Advantage Hospice Providers, Inc.

“Based on interview and record review, the agency failed to implement an alternate office or command post site to ensure business operations will continue during an actual emergency, which is necessary for supporting the care continuation, in a universe of 9 patients, when staff members provided differing information regarding the agency’s Emergency Preparedness Plan for the designated alternate office site during emergency event. This failure had the potential to disrupt the agencys ability to maintain continuous care, placing the agency’s patients at risk, and compromising their safety and quality of care during an emergency event. Findings: During an interview with a License Vocational Nurse 1 (LVN 1), on June 18, 2024, at 8:45 AM, LVN 1 stated she received Inservice material for Emergency Preparedness Plan last night. She also stated that she does not remember being told where the alternate office site will be during emergency. LVN 1 further stated she does not know where the alternative office site was to get more instruction during an emergency event. During an interview with a Hospice Aid 1 (HA 1), on June 18, 2024, at 10:45 AM, HA 1 stated she was not sure when the agencys Emergency Preparedness Plan in-services was given. She further stated it might have been 2 months ago, around April 2024. She further stated she was not sure where the alternate office site was to get more instruction during an emergency event. During an interview with Director of Patient Care Services (DPCS), on June 18, 2024, at 12:40 PM, the DPCS 1 stated the last time the agencys Emergency Preparedness Plan in-services was provided to the staff was sometime last month which is in May 2024. She further stated she was not sure where the alternate office site was during an emergency, but her guess was maybe in the parking area outside the agency office. During a concurrent interview and record review, on June 21, 2024, at 2:10 PM, with the Administrator (Admin), the Admin reviewed the agencys policy and procedure (P&P) titled, “;Emergency Management Plan,” revised April 26, 2024, which indicated, “;... Emergency Preparedness/disaster recall tree in the event that the agency or its surrounding obtain in any natural disaster or fire, the office staff will meet with field staff to reconcile all informations and patients condition in the 1st Command Post: PARKING LOT OF [name of local store 1] 8850 FOOTHILL BLVD., RANCHO CUCAMONGA (4.1 miles) 2No Command Post: PARKING LOT OF [name of local store 2] AT: 1333 N Mountain Ave, Ontario, CA 91762 ( 1.8 miles)3rd Command Post : Administrator’s Home : 7224 Birch Tree Place, Fontana, CA 92336...” The Admin stated she and the agency consultant were responsible for the agencys Emergency Preparedness Plan and confirmed that she did not have documentation to show the alternate office site/command post had been provided to all staff to maintain essential functions during emergency even. Furthermore, she stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to ensure patient records were readily available to provide adequate support and maintain continuity of care during an emergency, when the agencys emergency prepared policy and procedure did not contain the patient roster. This failure had the potential for the agency to not be able to adequately assess and address the needs of patient to implement immediate intervention during emergencies, putting 9 patients safety and well-being at risk during emergency event. Findings: A review of the agency’s “Emergency Preparedness Program Binder,” from March 1, 2023, to June 21, 2024, was conducted. The agencys Emergency Preparedness Program Binder did not contain the patient roster, which should be readily available to provide adequate support and maintain continuity of care during an emergency. During an interview on June 21, 2024, at 1:00 PM, with the Administrator (Admin), the Admin stated she and the agency consultant were responsible for the agencys emergency preparedness plan, which includes updating patient roster. The Admin emphasized the importance of having the patient roster readily available was to provide adequate support and maintain continuity of care during emergency events. The Admin was not able to provide an explanation as to why the patient roster had not been updated. A concurrent interview and record review on June 21, 2024, at 2:30 PM, was conducted with the Admin. The Admin reviewed of the agency’s undated policy and procedure (P&P) titled, “ Emergency Preparedness Plan,” revised April 26, 2024, which indicated, “;...Purpose. The purpose of this Emergency Operations Plan is to provide planning, training and establish preparedness to respond to the effects of potential emergencies whether they are manmade or natural disasters... Policy... B. Agency will utilize an Emergency Preparedness Plan in the event a situation occurs that could potentially affect the needs for its services or its ability to provide those services... Procedures... 6. Patient Triage. a. Agency will maintain a current list of patients categorized into groups based on services provided to the patient by the agency, need for continuity of services being provided, and availability of someone to assume responsibility for a patient’s emergency response plan if needed by the patient...” The Admin stated that she was not aware the updated patient roster needed to be maintained as per the agencys P&P. The Admin further stated that the agency did not follow the policy.”

“Based on interviews and record reviews, the agency failed to implement an alternate communication method to ensure continued communication with staff and with Federal, State, tribal, regional, and local emergency management agencies during an actual emergency. Staff members not able provided information regarding the agency’s Emergency Preparedness Plan for alternate communication methods during emergency events. This failure had the potential to prevent the agency from adequately communicating patient needs to implement immediate interventions and maintain continuous care during emergencies with staff and with Federal, State, tribal, regional, and local emergency management agencies. This put the safety and well-being of 9 patients at risk during emergency events. Findings: During an interview with a License Vocational Nurse 1 (LVN 1), on June 18, 2024, at 8:55 AM, LVN 1 stated she received In-service material for Emergency Preparedness Plan last night but was not informed about the alternate communication methods for emergencies. LVN 1 further stated that she does not know how to communicate patient needs when primary communication methods are unavailable during emergency events.During an interview with a Hospice Aid 1 (HA 1), on June 18, 2024, at 10:50 AM, HA 1 stated she was not sure when the agencys Emergency Preparedness Plan in-services was given and stated it might have been 2 months ago, around April 2024. LVN 1 further stated that she does not know how to communicate patient needs when primary communication methods are unavailable during emergency events. During an interview with Director of Patient Care Services (DPCS), on June 18, 2024, at 12:45 PM, the DPCS 1 stated the last time the agencys Emergency Preparedness Plan in-services was provided to the staff was sometime last month which is in May 2024. She further stated she was not sure what is the alternate communication methods required to communicate patient needs when primary communication methods are unavailable during emergency events. During a concurrent interview and record review, on June 21, 2024, at 1:10 PM, with the Administrator (Admin), the Admin reviewed the agencys policy and procedure (P&P) titled, “;Emergency Management Plan,” revised April 26, 2024, which indicated, “;... Clinical staff will communicate with means available. If the primary modes of communication with phone or cellphone fails, other methods may be used; a. Texting. Text if you can, instead of calling, to conserve battery power and minimize congestion on cell networks, the Federal Communications Commission recommends.b. Satellites phones. c. Internet technologies, email or. d. CB radios or HAM radios, if available. Cell phones and radios were information lifelines for many, so backup power systems and car phone chargers should also be part of any emergency kit. Local radio and / or television stations will be contacted by the Agency as a method of communicating with the patient population and staff, as appropriate. If no means of communication is available, then all staff members who can safely travel to report to the office if operational or alternate site if office is not operational for assignments. The use of Thomas Guide map as to substitute for Wi-Fi GPS navigation to locate patient or staff, if power or network failed...” The Admin stated she and the agency consultant were responsible for the agencys Emergency Preparedness Plan and confirmed that she did not have documentation to show the alternate communication methods had been provided to all staff to maintain essential functions during emergency event. Furthermore, she stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to ensure a medication reconciliation (define) was conducted during the initial and recertification assessment for two of nine sampled patients (Patients 1 and 3) when: For Patient 1: Two medications the patient was taking were not on the Medication Profile (MP-a current list of all medications prescribed for a specific patient), and one medication was found past expiration date available to use. For Patient 3: One medication the patient was taking were not on MP, and one medication was on the MP medication was not available.These failures had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), , indicated a start of care date of March 11, 2024 with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of June 9, 2024 to August 7, 2024. Patient 1 had diagnoses that included chronic kidney disease (a long-term condition where the kidneys do not work as well as they should). During a home visit on June 18, 2024, with Licensed Vocational Nurse 1 (LVN 1) and in the presence of Patient 1 and Patient 1s wife, an observation of Patient 1s actual medication bottles, available in the home, were compared with Patient 1s most current MP. During a concurrent observation and interview on June 18, 2024, at 9:35 AM, with LVN 1, LVN 1 checked a bottle of Vitamin D3 (supplement) 50 mcg (microgram-a unit of measure) 2,0000 IU (international units-a unit of measure) one tablet by mouth daily. LVN 1 reviewed Patient 1s MP, which had no indication of the order of Vitamin D-3 Vitamin D-3 was not Patient 1s MP. During an interview on June 18, 2024, at 9:40 AM, with Patients 1 wife, Patient 1 wife stated, “;He had been taking Vitamin D-3 since in the beginning of starting hospice. Hes doctor is aware of it.” During a concurrent observation and interview on June 18, 2024, at 9:45 AM, with LVN 1, LVN 1 checked a bottle of Areds 2 (eye vitamin and mineral supplement) one tablet by mouth daily. Patient 1s MP has no indication of the order of Areds 2 one tablet by mouth daily. LVN 1 reviewed Patient 1s MP, which had no indication of the order of Areds 2 was not on Patient 1 MP. During an interview on June 18, 2024, at 9:50 AM, with Patient 1 wife, Patient 1 wife stated, “;He had been taking Areds 2 since in the beginning of starting home health. Hes doctor is aware of it. During a concurrent observation and interview on June 18, 2024, at 9:55 AM, with LVN 1, LVN 1 checked a tube of lidocaine ointment (prescription anesthetic cream) 5% (unit of measurement) apply moderate amount twice a day for pain. Patient 1s MP has no indication of the order of lidocaine ointment apply moderate amount twice a day for pain. LVN 1 reviewed Patient 1s MP, which had no indication of the order of lidocaine ointment was not on Patient 1 MP. During further observation on June 18, 2024, at 10:00 AM, with LVN 1, indicated the lidocaine ointment expiration date was March 2023. LVN 1 verified Patient 1s tube of lidocaine ointment 15 months had passed the expiration day and available to use for Patient 1. 2. A review of Patient 3s face sheet, indicated a start of care date of April 25, 2024 with a certification period of April 25, 2024 to July 23, 2024. Patient 1 had diagnoses that included malignant neoplasm of tonsil (a type of head and neck cancer [disease in which some of the body’s cells grow uncontrollably]) During a home visit on June 18, 2024, at 1:10 PM with Director of Patient Care Services and in the presence of Patient 3 and Patient 3s medication technician, an observation of Patient 3s actual medications available in the home were compared with Patient 3s most current MP. During a concurrent observation and interview on June 18, 2024, at 1:10 PM, with DPCS, DPCS checked a medication box of levothyroxine (medications called hormones. It works by replacing thyroid hormone that is normally produced by the body) 13 mcg (microgram-a unit of measure) one tablet by mouth in the morning. Patient 3s MP has no indication of the order of levothyroxine 13 mcg one tablet by mouth in the morning. DPCS reviewed Patient 3s MP, which had no indication of the order of levothyroxine was not on Patient 3 MP. During an interview on June 18, 2024, at 1:15 PM, with Patient 3 medication technician , she stated Patient 3 had been taking the medication since admission to assisted living facility and admission to hospice care which is May 20, 2024.” During a concurrent observation and interview on June 18, 2024, at 1:20 PM with the DPCS, the DPCS reviewed Patient 3s MP. The order indicated Mirtazapine (used to treat depression, a mental health condition) 7.5 mg (milligrams, a unit of measure) one tablet by mouth at bedtime. The DPCS verified that this medication was not available for Patient 3’s use. During a concurrent observation and interview on June 18, 2024, at 1:30 PM, with DPCS, DPCS stated, “;The printed MP should have been updated.” During an interview on June 19, 2024, at 4:36 PM, with DPCS, DPCS stated, “;It was Case Manager’s responsibility to update Medication Profile when there’s any new order or changes. Nurses should have been reviewing and updating medication profile on their visits.” During a concurrent interview and record review on June 19, 2024, at 4:36 PM, the DPCS reviewed the agencys policy and procedure (P&P) titled “;Medication Profile,” revised 2013, which indicated, “;PURPOSE To define the use of the medication profile in evaluating a patient’s current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE... 2. The admitting nurse will initiate a medication profile to document the current medication regiment... 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. ...”. The DPCS stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to ensure that the initial plan of care, which contains of physician orders, initial assessment, comprehensive assessment, and clinical notes, for one of the nine sampled patients (Patient 5), was authenticated (a method to confirm the document is reliable and legally valid) with a physicians signature and title, dated, and timed to verify its accuracy and reliability. This failure potentially affected the accurate delivery of continuing care to meet Patient 5s needs. Findings: A review of Patient 5s face sheet (a document that gives a summary of patients information), indicated a start of care date of May 10, 2024, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of May 10, 2024, to August 7, 2024. Patient 5 had diagnoses that included Parkinson disease (is a movement disorder) without dyskinesia (involuntary movements) and without mention of fluctuations (ability to move on and off. A review of Patient 5s initial plan of care dated May 10, 2024, indicated the Medical Doctor (MD- doctor of medicine; aka physician) did not sign and date the assessment. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on June 21, 2024, at 10:53 AM, the DPCS reviewed Patient 5s initial plan of care and acknowledged that it was not signed and dated by the physician. The DPCS stated it should have been signed by the physician, but it was not. During a concurrent interview and record review, with the DPCS, on June 21, 2024, at 11:20 AM, the DPCS reviewed the agencys Policy and Procedure (P&P) titled “;verification of physician order,” revised 2013, and stated that she was aware that the plan of care, including physician orders, should be signed by the MD, but she was unaware that it was supposed to be completed within 30 days of the assessment. The Admin further stated that the agency did not follow this policy to ensure that the MD signed and dated it within this timeframe. A review of the agencys P&P titled “;verification of physician order,” revised 2013, the P&P, indicated, “;PURPOSE To ensure that accurate physician (or other authorized licensed independent practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation. POLICY Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to hospice patients.... A qualified individual will review each order or prescription before care is provided. The sole exception for verification will be emergency orders or prescriptions where a verification delay would likely result in an adverse result for the patient.... Procedure. Signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed from the record...”. A review of the agencys policy and procedure (P&P) titled “;Contents of the Clinical Record,” revised 2013, indicated, “;PURPOSE To outline the requirements for and components of a clinical record. POLICY A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.””

“Based on observation, interview, and record review, the agency failed to ensure that clinical records, their contents, and the information therein were safeguarded against loss or unauthorized use; when the cabinet, where the agency kept patient clinical charts, was found unlocked. This failure had the potential to cause privacy violations, allowing unauthorized individuals to gain access to and alter patient records in universe of 9 patients. Findings: During a tour of the agency on June 20, 2024, at 12:58 PM, with the Administrator (Admin), it was observed that the cabinet, where the agency kept patient clinical records, was unlocked. The Admin was unable to find the key when asked to secure the cabinet. During a follow up interview on June 20, 2024, at 1:05 PM, with the Admin, the Admin stated that she was responsible for keeping patient clinical records safe from loss and unauthorized use. The Admin further stated that the cabinet should have been locked at all times. During a concurrent interview and record review, with the Admin, June 20, 2024, at 2:00 PM, the Admin reviewed the agencys policy and procedure (P&P) titled “;Safe Guarding/Retrieval of Clinical Records,” revised 2013, which indicated, “;PURPOSE To establish a procedure for the protection of patient clinical record information from loss or unauthorized use. POLICY Hospice will safeguard the clinical record against loss or unauthorized use. The clinical record will be safeguarded in compliance with Health Insurance Portability and Accountability Act (HIPAA) privacy requirements. PROCEDURE All patient clinical records will be maintained in locked, file cabinets in a designated clinical records room: D. The files will be locked each night. E. The clinical record room itself will be locked each night. F. The clinical record room will monitor during working hours. G. If the room must be left unattended, the door will be locked. H. Only authorized personnel will have access...”. The Admin stated the agency did not follow the policy.”