Morning Breeze Hospice Inc.

“Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #7 was admitted 12/04/24, and as of 12/12/24 there was no evidence of an Initial Bereavement Risk Assessment completed.”

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 IDG/ Nurse note 8/28/24 included discussion of a new wound and orders from Omni Wound Physician. The plan of care nor the “issues/problems” for Integumentary were updated to reflect the new wound. The wound care orders from Omni Wound Physician were in a coordination letter, however; the orders were not transcribed to the Medication/ Treatment profile and Plan of Care.”

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #3 IDG/ Nurse note 8/28/24 included discussion of a new wound and orders from Omni Wound Physician. The plan of care nor the “issues/problems” for Integumentary were updated to reflect the new wound. The wound care orders from Omni Wound Physician were in a coordination letter, however; the orders were not transcribed and documented on the Plan of Care.”

“Upon personnel record review, 3 of 15 (Personnel #9, 14, 15) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #9, 14, 15: There is no evidence that personnel #9 had emergency preparedness training. There are no personnel files available personnel #14,15 for bereavement and volunteer coordinators during survey.”

“Upon patient record review, 6 of 14 (Patient #2, 3, 9, 10, 12, 13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2: Patient is transfer in, but there is no documented evidence that the receiving hospice gave patient the opportunity to choose attending physician. There is an Election of Medicare Hospice Benefit form signed, but space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed. Patient #3: Patient is transfer in, but there is no documented evidence that the receiving hospice gave patient the opportunity to choose attending physician. Patient #9: Election of Medicare Hospice Benefit form signed, but space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed. Patient #10: Election of Medicare Hospice Benefit form signed, but space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed. Patient #12: No election statement at all or therefore, no documented evidence patient chose physician. Patient #13: Election of Medicare Hospice Benefit form signed, but space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed.”

“Upon patient record review, 3 of 14 (Patient #1, 3, 4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: 3/18/24 order for Triple Antibiotic First Aide Topical ointment as needed infection. No site specified. 4/5/24 MD order miswritten as Tobramycin/Dexamethasone 0.3%-0.1% Ophthalmic suspension 1 tab as needed for no BM x 5 days. Patient #3: Ciprofloxacin 0.3% ophthalmic 2 drops qid x 7 days. does not specify which or both eyes and Gentamicin 0.3 sulfate ophthalmic solution 2 drops as needed. Does not specify which or both eyes. Systane Balance 0.6% lubricant eye drops 2x/day as needed. Does not specify which or both eyes. Patient #4: During home visit to patient, noted that patient’s routine medications had not yet been added to agency medication profile. Nurse stated that they were in “que” for physician to sign, but office staff unable to verify. Those medications included Losartan, Amolodipine, Aricept, Flomax, Vit D3, Lipitor, Lidocaine patches.”

“Upon patient record review, 2 of 14 (Patient #1, 8) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #1: 4/24/24 Nurse instructed daughter use Fleet saline rectal enema every week as needed if no BM in 1 week per md order. Last BM documented as 4/22/24. Order actually written as Fleets Enema 1 bottle as needed for no BM x 5 days. Patient #8: Patient had order for infusion secondary to dehydration. 2/6/23 order for 1/2 NS 50/ml/hr x 250 ml/day x 3 days. RN visit 2/8/24 (Thursday) when documented initiated peripheral IV and administered fluid. 2/9/24 (Friday). IV flushed with normal saline... no resistance felt. No s/sx of infiltration. 250 ml to be administered at 50 ml/hr. RN to follow up on Monday to remove IV. Reeducated. Documentation did not confirm specific education to family in regards to infusion and IV site management over the 3 days therapy was ordered.”

“Upon patient record review, 2 of 14 (Patient #3, 8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3: RN initial assessment notes stage 2 pressure ulcer note on patient’s medial right buttock. Family educated on importance of pressure offloading.... There are supply orders listed: 1/4/24 island dressing 4x4, 1/10/24 2x2 island dressing and Medihoney 2 tubes, but no related treatment order. Initial POC includes Ciprofloxacin 0.3% ophthalmic 2 drops qid x 7 days, does not specify which or both eyes and Gentamicin 0.3% sulfate ophthalmic solution 2 drops as needed. Does not specify which or both eyes. Systane Balance 0.6% lubricant eye drops 2x/day as needed. Does not specify which or both eyes. Patient #8: 2/6/23 order for 1/2 NS 50/ml/hr x 250 ml/day x 3 days. RN visit 2/8/24 (Thursday) when documented initiated peripheral IV and administered fluid. 2/9/24 (Friday). IV flushed with normal saline... no resistance felt. No s/sx of infiltration. 250 ml to be administered at 50 ml/hr. RN to follow up on Monday to remove IV. Orders were unclear if patient CG was to administer 3rd day of fluids. Additionally, there were no orders specific to peripheral IV management including no order for flushes/frequencies.”

“Upon client record review, 4 of 14 (Patient #1, 7, 9, 12) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #1: IDG meeting 2/22/24, 3/7/24, 3/21/24, 4/18/24, 5/2/24 have signatures by RN and physician only. Patient #7: IDG meeting 9/14/23, 9/28/23, 10/26/23, 11/09/23, 11/23/23, 12/07/23 signature by RN only. Patient #9: IDG meeting 12/7/23, 12/21/23, 1/4/24, signature by RN and MD only. Patient #12: IDG meeting 2/2/24, 2/14/24, 2/22/24, 3/7/24, 3/22/24, 4/5/24 by RN and MD only. Staff interview confirmed that electronic signatures are only verification of IDG participation. They report attendance of all required disciplines, but documentation does not confirm.”

“Upon patient record review, 5 of 14 (Patient #1, 2, 3, 5, 8) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #1: Admitted 7/17/23. 4/8/24 SN documented new wounds, “red” and initiated new wound care, but no update to IDG POC regarding treatment. Patient #2: SC initially documented as declined. Order 4/18/24 that patient daughter accepted SC with frequency of once/recert period and 2 prn. The IDG POC was not updated to reflect the current SC frequency. (4/18/24, 5/2/24 IDG meetings) Patient #3: Problem of impaired skin integrity r/t stage 2 decubitis. Proper goals and interventions, but states stage 2 on sacrum on IDG POC and identifies mid buttock in visit assessment/notes. No orders for wound care in record and no recent reference to wound care. 5/2/24 IDG note says no pressure sore noted or skin breakdown, but problems, goals, interventions not updated to reflect changes in status. Patient #5: Received orders for IVF secondary to dehydration (but unable to start IV). There were no Problems, goals, interventions related to dehydration in GI/nutrition included in IDG POC. Patient #8: Received orders for IVF secondary to dehydration with no update to problems, goals, interventions.”

“Upon client record review, 7 of 14 (Patient #1, 2, 5, 7, 9, 12, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: 5/6/24 SN note. Skin tear thigh. Nurse advised clean with NSS and apply island dressing. No order documented. In addition,3/18/24 order for Triple Antibiotic First Aide Topical ointment as needed infection. No site specified. 4/5/24 MD miswritten as Tobramycin/Dexamethasone 0.3%-0.1% Ophthalmic suspension 1 tab as needed for no BM x 5 days. 4/8/24 SN visit, nurse wrote: Redness on patient right foot, left foot measure 2cm x1cm and coccyx area (measure 6 cm x1cm). Skin intact. No drainage or odor. MD notified. Treatment. Cleanse with NSS pat dry and covered with island dressing. The treatment is still being provided. Frequency of treatment/dressing change unclear. No order was actually written and not included in Plan of Care other than as a supply order. Patient #2: Transferred in from another hospice 1/11/24. MSW initial visit 1/11/24 with 1/11/24 frequency order for MSW every recertification and 2 prn. There was no visit documented for 3/2-4/30/24 recertification period. Patient #5: MD ordered peripheral infusion r/t dehydration on 3/21/24. Nurse did not follow POC until 7 days later and no explanation documented for delay of care. Patient #7: Admitted 7/31/23. No discipline frequency orders included in POC until 10/12/24 when added SN 2/wk and 3 prn. There were no orders updated to include MSW/SC. MSW visits 9/20/23 and 12/14/23. SC made visits 9/28/23 and 12/08/23. SN visits made 2x/week (including 9/25, 9/28; 10/2, 10/5) Patient #8: 2/23/23 visit LVN stage 3 pressure ulcer on coccyx area and stage 2 ulcer on right lower back. SN cleanse wound with NSS. Pat dry and covered with island dressing. There is no order for wound care, (other than items listed as supply orders). Patient #9: Admitted 4/22/23. No MSW/SC discipline frequency orders included in POC. MSW (7/14/23, 10/10/23, 1/10/24) and SC (5/25/23, 8/10/23, 11/8/23, 1/19/24) visits made with no orders. Patient #12: Patient on service 1/26/23-4/18/24. Initial and ongoing POC frequency: LCSW 1/month and 1 prn. SC 1/month and 2 prn. SN 1/wk and 3 prn. Only nursing visits provided. There were no SW/SC visits at all. Patient #13: Patient on service 1/6/23-1/9/23. IDG/POC frequency HA 3x/week. There was no other ordered frequency for other disciplines, including SN. SN saw patient 1/9/23.”

“Upon patient record review 1 of 14 (Patient #12) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #12: Communication noted call from LVN and left message that patient complains of both eyes watery in the evening and requests for eye drops. Patient is also concerned about right big toe fungus. No pain. Patient would like MD advice to see if it is treatable or if it should be left alone. Please provide advice. There was no documented evidence of additional communication and/or follow and no update to POC.”

“Upon patient record review, 6 of 14 (Patient #6, 7, 8, 9, 10, 11) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients #6, 7, 8, 9, 10, 11: There is no evidence of post-death bereavement risk assessment and offer of bereavement services and/or declination of services documented in patient record. There are no post death bereavement care plans and no post death bereavement activity.”

“Upon personnel record review, 1 of 15 (Personnel #6 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #6: There is no documented competency assessment/validation”

“Upon patient record review 1 of 14 (Patient #12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #12: Admitted 1/26/23. HA visits documented as provided 1/31/23 and 2/2/23, per HA Care Plan. However, there was no physician order and no HA frequency in Plan of Care. There were no other visits after 2/2/23.”

“Upon patient record review 1 of 14 (Patient #3) did not have evidence in the patient record that the hospice aides report: • Changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice’s policies and procedures Patient #3: 2/20/24 communication note and HA note 2/19/24 regarding patient CG chief complaint: no early visit, no late visit, no weekend visits too and he like to bed bath next visit, and reported could not come to an agreement with patient son on weekend visit. The HA documented reported to office staff. There was no documented evidence of communication to RN and/or RN follow up with family regarding any revision to HA scheduled/assignment/frequency.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was no evidence the governing body ensured HR requirements such as job descriptions, orientation, competencies were conducted for staff, oversee and ensure Medicare regulations and billing requirements are met with appropriate election of benefit forms and admission process and certification of terminal illness by physicians and face-to-face requirements met, ensure core and non-core services are available , establish bereavement program, or volunteer recruitment/retention and use of volunteer(s).”

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Agency does not demonstrate capability to provide bereavement services or volunteer services. There were no personnel files for bereavement and volunteer coordinators available to confirm capability at time of survey.”

“Upon patient record review, 10 of 14(Patient #4-11, 13,14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient #4: Admitted 5/10/24. The initial CTI includes no documented narrative by physician to support eligibility. Patient #5: Admitted 3/20/24. The initial CTI includes no documented narrative by physician to support eligibility. Patient #6: Admitted 4/18/24. The initial CTI includes no documented narrative by physician to support eligibility. Patient #7: Admitted 7/31/23 in Benefit Period 7. The initial CTI (Benefit #7) includes no documented narrative by physician to support eligibility Patient #8: Admitted 7/21/23. The initial CTI includes no documented narrative by physician to support eligibility. Patient #9: Admitted 4/22/23. The initial CTI includes no documented narrative by physician to support eligibility Patient #10 Admitted 4/13/23. The initial CTI includes no documented narrative by physician to support eligibility Patient #11: Admitted 4/5/23.The initial CTI includes no documented narrative by physician to support eligibility Patient #13: Admitted 1/6/23. The initial CTI includes no documented narrative by physician to support eligibility Patient #14: Admitted 1/29/24. The initial CTI includes no documented narrative by physician to support eligibility”

“Upon patient record review, 6 of 14 (Patient #1, 2, 3, 7,8,9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. Patient #1: CTI Benefit period 4 (3/13-5/11/24) signed 3/18. No verbal recertification documented. Also, no physician narrative to support eligibility. Patient #2: CTI Benefit period 4 (3/2-4/30/24) signed 3/11. No verbal recertification documented. CTI Benefit period #5 (5/1-6/29/24) signed 5/18. No verbal recertification documented. Patient #3: CTI Benefit #5 (4/10/24-6/8/24) signed 4/15. No documented verbal recertification. Patient #7: Patient admitted in Benefit period #7. CTI Benefit Period 7 (7/31/23-9/28/23) signed 10/26/23. No verbal recertification documented. Also, CTI for Benefit Periods 8, 9 include no physician narrative to support eligibility. Patient #8: CTI for Benefit Periods 2, 3 include no physician narrative to support eligibility. Patient #9: CTI for Benefit Periods 2, 3, 4 include no physician narrative to support eligibility.”

“Upon patient client record review, 8 of 14 (Patient #2, 3, 8, 9, 10, 12, 13, 14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: Transferred in from another hospice provider. There is no documented evidence that patient had the right to choose attending physician. Although there was a signed Medicare Hospice Benefit election form, the space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed. The space allocated for hospice services to begin on..... is also left blank. Patient #3: Transferred in from another hospice provider. There is no Medicare Hospice Benefit election and no other space or evidence that patient had the right to choose attending physician for receiving hospice. Patient #8: There was no documented evidence of consent form, including evidence patient received copies of the notice of patient rights. Patient #9: Although there was a signed Medicare Hospice Benefit election form, the space allocated for the effective date/services to begin and the space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed. The space allocated for hospice services to begin on..... is also left blank. There was no documented evidence of consent form, including evidence patient received copies of the notice of patient rights. Patient #10: Although there was a signed Medicare Hospice Benefit election form, the space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed. The space allocated for hospice services to begin on..... is also left blank. MD choice completely blank Patient #12: There is no Medicare Hospice Benefit election form at all. There is therefore, no documented effective date for services to begin and and no other space or evidence that patient had the right to choose attending physician for receiving hospice. Patient #13: Although there was a signed Medicare Hospice Benefit election form, the space allocated for the effective date/services to begin and the space allocated for patient’s right to choose attending physician is blank. There is no box checked for I do not choose... or my choice for my attending physician is.... and no physician information completed. Patient #14: There was no documented evidence of consent form, including evidence patient received copies of the notice of patient rights.”

“Upon patient client record review, 3 of 14 (Patient #4,5,7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: CTI is signed 5/13/24. There is a verbal certification date entered as 5/10/24, but the space for obtained by is left blank. Patient #5: Order for IVF 3/21/24. Visit made 3/28/24. RN documented Attempted multiple times to start PIV, however unsuccessful. Spoke with daughter who was present at bedside. Daughter reports that patients is a hard stick and not to attempt starting anymore IVs. IDT and doctor made aware. Documentation is incomplete in regards to IV attempts. Patient #7 Comprehensive assessment. Signed by PM RN to close note on behalf of staff assigned. Date 11/09/23. Staff assigned shown to be NMH, RN.”