Arch Hospice, LLC

“Upon observation and home visits, 3 of 3 (Patient #1,2,3) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. #1-SN did not lay barrier down prior to placing nursing bag on soft-upholstered surface. The SN placed the equipment directly on the bare patient over-bed table and did not disinfect equipment prior to use on patient. #2-SN did not place barrier between nursing bag on soft-upholstered chair. SN placed equipment directly on bare over-bed table, without disinfecting prior to use on patient. #3-SN did not place barrier between nursing bag and soft-upholstered chair. SN placed equipment directly on bare over-bed table, without disinfecting prior to use on patient. Pillows from patient bed were placed directly on nursing bag, covering entire surface, as patient was cleaned/repositioned.”

“Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies identified the patient population that would be at risk during an emergent event and services that the facility would be able to provide in an emergency. This failure had the potential to affect the current eight patients receiving care from the hospice facility. Findings include: Review of the facility’s EPP on 11/21/24 at 3:10 PM, with the Administrator revealed that the EPP did not address the services the facility would be able to provide in an emergency or the patient population that would be at risk in the event of an emergency. During an interview on 11/21/24 at 3:17 PM, the Administrator noted level one risk patients were identified. When asked how many levels, the Administrator responded three and confirmed level two and three were not identified in the plan. When asked what services the facility would be able to provide, the Administrator stated he/she could look to see if that was recorded in the EPP, but he/she was not aware of any services being identified.”

“Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies and procedures were reviewed every two years. This failure had the potential to negatively affect the current eight patients and/or staff in the facility in the event of an emergency. Findings include: During a review of the facility EPP on 11/21/24 at 3:10 PM with the Administrator, the policies showed the last review date was August of 2020 and no documentation was found to show the EPP had been reviewed since 2020. During an interview on 11/21/24 at 3:25 PM, the Administrator stated, “I don’t have a document [that shows] that it is reviewed [every two years].””

“Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the subsistence needs of food, water, and pharmaceuticals for the patients and staff in an emergency event, the alternate energy sources to maintain the temperatures and lighting, or a plan for sewage and waste disposal in an emergency event. This failure had the potential to affect the current eight patients receiving care from the hospice facility. Findings include: During a review of the facility’s EPP on 11/21/24 at 3:10 PM with the Administrator, it was revealed there was no policy or procedure regarding food and pharmaceutical subsistence needs of patients and staff; a policy/procedure regarding alternate energy sources for maintaining temperature and lights for their patients, or a policy/procedure regarding the removal of waste and sewage. During an interview on 11/21/24 at 3:39 PM, the Administrator pointed out the EPP (page 2.1.4) stated, “Patients will be responsible for replenishing their own medications and related supplies.” and on page 2.1.5, “The Agency will work with supply vendors, local home medical equipment companies, local hospitals and/or the Red Cross to replenish medical supplies and non-medical supplies, including subsistence needs (e.g., food, water, clothing and shelter)” but confirmed no plan/procedure/policy was in place for ensuring the needs would be met for subsistence needs, alternate energy sources, or the disposal of waste and sewage in an emergent event.”

“Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the provision of means for staff to provide care in an emergency event. This failure had the potential to affect the current eight patients receiving care in the facility and any outpatients that receiving care in the facility. Findings include: During a review of the facility’s EPP on 11/21/24 at 3:10 PM with the Administrator, it was revealed there was no policy or procedure regarding the facility provision of personal protective equipment (PPE) or means of decontamination of equipment taken into patient’s home for the provision of safe care for the patients and to ensure staff protection during an emergency event. During an interview on 11/21/24 at 3:46 PM, the Administrator stated “We can order PPE to provide to them” but confirmed that the plan did not contain any plan or procedure regarding the provision of PPE to staff or any method for disinfection of equipment used with multiple patients.”

“Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed a system of tracking for staff and patients during an emergent event. This failure had the potential to affect the current eight patients receiving care from the facility and/or facility staff. Findings include: During a review of the facility’s EPP on 11/21/24 at 3:10 PM with the Administrator, no tracking system was identified in the emergency plan. During an interview on 11/21/24 at 3:53 PM, the Administrator stated, “I do not have a specific plan. I can print a report for level one, two, and three [patient assistance required levels] but no tracking [plan].””

“Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed procedures for sheltering in place for staff, patients, and/or visitors present during an emergency event. This failure had the potential to affect the current eight patients receiving care from the facility. Findings include: During a review of the facility’s EPP on 11/21/24 at 3:10 PM with the Administrator, no policy or procedures regarding the sheltering in place for anyone in the facility during an emergent event was noted. During an interview on 11/21/24 at 3:55 PM regarding procedures for sheltering in place, the Administrator stated, “It is not defined.””

“Based on interview and review of the facility Emergency Operations Plan, also known as Emergency Preparedness Plan (EPP), the facility failed to include the role of the facility if a waiver was declared in accordance with section 1135 of the Social Security Act. This failure had the potential to affect the eight patients receiving care and services from the organization and hindered the organization’s ability to provide care and services and keep patients safe during an emergency Findings include: Review of the facility’s EPP Communication Plan with the Administrator on 11/21/24 at 3:10 PM did not reveal any policy or procedure regarding the role of the facility if the Health and Human Services Secretary should declare a section 1135 waiver. During an interview on 11/21/24 at 4:00 PM, the Administrator confirmed the EPP did not address an 1135 waiver stating, “It’s not showing anything.””

“Based on interview and review of the facility’s Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP), the Hospice failed to maintain a current list of names and contact information in the “Emergency Preparedness Communication Plan” that included other hospice facilities. This failure had the potential to affect the eight patients receiving care from the facility and could delay the facility’s ability to respond to an emergency. This failure had the potential to affect the eight patients receiving care and services from the facility. Findings include: Review of the facility’s EPP Communication Plan on 11/21/24 at 3:10 PM with the Administrator revealed no other hospice names or contact information was included in the plan. In an interview on 11/21/24 at 4:06 PM, the Administrator confirmed no other hospice contact information was identified, stating, “I have not included that.””

“Based on interview and review of the facility’s documentation, the facility failed to ensure the Emergency Operations Plan, also known as the Emergency Preparedness (EP) training and testing program had a documented review and update every two years. This failure had the potential to affect the staff and eight patients currently receiving care and services from the hospice facility in an emergency event. Findings Include: Review of the facility’s Emergency Preparedness (EP) on 11/21/24 at 3:10 PM did not reveal documentation that the EP training and testing, based on the emergency plan from the all hazards risk assessment, was reviewed and updated (as necessary) every two years, with all training being dated August of 2020. In an interview on 11/21/24 at 4:22 PM regarding review and revision of the training and testing program, the Administrator stated, “No, not updated in the past two years.””

“Based on interview and review of the facility’s documentation, the facility failed to ensure the Emergency Operations Plan, also known as the Emergency Preparedness Plan (EPP) documented a community based full scale exercises to test the EPP; or the documentation of facility efforts to identify a full-scale community-based exercise. This failure had the potential to affect the eight current patients receiving care and services from the hospice; staff, volunteers, or visitors in the facility in an emergent event Findings include: Review of the facility’s EPP on 11/21/24 at 3:10 PM with the Administrator did not reveal any documentation of the facility participation in, or documented attempts to identify a community based exercise every two years. The exercises contained in the facility EP were for a “Table Top Drill or Exercise” regarding a fire emergency on 09/20/24 with a “Drill/Exercise Evaluation Form” that stated it was a “Full Scale Emergency Drill.” Along with the emergency exercise information was documentation of EP training occurring on the same date, 09/20/24. During an interview on 11/21/24 at 4:25 PM, the Administrator confirmed the full scale and the tabletop exercises were the same scenario and completed the same day.”

“Based on interview, record review, and policy review, the Hospice Agency failed to ensure that medications for managing symptoms of insomnia, agitation, anxiety, and pain were ordered and available for two of nine patients (Patient (P) 1, and P2) active sampled patients out of a total sample of 13. This deficient practice had the potential to cause distressing symptoms to both patients Findings include: 1. Review of P1’s “Plan of Care Order,” dated 09/11/24 and found in P1’s Electronic Medical Record (EMR) under the “Care Plan” tab, indicated that P1 was admitted to hospice with a primary diagnosis of senile degeneration of the brain with comorbidities of dementia, anxiety disorder, major depressive disorder, and pain. Review of P1’s “LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse) – Skilled Nursing Visit,” dated 09/18/24 and found in P1’s EMR under the “Nursing” tab, indicated that P1 was disoriented, had difficulty coping, had sleep disturbance, was moody, and got mad easily due to confusion. Review of P1’s “RN (Registered Nurse) – Skilled Nursing Visit,” dated 09/24/24 and found in P1’s EMR under the “Nursing” tab, indicated that P1 had difficulty coping, sleep was interrupted, would be awake at night, and would be resistive to care. Review of P1s “LPN/LVN – Skilled Nursing Visit,” dated 10/02/24 and found in P1’s EMR under the “Nursing” tab, indicated that P1 had difficulty coping, got upset easily, and was an elopement risk and was trying to escape from the group home at times. Review of P1’s “RN – Skilled Nursing Visits,” dated 10/08/24 and 10/22/24 and found in P1’s EMR under the “Nursing” tab, indicated that P1 had difficulty coping, sleep was interrupted at night and would wake in the middle of the night and would be resistive to following direction. Review of P1’s “RN – Skilled Nursing Visit,” dated 11/05/24 and 11/13/24 and found in P1’s EMR under the “Nursing” tab, indicated that when P1 was anxious, he/she would walk around the group home with no direction. Review of P1’s “Medications List,” found in P1’s EMR under the “Orders” tab, indicated that the patient was not ordered comfort medications to manage his/her symptoms of anxiety, agitation, and insomnia. 2. Review of P2’s “RN Initial Assessment,” dated 11/04/24 and found in P2’s EMR under the “Nursing” tab, indicated that a non-verbal pain assessment was performed by the RN, and the RN documented that P2 was “vocal (sighs, gasps, moans, groans, cries) and restless (constant or intermittent shifting of position, rocking, inability to keep still).” The RN documented a PAINAD (pain assessment used for patients with advanced dementia) scoring of five, indicating a medium intensity of pain for P2. Review of P2’s “Medications List,” found in P2’s EMR under the “Orders” tab, indicated that the patient was not ordered any medication for pain management. During an interview on 11/22/24 at 12:30 PM, RN 1 confirmed that comfort medications were not ordered and were not available for P1’s symptoms of anxiety, agitation, and insomnia. RN1 confirmed there were no medications ordered to help control P2’s pain symptoms. Review of the agency’s policy titled, “Medication Monitoring,” revised August 2020, indicated, “. . . A Registered nurse reviews all of the patients prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy on an ongoing basis. This review is done in collaboration with other IDG (Interdisciplinary Group) members which may include a physician, and/or pharmacist during the IDG meeting and whenever needed. This review includes, but is not limited to . . . The need for pharmacological or non-pharmacological interventions for pain and other symptom management as applicable to the patient . . .””

“Based on record review and interview, the facility failed to ensure a cardiopulmonary resuscitation (CPR) directive had a licensed healthcare provider signature required to ensure the form was valid and would be followed by emergency medical service personnel for one of thirteen patients (Patient (P) 2) reviewed. This failure had the potential to adversely affect the patient by not having their expressed medical directives followed. Findings include: Review of P2’s electronic medical record (EMR) showed an admission date of 11/04/24. During a home visit on 11/20/24 at 3:30 PM, P2’s Hospice chart in the home was reviewed and an orange paper “Pre-Hospital Medical Care Directive (Do Not Resuscitate),” form date 03/18, showed P2’s representative signed on 11/04/24. Toward the lower half of the page the form stated:”Signature of Doctor or other Health Care Provider” and a section for “Signature of Witness to My Directive.” Both areas were without a signature or notary public validation. Review of P2’s EMR on 11/21/24 showed the form had a physician signature in the section for “Information about My Doctor and Hospice” but not on the physician line. Upon request of a DNR blank form, the form was noted to have a date of 01/2023 and showed “Signature of Doctor or Other Health Care Provider (Required).” During an interview on 11/21/24 at 11:00 AM, the Administrator stated the form was signed by the physician, and he/she emailed a copy to the owner of the facility where P2 resided. He/she confirmed that the signed sheet should be in P2’s chart. He/she stated an unsigned form was considered to not be valid. Review of the facility policy titled “Do Not Resuscitate (DNR),” revised August 2020, revealed:”Policy Hospice will obtain current orders regarding resuscitation from patient’s physician and proceed according to patient’s wishes and applicable laws and regulations.” Review of the Arizona State website (https://www.azdhs.gov/documents/preparedness/emergency-medical-services-trauma-system/DNR/dnr-who-can-sign.pdf) showed: “A.R.S. 36-3251 (Prehospital medical care directives; form; effect; immunity; definitions) empowers EMS providers to honor the medical care directives of qualified individuals who have completed all required fields of the prehospital medical care directive as prescribed in that statute. Along with other required information, the form must be signed by the patient/patient’s qualified representative, one witness, and a licensed health care provider. A question was raised about who qualifies as a “Licensed Health Care Provider” and is able to sign the prehospital medical care directive form. Per A.R.S. § 36-3201 (7), the following classes of licensed health care practitioner are able to advise the patient on the impact of signing the form and are also able to sign the form: -Arizona Licensed Practical Nurse, -Arizona Registered Nurse, -Arizona Nurse Practitioner, -Arizona Licensed Medical Doctor, -Arizona Licensed Doctor of Osteopathy, -Arizona Licensed Physician Assistant.””

“Based on interview, record review, and policy review, the Hospice Agency failed to ensure that medications listed on the hospice agencys medication list were the same medications listed on the group homes medication list for one of 13 patients (Patient (P) 2) whose medications were reviewed out of a total sample of 13. This had the potential to cause P2 to suffer adverse drug events. Findings include: During a review of P2’s “Medication Administration Record (MAR),” in P2’s group home and for the month of November 2024, revealed that the patient was being given Eliquis (a blood thinner) 5 milligram (mg) tablets twice a day for deep vein thrombosis (a blood clot in a vein deep within the body) and escitalopram (Lexapro, an antidepressant) 20 mg tablet once a day for depression. Review of P2’s “Medication List,” dated 11/04/24 and found in P2’s Electronic Medical Record (EMR) under the “Orders” tab, indicated that Eliquis and escitalopram were not listed on the hospice agencys medication list. During an interview on 11/20/24 at 10:15 AM, Registered Nurse (RN) 1 confirmed that the Eliquis and escitalopram medications listed on the group homes MAR were not listed on the hospice agencys medication list. RN1 confirmed that a correct medication reconciliation had not been performed by the hospice nursing staff during the first three weeks of the month of November. Review of the agencys policy titled, “Medication Monitoring,” dated August 2020, indicated, “. . . A Registered nurse reviews all of the patients prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy on an ongoing basis . . .””

“Based on record review, interview, and policy review, the facility failed to ensure an initial bereavement assessment was completed for three of thirteen patients (Patient (P) 4, P5, and P8) reviewed. This failure had the potential for significant negative effects on the families of deceased patients, including increased risk of mental health issues from the difficulty of coping with grief such as depression and/or anxiety, and a lack of support following a death could potentially impact their well-being. Findings include: 1. Review of a 08/29/24 “RN [Registered Nurse] Initial Assessment,” from the electronic medical record (EMR), revealed P4 was admitted on that date with a terminal diagnosis of senile degeneration of the brain. Review of the 09/02/24 “MSW [Masters in Social Work] Assessment” did not address bereavement. Review of the 09/02/24 “Chaplain/Counselor Assessment” did not address bereavement. Further review of the EMR did not show that an initial bereavement assessment had been completed. During an interview on 11/21/24 at 10:30 AM, the MSW stated he/she was not responsible for the bereavement assessment and that it was done by the Chaplain. 2. Review of P5’s printed “Face Sheet” showed a hospice admission date of 08/01/24 with a terminal diagnosis of senile degeneration of the brain. Review of P5’s EMR “Chaplain/Counselor” tab showed a “Bereavement Assessment” with a target date of 08/02/24 was not yet completed. 3. Review of P8’s printed “Face Sheet” showed a hospice admission date of 03/07/24 with a terminal diagnosis of senile degeneration of the brain. Review of P8’s EMR “Chaplain/Counselor” tab for the first period of the hospice admission (03/07/24 – 06/04/24) showed no bereavement assessment was completed. During an interview on 11/21/24 at 2:50 PM, the Chaplain confirmed the initial bereavement assessment should be completed in the first five days after admission and documented in the patient’s record. Review of the facility policy titled “Bereavement Services,” revised August 2020, revealed:” . . . Procedure . . . 2. An initial Bereavement Risk Assessment will be performed as a part of theComprehensive Assessment. Depending on the initial assessment, a plan of care will bedeveloped to include specific counseling to patient and family members to be providedby the Social Worker, Chaplain or Bereavement Counselor . . .””

“Based on interview, record review, and policy review, the Hospice Agency failed to ensure that care plans for all patient problems were created for three of nine (Patient (P) 2, P10, and P13) active sampled patients out of a total sample of 13. This deficient practice had the potential to affect the patients quality of life. Findings include: 1. Review of P2’s “RN (Registered Nurse) Initial Assessment,” dated 11/04/24 and found in P2’s Electronic Medical Record (EMR) under the “Nursing” tab, indicated that a non-verbal pain assessment was performed by the RN, and the RN had documented that P2 was “vocal (sighs, gasps, moans, groans, cries) and restless (constant or intermittent shifting of position, rocking, inability to keep still).” The RN documented a PAINAD (pain assessment used for patients with advanced dementia) score of five for P2, indicating medium intensity of pain. Review of P2’s “Plan of Care Order,” dated 11/04/24 and found in P2’s EMR under the “Care Plan” tab, indicated no care plan was started to include pain management interventions. 2. Review of P10’s “RN – Skilled Nursing Visits,” dated 11/05/24, 11/07/24, 11/13/24, and 11/19/24 and found in P9’s EMR under the “Nursing” tab, indicated that P10 had a “pressure injury on buttocks.” Review of P10’s “Physician Order,” dated 11/14/24 and found in P10’s EMR under the “Orders” tab, indicated wound care orders for dressing changes for a right second toe wound. Review of P10’s “Plan of Care Order,” dated 10/01/24 and found in P10’s EMR under the “Care Plan” tab, indicated no update to the care plan was completed to include interventions for wound care/skin integrity. 3. Review of P13’s “RN – Skilled Nursing Visits,” dated 10/15/24, 10/23/24, 10/29/24, 11/09/24, 11/12/24, and 11/19/24 and found in P13’s EMR under the “Nursing” tab, indicated that P13 had shortness of breath when walking more than 20 feet, climbing stairs, and with agitation. Review of P13’s “Plan of Care Order,” dated 10/11/24 and found in P13’s EMR under the “Care Plan” tab, indicated no update to the care plan was completed to include interventions for shortness of breath. During an interview on 11/22/24 at 12:30 PM, RN1 confirmed that a care plan was not started for P2’s pain symptoms, that the care plan was not updated for P10’s wound care, and that the care plan was not updated for P13’s shortness of breath. Review of the agencys policy titled “Initial Assessment/Comprehensive Assessment,” revised August 2020, indicated “. . . The comprehensive assessment will include data elements that allow for measurement of outcomes. Hospice will measure and document data in the same way for all patients. The data elements will take into consideration aspects of care related to Hospice and palliation . . . The data elements for each patient will be used in individual patient care planning and in the coordination of services . . .””

“Based on interview, record review, and policy review, the Hospice Agency failed to perform complete pain assessments for four of nine (Patient (P) 1, P2, P9 and P13) active sampled patients out of a total sample of 13. This deficient practice had the potential to affect the patients quality of life. Findings include: 1. Review of P1’s “LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse) – Skilled Nursing Visits,” dated 09/18/24, 10/30/24 and found in P1’s Electronic Medical Record (EMR) under the “Nursing” tab, indicated no documentation that a pain assessment was performed. Review of P1’s “RN (Registered Nurse) – Skilled Nursing Visits,” dated 09/24/24, 10/08/24 and 10/22/24 and found in P1’s EMR under the “Nursing” tab, indicated no documentation that a pain assessment was performed. 2. Review of P2’s “RN – Skilled Nursing Visit,” dated 11/12/24 and found in P2’s EMR under the “Nursing” tab, indicated no documentation that a pain assessment was performed. 3. Review of P9’s “RN – Skilled Nursing Visits,” dated 10/14/24, 11/5/24, 11/7/24, 11/13/24 and 11/19/24 and found in P9’s EMR under the “Nursing” tab, indicated no documentation that a pain assessment was performed. 4. Review of P13’s “RN – Skilled Nursing Visit,” dated 10/15/24 and found in P13’s EMR under the “Nursing” tab, indicated no documentation that a pain assessment was performed. During an interview on 11/22/24 at 12:30 PM, RN 1 confirmed that pain assessments were not performed at all skilled nursing visits for P1, P2, P9, and P13. Review of the agency’s policy titled, “Pain Assessment and Reassessment,” revised August 2020, indicated, “. . . Each patient will have pain reassessed on an ongoing basis using established criteria including: Location. Intensity (using pain rating scale). Duration. Frequency, Character, eg., dull, throbbing, aching, sharp, etc. Current pain therapy or treatment, effectiveness of current therapy or treatments . . .””

“Based on interview, document review, and policy review, the Hospice Agency failed to ensure that a Performance Improvement Project was completed for 2023 and 2024 based on the results of the agency’s quality monitoring. This deficient practice had the potential to adversely affect all eight patients receiving care from the agency. Findings include: Review of the agency’s QAPI documentation, found in the “Quality Assurance” binder, revealed no started or completed performance improvement projects for 2023 and 2024. During an interview on 11/19/24 at 4:40 PM, the Administrator confirmed that performance improvement projects were not started or completed for 2023 and 2024. Review of the agency’s policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised August 2020, indicated “. . . The number and scope of the performance improvement projects conducted annually by [the agency] will be based on the needs of the population as well as internal needs. [The agency’s] performance improvement projects will reflect the scope, complexity and past performance of the services and operations. [The agency] will document the performance improvement projects, the reasons for conducting the projects and measure the progress achieved . . .””

“Based on observation, interview, policy review, and the Heathecareers website review, the Hospice Agency failed to ensure that standard precautions were maintained during and after direct patient care for two of three patients (Patient (P) 2 and P3) observed during home visits out of a total sample of 13. This deficient practice had the potential to adversely affect all eight patients receiving care from the hospice agency. Findings include: 1. During an observation of a home care visit for P2, performed on 11/20/24 at 10:10 AM, Registered Nurse (RN) 1 placed a nursing bag on a soiled countertop/breakfast bar located in the kitchen where patients eat without first placing a barrier down. During an interview on 11/20/24 at 10:15 AM, RN1 confirmed that he/she failed to use a plastic bag as a barrier before placing the nursing bag on the counter. Review of the agency’s policy titled, “Nursing Bag Technique,” revised August 2020, indicated, “. . . 1. Before entering the home, make sure the bag is stocked with bacteriostatic foam/liquid/gel and plastic trash bags (preferably in a side pocket). 2. Upon entering the home, place the bag on a clean surface. Paper towels or a plastic bag may be used to create a clean area . . .” Review of the Healthecareers website at https://www.healthecareers.com/nurse-resources/nursing-patient-care/proper-bag-technique indicated, “. . . Once in the patients home, select a clean, flat, hard surface to place bag and set up work area . . . (Note: Use a barrier under bag to help prevent the transmission of infections, McGoldrick, 2009) . . .” 2. During a home visit on 11/20/24 at 3:40 PM, RN2 removed a blood pressure cuff, oxygen saturation oximeter, and stethoscope from her personal bag and used the equipment to assess P3’s vital signs and listen to her abdomen. RN2 then put the equipment back into her bag without cleaning it. During an interview on 11/20/24 at 4:12 PM regarding the disinfection of the equipment between use on patients, RN2 stated he/she cleaned them off in the car with baby wipes. When asked if the baby wipes had an Environmental Protection Agency (EPA) registration number for disinfection, RN2 responded, “No” and stated the facility did not provide disinfectant wipes. During an interview on 11/21/24 at 10:05 AM regarding the provision of disinfectant wipes for staff to ensure equipment used with different patients, the Administrator stated they had wipes for employees and took me to the storage area where no disinfectant wipes were located. Review of the facility policy titled “Standard Precautions,” revised August 2020, did not address disinfection of equipment. Review of the Centers for Disease Control (CDC) website (https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html)”4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices...4.b. Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions. . . .””

“Based on interview, record review, and policy review, the facility failed to ensure one of thirteen patients (Patient (P) 12) had physician’s orders for medications being administered. This failure had the potential to cause confusion related to the resident’s care needs. Findings include: Review of P12’s electronic medical record (EMR) showed an admission date to the hospice of 04/13/24. Review of P12’s EMR “RN [Registered Nurse] Skilled Nursing Visit” for 10/24/24 showed in the section “Assessment / Instruction / Performance” was written “. . . [P12’s name] is awake, lying in bed, watching TV. [He/she] still has on and off SOB [shortness of breath], oxygen still at 4L/NC [Liters per Nasal Canula] . . .” Review of P12’s 10/31/24, 11/07/24, and 11/14/24 “RN Skilled Nursing Visit” notes revealed the nurse wrote “. . . [He/she] has on and off SOB, oxygen at 4L/NC . . .” Review of P12’s printed “Medication Profile” did not show an order for oxygen. During an interview on 11/21/24 at 1:23 PM, the Administrator confirmed the oxygen being used was not on P12’s physician’s orders and stated, “Oxygen should be on the orders if continuous, well, even for PRN [as needed] oxygen.” Review of the facility policy titled, “Physician Orders,” revised August 2020, revealed, “Policy Nursing and other services that require a physician’s order will be provided in accordance with a physician’s order . . . Procedure 1. The IDG [Interdisciplinary Group] plan of care is established in consultation with the physician, Medical Director, Hospice staff, the patient and members of the patient’s family. The plan of care may include: ...-Medications and treatments -Equipment and supplies required, e.g. enteral and IV [intravenous] pumps and settings, oxygen including flow rate, delivery device, hours of use, . . . 5. Drugs and treatments are administered by staff only as ordered by physician . . . 7. Orders are verified when: -There are questions or discrepancies with orders . . .” Review of the facility policy titled, “Standards of Practice,” revised August 2020, revealed:”. . . Procedure . . . 2. Hospice staff will provide care, treatment and services to each patient according to the IDG plan of care and physician orders.””