Community Hospice

“Based on record review and interview the agency failed to ensure the Medical Social Worker had completed their evaluation visit within 5 days of the date of election, in 1 of 17 active clinical records, of 23 total records reviewed. (Patient #21) Findings include: 1. Review of an agency document revised June 2022, titled HOSPICE – Initial Assessment indicated, “;PURPOSE To provide guidelines for the initial assessment and Plan of Care (POC) for patients in the Hospice setting ... POLICY STATEMENT: ... 4. The Interdisciplinary Group (IDG), in consultation with the patients physician, will complete the comprehensive assessment no later than five (5) calendar days after the election of Hospice care ...” 2. Review of the clinical record for Patient #21 with an Election of Benefit date of 03-20-2024 and a benefit period of 03-20-2024 to 06-17-2024, The record contained a communication note dated 03-20-2024, which detailed a conversation between Social Worker (SW) 4 and a family member, the note went on to detail two additional attempts made to reach another family member. No other calls or attempted contacts were documented after that day. The Social Work evaluation visit did not occur until 03-28-2024. 3. On 04-05-2024 at 11:00 AM when queried as to Patient #21’s schedule and the Social Work evaluation visit not occurring until 03-28-2024, the Quality Control Coordinator indicated the Social Worker usually aims for the fifth day, often goes on day five, and confirmed there were not other calls or contacts documented after 03-20-2024 from SW 4 made to the patient or family. Indicated would have expected another attempt would have been made, and indicated SW 4 could have done so but had not documented this. On 04-05-2024 at 11:51 AM in an interview regarding Patient #21, SW 4 indicated their usual practice was to contact a patient/family within the first five days, and could call on day one. Indicated had spoken to a family member on 03-20-2024 who was not with the patient, and called another family twice but received no response. Indicated did not have any additional contact between 03-20-2024 and 03-28-2024.”

“Based on observation, record review, and interview, the hospice agency failed to ensure all medications were reviewed during the comprehensive recertification assessment and failed to ensure an accurate medication list was maintained for 3 of 6 active patient records reviewed with at least one recertification benefit period (Patient #2, 9 and 17). Findings include: On 04-03-2024 at 11:00 AM during a home visit for Patient #9, Registered Nurse (RN) 1 was observed conducting a scheduled Recertification visit. RN 1 indicated, “;Lasix needed refilled” but was not observed reviewing any medications kept in the patients home. A handwritten list of medications was found in the patients folder and Clinical Manager 1 indicated this was not likely the most current list, but would have been from the patients admission visit. There were no dates written on the page. On 04-04-2024 at 4:28 PM, Clinical Manager 1 indicated during a Recertification visit the patients’ medication list should be reviewed, further indicated they did not see RN 1 review Patient #9s medications during the home visit. On 04-05-2024 at 8:19 AM in an interview, when queried regarding medication reconciliation during the home visit for Patient #9, RN 1 indicated medications are reviewed at the beginning of the week and the patient had been seen earlier in the week. When queried as to how a full medication review or reconciliation was performed, indicated verifying with the patient and reviewing the patients medication bottles in the home, including prescribed medication and over-the-counter medications. RN 1 indicated would update the patient’s medication list in the home, and “;will go off of that one”. When queried as to how the list in the home is updated with changes to medications, RN 1 indicated would cross it out and then write in the new one. Informed RN 1, there were no medications crossed out and no dates on the medication list in the home, RN 1 offered nothing further. On 04-05-2024 at 10:53 AM, the Quality Control Coordinator indicated the visit on 04-03-2024 was indeed a Recertification visit and indicated there is a box within the nursing documentation, medications last reviewed which nursing staff are expected to check off when patients medications are reviewed and indicated this box for Patient #9 was marked as being last reviewed on 03-13-2024. Indicated further, nurses are expected to, “;pull everything out and check that off” and, “;we are teaching we should do this every week”. Findings include: 1. The policy “;Care for Nursing Facility Residents / Hospice Plan of Care” indicated the hospice case manager checks patient record for order changes with each visit. 2. The policy “;Medication Management indicated a drug profile is maintained for every patient and includes a listing of the current medication orders for each patient. 3. Patient #2s clinical record evidenced an election of hospice benefit on 2/19/23 and included a current medication list as of 4/02/24. The record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review of Patient #2s medications and failed to collaborate with physician regarding medication differences. During a home visit observation conducted with Patient #2 and RN 2 on 4/03/24 beginning at 9:44 AM, RN 2 failed to reconcile medications during the visit. Surveyor comparison of the hospice agencys medication list against the medications in the home evidenced the following discrepancies: a) Lorazepam (used to treat anxiety) 0.5 milligram (mg), 1 tablet every 2 hours as needed for anxiety. The hospice agencys records failed to evidence an order for Lorazepam. b) Sinemet (used to treat shaking (tremor), muscle stiffness and slow and unsteady movements) 25-100 mg, 1 tablet three times a day. The hospice agency failed to evidence the correct order frequency for this medication. c) Glycopyrrolate (used to treat peptic ulcers), 1 mg tablet every 6 hours as needed for excessive saliva production. The hospice agency failed to evidence the correct order frequency for this medication. During an interview on 4/03/24 beginning at 10:22 AM, Other Person H verified the medications in the home and indicated the frequency of the medications has not changed for at least the past couple of months. During an interview on 4/03/24 beginning at 4:24 PM, RN 2 indicated they verify medications in the home weekly. During an interview on 4/04/24 beginning at 3:38 PM, Clinical Manager 1 indicated the order frequency for Glycopyrrolate and Sinemet did not match the hospice agency medication list and indicated the medication lorazepam was not listed on the hospice agency medication list. During an interview on 4/04/24 beginning at 4:48 PM, Clinical Manager 2 indicated RN 2 did not perform a medication reconciliation during the home visit on 4/03/24 and indicated medications should be reviewed in the home at least weekly. 4. Patient #17s clinical record evidenced an election of hospice benefit on 10/17/23 and included a current medication list as of 4/03/24. The record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #17s medications. Clinical records were obtained from Entity I during a home visit observation. Comparison of Entity Is active medication list, which included current medications as of 4/04/24, and the hospice agencys medication list evidenced the following discrepancies: a) Eucerin cream (used for dry skin) was observed sitting on the bedside table in Patient #17s room; was listed as daily on Entity Is active medication list effective 10/27/21 and not listed on the hospice agency medication profile. b) Melatonin (used to treat insomnia) 3 mg tablet was listed as daily at bedtime on Entity Is active medication list effective 9/28/21 and not listed on the hospice agency medication profile. c) Nystatin (used to treat fungal rash under right armpit) 100,000 unit/gram powder was listed as every shift on Entity Is active medication list effective 2/15/24 and not listed on the hospice agency medication profile. d) Nystatin (used to treat rash on right arm antecubital) 100,000 unit/gram cream was listed as twice a day for 7 days on Entity Is active medication list effective 4/02/24 and not listed on the hospice agency medication profile. e) Vesicare (used to treat overactive bladder) 5 mg tablet was listed as daily on Entity Is active medication list effective 1/12/24 and not listed on the hospice agency medication profile. f) Pharmacy compounded medication (Nystatin and Zinc ointment) (used to treat skin irritation) was listed on the hospice agency medication profile and not listed as an active medication on Entity Is medication list. g) Nystatin (used to treat red, rash under right arm and abdominal folds) 100,000 unit/g was listed as three times daily as needed on the hospice agency medication profile and not listed as an active medication on Entity Is medication list During an interview on 4/04/24 beginning at 3:45 PM, RN 3 indicated they reconcile medications with skilled nursing facilities once a week. During an interview on 4/04/24 beginning at 3:38 PM, Clinical Manager 1 indicated the RN Case Manager should be reconciling medications preferably at every visit but at least weekly and during an interview on 4/05/24 beginning at 9:40 AM, Clinical Manager 1 indicated the clinical record for Patient #17 failed to evidence the above medication updates to the hospice agency medication profile.”

“Based on observation, record review and interview, the agency failed to ensure wound care treatment orders were identified on the plan of care (POC) in 2 of 4 active patient records with wounds (Patient #11 and 17). Findings include: Patient #11s clinical record included a current POC 1 Update F for benefit period 1/24/24 to 4/2/24 last updated on 3/22/24. The clinical record included a skilled nurse (SN) note dated 2/07/24 which indicated Registered Nurse (RN) 7 applied Allevyn to a skin irregularity on Patient #11s back. The clinical record failed to include orders for this dressing. A SN note dated 3/25/24 indicated RN 7 removed a dressing from a wound on Patient #11s back and noted green pus, cleansed the wound with normal saline, painted with betadine, and covered with an Allevyn dressing. The SN note indicated RN 7 finished changing the patient and then contacted the physician. During an interview on 4/04/24 at 3:48 PM, RN 7 relayed there was no need for an order for the Allevyn dressing placed on 2/07/24 because the skin was not open at that time. RN 7 further relayed they werent sure where the order for the wound care performed on 3/25/24 was documented. During an interview on 4/05/24 beginning at 10:35 AM, Clinical Manager 1 indicated the expectation would be for the RN to obtain an order prior to placing an Allevyn dressing and relayed the clinical record did not include an order for the Allevyn placement on Patient #11s back on 2/07/24. Clinical Manager 1 also indicated the RN should have wound care orders prior to performing wound care and that the clinical record did not include orders for the wound care performed by RN 7 on 3/25/24. Findings include: 1. The policy “;Care for Nursing Facility Residents / Hospice Plan of Care” indicated the hospice case manager checks patient record for order changes with each visit. 2. The policy “;Medication Management indicated a drug profile is maintained for every patient and includes a listing of the current medication orders for each patient. 3. The policy “;Patient Self-Administration of Medication” indicated the RN will complete a medication reconciliation at admission and recertification and assess patients use of over-the-counter (OTC) medications, document with start date. 5. Patient #17s clinical record included a current POC Update H for benefit period 1/15/24 to 4/13/24 last updated on 3/21/24. Clinical records were obtained from Entity I during a home visit observation. Comparison of Entity Is active orders list and the hospice agencys active orders evidenced the following discrepancies: a) Wound care treatment order to cleanse the sacrum wound with NS and pat dry. Apply skin prep to peri wound. Gently pack with silver alginate and cover with Optifoam daily and as needed was listed on Entity Ds active orders effective 1/12/24. The clinical record for Patient #17 failed to evidence wound care treatment orders. During an interview on 4/04/24 beginning at 3:45 PM, RN 3 indicated they reconcile orders for Patient #17 once a week. During an interview on 4/05/24 beginning at 9:40 AM, Clinical Manager 1 indicated the POC for Patient #17 was missing wound care treatment orders and indicated all wound care treatment orders should be listed on the POC.”

“Based on record review and interview the agency failed to ensure care and services were provided following the plan of care in 6 of 15 active records reviewed. (Patients #2, 4, 11, 12, 17, and 23) Findings include: Patient #11s clinical record included a POC for benefit period 1/24/24 to 4/02/24 which indicated Patient #11 was to receive HHA visits 1 time per week for 1 week and 2 times per week for 12 weeks and SN visits 2 times per day for 2 days, 1 time per week for 1 week and 2 times per week for 12 weeks. The clinical record for Patient #11 failed to evidence HHA visits were performed 2 times during the weeks of 2/18/24 and 3/03/24; failed to evidence SN visits were performed 2 times during the weeks of 2/18/24 and 2/25/24; and failed to evidence documentation the patient and/or caregiver and physician were notified of the change in visit frequency. During an interview on 4/04/24 at 3:48 PM, RN 7 indicated they did not remember why the SN visits were missed and indicated they did not document the reason. During an interview on 4/5/24 at 11:55 AM, CNA 2 indicated they did not see documentation regarding the missed HHA visits in their phone application used to document HHA visits. CNA 2 relayed there was one HHA visit that was not performed because facility staff had already provided care but could not remember which date that was. On 4/3/24, Clinical Manager 1 relayed Patient #11s clinical record did not include missed visit documentation for any of the missed visits. Patient #2s clinical record included a POC for benefit period 2/14/24 to 4/13/24 which indicated Patient #2 was to receive home health aide (HHA) and Skilled Nurse (SN) visits two (2) times a week. The clinical record for Patient #2 failed to evidence HHA visits were performed two times during the weeks of 1/23/24 and 2/11/24; failed to evidence SN visits were performed two times during the weeks of 2/04/24 and 3/24/24 and failed to evidence documentation the patient and/or caregiver and physician were notified in the change in visit frequency. During an interview on 4/03/24 beginning at 4:24 PM, RN 2 indicated they document missed visits in the clinical record and did not notify the physician. Patient #17s clinical record included a POC for benefit period 1/15/24 to 4/13/24 which indicated Patient #17 was to receive HHA visits two (2) times a week. The clinical record for Patient #17 failed to evidence HHA visits were performed two times during the weeks of 1/14/24 and 2/04/24; failed to evidence documentation the patient and/or caregiver and physician were notified in the change in visit frequency and failed to evidence any coordination notes regarding missed visit frequencies. During an interview on 4/04/24 beginning at 3:45 PM, RN 3 indicated they document missed visits on a coordination note in the clinical record and they do not notify the physician. Patient #23s clinical record included a POC for benefit period 2/15/24 to 5/14/24 which indicated Patient #23 was to receive SN visits two (2) times a week. The clinical record failed to evidence SN visits were performed two times during the weeks of 2/18/24, 2/26/24 and 3/10/24 and failed to evidence documentation the patient and/or caregiver and physician were notified in the change in visit frequency. During an interview on 4/04/24 beginning at 2:05 PM, Clinical Manager 1 indicated the patient and physician should have been notified regarding missed visits and the POC frequency orders should have been updated when not able to be met. During an interview on 4/5/24 beginning at 9:40 AM, Clinical Manager 1 indicated the clinical record for Patient #23 does not include any documentation regarding missed visits during the weeks of 2/18/24, 2/26/24 or 3/10/24. 1. A review of an agencys policy dated 08/2019 revised 06/2022 titled HOSPICE – Nursing Care revealed, “; ... PROCEDURE ... 2. The Hospice nurse participates in the Plan of Care (POC) ... implementation ... “;. A review of an agencys policy dated 08/2019 revised 06/2022 titled HOSPICE – Plan of Care revealed, “; ... PROCEDURE ... scope and frequency of services necessary to meet those needs ... “;. 2. A clinical record review on 04/02/2024 for PT #4, with a start of care 10/26/2023, and a primary diagnosis of Protein Calorie Malnutrition (abnormal weight loss) evidenced by an agency document titled “Hospice Plan of Care” for certification period 01/24/2024 through 04/22/2024, dated and electronically signed by Administrative Staff 5. This plan of care had an area subtitled “Planned Visits” which revealed, “Hospice Aide Visits 2 visits every week for 13 weeks ... “;. Further review of the clinical record for PT #4 evidenced 1 home health aide visit on 01/22/2024 for the week of 01/21/2024 through 01/27/2024, 1 home health aide visit on 01/29/2024 for the week of 01/28/2024 through 02/03/2024, 1 home health aide visit on 02/15/2024 for the week of 02/11/2024 through 02/17/2024, 1 home health aide visit on 03/05/2024 for the week of 03/03/2024 through 03/09/2024, and 1 home health aide visit on 03/20/2024 for the week of 03/17/2024 through 03/23/2024. A review of skilled nursing visits failed to evidence personal care was provided during the weeks of the missed home health aide visits. The clinical record failed to evidence missed visit notes or communication notes regarding the missed visits. 3. A clinical record review on 04/04/2024 for PT #12, with a start of care 03/07/2023, and a primary diagnosis of Alzheimers (a progressive disease that destroys memory and other important mental functions. Brain cell connections and the cells themselves degenerate and die, eventually destroying memory and other important mental functions) evidenced by an agency document titled “Hospice Plan of Care” for certification period 03/07/2024 through 06/04/2024, dated and electronically signed by Administrative Staff 5. This plan of care had an area subtitled “Planned Visits” which revealed, “Hospice Aide Visits 2 visits every week for 13 weeks ... “;. Further review of the clinical record for PT #12 evidenced 0 home health aide visits for the week of 03/07/2024 through 03/09/2024, 1 home health aide visit for the week of 03/10/2024 through 03/16/2024, and 0 home health aide visits for the week of 03/24/2024 through 03/30/2024. The clinical record failed to evidence missed visit notes or communication notes regarding the missed visits. 4. On 04/03/2024 at 10:48 AM, RN 3 indicated that if the Home Health Aide (HHA) calls off or has a missed visit, they would cover the aide visit and provide the care themselves. When queried how they ensured the aides were showing up, RN 3 indicated they would ask the patient and family or if the patient was in a facility would ask the staff. On 04/04/2023 at 2 PM, Administrative Staff 6 indicated HHA are to notify their supervisor if they are going to miss their visit, and the supervisor should document a missed visit, they could offer an end-of-week visit, but they do not offer weekend visits due to staff unavailability. On 04/04/2024 at 1:20 PM, Administrative Staff 7 indicated Registered Nurse Case Managers (RNCM) should be building a missed visit report for each of their patients, indicated their current system Entity G (an Electronic Medical Record System) they used did not have a reporting system for nurses to utilize, they indicated the process was aides were to call RNCM, the visit should be documented as a missed visit, and it should be made up later in the week, and further indicated the only way for anyone to track visits is to review each record, every day to verify visits were completed. Administrative Staff 7 indicated there were not missed visits or communication notes of missed visits for Patients #4 and #12.”

“Based on record review, observation, and interview the agency failed to ensure staff followed proper infection control practices in 3 of 3 skilled nurse home visits observed. (Patients #2, #9, and #17) Findings include: 3. During a home visit observation conducted with Patient #2 and RN 2 on 4/03/24 beginning at 9:44 AM. RN 2 was observed performing an assessment which included vitals of Patient #2. RN 2 failed to remove gloves and complete hand hygiene prior to re-entering the nursing bag for additional supplies. RN 2 failed to cleanse the thermometer before placing it back in the nursing bag. RN 2 cleansed the blood pressure cuff, pulse oximeter and tape measure with an alcohol wipe and placed immediately into the nursing bag while still wet. RN 2 removed their gloves and wiped hands with an alcohol wipe. RN 2 failed to perform proper hand hygiene after removing their gloves. During an interview on 4/03/24 beginning at 10:19 AM, RN 2 indicated hand sanitizer should be before touching the patient and before and after glove changes. During an interview on 4/03/24 beginning at 3:30 PM, Clinical Manager 2 indicated hand hygiene should be performed before touching the patient, before and after gloves, when soiled and anytime you touch the nursing bag. 4. During a home visit observation conducted with Patient #17 and RN 3 on 4/04/24 beginning at 9:48 AM, RN 3 performed hand hygiene using an alcohol based hand sanitizer (ABHS). RN 3 then used the bed control to lower the head of the bed. RN 3 applied gloves and performed wound care to Patient #17s coccyx. RN 3 failed to perform hand hygiene after touching the bed control prior to donning gloves. After the wound care treatment, RN 3 was observed opening the nightstand drawers. RN 3 failed to remove gloves and perform hand hygiene before looking for additional supplies in the nightstand drawers. During an interview on 4/04/24 beginning at 10:20 AM, RN 3 indicated hand hygiene should be performed when entering and exiting the room, before and after glove changes, and after touching the patient. During an interview on 4/04/24 beginning at 3:38 PM, Clinical Manager 1 indicated hand hygiene should be performed before seeing a patient, after pt care, anytime you touch any pt belongings, bodily fluids, or wound dressings. 1. Review of an agency document revised June 2022, titled Hand Hygiene indicated, “;Purpose and Policy: 1. Hand hygiene is performed by all employees to maintain cleanliness of their hands and to prevent cross-contamination and the spread of infection. 2. Hand Hygiene is performed before and after direct patient contact ... Procedure: Hand Hygiene is performed: ... before and after direct patient contact ... after removing gloves ... 4. Use of Gloves: The use of gloves does not eliminate the need to perform hand hygiene ... Change gloves between task on the same patient to prevent cross contamination ...” Review of an agency document revised October 2022, titled Dressing Change indicated, “;... PROCEDURE: A. Clean dressing change: 1. Wash Hands. Don clean gloves ... 3. ... Dispose of dressing and gloves in appropriate receptacle. 4. Wash Hands ...” Review of an agency document revised June 2022, titled Bag Technique indicated, “;Purpose and and Policy: Infection control guidelines; including standard precautions, will be followed when field employees utilize a bag to carry patient care supplies. These guidelines will promote consistency with bag technique and assist with prevention and control of infections. Procedure: ... 2. Observe the principles of Standard Precautions at all times ... 4. Once in a patients home, select a clean, hard, dry surface to place the bag. A barrier may be used if the surface is not clean. 5. ... do not place bag on the floor ...” Review of an agency document revised June 2022, titled HOSPICE – Clinical Equipment Management indicated, “;Purpose: To promote safe and effective use of Company-owned patient care equipment. Policy: ... 3. Equipment should be handled and stored in manner which minimizes the risk of contamination of infection agents ...” 2. On 04-03-2024 at 11:00 AM, during a home visit for Patient #9, Registered Nurse (RN) 1 was observed providing wound care. The patient would perform wound care in the nurse’s absence and kept supplies in a clear container without a lid on the kitchen table. The nurse performed hand hygiene, donned gloves, set a new disposable barrier on the table adjacent to the patient, and then proceeded to grab a saline bottle and tube of topical antibiotic from the patients open container and placed these items on the clean barrier, then proceeded with wound care with the same gloves. Later in the visit, RN 1 was sanitizing a scale used to weigh the patient. Once weight obtained, the nurse picked up the scale and proceeded to wipe it down with sanitizing wipes, one ‘foot’ of the scale rested on the nurse’s forearm and against their uniform, and then was flipped over to sanitize the other side. The scale was then immediately set atop other vital sign equipment (sphygmomanometer, temporal thermometer, and pulse oximeter) which had already been sanitized and dried. Before leaving the visit, RN 1 was returning equipment to the nursing bag which sat on the floor of the kitchen, and the bags strap fell to the floor. The nurse picked up and straightened the strap, then put the strap over their shoulder. When queried as to the nursing bag being set on the kitchen floor, RN 1 indicated, “should have probably used a barrier there too”. On 04-04-2024 at 4:51 PM in an interview with Clinical Manager 1 and the Quality Control Coordinator, the Coordinator indicated the nurse should have sanitized the nursing bag strap. On 04-05-2024 at 8:19 AM in an interview, RN 1 indicated should have cleaned off the strap before putting it over their shoulder, should have sanitized in between using the normal saline bottle and the tube of antibiotic placed on the disposable barrier before providing wound care, should have sanitized their shirt after the scale had made contact with their clothing and should have put the scale on its own disposable barrier.”

“Based on observation, record review, and interview, the hospice agency failed to ensure the Registered Nurse assessed and/or reassessed the patient per hospice policy to ensure the needs of the patient were met for 3 of 17 active patient records reviewed (Patient #2, #11, and #17). Findings include: Patient #2s clinical record included a plan of care for the benefit period 2/14/24 to 4/13/24. The plan of care indicated the patient’s terminal diagnosis was progressive supranuclear palsy-parkinsonism syndrome. A home visit observation was conducted on 4/03/24 beginning at 9:44 AM with Patient #2 and Registered Nurse (RN) 2. During the home visit, RN 2 was observed performing an assessment of Patient #2s lung sounds, heart tones and bowel sounds. The nurse listened to Patient #2s anterior lung sounds for less than 5 seconds, listened to the heart tones for 12 seconds and listened to bowel sounds in 2 quadrants only. RN 2 failed to listen to the posterior lung sounds; failed to listen to the heart tones for 60 seconds and failed to assess bowel sounds in all 4 quadrants. RN 2 assessed Patient #2s feet up to the knees and asked Other Person H if Patient #2 had any skin issues or redness. RN 2 failed to perform a complete head to toe skin assessment during the visit. During an interview on 4/03/24 beginning at 10:19 AM, RN 2 indicated the heart rate should be assessed for 30 to 60 seconds, the lungs should be assessed anteriorly and posteriorly, and all 4 quadrants of bowel should be assessed. RN 2 also indicated they perform a complete skin assessment weekly. During an interview on 4/03/24 beginning at 3:30 PM, Clinical Manager 2 indicated heart rate should be assessed for 60 seconds, lungs should be assessed front and back in all 4 lobes and bowels should be assessed in all 4 quadrants every visit. They also indicated the skin assessment is a part of the visit flowsheet and should be performed every visit. During an interview on 4/04/24 beginning at 4:48 PM, Clinical Manager 2 indicated RN 2 did not perform a complete skin assessment of Patient #2 during the home visit observation on 4/03/24. Patient #17s clinical record included a plan of care for the benefit period 1/15/24 to 4/13/24. The plan of care indicated the patient’s terminal diagnosis was cerebrovascular accident. A home visit observation was conducted on 4/04/24 beginning at 9:48 AM with Patient #17 and RN 3. During the home visit, RN 3 was observed performing an assessment of Patient #17s lung sounds and heart tones. The nurse listened to Patient #17s anterior and lateral lung sounds and heart tones for less than 10 seconds. RN 3 failed to listen to the posterior lung sounds; failed to listen to the heart tones for 60 seconds and failed to assess bowel sounds. RN 3 assessed Patient #17s coccyx wound and performed wound care. RN 3 failed to perform a complete head-to-toe skin assessment during the visit. During an interview on 4/04/24 beginning at 10:20 AM, RN 3 indicated the heart should be assessed for 1 minute, the lungs should be assessed for 1 minute in all 6 areas, the bowel sounds should b e assessed in all 4 quadrants and indicated they perform a skin assessment every visit. During an interview on 4/04/24 beginning at 4:48 PM, Clinical Manager 1 indicated RN 3 did not perform a complete skin assessment of Patient #17 during the home visit observation on 4/04/24. During an interview on 4/04/24 beginning at 3:38 PM, Clinical Manager 1 indicated the head-to-toe skin assessment should be performed every visit with a minimum of once a week. 1. The Hospice Comprehensive and Ongoing Assessment policy, revised 06/2022, indicated the comprehensive assessment will include but not be limited to vital signs, breath sounds, and skin integrity, and indicated common physical symptoms are assessed at the time of admission and on an ongoing basis for symptom identification and management, including but not limited to, skin breakdown and dyspnea. The policy further indicated that during each home visit hospice staff will reevaluate the patient according to the problems identified at the initial visit and afterwards and that reassessments will be conducted and documented as frequently as the condition of the patient requires but no less often than every 15 days. 2. The Obtaining Vital Signs policy, revised 10/2019, indicated blood pressure should be taken using a blood pressure cuff and stethoscope or using an aneroid or digital blood pressure sphygmomanometer. The policy further indicated the blood pressure cuff should be centered over the patients brachial artery on the inside of the patients arm with the cuff at the patients heart level. 3. Patient #11s clinical record included a plan of care (POC) for the benefit period 1/24/24 to 4/02/24. The POC indicated the patient’s terminal diagnosis was dementia in Alzheimers disease. Patient #11s clinical record failed to evidence assessment of a skin assessment during skilled nurse (SN) visits on 2/9/24, 2/12/24, 2/19/24, 3/11/24, or 3/20/24 to reevaluate a skin abnormality on Patient #11s back that was previously noted in a SN note on 2/7/24. During an interview on 4/04/24 at 3:48 PM, Registered Nurse (RN) 7 indicated they always do a skin assessment during a skilled nurse visit and were not sure why it wasnt documented. During an interview on 4/04/24 beginning at 10:35 AM, Clinical Manager 1 indicated the RN should do a full skin assessment as part of a comprehensive head-to-toe assessment as least once per week and relayed there was no documentation of a skin assessment in SN notes from 2/09/24, 2/12/24, 2/19/24, 3/11/24, and 3/20/24.”

“Based on record review and interview, the hospice agency failed to ensure the Registered Nurse (RN) performed hospice aide supervisory visits at least every 14 days for 2 of 5 records reviewed of patients who received hospice aide services for at least 15 days (Patient #11 and #17). Findings include: Review of Patient #17s clinical record evidenced HHA visits were performed on 1/17/24, 1/23/24, 1/27/24, 1/30/24, 2/02/24, 2/06/24, 2/14/24, 2/15/24, 2/21/24, 2/23/24, 2/27/24, 2/29/24, 3/05/24, 3/07/24, 3/12/24, 3/14/24, 3/21/24, 3/26/24 and 4/02/24 this certification period. Home Health Supervisory visits were performed by the Registered Nurse on 1/30/24, 2/13/24, 2/16/24, 3/05/24 and 3/19/24. The clinical record failed to evidence HHA supervisory visits were performed at least every 14 days. During an interview on 4/04/24 beginning at 3:45 PM, RN 3 indicated they perform a HHA supervisory visit every 2 weeks and document the supervisory visit in the skilled nurse visit note. During an interview on 4/05/24 beginning at 9:40 AM, Clinical Manager 1 indicated the clinical record for Patient #17 failed to evidence HHA Supervisory visits were completed at least every 14 days between 2/16/24 and 3/05/24 and 3/19/24 and 4/04/24. The Hospice Nursing Care policy, revised 06/2022, indicated the RN supervises the hospice aides in the home. Review of Patient #11s clinical record evidenced (home hospice aide) HHA visits were performed on 1/25/24, 1/30/24, 2/06/24, 2/08/24, 2/13/24, 2/14/24, 2/22/24, 2/28/24, 3/01/24, 3/08/24, 3/13/24, 3/15/24, 3/27/24, 3/29/24, and 4/03/24. The clinical record failed to evidence HHA supervisory visits were performed. During an interview on 4/04/24 beginning at 3:48 PM, RN 7 indicated they sometimes do co-visits with the HHA and that supervisory visits are documented in the skilled nurse note. RN 7 indicated they could not find documentation of their HHA supervisory visits for Patient #11. On 4/03/24 at 3:56 PM, Clinical Manager 1 relayed there were no hospice aide supervisory visits done for Patient #11. On 4/05/24 at 2:39 PM, Clinical Manager 2 indicated there was no hospice policy they knew of that addresses the frequency of aide supervisory visits because the regulations say every 14 days.”

“Based on observation, record review, and interview, the home health agency failed to ensure wound care treatment orders were obtained for 2 of 4 active patient records reviewed with wounds (Patient #11 and 17), with the potential to affect all active patients with wounds. Patient #11s clinical record included a current POC 1 Update F for benefit period 1/24/24 to 4/2/24 last updated on 3/22/24. The clinical record included a skilled nurse (SN) note dated 2/07/24 which indicated Registered Nurse (RN) 7 applied Allevyn to a skin irregularity on Patient #11s back. The clinical record failed to include orders for this dressing. A SN note dated 3/25/24 indicated RN 7 removed a dressing from a wound on Patient #11s back and noted green pus, cleansed the wound with normal saline, painted with betadine, and covered with an Allevyn dressing. The SN note indicated RN 7 finished changing the patient and then contacted the physician. During an interview on 4/04/24 at 3:48 PM, RN 7 relayed there was no need for an order for the Allevyn dressing placed on 2/07/24 because the skin was not open at that time. RN 7 further relayed they werent sure where the order for the wound care performed on 3/25/24 was documented. During an interview on 4/05/24 beginning at 10:35 AM, Clinical Manager 1 indicated the expectation would be for the RN to obtain an order prior to placing an Allevyn dressing and relayed the clinical record did not include an order for the Allevyn placement on Patient #11s back on 2/07/24. Clinical Manager 1 also indicated the RN should have wound care orders prior to performing wound care and that the clinical record did not include orders for the wound care performed by RN 7 on 3/25/24. Findings include: 1. The policy “;Plan of Care” indicated the Plan of Care (POC) must address the patient, caregiver and family needs and identification of the services to be provided, as well as the scope and frequency of services necessary to meet those needs. 2. The policy “;Verbal and Written Orders-General” indicated all orders of medication and treatment shall be written into the medical chart of the patient. 3. 4. A home visit observation was conducted on 4/04/24 beginning at 9:48 AM with Patient #17 and Registered Nurse (RN) 3. During the home visit, RN 3 was observed performing wound care to Patient #17s sacrum. Clinical records were obtained from Entity I during the home visit observation. Comparison of Entity Is active orders list and the hospice agencys active orders evidenced the following discrepancies: a) Wound care treatment order to cleanse the sacrum wound with NS and pat dry. Apply skin prep to peri wound. Gently pack with silver alginate and cover with Optifoam daily and as needed was listed on Entity Ds active orders effective 1/12/24. Patient #17s clinical record included a plan of care for the benefit period 1/15/24 to 4/13/24 which failed to evidence wound care orders. During an interview on 4/04/24 beginning at 3:45 PM, RN 3 indicated they performed wound care based on the wound care orders from Entity I and they indicated they reconcile orders for Patient #17 once a week. During an interview on 4/05/24 beginning at 9:40 AM, Clinical Manager 1 indicated the clinical record for Patient #17 was missing wound care treatment orders and indicated all wound care treatment orders should be listed on the Plan of Care in the clinical record.”

“Based on record review and interview, the hospice agency failed to ensure a discharge summary was completed for 1 of 2 clinical records of patients who revoked their hospice election (Patient #16). Findings include: 1. The Discharge from Hospice policy, revised 06/2022, indicated the Hospice Manager is responsible for ensuring the necessary paperwork, including a discharge summary, is completed at the time of discharge. 2. The Hospice Content of the Clinical Record policy, dated 06/2022, indicated the minimum content of the clinical records includes, but not limited to, discharge summary. 3. Patient #16s clinical record included a Revocation of Hospice Benefit form signed by Patient #16 on 2/13/24. The clinical record failed to include a discharge summary. 4. On 4/03/24 at 4:06 PM, the Quality Control Coordinator indicated all they could find related to Patient #16s discharge was the Revocation of Hospice Benefits form. 5. On 4/04/24 at 10:01 AM, the Quality Control Coordinator indicated the hospice agency does not do a discharge summary for revocations. 6. On 4/04/24 at 10:05 AM, the Administrator indicated the hospice agency would complete a discharge summary for a revocation patient who had an outside physician because they would need to coordinate care.”

“Based on record review and interview the agency failed to ensure a verbal order for medication had been incorporated into the plan of care, by 1 of 2 Licensed Practical Nurses. (Licensed Practical Nurse (LPN) 1) Findings include: 2. Review of Patient #17s clinical record included a current medication list as of 4/03/24 and a Licensed Practical Nurse (LPN) visit note dated 4/02/24. The 4/02/24 visit note indicated LPN 1 received a verbal order to apply Nystatin cream to redness on Patient #17s right forearm. Clinical records were obtained from Entity I during a home visit observation on 4/04/24. Comparison of Entity Is active medication list, which included current medications as of 4/04/24, and the hospice agencys medication list evidenced the following discrepancies: a) Nystatin (used to treat rash on right arm antecubital) 100,000 unit/gram cream was listed as twice a day for 7 days on Entity Is active medication list effective 4/02/24 and was not listed on the hospice agency medication profile. The clinical record for Patient #17 failed to evidence a verbal order was written by LPN 1 for the Nystatin cream on 4/02/24 and Registered Nurse (RN) 1 failed to reconcile medications during the home visit observation on 4/04/24. 3. During an interview on 4/04/24 beginning at 3:45 PM, RN 3 indicated they reconcile medications with skilled nursing facilities once a week. 4. During an interview on 4/04/24 beginning at 3:38 PM, Clinical Manager 1 indicated the RN Case Manager should be reconciling medications preferably at every visit but at least weekly. 5. During an interview on 4/05/24 beginning at 9:40 AM, Clinical Manager 1 indicated all orders should be put into the clinical record immediately when received and indicated the clinical record for Patient #17 failed to evidence the verbal order for Nystatin cream on the hospice agency medication profile. 1. Review of an agency document revised June 2022, titled HOSPICE – Verbal and Written Orders – General indicated, “;STATEMENT OF PURPOSE: To provide patient services and care consistent with their Plan of Care under the direction of their attending and/or treating physician and to communicate the medical care that the patient is to receive while in the care of Hospice. POLICY STATEMENT: A. ... All orders of medication and treatment shall be written into the medical chart of the patient ... PROCEDURE: ... B. Verbal/Telephone orders ... 9. Record the verbal/telephone order immediately in the patients medical record ... 10. Indicate either telephone or verbal order in the written record ... C. The prescribing practitioner must sign the written record of the verbal/telephone order according to state and federal guidelines ...” Review of an agency document revised June 2022, titled Medication Management indicated, “;Purpose: To ensure the safe administration of medications to Hospice patients. Policy: 1. The pharmaceutical needs of the patient are managed in a manner consistent with applicable Federal and State laws and accepted Standards of Practice ... 5. A drug profile is maintained for every patient and includes a list of the current medication orders for each patient ...””

“Based on record review and interview, the hospice agency failed to ensure agency staff had a criminal background check within 3 months of employment at the hospice agency for 2 of 3 direct patient care Registered Nurse (RN) personnel records reviewed (RN 2 and RN 3). Findings include: 1. The Background Screening Guidelines policy indicated background checks are performed on all candidates upon accepting an offer of employment and on all those who are transferred or promoted as deemed necessary. 2. RN 2s personnel record included a hospice agency hire date of 5/18/20. The record failed to include a criminal background check from within 3 months of employment at the hospice agency. On 4/04/24 at 12:38 PM, Corporate Person 1 indicated RN 2s personnel record did not include a criminal background check within 3 months of employment with the hospice agency. 3. RN 3s personnel record included a hospice agency hire date of 5/15/23. The record failed to include a criminal background check from within 3 months of hospice agency employment. On 4/04/24 at 12:30 PM, Corporate Person 1 indicated RN 3s personnel record did not include a criminal background check within 3 months of employment with the hospice agency. 4. On 4/04/24 at 10:39 AM, the Administrator relayed they do not have access to personnel records and that we would have to review them with Corporate Person 1.”