient to the hospital. The Medical director stated the protocol would be to inform staff to call 911. A review of Patient 1's Visit Note (LVN) dated 5/29/22 at 9:00 p.m. indicated Patient 1 was awake, moaning and groaning, had respiratory distress, and was trying to speak but unable. Patient 1's physician was notified of the patient's respiratory distress and ordered to increase oxygen to 5 liters per minute, start morphine sulfate (medication used to treat moderate to severe pain) every 4 hours as needed for respiratory distress. A review of Patient 1's Continuous Care Documentation Note (LVN) dated 5/30/22 at 8:00 a.m. indicated the patient was unresponsive, breathing was rapid, short and shallow. The patient was given morphine sulfate 0.5 milliliters. At 9:50 a.m., the patient has stopped breathing and no heartbeat. The patient's family was notified. The Discharge Summary dated 5/30/22, indicated the physician had pronounced Patient 1 expired at 9:50 a.m. on 5/30/22.

Observed in Emergency Management Session. During review of the Emergency Management plan and discussion with the CNO, the surveyor noted that no alternative strategies were developed to contact patients, staff, or case managers if communication systems were down.

Observed in Data Session. During the Data Session and discussion with the CNO, DPCS and 3 compliance nurses, the surveyor noted that a family member's complaints were not addressed within the time frame designated by the HCO's Compliant Grievance Process policy, 5 days. For example, a grievance was called to the DCPS by a patient's son, no investigation was completed and 6 days later the state arrived to investigate and the CNO became aware. The CNO then completed an investigation, outside the policy time frame.

Observed in Patient Home. In 2 of 2 home visits conducted, with nurses the surveyor noted that the organization had not assessed potential medication-related problems. For example, during HV#1 the RN did not complete a medication assessment until at the end of the visit the manager accompanying the surveyor told her to do a medication assessment. During HV#3 the LVN performed an incomplete medication assessment. She reviewed the oral pills and tablets, but did not review the DuoNeb or refrigerated medications (Roxanol and suppositories). This was confirmed with the CNO and DPCS present.

Observed in Record Review. In 15 of 15 patient records reviewed, the surveyor noted that the organization did not plan the patient's care and services necessary to meet the patient and family-specific needs identified in a comprehensive assessment. For example, during record reviews RR#1-10, HV#1-3, and BR#1-3 every record's frequency was identical, SN1-3wk, HHA 2wk, MSW 1mo and CH 1mo. The different patients had a variety of needs, some with wounds and others with complex family situations. When the staff was questioned about this the surveyor was told that the previous DPCS instructed the staff to only use these frequencies. This was confirmed with the CNO and DPCS.

Observed in Record Review. In 15 of 15 patient records reviewed, the surveyor noted that the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, in HV#1 record 3 of 9 goals had no time frames and 5 of 9 goals stated throughout certification period. HV#2 5 of 10 goals had no time frames and 5 of 10 goals stated during certification period. HV#3 10 of 10 goals during certification period. Diabetes goal Pt/pcg will verbalize/express understanding of medication has continued for 3 months without evidence of resolution. BR#1 bereavement POC goals were not individualized and had no time frames. All 13 records included similar goals that were not individualized. This was discussed and agreed upon with the CNO, DPCS, and 3 compliance RNs present.

Observed in Patient Home. In 2 of 13 resident records reviewed, the surveyor noted that care was not provided according to the individualized hospice plan of care. For example, during home visit HV#1 the hospice POC required the RN to provide wound care to coccyx, buttock and elbow on visit days. The nurse did not provide the care or look at the wounds during the visit. Also, in record review BR#3 the bereavement POC required contact with the bereaved son, however the contact was delayed for approximately 3 months. When the Social Worker did make contact the bereaved had found twice a week counseling on his own. The social worker updated the POC to weekly contact with the bereaved son, however no contact has been documented in the record since the updated POC 1 month ago. This was discussed and confirmed with the CNO present.

Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor noted that the staff failed to perform hand hygiene consistent with the organization's policy. For example, during HV#1 the RN entered the nursing bag greater than 3 times without first performing hand hygiene, as required by policy. During HV#2 the HHA interacted with the patient and his environment and then handled her B/P cuff and oxygen saturation equipment without first performing hand hygiene per policy. During HV#3 the LVN entered the nursing bag greater than 2 times without first performing hand hygiene and greater than 3 times did not perform hand hygiene after removing gloves, both required by policy.This was discussed with the CNO and DPCS present. Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor noted that the organization had not followed accepted standards in performing disinfection of medical supplies and devices. For example, during HV#2 the HHA did not perform any disinfection of the oxygen saturation equipment prior to putting it away and she placed the B/P cuff into its container after use and returned to it later to wipe it with alcohol and then return it to the uncleaned container. During HV#1 the RN did not follow contact time (wet time) as specified by the Clorox disinfectant manufacturer’s IFUs. The nurse wiped the B/P cuff with the Clorox wipe and immediately returned it to her bag, the product required a 4 minute contact time. During HV#3 the LVN did not follow contact time (wet time) as specified by the Lysol wipes disinfectant manufacturer’s IFUs. The nurse wiped the B/P cuff with the Lysol wipe and immediately returned it to her bag, the product required a 4 minute contact time. This was discussed with the CNO and DPCS present.

Observed in Record Review. In 1 of 3 bereavement records reviewed, the surveyor noted that hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery individualized to the bereaved. For example, record review BR#3 the bereavement POC required contact with the bereaved son, however the contact was delayed for approximately 3 months. When the Social Worker did make contact the bereaved had found twice a week counseling on his own. The social worker updated the POC to weekly contact with the bereaved son, however no contact has been documented in the record since the updated POC one month ago. This was discussed and confirmed with the CNO present.

Observed in HR File Review. In 1 of 1 HR files reviewed, for aide services the surveyor noted that the aide record did not include documentation of 12 hours of in-service training. For example, the aides file did not have any in-service hours documented for 2019. This was confirmed with the CNO.

Observed in Leadership Session. The Governing Body did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.52, 418.56, 418.60 and §418.64.

Observed in HR File Review. In 3 of 8 HR files reviewed, the surveyor noted that staff competence was not assessed and documented once every three years. For example, the Medical Director and Bereavement Coordinator/Spirtual Counselor files did not include documentation of competencies every 3 years. The competency documented in the aide's file was incomplete. This was confirmed with the CNO present.

Observed in Patient Home. During HV#1 the surveyor noted that the organization updated the plan of care oxygen order but did not update the record. For example, oxygen had been updated from 2 liters per nasal cannula to 5 liters per nasal cannula on the POC, however the medication list that the organization used to indicate oxygen therapy per organization policy and process was not updated and the documentation in the patient's home folder was not updated. This was confirmed with the CNO present.

Observed in Record Review. In 2 of 15 patient records reviewed, the surveyor noted that not all entries into the patient records were complete and did not include the core hospice services. For example, BR#1 the final IDG note did not have a nurse signature and did not have a Chaplain signature. HV#1's most recent IDG from 1 week ago did not have a nurse signature. This was confirmed with the CNO present.

Observed in Record Review. During HV#1 the surveyor noted that the organization updated the plan of care oxygen order but did not document education for the caregiver. For example, oxygen had been updated from 2 liters per nasal cannula to 5 liters per nasal cannula on the POC, however the medication list that the organization used to indicate oxygen therapy was not updated and the documentation in the patient's home folder was not updated. This was confirmed with the CNO present. Observed in Patient Home. During HV#2 the surveyor noted that the patient was assessed to be at high risk for fall but no individualized education was documented. For example, the patient used DME such as a rolling walker and the fall risk score was documented as 15, high risk for fall. The record included documents Fall Prevention Program and Fall Contract however they were both blank. The electronic record included a general safety check box, but no individualized fall reduction strategies or documented education. This was confirmed with the CNO present.

Observed in Patient Home. In 1 of 2 home visits conducted, with oxygen therapy the surveyor noted that the organization did not manage safety risks. For example, during HV#3 no action was taken on an E-tank cylinder in a stand standing on top of a dresser table in the patient's bedroom, approximately 3-4 feet off the floor. The caregiver reported the E-tank was stored there since it was delivered. There was no documented oxygen safety education related to this storage location in the record. This was confirmed with the DPCS present.

Observed in HR File Review. In 3 of 8 HR files reviewed, the surveyor noted that a criminal background check was not completed upon hire. For example, the Hospice Aide, Volunteer and Volunteer Coordinator's records each included a single line on a paper for a background check with no indication or logo of the company used and no date when the check was run or provided to the organization. Also, the organization's policy required the background check to include OIG and no documentation from OIG was included in these same 3 files. This was confirmed with the CNO present.