Every finding on record at V Care Hospice, LLC

Based on record reviews and interviews, the hospice failed to ensure a Registered Nurse (RN) completed an initial assessment within 48 hours of the signed notice of election for 6 of 20 patient (Pt) charts reviewed. (Patients #1, #2, #3, #15, #16 and #18). --- Record review on 4/01/24 at 1:46 PM revealed Pt #1 was admitted to the hospice on 11/20/23 for senile degeneration of brain. Review of the chart revealed the notice of election (NOE) was signed on 11/20/23 with the initial RN assessment completed on 11/20/23 by a Licensed Practical Nurse (LPN) and not a Registered Nurse (RN). A routine visit was conducted by an RN on 11/22/23. During an interview on 4/03/24 at 2:26 PM, the Executive Director stated, ";The initial assessment should have been completed by an RN". Record review on 4/01/24 at 2:42 PM revealed Pt #2 was admitted to the hospice on 11/20/23 for Chronic Obstructive Pulmonary Disease (COPD). Review of the chart revealed the NOE was signed on 11/20/23 with the initial RN assessment completed on 11/20/23 by an LPN and not a RN. A routine RN visit was conducted on the patient on 10/25/23. During an interview on 4/03/24 at 2:49 PM, the Executive Director verified the findings. Record review on 4/01/24 at 3:25 PM revealed Pt #3 was admitted to the hospice on 10/05/23 for COPD. Review of the chart revealed the NOE was signed on 10/05/23 with the initial RN assessment completed on 10/05/23 by an LPN and not a RN. A RN visit was not conducted on the patient until 12/21/23. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/02/24 at 2:12 PM revealed Pt #15 was admitted to the hospice on 11/09/23 for senile degeneration of brain. Review of the chart revealed the NOE was signed on 11/09/23 with the initial RN assessment completed on 11/09/23 by an LPN and not a RN. A RN visit was not conducted until 11/21/23. During an interview on 4/03/24 at 3:33 PM, the Executive Director verified the findings. Record review on 4/02/24 at 3:50 PM revealed Pt #16 was admitted to the hospice on 8/15/23 for Cerebrovascular Disease, unspecified. Review of the chart revealed the NOE was signed on 8/15/23 with the initial RN assessment completed on 8/15/23 by an LPN and not a RN. During an interview on 4/03/24 at 3:36 PM, the Executive Director verified the findings. Record review on 4/03/24 at 10:20 AM revealed Pt #18 was admitted to the hospice on 8/29/23 for malignant neoplasm of descending colon. Review of the chart revealed the NOE was signed on 8/29/23 with the initial assessment completed on 8/29/23 by an LPN and not a RN. During an interview on 4/03/24 at 3:54 PM, the Executive Director verified the findings.

Based on record reviews, interviews, and review of facility policy and procedure, the hospice facility failed to ensure core disciplines attended the Interdisciplinary Team (IDT) meetings for 19 of 20 patient records reviewed. (Patients #1 ,#2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19 and #20). --- Record review on 4/01/24 at 1:46 PM of Pt #1 revealed Pt #1 was admitted to the hospice on 11/20/23 for senile degeneration of brain. Review of the ";Interdisciplinary Team (IDT) Review" dated 11/30/23 revealed no documented attendance by a Social Worker (SW) for the meeting. During an interview on 4/03/24 at 2:26 PM, the Executive Director verified the findings. Record review on 4/01/24 at 2:42 PM of Pt #2 revealed Pt #2 was admitted to the hospice on 11/20/23 for Chronic Obstructive Pulmonary Disease (COPD). Review of the ";Interdisciplinary Team Review" dated 11/30/23 and 1/11/24 revealed no documented attendance by the SW for the meeting. During an interview on 4/03/24 at 2:49 PM, the Executive Director verified the findings. Record review on 4/01/24 at 3:27 PM of Pt #3 revealed Pt #3 was admitted to the hospice on 10/05/23 for COPD. Review of the ";Interdisciplinary Team (IDT) Review" dated 10/09/23 revealed no documented attendance by the SW or chaplain; 10/19/23 no SW and/or chaplain; 10/23/23 no SW and/or chaplain; 11/06/23 no SW and/or chaplain; 11/16/23 no SW; 11/30/23 no SW and 12/14/23 no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/02/24 at 12:22 PM of Pt #9 revealed Pt #9 was admitted to the hospice on 6/27/23 for senile degeneration brain. Review of the ";Interdisciplinary Team (IDT) Review" dated 7/06/23 revealed no documented attendance by the SW; 7/19/23 no SW; 7/31/23 no SW; 8/14/23 no SW; 9/12/23 no SW and 10/09/23 no SW. During an interview on 4/03/24 at 3:19 PM, the Executive Director verified the findings. Record review on 4/02/24 at 2:12 PM of Pt #15 revealed Pt #15 was admitted to the hospice on 6/27/23 for senile degeneration brain. Review of the ";Interdisciplinary Team (IDT) Review" dated 11/16/23 revealed no documented attendance by the SW and/or chaplain; 11/30/23 no SW and 12/14/23 no SW. During an interview on 4/03/24 at 3:33 PM, the Executive Director verified the findings. Record review on 4/02/24 at 3:50 PM of Pt #16 revealed Pt #16 was admitted to the hospice on 8/15/23 for cerebrovascular disease. Review of the ";Interdisciplinary Team (IDT) Review" dated 10/23/23 revealed no documented attendance by the SW; 11/20/23 no SW; 11/30/23 no SW and/or chaplain; 1/11/24 no SW; and 1/25/24 no SW and/or Registered Nurse (RN). During an interview on 4/03/24 at 3:36 PM, the Executive Director verified the findings. Record review on 4/03/24 at 9:14 AM of Pt #17 revealed Pt #17 was admitted to the hospice on 8/21/23 for senile degeneration brain. Review of the ";Interdisciplinary Team (IDT) Review" dated 8/28/23 revealed no documented attendance by the SW; 9/12/23 no SW; 9/25/23 no SW; 10/09/23 no SW; 11/06/23 no SW; 11/16/23 no SW; and 11/30/23 no SW. During an interview on 4/03/24 at 3:51 PM, the Executive Director verified the findings. Record review on 4/03/24 at 10:20 AM of Pt #18 revealed Pt #18 was admitted to the hospice on 8/29/23 for malignant neoplasm of descending colon. Review of the ";Interdisciplinary Team (IDT) Review" dated 9/12/23 revealed no documented attendance by the SW; 9/25/23 no SW; 10/09/23 no SW; 10/23/23 no SW; 11/06/23 no SW; 11/20/23 no SW and 11/30/23 no SW. During an interview on 4/03/24 at 3:54 PM, the Executive Director verified the findings. Record review on 4/03/24 at 10:52 AM of Pt #19 revealed Pt #19 was admitted to the hospice on 1/03/24 for senile degeneration brain. Review of the ";Interdisciplinary Team (IDT) Review" dated 1/10/24 revealed no documented attendance by a SW and 1/24/24 no SW. During an interview on 4/03/24 at 4:01 PM, the Executive Director verified the findings. Record review on 4/03/24 at 11:22 AM of Pt #20 revealed Pt #20 was admitted to the hospice on 7/20/23 for Hypertensive heart and chronic kidney disease. Review of the ";Interdisciplinary Team (IDT) Review" dated 7/31/23 revealed no documented attendance by a SW; 7/19/23 no SW; 7/31/23 no SW; 8/14/23 no SW and 8/28/23 no SW. During an interview on 4/03/24 at 4:02 PM, the Executive Director verified the findings. Review of un-named facility policy revealed, ";The composition of the Hospice Interdisciplinary Team (IDT) is mandated by Medicare regulations for hospice programs in the United States. According to Medicare requirements, the following disciplines are required to be part of the IDT: 1. Physician or Nurse Practitioner...2. Registered Nurse (RN)...3. Social Worker...4. Chaplain or Spiritual Counselor...The interdisciplinary nature of the team ensures that patients receive comprehensive care addressing their physical, emotional, social, and spiritual needs throughout the hospice journey". Findings included: Record review on 04/02/24 at 08:45 AM of Pt #4 revealed Pt#4 was admitted to hospice on 08/16/23 for Senile Degeneration of the brain. Review of the ";Interdisciplinary Team" (IDT) dated 08/28/23 revealed no documented attendance by the Social Worker (SW); 09/12/23 no SW; 09/25/23 no Physician (MD), no Nurse (RN), no SW; 10/09/23 no SW; 11/06/23 no SW;11/16/23 no SW; 11/20/23 no Chaplain (CH), or SW; 11/26/23 no CH, no SW;11/30/23 no SW; 12/14/23 no SW; 01/25/24 no RN, no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 04/02/24 at 09:15 AM of Patient #5 revealed Pt#5 was admitted to hospice on 11/08/23 for Chronic Kidney Disease Stage 4. Review of the ";Interdisciplinary Team" (IDT) dated 11/16/23 revealed no documented attendance by the Social Worker (SW); 11/20/23 no Chaplain (CH) or SW; 11/26/23 no CH or SW; 11/30/23 no SW; 12/14/23 no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/2/24 at 9:55 AM of Patient #6 revealed Pt#6 was admitted to hospice on 02/13/23 for Chronic Heart Disease. Review of the ";Interdisciplinary Team" (IDT) dated 02/28/23 revealed no documented attendance by the Social Worker (SW); 05/24/23 no SW; 06/07/23 no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/2/24 at 10:35 AM of Patient #7 revealed Pt#7 was admitted to hospice on 06/20/23 for Sepsis. Review of the ";Interdisciplinary Team" (IDT) dated 07/06/23 revealed no documented attendance by the Social Worker (SW); 07/19/23 no SW; 07/31/23 no SW; 08/14/23 no SW; 09/12/23 no SW;09/25/23 no Physician (MD), Nurse (RN) or SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/2/24 at 11:23 AM of Patient #8 revealed Pt#8 was admitted to hospice on 10/19/23 for Chronic Heart Failure. Review of the ";Interdisciplinary Team" (IDT) dated 10/25/23 revealed no documented attendance by the Physician (MD), Chaplain (CH) or Social Worker (SW); 11/06/23 no SW; 11/16/23 no SW; 11/20/23 no CH or SW; 11/26/23 no CH or SW; 11/30/23 no SW; 12/14/23 no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/2/24 at 12:25 PM of Patient #10 revealed Pt#10 was admitted to hospice on 02/10/23 for Senile Degeneration. Review of the ";Interdisciplinary Team" (IDT) dated 02/28/23 revealed no documented attendance by the Social Worker (SW); 05/24/23 no SW; 06/07/23 no SW; 07/06/23 no SW; 07/19/23 no SW; 07/31/23 no SW; 08/14/23 no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/2/24 at 12: 59 PM of Patient #12 revealed Pt#12 was admitted to hospice on 11/11/23 for Thyroid Cancer. Review of the ";Interdisciplinary Team" (IDT) dated 11/16/23 revealed no documented attendance by the Social Worker (SW); 11/20/23 no Chaplain (CH) or SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/2/24 at 1:35 PM of Patient #13 revealed Pt#13 was admitted to hospice on 11/15/23 and a current patient for Chronic Obstructive Pulmonary Disease. Review of the ";Interdisciplinary Team" (IDT) dated 11/16/23 revealed no documented attendance by the Social Worker (SW); 11/20/23 no Chaplain (CH) or SW; 11/26/23 no CH or SW; 11/30/23 no SW; 12/14/23 no SW; 01/25/24 no Nurse (RN) or SW; 03/07/24 no SW; 03/21/24 no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings. Record review on 4/2/24 at 2:05 PM of Patient #14 revealed Pt#14 was admitted to hospice on 07/26/23 and a current patient for Stroke and High Blood Pressure. Review of the ";Interdisciplinary Team" (IDT) dated 07/31/23 revealed no documented attendance by the Social Worker (SW); 08/14/23 no SW; 08/28/23 no SW; 09/12/23 no SW; 09/25/23 no Physician (MD), no Nurse (RN), no SW; 10/09/23 no SW; 10/25/23 no MD, no CH or SW; 11/06/23 no SW; 11/16/23 no SW; 11/20/23 no CH or SW; 11/26/23 no CH or SW; 11/30/23 no SW; 12/14/23 no SW; 01/25/24 no RN or SW; 03/07/24 no SW; 03/21/24 no SW; 04/04/24 no SW. During an interview on 4/03/24 at 3:09 PM, the Executive Director verified the findings.

Based on record reviews and interviews, the hospice facility failed to ensure 5 of 5 patients reviewed for wound care had physician orders for treatment on the plan of care (POC). (Patients #1, #13, #14, #15 and #16). --- Record review on 4/01/24 at 1:46 PM revealed (Patient) Pt #1 was admitted to the hospice on 11/20/23 for senile degeneration of brain. Review of the chart revealed Pt #1 with ";Stage 4 pressure ulcers to bilateral heels, left heel 2 centi-meters (cm) x (by) 3 cm and right heel 3 cm x 1 cm; and stage 4 pressure ulcer to coccyx 5 cm x 4 cm with tunnelling present 0.5 cm in all directions". Further review of the chart revealed no wound care orders for Pt #1s pressure ulcers. During an interview on 4/3/24 at 2:41 PM, the Executive Director stated, ";We should have some orders in for doing wound care and I dont see any separate orders". Record review on 04/02/24 at 1:35 PM showed Patient #13 with a Start of Care date of 11/15/23. The patient received wound care to the scrotal area, but no Physician wound care orders were found in the patient record. This information was confirmed on 04/03/24 at 2:30 PM during an interview with the Executive Director who stated, ";They (the Nurses) know to do that". Record review on 04/02/24 at 2:05 PM showed Patient #14 with a Start of Care date of 07/26/23, The patient received wound care to a sebaceous cyst in the sacral area with no Physician orders for wound care. This information was confirmed on 04/03/24 at 2:34 PM in an interview with the Executive Director. Record review on 4/02/24 at 2:12 PM revealed Pt #15 was admitted to the hospice on 11/09/23 for senile degeneration of brain. Review of the chart revealed that on 12/27/23, Pt #15 had a left anterior forearm skin tear with serosanguineous drainage and a foul odor. Further review of the chart revealed no wound care orders for the skin tear area post the initial assessment. During an interview on 4/03/24 at 3:33 PM, the Executive Director confirmed the finding. Record review on 4/02/24 at 3:50 PM revealed Pt #16 was admitted to the hospice on 8/15/23 for Cerebrovascular Disease. Review of the chart revealed Pt #16 had a left knee anterior medial proximal wound on 12/22/23. Review of the chart revealed Pt #16s wound care was with a border foam dressing every 5 days and as needed if soiled. Further review of the chart revealed no physician orders for wound care since discovery of the wound. During an interview on 4/3/24 at 3:36 PM, the Executive Director verified the findings.

Based on record review, interview and review of facility policy and procedure, the hospice facility failed to ensure physician orders were obtained for 3 of 13 patient charts reviewed for discharge planning from hospice services. (Patients #2, #3, and #4, ). --- Record review on 4/01/24 at 1:46 PM of Pt #1 revealed Pt #1 was admitted to the hospice on 11/20/23 for senile degeneration of brain. Review of the chart revealed Pt #1 with ";Stage 4 pressure ulcers to bilateral heels, left heel 2 centimeters (cm) x (by) 3 cm and right heel 3 cm x 1 cm and stage 4 pressure ulcer to coccyx 5 cm x 4 cm with tunneling present 0.5 cm in all directions". Further review of the chart revealed no wound care orders for Pt #1s pressure ulcers. During an interview on 4/3/24 at 2:41 PM, the Executive Director stated, ";We should have some orders in for doing wound care and I dont see any separate orders". Record review on 4/02/24 at 2:12 PM of Pt #15 revealed Pt #15 was admitted to the hospice on 11/09/23 for senile degeneration of brain. Review of the chart revealed Pt #15 with a left anterior forearm skin tear with serosanguineous drainage with foul odor noted on 12/27/23 with no measurement. Review of the week of 12/31/23 to 1/06/24 revealed a measurement of the skin tear as 2.0 cm x 0.5 cm with no additional measurements. Further review of the chart revealed no wound care orders and/or weekly wound measurements of the skin tear area post the initial assessment. During an interview on 4/03/24 at 3:33 PM, the Executive Director stated, ";Wounds are to be measured once a week if not more if a change in condition". Record review on 4/02/24 at 3:50 PM of Pt #16 revealed Pt #16 was admitted to the hospice on 8/15/23 for Cerebrovascular Disease. Review of the chart revealed Pt #16 with a left knee anterior medial proximal wound on 12/22/23. Review of the chart revealed Pt #16s wound care was with a border foam dressing every 5 days and as needed if soiled. Further review of the chart revealed no physician orders for wound care and/or measurements of the wound since discovery. During an interview on 4/3/24 at 3:36 PM, the Executive Director verified the findings. Record review on 04/02/24 at 1:35 PM showed Patient #13 with a Start of Care 11/15/23 receiving wound care to the scrotal area but no Physician wound care orders or wound descriptions/measurements are found in the patient record. This information is confirmed on 04/03/24 at 2:30 PM in an interview with the Executive Director who stated ";they (the Nurses) know to do that". Record review on 04/02/24 at 2:05 PM showed Patient #14 with a Start of Care 07/26/23 receiving wound care to a sebaceous cyst in the sacral area yet no Physician orders for wound care, and no wound measurements are found in the record. This information is confirmed on 04/03/24 at 2:34 PM in an interview with the Executive Director.

Based on record reviews and interviews, the facility failed to complete Discharge Summaries for 5 of 20 patient charts reviewed. (Patients #2, #4, #5,# 8, and #19). --- Record review on 4/01/24 at 2:42 PM revealed Patient (Pt) #2 had been admitted to the hospice on 11/20/23 for Chronic Obstructive Pulmonary Disease (COPD). There was no discharge summary documented for the patient. During an interview on 4/3/24 at 3:02 PM, the Executive Director stated, ";I dont see anything for a discharge summary". Record review on 4/03/24 at 10:52 AM revealed Pt #19 had been admitted to the hospice on 1/03/24 for senile degeneration of brain. Further review of the chart revealed Pt #19 revoked hospice services on 1/19/24. There was no documentation of a completed discharge summary for the patient. During an interview on 4/3/24 at 4:01 PM, the Executive Director stated, ";I dont see a discharge summary." Record review on 4/1/24 at 12:05 PM showed Patient #4 with a Start of Care date of 08/16/23, and a discharge from the hospice on 02/11/24. There was no Discharge Summary in the record. In an interview on 04/03/24 at 2:15 PM, the Executive Director confirmed that the Discharge Summary was not in the record.

Based on review of the hospice's Emergency Preparedness Program (EPP) plan and interview, the hospice failed to ensure its EPP had a documented facility based and community-based risk assessment. --- The findings include: On 02/22/23 at 4:42 PM, review of the hospice's EPP revealed the hospice had no documentation of a facility based and community-based risk assessment. During an interview on 02/23/23 at 4:18 PM, the Administrator verified the findings.

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the hospice failed to ensure its EPP addressed the patient population served by the hospice. --- The findings include: On 02/22/23 at 4:43 PM, review of the hospice's EPP revealed the hospice's EPP had no documentation that addressed the patient population served by the hospice. During an interview on 02/23/23 at 4:19 PM, the Administrator verified the findings.

Based on record review and interview, the hospice failed to ensure the emergency preparedness plan contained a policy and procedure to address the security of patient medical documents of the facility. --- The findings include: On 02/22/23 at 4:45 PM, review of the hospice's emergency preparedness plan revealed there was no policy that addressed a system for preservation of patient information, confidentiality, security, and availability of patient records. During an interview on 02/23/23 at 4:20 PM, the Administrator verified the findings.

Based on review of the hospice's emergency preparedness plan and interview, the hospice failed to ensure the hospice's emergency preparedness plan contained a policy and procedure to address volunteers. --- The findings include: On 02/22/23 at 4:46 PM, review of the hospice's emergency preparedness plan revealed there was no documentation of a policy and procedure to address the use of volunteers in an emergency situation or designated health care professionals during surge needs during an emergency. During an interview on 02/23/23 at 4:21 PM, the Administrator verified the findings.

Based on review of the hospice's Emergency Preparedness Plan (EPP) and interview, the hospice failed to ensure it developed and maintained an active list of entities under arrangement, resident physicians, other clinic facilities, or volunteers for use during emergency situations. --- The findings include: On 02/22/23 at 4:47 PM, review of the hospice's emergency preparedness plan revealed the hospice has a policy for maintaining emergency contacts, but the policy had not been implemented as there was no contact information for staff, entities under arrangement, resident physicians, other clinic facilities, or volunteers. During an interview on 02/23/23 at 4:22 PM, the Administrator verified the findings. Facility policy, entitled, ";Emergency Preparedness" revealed, ";Hospice will maintain a current list of Emergency contact Numbers and Information for each of the counties in which it operates in...".

Based on record review, interview, and review of facility policy and procedure, the hospice failed to ensure the emergency preparedness plan contained documentation for primary and alternate means of communication. --- The findings include: On 02/22/23 at 4:48 PM, review of the hospice's emergency preparedness plan revealed there was no documentation for alternative means of communication with staff or federal, state and local emergency management agencies. During an interview on 02/23/23 at 4:23 PM, the Administrator verified the findings. Facility policy, entitled, ";Emergency Preparedness", revealed, ";Hospice shall maintain a means of communication with its local emergency management agency capable of transmitting information and/or data during periods when normal communication systems are inoperable...".

Based on review of the hospice's emergency preparedness plan and interview, the hospice failed to ensure the hospice's emergency preparedness plan contained a method for sharing patient information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care in an emergency. --- The findings include: On 02/22/23 at 4:49 PM, review of the hospice's emergency preparedness plan revealed there was no documented method for sharing information and medical documentation with other health providers to maintain continuity of care during an emergency. During an interview on 02/23/23 at 4:24 PM, the Administrator verified the findings.

Based on review of the hospice's emergency training records and interview, the hospice failed to ensure emergency preparedness training for all new employees for 1 of 1 hospice aide. (HA #1). --- The findings include: On 02/22/23 at 4:50 PM, review of HA #1s training file revealed HA #1 was hired on 02/01/23 and had no documentation of emergency preparedness training. During an interview on 02/23/23 at 11:23 AM, the Chief Operating Officer (COO) verified the findings.

Based on record reviews, interviews, and review of the hospice's policy and procedure, the hospice failed to ensure reconciliation of the patient's hospice medication profile with the skilled nursing facility (SNF) medication administration record (MAR) for 3 of 3 patients in a nursing care facility (Patient 1, 2, and 3) --- The findings include: During a SNF visit on 02/22/23 at 9:58 AM to 10:35 AM, review of Patient 2s medications on the SNF facilitys mar when compared with the hospice medication profile revealed Aspirin 81 mg, chew 1 tablet 3 times a week while the hospice medication profile revealed Aspirin 81 mg, take 1 tablet daily. The following SNF mar had the following medications that were not listed on the hospice medication profile: Potassium chloride ER 10 meq, take 1 tablet by mouth once daily. The findings were verified by the Administrator on 02/23/23 at 3:00 PM. During a SNF visit on 02/22/23 at 9:00 AM to 9:43 AM, review of Patient 3s medications on the SNF facilitys mar when compared with the hospice medication profile revealed Loperamide 2 mg, take 2 mg daily as needed for diarrhea while the hospice medication profile revealed Loperamide 2 mg, take 2 tablets after the first loose stool and then 1 tablet after subsequent episodes as needed not exceed 6 tablets in 24 hours. The following SNF mar had the following medication that was not listed on the hospice medication profile: Triamcinolone acetonide 0.025% topical cream 1 g (gram), apply 1 G topically in the morning and 1 G in the evening to affected area. The following hospice medication profile had the following medication that was not listed on the SNF facility mar: Thiamine 100 mg, 1 tablet daily. The findings were verified by the Administrator on 02/23/23 at 3:20 PM. PATIENT #1 On 2/22/23, at 9 a.m., a home visit was made to Patient #1. Patient #1 was admitted to the hospice with a diagnosis of Alzheimers (a disease affecting memory). The hospice medication list was compared with the facility medication list. The medications on the hospice list but not on the facility list included lorazepam and risperidone. Medications on the facility list but not on the hospice list included clopidrogel, colchicine, cyanocobalamin, memantine, Aricept, and aspirin. Loperamide 2 mg was on the hospice list to be administered three times a day, but on the facility list to be administered every four hours as needed.

Based on record review and interview, sutures were removed without a physician order for one of one patient with sutures. (Patient #4) --- On 2/21/23, at 3:30 p.m., Patient #4s record was reviewed. The record included a nurses visit note dated 2/13/23 which indicated the nurse removed sutures from the patients head. There was no physicians order in the record to remove sutures. During an interview on 02/23/23 at 1:40 PM, the Administrator/Director of Nursing (DON) stated, "I don't think I wrote an order to remove the sutures".

Based on record reviews and interview, the hospice failed to ensure the Master of Social Worker (MSW), Chaplain, and Volunteer completed home visits per the ordered frequency on the patient's plan of care for 2 of 11 patient charts reviewed. (Patient #9 and #10) --- The findings include: On 02/22/23 at 1:56 PM, review of Patient #9s chart revealed a visit frequency for the Volunteer for 1 time a week for 13 weeks starting 1/6/23 and the MSW (Master Social Work) visit frequency for 2 times a month for 3 months starting 1/6/23. Review of the benefit period dated 1/6/23 to 2/5/23 revealed 1 missed Volunteer visit the week of 01/08/23, 1 missed Volunteer visit the week of 01/15/23, and 1 missed MSW visit the week of 01/29/23. During an interview on 02/23/23 at 1:08 PM, the Administrator verified the findings. On 02/22/23 at 4:00 PM, review of Patient #10s chart revealed a visit frequency for the Chaplain for 1 time a week for 1 week and 2 times a month for 2 months and MSW visit 1 time a week for 1 week and 2 times a month for 2 months. Review of the benefit period dated 1/18/23 to 02/12/23 revealed 2 missed Chaplain visits for the month of January 2023 and 2 missed MSW visits for the month of January 2023. During an interview on 02/23/23 at 4:10 PM, the Administrator verified the findings.

Based on review of the hospice's Quality Assurance Process Improvement (QAPI) data and interview, the hospice's QAPI had no documentation that the data was measured, analyzed, or tracked adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. --- The findings include: Review of the hospices QAPI data on 02/24/23 at 9:35 AM revealed the hospice had no documentation that the hospice had indicators that tracked, analyzed and/or investigated adverse patient events to assess the care, services and operations of the hospice. During an interview on 02/24/23 at 10:00 AM, the Chief Executive Officer (CEO) verified the findings.

Based on review of the hospice's Quality Assurance Process Improvement (QAPI) data and interview, the hospice had no documentation that the hospice developed, implemented, and evaluated performance improvement projects (PIPS). --- The findings include: Review of the hospice's Quality Assurance Process Improvement (QAPI) data on 02/24/23 at 09:40 AM revealed the hospice had no documentation that the hospice had developed and implemented PIPS. On 02/24/23 at 10:00 AM, the Administrator stated, ";We didnt do any PIPS".

Based on review of the hospice's Quality Assurance Process Improvement (QAPI) and interview, the hospice failed to conduct, document reasons for, and measure any Performance Improvement Projects (PIPS). --- The findings include: Review of hospice's Quality Assurance Process Improvement documents on 02/24/23 at 09:40 AM revealed there was no documentation of development and/or measurement of any PIPS. On 02/24/23 at 10:00 AM, the Administrator stated, ";We didnt do any PIPS".

Based on observations, interview, and review of the hospice policy and procedure, the hospice failed to follow accepted standards of practice to prevent the potential transmission of infectious agents in the home care setting for 2 of 3 patient observations. (Patient #2 and #3) --- The findings include: Observations on 02/22/23 at 09:58 AM to 10:27 AM of Patient #2 revealed the Director of Nursing (DON) wearing soiled gloves disinfected a used Oxygen sensor, blood pressure cuff, and thermometer with a disinfecting wipe and placed the items into the nursing equipment bag. During an interview on 02/23/23 at 3:00 PM, the Administrator/Director of Nurses (DON) verified the findings. Observations on 02/22/23 from 9:00 AM to 09:40 AM of Patient #3 revealed the Administrator/DON wearing soiled gloves disinfected a used Oxygen sensor, blood pressure cuff, and thermometer with a disinfecting wipe and placed the items into the nursing equipment bag. During an interview on 02/23/23 at 3:00 PM, the Administrator/DON verified the findings.

Based on patient record review and interview, the hospice failed to complete the initial MSW (Master Social Work) assessment for one of five patient charts reviewed for care and services. (Patient #7) --- The findings include: On 2/22/23, at 4:20 PM, review of Patient #7's record revealed the patient was admitted on 2/15/23 with a primary diagnosis of unspecified disorder of the brain. Review of the document, titled, "Hospice MSW Admission Visit" dated 2/16/23 was completed by the Chaplain and not by the MSW. On 2/23/23 at 12:30 PM, Patient #7's record was reviewed with the Administrator/Director of Nursing who confirmed the Hospice MSW Admission Visit was completed by the Chaplain and not the MSW.

Based on observations, patient record reviews, and interview, the hospice failed to include fall prevention interventions in the hospice aide plan of care for one of five patient charts reviewed. (Patient #1) --- During an interview on 02/23/23 at 1:58 PM, the Admininstrator/DON stated, "The aide was not to leave the patient unattended and I probably did not document anywhere that I had verbalized those instructions to the aide". On 2/22/23, at 9 a.m., a home visit was made to Patient #1 with the Hospice Aide (HA). The HA was observed providing personal care to Patient #1. After transferring Patient #1 to the toilet, the HA was observed to leave her/him alone, while she left the patients room. While showering Patient #1, the HA stated, ";Youre really weak today...Youre not sitting up straight today...Youre leaning really bad...Im afraid you might fall over..." The HA was observed to leave Patient #1 alone in the shower while she left the bathroom. After personal care was complete, the HA transferred Patient #1 to a wheelchair and left the patients room. On 2/22/23, at 2:30 p.m. Patient #1s record was reviewed. The Registered Nurse visit note dated 2/21/23 was reviewed. The note indicated, ";...Risk for Injury...Fall Precautions...re-educated facility staff that patient is not to be left in the wheelchair alone in her room...Date of Last Fall...2/4/2023...Slipped off the toilet..." The HA Care Plan was reviewed and it did not include the instructions not to leave the patient alone in her wheelchair or alone sitting up."

Based on observations, patient record review, and interview, the hospice aide failed to report a change in the patient's condition to the nurse for one of three patients observed during a home visit. (Patient #1) --- During an interview on 02/23/23 at 1:58 PM, the Admininstrator/DON stated, "I was not aware of the patient's bleeding but was aware of the patient's weakness". On 2/22/23, at 9 a.m., a home visit was made to Patient #1 with the Hospice Aide (HA). After completing the Hospice Aide assignment for personal care to Patient #1, Patient #1 was observed to have blood dripping from the left side of her/his mouth down to her/his jaw. The HA was observed to wipe the blood. A few minutes later, blood was again observed dripping down from the left side of Patient #1s mouth to her/his jaw. The HA was observed to wipe the blood again. A concurrent interview was conducted with the HA. The HA stated Patient #1 had not had bleeding prior to this day. On 2/22/23, at 10:50 a.m., Patient #1s home/facility medication list was reviewed. The medication list indicated Patient #1 was receiving aspirin (prevents clots by thinning the blood) 81 mg daily and clopidrogel (prevents clots by thinning the blood) 75 mg daily. On 2/22/23, at 3:30 p.m., the HA visit note dated 2/22/23 was reviewed. There was not documented evidence the HA reported Patient #1s bleeding to the nurse.