Victoria Hospice Services, Inc.

“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 (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the 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: 1.The hospice agency failed to update the comprehensive assessment of Patient 15 that included accurate head to toe skin assessment that reflected the skin abnormality in patient’s left big toe in the bunion (hallux valgus: bony bump a the base of the big toe) area for one of eight sampled patients (Patient 15). For Patient 15, the patient was at risk for poor wound healing related to diagnosis of diabetes mellitus (a disease that occurs when an individuals blood glucose, also known as blood sugar is too high). This deficient practice resulted in the delay of care and treatment of Patient 15s deep tissue injury to the left big toe that was described as having a necrotic (dead) tissue, black in color in the center area, round, and measured approximately less than five centimeters (cm) in width and length. The delay in care and treatment can lead to an infection of underlying bone, and may potentially require wound debridement and hospitalization. This deficient practice also resulted in Patient 15 experiencing pain and discomfort as observed Patient 15 moaned and retracted her left foot when Licensed Vocational Nurse 1 touched the base and center of the left medial foot (Refer to L 533). 2. The hospice agency failed to assess and refer the need for a wound care consult service that reflected the skin abnormality in patient’s left big toe in the bunion (hallux valgus: bony bump at the base of the big toe) area for one of eight sampled patients (Patient 15). This deficient practice resulted in Patient 15 was not assessed, referred, and evaluated by wound care consult service for appropriate treatment and intervention (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the hospice agency 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, Interdisciplinary group (IDG, a team responsible for the holistic care of the hospice beneficiary), Care Planning, Coordination of Services was met as follows: 1. The HA failed to ensure the IDG meetings were held by all the members of interdisciplinary group to discuss patients’ comprehensive and ongoing assessments and care planning process for six out of ten sampled patients (Patient 15, Patient 16, Patient 17, Patient 18, Patient 20, and Patient 21). This deficient practice has the potential for the progress or decline in health status not identified by the IDG, to meet Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, and Patient 21 care goals. (Refer to L541). 2. The HA failed ensure the “Comfort Kit” (a prescribed set of medications that are kept in a patient’s home in the event of an emergency) were available for one out of eight sampled patients (Patient 16). This deficient practice had the potential for Patient 16 to experienced discomfort and delayed care. (Refer to L549). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written rules or law) mandated compliance with IDG, Care Planning, Coordination of Services to ensure the highest quality of care were provided to patients assessed to receive hospice services.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Quality Assessment and Performance Improvement (QAPI, the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI)) was met as follows: 1. The HA failed to identify and ensure a COVID-19 (an acute disease caused by coronavirus, which can cause fever and cough. It also capable of progressing to severe symptoms and is some cases cause death) case was included in their 2023 quality assessment and performance improvement (QAPI, a data driven and proactive approach to quality improvements) program when one of eight sampled patients (Patient 21) was diagnosed with COVID-19. This failure resulted in the hospice agencys inability to determine and identify areas of potential problems that could affect the patients highest quality of care by not monitoring and planning for a possible COVID-19 outbreak. (Refer to L562). 2. The HA failed to ensure they collected data for their contracted services to be able to monitor, assess, and evaluate their services in their QAPI program. This failure had the potential to result in missed opportunities for improvement, which might potentially have an adverse effect on patients. (Refer to L563). 3. The HA failed to ensure COVID-19 was included in their QAPI program. This failure resulted in the hospice agencys inability to determine and identify areas of potential problems that could affect the patients highest quality of care by not monitoring and planning for a possible COVID-19 outbreak among its patients, staff, and their families. (Refer to L569). 4. The HA failed to ensure their Governing Body failed to maintain an ongoing program for quality improvement and patient safety, was defined, implemented, and maintained, and evaluated annually. This deficient practice resulted in the inability of the hospice agency to identify issues, improve health outcomes, patient safety, and quality patient care. (Refer to L574). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Federal regulation for Quality Assessment and Performance Improvement (QAPI) program to ensure the provision of the highest quality of care to patients in a safe environment.”

“Based on interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Infection Control was not met as follows: The hospice agency (HA) failed to: 1. Ensure a process for tracking and securely documenting exposure of employees and patients who were tested positive for Covid-19 (an infectious disease caused by the SARS-COV-2 virus). (Refer to L579). 2. Ensure contingency plans for employees and patients that were tested Covid-19 positive, and or patients deemed to be exposed to COVID-19 positive employee or patient (Refer to L579). 3. Have a process for ensuring that the HA continues to follow all standards of infection prevention and control practice, for reducing the transmission and spread of COVID-19 in the HA, especially by the staff who was tested positive and/or have signs and symptoms of COVID-19. (Refer to L579). 4. Ensure all agency office and field employees (who provide any care, treatment, or other services for the HA and/or its patients) were updated on their Covid-19 vaccine status (Refer to L580). 5. Develop and implement a policy and procedures to monitor employee’s exposure to COVID-19 and screening status (Refer to L580). The cumulative effects of these systemic practices resulted in the HA’s inability to ensure the provision of quality health care in a safe environment which had the potential to result in placing patients and employees at risk for spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization, and/or death.”

“Based on interview and record review, the hospice agency (HA) failed to ensure that the emergency preparedness program (EP- the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) was updated annually as indicated in the HA’s policy and procedure. This deficient practice had the potential that staffs will not be able to provide the skills and knowledge on how to respond effectively during an emergency situation. A request was made to the Administrator (Admin) to review their Emergency preparedness plan (EPP) on 2/10/2024. On concurrent record review of the hospice agency’s EPP, noted that the address of the EPP and other vital information for the agency’s emergency phone tree was still for the old address in 8797 Beverly Blvd. Suite 310 West Hollywood, Ca 90048. On 2/11/2024, at 1:30 p.m., during a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services Designee (DPCSD), Admin confirmed that the address on the EPP (Emergency preparedness plan) was the previous address of the agency. Admin further stated that the EPP was not updated for the current agency location. A review of the HA’’s policy titled, “Emergency Management Plan”, revised 10/2019 indicated, The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish an maintain an emergency preparedness program that meets those regulations. The organization will establish an all-hazards approach to emerging preparedness that focuses on identifying hazards and developing emergency preparedness capabilities. Organization leadership will conduct a hazard vulnerability analysis (HVA) to identify potential emergencies (risks) that could impact the need for services or the ability to provide care to patients. The HVA is evaluated annually to reflect changes in organization; risk conditions, patient information and changes in staff. Staff will work with regional or county emerge cy management planning agencies, where available in: A. Establishing priorities among the potential emergencies identified in the hazard vulnerability analysis B. Defining organization’s role in relation to the community-wide emergency management program and the organization’s surge capacity. A review of the HA’’s policy titled, “Emergency Management Plan: Communication Plan”, revised 10/2019 indicated, The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The plan includes the following: 1. Names and contact information for the following: A. Staff B. Entities providing services under arrangement. C. Patients’ physician D. Other Hospices E. Volunteers, if applicable 2. Contact information for the following: A. Federal, state, tribal, regional and/or lo B. Other sources of assistance 3. Primary .and alternate means for communicating with the staff, federal, State, tribal, regional and local emergency management agencies 4. A method for sharing information and medical documentation for patients under the organization’s care as necessary. 5. A means of providing information about the general condition and location of patients under the organization’s care as permitted 6. A means of informing state and local emerge cy preparedness officials before, during and after an emergency on the following: A. Patients that the organization has been able to contact to determine service needs B. Patients in need of evacuation due to their medical or behavioral health, or conditions of the home environment 7. A means of providing information about the organization’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center or designee.”

“Based on record review, the hospice agency (HA) failed to ensure the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) plan/drill for office and field staffs in-service training/drill were completed in an annual basis. This failure had the potential to result in office and field staff to lack knowledge resulting to poorly respond ineffectively when an emergency/disaster situation occur. A request was made to the Administrator (Admin) to review their emergency preparedness plan (EPP) on 2/10/2024. On concurrent record review of the hospice agency’s EPP, noted that the address of the EPP and other vital information for the agency’s emergency phone tree was still for the old address in 8797 Beverly Blvd. Suite 310 West Hollywood, Ca 90048. On 2/11/2024 at 1:30 p.m., during a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services Designee (DPCSD), Admin confirmed that the address on the EPP (Emergency preparedness plan) was the previous address of the agency. When asked if they have conducted their in-services in the new office location, Admin stated it was in the previous office. Admin further confirmed “We have not” conducted the emergency drill after the HA transferred to the new office location. On concurrent review and interview with the admin on the same date and time, Admin showed that the record indicated the address of their former office, and the phone emergency tree was for the previous office location. When asked if they updated the EPPs phone emergency contact tree, Admin stated “;No”. A review of the HA’s policy titled “ Emergency Management Plan” revised 10/2019 indicated that the training and testing program is reviewed and updated at least annually. 1. The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response role to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable. 2. The training is provided annually and demonstrates staff knowledge of emergency procedures. 3. Organization leadership will provide for orientation and annually thereafter of all personnel regarding participation in the emergency management plan. Education to include: A. Specifics of organization’s emergency management plan B. Specific assigned emergency responsible C. information on developing their family’s Emergency response plan. D. Information regarding accessing housing/ and transportation for staff if necessary: 1. All training will be documented in the personnel record of staff, individuals under arrangement and volunteers, if applicable. Testing: Victoria Hospice Services Inc will test the emergency management plan, at each site included in the plan, at least annually, either I response to an actual emergency or in a planned exercise. 2. The agency participates in a full-scale exercise that is community-based or individual, facility-based, if a community-based exercise s not accessible. A. In the event an actual natural or man-made emergency occurred, the agency will be exempt for 1 year following the onset of the actual event. 3. An additional exercise is conducted and may include, but not limited to: A. A second full-scale exercise that is com unity-based or individual facility-based, or B. A tabletop exercise led by a facilitator and included group discussion, emergency scenarios and prepared questions designed to challenge an emergency plan. Victoria Hospice Services Inc will modify the emergency management plan in response to the critiques of the exercise. The next scheduled planned exercise will evaluate the effectiveness of the improvements that were made in response to the critiques of the previous exercise. If improvements require substantive recourses that can’t be accomplished by next planned exercise, interim improvements must be put in place until final resolution. The evaluation results and proposed improvements of any exercise or actual emergency will be presented to all staff, individuals under I agreement, volunteers as applicable and the Governing Body. The evaluation may be incorporated into the organization’s QAPI (Quality Assurance and Performance Improvement-is a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level) program.”

“Based on observation, interview, and record review, the hospice agency (HA) failed to assess and refer the need for a wound care consult service that reflected the skin abnormality in patient’s left big toe in the bunion (hallux valgus: bony bump at the base of the big toe) area for one of eight sampled patients (Patient 15). This deficient practice resulted in Patient 15 was not assessed, referred, and evaluated by wound care consult service for appropriate treatment and intervention. A review of Patient 15s admission record indicated a start of care (SOC) date of 12/1/2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing – related problems), Type 2 Diabetes Mellitus (a disease that occurs when an individuals blood glucose, also known as blood sugar is too high) and Alzheimers Disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 15’s Comprehensive Nursing Assessment dated 12/1/2023, indicated in Skin Assessment Section, skin status: normal; skin turgor: poor; and wounds and skin impairment: normal. A review of Patient 15s Plan of Care (POC)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, share resources and responsibilities) clinical record, dated 12/1/2023, indicated a frequency of skilled nurse (SN) visit to once a week and one PRN (as needed) visits, for symptoms management, to assess alteration in skin integrity (health and condition of the skin) every visit and to monitor any signs of skin breakdown. On 2/8/2024 at 10:30 a.m., a joint home visit conducted with the skilled nurse/Licensed Vocational Nurse (LVN 1) at Patient 15’s residence at the assisted living facility. During a concurrent interview with LVN 1, LVN 1 stated that Patient 15 has no existing wounds, skin issues or active wound treatment orders. Patient 15 was awake and oriented to her name only and was unable to express her needs. Upon performing skin assessment on Patient 15, LVN 1 removed Patient 15s shoes and observed a skin abnormality with black centered area, round and approximately less than five centimeters (cm) in width and length with red and maroon to purplish discoloration surrounding it. The skin abnormality was observed in Patient 15’s left big toe in the bunion (hallux valgus: bony bump a the base of the big toe) area. LVN 1 stated that it was a scab (a dry, rough protective crust that forms over a cut or wound during healing) from an old, healed wound. LVN 1stated that he started to visit Patient 15 in December of 2023 and was unable to remember when it was occurred or healed. Observed Patient 15 moaned and retracted her left foot when LVN 1 touched the base and center of the skin abnormality. LVN 1 stated that there was no existing wound care treatment or wound consult order particular to the skin abnormality for Patient 15s left big toe in the bunion area. During a concurrent interview and record review on 2/9/2024, at 10:00 a.m., with the Director of Patient Care Services Designee (DPCSD), Patient 15s Comprehensive Nursing Assessment (dated 12/1/2023), Skin Impairment Assessment (dated 12/12/2023 and 2/2/2024), and skilled visit notes (dated 12/3/2023, 12/7/2023, 12/12/2023, 12/18/2023, 12/20/2023, 12/27/2023, 1/8/2024, 1/17/2024, 1/19/2024, 1/23/2024 and 2/2/2024) indicated there was no assessment regarding Patient 15s skin abnormality located at the left big toe in the bunion (hallux valgus: bony bump at the base of the big toe) area. The DPCSD stated she was unable to provide any documented evidence of Patient 15s assessment of the skin abnormality left big toe in the bunion (hallux valgus: bony bump at the base of the big toe) area. DPCSD stated that the visiting nurses should follow the patients care plan and they should have been assessed, documented, and notified responsible parties of Patient 15s closed wound. DPCSD stated that it was important to have the patients wound monitored closely to determine if needed to be treated or referred to a wound care specialist. DPCSD further stated that if a wound is left unassessed and untreated, it could result into more serious complications. A further review of Patient 15s clinical records/Physicians Orders with the DPCSD indicated there were no wound care consult orders for the skin abnormality in patient’s left big toe in the bunion area. DPCSD stated if the wound in Patient 15s left big toe in the bunion area was identified, a wound consult will be ordered by the physician to have it treated properly. A review of the hospice agencys policy and procedure titled “;Comprehensive Assessment”, revised October 2019, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information, as relevant: section G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness. A review of the hospice agencys policy and procedure titled “;Ongoing Comprehensive Assessments”, revised October 2019”, indicated that the nurse will assess the patient on each visit, for: section G. Skin integrity. A review of the hospice agency’s undated policy and procedure titled “Wound Care Management and Assessment”, indicated that the HA was committed to providing comprehensive and compassionate care to hospice patients, which includes the effective management and assessment of wounds. All hospice patients will undergo a comprehensive wound assessment upon admission and regularly thereafter as part of their ongoing care plan and the assessments would include the type, size, location and characteristics of the wounds, as well as the patient’s pain level and overall comfort.”

“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 update the comprehensive assessment of Patient 15 that included accurate head to toe skin assessment that reflected the skin abnormality in patient’s left big toe in the bunion (hallux valgus: bony bump a the base of the big toe) area for one of eight sampled patients (Patient 15). For Patient 15, the patient was at risk for poor wound healing related to diagnosis of diabetes mellitus (a disease that occurs when an individuals blood glucose, also known as blood sugar is too high). This deficient practice resulted in the delay of care and treatment of Patient 15s deep tissue injury to the left big toe that was described as having a necrotic (dead) tissue, black in color in the center area, round, and measured approximately less than five centimeters (cm) in width and length. The delay in care and treatment can lead to an infection of underlying bone, and may potentially require wound debridement and hospitalization. This deficient practice also resulted in Patient 15 experiencing pain and discomfort as observed Patient 15 moaned and retracted her left foot when Licensed Vocational Nurse 1 touched the base and center of the left medial foot. On 2/9/2024 at 1:55 p.m. the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator and the Director of Patient Care Services Designee related to the hospice agency’s failure to update the comprehensive assessment of Patient 15 that included accurate head to toe skin assessment that reflected the skin abnormality in patient’s left big toe in the bunion (hallux valgus: bony bump a the base of the big toe) area. On 2/9/2024, at 2:56 p.m., the hospice agency sent an IJ Removal Plan (the facility’s plan of action to correct the deficient practices) by email. The survey team reviewed the IJ Removal Plan and notified the Administrator, the IJ Removal Plan was not accepted on 2/9/2024 at 5:01p.m. On 2/10/2024, at 11:56 a.m., the hospice agency sent a revised IJ Removal Plan by email. The survey team reviewed the IJ Removal Plan. The survey team notified the Administrator that the revised IJ Removal Plan was not accepted on 2/10/2024 at 2:48p.m. On 2/11/2024, at 4:34 p.m., the survey team completed the survey tasks, and exited with the Immediate Jeopardy (IJ) situation not removed. A review of Patient 15s admission record indicated a start of care (SOC) date of 12/1/2023 with diagnoses which include Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing – related problems), Type 2 Diabetes Mellitus and Alzheimers Disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 15’s Comprehensive Nursing Assessment dated 12/1/2023, indicated in the Skin Assessment Section, skin status: normal, skin turgor: poor and wounds and skin impairment: normal. A review of Patient 15s Plan of Care (POC)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, share resources and responsibilities) clinical record, dated 12/1/2023, indicated a frequency of skilled nurse (SN) visit to once a week and one PRN (as needed) visits, for symptoms management, to assess alteration in skin integrity (health and condition of the skin) every visit and to monitor for any signs of skin breakdown. On 2/8/2024 at 10:30 a.m., a joint home visit was conducted with the skilled nurse/Licensed Vocational Nurse (LVN 1) at Patient 15’s residence at the assisted living facility. During a concurrent interview with LVN 1, LVN 1 stated that Patient 15 had no existing wounds, skin issues or active wound treatment orders. Patient 15 was awake and oriented to her name only and was unable to express her needs. LVN 1 was observed performing a skin assessment to Patient 15. When LVN 1 removed Patient 15s shoes, there was a skin abnormality with a necrotic (dead) tissue, black in color in the center area, round, and measured approximately less than five centimeters (cm) in width and length with red and maroon to purplish discoloration surrounding it. The skin abnormality was observed in Patient 15’s left big toe in the bunion (hallux valgus: bony bump a the base of the big toe) area. Patient 15 was observed moaning (a sign of discomfort) and retracting her left foot when LVN 1 touched the base and center of the skin abnormality. LVN 1 stated that it was a scab from an old, healed wound. LVN 1 stated that he started to visit Patient 15 in December of 2023, and was unable to remember when the old wound occurred or healed. LVN 1 stated that there was no existing wound care treatment or wound consult order for this particular skin abnormality to Patient 15s left big toe in the bunion. During an interview on 2/8/2024 at 11:30 a.m., LVN 2, who is an employee at the assisted living facility, stated that Patient 15 has no existing wounds. A review of Patient 15s Skin Impairment Assessment dated 12/12/2023, indicated Patient 15 had a left ankle wound with a scar. There was no documented evidence of a skin abnormality on Patient 15’s left big toe in the bunion (hallux valgus: bony bump at the base of the big toe) area. A review of Patient 15s Licensed Vocational Visit Note dated 12/12/2023, indicated in the section titled, Skin: left leg wound that has a scab; healing properly. A review of Patient 15s Registered Nurse (RN) Visit Note dated 12/27/2023, indicated no new skin impairment, ankle wound healing. A review of Patient 15s Registered Nurse (RN) Visit Note dated 1/8/2024, indicated the patient skin was clean, dry and intact, and no new skin impairment. A review of Patient 15s Register Nurse (RN) Visit Note dated 1/9/2024, indicated the patients skin is intact. A review of Patient 15s Skin Impairment Assessment dated 2/2/2024, indicated Patient 15s skin is intact but at high risk for pressure injury. There was no documented evidence of a skin abnormality on Patient 15’s left big toe in the bunion. A review of Patient 15s Registered Nurse (RN) Visit Note dated 2/2/2024, indicated the patients skin was intact and there was no documentation regarding a skin abnormality on Patient 15’s left big toe in the bunion. During a concurrent interview and record review on 2/9/2024, at 10:00 a.m., with the Director of Patient Care Services Designee (DPCSD), Patient 15s Comprehensive Nursing Assessment (dated 12/1/2023), Skin Impairment Assessment (dated 12/12/2023 and 2/2/2024), and skilled visit notes (dated 12/3/2023, 12/7/2023, 12/12/2023, 12/18/2023, 12/20/2023, 12/27/2023, 1/8/2024, 1/17/2024, 1/19/2024, 1/23/2024 and 2/2/2024) indicated there was no documentation regarding Patient 15s skin abnormality located at left big toe in the bunion area. The DPCSD stated she was unable to provide any documented evidence of Patient 15s assessment of the skin abnormality on the left big toe in the bunion area. The DPCSD stated that the visiting nurses should follow the patients care plan and the patient should have been assessed for signs of skin breakdown, documented, and notified the responsible parties of Patient 15s closed wound. The DPCSD stated that it is important the patients wound is monitored closely to determine if needed to be treated or referred to a wound care specialist. The DPCSD further stated that if a wound is left unassessed and untreated, it could result into more serious complications. The DPCSD stated that the agency sent a Registered Nurse on 2/9/2024 to conduct a complete assessment of Patient 15s wound in the left medial foot. During a concurrent interview and record review on 2/9/2024 at 12:15 p.m., with DPCSD of Patient 15s Skilled Visit Note Short Form dated 2/9/2024, indicated in the Narrative Section, “;RN assessment done. All vitals within normal ranges. No non-verbal cues of pain noted during the visit. Patient has previously healed wounds, first one on left foot lateral side, left ankle. Both impairments skin is intact with no s/s of infection. Patient has a new wound on the left foot medial side impairment noted r/t previous healed wound. MD updated and received wound care orders: cleanse wound with normal saline, pat it dry, apply betadine over the wound and surrounding border, and cover with border gauze; repeat daily, or PRN when dislodged. MD also ordered a wound consult for further evaluation. Teaching provided to facility staff, and supplies ordered for wound care for STAT delivery”. A review of Patient 15s Skin Impairment assessment dated 2/9/2024, indicated in the list of the current locations section “;Location Description: foot -left DTI (purple or maroon localized area of discolored intact skin or blood‐filled blister due to damage of underlying soft tissue from pressure and/or shear) scar from previous injury, Size: 2cm length/2cm width/0depth, Color: B (Black), Drainage: S (Serosanguineous-fluids collected or leaving the body), Odor: N (No). A review of the Patient 15s Wound Assessment Form dated 2/10/2024 indicated the wound bed of the patients deep tissue injury on the left foot medial hallux was covered with 100 percent (%) with eschar (dead tissue). A review of the hospice agencys policy and procedures titled, “;Comprehensive Assessment”, revised October 2019, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including at least the following information, as relevant: section G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness. A review of the hospice agencys policy and procedures titled, “;Ongoing Comprehensive Assessments”, revised October 2019”, indicated that the nurse will assess the patient on each visit, for: section G. Skin integrity. A review of the hospice agency’s policy and procedures titled, “Wound Care Management and Assessment”, undated, indicated that the HA was committed to providing comprehensive and compassionate care to hospice patients, which includes the effective management and assessment of wounds. All hospice patients will undergo a comprehensive wound assessment upon admission and regularly thereafter as part of their ongoing care plan and the assessments would include the type, size, location and characteristics of the wounds, as well as the patient’s pain level and overall comfort. A review of the Wound Source dated 2/27/2024 indicated the major complication of Deep Tissue Injury is it can lead to osteomyelitis (infection of the underlying bone) or sinus tracts. A review of the National Library of Medicine on wound debridement indicated the indications for wound debridement is the removal of devitalized tissue such as necrotic tissue or slough. When the wound has presence of necrotic tissue, it may prevent the clinician from accurately assessing the wound’s extent and severity, even masking possible underlying infection. According to the National Library of Medicine on updates on wound healing, inflammation and scarring dated August 2021, diabetes mellitus is associated to poor wound healing and the wound complications in diabetic patients, including infections, wound dehiscence, and nonhealing wounds that become chronic.”

“Based on interview, and record review the hospice agency (HA) failed to ensure the IDG meetings were held by all the members of interdisciplinary group to discuss patients’ comprehensive and ongoing assessments and care planning process for six out of ten sampled patients (Patient 15, Patient 16, Patient 17, Patient 18, Patient 21, and Patient 22). This deficient practice has the potential for delay of care and the decline in health status not identified by the IDG, to meet Patient 15, Patient 16, Patient 17, Patient 18, Patient 21, and Patient 22 care goals. 5. A review of Patient 21s admission record indicated Patient 21 was admitted to HA on 8/30/2023, with a primary diagnosis of atherosclerotic heart disease. A review of Patient 21s “;Plan of Care/IDG Review”, indicated that the following IDG members did not sign the IDG document on the following dates: the hospice Medical Director, did not sign on 1/25/2024, the MSW did not sign on 12/14/2023,12/28/2023, 1/11/2024, and 1/25/2024, the RN did not sign on 1/25/2024, and the Chaplain, did not sign on 10/18/2023, 11/2/2023, 11/15/2023, 11/29/2023, 12/14/2023, 12/28/2023, 1/11/2024, and 1/25/2024. 6. A review of Patient 22s admission record indicated Patient 22 was admitted to the HA on 11/27/2023 with the primary diagnoses of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart’s left ventricle [one chamber of the heart] and type 2 diabetes (a chronic condition that happens when person have persistently high blood sugar levels). A review of Patient 22s “;POC/IDG Review”, indicated that the following IDG members did not sign on the IDG document on the following dates: the hospice Medical Director did not sign on 1/11/2024 and 1/25/2024, the MSW, did not sign on 12/28/2023, 1/11/2024, and 1/25/2024, the RN, did not sign on 12/14/2023, 1/11/2024, and 1/25/2024, and the Chaplain, did not sign on 11/27/2023, 11/29/2023, 12/14/2023, 12/28/2023, 1/11/2024, and 1/25/2024. During a telephone interview with the Director of Patient Care Services (DPCS) on 2/11/2024 at 10:36 a.m., the DPCS stated that the members of the IDG includes the MSW, Chaplain, MD, RNs and Licensed Vocational Nurses (LVNs), and has to sign and document the IDG meeting. A review of the HA’s policy titled “ Patient Change of Condition” indicated.. The interdisciplinary team, including physicians, nurses, social workers, and other relevant team members, will collaborate to develop and implement an individualized plan of care in response to change in condition. All changes in the patient’s condition and interventions will be thoroughly documented in the patient’s medical records. Documentation will include the date, time, and details of the observed changes and the subsequent actions taken. The IDT collaborate to develop and implement an individualized plan of care. Communicate changes and adjustments to the patient and family. 1. A review of Patient 15s admission record indicated a start of care (SOC) date of 12/1/2023 with terminal diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems), type 2 diabetes mellitus (a disease that occurs when an individuals blood glucose, also known as blood sugar is too high), and Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 15s “;Plan of Care/Interdisciplinary Group (POC, a nursing care plan provides direction on the type of nursing care the individual/family/community may need)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review”, indicated that the following IDG members did not sign on the IDG document on the following dates: the hospice Medical Director, did not sign on 12/01/2023, 1/11/2024, 1/25/2024, and 2/8/2024, the Chaplain, did not sign on 12/14/2023,12/28/2023, 1/11/2024, 1/25/2024, and 2/8/2024, and the Registered Nurse (RN), did not sign on 2/8/2024. 2. A review of Patient 16s admission record/Face Sheet indicated an SOC date of 3/25/2022, with a primary diagnosis of Alzheimers disease with late onset (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out simple tasks). A review of Patient 16s “;Plan of Care/IDG Review”, indicated that the following IDG members did not sign on the IDG document on the following dates: the Chaplain, did not sign on 11/29/2023,12/14/2023, 12/28/2023, 1/11/2024, and 1/25/2024, the RN, did not sign on 12/28/2023 and 1/25/2024, and the Medical Social Worker (MSW), has no signature on 11/29/2023, 12/14/2023, 12/28/2024, 1/11/2024, and 1/25/2024. 3. A review of Patient 17s admission record/Face Sheet indicated an SOC date of 11/29/2023, with a primary diagnosis of atherosclerotic heart disease (a buildup of fats, cholesterol, and other substances in and on the artery walls making it hard for blood to pass through). A review of Patient 17s “;Plan of Care/IDG Review”, indicated that the following IDG members did not sign on the IDG document on the following dates: the hospice Medical Director, did not sign on 1/25/2024, the Chaplain, did not sign on 11/29/2023, 12/14/2023, 12/28/2023, and 1/25/2024, and the MSW, did not sign on 11/29/2023, 12/14/2023, 12/28/2023, and 1/25/2024. 4. A review of Patient 18s admission record/Face Sheet indicated an SOC date of 1/18/2024, with a primary diagnosis of atherosclerotic heart disease. A review of Patient 18s “;Plan of Care/IDG Review”, indicated that the following IDG members did not sign on the IDG document on the following dates: the Chaplain and the MSW did not sign the IDG document on 1/18/2024 and 1/25/2024. During an interview with the Director of Patient Care Services Designee (DPCSD) on 2/9/2024 at 11:40 a.m., the DPCSD stated that the hospice Medical Director, Chaplain, and the MSW attended the IDG meeting, however, they missed signing on the documents to validate their attendance. The DPCSD stated, Medical Director, Chaplain, RN, and the MSW has to sign the IDG document to validate their attendance as members of the IDG team.”

“Based on observation, interview and record review the hospice agency (HA) failed to ensure the “Comfort Kit” (a prescribed set of medications that are kept in a patient’s home in the event of an emergency) were available for one of ten sampled patients (Patient 16). This deficient practice had the potential for Patient 16 to experienced discomfort and delayed care access to comfort kit. A review of Patient 16s admission record/Face Sheet indicated a start of care (SOC) date of 3/25/2022, with diagnosis of Alzheimers disease with late onset (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out simple task). A review of patient 16s Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 11/29/2023 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits twice a week and Certified Home Health Aide (CHHA) visits twice a week. During a joint home visit on 2/8/2024, at 10 a.m., with Licensed Vocational Nurse (LVN 1), at Patient 16’s residence, Patient 16 was observed sitting on her wheelchair comfortably, alert, oriented to her name only and unable to verbalize her needs. During an interview and a review of Patient 16s current medication profile and medication reconciliation on 2/8/2024 at 10 a.m., with LVN 1, Patient 16’s current medication profile and medication reconciliation were reviewed. LVN 1 stated, Patient 16 has no comfort kit medications (which includes Bisacodyl suppository 10 milligrams (mg) for constipation, Levsin 0.125mg tablet for excessive secretions, Lorazepam 2mg/ml bottle solution for anxiety/agitation, Morphine Sulfate 20mg/ml bottle solution for mild pain/shortness of breath/severe pain/respiratory distress, Tylenol suppository 650 mg for mild pain/fever and Zofran 4mg tablets for nausea/vomiting) but listed active medications on Patient 16’s medication profile. LVN 1 stated he did not know why it was not provided to Patient 16. LVN 1 stated that he performed the medication reconciliation of Patient 16s medications on his last visit for Patient 16 and did check if comfort kit was available. LVN 1 stated that it was important that the comfort kit medication readily available for use for a sudden change of condition or if needed. During an interview and a review of Patient 16’s clinical records on 2/9/2024, at 11:30 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated, there was no documentation that the comfort kit was provided to Patient 16. During a review of Patient 16s communication/progress log dated 3/25/2023, with the DPCSD, Patient 16s communication/progress log, the comments section indicated, “;Standard order for comfort kit placed on MAR for Patient 16 per MD orders, for change of condition, to be delivered to facility upon request. Facility updated”. DPCSD stated that Patient 16s family declined comfort kit medications unless it was needed. DPCSD stated that a physicians order to discontinue the comfort kit medications should have been done and updated to the patients active medication profile and the nurses should have documented that Patient 16s family declined for a comfort kit medication. DPCSD was unable to provide a policy and procedure related to comfort kit medications.”

“Based on interview and record review, the Hospice Agency (HA) failed to identify and ensure a COVID-19 (an acute disease caused by coronavirus, which can cause fever and cough. It also capable of progressing to severe symptoms and is some cases cause death) case was included in their 2023 quality assessment and performance improvement (QAPI , a data driven and proactive approach to quality improvements) program when one of eight sampled patients (Patient 21) diagnosed with COVID-19. This failure resulted in the hospice agencys inability to determine and identify areas of potential problems that could affect the patients highest quality of care by not monitoring and planning for a possible COVID-19 outbreak. A review of Patient 21s “Personal Information Sheet” indicated an admission date of 8/30/2023 with diagnoses including atherosclerotic heart disease (a common condition that develops when a sticky substance called plaque builds up inside persons artery that blocks blood flow to the heart) and toxic liver disease cirrhosis (the inflammation associated with toxic hepatitis [liver infection] can lead to liver damage and scarring). A review of the HA’s form titled “Communication Log”, indicated an entry was made on 8/30/2023 at 5:59 p.m., which specified Patient 21 had COVID-19 upon admission. Another entry was made on 1/2/2024 at 8:00 a.m., which indicated Patient 21s caregiver/son called to cancel the nurse visit because he was not feeling well. During an interview on 2/10/2024 at 2:20 p.m., with the Administrator (ADM), ADM stated he was the Administrator, QAPI coordinator, Governing Body, CEO, CFO, Secretary, President and Treasurer. ADM stated the HAs QAPI program was used to identify items that could be improved and to develop a plan to improve those items. During a concurrent interview and record review on 2/10/2024 at 3:00 p.m. with the Administrator (ADM) of HAs 2023 QAPI binder, ADM confirmed that there was no mention or documentation of any COVID-19 positive patients. During an interview on 2/11/2024 at 11:50 a.m., with the Director of Patient Care Services (DPCS), DPCS stated she was a member of the HAs QAPI committee. DPCS stated she does not have an assigned role or responsibilities in the HAs QAPI program. DPCS stated, “;I dont have a role/responsibility; not that I am aware of. Honestly, I just attend the meetings.” During an interview on 2/11/2024 at 12:17 p.m., with the Administrator (ADM), ADM stated the agency had a QAPI program, in which the committee met quarterly. ADM stated he goes over the agenda and meeting minutes with the staff. ADM stated the graphs generated from their Electronic Medical Record (EMR) were printed out as support. ADM stated he did not sign the 2023 third and fourth quarter QAPI meeting minutes. ADM stated, “;My signature would indicate that we went over the items. I did not review the information on the minutes.” ADM stated the 2023 third quarter QAPI was partially completed, and that the fourth quarter was not completed. A review of HAs form titled “;Board of Directors Annual Meeting Minutes” dated 1/15/2024, indicated “;Name of Officers, Directors, Governing Body – CEO, President, Secretary, CFO, Treasurer” all these officers were assigned to the ADM. Form also indicated “;Designation of Authority: Resolved, that the 4th quarter 2023 QAPI committee meeting was approved by the unanimous vote of the Directors”. Lastly, form also indicated it had one signature, that was the ADM’s signature. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 10/30/2023 (July-September 2023) which included eight pages, indicated on page one under “;Corona Virus COVID – 19; Findings/Discussion - “ there was no mention/documentation of any patient COVID-19 cases. Form also indicated the Administrator (ADM) and the Director of Patient Care Services (DPCS) were the responsible persons. Lastly, the form also indicated it was not signed by any QAPI member. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 1/30/2024 (October-December 2023) which included nine pages, indicated on page one under “;Findings/Discussion” there was no mentioned/documentation of any patient COVID-19 cases. Form also indicated the ADM and the DPCS were the responsible persons. Lastly, the form also indicated it was not signed by any QAPI member. A review of HAs policy and procedure titled “;Mission Statement” revised 10/2029, indicated “;We strive to create a culture of safety and quality...” A review of HAs policy and procedure titled “;Organizational Planning” revised 5/2023, indicated “;(HA) leaders are responsible for developing and implementing an effective, systemic, organization-wide planning process, which includes: ongoing monitoring to ensure that the organizational mission is maintained over time. The planning process will be monitored by leadership through a quarterly review of – quality assessment and performance improvement results.” A review of HAs policy and procedure titled, “;Policy Decision” revised 5/2023, indicated “;Senior management will meet monthly to discuss any of the following, as pertinent, but not limited to: Quality assessment and performance improvement program/activities, including measures, outcomes, results, and performance improvement team activities and the effectiveness of staff communication.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure they collected data for their contracted services to be able to monitor, assess, and evaluate their services in their quality assessment and performance improvement (QAPI, a data driven and proactive approach to quality improvements) program. This failure had the potential to result in missed opportunities for improvement, which could potentially have an adverse effect to patients with terminal diagnoses and their care. During a concurrent interview and record review on 2/10/2024 at 1:35 p.m. with the Office Manager (OM) of HA forms titled “;Quality Assessment and Performance Improvement – Pharmacy Services” dated 1/2018 and 1/2019, and “;Quality Assessment and Performance Improvement – Transportation Services” dated 1/15/2022, OM stated section “;Date of review” is the date she calls the contracted services for their feedback. OM stated she was asked to fill out the reports and place them in the QAPI binder annually, as per their policy. OM stated there is no documentation the contracted services were called in 2023. During an interview on 2/10/2024, at 2:20 p.m., with the Administrator (ADM), ADM stated he was the Administrator, QAPI coordinator, Governing Body: CEO, CFO, Secretary, President, and Treasurer. ADM stated the HAs QAPI program was used to identify items that could be improved and to develop a plan to improve those items. During a concurrent interview and record review on 2/10/2024 at 2:45 p.m., with the ADM of HA forms titled “;Quality Assessment and Performance Improvement – Pharmacy Services” dated 1/2018 and 1/2019, and “;Quality Assessment and Performance Improvement – Transportation Services” dated 1/15/2022, ADM stated pharmacy and transportation services were used on a contractual status. ADM stated these contracted services are placed in their QAPI program and were evaluated from patients and HA staff feedback. Pharmacy Service forms were not filled out or signed. Transportation Service form was signed by the Office Manager (OM) with what appears to be 1/17/2023 written on top of 1/15/2022. ADM stated OM was not a clinician and that she filled forms out from the information she was provided by the HAs clinicians. ADM stated the contracted services were not called for their feedback. ADM stated these forms were supposed to be filled out annually. During an interview on 2/11/2024 at 11:50 a.m., with the Director of Patient Care Services (DPCS), DPCS stated she was a member of the HAs QAPI committee. DPCS stated she does not have an assigned role or responsibilities in the HAs QAPI program. DPCS stated, “;I dont have a role/responsibility; not that I am aware of. Honestly, I just attend the meetings.” During an interview on 2/11/2024 at 12:17 p.m., with the Administrator (ADM), ADM stated the agency had a QAPI program, in which the committee met quarterly. ADM stated he goes over the agenda and meeting minutes with the staff. ADM stated the graphs generated from their Electronic Medical Record (EMR) were printed out as support. ADM stated he did not sign the 2023 third and fourth quarter QAPI meeting minutes. ADM stated, “;My signature would indicate that we went over the items. I did not review the information on the minutes.” ADM stated the 2023 third quarter QAPI was partially completed, and that the fourth quarter was not completed. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 10/30/2023 (July-September 2023) which included eight pages, indicated under section “;Topic – Pharmacy/DME/Transportation” and under section “;Findings/Discussion – No issues reported regarding the pharmacy, DME and transportation during this quarter.” Form also indicated it was not signed by any QAPI member. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 1/30/2024 (October-December 2023) which included nine pages, indicated under section “;Topic – Pharmacy/DME/Transportation” and under section “;Findings/Discussion – No issues reported regarding the pharmacy, DME and transportation during this quarter.” Form also indicated it was not signed by any QAPI member. During a concurrent interview and record review on 2/10/2024 at 3:00 p.m. with the Administrator (ADM) of HAs 2023 QAPI binder, ADM confirmed that there were no documents for the 2023 fourth quarter QAPI meeting and that the 2023 third quarter QAPI documents were not completed. ADM called the Office Manager (OM) and asked OM to provide the 2023 fourth quarter QAPI documents. OM stated she printed them out of their Electronic Medical Record (EMR) system. OM stated the participants join and go over their QAPI plan over a Video Conferencing Platform (VCP) quarterly. A review of HAs policy and procedure titled “;Mission Statement” revised 10/2029, indicated “;We strive to create a culture of safety and quality...” A review of HAs policy and procedure titled “;Organizational Planning” revised 5/2023, indicated “;(HA) leaders are responsible for developing and implementing an effective, systemic, organization-wide planning process, which includes: ongoing monitoring to ensure that the organizational mission is maintained over time. The planning process will be monitored by leadership through a quarterly review of – quality assessment and performance improvement results.” A review of HAs policy and procedure titled, “;Policy Decision” revised 5/2023, indicated “;Senior management will meet monthly to discuss any of the following, as pertinent, but not limited to: Quality assessment and performance improvement program/activities, including measures, outcomes, results, and performance improvement team activities and the effectiveness of staff communication.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure COVID-19 (an acute disease caused by coronavirus, which can cause fever and cough. It also capable of progressing to severe symptoms and is some cases cause death) was included in their quality assessment and performance improvement (QAPI, a data driven and proactive approach to quality improvements) program. This failure resulted in the hospice agencys inability to determine and identify areas of potential problems that could affect the patients highest quality of care by not monitoring and planning for a possible COVID-19 outbreak among its patients, staff, and their families. A review of Patient 21s “Personal Information Sheet” indicated an admission date of 8/30/2023 with diagnoses including atherosclerotic heart disease (a common condition that develops when a sticky substance called plaque builds up inside person’s artery that blocks blood flow to the heart) and toxic liver disease cirrhosis (the inflammation associated with toxic hepatitis [liver infection] can lead to liver damage and scarring). A review of the HA’s form titled “Communication Log”, indicated an entry was made on 8/30/2023 at 5:59 p.m., which specified Patient 21 had COVID-19 upon admission. Another entry was made on 1/2/2024 at 8:00 a.m., which indicated Patient 21s caregiver/son called to cancel the nurse visit because he was not feeling well. During an interview on 2/10/2024 at 2:20 p.m., with the Administrator (ADM), ADM stated he was the Administrator, QAPI coordinator, Governing Body: CEO, CFO, Secretary, President and Treasurer. ADM stated the HAs QAPI program was used to identify items that could be improved and to develop a plan to improve those items. During a concurrent interview and record review on 2/10/2024 at 3:00 p.m. with the Administrator (ADM) of HAs 2023 QAPI binder, ADM confirmed that there was no mention or documentation of any COVID-19 positive patients. During an interview on 2/11/2024 at 11:50 a.m. with the Director of Patient Care Services (DPCS), DPCS stated she was a member of the HAs QAPI committee. DPCS stated she does not have an assigned role or responsibilities in the HAs QAPI program. DPCS stated, “;I dont have a role/responsibility; not that I am aware of. Honestly, I just attend the meetings.” During an interview on 2/11/2024 at 12:17 p.m., with the Administrator (ADM), ADM stated the agency had a QAPI program, in which the committee met quarterly. ADM stated he goes over the agenda and meeting minutes with the staff. ADM stated the graphs generated from their Electronic Medical Record (EMR) were printed out as support. ADM stated he did not sign the 2023 third and fourth quarter QAPI meeting minutes. ADM stated, “;My signature would indicate that we went over the items. I did not review the information on the minutes.” ADM stated the 2023 third quarter QAPI was partially completed, and that the fourth quarter was not completed. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 10/30/2023 (July-September 2023) which included eight pages, indicated on page one under “;Corona Virus COVID – 19; Findings/Discussion - “ there was no mention/documentation of any patient COVID cases. Form also indicated the Administrator (ADM) and the Director of Patient Care Services (DPCS) were the responsible persons. Lastly, the form also indicated it was not signed by any QAPI member. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 1/30/2024 (October-December 2023) which included nine pages, indicated on page one under “;Findings/Discussion” there was no mentioned/documentation of any patient COVID-19 cases. Form also indicated the ADM and the DPCS were the responsible persons. Lastly, the form also indicated it was not signed by any QAPI member. A review of HAs form titled “;Board of Directors Annual Meeting Minutes” dated 1/15/2024, indicated “;Name of Officers, Directors, Governing Body – CEO, President, Secretary, CFO, Treasurer” all these officers were assigned to the ADM. Form also indicated “;Designation of Authority: Resolved, that the 4th quarter 2023 QAPI committee meeting was approved by the unanimous vote of the Directors”. Lastly, form also indicated it had one signature, that was the ADM’s signature. A review of HAs policy and procedure titled “;Mission Statement” revised 10/2029, indicated “;We strive to create a culture of safety and quality...” A review of HAs policy and procedure titled “;Organizational Planning” revised 5/2023, indicated “;(HA) leaders are responsible for developing and implementing an effective, systemic, organization-wide planning process, which includes: ongoing monitoring to ensure that the organizational mission is maintained over time. The planning process will be monitored by leadership through a quarterly review of – quality assessment and performance improvement results.” A review of HAs policy and procedure titled, “;Policy Decision” revised 5/2023, indicated “;Senior management will meet monthly to discuss any of the following, as pertinent, but not limited to: Quality assessment and performance improvement program/activities, including measures, outcomes, results, and performance improvement team activities and the effectiveness of staff communication.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure their Governing Body failed to maintain an ongoing program for quality improvement and patient safety was defined, implemented, maintained, and evaluated annually. This deficient practice resulted in the inability of the hospice agency to identify issues, improve health outcomes, patient safety, and quality patient care. During an interview on 2/10/2024 at 2:20 p.m., with the Administrator (ADM), ADM stated he was the Administrator, QAPI coordinator, Governing Body: CEO, CFO, Secretary, President and Treasurer. ADM stated the HAs QAPI program was used to identify items that could be improved and to develop a plan to improve those items. During an interview on 2/11/2024 at 11:50 a.m., with the Director of Patient Care Services (DPCS), DPCS stated she was a member of the HAs QAPI committee. DPCS stated she does not have an assigned role or responsibilities in the HAs QAPI program. DPCS stated, “;I dont have a role/responsibility; not that I am aware of. Honestly, I just attend the meetings.” During an interview on 2/11/2024 at 12:17 p.m., with the Administrator (ADM), ADM stated the agency had a QAPI program, in which the committee met quarterly. ADM stated he goes over the agenda and meeting minutes with the staff. ADM stated the graphs generated from their Electronic Medical Record (EMR) were printed out as support. ADM stated he did not sign the 2023 third and fourth quarter QAPI meeting minutes. ADM stated, “;My signature would indicate that we went over the items. I did not review the information on the minutes.” ADM stated the 2023 third quarter QAPI was partially completed, and that the fourth quarter was not completed. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 10/30/2023 (July-September 2023), indicated it was not signed by any QAPI member. A review of HAs form titled “;Quality Assessment & Performance Improvement Meeting Minutes” dated 1/30/2024 (October-December 2023), indicated it was not signed by any QAPI member. A review of HAs form titled “;Board of Directors Annual Meeting Minutes” dated 1/15/2024, indicated “;Name of Officers, Directors, Governing Body – CEO, President, Secretary, CFO, Treasurer” all these officers were assigned to the ADM. Form also indicated “;Designation of Authority: Resolved, that the 4th quarter 2023 QAPI committee meeting was approved by the unanimous vote of the Directors”. Lastly, form also indicated it had one signature, that of the ADM signature. A review of HAs policy and procedure titled “;Mission Statement” revised 10/2029, indicated “;We strive to create a culture of safety and quality...” A review of HAs policy and procedure titled “;Organizational Planning” revised 5/2023, indicated “;(HA) leaders are responsible for developing and implementing an effective, systemic, organization-wide planning process, which includes: ongoing monitoring to ensure that the organizational mission is maintained over time. The planning process will be monitored by leadership through a quarterly review of – quality assessment and performance improvement results.” A review of HAs policy and procedure titled, “;Policy Decision” revised 5/2023, indicated “;Senior management will meet monthly to discuss any of the following, as pertinent, but not limited to: Quality assessment and performance improvement program/activities, including measures, outcomes, results, and performance improvement team activities and the effectiveness of staff communication.””

“Based on interview and record review, the hospice agency (HA) failed to develop and implement its policy and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) infection control for all office and field employees and for 44 patients. The hospice agency (HA) failed to ensure a process for tracking and securely documenting exposure of employees and patients who were tested positive for Covid-19 (an infectious disease caused by the SARS-COV-2 virus), failed to ensure contingency plans for employees and patients that were tested Covid-19 positive, and or patients deemed to be exposed to COVID-19 positive employee or patient, and have a process for ensuring that the HA continues to follow all standards of infection prevention and control practice, for reducing the transmission and spread of COVID-19 in the HA, especially by the staff who was tested positive and/or have signs and symptoms of COVID-19. This deficient practices had the potential to result in placing all patients and employees at risk for spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization, and/or death. A review of the agencys census during an approved Full Medicare Survey on 2/7/2024 to 2/11/2024, indicated the hospice agency’s (HA) active census was 44 patients. A request was made to review the HA’s Covid-19 Mitigation Plan (a guidance provides and recommends general mitigation strategies for reducing the transmission of COVID-19 in workplaces to protect the staff and their patients) on 2/10/2024. A review of Patient 21’s “Personal Information Sheet”, indicated that Patient 21 was admitted on 8/30/2023 with the diagnosis of atherosclerotic heart disease (a common condition that develops when a sticky substance called plaque builds up inside the artery that blocks blood flow to the heart) and toxic liver disease cirrhosis (the inflammation associated with toxic hepatitis [liver infection caused by the virus] can lead to liver damage and scarring). A review of the HA’s “Communication Log” on 2/10/2024, indicated that on 8/30/2023 at 5:59 p.m., upon admission was endorsed that Patient 21 tested positive for Covid-19. An entry in the communication log dated 1/2/2024 at 8:00 a.m., indicated that the agency received a call from Patient 21’s caregiver/son stating he was not feeling very well and wanted to decline the nurse home visit. Further record review indicated that a nurse conducted a home visit on 1/3/2024 at 2:45 p.m. On a concurrent review of the skilled nurses (SN) note on 1/3/2024 at 2:45 p.m., indicated that the SN confirmed that the son tested positive for Covid-19. During an interview with the Administrator (ADM) on 2/10/2024 at 1:35 p.m., ADM stated that they monitor Covid-19 on Hospice MD. A concurrent review with the ADM on Patient 21s skilled nursing notes and communication log, indicated that there were no communication notes, nursing notes, and monitoring for staff and other patients when they admitted Covid-19 positive patient. ADM also stated the agency encouraged complete PPE (Personal Protective Equipment, an equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses. These injuries and illnesses may result from contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards) for the staff that went to visit the patient. When asked what the agency did to monitor staff and other patients for exposure with Covid-19 when the SN conducted the admission of Patient 21 who was tested Covid-19 positive, when the son refused a home visit 1/2/2024, and SN conducted home visit on 1/3/24, the ADM was not able to provide any documentation that the agency monitored and tracked staff exposure to Covid-19. During a concurrent record review, the ADM was not able to provide any documentation that the agency monitored and tracked staff exposure to Covid-19 and if there were other patients who were visited by the same SN. During an interview with the Director of Patient Care Services (DPCS) on 2/11/2024 at 10:30 a.m., DPCS confirmed that Patient 21 was Covid-19 positive upon admission. DPCS stated we just follow the standard precautions and let the staff know that the patient they are admitting or visiting is Covid-19 positive. DPCS further stated that the agency was testing staff who feel that they have signs and symptoms of Covid-19, the staff need to be tested. When asked if that information was recorded or if there is any documentation, the DPCS stated “;I dont believe so.” A review of the HA’s policy titled “Covid-19 Policy” numbered 2023-901, indicated “The purpose of this policy is to mitigate the spread of respiratory infections, particularly COVID-19, among patients, family members, visitors, and hospice staff within our organization. This policy is based on guidance provided by the Centers for Disease Control and Prevention (CDC) and local health advisories. The following measures will be implemented: 1. Reporting Suspected COVID-19 Cases: • Any patient suspected of having COVID-19 symptoms or exposure must be promptly reported to the hospice agency. • The hospice agency will follow established protocols for assessing, managing, and reporting suspected cases of COVID-19. 2. Pre-Visit Screening: • Hospice staff are required to contact the patient or their family before scheduling a visit to inquire about COVID-19 symptoms or potential exposure. • If the patient or any family member exhibits COVID-19 symptoms or has been in close contact with a confirmed case, the visit will be rescheduled or conducted via telehealth , if feasible. 3. Personal Protective Equipment (PPE): • Hospice staff must wear appropriate PPE, including masks, gloves, and eye protection, during all patient interactions to prevent transmission of infection. • PPE must be worn according to CDC guidelines and organizational policies. 4. Documentation: • Patients diagnosed with COVID-19 must be accurately documented in the electronic medical record (EMR), including relevant symptoms, test results, and treatment plans. • Documentation must be complete, timely, and in compliance with regulatory requirements. 5. Testing and Monitoring: Patients diagnosed with COVID-19 will be monitored closely, and testing will be conducted after the required number of days to assess if the patient remains positive for the virus. • Testing protocols will adhere to CDC guidelines and recommendations from local health authorities. 6. Telehealth Coordination of Care: • Telehealth services will be utilized as appropriate to minimize in-person contact and reduce the risk of COVID-19 transmission. • Coordination of care via telehealth will align with current healthcare waivers applicable to hospice agencies. 7. COVID-19 Information and Education: • Information and education about COVID-19 will be provided to patients, families, and hospice staff to promote awareness, prevention, and adherence to safety protocols. Responsibilities: It is the responsibility of all hospice staff members to adhere to this policy and actively participate in the implementation of COVID-19 prevention measures. Review and Revision: This policy will be reviewed regularly to ensure alignment with CDC guidelines, local health advisories, and regulatory requirements. Any necessary revisions will be made in consultation with relevant stakeholders.”

“Based on interview and record review, the hospice agency (HA) failed to: 1. Ensure all agency office and field employees (who provide any care, treatment, or other services for the HA and/or its patients) were updated on their Covid-19 vaccine status. 2. Develop and implement a policy and procedures to monitor employee’s exposure to COVID-19 and screening status. This deficient practice had the potential for risk in the transmission this dangerous and communicable disease to all vulnerable hospice patients, office staff, field staff, and patient’s families and or visitors. A review of the agencys census during an approved Full Medicare Survey on 2/7/2024 to 2/11/2024, indicated the hospice agency’s (HA) active census was 44 patients. A request was made to review the HA’s Covid-19 Mitigation Plan (a guidance provides and recommends general mitigation strategies for reducing the transmission of COVID-19 in workplaces to protect the staff and their patients) on 2/10/2024. A review of Patient 21’s “Personal Information Sheet”, indicated that Patient 21 was admitted on 8/30/2023 with the diagnosis of atherosclerotic heart disease (a common condition that develops when a sticky substance called plaque builds up inside the artery that blocks blood flow to the heart) and toxic liver disease cirrhosis (the inflammation associated with toxic hepatitis [liver infection caused by the virus] can lead to liver damage and scarring). A review of the HA’s “Communication Log” on 2/10/2024, indicated that on 8/30/2023 at 5:59 p.m., upon admission was endorsed that Patient 21 tested positive for Covid-19. An entry in the communication log dated 1/2/2024 at 8:00 a.m., indicated that the agency received a call from Patient 21’s caregiver/son stating he was not feeling very well and wanted to decline the nurse home visit. Further record review indicated that a nurse conducted a home visit on 1/3/2024 at 2:45 p.m. On a concurrent review of the skilled nurses (SN) note on 1/3/2024 at 2:45 p.m., indicated that the SN confirmed that the son tested positive for Covid-19. During an interview with the Administrator (ADM) on 2/10/2024 at 1:35 p.m., ADM stated that they monitor Covid-19 on Hospice MD website. A concurrent review with the ADM on Patient 21s skilled nursing notes and communication log, indicated that there were no communication notes, nursing notes, and monitoring for staff and other patients when they admitted Covid-19 positive patient. ADM further stated the agency encouraged complete PPE (Personal Protective Equipment, an equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses. These injuries and illnesses may result from contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards) for the staff that went to visit the patient. When asked what the agency did to monitor staff and other patients for exposure with Covid-19 when the SN conducted the admission of Patient 21 who was tested Covid-19 positive, when the son refused a home visit 1/2/2024, and SN conducted home visit on 1/3/2024, the ADM was not able to provide any documentation that the agency monitored and tracked staff exposure to Covid-19. During a concurrent record review, the ADM was not able to provide any documentation that the agency monitored and tracked staff exposure to Covid-19 and if there were other patients who were visited by the same SN. When asked the ADM how agency monitors staff’s and patients’ Covid-19 vaccinations, the ADM was unable to provide any documentation for tracking and monitoring of staff’s and patients’ vaccinations for Covid-19. A review of the HA’s QAPI (Quality Assurance and Performance Improvement (QAPI) is a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level) program on 2/10/2024 at 1:35 p.m., indicated that the HA’s Covid-19 infection was not included, tracked, and monitored under QAPI. A review of the HA’s undated Covid-19 Policy on 2/10/2024, the policy indicated, “The purpose of this policy is to mitigate the spread of respiratory infections, particularly COVID-19, among patients, family members, visitors, and hospice staff within our organization. This policy is based on guidance provided by the Centers for Disease Control and Prevention (CDC) and local health advisories. Patients diagnosed with COVID-19 must be accurately documented in the electronic medical record (EMR), including relevant symptoms, test results, and treatment plans. Documentation must be complete, timely, and in compliance with regulatory requirements. Telehealth Coordination of Care: Telehealth services will be utilized as appropriate to minimize in-person contact and reduce the risk of COVID-19 transmission. Coordination of care via telehealth will align with current healthcare waivers applicable to hospice agencies. COVID-19 Information and Education: Information and education about COVID-19 will be provided to patients, families, and hospice staff to promote awareness, prevention, and adherence to safety protocols. Responsibilities: It is the responsibility of all hospice staff members to adhere to this policy and actively participate in the implementation of COVID-19 prevention measures. Review and Revision: This policy will be reviewed regularly to ensure alignment with CDC guidelines, local health advisories, and regulatory requirements. Any necessary revisions will be made in consultation with relevant stakeholders”. A review of the HA’s undated document titled “Job Description: Administrator”, indicated, “The Administrator is responsible for the overall direction of the day to day operations of the hospice services... is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. 2. Ensuring organizational compliance with legal, regulatory and accreditation requirements. Assuring that all business conduct is above minimum standards required by law and will not condone any activities that achieve results through violation of the law, unethical business or patient care practices. Ensuring hospice personnel stay current with clinical information and practices. Staff development including orientation, in-service, continuing education, competency testing and quality assessment performance improvement.””

“Based on observation, interview and record review the facility failed to provide a “Comfort Kit” (a prescribed set of medications that are kept in a patient’s home in the event of an emergency) for one (1) of eight (8) sampled patients (Patient 16). This failure had the potential to result in patients not receiving their comfort medications when needed on a timely basis. A review of patient 16s admission record/Face Sheet indicated a start of care (SOC) date of 3/25/2022, with a primary diagnosis of Alzheimers Disease With Late Onset (is a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out simple task). A review of patient 16s plan of care (POC)/Interdisciplinary group (IDG) Review dated 11/29/2023 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits twice a week and Certified Home Health Aide (CHHA) visits twice a week. During a joint home visit with Licensed Vocational Nurse (LVN 1) on 2/8/2024, at 10:00 a.m., Patient 1 was observed sitting on her wheelchair comfortably. Patient 1 was alert, oriented to her name only and unable to verbalize her needs. During a concurrent review of Patient 16s current medication profile and medication reconciliation with LVN 1, Patient 1 has no comfort kit medications (which includes Bisacodyl suppository 10 milligrams (mg) for constipation, Levsin 0.125mg tablet for excessive secretions, Lorazepam 2mg/ml bottle solution for anxiety/agitation, Morphine Sulfate 20mg/ml bottle solution for mild pain/shortness of breath/severe pain/respiratory distress, Tylenol suppository 650 mg for mild pain/fever and Zofran 4mg tablets for nausea/vomiting) but listed as an active medications. LVN 1 stated he does not know why it was not provided to patient 16 and stated that he did a medication reconciliation of Patient 16s medications from his last visit last week but was unable to check if comfort kit was available. LVN 1 stated that it is important to have comfort kit medication readily available to use when a patient has a sudden change of condition or if needed. On 2/9/2024, at 11:30 a.m., during a concurrent interview and review of Patient 16s clinical records with the Director of Patient Care Services Designee, there was no documented evidence the comfort kit was provided to Patient 16. A further review of Patient 16s communication/progress log dated 3/25/2023, with the DPCSD indicated the comments section “;Standard order for comfort kit placed on MAR for Patient per MD orders. Medications not sent: medications approved by MD for change of condition to be delivered to facility upon request. Facility updated”. DPCSD stated that Patient 16s family declined comfort kit medications unless it is needed but DPCSD. DPCSD stated that a physicians order to discontinue the comfort kit medications should have been done and updated to the patients active medication profile and the nurses should have documented that Patient 16s family declined for a comfort kit medication. DPCSD was unable to provide a policy and procedure related to comfort kit medications.”

“Based on observation, interview, and record review, the Hospice Agency (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 Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), care planning, coordination of services was met as follows: a. The HA failed to provide services as indicated in the plan of care for one of 14 patients (Patient 8). For Patient 8, the hospice SN (skilled nurse) failed to assess wound condition on every visit. This deficient practice placed the patient at a potential risk for a delay of wound healing. (Refer to L543). b. RN 1 (registered nurse) failed to ensure the physician was notified regarding a patient’s hypotension crisis for one out of 14 sampled patients (Patient 9). This failure had the potential to result in patient’s end of life care needs not met. (Refer to L554). c. The HA failed to ensure the care and services were provided in accordance with the plan of care for three of 14 sampled patients (Patient 1, Patient 8, and Patient 9) by failing to: 1. Ensure to provide skilled nurse visits in accordance with the plan of care to Patient 1. 2. Ensure to monitor and provide follow-up calls/visits for a reported change of condition of Patient 1 (COC, a sudden clinically important deviation from a patient’s baseline in physical, cognitive, behavioral, or functional domains). 3. Ensure Comfort Kit medications (medications kept in the home to quickly treat symptoms that may occur in terminally ill patient) was available to Patient 1 during her final stages of the dying process. 4. Ensure Patient 8 had wound care medication cream available for the treatment of pressure injuries (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). 5. Ensure the visiting nurse (Licensed Vocational Nurse 2) provided teaching for hypotension (low blood pressure) medication for Patient 9. The non-compliance caused delayed care and undetected signs of physical and emotional needs when transitioning to the final stages of the dying process. (Refer to L555). 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 highest quality health care is provided to patients assessed to receive hospice services.”

“Based on 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 Organizational Environment was met as follows: The HA failed to ensure one of 14 sampled patients (Patient 1) was treated with dignity, comfort, and respect. As a result, the non-compliance resulted in Patient 1 not being treated with comfort, dignity, and respect, and Patient l’s family felt humiliated and disrespected by the HA not responding to Patient 1s comfort needs (Refer to L650). 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 highest quality health care is provided to patients assessed to receive hospice services.”

“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 (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the 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: 1. The hospice agency’s nursing staff (in general) failed to ensure to conduct a pressure ulcer/injury wound (injury to skin and underlying tissue resulting from prolonged pressure on the skin) complete assessment that included the size of the pressure ulcer/injury wound in accordance with the HAs policy and procedure for one of 14 sampled patients (Patient 1). (Refer to L524) 2. The hospice agency failed to assess the patient’s eligibility (the quality or state of being eligible) for hospice services related to the palliation (easing the severity of a pain or a disease without removing the cause) and management of the terminal illness (an illness or condition which cannot be cured and is likely to lead to someone’s death), and related conditions for two of 14 sampled patients (Patient 4 and Patient 6). (Refer to L532) The cumulative effect of 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 has six months or less to live) failed to inform two of 14 sampled patients (Patient 4 and Patient 6) about the services the HA provided and the limitations of these services. This deficient practice resulted for Patient 4 and Patient 6 not to be informed about the purpose of the hospice care services and had the potential not to meet the needs of Patient 4 and Patient 6. Findings: a. During a review of Patient 4s admission record indicated a start of care (SOC) date of 3/4/2023 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 4’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/4/2023, the POC/IDG indicated the frequency of visits of skilled nurse (SN) to two visits per week plus three prn (as needed) visits, the spiritual counselor (SC) and social worker (MSW) to visit one-time then prn. Volunteer service was declined. During a joint home visit, on 12/6/2023 at 11:45 a.m., with the Licensed Vocational Nurse 3 (LVN 3) at Patient 4s residence, Patient 4 was observed sitting up in bed, awake, alert and hard-of-hearing. During an interview on 12/6/2023, at 12:02 p.m. with the patients family member (FAM 3), FAM 3 stated no doctor or nurses (in general) told him Patient 4 had six months or less to live. FM 3 stated Patient 4 walked around the house regularly using a walker(a type of mobility aid that offers stability and support while walking), was not dying, and did not know that hospice care was for those patients with terminal illness. b. During a review of Patient 6s admission record indicated a start of care date of 11/3/2023 with a terminal diagnosis of heart failure (a chronic condition in which the heart does not pump blood as well as it should), unspecified. During a review of Patient 6’s POC/IDG form, dated 11/3/2023, the POC/IDG indicated the frequency of visits of skilled nurse to two visits per week plus three prn visits for pain and symptom management, and the social worker to visit once a month. Spiritual counselor and hospice aide services were declined. During a telephone interview on 12/7/2023, at 2:08 p.m., with Patient 6, Patient 6 stated he was not dying, and no doctor or any nurses (in general) from the hospice agency told him that he has six months or less to live. Patient 6 stated his understanding of hospice care was to have a nurse that comes see him every week. During a review of the agencys policy and procedure titled, “;Rights/Responsibilities”, revised May 2023, the Rights/Responsibilities policy, indicated each patient will be an active, informed participant in his/her plan of care. The patient, authorized decision-maker or legal representative will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care, and the organizations mission and care and services provided directly or through contractual arrangements.”

“Based on 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 nursing staff (in general) conducted a pressure ulcer/injury wound (injury to skin and underlying tissue resulting from prolonged pressure on the skin) complete assessment that included the size of the pressure ulcer/injury wound in accordance with the HAs Wound Care Management and Assessment policy and procedure for one of 14 sampled patients (Patient 1). This deficient practice had the potential to result in the delayed care of Patient 1’s pressure ulcer/injury wound treatment and had the potential for Patient 1 to experience pain, infection, discomfort, and worsening of the pressure ulcer/injury wound. Findings: During a review of Patient 1s admission record indicated a start of care (SOC) date of 10/14/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Patient 1’s Plan of Care (POC)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) form, dated 10/18/2023, the POC/IDG indicated the frequency of visits of skilled nurse (SN) to two visits per week plus three prn (as needed) visits to assess alteration in skin integrity (the health of the skin) every visit, and to monitor the effectiveness of current and new medication/treatment. During a concurrent interview and record review, on 12/7/2023, at 3:25 p.m., with the Director of Patient Care Services (DPCS), Patient 1s Skin Impairment Assessment dated 10/30/2023, 11/9/2023, and 11/13/2023 was reviewed. The Skin Impairment Assessment indicated; Patient 1 developed a Stage 2 pressure ulcer/injury (a break in the top two layers of skin) on the coccyx area (tailbone) on 10/30/2023. The Skin Impairment Assessment indicated there was no assessment regarding Patient 1’s pressure ulcer/injury wound size. The DPCS stated she was not able to find the documented evidence of Patient 1’s Stage 2 pressure injury measurements and description on Patient 1’s coccyx area. The DPCS stated Patient’s 1’s pressure ulcer/injury wound should have been assessed and measured completely. During a review of the agency’s undated policy and procedure titled, “Wound Care Management and Assessment,” the Wound Care Management and Assessment policy and procedure indicated the HA was committed to providing comprehensive and compassionate care to hospice patients, which includes the effective management and assessment of wounds. All hospice patients will undergo a comprehensive wound assessment upon admission and regularly thereafter as part of their ongoing care plan. The Wound Care Management and Assessment policy and procedure indicated the assessments would include the type, size, location, and characteristics of the wounds, as well as the patients pain level and overall comfort.”

“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 assess the patient’s eligibility (the quality or state of being eligible) for hospice services related to the palliation (easing the severity of a pain or a disease without removing the cause) and management of the terminal illness (an illness or condition which cannot be cured and is likely to lead to someone’s death) and related conditions for two of 14 sampled patients (Patient 4 and Patient 6). This deficient practice had the potential to result in the misuse of the provision of the hospice services benefits that could affect (Patient 4 and Patient 6) mental, physical, and psychosocial well-being and quality of life. Findings: a. During a review of Patient 4s admission record indicated a start of care (SOC) date of 3/4/2023 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 4’s “;Re-Cert Assessment,” (nursing recertification 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), conducted by Registered Nurse 2 (RN 2), dated 10/23/2023, indicated Patient 4 was awake, alert, oriented to place and person, ambulatory, had regular pulse rate (the number of times your heart beats per minute) and normal respirations (breathing) and blood pressure (a measure of the force that your heart uses to pump blood around your body). The Re-Cert Assessment indicated Patient 4 was on NYHA IV stage of heart failure (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). During a review of Patient 4s LCD Hospice Eligibility Determination (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits eligibility) form for heart disease, dated 10/23/2023, indicated Patient 4 did not qualify per LCD guidelines. During a review of Patient 4’s “Physician Certification for Hospice Benefit,” (Physician’s certification of the patient being terminally ill to have Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities] hospice benefit) from 10/30/2023 to 12/28/2023, indicated Patient 4’s terminal diagnoses was atherosclerotic heart disease without angina pectoris. The Medical Director indicated Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physician Certification for Hospice Benefit form indicated there was no documentation that the HA’s Medical Director communicated with Patient 4s primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Patient 4’s “Certifying Physician Summary,” from 10/30/2023 to 12/28/2023, section indicated there was no supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy (an examination of tissue removed from a living body) results to support Patient 4s terminal illness diagnosis. During a joint home visit, on 12/6/2023, at 11:45 a.m., with Licensed Vocational Nurse 3 (LVN 3) at Patient 4s residence, Patient 4 was observed sitting up in bed, awake, alert, and hard-of-hearing. Patient 4 denied having shortness of breath or chest pain. During an interview on 12/6/2023, at 12:02 p.m. with the patients family member (FAM 3), FAM 3 stated no doctor or nurses (in general) told him that Patient 4 had six months or less to live. FM 3 stated Patient 4 walked around the house regularly used a walker (is a type of mobility aid that offers stability and support while walking) to walk, was not dying, and did not know that hospice care was for those patients with terminal illness. b. During a review of Patient 6s admission record indicated a start of care date of 11/3/2023 with a terminal diagnosis of heart failure (a chronic condition in which the heart does not pump blood as well as it should), unspecified. During a review of Patient 6’s Comprehensive Nursing Assessment, dated 11/3/2023, indicated Patient 6 was awake, alert, oriented (to person, place, and time), had no cardiac-related pain, no dizziness, had normal respirations, had mild dyspnea (shortness of breath) with mild exertion, and ambulatory using a cane or walker. The Comprehensive Nursing Assessment indicated Patient 6 was on NYHA Stage IV of heart failure. During a review of Patient 6’s “Physician Certification for Hospice Benefit” from 11/3/2023 to 1/31/2024, indicated Patient 6’s terminal diagnoses was heart failure. The Physician Certification for Hospice Benefit form indicated the Medical Director wrote Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physician Certification for Hospice Benefit indicated there was no documentation that the HA’s Medical Director communicated with Patient 6s primary physician to certify Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Patient 6’s “Certifying Physician Summary,” from 11/3/2023 to 1/31/2024, indicated there was no supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 6s terminal illness diagnosis. During a review of Patient 6s LCD Hospice Eligibility Determination form for Heart Disease, dated 11/3/2023, indicated Patient 6 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked “yes” in section 1 that Patient 6 had been ruled out as a candidate for surgical procedures and was optimally treated for heart disease with diuretics (medications that are useful in treating heart failure, a condition in which the body holds too much water) and vasodilators (medicines that useful in managing high blood pressure). Section 2 was marked “yes” that Patient 6s heart disease met the criteria for NYHA Class IV level. During a telephone interview on 12/7/2023, at 2:08 p.m., with Patient 6, Patient 6 stated he was not dying, and no doctor or any nurses (in general) from the agency told him that he had six months or less to live. Patient 6 stated he was not ruled out for any surgical procedure, and his understanding of hospice care was to have a nurse who came to see him every week. During an interview on 12/7/2023, at 3:25 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence Patient 4 and Patient 6 had met the criteria for NYHA Class IV level for heart disease and should have been discharged from hospice service. During a review of the agency’s policy and procedure titled, “;”Admission Criteria and Process”, revised October 2019, indicated Victoria Hospice Services Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determine by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Victoria Hospice Services Inc reserves the right not to accept any patient who does not meet the admission criteria. Victoria Hospice Services Inc will admit a patient only on recommendation of the Medical Director in consultation with, or input from, the patients attending physician. During a review of the agencys policy and procedure titled “;Certification of Terminal Illness,” revised May 2023, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.”

“Based on observation, interview, and record review, the hospice agency’s staff (in general) failed to provide services as indicated in the plan of care for one of 14 patients (Patient 8). For Patient 8, the hospice SN (skilled nurse) failed to assess Patient 8’s skin wounds--pressure injuries (localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices) every visit. This deficient practice placed Patient 8 at risk for delay of wound healing and infection. During a review of Patient 8s Admission Record, the Admission Record indicated a start of care date of 10/14/2023, with a terminal diagnosis of Neoplasm of unspecified behavior of brain (cancerous tumor of the brain). During a review of Patient 8’s Physician Order Sheet dated 11/13/2023, the Physician Orders indicated to provide wound care as follows: 1. Wound 1: Stage 4 (full-thickness skin and tissue loss) in the coccyx (tail bone) pressure injury to cleanse with normal saline (sterile water), pat dry, apply Gentamycin (medication ointment treat skin infections caused by certain bacteria) ointment 0.1 percent, pack with loose gauze and cover with dry dressing daily and as needed. 2. Wound 2: Stage 2 (skin loss, abrasions, and blisters) right back pressure injury: to cleanse with normal saline, pat dry, apply Gentamycin ointment 0.1 percent , pack with loose gauze and cover with dry dressing daily and as needed. 3. Wound 3: Stage 2 right shoulder pressure sore: to cleanse with normal saline, pat dry, apply Gentamycin ointment 0.1 percent, pack with loose gauze and cover with dry dressing daily and as needed. During a review of Patient 8’s POC/IDG form, dated 11/29/2023, the POC/IDG indicated the frequency of visits of Licensed Vocational Nurse (LVN) to once per week, social worker (MSW) to conduct initial evaluation within five days of admission then as needed. During an observation on 12/6/2023, at 11 a.m., at Patient 8s residence with LVN 3, Patient 8 was lying in bed. Patient was observed with a Stage 4 coccyx pressure injury, a Stage 2 right back pressure injury and a Stage 2 right shoulder pressure sore. A review of Patient 8’s Visit Note RN from dates 11/13/23 to 12/3/23, indicated no documented evidence the visiting nurse was assessing the patients existing open wounds during wound care visits. During an interview on 12/8/23, at 1 p.m., with the DPCS, the DPCS stated the visiting nurse should be assessing the patient’s open wounds during their visits. A review of the facility’s policy and procedure “Wound Care, indicated the skilled nurse will document the wound progress according to the individualized plan of care including description of drainage. Wound surface and surrounding tissue.”

“Based on observation, interview, and record review, the Hospice Agency’s Registered Nurse 1 (RN 1) failed to notify the physician regarding a hypotension (low blood pressure) for one out of 14 sampled patients (Patient 9). This failure had the potential for Patient 9 to experience harm and injury. During a review of Patient 9s Admission Record, the Admission Record indicated a start of care date of 9/1/2023, with a terminal diagnosis of Alzheimer’s disease. During a review of Patient 9’s Physician Order Sheet dated 9/1/2023, the Physician Orders indicated to administer Midodrine Hydrochloride (medication used to treat low blood pressure) 5 mg (milligrams) one tablet every eight hours for hypotension (low blood pressure), to administer when systolic (measures the pressure in the arteries when the heart beats) B/P (blood pressure) was below 90. During a review of Patient 9’s POC/IDG form dated 11/29/23, the POC/IDG form indicated the frequency of visits of licensed vocational nurse (LVN) to twice per week and as needed, social worker (MSW) to conduct initial evaluation within five days of admission then as needed. Under the Cardiovascular section included in the POC indicated the patient with declining systolic B/P to below 90 related to progression of the disease. The SN (skilled nurse) interventions were to monitor/assess effectiveness of current and new medication/treatment and assess/monitor cardiac status every visits. During a home visit observation at Patient 9s residence with LVN 4 On 12/6/2023, at 12:30 p.m., Patient 9 was lying in bed and RN 1 took Patient 9’s blood pressure. RN 1 stated Patient 9s blood pressures reading was 87/49 (low). During an interview on 12/6/2023, at 1 p.m., with Caregiver 2, Caregiver 2 stated Patient 9’s blood pressure reading was around 87/52 (low) for three days. Caregiver stated she was aware Patient 9 had the Midodrine medication for her low blood pressure reading but she was not giving it at all. Patient 9 stated the visiting nurse (in general) did not check Patient 9’s medications during their visits and there was no teaching provided by the visiting nurse on the Midodrine medication so she was scared to give it. During a review of patient 9’s clinical record on 12/7/2023, at 11 a.m., indicated no documented evidence that RN 1 notified the physician of Patient 9’s low blood pressure readings. During an interview on 12/8/2023, at 1 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated RN 1 should have notified the physician regarding Patient 9’s hypotension crisis. During a review of the agencys undated policy and procedure titled, “;Monitoring Patient’s Response/Reporting To Physician”, indicated the patient’s physician and/or the hospice Medical Director will be contacted on the same day when there are changes in patient’s condition and in the patient’s expected response to hospice care or medications.”

“Based on observation, interview, and record review, the Hospice Agency (agency providing care to terminally ill patients who have six months or less to live) failed to provide care and services in accordance with the plan of care for three of 14 sampled patients (Patient 1, Patient 8, and Patient 9) by failing to: 1. Ensure to provide skilled nurse visits in accordance with the plan of care to Patient 1. 2. Ensure to monitor and provide follow-up calls/visits for a reported change of condition of Patient 1 (COC, a sudden clinically important deviation from a patient’s baseline in physical, cognitive, behavioral, or functional domains). 3. Ensure Comfort Kit medications (medications kept in the home to quickly treat symptoms that may occur in terminally ill patient) was available to Patient 1 during her final stages of the dying process. On 11/24/2023 at 3 pm, Patient 1s Family Member (FAM 1) called the Case Manager to notify the agency Patient 1 was uncomfortable and unable to sleep and Patient 1 ran out of morphine (a prescription medicine used to treat moderate to severe pain). The HA did not send a nurse to Patient 1s home from 11/24/2023 to 11/26/2023. On 11/27/2023 at 12:30 am, FAM 1 called the HA to notify them Patient 1 was not breathing. On 11/27/2023 at 1:37 am, LVN 1 saw Patient 1 had expired. 4. Ensure Patient 8 had wound care medication cream available for the treatment of pressure injuries (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). 5. Ensure the visiting nurse (Licensed Vocational Nurse 2) provided teaching for hypotension (low blood pressure) medication for Patient 9. These deficient practices caused delay of care and undetected signs of physical, emotional, and spiritual needs for Patient 1, Patient 8, and Patient 9 due to the facilitys failure to provide care and services in accordance with the plan of care for Patient 1, Patient 8, and Patient 9. On 12/7/2023 at 10:55 a.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agencys Administrator and the Director of Patient Care Services (DPCS). On 12/7/2023, at 2:10 p.m., the agency sent the IJ Removal Plan (the facilitys plan of action to correct the deficient practices), and the survey team notified the DPCS the IJ Removal Plan was not accepted at 2:45 p.m. On 12/8/2023, at 12 p.m., the agency sent a revised IJ Removal Plan, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 12/8/2023, at 12:30 p.m. On 12/8/2023, at 2:30 p.m., the agency sent a revised IJ Removal Plan, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 12/8/2023, at 3 p.m. On 12/8/2023, at 4 p.m., the survey team completed the survey tasks and exited with the IJ situation not removed. On 12/19/2023 the DO reviewed and accepted the written IJ removal plan for L555. A review of the HA’s IJ removal plan indicated the following: On 12/6/2023, Patient 8 received the Gentamycin cream. On 12/6/2023, Patient 9 received the Midodrine and the HA educated the caregiver. On 12/8/2023, all active patients had Comfort Kit medications and care plans were updated. On 12/8/2023 the Director of Nurses (DON) monitored the nursing field visits to the active patients. On 12/11/2023, the HA created a new policy to address changes in condition of a patient and in-serviced the HA staff. On 12/14/2023, the HA updated all active patients’ care plans. On 12/20/2023, the survey team verified the IJ removal plan onsite and removed the IJ for L555 on 12/20/2023 at 1:38 p.m. Cross Reference L650 a. During a review of Patient 1s Admission Record, Patient 1s Admission Record indicated a start of care date of 10/14/2023, with a terminal diagnosis of Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review or Patient 1’s Plan of Care Summary dated 11/15/2023, the Plan of Care Summary indicated a physician’s order dated 10/16/2023, to administer Morphine Sulfate 20 mg (milligrams, a unit of measurement) per ml (milliliter, a unit of measurement) one ml sublingually (under the tongue) every two hours as needed. During a review of Patient 1s History of Visit Note LVN (license vocational nurse) indicated LVN 2 visited Patient 1 one time on 11/22/2023, and one missed visit for the week of 11/19/2023 to 11/25/23. During a review of Patient 1’s Communication Log dated 11/24/2023, timed at 1 p.m., the Communication Log indicated the Case Manager (CM1) received a call from FAM 1 stating a nurse visit was needed and Patient 1 had been declining and exhibited signs of increasing agitation (a feeling of irritability or severe restlessness) and refusing to eat. During an interview on 12/5/2023, at 12:33 p.m., with FAM 1, FAM 1 stated she called the HA on 11/24/2023, at 2 p.m., and spoke to CM 1 (case manager) and requested a nurse visit because Patient 1 was agitated, irritable, uncomfortable, and unable to sleep but no one from the HA came to visit Patient 1. FAM 1 sated Patient 1 ran out of Morphine, and she called the HA on 11/25/2023 multiple times and no one answered. FAM 1 stated she continued to call the HA and no one showed up from 11/24/2023 to 11/26/2023. FAM 1 stated Patient 1 died uncomfortably on 11/27/2023 and she (FAM 1) was upset about it. During an interview on 12/8/2023, at 1 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the HA received a call from FAM 1 on 11/24/2023 that Patient 1 had a COC, and the HA did not visit Patient 1 from 11/24/2023 to 11/26/2023. The DPCS stated patient care visit needed to be provided to Patient 1. The DPCS stated Patient 1s Comfort Kit needed to be available for Patient 1 and Morphine medication should always be available in accordance with the plan of care. b. During a review of Patient 8s Admission Record, the Admission Record indicated a start of care date of 10/14/2023, with a terminal diagnosis of Neoplasm of unspecified behavior of brain (cancerous tumor of the brain). During a review of Patient 8’s Physician Order Sheet dated 11/13/2023, the Physician Orders indicated to provide wound care as follows: 1. Wound 1: Stage 4 (full-thickness skin and tissue loss) in the coccyx (tail bone) pressure injury to cleanse with normal saline (sterile water), pat dry, apply Gentamycin (medication ointment treat skin infections caused by certain bacteria) ointment 0.1 percent, pack with loose gauze and cover with dry dressing daily and as needed. 2. Wound 2: Stage 2 (skin loss, abrasions and blisters) right back pressure injury: to cleanse with normal saline, pat dry, apply Gentamycin ointment 0.1 percent , pack with loose gauze and cover with dry dressing daily and as needed. 3. Wound 3: Stage 2 right shoulder pressure sore: to cleanse with normal saline, pat dry, apply Gentamycin ointment 0.1 percent, pack with loose gauze and cover with dry dressing daily and as needed. During a review of Patient 8’s POC/IDG form, dated 11/29/2023, the POC/IDG indicated the frequency of visits of Licensed Vocational Nurse (LVN) to once per week, social worker (MSW) to conduct initial evaluation within five days of admission then as needed. During an observation on 12/6/2023, at 11 a.m., at Patient 8s residence with LVN 3, Patient 8 was lying in bed. During an interview on 12/6/2023, at 11:30 a.m., with Caregiver 1, Caregiver 1stated she ran out of the Gentamycin ointment for four days and she told LVN 3 about it. Caregiver 1 stated she did not apply the Gentamycin ointment to Patient 8 for four days. During an interview on 12/6/23, at 11:45 a.m., with LVN 3, LVN 3 stated she was aware Patient 8’s Gentamycin ointment was running out. LVN 3 stated she notified the HA and ordered a refill for the Gentamycin ointment from the patient’s pharmacy on 12/2/2023. During an interview on 12/8/23, at 1 p.m., with the DPCS, the DPCS stated LVN 3 should have ordered a refill of the Gentamycin ointment. DPCS stated Patient 8 should always have a supply of Gentamycin ointment to apply at patient’s Stage 4 and Stage 2 open pressure injuries. The DPCS stated Patient 8’s clinical record indicated no documented evidence of a communication note to justify that LVN 3 notified the HA and ordered a refill of Gentamycin ointment for Patient 8. c. During a review of Patient 9s Admission Record, the Admission Record indicated a start of care date of 9/1/2023, with a terminal diagnosis of Alzheimer’s disease. During a review of Patient 9’s Physician Order Sheet dated 9/1/2023, the Physician Orders indicated to administer Midodrine Hydrochloride (medication used to treat low blood pressure) 5 mg (milligrams) one tablet every eight hours for hypotension (low blood pressure), to administer when systolic (measures the pressure in the arteries when the heart beats) B/P (blood pressure) was below 90. During a review of Patient 9’s POC/IDG form dated 11/29/23, the POC/IDG form indicated the frequency of visits of licensed vocational nurse (LVN) to twice per week and as needed, social worker (MSW) to conduct initial evaluation within five days of admission then as needed. Under the Cardiovascular section included in the POC indicated the patient with declining systolic B/P to below 90 related to progression of the disease. The SN (skilled nurse) interventions were to monitor/assess effectiveness of current and new medication/treatment and assess/monitor cardiac status every visits. During a home visit observation at Patient 9s residence with LVN 4 On 12/6/2023, at 12:30 p.m., Patient 9 was lying in bed and LVN 4 took Patient 9’s blood pressure. LVN 4 stated Patient 9s blood pressures reading was 87/49 (low). During an interview on 12/6/2023, at 1 p.m., with Caregiver 2, Caregiver 2 stated Patient 9’s blood pressure reading was around 87/52 for about three days now. Caregiver stated she was aware Patient 9 had the Midodrine medication for her low B/P reading but she was not giving it at all. Patient 9 stated the visiting nurse (in general) did not check Patient 9’s medications during their visits and there was no teaching provided by the visiting nurse on the Midodrine medication so she was scared to give it. During an interview on 12/8/2023, at 11:30 a.m., with the DPCS, stated the HA did not provide teachings to Caregiver 2 for the use of the Midodrine and stated that medication teaching should be provided to patients in accordance with the plan of care. During a review of the agency’s undated policy and procedure titled, “The Plan of Care,” 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, providing care to terminally ill patients who have six months or less to live) failed to ensure one of 14 sampled patients (Patient 1) was treated with dignity, comfort, and respect. On 11/24/2023, at 3 pm, Patient 1s Family Member (FAM 1) called the Case Manager (CM1) to notify the agency Patient 1 was uncomfortable and unable to sleep and Patient 1 ran out of morphine (a prescription medicine used to treat moderate to severe pain). The HA did not send a nurse to Patient 1s home from 11/24/2023 to 11/26/2023. On 11/27/2023 at 12:30 am, FAM 1 called the HA to notify the HA Patient 1 was not breathing. On 11/27/2023 at 1:37 am, LVN 2 saw Patient 1 had expired. While LVN 1 provided postmortem care (the care given once death has occurred) to Patient 1, LVN 1 received a phone call from a different hospice agency and placed the caller on a speaker phone. FAM 1 stated they felt humiliated and shocked the HA did not treat Patient 1 with dignity, comfort, and respect. As a result, the non-compliance resulted in Patient 1 not being treated with comfort, dignity, and respect, and Patient l’s family felt humiliated and disrespected by the HA not responding to Patient 1s comfort needs and placed the HAs remaining 40 active patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, and Patient 40) at risk for not being treated with comfort, dignity, and respect. On 12/7/2023 at 2:25 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agencys Administrator and the Director of Patient Care Services (DPCS) due to the facilitys failure to treat Patient 1 with comfort, dignity, and respect and also placed the remaining 40 active patients at risk for not being treated with comfort, dignity, and respect. On 12/8/2023, at 12 p.m., the agency sent an IJ Removal Plan, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 12/8/2023, at 12:30 p.m. On 12/8/2023, at 2:30 p.m., the agency sent a revised IJ Removal Plan, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 12/8/23, at 3 p.m. On 12/8/2023, at 4 p.m., the survey team completed the survey tasks, and exited with the Immediate Jeopardy not removed. On 12/19/2023 the DO reviewed and accepted the written IJ removal plan for L650. A review of the HA’s IJ removal plan indicated the following: On 12/5/2023, the HA removed LVN 1 from her assignments of direct patient care. On 12/7/2023, the HA developed a Comfort, Dignity, and Respect policy and procedure. On 12/14/2023, the HA called all active patients to ensure the HA treated them with comfort, dignity, and respect. On 12/20/2023, the survey team verified the IJ removal plan onsite and removed the IJ for L650 on 12/20/2023 at 2:11 p.m. Cross Reference L555 Findings: During a review of Patient 1s Admission Record, Patient 1s Admission Record indicated a start of care date of 10/14/2023, with a terminal diagnosis of Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review or Patient 1’s Plan of Care Summary dated 11/15/2023, the Plan of Care Summary indicated a physician’s order dated 10/16/2023, to administer Morphine Sulfate 20 mg (milligrams, a unit of measurement) per ml (milliliter, a unit of measurement) one ml sublingually (under the tongue) every two hours as needed. During a review of Patient 1s History of Visit Note LVN (license vocational nurse) indicated LVN 2 visited Patient 1 one time on 11/22/2023, and one missed visit for the week of 11/19/23 to 11/25/23. During a review of Patient 1’s Communication Log dated 11/24/2023, timed at 1 p.m., the Communication Log indicated the Case Manager (CM1) received a call from FAM 1 stating a nurse visit was needed and Patient 1 had been declining and exhibited signs of increasing agitation (a feeling of irritability or severe restlessness) and refusing to eat. During a review of the facilitys Patient List dated 12/5/2023, indicated the HA had 40 active patients. During an interview on 12/5/2023, at 12:33 p.m., with FAM 1, FAM 1 stated she called the HA on 11/24/2023, at 2 p.m., and spoke to CM 1 (case manager) and requested a nurse visit because Patient 1 was agitated, irritable, uncomfortable, and unable to sleep but no one from the HA came to visit Patient 1. FAM 1 sated Patient 1 ran out of Morphine, and she called the HA on 11/25/2023 multiple times and no one answered. FAM 1 stated she continued to call the HA and no one showed up from 11/24/2023 to 11/26/2023. FAM 1 stated Patient 1 died uncomfortably on 11/27/2023 and she (FAM 1) was upset about it. FAM 1 stated on 11/27/2023, LVN 1 was cleaning the body of Patient 1 and was talking to another nurse on her phone in speaker mode discussing about different task assignment for another patient and FAM 1 could hear out loud the other nurse shouting and saying bad words about their work situation. FAM 1 stated she felt shocked, humiliated, and disrespected by LVN 2 for her inappropriate behavior in front of her siblings while they were grieving. During an interview on 12/6/2023, at 8 a.m., with LVN 1, LVN 1 stated it was her “;job to answer all incoming calls even when providing care to any patient.” During an interview on 12/8/2023, at 12 p.m., with the ADM (administrator), the ADM stated LVN 1’s inappropriate behavior of taking incoming calls while providing patient care was unacceptable, and she should always show respect and professionalism while providing care. During an interview on 12/8/2023, at 1 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the HA received a call from FAM 1 on 11/24/2023 that Patient 1 had a COC, and the HA did not visit Patient 1 from 11/24/2023 to 11/26/2023. The DPCS stated patient care visit needed to be provided to Patient 1. The DPCS stated Patient 1s Comfort Kit (medications kept in the home to quickly treat symptoms that may occur in terminally ill patient) needed to be available for Patient 1 and Morphine medication should always be available in accordance with the plan of care. During a review of the HAs Care of the Dying Patient policy and procedure, with a revised date of May 2023, the Care of the Dying Patient policy and procedure indicated the HA recognized the importance of each patients and family/caregivers unique and individual needs within the home care setting. The policy indicated within the HAs framework, responsive and respectful care for the dying patients will be planned, implemented and monitored in order to: 1.Optimize the patients comfort and dignity. 2.Manage pain and symptoms through interventions that alleviate and/or control pain and assess the patients level of pain control. 3. Identify secondary symptoms, determine the patients response to treatment, and take, action to minimize such symptoms. 4.Cosider the psychosocial, emotional, and spiritual needs of the patient and family/caregiver. 5. Implement bereavement care that supports the patient and family/caregiver units coping mechanisms throughout the grief process.”

“Based on observation, interview and record review, the hospice agency failed to ensure the patient’s medical records were stored and safeguarded against loss and or unauthorized use. This deficient practice placed the patient’s clinical records at risk to be seen by unauthorized users. During an initial tour observation of the hospice agency on 12/5/2023, at 1 p.m., there were 14 boxes filled with patients’ clinical records unlocked stacked on top of each other in one corner by the end wall inside the conference room. There were no staff present in the room. During an interview on 12/5/2023, at 2 p.m., with the administrator (ADM), the ADM stated he would make sure the patients’ medical records were stored in a locked cabinet to keep the patients’ medical records protected from unauthorized users. A review of agency’s policy “ Protection of Records,” indicated that medical records should be stored in cabinets locked if not in use.”