Hospice By the Sea Inc.

“Observed in Building Tour. The door pair marked as an EXIT in the Long Term Care unit adjacent to the John Knox Inpatient Hospice Unit was equipped with delayed egress door hardware; however, there was no PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS sign on the door adjacent to the releasing device as required by NFPA 101-2012, 7.2.1.6.1.1(4). This exit served as one of the two required exits from the hospice unit. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission. Observed in Building Tour. A door pair marked as an EXIT at the end of the corridor by staff lounge 133 in the John Knox Inpatient Unit had a sign on the door that stated Staff Only thereby confusing the direction of egress. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission. Observed in Building Tour. Two 95-gallon red biohazardous waste containers were stored in a corridor closet by patient room 711. This closet was NOT protected as a hazardous area as the sliding doors to this closet were NOT self-closing or positive latching. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission. Observed in Building Tour. An open 1-inch conduit that penetrated the smoke barrier wall above the ceiling in the corridor by mechanical room 102 was NOT sealed. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission.”

“Observed in Building Tour. Three (3) electrical outlets within 5 feet of the sink in Nutrition Room 131C at the John Knox Inpatient Unit were NOT a ground-fault circuit interrupter (GFCI) protected circuit. This was verified by the Facilities Director. Observed in Building Tour. Five (5) unsecured oxygen H cylinders were observed outside in the oxygen manifold area. A securing chain was present, but was NOT in use. This was verified by the Facilities Director. Observed in Building Tour. Two (2) electrical outlets within 4 feet of the sink in the Medication room were NOT a ground-fault circuit interrupter (GFCI) protected circuit. This was verified by the Facilities Director.”

“Observed in Tracer Activities. During the tour of John Knox IPU, the unit manager confirmed that three of the ten room refrigerators had temperatures out of range during the last 37 days. Specifically, there were between five and ten days for each of those refrigerators that were out of range with no action documented. Observed in Tracer Activities. During the tour of the IPU in Boca, the Hospice Nurse surveyor noted that in the family room the refrigerator for family and guest use did not have a temperature documented on April 12. This was validated in a discussion with and observation by the OPEX Specialist.”

“Based on record review and interview, the Hospice failed to ensure the continuous assessment of each patient’s and family’s needs and implementation of the Interdisciplinary Plan of Care for 2 of 3 sampled patients as evidenced by the lack of written documentation of the weekly Skilled Nurses visits, as per the patients’ Plan of Care (Patient #1 and #2). The findings included: 1) Review of Patient #1s clinical record documented an admission to Hospice care on 05/08/24. Review of the physician’s order dated 05/09/24 documents a SN (Skilled Nurse) visits weekly for 8 weeks effective 05/12/24. Review of the patients record reveals no evidence of documentation of the physician’s ordered weekly Skilled Nurse’s visit for the week of May 12th through 18th; the week of May 26th through June 1st; the week of June 9th through June 15th and the week of June 23rd through June 29th. Review of Patient #1s Plan of Care (POC) dated 06/26/24 documents a physician’s order for a Skilled Nurse visit weekly for 8 weeks, effective 07/07/24. Review of the patients record reveals no evidence of documentation of the physician’s ordered weekly Skilled Nurse’s visit for the week of July 14th through July 20th and the week of July 28th through August 3rd. Review of Patient #1s “Coordination Notes” reveals a lack of written documentation regarding these multiple “missed” Skilled Nurse visits. On 08/28/24 at 9:10 AM, a side-by-side review of Patient #1s clinical record was conducted with the Compliance Resource Nurse (CRN). who confirmed Patient #1s missed visits, and the review of the patients “Coordination Notes” reveal no evidence of documentation of an explanation regarding the patients missed visits. On 08/28/24 at 10:00 AM, a joint interview was conducted the Corporate Compliance Officer (CCO) and the CRN; the CCO was apprised of Patient #1s missed Skilled Nurse visits; the CCO stated the way the “system” works is that whenever there is a visit, it populates to the calendar, when a scheduled visit is missed, it is removed from the calendar because it was not completed; the CCO stated that a missed visit is either documented on the “Coordination Notes” or the “Missed Visit Report;” a “missed visit “;extra context is needed to be written on the “Coordination Notes; the CCO was apprised of the lack of written documentation related to the missed visits under the “Coordination Notes” section; a side-by-side report of patients missed visits provided by the CCO was reviewed by the CRN; the report reveals reasons (codes) for missed visits as scheduling conflict, duplicate visit and/or caregiver or patient request day outside of the “Medicare week;” the CRN was asked to explain the report codes and the CRN asked to discuss it with the RN/Case Manager. On 08/28/24 at 10:35 AM, an interview via a telephone conference call was conducted with Staff A, Registered Nurse (RN) Case Manager (CM), Staff B, Team Manager and the CRN; Staff A stated Patient #1 was very difficult to get in touch with, (they) never got an answer when calling the patient, and never received a call back from the patient; Staff A stated for missed visits, she will have to write a narrative but uses the “missed visit template” (report) to avoid a writing repetition; Staff A, and Staff B were apprised that the patients “Coordination Notes” section lacks written documentation of the reason for Patient #1s multiple missed Skilled Nurse visits; Staff B, Manager stated it would be nice to have another nurse, “;unfortunately we dont have an extra nurse” and added that they have to triage the patient and sometimes the visit has to be moved; they cant always “cover” the patients visits; Staff B stated most of the patients must have a visit once a week, and sometimes not everybody can be seen, “;unfortunately”; Staff B stated her manager was aware of that; Staff B stated that patients do request not to be seen and that she encourages the nurses to document missed visits and added that she understands the records reviewed do not reflect that; she has addressed that with the nurses and the nurses are “working on that.” 2) Review of Patient #2s clinical record documented an admission to Hospice care on 02/08/24. The physician’s order dated 02/27/24 documents SN (Skilled Nurse) visits weekly for 10 weeks effective 02/25/24. Review reveals the patients record lacked written documentation of a weekly Skilled Nurse visit for the week of March10th through 16th and the week of April 14th through 20th. Review of Patient #2s POC (Plan Of Care) certification period from 05/08/24 to 08/05/24 documents a physician’s order for a Skilled Nurse visit weekly for 13 weeks, effective 05/08/24. Review reveals the patients record lacked written documentation of a weekly Skilled Nurse visit for the week of May 19th through 25th the week of June 2nd through 8th and the week of June 16th through 22nd. On 08/28/24 at 9:45 AM, a side-by-side review of Patient #2s clinical record was conducted with the Compliance Resource Nurse (CRN) who confirmed Patient #2s missed visits documentation. Review of the patients “Coordination Notes” lacks written documentation with an explanation regarding the patients missed visits. On 08/28/24 at 10:00 AM, a joint interview was conducted the Corporate Compliance Officer (CCO) and the CRN; the CCO was apprised of Patient #2s missed Skilled Nurse visits; the CCO stated the way the “system” works is that whenever there is a visit, it populates to the calendar, when a scheduled visit is missed, it is removed from the calendar because it was not completed; the CCO stated that a missed visit is either documented on the “Coordination Notes” or the “Missed Visit Report;” a “missed visit “;extra context is needed to be written on the “Coordination Notes; the CCO was apprised of the lack of written documentation related to the missed visits under the “Coordination Notes” section; a side-by-side report of patients missed visits provided by the CCO was reviewed by the CRN; the report reveals reasons (codes) for missed visits as scheduling conflict, duplicate visit and/or caregiver or patient request day outside of the “Medicare week;” the CRN was asked to explain the report codes and the CRN asked to discuss it with the RN/Case Manager. On 08/28/24 at 10:35 AM, an interview via a telephone conference call was conducted with Staff A, Registered Nurse (RN) Case Manager (CM), Staff B, Team Manager and the CRN; Staff A stated for missed visits, she will have to write a narrative but uses the “missed visit template” (report) to avoid a writing repetition; Staff A, and Staff B were apprised that the patients “Coordination Notes” section lacks written documentation of the reason for Patient #2s multiple missed Skilled Nurse visits; Staff B, Manager stated it would be nice to have another nurse, “;unfortunately we dont have an extra nurse” and added that they have to triage the patient and sometimes the visit has to be moved; they cant always “cover” the patients visits; Staff B stated most of the patients must have a visit once a week, and sometimes not everybody can be seen, “;unfortunately”; Staff B stated her manager was aware of that; Staff B stated that patients do request not to be seen and that she encourages the nurses to document missed visits and added that she understands the records reviewed do not reflect that; she has addressed that with the nurses and the nurses are “working on that.””

“Based on review of the Hospice’s Policies, record review and interview, the Hospice failed to follow the physician’s Plan of Care for 2 of 3 sampled patients (Patient #1 and #2). The findings included: 1) Review of the Hospice’s Policy titled, “;Plan of Care- Chapter 8 Provision of Care” revised on 03/2023 documents, “;...hospice in collaboration with the patient and family, develops an interdisciplinary plan of care (POC)...the initial POC is established before services are provided... team members shall document the patient/family agreement with the POC...” Review of the Hospice’s Policy titled, “;Interdisciplinary Plan of Care- Chapter 8 Provision of Care” revised on 03/2023 documents, “;The POC is developed to address the immediate needs identified in initial assessment and established before care, treatment and services are provided...the interdisciplinary team collaborates with the patient, family, physician...in developing a comprehensive plan of care that includes the following: a statement of the scope and frequency of services needed to meet the patients and familys needs...” Review of Patient #1s clinical record documents an admission to Hospice care on 05/08/24 and a physician’s order, dated 05/09/24 documents a SN (Skilled Nurse) visit weekly for 8 weeks effective 05/12/24. Review of Patient #1s clinical record reveals the following completed Skilled Nurse visits on: 05/09/24, 05/23/24, 06/07/24, a Skilled Nurse “Recertification” visit on 06/20/24 with a subsequent Skilled Nurse visit on 07/02/24. Review reveals a lack of weekly Skilled Nurse visits, as per the physician’s order, dated 05/09/24. Further review reveals the lack of a Skilled Nurse visit for the week of May 12th through 18th; the week of May 26th through June 1st; the week of June 9th through June 15th; and the week of June 23rd through June 29th. Review of Patient #1s POC, dated 06/26/24 documents a physician’s order for a Skilled Nurse visit weekly for 8 weeks effective 07/07/24. Review of Patient #1s clinical record reveals the following Skilled Nurse visits on 07/11/24, 07/22/24, 08/05/24 and 08/13/24. Further review reveals a lack of weekly Skilled Nurse visits as per the physician’s order dated 06/26/24 and the patient did not have a Skilled Nurse visit the week of July 14th through July 20th; and the week of July 28th through August 3rd. On 08/28/24 at 9:10 AM, a side-by-side review of Patient #1s clinical record was conducted with the Compliance Resource Nurse (CRN); the CRN confirmed Patient #1s physicians’ orders for a weekly Skilled Nurse visit was not done as ordered. On 08/28/24 at 10:00 AM, a joint interview was conducted the Corporate Compliance Officer (CCO) and the CRN; the CCO was apprised of the Skilled Nurse visits not being completed as per the physicians order. On 08/28/24 at 10:35 AM, an interview via a telephone conference call was conducted with Staff A, Registered Nurse (RN) Case Manager (CM), Staff B, Team Manager and the CRN; Staff A stated Patient #1 was very difficult to get in touch with, never got an answer when calling the patient, never received a call back from the patient; Staff A, and Staff B were apprised that the patients “Coordination Notes” section lacks written evidence of the reason for Patient #1s multiple missed Skilled Nurse visits; Staff B stated it would l nice to have another nurse, “;unfortunately we dont have an extra nurse” and added that they have to triage the patient and sometimes the visits have to be moved; they cant always cover the patients visits; Staff B stated most of the patients must have a visit once a week, and sometimes not everybody can be seen, “;unfortunately” and Staff B stated her manager was aware of that. 2) Review of Patient #2s clinical record documented an admission to Hospice care on 02/08/24 and the physician’s order, dated 02/27/24 documents a SN (Skilled Nurse) visits weekly for 10 weeks effective 02/25/24.Review of Patient #2s clinical record reveals the following completed Skilled Nurse visits on, 02/28/24, 03/07/24, 03/18/24, and 04/09/24. Further review reveals a lack of weekly Skilled Nurse visits as per the physician’s order, dated 02/25/24. Continued review reveals the patient did not have a Skilled Nurse visit the week of March10th through March 16th and the week of April 14th through April 20th. Review of Patient #2s POC (Plan Of Care) certification period from 05/08/24 to 08/05/24 documents a physician’s order for a Skilled Nurse visit weekly for 13 weeks, effective 05/08/24. Review of Patient #2s clinical record reveals the following completed Skilled Nurse visits on 05/09/24, 05/17/24, 05/30/24, 06/11/24, 06/24/24 and 07/03/24. Review reveals a lack of weekly Skilled Nurse visits as per the physician’s order, effective on 05/08/24. Continued review reveals the patient did not have a Skilled Nurse visit the week of May 19th through 25th, the week of June 2nd through 8th, and the week of June 16th through 22nd. On 08/28/24 at 9:45 AM, a side-by-side review of Patient #2s clinical record was conducted with the Compliance Resource Nurse (CRN) who confirmed that Patient #2s physician’s orders for a Skilled Nurse weekly visit was not done as ordered.”