Hope International Hospice, Inc.

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] program) regarding Patient Rights was met as follows: The hospice agency (HA) failed to ensure the patient/family has the right to lodge their complaints or grievance to be investigated by the hospice, document, and inform the complainant of the result or resolution of the complaint for one of 14 sample patients (Patient 1). This deficient practice resulted in the violation of patient’s rights for the hospice’s inability to respond immediately to their grievances/complaint presented and no documented evidence the quality-of-care issues was addressed and resolved for further treatment and intervention. Refer to L505. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Patient Rights to ensure patients’ rights are not violated and the highest quality of care are provided to patients certified to receive the hospice care benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process of the Patient) was met as follows. a. the hospice agency nursing staff failed to ensure a completed pressure wound assessment was conducted that included the location, stage, size, tunneling (a wound that’s progressed to form passageways underneath the surface of the skin), undermining (the region underneath the overlying loose skin around a pressure ulcer), peri-wound description, exudates (drainage), color, odor, necrotic (dead) tissue, and granulation (a wound progressing from the inflammatory phase of healing to the proliferative phase of healing) for two of 14 sampled patients (Patient 1 and Patient 11). (Refer to L524). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care were being provided to patients certified to receive the Medicare hospice benefits. Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The hospice agency nursing staff failed to ensure a completed pressure wound assessment was conducted that included the location, stage, size, tunneling (a wound that’s progressed to form passageways underneath the surface of the skin), undermining (the region underneath the overlying loose skin around a pressure ulcer), peri-wound description, exudates (drainage), color, odor, necrotic (dead) tissue, and granulation (a wound progressing from the inflammatory phase of healing to the proliferative phase of healing) for two of 14 sampled patients (Patient 1 and Patient 11). This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient’s discomfort and or pain. (Refer to L524) 2. The hospice agency failed to maintain an accurate, current medication profile for three of 14 sampled patients (Patient 3, Patient 8, and Patient 9). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. (Refer to L530) These systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based on observation, interview and record review, the Hospice Agency (HA- agency providing care to terminally ill patients who have six months or less to live] failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities] program) for IDG (Interdisciplinary group- which is a team of professionals that work together to provide holistic care for hospice patients that consists of a doctor, registered nurse, social worker, counselor and patients family and primary caregiver) Care Planning, and Coordination of Services was met as follows: Based on observation and record review, the HA’s Registered Nurse 3 (RN) and License Vocational Nurse 1 (LVN) failed to coordinate care by ensuring to notify physician promptly of change of wound status in order to provide proper wound care treatment for two newly identified Stage III pressure ulcers for one of 14 sampled patients (Patient 1). (Refer to L556). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation IDG, Care Planning, and Coordination of Services to ensure Patient 1 received the quality of hospice care. 1. The hospice nursing staff failed to provide service as indicated in the plan of care (POC) for one of 14 sampled patients (Patient 9). For Patient 9, the hospice skilled nurse failed to irrigate patients foley catheter (or urinary catheter, a hollow tube inserted into the bladder to drain or collect urine) as ordered. This deficient practice has the potential Patient 9s foley catheter become blocked with debris and urine sediments leading to a buildup of urine in the bladder, causing discomfort, potential bladder damage, and increased risk of urinary tract infection (UTI- an infection in the bladder/urinary tract). (Refer to L543) 2. The hospice agency nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) was notified and the notification was documented when ordered home visit service was missed for one out of 14 sampled patients (Patient 9). This failure had the potential to result in patients end of life care needs not being met. (Refer to L554) 3. The hospice agency failed to ensure ordered hospice aide service was provided in accordance with the plan of care for one of 14 sampled patients (Patient 9). This failure had the potential to negatively affect the patients’ physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. (Refer to L555) 4. The hospice skilled nurses failed to coordinate care by ensuring to notify physician promptly of change of wound status in order to provide proper wound care treatment for two newly identified Stage III pressure ulcers (Full-thickness loss of skin. Dead and black tissue may be visible) for one of 14 sampled patients (Patient 1). This deficient practice placed the patients wounds at risk for slow healing process. (Refer to L556) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Federal, State, Local Laws and Regulations as follows: The Hospice Agency (HA, agency that gives special care to people who are near the end of life and have stopped treatment to cure or control their diseases) failed to disclose sharing the hospice agency’s space/suite/location licensed and certified by the Department with another entity/agency at the same space/suite/location. This failure had resulted in the violation of the Federal and State laws and regulations. (Refer to L799). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with federal regulations for Federal, State, Local Laws and Regulations to ensure healthcare organizations must meet the requirements to participate in federal healthcare programs.”

“Based on interview and record review, the hospice agency (HA) failed to ensure the patient/family has the right to lodge their complaints or grievance to be investigated by the hospice, document, and inform the complainant of the result or resolution of the complaint for one of 14 sample patients (Patient 1). Patient 1’s family member (FM 1) complained about Patient 1’s open wound at sacral (triangular shaped bone located at the base of the lumbar vertebrae) area that became worst and not being promptly treated by the hospice visiting nurses. This deficient practice resulted in the violation of patient’s rights for the hospice’s inability to respond immediately to their grievances/complaint presented and the quality-of-care issues was not be addressed and resolved for further treatment and intervention. On 11/5/2024, at 11 a.m., a complaint validation survey was conducted at the home health agency (HHA) regarding Patient 1’s open wound at sacral (triangular bone at the base of the spine) area that became worst and not being treated accordingly by hospice visiting nurses. A review of Patient 1’s Face Sheet (admission record) indicated the Patient 1 was admitted for hospice care on 5/13/2024. The diagnosis included unspecified malignant neoplasm of anus (a rare cancer that develops in the tissues of the anus). During a review of Patient 1’s Registered Nurse (RN) Visit Note dated 5/29/2024, indicated Patient 1 had developed a right heel blister (fluid filled swelling) measuring 3 centimeters (cm) in length by 5 cm in width by 4 cm in depth, with no drainage and with black color. Patient 1 also had a sacro-coccyx (triangular bone-tailbone) excoriation measuring 4 cm in length by 3 cm in width, with no drainage or odor. During a review of Patient 1’s Plan of Care (POC, the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 6/7/2024, indicated an order for RN to provide skilled nursing (SN) visits of once a week, License Vocational Nurse (LVN) to provide SN visits of once a week, to assess skin integrity and changes in wound status, to perform observations of all physical systems and pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. The SN intervention was to provide wound care treatment as follows: Right heel Blister- to cleanse with Normal Saline, pat dry, cover with Tegaderm to unruptured blister as needed, may apply Triple antibiotic ointment and cover with dry dressing, secure with tape daily if blister is ruptured, Sacro-coccyx excoriation- to cleanse with Normal Saline, pat dry, apply anti-bacterial skin care with Aloe Vera, Vitamin A&D Alantoin cream, cover with dry dressing and secure with tape daily. During a review of Patient 1’s LVN Visit Note dated 10/4/2024, indicated Patient 1 had a Stage 3 (a full thickness pressure ulcer that extends through the skin and into the fat tissue but does not reach muscle, tendon, or bone) right heel of foot pressure ulcer measuring 3 centimeters (cm) in length by 3 cm in width with no drainage and a Stage 3 sacrum pressure ulcer with no wound size measurement provided and no drainage or odor. During a review of Patient 1’s Communication Log dated 10/22/2024, indicated that FM 1 reported to the HA complaining that Patient 1’s was not receiving proper wound care for her worsening wounds and asked the hospice facility staff for Patient 1 to be transferred to a skilled nursing facility. During an interview on 11/5/2024, at 2 p.m., with the Director of Patient Care Services (DPCS) stated, Patient 1’s family was complaining regarding poor wound care treatment provided by the hospice visiting nurse. DPCS further stated that FM 1 filed a grievance, but the agency failed to document the complaint in their grievance book in order to find a resolution to the issue as per their agencys policy. During a review of the agencys policy and procedure titled, “;Grievances and Complaints”, revised 7/14/2023, indicated at the time of admission, and as needed, patient/client and/or family/caregiver shall be informed of their rights to voice grievances regarding treatment or care, lack of respect of property, or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal. Grievances received from a patient/client and/or family/caregiver will be promptly reported to Office Leadership/Designee for assessment determination.”

“Based on interview and record review, the hospice nursing staff failed to ensure a comprehensive wound assessment was conducted that included the location, stage, size, tunneling (a wound that’s progressed to form passageways underneath the surface of the skin), undermining (the region underneath the overlying loose skin around a pressure ulcer), peri-wound description, exudates (drainage), color, odor, necrotic (dead) tissue, and granulation (a wound progressing from the inflammatory phase of healing to the proliferative phase of healing) for two of 14 sampled patients (Patient 1 and Patient 11). This deficient practice had the potential to result in the delayed provision of wound treatment that could lead to infection and deterioration of the wound causing patient’s discomfort and or pain. Findings: During a review of Patient 11’s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 3/3/2023, with a terminal diagnosis of chronic systolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Patient 11’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 9/13/2024, the POC/IDG Review form indicated the frequency of visits of the licensed vocational nurse (LVN) to one visit per week plus 1 prn (or pro re nata, which means “;as needed”) visits to assess and monitor effectiveness of medications, to assess safety concerns and issues, to assess alteration in skin integrity every visit, and to assess changes in wound status – check size, integrity, location, type, stage, signs and symptoms of infection, drainage, effectiveness of current treatment. During a review of Patients 11s Visit Note RN (registered nurse) record, dated 9/13/2024 and conducted by RN 2, the visit note RN indicated Patient 11 had pressure Ulcer/injury stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the buttocks. There was no documented evidence a completed wound assessment was conducted of the stage 2 pressure ulcer identifying the size, tunneling, undermining, integrity, signs and symptoms of infection, and drainage. During a phone interview of RN 2, on 11/7/2024 at 4:19 p.m., RN 2 stated she assessed a stage 2 pressure ulcer on Patient 11s left upper thigh closed to the patients left buttock on her visit on 9/13/2024. RN 2 stated she assessed and measure the wound but was unable to provide an explanation why there was no documented evidence a completed wound assessment was conducted on her visit on 9/13/2024. During a concurrent interview and record review, on 11/8/2024 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 11s Visit Note RN dated 9/13/2024. The DPCS stated that she was not able to find documented evidence Patient 11 stage 2 pressure injury was assessed with the size measurement, and wound status on 9/13/2024. The DPCS stated the patient’s wound should have been assessed completely which includes wound size, color, drainage and signs of infection. a. A review of Patient 1’s Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 5/13/2024, with a diagnosis that included unspecified malignant neoplasm of anus (a rare cancer that develops in the tissues of the anus). During a review of Patient 1’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 6/7/202024, the POC/IDG Review form indicated the frequency of visits of the licensed vocational nurse (LVN) to one visit per week plus 1 prn (or pro re nata, which means “;as needed”) visits to assess and monitor effectiveness of medications, to assess safety concerns and issues, to assess alteration in skin integrity every visit, and to assess changes in wound status – check size, integrity, location, type, stage, signs and symptoms of infection, drainage, effectiveness of current treatment. One of the SN intervention was to provide wound care to Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) sacrum area (radiation burn) as follows: to cleanse with Normal Saline, skin care with Aloe Vera, Vitamin A&D Alantoin cream to sacrum area daily. During a review of Patients 1s Visit Note LVN dated 5/4, 5/24, 5/31/24, 6/7, 6/14,6/26/24, 7/10, 7/19, 7/26/24, 8/9, 8/16, 8/23, 8/30/24, 9/6, 9/27/24, /2024, , /2029/13/2024, indicated Patient 1 had a Stage II pressure Ulcer/injury stage 2 on sacrum area. There was no documented evidence a completed wound assessment was conducted of the stage 2 pressure ulcer identifying the size, tunneling, undermining, integrity, signs and symptoms of infection, and drainage. An attempt to review the HA’s wound management policy on 11/8/2024, at 1 p.m., but the DPCS could not provide any policy on file. During an interview with the DPCS, she stated the HA does not have any copy of the wound management policy at this time. The DPCS further stated the patient’s wound should have been assessed completely which includes wound size, color, drainage and signs of infection.”

“Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate and current medication profile for three of 14 sampled patients (Patient 3, Patient 8, and Patient 9). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions (harmful, unintended result caused by taking medication). b. During a review of Patient 8s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 7/31/2024 with a terminal diagnosis of other specified chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Patient 8’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 10/11/2024, the POC/IDG Review form indicated the frequency of visits of the registered nurse (RN) and the licensed vocational nurse (LVN) to one visit per week plus 1 prn (or pro re nata, which means “;as needed”) visits to assess and monitor effectiveness of medications, and to instruct patient/patient caregiver (pcg) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines). During a joint home visit, on 11/6/2024 at 1:55 p.m. with the registered nurse (RN 1) at Patient 8s residence, Patient 8 was observed sitting on a sofa, awake, alert, disoriented and confused, accompanied by a family member (FM 3). During a review of Patient 8s current medication, on 11/6/2024 at 2:10 p.m., with FM 3, a bottle of Robitussin DM (medication to relieve cough) 10 milliliters (ml, a unit of measurement) oral every 4 hours as needed for cough and congestion, and Bactrim DS (medication that can treat or prevent infections) 20 ml oral twice daily for 7 days could not be found. However, the patients current medication profile list provided by the HA indicated patient was still taking these medications. During an interview with FM 1, she stated Patient 8 was not taking these medications for a couple of months. c. During a review of Patient 9s face sheet, the face sheet indicated a SOC date of 4/24/2020 with a terminal diagnosis of Alzheimers Disease, unspecified (a disease characterized by a progressive decline in mental abilities). During a review of Patient 9’s POC/IDG Review form dated 10/11/2024, the POC/IDG Review form indicated the frequency of visit of the licensed vocational nurse to one visit per week plus 1 prn visit to administer medication as per physicians (md) order, assess and monitor effectiveness/side effects of medications, and to instruct patient/pcg regarding new medication/treatment order and side effects. During a joint home visit, on 11/6/2024 at 1:00 p.m. with the RN 1 at Patient 9s residence, Patient 9 was observed lying in a hospital bed, asleep but arousable, accompanied by a family member (FM 2). During a review of Patient 9s current medication, on 11/6/2024 at 1:18 p.m., with FM 2, a bottle of Roxanol 20mg/ml concentrated solution (medication indicated for pain and shortness of breath) and Ativan 0.5 mg tablet give 1 tablet sublingual (is placed underneath the tongue) every 4 hours as needed for agitation/restlessness could not be found. However, the patients current medication profile list provided by the HA indicated Patient 9 was still taking these medications. During an interview with FM 2, she stated she could not remember the last time Patient 9 took these medications. During an interview on 11/8/2024 at 11:15 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated the HA nursing staff reconcile medications once a month only. The DPCS stated there will be an increased risk of medication errors if medication reconciliation was not being conducted frequently or on every nurses visit. During a review of the hospice agencys policy and procedure (P&P) titled, Medication Profile dated October 2014, the P&P indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. During a review of Patient 3s Patient Information Sheet, the Patient Information sheet indicated Patient 3s start of care (SOC) date was 10/24/2024, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis (outcome) and no known cure) of unspecified heart failure ( a medical condition where the heart is unable to pump enough blood to meet the body’s needs). During a review of Patient 3’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 11/5/2024, the POC/IDG indicated the frequency of visits of Licensed Vocational Nurse (LVN, in general) to one visit per week plus one prn (as needed) visits to administer and monitor the effectiveness of medication, and to instruct the patient caregiver (PCG) regarding prescribed medication and side effects (are unwanted undesirable effects). There were physician’s order that was included in the POC as follows: a. to administer Zolpidem 5 milligrams (mg) one tab at bedtime as needed for insomnia. b. Tramadol 100 mg 2 tabs twice daily for pain management. During a joint home visit conducted with the RN 4 on 11/7/2024, at 11:30 a.m., at Patient 3’s home, Patient 3 was observed lying in bed, well groomed and sleeping. During a review of Patient 3’s current medication at home on 11/7/2024, at 12:20 p.m., with RN 4, there was a bottle of Tramadol 50 mg one tab as needed every 6 to 8 hours for pain and a bottle of Zolpidem 10 mg one tab as needed for insomnia. During an interview on 11/7/2024, at 12:45 p.m., with Family Member 2 (family member), when she was asked if the visiting nurse checks patient 3’s medication during their visits, she stated the visiting nurse does not check the actual bottle but will just asked if there were any new medications that arrived. During an interview on 11/8/2024, at 1:35 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse needed to review patients current medication on every visit and update the medication profile in the patients clinical record. During a review of the hospice agencys undated policy and procedure titled, “;Medication Profile,” indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.”

“Based on observation, interview, and record review, the hospice nursing staff failed to provide nursing services as indicated in the plan of care (POC) for one of 14 sampled patients with a Foley catheter (Patient 9). For Patient 9, the hospice skilled nurse failed to irrigate patients Foley catheter (or urinary catheter, a hollow tube inserted into the bladder to drain or collect urine) as ordered on the POC. This deficient practice has the potential to result in pooling of the urine (collection of urine in the bladder indicating the urine is not draining properly due to blockage) causing the patient to manifest pain, discomfort, and/or signs/symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Patient 9s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 4/24/2020 with a terminal diagnosis of Alzheimers Disease, unspecified (a disease characterized by a progressive decline in mental abilities). During a review of Patient 9’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) dated 10/11/2024, the indicated the frequency of visits of the skilled nurse (SN) to one visit per week plus 1 prn (or pro re nata, which means “;as needed”) visit, and the hospice aide to three times a week. Social worker (MSW) and the chaplain (SC) service was declined. A POC titled, Genitourinary (refers to organs that are responsible for reproduction and the elimination of waste products through urine), indicated Patient 9 has a Foley catheter. The goal indicated that patient will be free of complications of catheter use and free from signs and symptoms of UTI. The care plan interventions included to irrigate catheter with 60 cubic centimeters (cc -unit of volume) of normal saline (a saltwater solution) two times a week to reduce the risk of clogging. During a joint home visit, on 11/6/2024 at 1 p.m., with the RN 1 at Patient 9s residence, Patient 9 was observed lying in a hospital bed, asleep but arousable, and had a Foley catheter attached to a urinary drainage bag with dark yellow urine. During this visit it was observed RN 1 did not irrigate Patient 9s Foley catheter. During a review of Patient 9s Visit Note RN form, dated 10/3/2024, 10/17/2024, 10/24/2024, and 10/31/2024, indicated no documented evidence Patient 9s Foley catheter was irrigated or flushed with 60 cc of normal saline by the skilled nurse each visit. During an interview on 11/8/2024 at 11:15 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated and confirmed there was no documented evidence Patient 9s Foley catheter was irrigated with 60 cc of normal saline twice a week in accordance with the plan of care. The DPCS stated the hospice SN should irrigate patients catheter as ordered during each home visit to prevent clogging that could lead to UTI. During a review of the agency’s policy and procedure (P&P) titled, The Plan of Care, revised October 2014, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on interview and record review, the hospice agency (HA) nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) was notified and the notification was documented when ordered home visit service was missed for one out of 14 sampled patients (Patient 9). This failure had the potential to result in patients end of life care needs not being met. Findings: During a review of Patient 9s face sheet (front page of the chart that contains a summary of basic information about the patient) indicated a start of care (SOC) date of 4/24/2020 with a terminal diagnosis of Alzheimers Disease, unspecified (a disease characterized by a progressive decline in mental abilities). During a review of Patient 9’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 10/11/2024, the POC/IDG Review form indicated the frequency of visit of the licensed vocational nurse to one visit per week plus 1 prn (or pro re nata, which means “;as needed”) visit to assess/monitor changes in neurological (refers to the nervous system, which includes the brain, spinal cord, and peripheral nerves) status, to monitor skin, to assess and monitor effectiveness/side effects of medications, and to instruct patient caregiver (PCG) regarding safe environment at home. During a review of Patient 9s skilled nurse History of Visit Notes indicated that there was skilled nurse (SN) missed visit note documented on 10/22/2024 and 10/29/2024. During a further review of Patient 9s clinical record indicated there was no documented evidence that the skilled nursing staff had coordinated with the IDG about the missed visits on 10/22/2024 and 10/29/2024 in accordance with the agencys policy and procedure. During a concurrent interview and record review, on 11/8/2024 at 11:15 a.m., with the Director of Patient Care Services (DPCS) of Patient 9s SN missed visit notes dated 10/22/2024 and 10/29/2024, DPCS stated the visiting skilled nurse did not notify the HA or IDG about the missed visits. DPCS stated the HA only became aware two weeks after the missed visits. The DPCS stated for any missed visits, IDG should be notified promptly by the field nurses and notification should be documented in the patients records. During a review of the agencys policy and procedure (P&P) titled, Communication with Office dated December 2008, the P&P indicated clinicians will contact the office daily to confirm their schedules and caseload and receive reports on patients. Clinicians will communicate with the office to verify that all planned visits for the day were made.”

“Based on interview and record review, the hospice agency (HA) failed to ensure ordered hospice aide service was provided in accordance with the plan of care (POC) for one of 14 sampled patients (Patient 9). This failure had the potential to negatively affect the patients’ physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. Findings: During a review of Patient 9s face sheet (front page of the chart that contains a summary of basic information about the patient) indicated a start of care (SOC) date of 4/24/2020 with a terminal diagnosis of Alzheimers Disease, unspecified (a disease characterized by a progressive decline in mental abilities). During a review of Patient 9’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 9/27/2024, the POC/IDG Review form indicated the frequency of visits of the skilled nurse (SN) to one visit per week plus 1 prn (or pro re nata, which means “;as needed”) visit, and the hospice aide to three times a week. Social worker (MSW) and the chaplain (SC) service was declined. During a review of Patient 9s History of Hospice Aide Visits form, the hospice aide visit form indicated that for the week starting on 9/29/2024 (Sunday) and ending on 10/5/2024 (Saturday), there was no hospice aide visits that were conducted for Patient 9. During an interview, on 11/8/2024 at 11:15 a.m., with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency’s policy and procedure (P&P) titled, The Plan of Care, revised October 2014, the P&P indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on interview and record review, the Registered Nurse 4 (RN) and License Vocational Nurse 1 (LVN) failed to notify the physician promptly of patient’s significant change of wound status for one of 14 sampled patients (Patient 1). This deficient practice placed the patient’s wounds at risk for delayed treatment and intervention resulting to the decline of the wounds and healing process. On 11/5/2024, at 11 a.m., a complaint validation survey was conducted at the home health agency (HHA) regarding Patient 1’s open wound at sacral area that became worst and not being treated accordingly by hospice visiting nurses. A review of Patient 1’s Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 1 on 5/13/2024, with a diagnosis that included unspecified malignant neoplasm of anus (a rare cancer that develops in the tissues of the anus). During a review of Patient 1’s Communication Log dated 10/22/2024, indicated that FM 1 reported to the HA complaining that Patient 1’s was not receiving proper wound care for her worsening wounds and asked to be transferred to a skilled nursing facility. During a review of Patient 1’s Registered Nurse (RN) Visit Note dated 5/29/2024, indicated Patient 1 had developed a right heel blister measuring 3 centimeters (cm) in length by 5 cm in width by 4 cm in depth, with no drainage, and a sacro-coccyx excoriation measuring 4 cm in length by 3 cm in width, with no drainage or odor. During a review of Patient 1’s Plan of Care (POC, the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 6/7/2024, the POC indicated an order for RN to provide skilled nursing (SN) visits of once a week, License Vocational Nurse (LVN) to provide SN visits of once a week, to assess skin integrity and changes in wound status, to perform observations of all physical systems and pain each shift and as needed and report all adverse (bad) changes to the physician/RN supervisor/Caregiver. The SN intervention was to provide wound care as follows: Right heel Blister- to cleanse with Normal Saline, pat dry, cover with Tegaderm to unruptured blister as needed, may apply Triple antibiotic ointment and cover with dry dressing, secure with tape daily if blister is ruptured, Sacro-coccyx excoriation- to cleanse with Normal Saline, pat dry, apply anti-bacterial skin care wih Aloe Vera, Vitamin A&D Alantoin cream, cover with dry dressing and secure with tape daily. During a review of Patient 1’s LVN Visit Note dated 10/4/2024, indicated Patient 1 had developed a Stage 3 right heel pressure ulcer (full thickness skin loss that extends into the subcutaneous tissue) measuring 3 centimeters (cm) in length by 3 cm in width with no drainage. LVN 1 provided wound treatment to Stage 3 right heel pressure ulcer as follows: cleansed wound with Normal Saline, patted dry, applied Triple antibiotic ointment and covered with dry dressing, secured with tape; Patient 1 also developed a Stage 3 sacrum pressure ulcer with no wound size measurement provided, no drainage or odor. LVN 1 provided wound treatment to Stage 3 sacrum pressure ulcer as follows: cleansed the wound with Normal Saline, patted dry, applied anti-bacterial skin care with Aloe Vera, Vitamin A&D Alantoin cream, covered with dry dressing and secured with tape. There was no documented evidence the physician was notified of Patient 1’s Stage III right heel and sacrum pressure ulcers to obtain wound treatment orders. During a review of Patient 1’s Wound Specialist Progress Report dated 10/9/2024, indicated Patient had a Stage III sacro-coccyx pressure ulcer measuring 3.3 cm in length by 3.02 cm in width by 0.2 cm in depth with serosanguineous drainage and a Stage III right heel pressure sore measuring 1.6 cm in length by 1.48 cm in width by 0.3 cm in depth with serosanguineous drainage and wound debridement on both wounds were performed. During a review of Patient 1’s physician’s orders dated 10/16/2024, indicated the following wound treatment orders for both Stage III right heel and sacrum pressure sores as follows: to cleanse wound with wound cleanser, pat dry, apply Tetracyte (topical antibiotic) to wound bed, followed by collagen and oil emulsion gauze, then cover with foam with silicone bordered dressing three times weekly. During a review of Patient 1’s LVN Visit Note dated 10/16/2024, indicated LVN 1 started the new wound treatment ordered for the Stage III right heel and sacrum area, 12 days after these wounds were identified. During an interview on 11/7/2024, at 2 p.m., with the Medical Director (MD), he stated he was aware of Patient 1’s Stage III right heel and sacrum pressure ulcers but since Patient 1’s under radiation and chemotherapy treatments, Patient 1’s wounds would continue to get worsen, therefore, the HA’s goal was not to do aggressive wound treatments but only to provide comfort measures. MD also stated Patient 1’s wounds were still treated with prescribed Triple antibiotics ointment to prevent the wound to get infected. MD further stated the HA had arranged a wound specialist visit on 10/9/2024, to evaluate the patient’s wound condition. During an interview on 11/8/2024, with LVN 1, she stated she called and notified the physician on 10/4/2024, but she did not document it in her nursing notes. LVN 1 also stated that she provided new wound treatment orders on Patient 1’s Stage III right heel and sacrum pressure sores on 10/16/2024. During an interview on 11/8/2024, at 1 p.m., with the Director Of Patient Care services (DPCS), when asked why the visiting nurse did not notify the physician regarding Patient 1’s change of wound status and the delay to obtain new wound treatment orders, DPCS stated the HA requested a wound specialist visit to evaluate patient’s wound first and waited until the wound specialist recommends new treatment order for Patient 1’s Stage III pressure sores. DPCS also agreed that the physician should have been notified right away to obtain proper wound treatment for Patient 1’s Stage III wounds. A review of the HAs undated policy and procedure “ Coordination of Care with Contract Agreement”, indicated the hospice program will retain responsibility for evaluating services, maintaining professional management responsibility, and ensuring continuity of care in all settings through its performance improvement program or corporate compliance program.”

“Based on observation, interview and record review, the Hospice Agency (HA, agency that gives special care to people who are near the end of life and have stopped treatment to cure or control their diseases) failed to disclose sharing the hospice agency’s space/suite/location licensed and certified by the Department with another entity/agency at the same space/suite/location. This failure had resulted in the violation of the Federal and State laws and regulations. An unannounced complaint validation survey visit was conducted on 11/5/2024, at 11:00 a.m., at this proposed approved location, 20705 South Western Avenue, Suite 112, Torrance, CA 90501. On 11/5/2024, at 1 p.m., during a facility tour and interview with the Director of Patient Care Services (DPCS), HA was observed to be sharing the suite with another business entity identified to be a home caregiver agency (Hope International Homecare, Incorporated). Both entities had one entrance door in Suite 212, with a posted sign for Hope International Homecare, Inc. Inside the office location, there was one receptionist and reception area right by the entrance shared by these two entities. There were 6 office rooms occupied by office staff located in the middle space of the office which belonged to the HA. The front area space by the reception area next to the entrance door was occupied by staff that belonged to the caregiver agency. A review of a copy of the City of Los Angeles Tax Registration Certificate (business permit) with a date issued as active since 1/16/2024, indicated that this permit was issued to Hope International Hospice Inc and Hope International Homecare, Inc at this address: 20705 South Western Avenue, suite 112, Torrance, CA 90501. On 11/5/2024, at 2 p.m., during an interview with the DPCS, stated she both owned the HA and homecare agency, and she was using the space in the front lobby to house for the Caregiver agency. The DPCS also stated that she agreed the HA should only be the only existing business entity under their license. The DPCS further stated that they have separate staff, and they dont share patients information of the two agencies and observe patients privacy of their health records. A review of the HHAs undated policy “;Professional Advisory Committee”, indicated the committee will establish and review policies and procedures and oversee regulatory compliance in the following areas: -compliance with law and regulation.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatment that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure the drug profile contained the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of Alzheimer’s disease. The patient resided at a skilled nursing facility (SNF). During the home visit observation with the Hospice Aide (HA) (Personnel Record 7), a review of the patient’s medications was completed by comparing the hospice medication profile with the SNF medication administration record. The hospice medication profile contained the following medications not listed on the SNF medication administration record: Albuterol Sulfate inhaler every 2 hours as needed dated 11/18/2023 and DuoNeb every 4 hours as needed 11/18/2023. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 04/05/2024 for the diagnosis of heart failure. The patient resided at a SNF. During the home visit observation, a review of the patient’s medications was completed by comparing the hospice medication profile with the SNF medication administration record. The SNF medication administration record contained the following supplements not listed on the hospice medication profile: Glucerna with meals dated 01/30/2024 and Ensure twice daily dated 05/18/2024. During an interview and joint record review on 05/31/2024, the Alternate Administrator/Director of Patient Care Services confirmed the medication profiles had not been reconciled.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 6 of 9 (67%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) provided written patient care instructions for the hospice aide. Clinical Record 2: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of Alzheimer’s disease. The initial nursing assessment dated 11/18/2023 included documentation that the patient had “Stage IV wound to the Sacro coccyx area covered with foam dressings.” The hospice aide care plan dated 11/18/2023 assigned the aide the tasks of bathing via shower chair, peri care, visualize condition of skin and report to RN every visit. The aide care plan did not include notification to the aide of the patient’s wound and did not provide instructions for how to care for the wound and wound dressing while providing care to the patient. Clinical Record 5: The patient elected the hospice benefit on 05/13/2024 for the diagnosis of malignant neoplasm of the anus. The initial nursing assessment dated 05/13/2024 included documentation that the patient had a “Stage II wound to rectum.” The hospice aide care plan dated 05/13/2024 assigned the aide the tasks of bathing via bed bath, peri care, visualize condition of skin and report to RN every visit. The aide care plan did not include notification to the aide of the patient’s wound and did not provide instructions for how to care for the wound and wound dressing while providing care to the patient. Clinical Record 7: The patient elected the hospice benefit on 05/07/2024 for the diagnosis of liver disease. The initial nursing assessment dated 05/07/2024 included documentation that the patient had a “pressure ulcer left buttock.” The hospice aide care plan dated 05/07/2024 assigned the aide the tasks of bathing via bed bath, peri care, visualize condition of skin and report to RN every visit. The aide care plan did not include notification to the aide of the patient’s wound and did not provide instructions for how to care for the wound and wound dressing while providing care to the patient. Clinical Record 8: The patient elected the hospice benefit on 04/17/2024 for the diagnosis of Alzheimer’s disease. The nursing assessment dated 05/07/2024 included documentation of a physician’s order for wound care to a “Stage II pressure ulcer to left buttocks, cover with gauze.” The hospice aide care plan dated 04/28/2024 assigned that aide the tasks of bathing via bed bath, peri care, visualize condition of skin and report to RN every visit. The aide care plan did not include notification to the aide of the patient’s wound and did not provide instructions for how to care for the wound and wound dressing while providing care to the patient. Clinical Record 9: The patient elected the hospice benefit on 04/27/2024 for the diagnosis of chronic respiratory failure with hypoxia. The initial nursing assessment dated 04/27/2024 included documentation that the patient was on 2 liters per minute of oxygen continuously. The hospice aide care plan dated 04/27/2027 assigned the aide the tasks of bathing via shower chair, shampooing the hair, and dressing the patient, and listed the patient’s mental status as confused. The aide care plan did not include specific instructions for the use of oxygen during assigned tasks. Clinical Record 14: The patient elected the hospice benefit on 05/05/2024 for the diagnosis of malignant neoplasm of sigmoid colon. The initial nursing assessment dated 05/05/2024 included documentation that the patient had a “Stage III coccyx wound covered with gauze and that the patient was on Keppra for seizures.” The hospice aide care plan dated 05/05/2024 assigned the aide the tasks of bathing via bed bath, peri care, visualize condition of skin and report to RN every visit. The aide care plan did not include notification to the aide of the patient’s wound and did not provide instructions for how to care for the wound and wound dressing while providing care to the patient and did not notify the aide that the patient was on seizure precautions. During an interview and joint record review on 05/30/2024, the Alternate Administrator/Director of Patient Care Services confirmed specific instructions for the wounds and continuous oxygen had not been added to the aide care plans.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and observation. In 1 of 9 (11%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services included in the plan of care. Clinical Record 13: The patient elected the hospice benefit on 01/25/2024 for the diagnosis of heart failure. The hospice aide care plan dated 01/25/2025 assigned the aide the task of providing a shower for the patient. The hospice aide visit note dated 02/27/2024 included documentation that the aide provided a bed bath to the patient. During an interview and joint record review on 05/30/2024, the Alternate Administrator/Director of Patient Care Services confirmed the aide did not follow the plan of care.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed with a recertification of terminal illness required, the agency did not ensure the recertification of the terminal illness included the Medical Director or physician designee’s review of the patient’s clinical information. Clinical Record 2: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of Alzheimer’s disease. The recertification of terminal illness narratives for benefit periods 4, 5, and 6 included the same narrative, “98-year-old [patient] with end-stage Alzheimer’s Dementia. [Patient] is 100% bed-bound and dependent on ADL [activities of daily living] 6/6. This patient requires hospice supportive care.” The recertification of terminal illness did not include documentation that the physician reviewed the patient’s clinical information. During an interview and joint record review on 05/30/2024, the Alternate Administrator/Director of Patient Care Services and the Medical Director discussed this with the Associate Medical Director who would need to compose the narrative after review of the clinical information.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient revoked hospice care or was discharged for no longer being terminally ill, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient elected the hospice benefit on 04/15/2023 for the diagnosis of malignant neoplasm of the bronchus or lung. The patient was discharged for extended prognosis on 10/11/2023. The clinical record contained no documented evidence the discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: The patient elected the hospice benefit on 01/03/2024 for the diagnosis of malignant neoplasm of the breast. The patient revoked the hospice benefit on 01/29/2024. The clinical record contained no documented evidence the discharge summary was forwarded to the patient’s attending physician. During an interview and joint record review on 05/30/2024, the Alternate Administrator/Director of Patient Care Services confirmed the discharge summaries had not been forwarded or faxed to attending physician(s) receiving the patients for care after the patient’s discharge from the hospice.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF [skilled nursing facility/nursing facility]. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient resided in a SNF/NF, the agency did not ensure the written plan of care was established and maintained in consultation with the SNF/NF. Clinical Record 2: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of Alzheimer’s disease. The patient resided in a SNF/NF. There was no documented evidence in the clinical record that the patient’s written plan of care was established and maintained in consultation with the SNF/NF. Clinical Record 3: The patient elected the hospice benefit on 04/05/2024 for the diagnosis of heart failure. The patient resided in a SNF/NF. There was no documented evidence in the clinical record that the patient’s written plan of care was established and maintained in consultation with the SNF/NF. During an interview and joint record review on 05/30/2024, the Alternate Administrator/Director of Patient Care Services confirmed a written plan of care established in coordination with the SNF/NF had not been included in the clinical record.”