Lakeside Hospice Inc.

“Based on a review of the hospice’s Emergency Preparedness drills, tabletop exercises, and emergency events, it was determined the agency failed to analyze the hospice’s response to drills, tabletop exercises, and emergency events. A review of the Emergency Preparedness drills, exercises and actual events for 2024 and 2025 revealed the agency failed to analyze the events after the occurrence and revise any plans as needed from the information analyzed. An interview was conducted on 5/15/25 at 10:15 AM with Employee Identifier # 2, Volunteer Coordinator, who confirmed the agency failed to analyze the events as required by CMS.”

“Based on review of medical records (MR), agency policies and procedures, and interviews, it was determined the agency failed to complete the Volunteer Assessment as ordered and assign frequencies of Volunteer visits within five working days after notification of the request according to agency policy. This deficient practice did affect 3 of 12 MR reviewed with assigned Volunteer services including MR # 11, MR # 2, and MR # 7 and had the potential to affect all patients and caregivers (CG) served by this agency.Findings include:Agency Policy: Volunteer-ServicesPolicy Number: PC.V20Date Effective: NonePolicy:The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services and their caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the hospice program and its patients.Procedures: Volunteers are supervised by the Volunteer Coordinator and are used in prescribed roles including...a. providing emotional and practical support to patients and families...c. Assisting in bereavement education and support services... Agency Policy: Volunteers-AssignmentPolicy Number: PC.V10Date Effective: NonePolicy: Hospice Volunteers are assigned in a timely and appropriate manner. Patients and their family are provided with information regarding the services provided by volunteers...If the patient or family is interested in having a Volunteer, the Volunteer Coordinator is notified. Alternatively, the Volunteer Coordinator may initiate contact with the patient...Volunteer assignments are made within five working days after notification of the request... 1. MR # 11 was admitted to the agency on 12/4/24 with diagnoses including Parkinson’s Disease with Dyskinesia with Fluctuations and Falls. Review of the Hospice Plan of Care (POC) dated 12/4/24 revealed orders for Volunteer Services. Further review of the POC revealed no documentation the assessment was completed as ordered and failed to include the visit frequency.Review of the Volunteer Assessment dated 12/23/24, 19 days after the Hospice POC dated 12/4/24, revealed the patient was contacted on 12/18/24, 14 days after the orders for Volunteer Services, to review and discuss Volunteer services and other programs.The agency failed to complete the assessment ordered for Volunteer Services within five days and failed to include Volunteer visit frequency according to agency policy.An interview was conducted on 5/15/25 at 2:51 PM with EI # 1, Executive Director, who confirmed the agency failed to complete the assessment ordered for Volunteer services within five days and failed to include Volunteer visit frequency according to agency policy. 2. MR # 2 was admitted to the agency on 4/2/25 with diagnoses including Malignant Neoplasm of Frontal Lobe and Unspecified Convulsions.Review of the Hospice POC dated 4/2/25 revealed orders for Volunteer Services.Further review of the POC revealed no documentation the assessment was completed as ordered and failed to include the visit frequency. The agency failed to complete the assessment ordered for Volunteer Services within five days and failed to include Volunteer visit frequencies per agency policy.An interview was conducted on 5/15/25 at 3:03 PM with EI # 1, who confirmed the agency failed to complete the assessment ordered for Volunteer services within five days and failed to include Volunteer visit frequency according to agency policy.3. MR # 7 was admitted to the agency on 4/11/25 with diagnoses including Senile Degeneration of the Brain, Not Elsewhere Classified.Review of the Hospice POC dated 4/11/25 revealed orders for Volunteer Services.Further review of the POC revealed no documentation the assessment was completed as ordered and failed to include the visit frequency. The agency failed to complete the assessment as ordered for Volunteer Services within five days and failed to include Volunteer visit frequency according to agency policy. An interview was conducted on 5/15/25 at 3:24 PM with EI # 2, Volunteer Coordinator, who confirmed the agency failed to complete the assessment ordered for Volunteer services within five days and failed to include Volunteer visit frequency according to agency policy.”

“Based on review of medical records (MR), agency policies and procedures, and interviews, it was determined the agency failed to ensure staff:a. Volunteer frequencies were included in the Plan of Care (POC).b. Wound care orders were included in the POC. This deficient practice did affect four out of 14 MR reviewed including MR # 11, MR # 2, MR # 7, and MR # 4, and had the potential to affect all patients served by the agency.Findings include:Agency policy: Plan of CarePolicy Number: PC.P40Date Effective: NonePolicy:The care and services provided to Lakeside Hospice patients and their families are in accordance with an individualized, written plan of care established by the hospice Interdisciplinary Group (IDG) in collaboration with the patient’s attending physician (if any), and , if appropriate, the patient and/ or his/her representative.Procedure:The patient’s plan of care specifies the care and services necessary to meet the needs pf the patient/family as identified in the initial, comprehensive and updated assessments of the patient... 5. The plan of care is reviewed and updated by the IDG every 15 days or more frequently is the patient’s condition warrants... 4. MR # 4 was admitted to the agency on 3/23/25 with a terminal diagnosis of Heart Disease, Unspecified. A review of the POC dated 3/23/25 revealed orders for SN three times a week for one week, two times a week for 12 weeks. Wound care orders as follows: Wound: one Right lower extremity (RLE) Type: Cellulitis. Clean wound with soap and water. Rinse well. Wrap legs with rolled gauze, secure with tape, secure with ace wrap from base of toe to just below the knee daily. There was no order for who was to perform the wound care.Wound: two Left lower extremity (LLE) There were no orders for what to clean and pack the wound with, no orders of how to secure the dressing or how often the wound care was to be completed and by who.A review of the Interdisciplinary Team Meeting notes dated 3/26/25, 4/9/25, 4/23/25, and 5/7/25 revealed no updated orders for the wound to the RLE and LLE.An interview was conducted on 5/15/25 at 3:12 pm with EI # 1, who reported the VA facility nurse was to perform the wound care only. EI # 1 confirmed the wound care orders were incomplete. 1. MR # 11 was admitted to the agency on 12/4/24 with diagnoses including Parkinson’s Disease with Dyskinesia with Fluctuations and Falls. Review of the Hospice POC dated 12/4/24 revealed orders for Volunteer Services.Further review of the POC revealed there was no documentation of frequencies for Volunteer Services.An interview was conducted on 5/15/25 at 2:51 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation of frequencies of Volunteer Services.2. MR # 2 was admitted to the agency on 4/2/25 with diagnoses including Malignant Neoplasm of Frontal Lobe and Unspecified Convulsions.Review of the Hospice POC dated 4/2/25 revealed orders for Volunteer Services.Further review of the POC revealed there was no documentation of frequencies for Volunteer Services.An interview was conducted on 5/15/25 at 3:03 PM with EI # 1, who confirmed there was no documentation of frequencies for volunteer services.3. MR # 7 was admitted to the agency on 4/11/25 with diagnoses including Senile Degeneration of the Brain, Not Elsewhere Classified and Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.Review of the Hospice POC dated 4/11/25 revealed orders for Volunteer Services.Further review of the POC revealed there was no documentation of frequencies for Volunteer Services.An interview was conducted on 5/15/25 at 3:24 PM with EI # 1, who confirmed there was no documentation of frequencies for Volunteer Services.”

“Based on observations, Policies and Procedures and staff interviews it was determined the agency failed to ensure the staff followed the Infection Control policy This affected one of four Home Visit (HV) observations, HV # 3, and had the potential to affect all patients served by this agency.Findings include:Agency Policy: Infection Control- Standard and Transmission-Based Precautions.Policy Number: PC.150Date: Not listed.Policy:Lakeside Hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard and transmission-based precautions...Procedures: 1.Hospice staff are required to use standard precautions in the care of all hospice patients, regardless of diagnosis or presumed infection status. Standard precautions include, but are not limited to:a. Hand hygiene before and after patient contact...b. Use of appropriate personal protective equipment including gloves, masks, gowns, face shields and eye protection. 1. An observation of a bed bath was conducted with HV # 3, on 5/14/25 at 9:35 AM with Employee Identifier (EI) # 3, Certified Nursing Assistant (CNA). During the observation, the CNA failed to perform hand hygiene prior to starting the patient bath and failed to perform hand hygiene after. The staff failed to perform hand hygiene after removing gloves and obtaining gloves stored in his/her pocket during care provided. An interview was conducted on 5/15/25 at 2:33 PM with EI # 1, Executive Director, who confirmed the staff failed to follow the agency’s infection control policy for hand hygiene.”

“Based on volunteer file reviews, interviews, and agency policy and procedures, it was determined the agency failed to ensure all volunteer staff were trained in Hospice Philosophy. This did affect three of five volunteer files reviewed and had the potential to affect all patients served by this agency.Findings include:Agency Policy: Volunteer-ServicesPolicy Number: PC.V20Date Effective: NonePolicy:The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services and their caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the hospice program and its patients.Procedures: Volunteers are supervised by the Volunteer Coordinator and are used in prescribed roles including...a. providing emotional and practical support to patients and families...c. Assisting in bereavement education and support services... 5. Volunteers are required to complete an orientation and training program prior to assignment to patients and caregivers... A review of volunteer files on 5/15/25 at 1:00 PM revealed three out of five volunteer files reviewed had no documentation of Hospice Philosophy training. An interview was conducted on 5/15/25 at 3:00 PM with Employee Identifier (EI) # 2, Volunteer Coordinator, who confirmed the volunteers had not received Hospice Philosophy training.”

“Based on review of employee personnel files, and interviews with staff it has been determined the agency failed to ensure all staff who performed patient care had a yearly competency check.This affected two of four staff members personnel files reviewed, and had the potential to affect all patients served by this agency. A review of the employee personnel files on 5/15/25 at 1:00 PM revealed no documentation of competency for two of four staff who perform patient care, including a Registered Nurse and a Licensed Practical Nurse.An interview was conducted on 5/15/25 at 1:20 PM with Employee Identifier # 1, Executive Director, who confirmed no competency had been performed for the two employees for 2024 or 2025 to date.”