Every finding on record at Whitewater Healthcare, LLC

Based on medical record review, policy review, and staff interview, it was determined the agency failed to ensure care and services were provided in accordance with the plan of care for 1 of 19 patients (Patients #11) whose record was reviewed. This had the potential to interfere with patient safety and coordination of patient care. Findings include: --- The Hospice had a policy titled, ";Pain Assessment" dated May 2024. The policy stated, ";The patients preferences for pain management will be reflected in the pain control measures selected." This policy was not followed. An example includes: Patient #11 was an 89 year old female who was admitted to hospice on 06/11/24 with the primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient #11s medical record included a POC included ";Need for observation and assessment of altered comfort – Hospice" with the intervention of ";Monitor pain level using appropriate pain scale." Patient #11s medical record documented a SN visit on 12/9/24 where the pain was assessed at a 5 and the narrative included ";Pt refused shower today due to breakthrough pain. Pt report intermittent pain to LLQ abdomen." There was no additional pain management information recorded or a documented intervention to address pain. The DCS was interviewed on 12/17/24 beginning at 3:00 PM and Patient #11s medical record was reviewed. When asked about when an intervention for pain would be expected the DCS reported, ";Anything over a 3 [pain scale] would need an intervention." The DCS confirmed there was not a documented intervention in Patient #11s medical record. The Hospice failed to ensure services outlined on Patient #11s POC were done.

Based on direct observation, medical record review, policy review, and staff interview, it was determined the hospice agency failed to ensure the patient and assisted living facility received and acknowledged instructions of the safe use of DME, specifically oxygen tanks, for 1 of 3 patients (Patient #2) whose care was observed. This had the potential to lead to the misuse and handling of DME. Findings include: --- A hospice policy titled, "Storage, handling, and Access to Supplies and Gases, Policy No. 4-087.1", revised May 2024, read: "Patients will receive, when appropriate, information and instruction regarding storage, handling, and access to supplies and medical gases." This policy was not followed. An example includes: Patient #2 was an 80 year old female on hospice services since 10/03/24 with a terminal diagnosis of congestive heart failure. Patient #2 resided in an Assisted Living facility. A supervised nursing visit was conducted on 12/17/24 at 11:00 AM at the facility. Patient #2 used 4 liters of oxygen continuously via nasal cannula with an oxygen concentrator. It was noted the patient had 13 oxygen tanks stored in her room between her bed and the wall. Patient #2's medical record was reviewed including the current plan of care. There was no mention of safe oxygen use and storage being taught to patient or facility. In an interview with Patient #2's nurse on 12/17/24, starting at 11:50 AM, she was asked why the patient had 13 oxygen tanks currently in her room. The nurse stated the patient liked to go out frequently and used them when she was not in her room using the oxygen concentrator. The nurse confirmed this was not a safe environment for the patient. The nurse also confirmed there was no teaching of safe oxygen use documented in the patient medical record for this or previous hospice visits. The DCS was interviewed on 12/17/24 beginning at 3:00 PM. He was asked if it was typical to have 13 oxygen tanks in a patient room. The DCS confirmed this was not appropriate. The DCS contacted the DME company to inquire about these tanks and was told they delivered whatever was ordered for the patient. The hospice agency did not ensure safe oxygen use and storage was taught to patient and facility.

Based on review of agency policy, record review, and staff interview, it was determined the hospice failed to ensure all grievances were investigated and resolved for 1 of 3 patients (Patient #8) who had a grievance and whose record was reviewed. This had the potential for improvements in patient care to be missed. Findings include: An agency policy titled "COMPLAINT/GRIEVANCE PROCESS," revised 4/2018 stated, "Corrective action will be specific and related to the complaint...resolution information will be communicated in writing to the patient or his/her representative filing the complaint." This policy was not followed. An example includes: Patient #8 was a 90 year old female admitted to the agency on 10/04/21 with a primary diagnosis of mantle cell lymphoma. Additional diagnoses included type 2 diabetes and hyperlipidemia. She received SN, MSW, and chaplain and aide services. Her record for the certification periods 10/04/21 to 12/02/21, 12/03/21 to 1/31/22, and 2/01/22 to 4/01/22 was reviewed. A grievance for Patient #8 was provided, dated 10/22/21. The note stated, "SIN [sic] CALLED RECORDING MOM IS NOT BEING BATHED. EXPLAINED TO SUNG [sic] THAT AID [sic] HAS GONE OUT AND PATIENT HAS REFUSED. HE STATED HE NEEDED HELP AT 8 IN THE MORNING NOT 11. REMINDED HIM THAT WHEN WE DISCUSS ORDERING AIDS [sic] THEY WOULD START AS SOON. [sic] SON UPSET ...EXPLAIN I WOULD CALL THE OFFICE AND THEY WOULD SEE WHAT THEY COULD DO ABOUT GETTING AN AIDE TO COME IN SOONER." The "Prevention" section of the grievance stated, "FOLLOW UP WITH PATIENT...CHANGE IN STAFF ASSIGNMENT." The "Intervention/Resolution Comments" portion of the grievance note was left blank. The grievance did not say if an aide was able to visit Patient #8 at an earlier time to facilitate cares. The DCS of the branch location where Patient #8 was receiving cares was interviewed on 2/02/22 at 3:46 PM. She stated she filled out the grievance report. She confirmed she did not complete the grievance report and did not follow up with Patient #8's son who made the grievance after the grievance was entered. The hospice failed to ensure all grievances were investigated and resolved.

Based on review of medical records and staff interview, it was determined the agency failed to ensure POCs specified the care and services necessary to meet patient-specific needs identified in the comprehensive assessment for 1 of 13 patients (Patient #2) whose records were reviewed. The lack of individualized POCs interfered with the agency's ability to direct patient care. Findings include: Patient #2 was a 50 year old female admitted to the agency on 6/15/21, with a terminal diagnosis of breast cancer. She received SN, MSW, and chaplain services. Her record for the certification period 6/15/21 to 9/12/21, was reviewed. Patient #2's medical record included a SOC RN assessment dated 6/15/21, signed by an RN. The assessment included Patient #2 required assistance in bathing, dressing, grooming, housekeeping, shopping, and meal preparation. The narrative note in the SOC RN assessment included, "PTs DAUGHTER [name] IS PTS CAREGIVER AND ASSISTS PT WITH ADLS." However, the assessment included, "INDICATE ANY LIMITATIONS THE CAREGIVER APPEARS TO HAVE: DIFFICULTY WITH OWN ADLS." There was no documentation in Patient #2's medical record her caregiver was assessed or evaluated on providing appropriate and effective help with Patient #2's ADL's. Additionally, there was no documentation a hospice aide was offered to assist with Patient #2's ADL's. The DCS from the branch location where Patient #2 received services was interviewed on 2/02/22 beginning at 3:00 PM, and Patient #2's medical record was reviewed in her presence. She confirmed the lack of clear documentation if Patient #2's caregiver was able to perform Patient #2's ADL's. When asked if a hospice aide was provided or offered for Patient #2, she stated she could not find documentation one had been offered. She stated a hospice aide should have been offered to Patient #2. The agency failed to meet Patient #2's needs related to her ADL's.

Based on agency policy review, medical record review, and staff interview, it was determined the agency failed to ensure plans of care included drugs and treatment necessary to meet the needs of 1 of 13 patients (Patient #2) whose records were reviewed. This resulted in incomplete POCs and had the potential to interfere with quality and coordination of patient care. Findings include: An agency policy titled "THE PLAN OF CARE," revised 4/2018 included, "The written plan of care will contain, but will not be limited to the following...Drugs and treatments." This policy was not followed. An example includes: Patient #2 was a 50 year old female admitted to the agency on 6/15/21 with a terminal diagnosis of breast cancer. She received SN, MSW, and chaplain services. Her record for the certification period 6/15/21 to 9/12/21 was reviewed. An SOC visit note, signed by the RNCM on 6/15/21, stated Patient #2 was experiencing nausea. The assessment included, "DOES THE NAUSEA SIGNIFICANTLY AFFECT THE PATIENT," and was answered "YES." The assessment indicated the medication Zofran (a medication for nausea) was started. Patient #2's POC and medication list did not include Zofran. The DCS was interviewed 2/02/22 beginning at 3:46 PM and Patient #2's medical record was reviewed in his presence. He confirmed the Zofran was not on Patient #2's medication list or POC. He confirmed all medications should have been listed on the POC or medication list. The agency failed to ensure POCs included all drugs.

Based on agency policy, medical record review, website review, and staff interview, it was determined the agency failed to ensure care and services were provided in accordance with the plan of care for 2 of 13 patients (Patients #2 and #8) whose records were reviewed. This had the potential to interfere with patient safety and coordination of patient care. Findings include: 1. Patient #2 was a 50 year old female admitted to the agency on 6/15/21 with a terminal diagnosis of breast cancer. She received SN, MSW, and chaplain services. Her record for the certification period 6/15/21 to 9/12/21 was reviewed Patient #2's medical record indicated she had a peritoneal drain placed in her abdomen to manage the fluid that was accumulating in her abdomen. Patient #2's POC included, "SKILLED NURSE TO PROVIDE INSTRUCTIONS RELATED TO PERITONEAL DRAIN SITE REGARDING INFECTION CONTROL, DRESSING CHANGES, AND SIGNS AND SYMPTOMS TO OBSERVE FOR AND REPORT." Patient #2's medical record included an RN visit note dated 6/17/21. The note included, "CG [caregiver] stated drainage from port is more of a milky color, SN obtained sample and took to lab. Waiting for results. No s/s [signs/symptoms] of infection at drain site." Patient #2's medical record included a lab report from the same day that showed no infection in the laboratory culture obtained from the peritoneal drain port. Patient #2's medical record included, and RN visit note dated 6/21/21. There was no documentation the RN assessed or observed Patient #2's peritoneal drain site. Patient #2's medical record included an RN visit note dated 6/24/21. The note included, "PT NOT ACTING AS SHE NORMALLY DOES, CG STATES PT HAS BEEN SAYING THINGS THAT ARE NOT NORMAL FOR PT, DIFFICULTY STANDING AND DECREASED APPETITE CG STATES PT BECOMES COGNITIVELY DISORIENTED WHEN SHE HAS AN INFECTION." The note also included that Patient #2 had a low-grade fever at 99.1 degrees Fahrenheit. There was no documentation of an assessment or observation of Patient #2's peritoneal drain site. Additionally, there was no documentation Patient #2's physician was made aware of her change in cognition. The Mayo Clinic website (https://www.mayoclinic.org/diseases-conditions/infectious-diseases/symptoms-causes/syc-20351173) accessed 2/08/22 stated: "Each infectious disease has its own specific signs and symptoms. General signs and symptoms common to a number of infectious diseases include: Fever Diarrhea Fatigue." Patient #2's medical record included a RN visit note dated 6/26/21. The note included, "SN RECEIVED CALL FROM PTS DAUGHTER THAT PT WAS NOT VERY RESPONSIVE AND HAVING DIFFICULT TIME SWALLOWING MEDS... PT UNABLE TO STAND AND INCONTINENT. UPON SN ARRIVAL PT LAYING IN BED AND UNAWARE OF SURROUNDINGS. SN PERFORMED VS [vital signs] AND ASSESSMENT, WNL, SN ASSESSED OTS [sic] DRESSING, RED STREAKS AND PUS DRAINING FROM THE SITE. PUS POCKET STARTED A FEW INCHES AWAY FROM DRAIN SITE. SPOKE WITH ON CALL ONCOLOGIST AND DECIDED TO GIVE THE FAMILY THE OPTION TO REVOKE HOSPICE AND SEND PT TO ER [emergency room]." Patient #2's medical record indicated she revoked hospice and was admitted to the hospital for sepsis and was given antibiotics. She reelected hospice after discharge from the hospital. The DCS was interviewed 2/02/22 beginning at 3:00 PM. He confirmed there was no documentation Patient #2's peritoneal drain site was assessed or observed on 6/21/21 and 6/24/21. Additionally, he confirmed there was no documentation Patient #2's hospice physician was notified of her change in cognition and low-grade fever. The agency failed to ensure Patient #2's peritoneal drain site was effectively assessed. 2. An agency policy titled "MISSED VISITS," revised 4/2018 stated the following: "2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG [interdisciplinary group] and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient's clinical record the following information 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patient's needs were met 5. Any other follow-up needed 6. Other person(s) that were notified of the missed visit 7. Signature of staff member reporting the information 3. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits." This policy was not followed. An example includes: Patient #8 was a 90 year old female admitted to the agency on 10/04/21 with a primary diagnosis of mantle cell lymphoma. Additional diagnoses included type 2 diabetes and hyperlipidemia. She received SN, MSW, and chaplain and aide services. Her record for the certification periods 10/04/21 to 12/02/21, 12/03/21 to 1/31/22, and 2/01/22 to 4/01/22 was reviewed. Patient #8's record included a POC add-on order dated 10/11/21 which stated, "HOME HEALTH AIDE [sic] SERVICE FOR ASSISTANCE WITH PERSONAL CARE AND ADL'S SECONDARY TO FUNCTIONAL LIMITATIONS WHICH PREVENT SELF-CARE. THERE IS NO WILLING OR ABLE CAREGIVER TO PROVIDE FOR HYGIENE NEEDS." The POC order stated the hospice aide was to see Patient #8 twice weekly effective 10/10/21. A grievance for Patient #8 was provided, dated 10/22/21. The note stated, "SIN [sic] CALLED RECORDING MOM IS NOT BEING BATHED. EXPLAINED TO SUNG [sic] THAT AID [sic] HAS GONE OUT AND PATIENT HAS REFUSED. HE STATED HE NEEDED HELP AT 8 IN THE MORNING NOT 11. REMINDED HIM THAT WHEN WE DISCUSS ORDERING AIDS [sic] THEY WOULD START AS SOON. [sic] SON UPSET...EXPLAIN I WOULD CALL THE OFFICE AND THEY WOULD SEE WHAT THEY COULD DO ABOUT GETTING AN AIDE TO COME IN SOONER." The "Prevention" section of the grievance stated, "FOLLOW UP WITH PATIENT...CHANGE IN STAFF ASSIGNMENT." The "Intervention/Resolution Comments" portion of the grievance note was left blank. Patient #8's record included the following: - Week of 10/10/21: no hospice aide visits were made. There were no missed aide visit notes for the week of 10/10/21. - Week of 10/17/21: On 10/19/21 there was a missed aide visit note due to "UNABLE TO GET A HOLD OF." There was an aide visit made on 10/21/21 that stated Patient #8 refused all cares. No hygiene or ADL services to Patient #8 were provided. - Week of 10/24/21: On 10/29/21 there was a missed aide visit note due to, "UNABLE TO GET A HOLD OF PT TO SCHEDUAL [sic] VISIT." There was no missed visit note for the other aide visit that was supposed to be provided. - Week of 10/31/21: The frequency of aide visits changed to once weekly. There was a missed aide visit note on 11/03/21 due to, "PATIENT WAS READY FOR THE DAY BEFORE I ARRIVE [sic] REFUSED SHOWER." - Week of 11/07/21: An aide visit was made on 11/10/21. This was the first time Patient #8 received services by a hospice aide since it was ordered on 10/10/21. - Week of 11/14/21: On 11/17/21 there was an aide missed visit note due to "PATIENT/CAREGIVER REFUSED." - Week of 11/21/21: There was no aide visit or aide missed visit note. - Week of 11/28/21: On 12/02/21 there was an aide missed visit note due to "NURSE GAVE BATH AT VISIT THIS WEEK." It was unclear why the aide did not provide other aide cares, besides bathing, that were ordered on the aide POC. - Weeks of 12/05/21, 12/12/21, 12/19/21, and 12/26/21: There were no aide visits made or aide missed visit notes. - Week of 1/02/22: On 1/04/22 an aide visit was made, however all hygiene and ADL services were refused due to, "FAMILY CANCLED [sic] LAST MINUTE ALL READY [sic] HAD PATIENT UP AND EATINF [sic] BREAKFAST." - Week of 1/09/22: An aide visit was made on 1/11/22. - Week of 1/16/22: There was no aide visit or missed visit note. - Week of 1/23/22: An aide visit was made on 1/25/22. The DCS and the DCS of the branch location where Patient #8 was receiving services were interviewed together on 2/02/22 at 3:46 PM. They confirmed the aide visits were not provided according to the POC. The DCS of the branch location stated there was only one aide working at the branch location and that aide was unable to make it to Patient #8. The DCS of the branch location stated nursing was doing some of the aide cares, but confirmed there was not enough documentation to support this. The hospice failed to provide services as ordered in the POC for Patient #8.

Based on medical record review and staff interview, it was determined the agency failed to ensure services were provided based on patient needs for 3 of 13 patients (Patients #5 - 7) whose records were reviewed. This had the potential for missed care delivery interventions. Findings include: 1. Patient #7 was a 79 year old male admitted to the agency on 12/22/21 with a terminal diagnosis of Alzheimer's Disease. He received SN, MSW, and aide and chaplain services. His record for the certification period 12/22/21 to 3/21/22 was reviewed. Patient #7's medical record included a coordination of care report dated 12/22/21 signed by the MSW. It included, "Volunteer support services consent received on 12/22/21. Care giver accepted volunteer services, VC [volunteer coordinator] to process placement. VC spoke with POA [power of attorney] on 12/22/21 informing them of the process and time line." Patient #7's medical record included an MSW evaluation assessment dated 12/22/21. It included: - In the section assessing need for homemaker services: "WIFE MET THIS NEED FOR PATIENT, BUT MAY NEED ASSISTANCE DUE TO THE STRAIN THAT CAREGIVING HAS BEEN ON HER." - The assessment also included: "PATIENTS WIFE IS BEGINNING TO FEEL THE STRAIN ASSOCIATED WITH CARING FOR HER HUSBAND." - In the narrative section the note included: "NUTRITIONAL NEEDS HAVE BEEN MET BUT DUE TO INCREASED CAREGIVER STRAIN SW SUGGESTED MEALS ON WHEELS WHICH THEY HAVE ACCEPTED. SW TO MAKE REFERRAL FOR THIS AS WELL AS RESPITE SERVICES THROUGH THE AREAS AGENCY ON AGING. PATIENTS WIFE HAS BEEN FUNCTIONING S [sic] THE MAIN CAREGIVER BUT THIS IS BECOMING INCREASINGLY DIFFICULT WITH SIH [sic] DECLINE...FAMILY DID ACCEPT A VOLUNTEER." There was no documentation in Patient #7's medical record that a volunteer was provided for Patient #7 and his caregiver. Additionally, there was no documentation of follow up on the status of respite services for Patient #7 and his caregiver. The DCS was interviewed 2/03/22 beginning at 9:00 AM and Patient #7's medical record was reviewed in his presence. He confirmed no volunteer was placed with Patient #7 or his caregiver. Additionally, he confirmed there was no documentation of follow up for respite services for Patient #7 or his caregiver. 2. Patient #6 was a 75 year old female admitted to the agency on 1/13/22 with a primary diagnosis of malnutrition. Additional diagnosis included COVID-19 and Alzheimer's disease. She received SN, MSW, chaplain and aide services, and massage therapy. Her record for the certification period 1/13/22 to 4/12/22 was reviewed. Patient #6's record included an RN SOC note, dated 1/13/22. The note stated, "WERE VOLUNTEER SERVICES OFFERED DURING THIS VISIT? YES AND SERVICES WERE ACCEPTED." Patient #6's record included a social work evaluation, dated 1/13/22, signed by the Social Worker. The note stated, "PATIENT SEEMS TO BE VERY SOCIAL AND DID ACCEPT VOLUNTEER SERVICES." The DCS was interviewed on 2/03/22 beginning at 9:43 AM. He confirmed Patient #6 had accepted volunteer services and had not been seen by a volunteer. He stated they only had one volunteer available, and the volunteer had not had time to see Patient #6. 2. Patient #5 was an 85 year old female admitted to the agency 11/28/21 with a primary diagnosis of cerebral infarction. Additional diagnoses included atrial fibrillation and malnutrition. She received SN, physical therapy, MSW, and aide and chaplain services. Her record for the certification period 11/28/21 to 2/25/22 was reviewed. Patient #5's record included a coordination note, dated 11/30/21, signed by the Social Worker. It stated, "VOLUNTEER SUPPORT SERVICES CONSENT RECEIVED ON 11/30/21. PATIENT ACCEPTED VOLUNTEER SERVICES, VC TO PROCESS PLACEMENT OF VOLUNTEER. VC SPOKE WITH PATIENT ON 11/30/21 INFORMING THEM OF THE PROCESS AND TIME LINE, ALSO SPOKE WITH RNCM AND MSW INFORMING OF THE SAME." The DCS was interviewed on 2/03/22 beginning at 9:43 AM. He confirmed Patient #5 had accepted volunteer services and had not been seen by a volunteer. He stated they only had one volunteer available, and the volunteer had not had time to see Patient #5. The agency failed to ensure services were provided based on patient needs.

Based on review of agency policy, medical records, and staff interview, it was determined the agency failed to ensure documentation of communication with patients' physicians for 1 of 13 patients (Patient #2) whose records were reviewed. This resulted in a lack of clarity as to the course of care and whether physicians had been contacted related to care that required practitioner input. Findings include: Patient #2 was a 50 year old female admitted to the agency on 6/15/21, with a terminal diagnosis of breast cancer. She received SN, MSW, and chaplain services. Her record for the certification period 6/15/21 to 9/12/21 was reviewed. Patient #2's medical record included an RN visit note dated 6/24/21. The note included, "PT NOT ACTING AS SHE NORMALLY DOES, CG STATES PT HAS BEEN SAYING THINGS THAT ARE NOT NORMAL FOR PT, DIFFICULTY STANDING AND DECREASED APPETITIE CG STATES PT BECOMES COGNITIVELY DISORIENTED WHEN SHE HAS AN INFECTION." The note also included that Patient #2 had a low-grade fever at 99.1 degrees Fahrenheit. There was no documentation Patient #2's physician was made aware of her change in cognition and that her caregiver suspected an infection. Patient #2's medical record included a RN visit note dated 6/26/21. The note included, "SN RECEIVED CALL FROM PTS DAUGHTER THAT PT WAS NOT VERY RESPONSIVE AND HAVING DIFFICULT TIME SWALLOWING MEDS...PT UNABLE TO STAND AND INCONTINENT. UPON SN ARRIVIAL PT LAYING IN BED AND UNAWARE OF SURROUNDINGS. SN PERFORMED VS AND ASSESSMENT, WNL, SN ASSESSED OTS [sic] DRESSING, RED STREAKS AND PUS DRAINING FROM THE SITE. PUS POCKET STARTED A FEW INCHES AWAY FROM DRAIN SITE. SPOKE WITH ON CALL ONCOLOGIST AND DECIDED TO GIVE THE FAMILY THE OPTION TO REVOKE HOSPICE AND SEND PT TO ER." Patient #2's medical record indicated she revoked hospice and was admitted to the hospital for sepsis. The DCS was interviewed 2/2/22 beginning at 3:00 PM and Patient #2's medical record was reviewed in his presence. He confirmed there was no documentation Patient #2's hospice physician was notified of her change in cognition, low-grade fever, and caregivers concern of an infection for Patient #2 on 6/24/21. The agency failed to ensure coordination between clinicians and hospice physicians.

Based on review of CMS memorandum, patient record review, and staff interview, it was determined the hospice failed to follow accepted standards of practice to prevent the spread of infection. This caused a lack of patient screening for signs and symptoms of COVID-19 by the Massage Therapist for 3 of 3 patients (Patients#3, #5, and #9) who were receiving massage therapy and whose records were reviewed. Findings include: A CMS memorandum titled "Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies," dated 3/09/20 stated, "hospice agencies should be monitoring the health status of patients, residents, visitors, volunteers, and staff under their care setting for signs or symptoms of COVID-19." This guidance was not followed. Examples include: 1. Patient #3 was a 62 year old male admitted to the agency on 4/27/21 with a primary diagnosis of COPD. An additional diagnosis included weight loss. He received SN, MSW, massage therapy and chaplain services. His record for the certification period 4/17/21 to 7/25/21 was reviewed. Patient #3's record included 2 massage therapy visits, dated 4/30/21 and 5/03/21. Neither of the massage therapy visits included screening for signs and symptoms of COVID-19 prior to the visit. 2. Patient #5 was an 85 year old female admitted to the agency 11/28/21 with a primary diagnosis of cerebral infarction. Additional diagnoses included atrial fibrillation and malnutrition. She received SN, physical therapy, MSW, aide, massage therapy, and chaplain services. Her record for the certification period 11/28/21 to 2/25/22 was reviewed. Patient #5's record included massage therapy visits on 1/04/22, 1/11/22, 1/19/22, 1/25/22, and 2/01/22. None of the massage therapy visits included screening for signs and symptoms of COVID-19 prior to the visit. 3. Patient #9 was an 93 year old female admitted to the agency 6/25/21 with a primary diagnosis of protein calorie malnutrition. She received SN, PT, MSW, massage therapy, aide, and chaplain services. Her record for the certification period 12/11/21 to 2/08/22 was reviewed. Patient #9's record included massage therapy visits on 12/14/21, 12/21/21, 12/30/21, 1/04/22, 1/11/22, and 1/19/22 None of the massage therapy visits included screening for signs and symptoms of COVID-19 prior to the visit The DCS was interviewed on 2/03/22 beginning at 9:43 AM. Patients #3, #5, and #9's records were reviewed in his presence. He confirmed there was no documentation of the Massage Therapist screening the patients for signs and symptoms of COVID-19. He stated there was no function built into the visit note for the Massage Therapist to document the COVID-19 screening, however said she could have wrote it into the narrative section of the visit notes. The agency failed to ensure all staff screened patients for signs and symptoms of COVID-19.

Based on review of personnel files and staff interview, it was determined the facility failed to ensure all staff members received initial orientation when hired to the agency for 2 of 7 staff members (Staff A and B) whose personnel files were reviewed. This caused lack of documentation of orientation to specific job duties and tasks. Findings include: Seven staff personnel files were reviewed. Staff A and B's personnel files did not include documentation of initial orientation for either staff member. The HR manager was interviewed at the time the personnel files were reviewed on 2/03/22 at 1:55 PM. She confirmed Staff A and B did not have initial orientation documented in their personnel files. She stated the agency was bought by a corporation in 2020, and anyone who worked for the hospice prior to the acquisition was not re-oriented, including Staff A and B. An initial orientation for Staff A and B from before the acquisition was also requested, but the HR manager stated they were not available. The hospice failed to provide an initial orientation to all employees.

Based on review of agency policy, record review, and staff interview, it was determined the hospice failed to ensure a discharge summary was sent for patients who were discharged to a Medicare/Medicaid-certified facility for 3 of 3 patients (Patients #2 - 4) who were discharged or revoked from hospice services and whose records were reviewed. This caused the potential for lack of sharing of important information between the hospice and other Medicare certified facilities. Findings include: An agency policy titled "DISCHARGE FROM HOSPICE PROGRAM," revised 4/2018 stated the following: "Discharge criteria... 2. Patient leaves service area of Symbii-Idaho Hospice... 5. The patient revokes hospice election... PROCEDURE 3. When a patient is discharged, transferred, or referred to another organization, relevant information will include: a. Reason for transfer or discharge b. Physical and psychosocial status at the time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up c. Summary of the care provided and progress toward achieving goals... 4. Documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours." This policy was not followed. Examples include: 1. Patient #3 was a 62 year old male admitted to the agency on 4/27/21 with a primary diagnosis of COPD. An additional diagnosis included weight loss. He received SN, MSW, and massage therapy and chaplain services. His record for the certification period 4/17/21 to 7/25/21 was reviewed. Patient #3's record included a client coordination note, dated 5/12/21, signed by the RN. The note stated, "PATIENT DISCHARGE FROM HOSPICE SERVICES DUE TO MOVED OUT OF SERVICE AREA. PATIENT ADMITTED TO [local Medicare certified hospital] ON 5/08/22. [sic]" Patient #3's record did not include documentation a hospice discharge summary for Patient #3 was sent to the local Medicare certified hospital. The DCS was interviewed on 2/03/22 at 9:43 AM. He confirmed there was no documentation that a discharge summary for Patient #3 was sent to the local Medicare certified hospital after his discharge. 2. Patient #4 was an 82 year old female admitted to the agency 5/30/19 with a primary diagnosis of hypertensive heart disease with heart failure. Additional diagnoses included arthritis and myositis. She received SN, MSW, and chaplain and aide services. Her record for the certification period 5/19/21 to 6/17/21 was reviewed. Patient #4's record included a discharge note, dated 6/17/21, signed by the RN. It stated, "PATIENT DETERMINED TO BE ELIGIBLE FOR SURGERY IF SHE OPTS TO DO SO. PLAN TO TRANSFER TO [local Medicare certified hospital]. FAMILY MADE CHOICE TO REVOKE HOSPICE SERVICES TO SEEK MEDICAL CARE. DISCHARGE FROM AGENCY." Patient #4's record did not include documentation a hospice discharge summary for Patient #4 was sent to the local Medicare certified hospital. The DCS was interviewed on 2/03/22 at 9:43 AM. Documentation that a discharge summary for Patient #4 was sent to the local Medicare certified hospital was requested, but not provided prior to survey exit. 3. Patient #2 was a 50 year old female admitted to the agency on 6/15/21, with a terminal diagnosis of breast cancer. She received SN, MSW, and chaplain services. Her record for the certification period 6/15/21 to 9/12/21 was reviewed Patient #2's medical record included a RN visit note dated 6/26/21. The note included, "SN RECEIVED CALL FROM PTS DAUGHTER THAT PT WAS NOT VERY RESPONSIVE AND HAVING DIFFICULT TIME SWALLOWING MEDS ... PT UNABLE TO STAND AND INCONTINENT. UPON SN ARRIVAL PT LAYING IN BED AND UNAWARE OF SURROUNDINGS. SN PERFORMED VS AND ASSESSMENT, WNL, SN ASSESSED OTS [sic] DRESSING, RED STREAKS AND PUS DRAINING FROM THE SITE. PUS POCKET STARTED A FEW INCHES AWAY FROM DRAIN SITE. SPOKE WITH ON CALL ONCOLOGIST AND DECIDED TO GIVE THE FAMILY THE OPTION TO REVOKE HOSPICE AND SEND PT TO ER." Patient #2's medical record indicated she revoked hospice and was admitted to the hospital for sepsis. Patient #2's record did not include documentation a hospice discharge summary for Patient #2 was sent to the local Medicare certified hospital. The DCS was interviewed on 2/03/22 at 9:43 AM. He confirmed there was no documentation that a discharge summary for Patient #2 was sent to the local Medicare certified hospital after his discharge. The hospice failed to ensure a discharge summary was sent to the receiving Medicare certified facility for patients who were discharged.