Amenity Health Care Inc.

“Based on a review of the hospice’s Emergency Preparedness Program and Plan, and staff interview, it was determined the hospice failed to ensure that it conducted the required Agency and community exercises bi-annually to ensure the effectiveness of the hospice’s Emergency Preparedness Plan. This has the potential to affect all patients receiving hospice services. Findings Include: 1. The hospice’s Emergency Preparedness Plan was reviewed on 6/5/24. The Plan lacked documentation that full-scale community or individual testing exercises were conducted by the hospice for the years reviewed (2022, 2023 and 2024). 2. During an interview with the Medical Director on 6/6/23 at 10:45 AM, it was confirmed the hospice failed to provide a full-scale individual or community-based Emergency Preparedness testing of its Emergency Plan for the years reviewed.”

“Based on clinical records review, hospice policy review and staff interview, it was determined that the hospice failed to ensure bereavement services were provided to the bereaved after patients expire. This was found in 3 of 3 (Patients #15,16 and 17) clinical records reviewed. Findings include: 1. Pt #15 was admitted to hospice services on 6/27/23 with Diagnosis of Chronic Diastolic (congestive) Heart failure. The clinical record was reviewed on 6/4/24. The clinical record contained a discharge summary indicating Pt #15 expired on 7/3/23. The clinical record lacked documentation indicating bereavement services were provided after patient expired. 2. Pt #16 was admitted to hospice services on 6/12/23 with Diagnosis of Malignant Neoplasm of Upper-Outer Quadrant of Left Female Breast. The clinical record was reviewed on 6/4/24. The clinical record contained a discharge summary indicating Pt#16 expired on 6/21/23. The clinical record lacked documentation indicating bereavement services were provided after patient expired. 3. Pt #17 was admitted to hospice services on 6/8/23 with Diagnosis of Cerebral Infarct due to Unspecified Occlusion of Cerebral Artery. The clinical record was reviewed on 6/4/24. The clinical record contained a discharge summary indicating Pt #17 expired on 6/15/23. The clinical record lacked documentation indicating bereavement services were provided after patient expired. 4. The hospice policy titled “Scope of services - Bereavement” was reviewed on 6/4/24, the policy required...”...B.. Following the Death...1...Within 1 month after the death, bereavement services will be offered to those identified by the IDT....3..Contact with bereavement clients will be maintained for a period of at least 13 months following the death of the patient unless there is documented evidence of services being refused.” 5. During an interview with the Director of Nursing on 6/5/24 at 2:00 PM. The Director of Nursing confirmed patients did not contain a bereavement follow up after death.”

“Based on a review of clinical records, hospice policy, and staff interview, it was determined that in 6 of 19 (Patients #6, 9, 11, 19, 12, and 14) clinical records reviewed, the hospice failed to ensure clinical documentation entered into the clinical record was complete and/or entered in a timely manner. 5. Pt #12 was admitted for hospice services on 11/21/23 with Diagnosis of Senile Degeneration of the Brain. The clinical record was reviewed on 6/4/24. The record contained an “;IDG Meeting Report” for the certification period of 2/10/24 to 5/18/24 requiring: HHA Frequency: 2 times a week for 13 weeks start date 2/19/24 end date 5/18/24. The record lacked documentation of an aide visit note for the week of 4/14/24 to 4/20/24. The aide visit was conducted on 4/19/24 but as of 6/6/24, the aide visit note was not incorporated into the clinical record. 6. Pt #14 was admitted for hospice services on 4/7/23 with the Diagnosis of Malignant Neoplasm of right female breast. The clinical record was reviewed on 6/4/24. The record contained an “;IDG Meeting Report” for the certification period of 4/1/24 to 5/30/24 requiring: HHA Frequency: 2 times a week for 9 weeks start date 4/1/24 end date 5/30/24. The record lacked documentation of an aide visit note for the week of 4/14/24 to 4/20/24. The aide visit was conducted on 4/19/24 but as of 6/6/24, the aide visit note was not incorporated into the clinical record. 7. The policy “;Clinical Records” dated 12/2019 was reviewed on 6/6/24 and required: “;6. Documentation will be accurate and readily available to the attending physician and (Hospice) staff...Procedure...2. All entries shall be current. Entries are required to be made within 24 hours of collection of the data.” 8. The policy “;Wound Care” was reviewed on 6/6/24 and required: “;Documentation of wound assessment and management is completed in the EMR. 9. During an interview with the Director of Nursing on 6/6/24 at 9:45 AM and at 11:00 AM, it was stated that the documentation in the clinical record should be complete, and the visit note should be incorporated into the record after the visit is completed. During the same interviews, the above findings were confirmed. Findings include: 1. Pt #6 was admitted for hospice services on 9/6/23 with Diagnosis of Unspecified Cerebrovascular Disease. The clinical record was reviewed on 6/4/24. The record contained the “Hospice Nursing Clinical Note” for services the registered nurse provided weekly from 4/1/24 to 5/21/24 that included, the Pt had a “right elbow pressure ulcer” wound. The Clinical Note required the nurse to document information of each wound which included: Stage, length, width, square centimeters, depth, undermining, tunneling; description of the surrounding tissue, wound bed, and drainage if present. The weekly Clinical Notes lacked a description of the wound, as required by the hospice. 2. Pt #9 was admitted for hospice services on 5/16/24 with Diagnosis of End Stage Renal Disease. The clinical record was reviewed on 6/5/24. The record contained the “Hospice Nursing Clinical Note” for services the registered nurse provided weekly from 5/20/24 to 6/3/24 that included: “Pt has multiple skin tear on bilateral arms and legs that requires wound care at least 3 a week”. The weekly Clinical Notes lacked a description of the skin tears, as required by the hospice. 3. Pt #11 was admitted for hospice services on 1/18/24 with Diagnosis of Unspecified Cerebrovascular Disease. The clinical record was reviewed on 6/6/24. The record contained the “Hospice Nursing Clinical Note” for services the registered nurse provided 1 to 2 times a week from 4/2/24 to 5/20/24 that included, the Pt had an “unstageable sacral ulcer” wound. The Clinical Notes lacked a description of the sacral ulcer, as required by the hospice. 4. Pt. #19 was admitted for hospice services on 12/19/23 with Diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 to 4/ Unspecified Chronic Kidney Disease. The closed clinical record was reviewed on 6/5/24. The record contained the “Hospice Nursing Clinical Note” for services provided 1 to 2 times a week by the registered nurse from 1/3/24 to 1/16/24 that included, the Pt had a “stage 2 right inner thigh pressure ulcer” wound. The “Hospice Nursing Clinical Note” for services provided 1 to 2 times a week by the registered nurse from 1/5/24 to 1/16/24, included the Pt had an “unstageable left ischium pressure ulcer” wound. As of 6/5/24, the Clinical Notes lacked a description of both wounds. The Pt revoked hospice on 1/18/24.”