Every finding on record at The Dale County Health Care Authority

Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure all core members attended and participated in the Interdisciplinary Team (IDT). This deficient practice did affect seven of 14 MR's reviewed, including, MR # 10, Home Visit (HV) # 1, MR # 7, MR # 1, MR # 2, MR # 4, MR # 3, and had the potential to affect all patients and caregivers served by this agency. Findings include: Agency Policy: Interdisciplinary Group Meeting Policy Number: 4-032.1 Policy Date: 11/2013 Purpose: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. Policy: The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care...no less frequently than every 15 days... The Medical Director and all hospice interdisciplinary group members will be present... Procedure: Members at the interdisciplinary group meeting will sign an attendance form ... --- 7. MR # 3 was admitted on 12/2/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the IDT meeting notes dated 12/17/24, 12/31/24, 1/13/25, and 1/28/25 revealed no documentation the IDT core members participated or signed the document. An interview was conducted on 2/6/24 at 11:21 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 4. MR # 1 was admitted on 10/21/24 and recertified for hospice care from 12/20/24 to 2/17/25 with a primary diagnosis of Malignant Neoplasm of the Brain Stem. Review of the IDT meeting notes dated 1/13/25 revealed no documentation the IDT core members participated or signed the IDT document. On 1/28/25, documentation revealed the social worker was the only core member to participate or sign the IDT document. An interview conducted on 2/6/25 at 11:22 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 5. MR # 2 was admitted on 12/14/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the IDT meeting note dated 1/28/25 revealed the social worker was the only member of the IDT who participated or signed the IDT document. An interview conducted on 2/6/25 at 11:27 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 6. MR # 4 was admitted on 11/9/24 with a primary diagnosis of End Stage Renal Disease. Review of the IDT meeting note dated 12/3/24 revealed no documentation the physician participated or signed the document. The IDT meeting notes dated 12/17/24, 12/31/24, 1/13/25, and 1/28/25 revealed no documentation the core members of the IDT participated or signed the document. An interview conducted on 2/6/25 at 11:34 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 1. MR # 10 was admitted on 12/13/23 and recertified for hospice care from 10/25/24 to 12/24/24 with a primary diagnosis of Alzheimer's Disease, Unspecified. Review of the Hospice IDT meeting notes dated 11/5/24, 11/19/24, 12/3/24, 12/17/24, and 12/31/24 revealed no documentation a chaplain or spiritual leader participated or signed the IDT. An interview conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 2. HV # 1 was admitted on 12/31/24 with a primary diagnosis of Alzheimer's Disease. Review of the Hospice IDT meeting note dated 1/28/25 revealed no documentation a chaplain or spiritual leader participated or signed the IDT. An interview conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 3. MR # 7 was admitted on 1/9/25 with a primary diagnosis of Heart Disease, Unspecified. Review of the Hospice IDT meeting note dated 1/28/25 revealed no documentation a chaplain or spiritual leader participated or signed the IDT. An interview conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure all core members participated in the IDT meetings.

Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure a range of visit frequency was included in the Plan of Care (POC) to meet each patient's needs, and the staff followed the ordered frequency when included. This deficient practice affected six of 14 MR's reviewed including MR # 10, MR # 7, Home Visit (HV) # 1, MR # 1, HV # 3, MR # 4, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: The Plan of Care Policy Number: 4-027.1-3 Policy Date: 11/2013 Purpose: To ensure that an individualized plan of care is completed... Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted... Procedure: ...4. The plan of care will identify the patient's needs and services to meet those needs...It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs, goals and outcome achievement... ...11. The written plan of care may contain, but will not be limited to, the following: ...M. Frequency/Amount/Duration of services... ...14. Care provided to the patient will be in accordance with the plan of care. --- 4. MR # 1 was admitted on 10/21/24 and recertified for hospice care from 12/20/24 to 2/17/25 with a primary diagnosis of Malignant Neoplasm of the Brain Stem. Review of the Hospice IDT meeting note dated 12/31/24 revealed physician's orders for the next benefit period of 12/20/24 to 2/17/25 for the hospice aide (HA) frequency of three times per week for patient care established in the HA care plan. A review of the HA visit notes revealed the week of 12/23/24 the HA completed two of the three visits ordered and no missed visit was completed. An interview was conducted on 2/6/25 at 11:22 AM, with EI # 1, who confirmed the HA did not follow the ordered frequency or complete a missed visit note. 5. HV # 3 was admitted on 1/9/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of the Hospice Plan of Care dated 1/9/25 revealed an order for SN two times a week, then one time a week. A review of the SN notes revealed the SN only completed one visit the week of 1/9/25. An interview was conducted on 2/6/25 at 11:33 AM with EI # 1, who confirmed the SN did not follow the ordered frequency or complete a missed visit note. 6. MR # 4 was admitted on 11/9/24 with a primary diagnosis of End Stage Renal Disease. A review of the Hospice Interdisciplinary Team meeting note dated 12/17/24 revealed orders for HA two times a week. A review of the HA visit notes revealed one visit completed on week of 12/23/24 and no missed visit note completed. An interview was conducted on 2/6/25 at 11:34 AM with EI # 1, who confirmed the HA did not follow the ordered frequency or complete a missed visit note. 1. MR # 10 was admitted 12/31/23 and recertified for hospice care from 12/25/24 to 2/22/25 with a primary diagnosis of Alzheimer's Disease. Review of the Hospice Interdisciplinary Team (IDT) meeting note dated 12/17/24 revealed physician's orders for the next benefit period of 12/25/24 to 2/22/25 for Skilled Nurse (SN) "as requested." Review of the Hospice Interdisciplinary Team meeting note date 12/31/24 revealed orders for SN frequency "as requested." There was no documentation a visit frequency was planned to meet the patient's needs. An interview was conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to include a planned visit frequency to meet the patient and family/caregiver needs. 2. MR # 7 was admitted on 1/9/25 with a primary diagnosis of Heart Disease, Unspecified. Review of the Hospice POC dated 1/9/25 revealed no ordered frequency or goals for the Social Worker. Review of the Visit notes revealed the Social Worker Comprehensive Assessment was completed on 1/9/25. An interview was conducted on 2/6/25 at 11:35 AM with EI # 1 who confirmed the agency failed to ensure a visit frequency for the social worker was included in the POC. 3. HV # 1 was admitted on 12/31/24 with a primary diagnosis of Alzheimer's Disease. Review of the Hospice POC dated 12/31/24 revealed no physician's orders for chaplain visits. Review of the Nursing Admit Comprehensive Assessment dated 12/31/24 revealed no documentation chaplain services were offered or refused. There was no documentation a chaplain visit was completed. An interview was conducted on 2/6/25 at 12:00 PM with EI # 1 who confirmed there was no documentation a visit frequency for chaplain services was ordered on the POC and there was no documentation on the initial comprehensive assessment that chaplain services were offered or refused.

Based on review of medical records (MR), agency policies and procedures, and interviews with staff, it was determined the agency failed to ensure a frequency of visits was included on the Aide Care Plan. This deficient practice affected one of ten records reviewed with orders for Hospice Aide services including Home Visit (HV) # 1 and had the potential to affect all patients with orders for Hospice Aides. Findings include: Agency Policy: The Plan of Care Policy Number: 4-027.1 Policy Date: 11/2023 Purpose: To ensure that an individualized plan of care (POC) is completed... Policy: The (POC) will be based on the initial, comprehensive and ongoing comprehensive assessment... Procedure: ...11. The written (POC) may contain, but not limited to the following: ...M. Frequency/Amount/Duration of services... Agency Policy: Hospice Aide Services Policy Number: 4-003.1 Policy Date: 11/2013 Purpose: To specify the role of the hospice aide... Policy: Hospice aide services will include...activities in accordance with the plan of care and physician's ... orders will be assigned and supervised by a hospice registered nurse (RN)... Procedure: ...3. Hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record... --- 1. HV # 1 was admitted on 12/31/24 with a primary diagnosis of Alzheimer's Disease. Review of the POC dated 12/31/24 revealed physician's orders for interventions by discipline including Certified Nursing Assistant (CNA). HV # 1 requires the assistance of the Hospice Aide (HA). There was no documentation of a frequency for the HA in the POC. Review of the Aide Support Care Plan dated 12/31/24 revealed orders for interventions including personal care, vital signs, and housekeeping duties. There was no frequency of visits included in the Aide Support Care Plan. There was no documentation a HA visit was completed during week one from 12/31/24 to 1/5/25. An interview was conducted on 2/6/25 at 12:00 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to include a visit frequency on the Hospice POC and on the Aide Support Care Plan.

Based on medical Record (MR) review, policy and procedure, and Interviews with the staff it was determined the agency failed to ensure the Hospice Aide (HA) followed the plan of care (POC) and Agency policy. This affected four of 10 medical records reviewed with hospice aide services, to include MR # 4, MR # 1, MR # 3, Home Visit (HV) # 2, and had the potential to affect all patients receiving hospice aide services. Findings include: Agency Policy and Procedure: Hospice Aide Services Number: 4-003.1 Date: November 2013 Purpose: To specify the role of the hospice aide and/ or homemaker in hospice care. Policy: Hospice aide services will include personal care services provided by trained hospice aides... Procedure: ...4. Hospice aide duties may include: ...d. Reporting changes in the patient's condition and needs... 5. Hospice aides will document care provided in accordance with the hospice aide assignment... --- 3. MR # 3 was admitted on 12/2/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. A review of the hospice aide plan of care dated 12/2/24 revealed orders for the hospice aide to document the patient's last bowel movement every visit and notify the nurse if greater than three days. A review of the HA visit notes dated 12/18/24, 12/23/24, 1/6/25, 1/13/25, 1/15/25, 1/20/25, 1/27/25, and 1/29/25 revealed the HA failed to document the patient's last BM. An interview was conducted on 2/6/25 at 11:21 AM with EI # 1 who confirmed the HA failed to follow the plan of care. 4. HV # 2 was admitted on 8/29/24 and recertified for continued hospice care on 11/27/24 to 2/24/24 with a primary diagnosis of Parkinson's Disease with Dyskinesia, without Mention of Fluctuations. A review of the HA POC dated 12/30/24 revealed orders for the HA to document the patient's last BM every visit and notify the nurse if greater than three days. HA to check heart rate, respirations, temperature, and pain rating every visit, and notify the nurse for heart rate less than 50 or greater than 120, respirations less than ten and greater than 40, temperature greater than 101, and pain rating that is unrelieved or greater than seven. A review of the HA visit note dated 1/20/25 revealed the HA failed to document the heart rate, respirations, temperature, and pain rating. A review of the HA visit note dated 2/3/25 revealed the HA failed to document the patient's last BM. An interview was conducted on 2/6/25 at 11:16 AM with EI # 1 who confirmed the HA failed to follow the plan of care. 1. MR # 4 was admitted on 11/9/24 with a primary diagnosis of End Stage Renal Disease. A review of the hospice aide POC dated 11/9/24 revealed orders for the HA to document the patient's last bowel movement (BM) every visit, and notify the nurse if greater than three days. HA to check heart rate, respirations and temperature every visit, and notify the nurse for heart rate less than 50 or greater than 120, respirations less than 10 or greater than 40, and temperature greater than 101. A review of the HA visit notes dated 11/20/24, 11/27/24, 12/6/24,1/9/25,1/15/25, and 1/20/25 revealed the HA failed to document the patient's last BM. A review of the HA visit note dated 1/24/25 revealed the HA failed to document the temperature, respirations, and heart rate for the patient. An interview was conducted on 2/6/25 at 11:34 AM with Employee Identifier (EI) # 1, Director, who confirmed the HA failed to follow the plan of care and agency policy. 2. MR # 1 was admitted on 10/21/24 and recertified for continued hospice care 12/20/24 to 2/17/25 with the primary diagnosis of Malignant Neoplasm of the Brain Stem. A review of the hospice aide POC dated 11/19/24 revealed orders for the HA to document the patient's last BM every visit, and notify the nurse if greater than three days. A review of the HA visit notes dated 12/22/24, 12/23/24, 12/27/24, 1/1/25, and 1/10/25 revealed the HA failed to document the patient's last BM. An interview was conducted on 2/6/25 at 11:22 AM with EI # 1, who confirmed the HA failed to follow the plan of care and agency policy.

Based on interviews with agency staff, and policies and procedures, it was determined the agency failed to use volunteers in the office performing administrative duties, or providing direct patient services. This had the potential to affect all patients served by the facility. Findings include: Agency Policy: Volunteer Services Policy number: 4-007.1 Dated: November 2013 Purpose: To ensure that qualified volunteer provide appropriate services in accordance with the plan of care and hospice program needs. Policy: Community Hospice of Dale Medical Center will provide volunteer services under the direction of Volunteer Coordinator and with the assistance of trained hospice volunteers... Volunteers may work in a variety of capacities, including: ... 4. Office Volunteers lend their services working in the hospice's administrative offices. The activities may include assembling information packets, filing , photocopying and assisting with mailing... --- Review of the program data and interview with Employee Identifier (EI) # 3, Volunteer Coordinator, conducted 2/6/25 at 08:57 AM revealed no documentation of eligible hours provided by volunteers, including the type of services and time worked. An interview was conducted on 2/6/25 at 09:32 AM with EI # 1, Director, who confirmed no volunteer services were available.

Based on review of medical records (MR), agency policies and procedures, and interviews, it was determined the agency failed to ensure the plan of care included individualized goals related to each discipline /service provided. This deficient practice affected 2 of 11 MR reviewed including MR # 6, Home Visit (HV) # 2, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Interdisciplinary Group Plan of Care Policy Number: 4-031.1 No Policy Date ...Policy: ...The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve... Agency Policy: Interdisciplinary Group Meeting Policy Number: 4-032.1 Policy Date: 11/2013 ...Procedure: ...3. Level of services will be reviewed for new and ongoing patients based on hospice team assessments... 5. A plan of care update will be completed for each patient and family/caregiver... 6. An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include: a. Pharmacotherapeutic effectiveness of symptom management outcomes b. An increase or decrease in symptoms of acuity c. Increases or decreases in frequency of visits by team members and reason for the change. d. Changes in the location of care e. Psychosocial and other consultations... f. Changes that may contribute to risk for pathological grief g. Ongoing spiritual support h. Plan for changes in treatments or procedures... 1. MR # 6 was admitted to hospice on 1/20/2021 with a primary diagnosis of Paroxysmal Atrial Fibrillation. Review of the the Hospice Plan of Care (POC) dated 1/20/2021 revealed the following discipline frequencies: Skilled Nurse (SN) 1 x week x 1 then 2 x a week, Social Worker (SW) 1 x a month, and Certified Nursing Assistant (CNA) 1 x a week x 1 then 2 x a week. Further review of the POC dated 1/20/2021 revealed the following goals for each discipline: SN goals: "...to manage pain and symptoms related to terminal diagnosis..." SW "... to manage pain and symptoms related to terminal diagnosis..." CNA "...to manage pain and symptoms related to terminal diagnosis..." Review of the Hospice Interdisciplinary Team (IDT) note dated 2/3/2021 revealed the following goals: SW "... to manage pain and symptoms related to terminal diagnosis..." CNA "... to manage pain and symptoms related to terminal diagnosis..." The goals of care were not individualized for each discipline and related to the identified needs of the patient and family/caregiver. In an interview conducted on 2/17/22 at 11:30 AM, Employee Identifier (EI) # 1, Hospice Director, confirmed the agency failed to establish individualized goals for each patient. 2. HV # 2 was admitted 12/30/21 with diagnoses including Hypertensive Chronic Kidney Disease and History of Malignant Neoplasm of Prostate. Review of the Hospice POC dated 12/30/21 revealed the following goal for each discipline: SN - Hospice to manage pain and symptoms related to terminal diagnosis and related conditions. SW - Hospice to manage pain and symptoms related to terminal diagnosis and related conditions. CNA - Hospice to manage pain and symptoms related to terminal diagnosis and related conditions. CH (Chaplain) - Hospice to manage pain and symptoms related to terminal diagnosis and related conditions. The goals of care were not individualized for each discipline and related to the identified needs of the patient and family/caregiver. Review of the IDT meeting note dated 1/5/22 revealed the same goal for all disciplines: Hospice to manage pain and symptoms related to terminal diagnosis and related conditions. Review of the IDT meeting notes dated 1/19/22 and 2/2/22 revealed the same one goal remained for the SN and CNA: Hospice to manage pain and symptoms related to terminal diagnosis and related conditions. There were no goals related to the suprapubic catheter changes nor the personal care and services provided by the hospice aide. An interview conducted 2/17/22 at 11:00 AM with EI # 1 confirmed the IDT failed to update and individualize the POC goals to reflect the needs of the patient and family/caregiver.

Based on Medical Record (MR) review, Agency Policy and Procedure, and interviews, it was determined the agency failed to ensure all core members of the Interdisciplinary Team (IDT) participated in and signed the IDT to develop individualized plans of care for each patient. This deficient practice affected 2 of 11 records reviewed including MR # 6 and MR # 5, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Interdisciplinary Group Membership and Responsibilities. Policy Number: 4-001.1 No Policy Date Purpose: To define the membership and responsibilities of the Interdisciplinary Group (IDG). Policy: The interdisciplinary group will collaborate with the patient's attending physician to develop an individualized written plan of care (POC)... Procedure: 1. The hospice interdisciplinary group membership includes at a minimum: a. Physician... b. Registered Nurse c. Social Worker d. Pastoral or other counselor... 3. The interdisciplinary group responsibilities include but are not limited to: a. Participation in the establishment of the plan of care for each patient admitted to the hospice service. b. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services... 1. MR # 6 was admitted to hospice on 1/20/2021 with a primary diagnosis of Paroxysmal Atrial Fibrillation. Review of the IDT meeting dated 2/3/2021 revealed no documentation the chaplain or other counselor attended the IDT meeting as part of the IDT team. There was no signature of the Chaplain or other counselor and no documentation by the Chaplain or the IDT that spiritual services were declined. Further review of the IDT dated 2/3/2021 revealed no documentation by the Chaplain or other counselor the spiritual services were declined and there was no signature the Chaplain or other counselor participated in IDT. In an interview conducted on 2/17/22 at 11:30 AM, Employee Identifier (EI) # 2, Chaplain, stated the Chaplain was not involved with planning for spiritual counseling due to family denial of need. In an interview conducted on 2/17/22 at 11:35 AM, EI # 1, Hospice Director, confirmed there was no IDT documentation of planning for spiritual counseling and all core members did not participate in the IDT. 2. MR # 5 was admitted to the agency on 9/3/21 with certification dates of 9/3/21 to 12/1/21 and admitting diagnosis of Sepsis, Unspecified Organism. Review of the POC dated 9/3/21 to 12/1/21 revealed no documentation or signatures by the Chaplain or the Social Worker in the development of the POC. Review of the IDT meeting dated 9/15/21 revealed no documentation the chaplain or other counselor attended the IDT meeting as part of the IDT team and no signature documented by the chaplain or other counselor. An interview was conducted on 2/17/22 at 12:15 PM with EI # 1 who confirmed the Social Worker and Chaplain did not sign the POC or the IDT meeting and stated the family refused both services. There was no documentation in the IDT meeting stating the family had refused the services by the Social Worker or the Chaplain.

Based on agency policy and procedure, review of medical records (MR) and interviews it was determined the agency failed to ensure the Hospice Aide (HA) followed the ordered visit frequency. This affected 2 of 7 records reviewed with HA services including Home Visit (HV) # 2 and MR # 8. This had the potential to affect all patients with HA services. Findings include: Agency Policy: The Plan Of Care Policy Number: 4-027.1 No Policy Date Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. Procedure: 4. The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed... 14. Care provided to the patient will be in accordance with the plan of care. 1. HV # 2 was admitted 12/30/21 with diagnoses including Hypertensive Chronic Kidney Disease and History of Malignant Neoplasm of Prostate. Review of the Hospice Plan of Care (HPOC) dated 12/30/21 revealed the CNA (certified nursing assistant - hospice aide) was to visit 3 times per week. Review of the MR revealed the HA visited 2 times the week of 1/10/22 and not 3 as ordered. An interview conducted 2/17/22 at 10:54 AM with Employee Identifier (EI) # 1, Hospice Director, confirmed there were only 2 HA visits the week of 1/10/22 and not 3 as ordered. 2. MR # 8 was admitted 5/5/21 and recertified for care 12/31/21 with diagnoses including Atherosclerotic Heart Disease. MR # 8 expired at home 2/6/22. Review of the Interdisciplinary Team (IDT) meeting notes dated 1/5/22, 1/19/22, and 2/2/22 revealed the HA was to visit 3 times per week. Review of the MR revealed the HA visited 2 times the weeks of 1/10/22, 1/17/22 and 1/31/22 and not 3 visit as ordered. An interview conducted 2/17/22 at 11:12 AM with EI # 1 confirmed the ordered HA visit frequency was not met.

Based on agency policy and procedure, review of medical records (MR) and interviews it was determined the agency failed to ensure: A. Wound care was provided as ordered in the plan of care. B. Orders were written for all medications administered by the hospice nurse. C. Treatment orders for obtaining lab tests on the next nurse visit were removed from the updated plan of care once completed. This affected 1 of 11 records reviewed including MR # 8, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: The Plan Of Care Policy Number: 4-027.1 No Policy Date Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. Procedure: 4. The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed... 14. Care provided to the patient will be in accordance with the plan of care. 1. MR # 8 was admitted 5/5/21 and recertified for care 12/31/21 with diagnosis including Atherosclerotic Heart Disease. MR # 8 expired at home 2/6/22. Review of the physician's order dated 1/21/22 revealed the following: Cleanse right heel with NS (normal saline), pat dry, apply calcium alginate to wound bed, cover with Mepilex Heel dressing, change every 7 days and as needed. Review of the skilled nurse visit (SNV) note dated 1/24/22 revealed the following: "checked R (right) heel and cleaned with soap and water and applied a mepilex." There was no documentation the wound was cleaned with NS and calcium alginate applied to the wound bed as ordered. Review of the SNV note dated 1/31/22 revealed the following: "checked area heel and cleaned with saline and changed dressing." There was no documentation calcium alginate was applied to the wound bed as ordered or what dressing was applied. Review of the SNV notes dated 2/4/22 and 2/6/22 revealed MR # 8 received Rocephin 1 gram IM (intramuscular) and Depomedrol 40 milligrams IM each visit. Review of the physician orders revealed an order dated 2/6/22 but no order for the Rocephin and Depomedrol administered on 2/4/22. The agency failed to ensure the plan of care included physician orders for all medications administered. Review of the Interdisciplinary Team (IDT) meeting notes dated 1/5/22, 1/19/22, and 2/2/22 revealed the following skilled nurse order: Draw CBC (complete blood count) on next skilled nurse visit. Review of the MR nursing notes dated 12/31/21 to 2/6/22 revealed no CBC was obtained. An interview conducted 2/17/22 at 11:12 AM with Employee Identifier (EI) # 1, Hospice Director, confirmed the ordered wound care was not followed, there was no order written for the Rocephin and Depomedrol administered on 2/4/22, and the IDT failed to update the plan of care and remove the order for the CBC.

Based on observation, agency policy and procedure, review of medical records and interviews it was determined the agency failed to ensure the Hospice Aide (HA) Support Care Plan was individualized to meet the needs of the patient to include care of a suprapubic catheter and dressing change. This affected 1 of 1 Home Visit (HV) with a HA, inlcuding HV # 2 and had the potential to affect all patients receiving aide services. Findings Include: Agency Policy: Hospice Aide Services Policy Number: 4-003.1 No Policy Date Policy: Services provided by an aide could include: bathing, shampoo...dry dressing change...These activities in accordance with the plan of care...will be assigned and supervised by a hospice registered nurse (RN)... Procedure: 1. The need for hospice aide services will be identified by the interdisciplinary group... 3. Hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record. 1. HV # 2 was admitted 12/30/21 with diagnoses including Hypertensive Chronic Kidney Disease and History of Malignant Neoplasm of Prostate. A home visit was conducted 2/15/22 at 11:25 AM to observe Employee Identifier (EI) # 3, Hospice Aide, provide care. HV # 2 was observed lying in bed, alert and oriented, with a suprapubic catheter connected to a bedside drainage bag. The catheter site was covered with a gauze dressing. EI # 3 performed hand hygiene, donned gloves and emptied the catheter drainage bag. During the bath, EI # 3 removed the gauze dressing covering the suprapubic catheter, cleaned the site and the catheter with soap and water, and replaced a dry gauze dressing over the site. Review of the Hospice Aide Care Plan revealed no interventions/tasks for the catheter nor the dry dressing. Review of the MR revealed the RN performed a HA supervisory visit on 1/13/22 with documentation the HA plan of care was reviewed, the HA was following the plan of care and no changes were made. Review of the HA visit note dated 2/15/22 revealed no documentation the HA emptied the catheter drainage bag, cleaned the suprapubic catheter site and changed the dry dressing covering the suprapubic catheter, as observed by the surveyor during the HV. An interview conducted 2/17/22 at 10:54 AM with EI # 1, Hospice Director, confirmed the HA Care Plan did not include care of the suprapubic catheter and the RN Case Manager should have updated the aide plan of care.

Based on agency policy and procedure, review of medical records (MR) and interviews it was determined the agency failed to ensure hospice aides (HA) clearly documented care provided as ordered in the plan of care. This affected 2 of 7 records with HA services including MR # 8, MR # 3 and had the potential to affect all patients with HA services. Findings Include: Agency Policy: Hospice Aide Services Policy Number: 4-003.1 No Policy Date Policy: Services provided by an aide could include: bathing, shampoo...dry dressing change...These activities in accordance with the plan of care...will be assigned and supervised by a hospice registered nurse (RN)... Procedure: 3. Hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record. 5. Hospice aides will document care provided in accordance with the hospice aide assignment. 1. MR # 8 was admitted 5/5/21 and recertified for care 12/31/21 with a diagnosis including Atherosclerotic Heart Disease. Review of the HA Support Care Plan dated 10/13/21 revealed the following tasks to be completed every visit: Last BM (bowel movement) - notify nurse if greater than 3 days Heart Rate Respirations Temperature Foot Care Hair Care - Shampoo as requested Nail Care - Clean only Oral Care Bad Bath Perineal Care Review of the HA visit note dated 1/3/22 revealed no Last BM date, Heart Rate, and a single squiggly line was drawn down through all check boxes for Foot Care, Hair Care, Nail Care, Oral Care, and Bed Bath. The surveyor was unable to determine what care was provided. Review of the HA visit note dated 1/5/22 revealed no Last BM date, and a single squiggly line was drawn down through all check boxes for Hair Care, Nail Care, Oral Care, Bed Bath and Perineal Care. The surveyor was unable to determine what care was provided. Review of the HA visit notes dated 1/12/22, 1/14/22, 1/19/22, 1/24/22 revealed no Last BM date, Heart Rate, and a single squiggly line was drawn down through all check boxes for Foot Care, Hair Care, Nail Care, Oral Care, Bed Bath and Perineal Care. The surveyor was unable to determine what care was provided. Review of the HA visit note dated 1/26/22, 1/28/22, and 1/31/22 revealed a single squiggly line was drawn down through all check boxes for Foot Care, Hair Care, Nail Care, Oral Care, Bed Bath and Perineal Care. The surveyor was unable to determine what care was provided. An interview conducted 2/17/22 at 11:15 AM with Employee Identifier (EI) # 1, Hospice Director, confirmed the HA failed to clearly document care provided. 2. MR # 3 was admitted 1/14/22 with diagnoses including Heart Failure Unspecified and Essential Hypertension. Reveiw of the HA Support Care Plan dated 1/14/22 revealed the following tasks to be completed every visit: Last BM (bowel movement) - notify nurse if greater than 3 days Heart Rate Respirations Temperature Foot Care Hair Care - Shampoo Nail Care - Clean only Oral Care Bad Bath Perineal Care Review of the HA visit note dated 2/1/22, 2/3/22, and 2/8/22 revealed a single squiggly line was drawn down through all check boxes for Foot Care, Hair Care, Nail Care, Oral Care, Bed Bath and Perineal Care. The surveyor was unable to determine what care was provided. An interview conducted 2/17/22 at 11:25 AM with EI # 1 confirmed the HA failed to clearly document care provided.