Every finding on record at Visiting Nurse Association of St. Luke's Home Health/Hospice, Inc.

Upon patient record review, 1 of 29 (Patient #24) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient # 24: RN documented phone call received from facility 12/01/23 (Friday). Facility stated that patient had developed rhonchi to his upper and lower lobes and that he now had a productive loose cough. Facility nurse requesting recommendation for attending to prescribe Mucinex and Hyoscyamine. Hospice nurse contacted hospice NP and subsequently advised facility nurse of NP recommendations. There was no follow up hospice nursing visit until 12/4/23 (Monday). During 12/04/23 SN visit, family informed nurse that facility PA had arrived to room prior to her visit and added another round of Prednisone. Nurse documented was unable to find PA or charge nurse in the building to discuss his plan of care. Family requested medication changes, nurse discussed, but not clear if those changes implemented that visit. SN documented patient to be comfortable during the RN visit. MSW Visit note 12/05/23: MSW documented that daughter ... was present for visit. She further documented that Patient was awake, however, did not respond to hospice team's greeting or basic questions. Daughter reports that patient has been sleeping majority of time.... Hospice team provided safe space for her to openly express her concerns and wish to change hospice.... had bad weekend with chest congestion.... did not feel supported by hospice.

Upon patient record review, 6 of 29 (Patient #6, 8, 9, 14, 19, 22) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6: Patient admitted 12/29/23 with chronic/unhealing sacral wound. Wife performing wound care in home. There is no related problem, goals, interventions on plan of care. Patient #8: Patient admitted 12/21/23, with existing chin wound and heel blister. There are no related problems, goals, interventions on plan of care. Patient #9: Patient admitted 12/20/23. Had Portocath and colostomy (that he is able to manage) at time of admission. No related problems, goals, interventions on plan of care. Patient #14 Patient admitted 12/06/23 with drain of liver absess RUA. RN referenced order to flush drain with saline RUA in initial comprehensive assessment. Patient family managing flushes, but there were no related problems, goals, interventions on plan of care. Patient #19 Patient admitted with right chest drain. There are no related problems, goals, interventions on plan of care. Patient #22: Patient admitted 1/19/24. Has Tenckhoff drain, long term pleural drain, Foley catheter and sacral wound. There were no related problems, goals and interventions on plan of care.

Upon patient record review, 6 of 29 (Patient #1, 7, 11, 14, 17, 18) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1, 7, 11, 14: Initial spiritual frequency is 1 to 3 visits as needed. There is no base frequency and there is not update to frequency. Patients #17, 18: Admitted 2/3/24 and 2/2/24 respectively. IPU Records have no documented visit frequency for SN, HA, SC, MSW.

Upon patient record review, 8 of 29 (Patient #2, 6, 8, 10, 11, 14, 19, 22) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: 1/5/24 SN Visit note included documentation of wound care for BL Buttocks - cleanse with soap and water and apply zinc oxide every shift. There is no documented order for the zinc oxide in the hospice plan of care. Patient #6: Admitted 12/22/23. Initial SN assessment includes that Patient admitted with chronic sacral wound - wife has been managing at home. "Patient does have a sacral wound on his buttock area on the left interior side of his buttocks.. Patient is using wound cleanser, patted dry with 4x4 gauze, 2x2 silver Alginate and 4x4 foam dressing. Wound is 7 cm long 3 cm wide about 1 cm tunnel." There is no documented order for wound care. Patient #8: Patient admitted 12/21/23, with existing chin wound and heel blister. Rx order for SilvaSorb Gel - Apply 1 dose topically every evening. Route apply externally. Zinc oxide Balmex = apply 1 app topically 2x/day. topically for skin protection Location and indications for neither are specified in order. Patient #10 and #22: Zinc Oxide Balmex. Apply 1 app topically 2x/day topically for skin protection. Order does not include specific location. Patient #11: Initial order for oxygen at 3L. 1/15/24, O2 SN note documents that patient O2 was infusing at 6L with no order documented for increase at that time. Patient #14: Patient admitted 12/06/23 with drain of liver abscess and SN initial comprehensive assessment documented "Noted order to flush drain with 10 cc saline RUA....Patient family managing flushes. Upon staff interview, the order was noted from pre-hospice care setting, but was not transferred/documented in hospice physician orders. Patient #19: Patient has long term pleural drain in place. There was a 6/4/23 order to drain Pleurix drain q 3 days up to 1 liter. The drain is "dry" at this point, but not removed. Interview with staff revealing the order to drain q 3 days should have been discontinued. SN documented pulmonary drain site cleaned (1/29, 1/31/24). There was no order specific to current site care.

Upon patient record review, 2 of 29 (Patient #2, 9) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2: SOC 12/28/23. 01/05/24 note includes buttocks wound with order to cleanse with soap and water and apply zinc oxide each shift. IDG Care Plan not updated with related problems, goals and interventions from updated assessment. Patient #9: SOC 12/19/23. Patient had CADD pump initiated for pain management 1/22/24. RN inadvertently included reference to subcu pain management, as opposed to portoacath access in related problems, goals and interventions for IDG Care Plan.

Upon patient record review, 5 of 29 (Patient #12, 13, 16, 17, 18) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #12: Assignment includes assist with bath and assist with shower. There is no statement addressing patient/CG's cognitive ability. Patient #13: Assignment includes assist with bath and assist with shower. There is no statement addressing patient/CG's cognitive ability. Patient #16: Assignment includes assist with bath and assist with shower. There is no statement addressing patient/CG's cognitive ability. Patient #17, 18: Inpatient records do not include frequency of which tasks are to be performed. Agency has practices in place, example assessing/reporting baths are offered/provided daily, but not clearly assigned frequency in aide assignment.

Upon patient record review 4 of 29 (Patient #2, 4, 6, 7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: HA assignment to provide assistance with bath, shampoo, dressing, apply lotion. bed linens, transfers. HA documented not needed 1/17/24 Patient #4: HA assignment to clean/tidy room and change linens. HA documented "not needed" for both 12/31/23 visit Patient #6: HA assignment for HA to encourage and offer fluid intake to patient, to assist shampoo and change linens. HA documented not needed for these tasks 1/12/24 Patient #7: HA assignment to clean/tidy room and change linens 1/23/24. HA documented not needed for these tasks 1/23/24

Upon client record review, 1 of 29 (Patient #25) did not have evidence that the discharge summary includes all required information. missing clinical summary piece Patient #25 - did not include current POC, orders, clinical summary to assist in post-discharge continuity of care.

Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. In compliance with 6.4.4.2 record keeping, a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. The agency policy is to perform inspection of electrical outlets in all patient rooms annually, the agency is unable to provide written records of inspection for 2023, last performed inspection record was 3/1/22 and did not include room 14.

Upon observation, there was no evidence the hazardous areas of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. In compliance with 19.7.8, portable space heaters are prohibited in all healthcare occupancies. During the inspection it was observed that a standing upright portable heater was located in the office of the nurse manager and underneath a desk. A second upright portable heater was located in the office of the nurse practitioner, also underneath a desk. Both offices are located within the protected smoke compartment of the facility. (Items removed prior to surveyor leaving the facility.) In accordance with 19.3.2.6 dispensers shall not be installed over an ignition source. During the inspection of the facility it was observed in room 14 that an ABHR dispenser is secured to a wall that is directly above an electrical outlet, an ignition source. (Corrected prior to surveyor leaving the facility.)

Based on a review of agency policy, patient clinical record, and an interview with the agency Administrator, the agency failed to adhere to agency policy 'Complaints Management' and 'On Call Service Policy' for one (1) of one (1) clinical records (CR) reviewed (CR#1). --- Findings Include: Agency policy was reviewed March 17, 2023 at approximately 11:30 a.m. Policy: ADM-8 'Complaints Management' 'Purpose' states "The VNA of St. Lukes Home Care are committed to supporting the rights of all patients, families, ..... to submit expressions of satisfaction or dissatisfaction regarding their experience with the agency and to seek resolution to their concerns. In addition, the agency seeks suggestions for service improvement from patients, their family members, and friends." Section III. 'Procedure' states "Complaints shall be resolved immediately, and the investigation shall begin within 24 hours of its receipt and should be resolved within 7 business days of receipt. .... Every member of the staff is responsible for ensuring his/her knowledge of and correct utilization of the complaint management process. Managers are accountable to assure that follow up occurs." 'Process' states: (a) Contact the complainant by telephone within 24 hours, or next business day, after receiving the complaint to acknowledge the complaint and gather additional information. During this call, the Supervisor shall negotiate a reasonable time frame (not to exceed 7 days) in which to get back in touch with the individual." .... The VP of Patient Care Services Home Health/hospice of the area named in the complaint shall: .... (g)(d) "Within 7 business days of receiving the complaint, forward the completed documentation to the Quality Resource Department." Policy ADM-33 'On-Call Service Policy' (I) 'Purpose' states "A system is in place to meet the 24 hour needs of the patients, to assure that patient/families will have appropriate, continuous access to agency staff and services." (III) 'Procedure' (1) "During normal working hours, calls are processed by the designated staff. At the end of the workday, the designated staff signs out to the Answering Service. ... The Answering Service screens and routes calls as directed. Home Health and Hospice calls are forwarded to the evening/weekend Supervisor, Coordinator or triage Nurse for triage and scheduling. An assessment of the situation may result in instruction over the phone, a home visit, emergency transport to the hospital, or Hospice inpatient facility. The triage nurse will contact the attending or Hospice physician as needed." (2) "Those calls needing an after-hours nursing visit will be forwarded to the "on-call" nurse." (4) An electronic calendar is maintained to assure access by all staff." (5) The assigned staff will maintain appropriate communication with each other to assure coordination of care ......." A review of CRs was conducted on March 17, 2023 at approximately 11:00 a.m. The patients start of care date (SOC) is included below. CR #1, Start of Care 02/06/23: Documentation provided of a complaint generated on 02/17/23 at 2:10 p.m. The agency 'Complaint/Grievance Tracking Form' listed the patient (CR#1) and was initiated by (Daughter #2). 'Type of Complaint/Grievance' "Delayed Care." 'Description of Complaint/Grievance' "Family states that they were calling all night and it took 5 hours for the nurse to arrive." 'Description of concern and steps taken to resolve the issue:' "Reviewed with (agency staff) that if there is a delay in nursing visit to dispatch support services to offer visit." Documentation provided includes the following: 02/17/23: "(Employee #5) spoke with the daughter (#2) who verbalized her concerns. VP (vice president) to call (daughter #2) on 01/18/23 (agency typographical error) to follow up." 02/18/23: "Patient died at 0445. VP did not call as patient had died and wanted family to have time to grieve. Family supported by hospice house nurse." 02/20/23: VP called (daughter #2) and scheduled a meeting with (daughter #2), VP, and President of VNA for 02/22/23 at 08:30." (> 24 hours or the next business day.) No documentation provided of contacting the complainant by telephone within 24 hours, or the next business day, per policy, after receiving the complaint to acknowledge the complaint and gather additional information. No documentation provided of the VP of Patient Care Services Home Health/Hospice of the area named in the complaint, forwarding the completed complaint documentation to the Quality Resource Department within 7 business days of receiving the complaint, per policy. Agency after hours 'Call Log' (after hours phone operated by employee #6) review March 17, 2023 at approximately 10:30 a.m. revealed the following: 02/17/23, 5:54 a.m.: Call received from (caregiver). 'Communication Note' (Patient) has been coughing ... sounds congested ... Skilled nurse suggested positioning for drainage and use of PRN 9as needed) medication as ordered for comfort. (Caregiver) asked if a nurse would visit this morning to assess. Skilled nurse told her message would be passed along to the office regarding same. Tiger text to the hospice team." 02/17/23, 6:26 a.m.: Call received from (daughter #1). "Communication Note' ...Telephone call from patient's daughter (daughter #1) demanding a nurse visit. .... (Patient) short of breath. Skilled nurse explained that the on call nurse is currently tied up on another visit and we will get a nurse to visit as soon as we can. Skilled nurse offered to have patient's morphine dose adjusted in the meantime and she was agreeable. Skilled nurse contacted (practitioner) regarding the same and the morphine dose was increased .... Skilled nurse called (daughter #1) and instructed the same. Skilled nurse also suggested she position (patient) on his side.... She verbalized understanding. Skilled nurse contacted on call nurse and also patients case manager regarding the same. (Patients) case manager is planning on visiting him first thing this morning and will make the visit. Tiger text to hospice team. Skilled nurse received another page from (patients) family. Skilled nurse notified case manager and she stated she was just on the phone with the family and they hung up on her." 02/17/23,7:57 a.m.: Call received from (daughter #2). No documentation details provided of this phone call. Per the agency Administrator, "There wasn't a 'Communication Note' since the agency normal business hours begin at 8:00 a.m. and the registered nurse case manager was already scheduled to visit the patient first thing in the morning." Documentation provided of the agency on call registered nurse visiting another patient on 02/17/23 between 6:32 a.m. - 8:29 a.m. 02/17/23, 8:35 a.m.: Documentation provided of a registered nurse arriving at the patients home at 8:35 a.m. "Three daughters present all very angry stating they have been calling for a nurse since 4:00 a.m. The on-call nurse was not available as they were at a death. Triage nurse attempted symptom management over the phone and family was not satisfied. ... Continued medication as ordered with no change in symptoms.... Patient accepted at inpatient unit ... Family in agreement with transfer. ... Family followed patient transport to the Hospice house." Documentation provided of an agency social worker (employee #2) visiting the family on 02/17/23 8:45 a.m.-10:17 a.m. No documentation provided of the agency on call social worker (employee #3) being dispatched to offer the family a visit/support and ensuring coordination of care after becoming aware (approximately 6:26 a.m.) that the on -call nurse was seeing another patient and was not available. An interview conducted with the agency Administrator on March17, 2023 at approximately 1:15 p.m. confirmed the above findings.

Based on a review of agency policy, patient clinical record, and an interview with the agency Administrator, the agency failed to adhere to agency policy 'Death of a Hospice Patient' for one (1) of one (1) clinical records (CR) reviewed (CR#1) and one (1) of one (1) interviews conducted (Interview #1). Findings Include: Agency policy was reviewed March 2, 2022 at approximately 2:15 p.m. Policy: HSP-30 'Death of a Hospice Patient/Unclaimed Bodies' 'Purpose' states "Members of the hospice's interdisciplinary group are available to attend patient deaths 24 hours a day, 7 days a week." Section III 'Procedure' (1) states "The RN Case Manager or designee visits the home of the patient when notified that the patient has died. The Social Worker, Chaplain, or Bereavement Coordinator may visit as appropriate." (10) "The hospice nurse and/or other hospice staff remain at the residence if needed until the body has been removed and the bereaved are coping effectively." A review of CRs was conducted on March 2, 2022 at approximately 2:00 p.m. The patients start of care date (SOC) is included below. CR#1 SOC 11/21/21: This patient resided at Facility #1. No documentation provided of the the RN Case Manager or designee visiting the home of the patient (facility) when notified that the patient had died nor of the hospice nurse and/or other hospice staff remain at the residence (facility) if needed until the body has been removed and the bereaved are coping effectively, per agency policy. 'MSW General Routine (Visit 11/23/21) entered by agency Social Worker #1 on 11/23/21 at 1:20 p.m. includes "Funeral plans are complete. (Facility #1) in (city). Patient will be cremated." Interview #1: An interview was conducted with the Administrator on March 2, 2022 at approximately 2:05 p.m. Per the Administrator, the agency follows the facilities (nursing home) rules. This facility (nursing home) requires the family to make the call to the funeral home." The facility did call the hospice agency and notified them of the patients death. Agency documentation, dated 11/30/21 at 4:59 a.m., was provided of Facility #1 notifying the hospice agency of the death of CR#1. 'Pronouncement of Death by: "Nursing facility RN." 'Pronouncement of Death time: "4:20 a.m." 'Pronouncement of Death Note: "Patient passed away and was pronounced by (facility RN) at (Facility #1). ...Coroner notified. (Funeral Home to be called as well." 'Bereavement Note' "RN at (Facility #1) notified patient's daughter that patient has passed away. Declined support services and declined to visit facility at this time." The Administrator was asked what the hospice agency typically does when a patient dies. The Administrator stated "Typically the agency asks the family if they want the agency to call the funeral home." "Typically the agency does call the funeral home in the presence of a family member." The Administrator was asked if there was a written agreement with Facility #1 stating that the facility will call the funeral home upon the death of a hospice agency patient. The Administrator stated "No." No other agency policy provided related to a patient death at a facility (patients home) versus a patient death at a patients personal home. An interview conducted with the agency Administrator on March 2, 2022 at approximately 2:40 p.m. confirmed the above findings.