Every finding on record at Teton Healthcare

Based on medical record review, observation, website review, and staff interview, it was determined the agency failed to ensure patient plans of care included interventions and changes based on ongoing assessments for 3 of 14 patients (Patients #4, #6 and #10) whose records were reviewed. This had the potential for identified needs to go unaddressed. Findings include: --- 2. Patient #10 was a 56 year old male admitted to the agency on 12/13/23 with a terminal diagnosis of alcohol induced dementia. Additional diagnoses included seizures, history of falls, and atrial fibrillation. He received SN, SW, aide, and chaplain services. His record for the certification period 12/13/23 to 2/10/24 was reviewed. Patient #10's record included an SN SOC note dated 12/13/23 which stated the following: - Fall documentation stated, "AT RISK FOR FALLING," and "UNSTEADY ON HIS FEET." - The nursing narrative stated, "HE IS A RE-ADMIT FROM A 12/9/23 REVOKE. HE HAS TWO FALLS THAT DAY CAUSING A SEVERE NOSEBLEED. POA/WIFE [name] DECIDED IT WOULD BE BEST TO HAVE HIM EVALUATED AT A HOSPITAL ... NO FRACTURES NOTED." - Head/neck assessment stated, "LEFT EYE CONTINUES TO HEAL FROM A FALL A WEEK PRIOR. EYE LID IS PURPLE." - Integumentary assessment stated, "HAS AN EXTENSIVE HISTORY OF FALLS. CURRENTLY NO OPEN WOUNDS NOTED, BILATERAL HANDS HAVE HEALING BRUISES, FACIAL BRUISING IS HEALING." Patient #10's POC was reviewed. There were no fall interventions or goals for Patient #10. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patient #10's record was reviewed in her presence. She confirmed there were no fall interventions on Patient #10's POC. She confirmed fall interventions would have benefitted Patient #10. 1. Patient 4 was a 59 year old male admitted to the agency on 11/14/24 with a terminal diagnosis of Protein Calorie Malnutrition. He received SN, MSW, and aide services. His record for the certification period 11/14/24 to 2/11/25 was reviewed.Patient #2's POC included, "INSTRUCT BOWEL PROTOCAL AS NEEDED." Additionally Patient #4s POC stated ";PATIENT WILL HAVE AN EFFECTIVE BOWEL PROGRAM."Patient #2's medical record included an RN start of care visit note dated 11/14/24. The note included that Patient #2s last bowel movement was on 11/11/24 3 days prior to the start of care. It also included that Patient #2 was started on a ";bowel regimen." Patient #2's medication list included 2 medications for constipation, MiraLAX, and Senna. Patient #2s medical record included a SN visit note dated 11/15/24. The note included that Patient #2s las bowel movement was on 11/12/24. Patient #2s medical record include a SN visit note dated 11/21/24. Under the assessment section titled ";GASTROINTESTINAL", the nurse documented ";NO CHANGES SINCE LAST VISIT." Additionally, under the section titled ";INTERVENTIONS PERFORMED" the record included ";INSTRUCTED PATIENT TO MONITOR DAILY BOWEL MOVEMENT AND TO CALL NURSE I NO BOWEL MOVEMENT IN 3 DAYS." There was no documentation on when Patient #2s last bowel movement was. Patient #2s medical record included a communication note dated 11/25/24 that stated, ";RECEIVED MESSAGE FROM ON CALL NURSE... CAREGIVER CHRISSIE STATES THAT PT HAD A VERY LARGE WHITE BM [BOWEL MOVEMENT]. HADNT [sic] HAD A BM IN 7 DAYS BEFORE THIS. THEY DENY ANY NEEDS TONIGHT AS PT IS EXHAUSTED AN SLEEPING BUT WOULD LIKE A VISIT TOMORROW. Patient #2s medical record included a SN visit note dated 11/26/24. The note included, ";SPOKE TO CAREGIVER ABOUT BM LAST NIGHT. CAREGIVER STATED THAT THEY DO NOT HAVE BOWEL MEDICATION AND HAVE NOT BEEN GIVING ANYTHING TO PATIENT." A home visit was conducted at Patient #2's home on 12/3/24 with an RN. During the discussion with the RN, Patient #2's caregiver was discussing Patient #2's constipation and stated that Patient #2 was crying when he was attempting to have a bowel movement. Additionally, the caregiver stated that she had not received the MiraLAX until Friday 11/29/24. The caregiver stated he was on a scheduled medication for diarrhea Loperamide. The nurse than stated she would change the Loperamide to as needed. Drugs.com (https://www.drugs.com/tips/loperamide-patient-tips) stated that Constipation is a side effect of too much loperamide. There was no documented follow up on why Patient #2s caregivers were not giving the prescribed bowel regimen. Additionally, there was no documentation patient #2's POC was updated to reflect his severe constipation. The DCS was interviewed on 12/4/24 beginning at 10:00 AM, and Patient #2s medical record was reviewed in her presence. She confirmed that Patient #2's Loperamide was discontinued as scheduled medication and changed to as needed. She confirmed there was no documentation on follow up with caregivers on why medications for constipation were not given. Additionally, she confirmed Patient's 2 POC was not updated with any changes prior to the home visit with the surveyor on 12/3/24.

Based on medical record review and staff interview, it was determined the agency failed to ensure care and services were provided in accordance with the plan of care for 3 of 14 patients (Patients #4, #9, and #11) whose records were reviewed. This had the potential to interfere with patient safety and coordination of patient care. Findings include: --- Patient #11 was a 89 year old male admitted to the Hospice on 11/07/24 with the primary terminal diagnosis of ";stroke" and additional comorbidities including but not limited to ";nontraumatic intracerebral hemorrhage, cerebral infarction, chronic systolic (congestive) heart failure, presence of xenogeneic heart valve, presence of other cardiac implants, non-rheumatic aortic (valve) stenosis, unspecified atrial fibrillation primary hypertension, atherosclerosis heart disease of native coronary artery without angina, inflammatory disease of prostate, peptic ulcer". Patient #11 received SN, MSW, Chaplain and HHA. An updated terminal illness was recorded at the 11/13/24 IDG meeting as ";unspecified severe protein-calorie malnutrition" and the POC was updated to include ";Hospice nurse to provide instructions related to nutrition and hydration status." Patient #11s medical record included a visit note dated 11/14/24, post change in diagnosis and POC, and included a nutritional assessment which stated ";No change since last visit." Visits dated 11/08/24, 11/11/24, 11/18/24, 11/19/24, 11/21/24, 11/25/24, and 12/2/24 all documented a nutritional assessment which stated ";No change since last visit." Vital signed documented in the medical record from the above mentioned visit dates did not include a weight. Additionally, narratives from these eight visits did not reference details of a nutritional assessment or education on nutrition. The DCS was interviewed on 12/03/24 at 2:35 PM and Patient #11s medical chart was reviewed. The DCS confirmed that POC and terminal diagnosis were changed and updated 11/13.24. The DCS further confirmed notes on 11/08/24, 11/11/24, 11/14/24, 11/18/24, 11/19/24, 11/21/24, 11/25/24, and 12/2/24 included documentation of ";No change since last visit" and no nutritional assessment or education on nutrition were documented. The agency failed to ensure Patient #11s POC was followed which could result in harm to the patient. 2. Patient #9 was an 88 year old female admitted to the agency on 12/14/23 with a terminal diagnosis of unspecified alzheimer's disease. Additional diagnoses included dementia and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 9/09/24 to 11/07/24 was reviewed. Patient #9's POC was reviewed and included nursing visits to be scheduled 1 time weekly. There were no nursing visits between 9/13/24 to 10/04/24. There was a missed visit note completed on 9/27/24, but there was no missed visit note for the week of 9/15/24. It was unclear why the SN visit was missed. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patient #9's medical record was reviewed in her presence. She confirmed there was no reason documented for the missed visit the week of 9/15/24. She stated the nurse should have completed a missed visit note. The agency failed to ensure all patients received services in accordance with the POC. 1. Patient 4 was a 59 year old male admitted to the agency on 11/14/24 with a terminal diagnosis of Protein Calorie Malnutrition. He received SN, MSW, and aide services. His record for the certification period 11/14/24 to 2/11/25 was reviewed.Patient #2's POC included, "INSTRUCT BOWEL PROTOCAL AS NEEDED." Additionally Patient #4s POC stated ";PATIENT WILL HAVE AN EFFECTIVE BOWEL PROGRAM."Patient #2's medical record included an RN start of care visit note dated 11/14/24. The note included that Patient #2s last bowel movement was on 11/11/24 3 days prior to the start of care. It also included that Patient #2 was started on a ";bowel regimen." Patient #2s medical record included a SN visit note dated 11/15/24. The note included that Patient #2s las bowel movement was on 11/12/24. Patient #2s medical record include a SN visit note dated 11/21/24. Under the assessment section titled ";GASTROINTESTINAL", the nurse documented ";NO CHANGES SINCE LAST VISIT." Additionally, under the section titled ";INTERVENTIONS PERFORMED" the record included ";INSTRUCTED PATIENT TO MONITOR DAILY BOWEL MOVEMENT AND TO CALL NURSE I NO BOWEL MOVEMENT IN 3 DAYS." There was no documentation on when Patient #2s las bowel movement was. Patient #2s medical record included a communication note dated 11/25/24 that stated, ";RECEIVED MESSAGE FROM ON CALL NURSE... CAREGIVER CHRISSIE STATES THAT PT HAD A VERY LARGE WHITE BM [BOWEL MOVEMENT]. HADNT HAD A BM IN 7 DAYS BEFORE THIS. THEY DENY ANY NEEDS TONIGHT AS PT IS EXHAUSTED AN SLEEPING BUT WOULD LIKE A VISIT TOMORROW. Patient #2s medical record included a SN visit note dated 11/26/24. The note included, ";SPOKE TO CAREGIVER ABOUT BM LAST NIGHT. CAREGIVER STATED THAT THEY DO NOT HAVE BOWEL MEDICATION AND HAVE NOT BEEN GIVING ANYTHING TO PATIENT." There was no documented follow up on why Patient #2s caregivers were not giving the prescribed bowel regimen. Patient #2 did not have his bowel movements monitored from 11/15/24 to 11/25/24, and did not have a bowel movement from 11/12/24 to 11/25/24. The DCS was interviewed on 12/4/24 beginning at 10:00 AM, and Patient #2s medical record was reviewed in her presence. When asked if Patient #2 required more frequent bowel monitoring, she stated ";Absolutely". Additionally, she stated the follow up to the prescribed bowel regimen should have been followed up on by the case manager. The agency failed to ensure services outlined on Patient #2s POC were done.

Based on medical record review and staff interview, it was determined the agency failed to ensure care was provided based on a current assessment of the patients needs for 1 of 14 patients (Patient #8) whose medical records were reviewed. Failure to ensure care and documentation were based on current assessment and status of the patient had the potential to cause patient needs to go unmet. Findings include: --- Patient #8 was a 78 year old female admitted to the agency on 1/15/24 with a terminal diagnosis of congestive heart failure. Additional diagnoses included chronic pain and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 1/15/24 to 4/13/24 was reviewed. 1. Patient #8's medical record included an SN note from 2/08/24 which stated, "PATIENT STATED THAT SHE FELL LAST NIGHT FROM HER CHAIR." Under the safety assessment, the same note stated, "PATIENT DENIES FALLS." It was unclear if Patient #8 fell the night before her 2/08/24 visit. There was no fall incident recorded for the 2/08/24 visit. Patient #8's medical record included another SN note from 2/15/24 which stated, "PATIENT STATED THAT SHE FELL LAST NIGHT FROM HER CHAIR." Under the safety assessment, the same note stated, "PATIENT DENIES FALLS." It was unclear if Patient #8 fell the night before her 2/15/24 visit. There was no fall incident recorded for the 2/25/24 visit. The DCS was interviewed on 12/04/24 beginning at 9:15 AM. She confirmed the fall documentation for Patient #8 was not clear. She confirmed there were no fall incidents documented for 2/08/24 or 2/15/24. 2. Patient #8's medical record included an SN note from 1/23/24 which included supervisory functions of the hospice aide, who was identified by name. It stated the patient was satisfied with the aide's cares, the aide followed the care plan, complied with infection control standards, and created a successful interpersonal relationship with the patient and family. Patient #8's medical record included the first aide visit was completed on 1/30/24, a week after the RN supervisory visit. There were no aide visits provided to Patient #8 prior to 1/30/24. It was unclear how the RN supervised the aide if no aide visits had been provided. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patient #8's record was reviewed with her. She confirmed there were no aide visits provided prior to 1/30/24. She confirmed the nurse could not have provided aide supervision without the aide having completed any visits for Patient #8. The agency failed to ensure care and documentation were based on current assessment of Patient #8.

Based on medical record review and staff interview, it was determined the agency failed to ensure ongoing assessment of spiritual needs for 2 of 14 patients (Patients #8 and #9) whose records were reviewed. Failure to ensure a spiritual assessment was completed on an ongoing basis had the potential to result in unmet spiritual needs. Findings include: --- 1. Patient #8 was a 78 year old female admitted to the agency on 1/15/24 with a terminal diagnosis of congestive heart failure. Additional diagnoses included chronic pain and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 1/15/24 to 4/13/24 was reviewed. Patient #8's medical record included a note by the chaplain on 3/10/24 and was titled, "CHAPLAIN HOSPICE PHONE VISIT." The note included a narrative which stated, "THE CHAPLAIN LEFT A DETAILED MESSAGE OF SPIRITUAL AND EMOTIONAL SUPPORT. A MESSAGE WAS LEFT AS THE POA DID NOT ANSWER THE PHONE FOR VOICE TO VOICE SUPPORT." The note also included a wellness screening which required assessment of the patient. It was unclear how Patient #8's spiritual needs were assessed if there was no contact with the Patient #8 or her representative. There was no documentation of an attempt made to see Patient #8 in person. 2. Patient #9 was a 78 year old female admitted to the agency on 1/15/24 with a terminal diagnosis of congestive heart failure. Additional diagnoses included chronic pain and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 1/15/24 to 4/13/24 was reviewed. a. Patient #9's record included a note by the chaplain on 10/18/24 and was titled, "CHAPLAIN HOSPICE PHONE VISIT." The note included a narrative which stated, "VOICE MESSAGE OF SUPPORT LEFT AFTER MULTIPLE ATTEMPTS AT A CALL." The note also included a wellness screening which required assessment of the patient. It was unclear how Patient #9's spiritual needs were assessed if there was no contact with the Patient #9 There was no documentation of an attempt made to see Patient #9 in person. b. Patient #9's record included a note by the chaplain on 10/22/24 and was titled, "CHAPLAIN HOSPICE PHONE VISIT." The note included a narrative which stated, "THE CHAPLAIN LEFT A DETAILED MESSAGE OF SPIRITUAL SUPPORT AFTER MULTIPLE FAILED ATTEMPS AT CONTACT." The note also included a wellness screening which required assessment of the patient. It was unclear how Patient #9's spiritual needs were assessed if there was no contact with the Patient #9 There was no documentation of an attempt made to see Patient #9 in person. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patients #8 and #9's medical record were reviewed with her. She confirmed no contact was made with either patient in the above three visits. She confirmed if no contact was made it should have been documented as a missed visit. She confirmed no spiritual assessment was made for the above 3 visits. The agency failed to ensure spiritual needs were assessed on an ongoing basis.

Based on EP communication plan review, and staff interview, it was determined the facility failed to develop a communication plan with contact information for all Federal, State, regional, and local emergency preparedness entities. This failure had the potential to hinder integrated emergency personnel response, and to hinder the coordination of patient care during an emergency. Findings include: The agency's geographical coverage area includes several counties in 2 states. The agency EP binder was reviewed on 12/16/21 beginning at approximately 8:00 AM. The EP plan included a, "Disaster/Emergency Manual Rosters & Contacts." The EP contacts and resources listed only covered the county and State where the parent branch office was located. It was unclear how the agency would communicate and coordinate the care of patients in counties outside of the branch office county in the event of a disaster. The Executive Director was interviewed on 12/16/21, beginning at 9:15 AM. She confirmed the agency process and contact did not include resources and contact information for all geographical areas where the agency provided services. The agency failed to integrate all emergency resources into their EP plan.

Based on observation, medical record review, staff interview and patient/caregiver interview, it was determined the agency failed to ensure a comprehensive medication list for patients were accurate and updated for 4 of 4 home visits (Patient #1, #2, #3, and #13) whose medications were reviewed by surveyors during home visits and whose records were reviewed. Incomplete medication information can interfere with the ability to evaluate for effectiveness of drug therapy, potential drug interactions, and side effects. Findings include: 1. Patient #2 was a 71 year old female admitted to the agency on 12/07/21 with a terminal diagnosis of emphysema and secondary diagnoses included DM type 2 and HTN. Patient #2 received SN, MSW, Chaplain, and HHA services. Patient #2's medical record, SOC comprehensive assessment, medication list, and POC, was reviewed for the certification period of 12/07/21 to 3/06/22. A visit was made to Patient #2's home on 12/14/21, beginning at 8:50 AM to observe an SN visit. The surveyor reviewed medications with Patient #2's caregiver/daughter. There were dicrepancies noted between the agency's current medication list and Patient #2's actual medications presented to the surveyor. They included: a. The agency's medication list included Anoro Ellipta 62.5 mcg-25mcg inhalation. The daughter stated this medication had been stopped prior to hospice. b. The agency's medication list included Fluticasone propionate 50 mcg nasal spray. This medication was not present in the home and the daughter stated it had been discontinued. c. The agency's medication list included Hydrocodone 10 mg - acetaminophen 325 mg tablet. This medication was not present in the home and the daughter stated that the patient has not taken this medication. d. The agency's medication list did not list the following comfort kit medications although the patient had these medications in the home and the patient had been given a dose of morphine the night prior to the visit after a documented fall. Morphine sulfate 0.25mg tab Lorazepam 0.25mg tab Atropine ophthalmic drops e. Patient #2 was using 3 liters of oxygen continuously. Oxygen was not listed on the agency medication profile. Patient #2's nurse was interviewed on 12/14/21, beginning at 9:45 AM. She confirmed that these medications should have been on the medication profile prior to the home visit. The Interim Administrator was interviewed on 12/16/21, beginning at 9:00 AM. Patient #2's medication profile was reviewed in her presence. She confirmed that the medication profile was inaccurate. Patient #2's medication profile was not accurate and had the potential for agency staff or caregivers/family to be unable to care for the patient as listed in the POC. 2. Patient #3 was a 97 year old female admitted to the agency on 11/03/21 with a terminal diagnosis of severe protein calorie malnutrition with dementia. Patient #3 received SN, MSW, Chaplain, and HHA services. Patient #3's medical record, including the SOC comprehensive assessment, medication list, and POC for the certification period of 11/03/21 to 1/31/22, was reviewed. A visit was made to Patient #3's home, an ALF, on 12/14/21, beginning at 1:30 PM to observe an SN visit. The surveyor reviewed medications and compared Patient #3's medication profile at the facility and the agency medication profile. Medication profile discrepancies included: a. The agency medical record medication profile included an order for Sucralfate 1 gram tablet. This was not included on the facility medication profile for Patient #3. b. The agency medical record medication profile included an order for Calmoseptine 0.44%-20.6%. This medication was not included on the facility medication profile for Patient #3. The Interim Administrator was interviewed on 12/16/21, beginning at 11:05 AM, and Patient #3's medical record was reviewed in her presence. She confirmed Patient #3's medication profile did not match the ALF medication profile. She confirmed that the expectation was that all medication profiles would match. Patient #3's medication profile was not accurate and had the potential for agency staff or facility staff to be unable to care for the patient as listed in the POC. 3. Patient #13 was a 91 year old female admitted to the agency on 11/06/21 with a terminal diagnosis of encephalopathy. Patient #13 received SN, MSW, and Chaplain services. Her record, including the POC, for the certification period of 11/06/21 to 2/03/22, was reviewed. A visit was made to Patient #13's home on 12/16/21, beginning at 3:45 PM, to observe a MSW visit. The surveyor reviewed medications with Patient #13 and her caregiver/daughter. Patient #13 and her daughter stated that Patient #13 took 5mg of Melatonin every night to help with sleep. Melatonin was not listed on the agency medication profile. An RN arrived to draw blood as the MSW was ending his visit. The RN was interviewed during her visit with Patient #13. She confirmed that Melatonin was not on the agency medication profile. The Interim Administrator was interviewed on 12/16/21, beginning at 4:35 PM, and Patient #13's medical record was reviewed in her presence. She confirmed Patient #13's medication profile was inaccurate. Patient #13's medication profile was not accurate and had the potential for agency staff or caregivers/family to be unable to care for the patient as listed in the POC. 4. Patient #1 was a 93 year old female admitted to the agency on 7/12/21 with a terminal diagnosis of cerebrovascular disease. Patient #1 received SN, HHA. MSW, and Chaplain services. Her record, including the POC, for the certification period of 10/10/21 to 1/07/22, was reviewed. A visit was made to Patient #1's home, an ALF, on 12/14/21, beginning at 10:30 AM, to observe a HHA visit. The surveyor requested Patient #1's medication record and POC from the facility. Patient #1's facility medication record listed, "CALMOSEPTINE 0.42-20.6% OINT [ointment] .... Apply a thin layer after each toileting." The agency medication record did not include Patient #1's Calmoseptine medication, although the agency provided the physician orders for the medication. The Interim Administrator was interviewed on 12/16/21, beginning at 10:35 AM, and Patient #1's agency medical record and faciity medication profile was reviewed in her presence. She confirmed Patient #1's agency medication profile was not accurate. Patient #1's medication profile was not accurate and had the potential for agency and facility staff to be unable to care for the patient as listed in the POC.

Based on staff interview and review of medical records, it was determined the agency failed to ensure POCs were updated as needed for 1 of 13 patients (Patient #3) whose records were reviewed. This resulted in a lack of interventions and goals being provided to meet patient needs. Findings include: Patient #3 was a 97 year old female admitted to hospice on 11/03/21 with a terminal diagnosis of severe protein calorie malnutrition and dementia. She received SN, MSW, HHA, and Chaplain services. Her record, including the POC, for the certification period of 11/03/21 to 1/31/22, was reviewed. Patient #3 had a witnessed fall on 11/22/21 with paramedic response due to head injury. Nursing notes dated 11/22/21 stated "...fell and hit the back of her head on a chair patient scalp does have a small laceration to posterior right side..." There was no further description or measurement of the laceration. The POC was not updated with interventions or goals to address Patient #3's new wound. The Interim Administrator was interviewed on 12/16/21, beginning at 11:05 AM, and Patient #3's medical record was reviewed in her presence. She confirmed the reported fall was documented for Patient #3 with mention of a head laceration. The Interim Administrator agreed that expectations included updating the POC to address Patient #3's new wound, including interventions and goals. Patient #3's POC was not updated to meet her changing needs.

Based on observation, medical record review, CDC infection control guidelines, CMS Memo review, and staff interview, it was determined the agency failed to ensure staff performed appropriate hand hygiene for 1 of 4 patients (Patient #13), whose care was observed and whose records were reviewed. Additionally, the agency failed to ensure aide care plans included delegated COVID-19 screening for 1 of 5 patients (Patient #4), who received aide services and whose records were reviewed. These combined issues had the potential to expose patients and staff to communicable disease and infection. Findings include: 1. CDC hand hygiene for healthcare providers guidelines, updated 1/08/21, stated to perform hand hygiene: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - After caring for a person with known or suspected infectious diarrhea - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient's immediate environment - After contact with blood, body fluids or contaminated surfaces - Immediately after glove removal These guidelines were not followed. Examples include: Patient #13 was a 91 year old female admitted to the agency on 7/12/21 with a terminal diagnosis of encephalopathy. Patient #13 received SN, MSW, and Chaplain services. Her record, including the POC, for the certification period of 11/06/21 to 2/03/21, was reviewed. A visit was made to Patient #13's home on 12/16/21, beginning at 3:45 PM, to observe a MSW visit. An RN arrived to draw blood as the MSW was ending his visit. After completing the blood draw with gloved hands, the RN did not remove her gloves or perform hand hygiene. The RN touched the table, supplies, accessed her bag, auscultated the patient with her stethoscope, and touched her documentation device with the same gloves used for the blood draw. The RN did not disinfect the stethoscope after use on the patient. The Interim Administrator was interviewed on 12/16/21, beginning at 4:35 PM. She stated that the agency followed CDC guidelines for infection control during patient care and the RN did not follow appropriate infection control guidelines during Patient #13's care. The agency failed to ensure staff performed appropriate hand hygiene during patient care. 2. COVID-19 screening was not included on Aide care plans. A CMS memo titled "Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies," released 3/09/20, stated, "hospice agencies should be monitoring the health status of patients, residents, visitors, volunteers, and staff under their care setting for signs or symptoms of COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors." This guideline was not followed. Examples include: Patient #4 was a 92 year old female admitted to the agency on 8/22/20 with a terminal diagnosis of Alzheimer's disease. Patient #4 received SN, MSW, Chaplain, and HHA services. Her record, including the POC, for the certification period of 10/16/21 to 12/14/21, was reviewed. Patient #4's medical record included an Aide Care Plan, dated 12/02/21, signed by an RN. The care plan did not include instructions to screen patient for COVID-19. It could not be determined how the aide followed agency procedure when screening Patient #4 for COVID-19 was not delegated by licensed staff. The Interim Administrator was interviewed on 12/16/21, beginning at 11:50 AM, and the Aide Care Plan was reviewed in her presence. She confirmed instruction and delegation of COVID-19 screening to aides by licensed staff was not included as part of the Aide Care Plan for Patient #4. COVID-19 screening delegation was not included on Aide Care Plans.

Based on medical record review and staff interview, it was determined the agency failed to ensure nursing needs of the patients were met for 1 of 4 patients (Patient #8) whose records were reviewed, had documented wounds, and lived in an ALF. This deficient practice could potentially result in unmet patient needs. Findings include: During the survey entrance interview of 10/08/21, beginning at 10:50 AM, the Interim Administrator stated, per agency practice, wounds were to be assessed and measured at least weekly and, depending on the severity of the wound, potentially every nursing visit. The agency's practice was not followed. Examples include: Patient #8 was an 87 year old female admitted to the agency on 7/09/21 with a terminal diagnosis of hypertensive heart disease with HF. Patient #8 received SN, MSW, and Chaplain services. Her record, including the POC, for the certification period of 10/07/21 to 1/04/22, was reviewed. Patient #8's medical record included a SOC comprehensive assessment, dated 7/09/21, signed by the RNCM. The assessment stated Patient #8 had a pressure ulcer on her right buttock, a pressure ulcer on her left Achilles tendon, and an abrasion to her right elbow. Wound assessments and wound care orders accompanied the wound descriptions. Patient #8's medical record included the following documentation: - A Coordination Note, dated 7/15/21, signed by the RNCM, stated, "Bandages in place, facility staff to provide wound care at this time." - A Coordination Note, dated 7/16/21, signed by an RN, stated, " ...facility staff had already treated and changed pt wound dressing." - A Coordination Note, dated 7/17/21, signed by an RN, stated, "Facility provided wound care." - A Coordination Note, dated 7/21/21, signed by the RNCM, stated, "All bandages are in place at this time." - A Coordination Note, dated 7/23/21, signed by the RNCM, stated, "All bandages are in place at this time." - A Coordination Note, dated 7/27/21, signed by the RNCM, stated, "Bandages are in place today and facility wound care nurse performed wound care to affected areas." - A Coordination Note, dated 7/30/21, signed by the RNCM, stated, "All bandages in place as facility wound care nurse performs wound care treatments." - A Coordination Note, dated 8/03/21, signed by the RNCM, stated, "Bandages in place." - A Coordination Note, dated 8/13/21, signed by an RN, stated, "Facility nurse said she treats pt wounds on certain days and there's no need to change pt wound dressings at this time." - A Coordination Note, dated 8/19/21, signed by an LPN, stated, "Staff has been doing wound care as ordered. Dressing intact." - A Coordination Note, dated 8/24/21, signed by the RNCM, stated, "Multiple bandages present ... received report from wound care nurse ... " - A Coordination Note, dated 9/08/21, signed by the RNCM, stated, "Facility wound care nurse [name] performs wound care treatment for patient." - A Coordination Note, dated 9/24/21, signed by the RNCM, stated, "All bandages are in place. Was not able to view bandage to R hip due to patient position." - A Coordination Note, dated 9/28/21, signed by the RNCM, stated, "Bandages in place to RUE [right upper extremity], R hip and feet bilaterally." - A Coordination Note, dated 10/20/21, signed by the RNCM, stated, "All bandages are in place at this time." - A Coordination Note, dated 10/22/21, signed by the RNCM, stated, "Received report from wound care nurse [name] regarding R hip wound. Pink tissue noted with copious amounts of serous drainage." - A Coordination Note, dated 10/26/21, signed by the RNCM, stated, "Bandages in place." - A Coordination Note, dated 11/07/21, signed by the RNCM, stated, "Wound to R hip is covered with new bandage." - A Coordination Note, dated 11/19/21, signed by the RNCM, stated, "Bandages in place." - A Coordination Note, dated 12/07/21, signed by the RNCM, stated, "Bandages in place." Patient #8's subsequent nursing visits after the SOC did not document any wound assessments for 20 weeks after the SOC. Patient #8's medical record did not include any coordination documentation that the RNCM was ensuring that Patient #8's wound care nursing needs were being met by the facility. It could not be determined if Patient #8's wounds were healing or deteriorating. The Interim Administrator was interviewed on 12/16/21, beginning at 1:45 PM, and Patient #8's medical record was reviewed in her presence. She confirmed there was no documentation of wound assessments performed by agency nursing after the SOC and no documentation of coordination with the facility provided wound care. The agency failed to ensure Patient #8's wound care nursing needs were met.

Based on medical record review and staff interview, it was determined the agency failed to ensure care and services were provided in accordance with the plan of care for 2 of 12 patients (Patients #3 and #8) whose records were reviewed. This resulted in the HHA performing care without prior authorization from the nurse or physician. This had the potential for the aide to be working outside of their scope of practice. Findings include: 1. Patient #3 was a 97 year old femaile admitted to hospice on 11/03/21 with a terminal diagnosis of severe protein calorie malnutrition and dementia. She received SN, MSW, HHA, and chaplain services. Her record, including the POC, for the certification period of 11/03/21 to 1/31/22, was reviewed. - A Coordination Note, dated 12/10/21, signed by an Aide, stated "...took her to the restroom abd[sic] filed her nail..." Nail care is not listed in the Aide POC. - A Coordination Note, dated 12/08/21, signed by an Aide stated, "...gave her a shower, washed her hair and perineal care. Applied lotion and filed her nails..." Perineal care and nail care were not listed in the Aide POC. - A Coordination Note, dated 11/16/21, signed by an Aide, stated "...gave her a shower, washed her hair and perineal care. shaved her wiskers[sic] ..." Perineal care and shaving were not listed in the Aide POC. The Interim Administrator was interviewed on 12/16/21, beginning at 11:05 AM, and Patient #3's medical record was reviewed in her presence. She confirmed that the Aide POC was not complete. She stated that the RN should have updated the POC to include perineal care, nail care and shaving her whiskers. The agency failed to ensure Patient #3's Aide POC was updated and the Aide was performing care not delgated on the POC. 2. Patient #8 was an 87 year old female admitted to the agency on 7/09/21 with a terminal diagnosis of hypertensive heart disease with heart failure. Patient #8 received SN, MSW, and Chaplain services. Her record, including the POC, for the certification period of 10/07/21 to 1/04/22, was reviewed. Patient #8's medical record included an Aide Care Plan that delegated and instructed the Aide to perform the following service, "Bathing - Bed Bath." This care plan was not followed. Examples include: - A Visit Note Report, dated 11/30/21, and signed by an aide, stated, "SERVICE: BATHING - BED BATH COMPLETED N [NO] NOTE: SHOWER UPON REQUEST" - A Visit Note Report, dated 12/03/21, and signed by an aide, stated, "SERVICE: BATHING - BED BATH COMPLETED N [NO] NOTE: SHOWER" - A Visit Note Report, dated 12/07/21, and signed by an aide, stated, "SERVICE: BATHING - BED BATH COMPLETED N [NO] NOTE: SHOWER TODAY" - A Visit Note Report, dated 12/10/21, and signed by an aide, stated, "SERVICE: BATHING - BED BATH COMPLETED N [NO] NOTE: SHOWER TODAY" - A Visit Note Report, dated 12/14/21, and signed by an aide, stated, "SERVICE: BATHING - BED BATH COMPLETED N [NO] NOTE: SHOWER" The Interim Administrator was interviewed 12/16/21, beginning at 1:45 PM and Patient #8's medical record was reviewed in her presence. She confirmed the aide was performing care that had not been delegated by a licensed professional and the RN should have updated the Aide POC. The agency failed to ensure Patient #8's Aide POC was updated and the Aide was performing care not delgated on the POC.

Based on personnel file review and staff interview, it was determined there was no documented evidence that the hospice provided orientation about the hospice philosophy to all employees who had patient and family contact for 4 of 4 new personnel hires in 2021 and whose personnel files were reviewed (Staff #A, #B, #C, and #D). This had the potential for staff to lack the understanding of hospice philosophy necessary to care for hospice patients. Examples include: Personnel files were reviewed with the Interim Administrator on 12/15/21 beginning at 2:30 PM. When asked for proof of orientation to the hospice philosophy for Staff #A, #B, #C, and #D, the Interim Administrator stated that hospice orientation education was provided via a computer module that was assigned as part of new hire onboarding process. The Interim Administrator confirmed there was no documented evidence that staff members #A, #B, #C, and #D had completed the modules and were oriented to the hospice philosophy due to a "glitch in the system." She confirmed the onboarding computer module, "Orientating to Hospice Care (REL-HOS-O-OHC) - hospice philosophy," had not been assigned for the 4 new staff members to complete. The agency failed to ensure all staff were orientated to hospice philosophy.

Based on personnel file review and staff interview, it was determined the agency failed to ensure assessment of clinical staff competencies for 1 of 3 nursing staff whose personnel files were reviewed. This resulted in a lack of validated competencies to ensure nursing clinical staff provided safe patient care. Findings include: Agency personnel files for nursing staff were reviewed on 12/15/21, beginning at 10:30 AM. Validated clinical staff competencies could not be located for 1 of 3 nursing staff. The Interim Administrator, who provided personnel file oversight, was interviewed on 12/15/21, beginning at 2:30 PM. She confirmed the missing clinical competencies for 1 RN. The agency failed to ensure competencies of all nursing staff were completed.

Based on record review and staff interview, it was determined the facility failed to ensure patient record entries were complete and authenticated for 5 of 13 patients who received Chaplain visits (Patients #1, #4, #7, #8, and #13) This resulted in the inability to authenticate the chaplain visits. Findings include: 1. Patient #8 was an 87 year old female admitted to the agency on 7/09/21 with a terminal diagnosis of hypertensive heart disease with HF. Patient #8 received SN, MSW, and Chaplain services. Her record, including the POC, for the certification period of 10/07/21 to 1/04/22, was reviewed. Patient #8's medical record included Chaplain visit notes dated 7/12/21, 7/26/21, 8/12/21, 9/20/21. The visit note documentation did not contain signatures from the patient or a caregiver/family member. The visit notes were incomplete. The Interim Administrator was interviewed on 12/16/21, beginning at 11:50 AM. She confirmed the missing signatures from the 4 Chaplain visit notes and stated it was agency expectation for visit notes from all disciplines to be signed by the patient or a caregiver/family member to confirm the clinician was at the visit and performed bedside charting. The agency failed to ensure Chaplain visit notes were appropriately authenticated. 2. Patient #4 was a 92 year old female admitted to the agency on 8/22/20 with a terminal diagnosis of Alzheimer's disease. Patient #4 received SN, MSW, Chaplain, and HHA services. Her record, including the POC, for the certification period of 10/16/21 to 12/14/21, was reviewed. Patient #4's medical record included Chaplain visit notes dated 11/01/21 and 12/03/21. The visit note documentation did not contain signatures from the patient or a caregiver/family member. The visit notes were incomplete. The Interim Administrator was interviewed on 12/16/21, beginning at 11:50 AM. She confirmed the missing signatures from the 2 Chaplain visit notes and stated it was agency expectation for visit notes from all disciplines to be signed by the patient or a caregiver/family member to confirm the clinician was at the visit and performed bedside charting. The agency failed to ensure Chaplain visit notes were appropriately authenticated. 3. Patient #13 was a 91 year old female admitted to the agency on 7/12/21 with a terminal diagnosis of encephalopathy. Patient #13 received SN, MSW, and Chaplain services. Her record, including the POC, for the certification period of 11/06/21 to 2/03/21, was reviewed. Patient #13's medical record included Chaplain visit notes dated 11/06/21 and 11/14/21. The visit note documentation did not contain a signature from the patient or a caregiver/family member. The visit notes were incomplete. The Interim Administrator was interviewed on 12/16/21, beginning at 11:50 AM. She confirmed the missing signatures from the 2 Chaplain visit notes and stated it was agency expectation for visit notes from all disciplines to be signed by the patient or a caregiver/family member to confirm the clinician was at the visit and performed bedside charting. The agency failed to ensure Chaplain visit notes were appropriately authenticated. 4. Patient #1 was a 93 year old female admitted to the agency on 7/12/21 with a terminal diagnosis of cerebrovascular disease. Patient #1 received SN, HHA. MSW, and Chaplain services. Her record, including the POC, for the certification period of 11/06/21 to 2/03/21, was reviewed. Patient #1's medical record included Chaplain visit notes dated 11/05/21 and 12/06/21. The visit note documentation did not contain a signature from the patient or a caregiver/family member. The visit notes were incomplete. The Interim Administrator was interviewed on 12/16/21, beginning at 11:50 AM. She confirmed the missing signatures from the 2 Chaplain visit notes and stated it was agency expectation for visit notes from all disciplines to be signed by the patient or a caregiver/family member to confirm the clinician was at the visit and performing bedside charting. The agency failed to ensure Chaplain visit notes were appropriately authenticated. 5. Patient #7 was a 89 year old female admitted to the agency on 8/14/20 with a terminal diagnosis of malignant neoplasm of the the colon. She received SN, HHA, and Chaplain services. Her record, including the POC, for the certification period of 12/07/21 to 2/04/21, was reviewed. Patient #7's medical record included Chaplain visit notes dated 12/14/21. The visit note documentation did not contain a signature from the patient or a caregiver/family member. The visit note was incomplete. The Interim Administrator was interviewed on 12/16/21, beginning at 11:50 AM. She confirmed the missing signatures from the Chaplain visit notes and stated it was agency expectation for visit notes from all disciplines to be signed by the patient or a caregiver/family member to confirm the clinician was at the visit and performing bedside charting. The agency failed to ensure Chaplain visit notes were appropriately authenticated.