Every finding on record at Toluca Hospice, Inc

d. A review of Patient 5's clinical record indicated, Patient 5 was 46 years female who started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 could drive. During an interview with Patient 5 on 9/7/2022, at 10:30 a.m., it was observed Patient 5 was alert, oriented, and was able to communicate well. Patient 5 stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehensive Nursing Assessment" dated 12/28/2021 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane, and had steady gait. Patient 5 had mild dyspnea with mild exertion, and requires oxygen at 2 liters per minute as needed. Patient 5 was observed using chest accessory muscle after activity or walking, and the oxygen saturation at room air was 85 percent. The patient took two puffs of her Albuterol HFA 90 mcg oral inhalation, and after few minutes of rest, the patient's oxygen saturation had improved to 90 percent. Patient 5 had dull ache pain on both lower legs at a level of 4/10 on a pain scale. Diclofenac Sodium 1 % topical 2-4 times per day for pain management, and the pain was managed well ( reassessed pain prior to end the visit and the pain level was 2/10). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 12/28/2021, indicated the section 1 and 2 should be met. It indicated Patient 5 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity, had Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 12/28/2021 to 3/27/2022, indicated, Patient 5's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". e. A review of Patient 6's clinical record indicated, Patient 6 was 64 years old male who started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehensive Nursing Assessment" dated 7/14/2021 indicated Patient 6 was alert and oriented, used a cane for ambulation, and bowel and urinary status was continent. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/14/2021, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Increased visits to Emergency Room *Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, or had Increased visits to Emergency Room, and the oxygen saturation rate was less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 6's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". f. A review of Patient 7's clinical record indicated, the patient was 60 years old male who started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks 2 week plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehensive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. Patient 7 had mild dyspnea with mild exertion, and oxygen saturation was 97 percent. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, was check marked as "None". The need for the Volunteer or community support was blank. The nurse's narrative indicated Patient 7 was observed with on and off shortness of breath and was on Albuterol 90 mcg/Actuation inhalation Aerosol 90 mcg 1-2 puffs inhaler three times a day as needed for shortness of breath/wheezing. Patient 7 had generalized body pain and was on Norco 10 mg-325 mg one tablet by mouth every 6 hours as needed for pain. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 2/28/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 millimeter Mercury (mmHg). A review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 millimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 7's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient was 44 years old male who started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's "Comprehensive Nursing Assessment" dated 1/21/2022 indicated Patient 8 was alert and oriented, needed stand by assist for ambulation. Patient 8 had mild dyspnea with mild exertion, and oxygen saturation was 92 percent. Patient 8 was continent in bowel and bladder. The need of Hospice aide, and the need of community support were check marked as "None". The need for the Volunteer was check marked for errands. The nurse's narrative indicated Patient 8 was 43 years old male with last hospitalization on 9/18/2021 to 9/21/2021 for evaluation and treatment of left lower extremity torn ligament. According to the patient, his condition had progressively deteriorated in the past few months, evidence of dyspnea with activity and even at rest. Upon assessment, the patient was sitting in a chair and had a pain level to be 8/10. The patient was placed with medication of Norco 10/325 mg one tablet orally every 6 hours as needed for moderate to severe pain and Tylenol 500 mg every 6 hours for breakthrough pain. At the end of the visit and assessment, the patient was noted relaxed without any discomfort, no shortness of breath, and the pain level was 0/10. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 1/21/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 1/21/2022 to 4/20/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the physician's narrative that Patient 8 no longer wants to continue aggressive treatment and stated he wanted comfort measures only. It was indicated in the section of "Certifying Physician Summary" that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 8's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8 were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians that Patient 5, 6, 7, 8, had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of the agency's comprehensive assessment revised in April 2017 indicated the agency must assure the data elements allow for measurement of outcomes, and the Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Based on observation, interview and record review, the hospice agency's skilled nurse (SN) failed to provide education and training to patient/caregiver as identified in the plan of care (POC) for three of 11 sampled patients (Patients 4, 8 and 10). 1. For Patient 4, education/instruction regarding the maintenance of oxygen equipment were not provided to patient and/or caregiver. 2. For Patient 8, education regarding aspiration precautions, nutrition, and positioning were not provided to patient/family/PCG (patient caregiver). 3. For Patient 10, education regarding positioning, safe use of DMEs (Durable medical equipment, any medical equipment used in the home to aid in a better quality of living), and reason for increased risk of falls were not provided to patient/family/PCG. These deficient practices could place the patient at risk of not meeting their healthcare needs. Findings: a. A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 4/26/2022, with diagnoses of senile degeneration of brain, stage IV pressure ulcer of sacral region, and stage III pressure ulcer of right buttock. A review of the Comprehensive Nursing Assessment dated 4/27/2022 indicated Patient 4 had used oxygen at 2 liters per minute via nasal annular as needed for mild dyspnea (difficulty breathing). A review of the POC/IDG Review, dated 4/27/2022, indicated the Skilled Nurse (SN) visits were three times per week, Hospice Aide (HA) visits were one to two times a week, the Medical Social Worker (MSW) and the spiritual counselor visits were for initial evaluation and support. The POC/IDG indicated the SN was to educate family/primary caregiver (PCG) about increase in weakness. The POC/IDG did not indicate care/service for dyspnea. On 5/27/2022, at 10:25 a.m., Patient 4's home visit was conducted jointly with Licensed Vocational Nurse 1 (LVN 1) at the Board and Care facility. Patient 4 was lying in a hospital bed and Family Member 1 was next to the patient. The patient was receiving oxygen at 4 liters per minutes via nasal annular, and there was a humidifier bottle connected to the oxygen concentrator. Both nasal cannula and the humidifier bottle were not labeled with the date when it was placed/applied. At 11 a.m., during an interview with LVN 1, she was not able to answer how long the nasal annular and the humidifier bottle had been used. LVN 1 stated nasal cannula and the humidifier bottle should be changed every month. During an interview with Family Member 1 at the same time, she stated both nasal cannula and the humidifier bottle had been used since approximately two weeks ago. Family member 1 stated she was not provided instruction on how long the nasal cannula and humidifier bottle could be used. During an interview with the Director of Patient Care Services (DPCS) on 5/31/2022, at 2 p.m., she stated the oxygen nasal cannula and the humidifier bottle should have been changed weekly. The DPCS stated she was not able to provide the documented evidence the oxygen nasal cannula and the humidifier bottle had been changed weekly, and the agency had provided instruction to Family or PCG regarding the oxygen equipment maintenance including oxygen nasal cannula and the humidifier bottle . A review of the agency's undated policy titled "Cleaning and Disinfecting Oxygen Equipment" indicated to clean humidifier container weekly with mild soap and water. If extras are not available, to refill with distilled water after drying with a clean paper towel. For clients receiving continuous oxygen therapy, it indicated to replace cannula, mask, tubing and catheter as needed. However, it did not indicate the maximum time frame that the cannula, mask, tubing and catheter could be used. A review of the "Oxygen Equipment" by the University of California San Francisco (UCSF) indicated the oxygen annular should be changed every week. It indicated if humidifier was used, to empty it at least once a day, wash the bottle with soap and warm water, make sure all the soap was rinsed out, and refill the bottle with distilled water. b. A review of Patient 8's clinical record indicated he was admitted to the hospice agency on 3/25/2022, with a diagnosis including Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by symptoms like impairment of memory). A review of Patient 8's POC from 3/25/2022 to 6/22/2022, indicated the skilled nurse to provide the following education and training to Patient 8 and/or to his care giver (PCG) during the home visits: a) educate patient/family/PCG on aspiration precautions b) educate patient/family/PCG on nutritional/appetite changes expected, related to disease process c) teach need for offering fluids, nutritious liquid supplements, ice chips, positioning as tolerated During an interview and clinical record review with the director of patient care services (DPCS) on 6/01/2022, at 11:30 a.m., the clinical visit notes from 3/25/2022 to 5/21/2022 were reviewed. The DPCS concurred there were no clinical notes found indicating education and training were provided to Patient 8 and/or his PCG. DPCS stated education and training to patient and/or PCG should be done on every skilled nursing visit and be documented on the patient clinical record. c. A review of Patient 10's clinical record indicated she was admitted to the hospice agency on 10/22/2021, with diagnosis including senile degeneration of brain, not elsewhere classified (mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). A review of Patient 10's POC from 3/20/2022 to 5/19/2022, indicated the skilled nurse would provide the following education and training to Patient 10 and/or to his care giver (PCG) during the home visits: a) instruct patient/family/PCG in positioning as tolerated to promote circulation b) instruct on safe use of DMEs provided to patient c) teach PCG on reasons for increased for fall During an interview and clinical record review with the director of patient care services (DPCS) on 6/01/2022, at 11:30 a.m., the clinical visit notes from 3/20/2022 to 5/19/2022 were reviewed. The DPCS concurred there were no clinical notes found with documentation of education and training on the above topics provided to Patient 10 and/or his PCG. DPCS stated education and training to patient and/or PCG should be done on every skilled nursing visit and be documented on the patient clinical record. A review of the hospice agency's policy titled, "Plan of Care: Interdisciplinary Group, Care Planning and Coordination of Services", dated 01/01/2015, indicated the hospice will develop and maintain a system of communication and integration to ensure that care and services are provided in accordance of the POC, and the care and services provided are based on all assessments of the patient/family needs.

c. A review of Patient 5's clinical record indicated the patient started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of Patient 5's Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of Patient 5's record indicated there was documented evidence the skilled nurse (SN) had visited Patient 5 for the weeks from 7/3/2022 to 7/9/2022 and 8/28/2022 to 9/3/2022. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:20 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 5 on above time period. LVN 1 stated the above missed visits should have been rescheduled, but she was not able to provide the documented evidence rescheduled visit was made. d. A review of Patient 6's clinical record indicated the patient started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of Patient 6's Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's record indicated there was documented evidence the skilled nurse (SN) had visited Patient 6 the weeks from 8/7/2022 to 8/13/2022 and 8/21/2022 to 8/27/2022. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:30 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 6 on the above time period. LVN 1 stated the above missed visits should have been rescheduled, but she was not able to provide the documented evidence rescheduled visit was made. e. A review of Patient 7's clinical record indicated the patient started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's record indicated there was no documented evidence the skilled nurse (SN) had visited Patient 7 from 3/13/2022 to 3/26/2022 (for two weeks) and 8/12/2022 to 9/11/2022 (for four weeks). During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:35 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 7 on the above days. LVN 1 stated she could not find the reason why the SN visit was not made on above days, and could not find the documentation the above missed visit was reported to the IDG. A review of the agency's policy titled, "Miss Visit" revised in April 2017 indicated if visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit was missed and not rescheduled, the clinician would notify the IDG and clinical supervisor of the missed visit and reason for missed visit. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. f. A review of Patient 12's clinical record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) frequency of visits of once per week and one as needed to assess cardiac, neurological and sensory status, to teach patient on safe transfer techniques, and to assess and monitor effectiveness of medications, pain and severity, and nutritional needs every visit. A review of Patient 12's history of SN visits for August 2022 indicated there was no recorded visits or notes from the Skilled nurse from the week starting 8/14/2022 to 8/20/2022. During a concurrent interview and record review with the Case Auditor (LVN 1), on 9/12/2022 at 2:15 p.m., LVN 1 stated SN visits for Patient 12 was once a week. LVN 1 was unable to provide the SN visit notes or documented evidence Patient 12 or his family and/or caregiver refused SN visit from 8/14/2022 to 8/20/2022. g. A review of Patient 13's clinical record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed to assess and monitor effectiveness of medications, oxygen saturation, cardiac status, and nutritional needs every visit. A review of Patient 13's history of SN visits for July 2022 and August 2022 indicated there was no recorded visits or notes from the Skilled nurse from the week starting 7/31/2022 to 8/06/2022. During a concurrent interview and record review with the Case Auditor (LVN 1), on 9/12/2022 at 2:15 p.m., LVN 1 stated SN visits for Patient 13 was once a week. LVN 1 stated she was unable to provide the SN visit notes or documented evidence Patient 13 or his family and/or caregiver refused SN visit from 7/31/2022 to 8/06/2022. A review of the agency's policy and procedure titled, "The Plan of Care", revised April 2017, indicated the care provided to the patient must be in accordance with the plan of care.

Based on observation, interview and record review, the skilled nurse (SN) failed to wash/sanitize hands after removing soiled gloves during wound care treatment for one out of 11 sample patients (Patient 4). This deficient practice has the potential to transmit infectious agents to patients in the facility. Findings: A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 4/26/2022, with diagnoses of senile degeneration of brain, Stage IV pressure ulcer of sacral region, and Stage III pressure ulcer of right buttock. A review of the Comprehensive Nursing Assessment dated 4/27/2022 indicated Patient 4 had Stage III pressure ulcer on the right buttock measuring 1.9 x 1.2, and Stage IV pressure ulcer on the sacrococcygeal area measuring 6.1 x 7.5. A review of Patient 4's POC/IDG Review, dated 4/27/2022, indicated the Skilled Nurse (SN) visits were three times per week. SN was to cleanse the Stage IV wound in the sacrococcygeal area and the Stage III pressure ulcer in the right buttock every visit with wound cleanser, pat dry, apply collagen powder and triple antibiotic, then cover with dressing daily or as needed when the dressing is soiled. On 5/27/2022, at 10:25 a.m., a home visit was conducted with Licensed Vocational Nurse 1 (LVN 1) at the Board and Care facility where Patient 4 resided. Patient 4 was lying in a hospital bed and Family member 1 was next to the patient. At 10:45 a.m., LVN 1 cleansed the patient's bowel movement and removed old/soiled dressing from Patient 4's sacral area. LVN 1 took off the gloves and put the new gloves without washing/sanitizing hands. LVN 1 cleansed the wound with wound cleanser, patted it dry, applied collagen powder and triple antibiotic, packed the wound with dry 4 x 4 gauze, and covered with adhesive foam dressing. During an interview with LVN 1 on 5/27/2022, at 11:20 a.m., she stated she should have washed/sanitized hands after the removing of gloves that was used to clean bowel movement and touched soiled dressing. A review of the agency's policy of undated "Hand-washing/Hand Sanitizing" indicated hands should be sanitized using hand sanitizing solutions when removal of gloves or between patients.

Based on interview and record review, the hospice agency failed to ensure the clinical record contained clinical information including signed copies of advanced directives (a legal document that provides guidance for medical and health-care decisions) for one of 11 sampled patients (Patients 8). This deficient practice had the potential for the patient's end of life preferences/choices to not be honored or implemented during an emergency or dying process. Findings: A review of Patient 8's Face Sheet form, indicated Patient 8 was admitted to the hospice agency on 3/25/2022, with a primary diagnosis of Alzheimer's disease, unspecified (a progressive disease that destroys memory and other important mental functions). A review of Patient 8's Psychosocial Assessment dated 3/30/2022, indicated Patient 8 having a Durable Power of Attorney (DPOA) or health Care Agent and a copy has been provided to the hospice agency. No copies of the Advanced Healthcare Directives (AHCD) or DPOA were located in the patient's clinical record. During an interview with the Director of Patient Care Services (DPCS) on 6/01/2022, at 11:30 a.m., DPCS confirmed the hospice had no copies of the AHCD or DPOA documents for Patient 8 on file. A review of the agency's policy and procedure titled "Advanced Directives - Written Information to Patients", dated 01/01/2015, indicated the hospice agency will comply with the requirements of federal and state law regarding advance directives. If an advance directive was executed, a copy will be obtained and placed in the patient's file.

Based on observation, interview and record review, the facility failed to provide a "Comfort Kit" (a prescribed set of medications that are kept in a patient's home in the event of an emergency) for one out of 11 sampled patients (Patient 8). This deficient practice had the potential to result in patients not receiving their comfort medications on a timely basis. Findings: A review of Patient 8's clinical record indicated he was admitted to the hospice agency on 3/25/2022, with a diagnosis including Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by symptoms like impairment of memory). A review of Patient 8's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 3/25/2022 to 6/22/2022, the space "Physician Summary" indicated Patient 8 has right-sided weakness with tremors (shaking) noted to bilateral hands and lower extremities (lower leg), non-ambulatory, non-verbal, disoriented and confused, had difficulty swallowing, requiring maximum assistance with all of his activities of daily living (ADL's, like bathing, toileting, dressing, eating, mobility). It also indicated Patient 8 has a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 8's "Plan of Care" (POC) Summary, dated 3/25/2022, indicated Skilled Nurse (SN) was to visit twice a week for pain and comfort management, Certified Home Health Aide (CHHA) was to visit three times a week to assist patient with ADL's, personal care and hygiene, MSW (Social worker) to follow-up on a monthly basis, and SC (Spiritual Counselor) to follow-up once a month. A review of Patient 8's Comprehensive Nursing Assessment dated 3/25/2022 indicated Patient 8 was awake, disoriented, confused and non-ambulatory. Under the ADL assessment, it indicated Patient 8 needed maximum assistance for toileting, dressing, feeding, transfer, and bathing. During a joint home visit to Patient 8's home at the Board and Care Facility, on 5/27/2022, at 10:30 a.m., with License Vocational Nurse (LVN 2), Patient 8 was observed fully clothed, sitting by self on a recliner in the living room. Patient 8 eyes were closed, and unable to answer to any questions asked. During an interview on 5/27/2022 at 11:00 a.m., LVN 2 was asked if a Comfort Kit was provided for Patient 8. LVN 2 stated, "for now we don't have it, but an arrangement has already been made to get a Comfort kit for the patient". During an interview with the Director of Patient Care Services (DPCS) on 6/01/2022, at 11:30 a.m., DPCS stated that Comfort Kits are only sent when there is a decline in a patient. DPCS stated that Patient 8 did not have a Comfort Kit but can get one for him right away. A review of the agency's Policy and Procedure titled, "Comfort Packs and Seizure Kits", dated 01/01/2015, indicated that it is the policy of Embrace Healthcare to provide prompt availability of medications to each hospice patient.