Every finding on record at Vertex Hospice Care, Inc

Based on interview, and record review, the hospice agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the hospice staffs' lack of knowledge to readily and effectively respond during an emergency crisis situation. --- On 12/31/22, at 11:30 a.m., during an interview with director of patient care services (DPCS), the DPCS stated she did not conduct the emergency preparedness training for all staffs. During a review of the agency's emergency preparedness program documentation, the agency had no documented evidence the emergency preparedness training was conducted to all HHA staffs. A review of the HHA's undated policy and procedure titled, "Emergency Preparedness Plan" indicated, the plan uses the term "all hazard" to address all types of incidents. The incidents which may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and environment.

Based on interview, and record review, the Hospice Agency (HA) failed to ensure the patient plan of care was available at the patient's home hospice folder for one of eleven sampled patients (Patient 7). This deficient practice can result to the patient and family being unaware of the expected hospice services to be provided while the patient is under the hospice agency's care. --- A review of Patient 7s ";Personal Information" indicated Patient7 was a 99-year-old female with a Start of Care (SOC) date of 5/19/2022 with diagnosis of Alzheimers Disease (memory loss). A joint home visit was conducted with Registered Nurse (RN) 1 on 12/29/2022 at 11 a.m. at Patient 7s residence. During an interview and concurrent record review, Patient 7s hospice home folder did not indicate a Plan of Care (POC). RN1 stated, ";The folder does not have the POC. I was not sure if they should have it. No one told me to have it here." RN1 also stated that it is important to have both the POC and the medication profile at home, ";so that the family knows what they are giving and what is ordered. Also, the clinicians know what orders to do." During an interview on 12/30/2022 at 10:10 a.m. with the Administrator (ADM), the ADM stated that there should be a POC at patients' homes, ";The caregiver, patient, family should be in accordance with what we wrote there, and we also need their coordination as well. So, we can achieve and resolve the issue." A review of facilitys policy and procedure titled, ";Patient Bill of Rights" revised 2014, indicated ";Patients have the right: To be notified in advance about the care that is to be furnished, any changes to the care to be furnished, the types (disciplines) of the caregivers who will furnish the care and the frequency of the visits that are proposed to be furnished." A review of facilitys policy and procedure titled, ";Assessment and Reassessment Guidelines" revised 2014, indicated ";Pertinent assessment and reassessment data will be communicated to...patient...by...in writing."

Based on interview and record review, the Hospice Agency (HA) failed to ensure all members of the interdisciplinary group (IDG) were consulted in the development of the plan of care within 5 days of start of care for three of eleven sampled patients (Patient 7, Patient 8, and Patient 11) and failed to ensure all were involved in the completion of the comprehensive reassessment for two of eleven sampled patients (Patient 9 and Patient 11). This failure has the potential to result in the patient's hospice needs will not be identified necessary to develop the patient's plan of care. --- a. During a review of Patient 7s ";Personal Information" indicated Patient 7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of Patient 7s Electronic Medical Record (EMR), Patient 7s EMR indicted P7s SOC was on 5/19/2021 and her first IDG meeting was held on 6/1/2021. b. During a review of Patient 8s ";Personal Information" indicated Patient 8 was a 78 year old female with a Start of Care (SOC) date of 11/2/2021 and a primary diagnosis of Alzheimers Disease (memory loss). During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the ADM of P8s EMR, P8s EMR indicted P8s SOC was on 11/2/2021 and her first IDG meeting was held on 11/11/2021. c. During a review of Patient 9s ";Personal Information" indicated Patient 9 was a 79 year old female with a Start of Care (SOC) date of 11/4/2021 and a primary diagnosis of unspecified combined systolic and diastolic congestive heart failure. During a review of Patient 9s ";POC/IDG Review" dated 11/24/2021, indicated under IDG Discussion/Update Comprehensive Assessment Review Spiritual and Other Physician was left blank. During a review of Patient 9s ";POC/IDG Review" dated 12/15/2021, indicated under IDG Discussion/Update Comprehensive Assessment Review Other Physician was left blank. d. During a review of Patient 11s ";Personal Information" indicated Patient 11 was a 30 year old male with a Start of Care (SOC) date of 12/4/2021 and a primary diagnosis of acute and chronic respiratory failure with hypoxia (difficulty breathing). During a review of Patient 11s ";POC/IDG Review" dated 12/15/2021, indicated under IDG Discussion/Update Comprehensive Assessment Review Other Physician was left blank. During a review of Patient 11s ";POC/IDG Review" dated 12/29/2021, indicated under IDG Discussion/Update Comprehensive Assessment Review Other Physician was left blank. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the ADM of Patient 11s EMR, Patient 11s EMR indicated Patient 11s SOC was on 12/4/2021 and his first IDG meeting was held on 12/15/2021. During an interview on 12/30/2022 at 2:30 p.m. with the ADM, the ADM stated that a patients initial IDG meeting was to be held ";a couple of days after admission, to check for patient update and clinical status." ADM also stated that the IDG directs ";how we will provide care to specific patient based on their needs. The IDG entails contribution of each team members. Lastly, the ADM stated that all IDG members should input their summaries. ADM stated, ";To authenticate the findings of the staff, that he is made aware of and to contribute. He does his visits to, on recerts." A review of facilitys policy and procedure titled, ";Initial Assessment/Comprehensive Assessment" revised 2015, indicated ";The Hospice IDG...must complete the comprehensive assessment no later than 5 calendar days after patients election of Hospice care." A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Hospice has developed and maintains a system of communication and integration to: Ensure that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs." A review of facilitys policy and procedure titled, ";Coordination of Services" revised 2014, indicated ";All members of the IDG participate in care planning and document problems, interventions, goals, observations, and outcomes..." A review of facilitys policy and procedure titled, ";Assessment and Reassessment Guidelines" revised 2014, indicated ";The type, extent, and content of assessment and reassessment performed by each discipline are defined by Hospice discipline-specific documentation tools and forms." A review of facilitys policy and procedure titled, ";IDG Care Planning Process" revised 2014, indicated ";The IDG (in collaboration with the patients attending physician) reviews, revises, and documents..." A review of facilitys policy and procedure titled, ";Reassessment/Update to the Comprehensive Assessment" revised 2014, indicated ";Each patient will have appropriate reassessment and updates to the comprehensive assessment performed and documented. Such reassessment will be documented on discipline-specific visit notes.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for one of eleven patients (Patient 2). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. --- During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a record review of P7s ";Current Treatment/Medication/DME List" indicated P7s was ordered on: 7/25/22 (start date) – no stop date written - Lactulose (Pineapple-Orange) 10g/15ml solution 30ml oral BID (twice a day) and on 9/6/22 (start day) – no stop date written – Lactulose 20g/30ml solution 30 ml oral BID. During a joint home visit on 12/29/2022 with Registered Nurse 1 (RN1) to Patient 7s (P7) home, P7 medications were not reconciliated by RN1, RN1 stated, ";I go through their medicine and the medication sheet looking to see if there is anything missing and needs to be refilled. I check the dosages, frequency, and check that they are giving it." When asked if he checked the expiration date, RN1 stated, ";I need to work on that, I need to check those expiration dates." During an interview on 12/30/22 at 2:30 p.m. with the Administrator (ADM), the ADM confirmed that there were two orders for Lactulose on P7s medication profile sheet. ADM stated, ";There should have only been one, the most recent one." During a record review of P7s hospice folder indicated there was Medication Profile at home. RN1 stated, ";The folder does not have the POC or the medication list. I was not sure they should have it, no one told me to have it here." RN1 also stated that it is important to have both the POC and the medication profile at home, ";So that the family knows what they are giving and what is ordered. Also, the clinicians know what orders to do." During an interview on 12/30/2022 at 10:10 a.m. with the Administrator (ADM), the ADM stated that there should be a medication profile list at patients home, ";Yes, so that they have a map, what if they forget. There should be a list that they should follow through. At least they will know what it is used for and the indications." The ADM also stated that medication reconciliation should be done with every LVN and RN visit. A review of facilitys policy and procedure titled, ";Medication Monitoring" revised 2014 indicated ";A registered nurse reviews all of the patients prescription... This review is done in collaboration with other IDG members...This review includes but is not limited to: Duplicate drug therapy." A review of facilitys policy and procedure titled, ";Medication Reconciliation" revised March 2013, indicated ";Medications orders while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication." A review of facilitys policy and procedure titled, ";Patient Record Content" revised 2015, indicated ";Hospice will provide an accurate and current patient record.... The record must contain correct clinical information... Each patient record will contain the following as applicable: A current medication profile... A review of facilitys policy and procedure titled, ";Assessment and Reassessment Guidelines" revised 2014, indicated ";Pertinent assessment and reassessment data will be communicated to...patient...by...in writing." A review of facilitys policy and procedure titled, ";Patient Bill of Rights" revised 2014, indicated ";Patients have the right: To be notified in advance about the care that is to be furnished..." A review of Patient 2's face sheet on indicated the patient was admitted to the hospice agency on 12/24/22, with primary diagnosis of senile degeneration of the brain ( mental loss of intellectual ability that is associated with old age). A review of Patient 2's "POC Summary" dated 12/28/22, indicated the Skilled Nurse (SN) visit was two times a week and three as needed visits. On 12/29/22, at 11 a.m., during a joint home visit with Registered Nurse 1 (RN 1), Patient 2 was observed lying in bed asleep. During Patient 2's medication review compared with the medication profile, it was noticed that the patient had containers of Hydrochlorothiozide 12.5 milligram (mg) to take one tablet daily and Omeprazole 20 mg one tab daily. During an interview with the boarding care facility Medication Technician 1 (Med Tech), she stated that the patient no longer takes the Hydrochlorothiozide 12.5 milligram (mg) and Omeprazole 20 mg medications since two months ago. During an interview with RN 1 on 12/29/22, at 11:20 a.m., he stated he should have asked Med Tech1 if patient was still taking her prescribed medications on every visits. A review of the agency's policy titled " Medication Profile " , indicated the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for one out of eleven sample selected patients (Patient 7). This deficient practice had potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition --- During a review of Patient 7s ";Personal Information", it indicated Patient 7 was a 99-year-old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a telephone interview on 12/28/2022 at 1:25 p.m., Registered Nurse 1 (RN) stated, ";The comprehensive assessment should be done on admission, then at 3 months and after that, every 2 months." During a telephone interview on 12/28/2022 at 1:50 p.m., RN2 stated, ";I only do supervisory visits. I dont do comprehensive assessment visits or recertification assessment visits." During a record review on 12/28/2022 at 2 p.m. of Patient 7s Electronic Medical Record (EMR), the EMR under Nursing Assessment indicated there was only one documented comprehensive nursing assessment on 5/19/2022. Patient 7s recertification comprehensive nursing assessment was requested but was unable to provide the document. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m., with the Administrator (ADM) of P7s Electronic Medical Record (EMR), the EMR indicated there was no documented comprehensive reassessment completed for Patient 7. The ADM stated that a comprehensive reassessment should be completed ";90, 90, 60, 60. The supervisory notes are not the same as a comprehensive assessment. The patient needs to be thoroughly assessed, any decline nutritional, ADLs (Activities of Daily Living), the current status needs to be assessed to see if the patient still qualifies for hospice care or if we need to discharge the patient" A review of facilitys policy and procedure titled, ";Reassessment/Update to the Comprehensive Assessment" revised 2014, indicated ";Each patient will have appropriate reassessment and updates to the comprehensive assessment performed and documented. Such reassessment will be documented on discipline-specific visit notes. Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan." A review of facilitys policy and procedure titled, ";Patient Record Content" revised 2015, indicated ";Hospice will provide an accurate and current patient record.... Each patient record will contain the following as applicable: Updates to the comprehensive assessment." A review of facilitys policy and procedure titled, ";IDG Care Planning Process" revised 2014, indicated ";In order to assure that care provided is appropriately planned to meet each patients specific needs and problems, Hospice will utilize data/information gathered during the...updates to the comprehensive assessment and reassessments..." A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Ensure that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs." A review of facilitys policy and procedure titled, ";Nursing Services" revised 2014, indicated ";Professional nursing services will be provided by a registered nurse and include: Initial and ongoing comprehensive assessments..." A review of facilitys policy and procedure titled, ";Assessment and Reassessment Guidelines" revised 2014, indicated ";The type, extent, and content of assessment and reassessment performed by each discipline are defined by Hospice discipline-specific documentation tools and forms. Pertinent assessment and reassessment data will be communicated to team members, the IDG, patient and the patient physician..."

Based on observation, interview and record review, the hospice agency failed to notify the physician regarding a newly identified pressure sore on the right buttocks for one out of eleven patients (Patient 1). This deficient practice placed the patient's wound at risk for delay of healing. --- A review of Patient 1's face sheet indicated Patient 1 was admitted to the hospice agency on 11/22/22, with primary diagnosis of atherosclerosis heart disease (a buildup of fats, cholesterol and other substances in and on the artery walls). A review of Patient 1's "Plan of Care " dated 12/28/22, indicated a skilled nurse (SN) was to visit the patient once per week and three as needed visits, to assess skin condition and provide wound treatment on Stage 1 sacral pressure sore as follows; to cleanse with normal saline, pat dry and apply calmoseptine ointment daily and as needed. On 12/30/22, at 12 p.m., a home visit was conducted at Patient 1's residence with Registered Nurse (RN) 1. Patient 1 was lying down on her bed, unable to move from side to side. Patient 1 was observed with a newly developed Stage 1 pressure sore at the right buttocks . On 12/30/22, at 12:15 p.m., during an interview with Patient 1's caregiver, she stated the right buttocks redness is new and she did not see that since yesterday. On 12/30/22, at 12:25 p.m., during an interview, RN1 stated Patient 1 has reddened area on her right buttocks that does not turn white when pressed. On 12/31/22, at 12 p.m., during an interview with the Director of Patient Care Services (DPCS), when asked if RN 1 had notified the physician regarding Patient 1's new sore at her right buttocks, she stated no and she was not aware of it. A further review of Patient 1's clinical record did not indicate documented evidence the physician was notified of Patient 1's newly developed Stage 1 pressure sore at the right buttocks. A review of agencys undated policy titled, ";Change of Condition", indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition.

Based on observation, interview, and record review, the hospice agency failed to: 1.Develop and implement plans of care for skin integrity for one of 11 patients (Patient 1). Patient 1 had a physician's order for the skilled nurse to provide wound care to sacral area (Stage 1). There was no documented evidence of wound assessment was conducted every visit. This deficient practice placed the patients at a potential risk for a delay of wound healing that could lead to patient's discomfort and further integumentary complications. 2.Ensure three of eleven sampled patients (Patient 7, Patient 10, and Patient 11) individualized written Plan of Care (POC) were being followed. This failure resulted in patients missing elements of their care due to missed visits. --- A review of Patient 1's face sheet indicated the patient was admitted to the hospice agency on 11/22/22, with primary diagnosis of artherosclerosis heart disease (a build up of fats , cholesterol and other substances in and on the artery walls). A review of Patient 1's "Plan of Care " dated 12/28/22, indicated a skilled nurse (SN) was to visit the patient once per week and three as needed visits, to assess skin condition and provide wound treatment on Stage 1 sacral pressure sore as follows; to cleanse with normal saline, pat dry and apply Calmoseptine ointment daily and as needed. On 12/30/22, at 12 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was alert and oriented and she was lying down on her bed unable to move from side to side. Patient 1 was observed to have a Stage 1 sacral buttocks pressure sore. A review of Patient 1's Hospice Visit Note RN dated 12/10, and 12/20/22, indicated no documented evidence that the visiting nurse assessed the Stage 1 pressure ulcer on sacral area as part of their skin assessment. On 12/31/22, at 2p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should be assessing the patient's skin condition especially when the are providing wound care on every visits. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits. During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a review of P7s ";POC/IDG Review" dated 6/1/2022 and 12/14/2022, indicated under frequency of visit ";LVN 2 per week". During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P7s Electronic Medical Record (EMR), the ADM was unable to state why P7 had two skilled nursing visits for the week of 11/21/2022 and 12/18/2022. ADM stated, ";We need to find a replacement and reason for the missed visit. There should be documented why there was a missed visit. There is nothing, no comm notes." During a review of Patient 10s (P10) ";Personal Information" indicated P10 was a 96 year old male with a Start of Care (SOC) date of 12/24/2021 and a primary diagnosis of basal cell carcinoma of skin (skin cancer). During a record review of P10s ";POC/IDG Review" dated December 29, 2021, indicated P10s frequency visit was HA (Home Aide) 3 per week, LVN (License Vocational Nurse) 2 per week + 3 PRN (as needed) visits, MSW (Medical Social Worker) 1 per month + 1 PRN. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P10s Electronic Medical Record (EMR), the ADM was unable to state why P10 had two missed Certified Home Health Aide (CHHA) for the week of 12/26/21 to 1/1/22. ADM stated there were no communication notes that state why P10 had missed visits. During a review of Patient 11s (P11) ";Personal Information" indicated P11 was a 30 year old male with a Start of Care (SOC) date of 12/4/2021 and a primary diagnosis of acute and chronic respiratory failure with hypoxia (difficulty breathing). During a record review of P11s ";POC/IDG Review" dated 12/15/21, indicated P11 under frequency of visit RN (registered Nurse) 1 per week + 3 PRN (as needed) visits. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P11s Electronic Medical Record (EMR), the ADM was unable to state why P11 had two registered nurse visits for the week of 12/19/2021 and 1/2/22. ADM confirmed the missed visits and stated there were no communication notes to explain why there were missed. A review of facilitys policy and procedure titled, ";Coordination of Services" revised 2014, indicated ";Coordination of services and continuity of care is facilitated by established formal and informal communication mechanism between all disciplines providing care. These communication mechanisms include... g. missed visit reports at least 24-48 hours when a visit is missed. A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Hospice staff members regularly communicate to ensure that their efforts coordinated effectively and ultimately support the objectives outlined in the IDG plan of care." A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Ensure that care and services are provided in accordance with the plan of care..."

Based on observation, interview, and record review, the facility failed to document the frequency and disciplines on the Plan of Care for three of eleven sampled patients (Patient 7, Patient 8, and Patient 11). This failure had the potential to result in patient and family confusion and not knowing when, who, or what type of services is being offered to the patient. --- During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a review of P7s ";Patient List by Staff Assignment" indicated P7 had a Home Aide, Licensed Vocational Nurse, Medical Doctor, Medical Social Worker, Registered Nurse, Spiritual Counselor, and a Volunteer. During a review of P7s ";POC/IDG Review" dated 6/1/2022 and 12/14/2022, indicated under frequency of visit ";LVN 2 per week". During a record review of P7s ";Plan of Care" dated December 28,2022, indicated under frequency of visit ";LVN 2 per week". It also indicated P7 staff assignment was SC (Spiritual Counselor), MSW (Medical Social Worker), LVN (License Vocational Nurse), RN (Registered Nurse), HA (Home Aide), MD (Medical Doctor), VOL (Volunteer). During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P7s Electronic Medical Record (EMR), the ADM stated that P7 had a frequency listed of LVN (License Vocational Nurse) two times per week, but unable to locate the frequencies for any other disciplines involved in P7s care. During a review of Patient 8s (P8) ";Personal Information" indicated P8 was a 78 year old female with a Start of Care (SOC) date of 11/2/2021 and a primary diagnosis of Alzheimers Disease (memory loss). During a review of P8s ";POC/IDG Review" dated 12/15/2021 and 12/29/2022, indicated under frequency of visit: HA (Hospice Aide) 2 per week, LVN (License Vocational Nurse) 2 per week + 2 PRN (as needed) visits. During a record review of P8s ";Plan of Care" dated December 28,2022, indicated P8s staff assignment was SC (Spiritual Counselor), MSW (Medical Social Worker), LVN (License Vocational Nurse), RN (Registered Nurse), HA (Home Aide), MD (Medical Doctor), VOL (Volunteer). During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P8s Electronic Medical Record (EMR), the ADM stated that P8 had a frequency listed of LVN (License Vocational Nurse) two times per week plus two PRN (as needed) visits and HA (Home Aide) two times per week, but unable to locate the frequencies for any other disciplines involved in P8s care. During a review of Patient 11s (P11) ";Personal Information" indicated P11 was a 30 year old male with a Start of Care (SOC) date of 12/4/2021 and a primary diagnosis of acute and chronic respiratory failure with hypoxia (difficulty breathing). During a review of P11s ";POC/IDG Review" dated 12/15/2021 and 12/29/2021, , indicated P11 under frequency of visit RN (registered Nurse) 1 per week + 3 PRN (as needed) visits. It also indicated P11s staff assignment was SC (Spiritual Counselor), MSW (Medical Social Worker), RN (Registered Nurse), HA (Home Aide), MD (Medical Doctor), VOL (Volunteer). During a record review of P11s ";Plan of Care" dated 12/28/21 indicated P11 under frequency of visit RN (registered Nurse) 1 per week + 3 PRN (as needed) visits. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P11s Electronic Medical Record (EMR), the ADM stated that P11 had a frequency listed of RN (Registered Nurse) one time per week, but unable to locate the frequencies for any other disciplines involved in P11s care. A review of facilitys policy and procedure titled, ";IDG Care Planning Process" revised 2014, indicated ";An individualized written plan of care is developed for each patient. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including: A detailed statement of the scope and frequency of services..." A review of facilitys policy and procedure titled, ";Patient Bill of Rights" revised 2014, indicated ";Patients have the right: To be notified in advance about the care that is to be furnished, any changes to the care to be furnished, the types (disciplines) of the caregivers who will furnish the care and the frequency of the visits that are proposed to be furnished." A review of facilitys policy and procedure titled, ";Patient Record Content" revised 2015, indicated ";Hospice will provide an accurate and current patient record... The record must contain correct clinical information... Identity of others know to be involved in patients care/services."

Based on observation, interview and record review, the hospice agency failed to: 1.Obtain physician orders for A&D ointment mixed to calmoseptine ointment as part of wound care orders for one out of eleven patients (Patient 1). This deficient practice placed the patient's wound at risk for delay of wound healing. 2.Document the medications and treatments on the plan of care for three of eleven sampled patients (Patient 7, Patient 8, and Patient 11). This failure had the potential to result in patient and family confusion and not knowing what medications or treatments were ordered for the patients. --- A review of Patient 1's face sheet indicated the patient was admitted to the hospice agency on 11/22/22, with primary diagnosis of artherosclerosis heart disease (a build up of fats , cholesterol and other substances in and on the artery walls). A review of Patient 1's "Plan of Care " dated 12/28/22, indicated a skilled nurse (SN) was to visit the patient once per week and three as needed visits, to assess skin condition and provide wound treatment on Stage 1 sacral pressure sore as follows; to cleanse with normal saline, pat dry and apply Calmoseptine ointment daily and as needed. On 12/30/22, at 12 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was alert and oriented and she was lying down on her bed unable to move from side to side. RN 1 was observed providing wound care to patient's Stage 1 sacral buttocks pressure sore. RN 1 initially washed his hands and donned a new pair of gloves. RN 1 removed the soiled dressing at sacral area, cleansed the Stage 1 sacral area pressure sore with Normal Saline and clean dry gauze two times, applied Calmoseptine mixed with A&D ointment to sacral area and covered with Mepilex dressing. A further review of Patient 1's clinical record indicated no documented evidence of a wound care order to apply A&D ointment mixed with Calmoseptine to Patient 1's sacral area redness. On 12/31/22, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should obtain physician's orders for A&D ointment to be mixed with Calmoseptine when providing wound care. During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a record review of P7s ";Plan of Care" dated December 28,2022, indicated there were no medications or treatments mentioned. During a record review of P7s ";Current Treatment/Medication/DME List" indicated P7 was prescribed medications, DME (Durable Medical Equipment), and supplies. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P7s Electronic Medical Record (EMR), the ADM stated that she was unable to locate P7s medications or diet on P7s POC. ADM stated that the POC needs to have patients diets mentioned, ";Yes, for patient to be able to assess nutritional status and better teaching for family and care givers involved." During a review of Patient 8s (P8) ";Personal Information" indicated P8 was a 78 year old female with a Start of Care (SOC) date of 11/2/2021 and a primary diagnosis of Alzheimers Disease (memory loss). During a record review of P8s ";Plan of Care" dated December 28,2022, indicated there were no medications or treatments mentioned. During a record review of P8s ";Current Treatment/Medication/DME List" indicated P8 was prescribed medications, DME (Durable Medical Equipment), and wound treatments. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P8s Electronic Medical Record (EMR), the ADM stated that there were no medications or treatments documented on P8s POC. During a review of Patient 11s (P11) ";Personal Information" indicated P11 was a 30 year old male with a Start of Care (SOC) date of 12/4/2021 and a primary diagnosis of acute and chronic respiratory failure with hypoxia (difficulty breathing). During a record review of P11s ";Plan of Care" dated 12/28/21 indicated there were no medication or treatments mentioned. During a record review of P11s ";Current Treatment/Medication/DME List" indicated P11 was prescribed medications and tracheostomy treatment. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P11s Electronic Medical Record (EMR), the ADM stated that there were no medications or treatments documented on P11s POC. During an interview on 12/30/2022 at 2:30 p.m. with the Administrator (ADM), the ADM stated that the Plan of Care (POC) is ";how we will provide care to specific patient based on their needs. The ADM also stated that the POC ";entails contribution of each team member. Lastly, the ADM stated that the POC is their map to provision of care." A review of facilitys policy and procedure titled, ";IDG Care Planning Process" revised 2014, indicated ";An individualized written plan of care is developed for each patient. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including: Drugs and treatments..." A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Ensure that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs." A review of facilitys policy and procedure titled, ";Medication Monitoring" revised 2014 indicated ";Findings, conclusions, and recommendations from medication monitoring are documented and communicated to other relevant care providers as appropriate."

Based on observation, interview, and record review, the facility failed to document the medications and treatments on the Plan of Care for one of eleven sampled patients (Patient 7). This failure had the potential to result in patient and family confusion and not knowing what medications or treatments were ordered for the patients. --- During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a record review of P7s ";Plan of Care" dated December 28,2022, indicated there were no supplies mentioned. During a record review of P7s ";Current Treatment/Medication/DME List" indicated P7 was prescribed medications, DME (Durable Medical Equipment), and supplies. During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P7s Electronic Medical Record (EMR), the ADM stated that she was unable to locate P7s supplies on P7s POC. During an interview on 12/30/2022 at 2:30 p.m. with the Administrator (ADM), the ADM stated that the Plan of Care (POC) is ";how we will provide care to specific patient based on their needs. The ADM also stated that the POC ";entails contribution of each team member. Lastly, the ADM stated that the POC is their map to provision of care." A review of facilitys policy and procedure titled, ";IDG Care Planning Process" revised 2014, indicated ";An individualized written plan of care is developed for each patient. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including: Medical supplies and appliances..." A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Ensure that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs."

Based on observation, interview and record review, the hospice staff failed to revise and continuously review and revise the care plan for a patient with existing stage 1 (skin appears reddened, with no breaks) sacral (near the lower back and spine) pressure sore (bedsore) for one out of eleven patients (Patient 11). This deficient practice placed the patient's sacral sore at a potential risk for delay of healing. --- A review of Patient 1's face sheet indicated the patient was admitted to the hospice agency on 11/22/22, with primary diagnosis of artherosclerosis heart disease (a build up of fats, cholesterol and other substances in and on the artery walls). A review of Patient 1's "Plan of Care " dated 12/28/22, indicated a skilled nurse (SN) was to visit the patient once per week and three as needed visits, to assess skin condition and provide wound treatment on Stage 1 sacral pressure sore as follows; to cleanse with normal saline, pat dry and apply Calmoseptine ointment (a barrier that protects from moisture) daily and as needed. On 12/30/22, at 12 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was alert and oriented and she was lying down on her bed unable to move from side to side. Patient 1 was observed to have a Stage 1 sacral buttocks pressure sore. A further review of Patient 1's clinical record indicated no documented evidence a care plan was developed for the patient's existing Stage 1 sacral pressure sore being attended to. On 12/31/22, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should have developed a care plan for Patient1's existing stage 1 sacral sore. A review of the facility's policy and procedure "Plan Of Care", indicated care provided to the patient will be in accordance with the plan of care.

Based on interview and record review, the Hospice Agency (HA) failed to communicate a change in Certified Home Health Aide (CHHA) frequency in visits for one of eleven sampled patients (Patient 7). This failure placed the patients at risk for adverse actions and errors that could affect the patient's already compromised health status. --- During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a record review on 12/28/2022 at 2 p.m. of P7s Electronic Medical Record (EMR), the EMR showed P7 received Certified Home Health Aide (CHHA) services from 5/19/2022 to 7/15/2022. During a telephone interview on 12/28/2022 at 1:25 p.m. with Registered Nurse (RN1), RN1 stated that P7 was initially receiving CHHA services but refused that service in August. During a review of P7s ";Visit Note RN" dated 12/16/2022 indicated Registered Nurse 2 (RN2) documented a Home Aide supervisory note for Certified Home Health Aide 1 (CHHA1) on 12/16/2022. During a telephone interview on 12/30/2022 at 10 a.m. with RN2, RN2 stated, ";Whenever I did my notes, Im thinking it was the CHHA who is visiting the patient. Normally when I submit my notes, I put my notes regarding the disciplines... they should also notify me that there is no CHHA seeing the patient. Whenever we talk the daughter mentioned the care giver and I thought it was the hospice CHHA, because she said someone was taking care of the patient. Its my mistake." During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P7s electronic medical record (EMR), the EMR indicated P7 received CHHA services from 5/19/2022 to 7/15/2022. CHHA supervisory visits were documented every two weeks since 5/19/2022. ADM stated, ";we should have caught that, I will talk to (RN2)." A review of facilitys policy and procedure titled, ";Coordination of Services" revised 2014, indicated ";An assigned hospice RN coordinates the patients plan of care and facilitates the ongoing sharing of information with the attending physician... other members of the IDG..." It also indicated ";Coordination of services and continuity of care is facilitated by established formal and informal communication mechanism between all disciplines providing care." A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Hospice has developed and maintains a system of communication and integration to: Provide for and ensure the ongoing sharing of information between all disciplines... Staff provided the physician... and IDG with patient information on an ongoing basis regarding: Changes in...caregiver support."

Based on observation, interview, and record review, Registered Nurse 1 (RN 1) failed to wash hands in between wound care for one out of eleven patients (Patient 1) who had a Stage 1 (skin is not broken but is red or discolored) sacral (near the lower back and spine) pressure sore (bedsore). This failure had the potential to spread infection. --- A review of Patient 1's face sheet indicated the patient was admitted to the hospice agency on 11/22/22, with primary diagnosis of artherosclerosis heart disease (a build up of fats , cholesterol and other substances in and on the artery walls). A review of Patient 1's "Plan of Care " dated 12/28/22, indicated a skilled nurse (SN) was to visit the patient once per week and three as needed visits, to assess skin condition and provide wound treatment on Stage 1 sacral pressure sore as follows; to cleanse with normal saline, pat dry and apply Calmoseptine ointment daily and as needed. On 12/30/22, at 12 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was alert and oriented and she was lying down on her bed unable to move from side to side. RN 1 was observed providing wound care to patient's Stage 1 sacral buttocks pressure sore. RN 1 initially washed his hands and donned a new pair of gloves. RN 1 removed the soiled dressing at sacral area, cleansed the Stage 1 sacral area pressure sore with Normal Saline and clean dry gauze two times, applied Calmoseptine (moisture barrier ointment) mixed with A&D ointment to sacral area and covered with Mepilex dressing (self adherent, multilayer foam dressing) RN 1 did not change his gloves and wash his hands after removing soiled dressing and before cleaning the pressure sore. On 12/30/22, at 12:30 p.m., during an interview with RN 1, he stated he was nervous that he forgot to wash his hands after removing soiled dressing. A review of the hospice agency's policy and procedure dated 11/2017 and titled, "Hand Hygiene" , indicated hand decontamination should be performed before direct contact with patient using either an alcohol based hand rub or wash hands with an antimicrobial soap and water.

Based on interview and record review, the hospice agency failed to hire a qualified volunteer coordinator. This deficient practice had the potential for the patients not to receive volunteer services under the direction of a volunteer coordinator responsible for planning, organizing and directing a comprehensive volunteer services program. --- On 12/28/22, at 10 a.m., an unannounced re-certification visit was conducted at the hospice agency. On 12/31/22, at 11:30 a.m., during an interview with the DPCS (director of patient care services), she stated that the agency's Volunteer Coordinator resigned two months ago and the agency has no volunteer coordinator at this time. A review of the agency's policy of "Volunteer Services," indicated the hospice will provide volunteer services under the direction of a volunteer coordinator or staff member responsible for planning, organizing and directing a comprehensive volunteer services program and with the assistance of trained hospice volunteers.

Based on interview and record review, the hospice agency failed to ensure volunteer orientation and training was provided to 1 volunteer of the agency. This deficient practice resulted to the volunteer not having the knowledge on how to care for patients when providing home visits. --- On 12/28/22, at 10 a.m., an unannounced recertification revisit survey was conducted at the hospice agency. At 1:30 p.m., during an interview with the DPCS (director of patient care services), she stated that the hospice agency have hired Volunteer 1 on 1/10/22, but he had no volunteer training provided at this time. During further review of the agency's volunteer training log, the agency had no documented evidence that Volunteer 1 was provided volunteer training.

Based on interview and record review, the Hospice Agency (HA) failed to ensure that the medical record of one of eleven sampled patients (Patient 7) had correct information documented in her medical record. This failure had the potential to result in placing the patients at risk for adverse actions and errors that could affect the patient's already compromised health status. --- During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a review of P7s ";Patient List by Staff Assignment" indicated P7 had a Home Aide assigned. During a record review on 12/28/2022 at 2 p.m. of P7s Electronic Medical Record (EMR), the EMR showed P7 received Certified Home Health Aide (CHHA) services from 5/19/2022 to 7/15/2022. During a telephone interview on 12/28/2022 at 1:25 p.m. with RN1, RN1 stated that P7 was initially receiving CHHA services but refused that service in August. During a review of P7s ";Visit Note RN (registered Nurse)" dated 12/16/2022 indicated Registered Nurse 2 (RN2) documented a Home Aide supervisory note for Certified Home Health Aide 1 (CHHA1) on 12/16/2022. During a telephone interview on 12/30/2022 at 10 a.m. with RN2, RN2 stated that the Hospice Agency calls her every two weeks and asks her to do the supervisory visits. RN2 stated, ";Whenever I did my notes, Im thinking it was the CHHA who is visiting the patient. Normally when I submit my notes, I put my notes regarding the disciplines... they should also notify me that there is no CHHA seeing the patient. Whenever we talk the daughter mentioned the care giver and I thought it was the hospice CHHA, because she said someone was taking care of the patient. Its my mistake." During a concurrent interview and record review on 12/30/2022 at 2:30 p.m. with the Administrator (ADM) of P7s electronic medical record (EMR), the EMR indicated P7 received CHHA services from 5/19/2022 to 7/15/2022. CHHA supervisory visits were documented every two weeks since 5/19/2022. ADM stated, ";we should have caught that, I will talk to (RN2)." A review of facilitys policy and procedure titled, ";Patient Record Content" revised 2015, indicated ";Hospice will provide an accurate and current patient record... The record must contain correct clinical information..." A review of facilitys policy and procedure titled, ";Patient Record Entries: Authentication" revised 2014, indicated ";All entries in the patient record will be authenticated by staff...By authenticating entries in the patient record, staff is validating the correctness of the information."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the patients medical supplies were not expired. This failure had the potential to place the patients at risk for being taken care of with ineffective supplies which might cause infections or damage to the body. --- During a concurrent observation and interview on 12/28/2022 at 1:30 p.m. with the Administrator (ADM) of the HAs supply room, the ADM stated that their supplies are checked every two weeks for expiration and quantity. ADM stated it was important to check for expiration dates, ";So, we dont use it for patient, might cause side effects or it will not be effective." These were found in the supply room and showed to the ADM: BD Vacutainer Luer-Lock Access Device: expired 06/30/2022; Dressing Change Tegaderm Chloraprep: expired 05/01/2022; and 300ml canister for activ.a.c. therapy system: expired 01/31/2022 During a concurrent interview and record review on 10/30/2022 at 10:10 a.m. with the ADM of the supply check list, the ADM stated, ";The person who was checking our supplies went back to the Philippines... He did the last supply back in July of this year." The supply check list indicated the list was completed on 7/13/2022. A review of facilitys policy and procedure titled, ";Supply Maintenance" revised 2014, indicated ";Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to communicate a change of condition for one of eleven sampled patients (Patient 7). This failure resulted in the patients care team, including the doctor, not being aware of a change of condition. --- During a review of Patient 7s (P7) ";Personal Information" indicated P7 was a 99 year old female with a Start of Care (SOC) date of 5/19/2022 and a primary diagnosis of Alzheimers Disease (memory loss). During a joint home visit on 12/29/2022 with Registered Nurse 1 (RN1) to Patient 7s (P7) home, P7s oxygen saturation was fluctuating throughout visit, RN1 provided and titrated supplemental oxygen as ordered and needed. RN1 stated, ";I will call the office and let them know what is going on." During an interview on 12/30/22 at 2:30 p.m. with the Administrator (ADM), the ADM stated that she was made aware of P7s change of condition but was unable to locate any documentation of the physician being notified. ADM stated, ";The doctor needs to be made aware immediately." A review of facilitys policy and procedure titled, ";Coordination of Patient Care" revised March 2013, indicated ";Staff provided the physician... and IDG with patient information on an ongoing basis regarding: Current condition and changes in condition." A review of facilitys policy and procedure titled, ";Coordination of Services" revised 2014, indicated ";An assigned hospice RN coordinates the patients plan of care and facilitates the ongoing sharing of information with the attending physician... other members of the IDG..." A review of facilitys policy and procedure titled, ";Reassessment/Update to the Comprehensive Assessment" revised 2014, indicated ";Each patient will be reassessed when: a significant change in condition...or support system occurs. Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan." A review of facilitys policy and procedure titled, ";Patient Record Content" revised 2015, indicated ";Hospice will provide an accurate and current patient record.... The record must contain correct clinical information... Each patient record will contain the following as applicable: A statement of any change in patients condition."