Gentiva III

“Upon patient record review, 3 of 19 (Patients #3,#4,#11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medication profile contained duplicative listings of scheduled quetiapine daily, listed as both quetiapine and Seroquel. Patient 4: During home visit medication reconciliation, the patient’s caregiver denied having bisocodyl suppositories in the home or having any discussions with hospice regarding a need for the medication order on record. Patient 11: During home visit medication reconciliation, the patient’s caregiver denied use of spironolactone identified as scheduled on the profile.”

“Upon patient record review, 2 of 19 (Patients #7,#9) 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: The initial bereavement assessment was completed 6/18/25 with start of care 6/12/25. Patient 9: There was no evidence of a bereavement assessment.”

“Upon patient record review, 4 of 19 (Patients #1,#2,#11,#13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: There was no evidence of weekly wound measurements and assessments as required per agency policy since 1/20/26. Assessment completed during survey 2/5/26. Patient 2: There was no evidence of weekly wound measurements and assessments as required per agency policy from 12/23/25 to 1/6/26 and from 1/6/26 to 1/20/26. Patient 11: There was no evidence of weekly wound measurements and assessments as required per agency policy from 1/2/26 to 1/12/26. Patient 13: There was no evidence of weekly wound measurements and assessments as required per agency policy from 1/8/26 to 1/27/26 for right buttock wound and since 1/8/26 for sacral wound.”

“Upon patient record review, 3 of 19 (Patients #6,#10,#11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6: The medical record contained nursing documentation upon admission identifying patient history of CVA and seizure disorder. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Patient 10: The medical record contained nursing documentation upon admission identifying patient assessed as a high risk for falls and hospice diagnosis of Lewy Body dementia. There was no evidence of problems, goals, and interventions related to neurological dysfunction and fall safety included in the plan of care. Patient 11: The medical record contained nursing documentation upon admission identifying patient assessed as a high risk for falls, history of dementia and seizure disorder, and use of Eliquis. There was no evidence of problems, goals, and interventions related to fall safety, neurological dysfunction and risk for bleeding included in the plan of care.”

“Upon patient record review, 3 of 19 (Patients #3,#4,#11) 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: The medication profile contained duplicative orders for scheduled quetiapine daily, ordered as both quetiapine and Seroquel. Patient 4: During home visit medication reconciliation, the patient’s caregiver denied having bisocodyl suppositories in the home or having any discussions with hospice regarding a need for the medication order on record. Patient 11: During home visit medication reconciliation, the patient’s caregiver denied issues with edema and use of spironolactone as ordered per hospice records.”

“Upon patient record review, 4 of 19 (Patients #1,#11,#12,#14) 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 equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of an APP mattress. There was no evidence of an order for the DME included in the plan of care. Patient 11: The medical record contained nursing documentation upon recertification assessment 1/26/26 identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a cane, wheelchair, commode, and over bed table, and 11/26/25 identifying use of a geri-chair, hospital bed and shower chair. There was no evidence of orders for the DME included in the plan of care. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care.”

“Based on record review and interview, the hospice agency failed to protect and promote a patients rights for 1 of 1 record reviewed of a patient who was evaluated for hospice services but was not admitted to the agency (Patient #5). The severity of this deficiency evidenced the agency failed to protect and promote all patients rights, which resulted in Vista Hospice Care d/b/a Gentiva III being found out of compliance with Condition of Participation 42 CFR 418.52 Patients rights. Findings include: The review of agency policy #4-021 titled “;Admission Criteria and Process,” last revised 10/27/23, indicated the agencys considerations for accepting patients for care included “;a reasonable expectation that the patients hospice care needs (medical and non-medical) can be adequately met in the patients place of residence.” A patient would be “;referred to other resources if the hospice cannot meet his/her needs ... Referral sources will be notified when patient needs cannot be met and [the patient was] not being admitted to the hospice.” The policy indicated an “;initial home visit” would be conducted by a hospice Registered Nurse (RN) “;within the timeframe requested by the referral source ... or as ordered by the physician.” During the visit, the hospice RN was to “;assess the patients eligibility for hospice services ....” If a patient was found to not meet admission criteria, the agency was to notify the administrator, medical director, and “;referral source.” The policy indicated “;appropriate referrals to other sources of care” were to be made “;on behalf of the patient.” The review of an agency job description for the title “;Hospice Care Consultant” indicated an employee in this role was to be a “;consultative marketing representative.” Job responsibilities for the role included but were not limited to “;... assure effective communication both internally and externally ... obtain referrals and assure quality service.” The review of Patient #5s clinical record from Entity B, a skilled nursing facility, evidenced Patient was re-admitted to the facility on 4/10/24 following a hospitalization. Entity Bs clinical records evidenced a wound assessment dated 4/15/24 and completed by the facilitys nurse practitioner. The assessment evidenced Patient had 4 active wounds, described as follows: a. One “;abscess” wound to the abdominal pannus (excessive skin and/or fat hanging from the abdomen) measuring 3 centimeters (cm) in length by 3 centimeters in width by 2 centimeters in depth (3 cm x 3 cm x 2 cm). Wound care was to be performed daily and included cleansing the wound, applying calcium alginate (type of wound dressing), and covering with a foam dressing. b. Moisture-Associated Skin Damage (MASD, skin breakdown caused by prolonged exposure to moisture) to the left abdomen measuring 36 cm x 22 cm x 0.1 cm. Wound care was to be performed daily and included cleansing the area, applying Triamcinolone (a steroid cream used to treat various skin disorders), and covering with an abdominal (ABD pad) dressing. c. Two “;venous” wounds, one to the left lower leg and one to the right lower leg. The left lower leg wound measured 40 cm x 30 cm x 0.1 cm and the right leg wound measured 40 cm x 20 cm x 0.1 cm. Both wounds were observed to have slough (dead skin cells in a wound bed) present and “;purulent” exudate (thick drainage from a wound with a foul odor). Wound care to both leg wounds was to be performed daily and included cleaning the wounds, applying Triamcinolone cream, and covering with an ABD pad, rolled gauze wrap, and an ACE wrap from Patients toes to knee. Entity Bs medical record also indicated Patients active medications included but were not limited to: a. Fentanyl patch (an opioid pain medication, administered through the skin via a transdermal patch) b. Lyrica (a medication used to treat nerve pain) c. Percocet (a pain medication with both oxycodone, an opioid pain medication, and Tylenol) The review of Patient #5s clinical record evidenced a referral form, dated 4/17/24, which indicated Entity A, a sister hospice agency to Gentiva III, received a referral for hospice services on 4/16/24. The referral was sent from Entity B where Patient resided at the time of referral. Corporate Employee 1 was assigned as Hospice Care Coordinator. The referral form indicated durable medical equipment (DME) Patient needed included a bariatric hospital bed, bariatric wheelchair, bedside table, Hoyer lift, and a lift chair. The record evidenced an order for hospice evaluation and treatment, dated 4/19/24, signed by a nurse practitioner working for Entity B. Patient #5 was discharged from Entity B to Person D (primary caregiver)s home on 4/22/24 and RN 1 conducted an RN hospice evaluation the same day. During an interview with Corporate Staff 1 on 5/03/24 beginning at 1:24 PM, he reported his duties included coordinating referrals for hospice care. Corporate Staff 1 reported he primarily worked for Entity A, however if the staff member received a referral for a patient who resided outside of Entity As geographic service area, he would continue to coordinate the referral with a sister hospice agency, including Gentiva III. Corporate Staff 1 reported after Entity A received a hospice referral for Patient #5, he discovered Patient’s plan was to be discharged with hospice services to Person D’s home, which was outside of Entity As geographic service area. Corporate Staff 1 then sent the referral information to Gentiva III staff, as this hospice agency serviced the geographic area that Patient was planning to discharge. The staff member stated Gentiva III staff was to review the referral documents for Patients clinical “;appropriateness” for hospice. The employee went to Entity B to speak with Patient and Person D regarding “;benefits of hospice.” Corporate Staff 1 reported Patients caregivers were unable to safely meet Patients needs at Person Ds home without additional help. After a nurse practitioner at Entity B gave an order for hospice to evaluate and treat Patient, Corporate Staff 1 reported Administrator gave “;authorization” for Patient to be admitted to Gentiva III. The corporate staff informed Person E, an employee of Entity B, of the hospices “;verbal acceptance” of Patient for hospice services. DME was then ordered by the hospice agency and Patient was discharged to Person Ds home on 4/22/24. During an interview with Administrator on 5/03/24 beginning at 2:40 PM, Administrator reported if a patient was being discharged from a skilled nursing facility to a private residence with hospice services, the agency would conduct an RN hospice evaluation after the patient left the nursing facility. Administrator also reported Gentiva III staff would not have conducted a hospice evaluation of Patient #5 while he/she was still residing at Entity B since the skilled nursing facility was outside of the hospices geographic service area. During an interview with Administrator on 5/03/24 beginning at 4:40 PM, Administrator reported Patient had requested his/her RN hospice evaluation visit not be completed until Patient was discharged to Person Ds home. Administrator stated this request had been reported to the agency staff via email. The review of an email sent by Corporate Staff 2 on 4/16/24, indicated the employee had stated “;patient wanting to go home” on 4/22/24. The email correspondence provided failed to evidence Patient had requested to have his/her RN hospice evaluation visit conducted after he/she discharged from Entity B. During an interview with Corporate Staff 2 on 5/03/24 beginning at 4:51 PM, the employee reported the hospice care coordinators were non-clinical staff and were unable to determine when the RN hospice evaluation visit was to be performed. Corporate Staff 2 stated the hospice care coordinators role was to report the “;patient status” and when he/she was to be discharged, then office employees would schedule the visit. The review of Patients clinical record evidenced during the RN evaluation visit; RN 1 observed a urinary catheter which was draining clear, yellow urine with a “;normal” output. Patients pain was “;well managed,” he/she was bedbound, and his/her mobility was “;unchanged” for the previous 6 months. The patient had “;several wounds” to both of his/her lower extremities which were “;not new.” The evaluation visit note failed to evidence a description of Patients wounds. RN 1 relayed the assessment findings to Interim Medical Director, who determined Patient was not eligible for hospice services. RN 1 documented the hospice would make a referral for home health services and Patient would be re-evaluated for hospice services in 1 month. Patient was classified as a “;non-admit” in the agencys electronic medical record. The record failed to evidence documentation regarding a referral(s) made on Patients behalf. During an interview with RN 1 on 5/03/24 beginning at 1:43 PM, the nurse reported on 4/19/24 she was informed via email from Former Employee C of a scheduled RN hospice evaluation with Patient on 4/22/24. The nurse conducted the visit on 4/22/24 approximately 1 hour after Patient arrived at Person Ds home from Entity B. RN 1 reported Patient had been unhappy with the care he/she received from Entity B and the nurse felt Patient was requesting hospice services “;as a crutch” to discharge from Entity B. During the nurses assessment, she noted wounds to Patients bilateral lower legs and left abdomen. RN 1 did not remove the wounds dressings as they had recently been changed. Patient had been prescribed an antibiotic for cellulitis (an infection of the skin) at his/her abdominal wound. After RN 1s evaluation of Patient, she reported her findings to Interim Hospice Physician, who determined Patient was not eligible for hospice services. RN 1 reported she verbally reviewed with Person D how to change Patients wound dressings and recommended Patients controlled medication be stored in a lock box due to a household members history of drug abuse. The nurse stated the hospice agency was to refer Patient to a home health agency for home care assistance. During an interview with Administrator on 5/03/24 beginning at 2:32 PM, Administrator reported DME was ordered by Gentiva III staff and delivered to Person Ds home prior to Patients arrival on 4/22/24. DME had been ordered prior to a nurse evaluation to ensure Patient would have the equipment needed to discharge safely from Entity B. Administrator reported the hospice agency would “;preventively” order DME prior to a patients evaluation for hospice eligibility if the agency staff thought the equipment might be needed. If a patient had DME delivered prior to his/her hospice evaluation but the agency determined the patient was not hospice eligible, the agency would contact its DME supplier to arrange equipment pickup. Administrator reported after Patient #5 was not admitted to the agency, she provided Corporate Staff 1 a list of 3 prospective sources of care for Patient #5 and caregivers to contact. Administrator stated Gentiva III was not responsible for referring Patient to other sources of care as the agency had not provided any hospice services to Patient. Administrator reported any referrals or suggestions for other sources of care were conducted by the hospice care coordinator team. The review of an email sent from Administrator to Corporate Staff on 4/24/24 evidenced Administrator listed “;3 options for [Patient #5] ... to research and get some assistance,” which included 1 visiting physician group, 1 local physician, and 1 home health agency. During an interview with Corporate Staff 1 on 5/06/24 beginning at 11:48 AM, he reported Gentiva III did not make any referrals to a home health agency or physician groups for Patient. Corporate Employee 1 reported on 4/23/24 he referred Patient to Entity G, a hospice agency. Entity G reportedly declined to conduct a hospice evaluation of Patient. Corporate Staff 1 reported he informed Person E, an employee of Entity B, of Patients non-admittance to Gentiva III on 4/25/24. During an interview with Interim Medical Director on 5/06/24 beginning at 12:30 PM, he reported when the hospice agency received a referral, staff would generally attempt to conduct a RN hospice evaluation within 24 – 48 hours. Interim Medical Director was unsure if the nursing evaluation needed to be completed prior to a patient being discharfged from a skilled nursing facility to a private residence. The physician reported Patient #5s life expectancy was not 6 months or less, therefore the agency was unable to admit Patient for hospice services. Interim Medical Director reported the agency was not responsible for referring Patient to other sources of care as he/she had not received any hospice services. During an interview with Person D, primary caregiver for Patient #5, on 5/03/24 beginning at 3:06 PM, the caregiver reported prior to Patient being referred to hospice, Patient was told by Entity B staff that he/she could not be discharged home unless Patient established with a primary care physician (PCP) and home care services set up. Patient expressed interest in hospice care and a referral was made to Entity A. Person D reported prior to Patient being discharged from Entity B, Patient and Person D spoke with Corporate Staff 1 who indicated Patient was accepted by Gentiva III and would receive hospice services. The hospice then ordered and delivered DME, including a bariatric hospital bed, wheelchair, and Hoyer lift, to Person Ds home prior to Patient #5s discharge. Person D reported upon arrival to his/her home, Patients urine was “;black” and Patient had wounds to his/her bilateral lower legs, tailbone, and abdomen. Patient had a “;bad infection” to an open wound on his/her lower abdomen. Person D reported he/she was upset hearing Patient would not be accepted to the hospice agency, as he/she would not have allowed Patient to be discharged from Entity B without hospice services, since Patient did not have a PCP and the caregiver needed assistance with Patients care. Person D reported he/she was contacted by the hospices DME supply company on 4/23/24 to arrange pickup of the DME. Person D reported he/she then contacted Corporate Staff 1, who reportedly said, “;I meant to tell you, they said [Patient was] a candidate for hospice,” but Patient would not be accepted for hospice services until after an RN evaluation visit was conducted. Person D was told Patient could keep the DME for Patient’s use until he/she was set up with a PCP or a home health agency. Person D reported he/she had contacted a visiting physician group however Patient was declined due to insurance. RN 1 had reportedly stated Gentiva III would refer Patient to a home health agency, however Person D had not received any further information regarding a referral from hospice staff. The caregiver stated Patient had been given approximately 1 week supply of medications prior to discharge from Entity B, however Patient did not have a physician who could prescribe his/her medications. Patient “;ran out” of his/her supply of Percocet and Lyrica by 4/26/24. Person D reported Patient was in severe pain and would “;scream out” in pain when he/she was turned. Patients caregivers had difficulty keeping up with Patients extensive medical needs by themselves. Patient was taken to a local hospital on 5/01/24 due to the caregivers concerns regarding his/her condition and was still inpatient as of the date of the interview. During an interview with Person E, an employee of Entity B, on 5/07/24 beginning at 2:42 PM, the employee reported Patient #5 had requested a referral for hospice care as Patient wanted to go to Person D’s home and did not want any further hospitalizations. Patient was provided with a list of multiple hospice agencies, he/she chose Entity A, and Person E sent a referral to the hospice agency. Person E reported he/she was not aware the referral had been forwarded by Entity A to Gentiva III. Person E reported Corporate Staff 1 visited with Patient and had informed Person E that Patient #5 was accepted for hospice services. Person E stated Patient would not have been discharged from Entity B without an acceptance for hospice services as Patient did not have a PCP and required extensive assistance with personal care. Entity B then arranged Patients transportation to Person Ds home and the hospice agency set up for DME to be delivered to Person Ds home prior to Patients arrival. Person E reported prior to Patients discharge from Entity B, he/she had a wound to the abdominal pannus which had “;re-opened,” wounds to bilateral lower extremities, and a wound to the left abdomen. Patients wounds were debrided prior to discharge and he/she was on an antibiotic for a wound infection. Entity B was notified by Person D and Corporate Staff 1 on 4/26/24 that Patient had not been admitted to Gentiva III.”

“Based on observation, policy review, and interview, the hospice agency failed to ensure all staff followed standard precautions and agency policies and procedures specific to hand hygiene and bag technique (see Tag L579). Based on record review and interview, the hospice agency failed to ensure all employees with direct patient contact were screened for tuberculosis (TB, an infectious respiratory disease) upon hire according to agency policy for 6 of 14 personnel files reviewed of active employees hired after 10/25/17 with direct patient contact (Employees B, C, E, F, M, N). The scope and severity of the deficiencies evidenced the hospice agency failed to maintain an effective infection control program that protected patients, families, and employees, which resulted in Vista Hospice Care d/b/a Gentiva III being found out of compliance with Condition of Participation 42 CFR 418.60 Infection control. Findings include: 1. The review of agency policy #6-028 titled “;Tuberculosis Exposure Control Plan,” revised 1/12/24, indicated all employees with patient contact would be screened for TB “;upon hire and annually.” The initial screening was to be performed prior to the employee having direct patient contact and included either a two-step tuberculin skin test (TST, a screening test for TB which is done by injecting an inactive form of TB under the skin and observing for a reaction within a specific timeframe) or a TB blood test. For the 2-step TST, the area of injection was to be “;read” (assessed) within 48-72 hours of the injection. If the first skin test had a “;negative” result (no indication of TB infection) the second skin test was to be repeated within 1-3 weeks. For the TB blood test, if the result was “;positive,” the employee was to be considered “;TB infected” and was to be evaluated for TB disease, including following up with a physician and obtaining a chest x-ray (CXR). During an interview with Administrator on 5/14/24 beginning at 2:45 PM, she reported the agencys revisions to policy #6-028 were not related to the requirement for TB screening to be performed on hire. The agency had incorporated elements from another policy into #6-028. Administrator reported all staff were required to obtain a TB screening test upon hire through either a 2-step TST or TB blood test. During an interview with Corporate Staff 3 on 5/14/24 beginning at 4:40 PM, she reported the agencys requirement for TB testing on hire was last updated in 2021. This update added the TB blood test as a second option for employee TB screening required on hire. 2. The review of Employee Bs personnel file evidenced a hire date of 11/03/21 and first patient contact date of 11/21/21. The employees duties included direct patient contact. The file evidenced Employee Bs first of a 2-step TST was performed on 1/16/23. The employee was injected with the TST serum on 1/16/23 at 11:00 AM and the test was read on 1/19/23 at 3:00 PM. The file failed to evidence a the employee’s first TST was read within 48=72 hours of administration and failed to evidence a second TST was performed. 3. The review of Employee Cs personnel file evidenced a hire date of 3/03/21 and first patient contact date of 3/13/21. The employees duties included direct patient contact. The file failed to evidence Employee C had either a 2-step TST nor TB blood test performed upon hire. 4. The review of Employee Es personnel file evidenced a hire date of 5/15/23 and first patient contact date of 5/20/23. The employees duties included direct patient contact. The file failed to evidence Employee E was screened for TB until he/she had a TB blood test performed on 5/09/24, which had a positive result. The employee had been sent for a CXR on 5/13/24. The file failed to evidence Employee E was screened for TB upon hire per agency policy. During an interview with Employee E on 5/14/24 beginning at 12:29 PM, the employee reported his/her last TB screening test was approximately 2 years ago, prior to being hired at the hospice agency. The employee denied signs or symptoms of a TB infection, a history of TB infection, or a known exposure to someone with TB. 5. The review of Employee Fs personnel file evidenced a hire date of 3/21/22 and first patient contact date of 4/07/22. The employees duties included direct patient contact. The file evidenced Employee F received the first of the 2-step TST on 1/16/23. The file failed to evidence Employee F completed the second of the 2-step TST. 6. The review of Employee Ms personnel file evidenced a hire date of 6/05/23 and first patient contact date of 6/15/23. The employees duties included direct patient contact. The file failed to evidence Employee M was screened for TB until he/she received a TB blood test on 5/10/24. The file indicated the blood test results were pending. 7. The review of Employee Ns personnel file evidenced a hire date of 10/18/21 and first patient contact date of 10/26/21. The file failed to evidence Employee N was screened for TB until he/she received a TB blood test on 5/09/24. The file indicated the blood test results were pending. 8. During an interview with Administrator on 5/14/24 beginning at 8:48 AM, the employee reported in March 2024, the agency discovered multiple employees did not have record of TB screening test(s) performed upon hire. Administrator reported the agency had been working on getting all the personnel files up to date.”

“Based on record review and interview, the hospice agency failed to ensure upon hire all hospice aides completed a return demonstration of a patient transfer using a Hoyer lift (Tag L616) and failed to provide services that were included in the aide care plan and consistent with the hospice aide training (Tag L626). The severity of these deficiencies evidenced the hospice agency failed to ensure all hospice aide services were provided by staff who met the personnel requirements specified in 42 CFR 418.76(a), which resulted in Vista Hospice Care d/b/a Gentiva III being found out of compliance with Condition of Participation 42 CFR 418.76 Hospice aide and homemaker services.”

“Based on record review and interview, the hospice agency failed to evidence a documented facility-based and community-based risk assessment, using an all-hazards approach, which had the potential to affect all agency patients and staff. Findings include: The review of agency policy #6-037 titled “Emergency Management Plan,” revised 1/06/23, indicated the agency’s administrator or designee would “conduct an all-hazard risk assessment to identify potential emergencies that could affect the need for services or the ability to provide services.” The review of the agency’s Quality Assessment Performance Improvement (QAPI) meeting minutes for the meeting held on 2/14/24 indicated the agency’s emergency preparedness plan was reviewed and updated in January 2024. The review of the agencys Emergency Preparedness binders for 2023 and 2024 failed to evidence a documented facility-based and community-based risk assessment. During an interview with Administrator on 5/15/24 at 4:33 PM, when queried where the agencys facility-based and community-based risk assessment was kept, Administrator reported the risk assessments were completed by Corporate Staff 4, who was the “;safety officer.” During a follow-up interview with Administrator on 5/15/24 on 4:38 PM, the employee reported the agency had not completed a facility-based and community-based risk assessment.”

“Based on record review and interview, the hospice agency failed to evidence an after-action review was completed for the agencys emergency preparedness testing exercise conducted in 2024, which had the potential to affect all agency patients and staff. Findings include: The review of an agency document titled “;Emergency Drill Requirements” indicated a “;Disaster Drill Reporting Form/Post Emergency Evaluation” would be completed “;within 72 hours of drill/disaster to summarize events occurring during [a] disaster. It also includes a detailed evaluation to identify lessons learned and action items to improve.” The review of the agencys Emergency Preparedness binders for 2023 and 2024 indicated the agency completed a fire drill as a testing exercise of its emergency preparedness plan on 1/30/24. The emergency preparedness binders failed to evidence an after-action review was completed for the testing exercise. During an interview with Administrator on 5/15/24 beginning at 4:33 PM, Administrator reported the agency tested its emergency preparedness plan through a fire drill on 1/30/24. Administrator reported an after-action review was not completed after the fire drill.”

“Based on observation, record review, and interview, the hospice agency failed to ensure the interdisciplinary group (IDG) reviewed the patients medications to identify actual or potential allergic reactions for 1 of 2 home visit observations performed with a home health aide (Patient #3). Findings include: During a home visit observation with Patient #3 on 5/09/24 beginning at 10:56 AM, Patient was observed to have scattered bruising over his/her extremities, including a large bruise to his/her left shin. The review of Patient #3s clinical record evidenced a hospice benefit election date of 1/12/23. Patients referral documents indicated his/her allergies included Aspirin with a reaction of “;bruising.” The record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 5/02/24, which evidenced Patients allergies included Aspirin. The record evidenced Patients current medications included a low-dose Aspirin daily with a start date of 5/03/23. The record failed to evidence the IDG had reviewed Patients medications to identify actual or potential allergic reactions. During an interview with Patient #3 and Person J, family member for Patient #3, on 5/09/24 beginning at 12:09 PM, the family member reported Patient #3 had taken a low-dose Aspirin pill daily for “;years.” Neither Patient #3 nor Person J were aware of Patient an allergic reaction to Aspirin. During an interview with Registered Nurse (RN) 3 on 5/13/24 beginning at 3:52 PM, the nurse reported she was not aware of Patient having an allergy to Aspirin. RN 3 reported Patient had an intermittent generalized rash over the past few weeks. During RN 3’s visit with Patient on 5/08/24, RN 3 reported she observed Patients left shin looked “;terrible ... like a bruise” and thought Patient may have developed it while he/she was scratching the area.”

“Based on record review and interview, the hospice agencys Quality Assessment and Performance Improvement (QAPI) program failed to incorporate and aggregate data elements from all patients’ comprehensive assessments and allowed for the measurement of outcomes, which had the potential to affect all agency patients. Findings include: The review of an agency document titled “;Quality Assessment Performance Improvement (QAPI) Plan 2024” indicated data to be collected for the agencys QAPI program included “;comprehensive chart audits” with a sample size of “;10 records or 10% of the census, which ever is greater (including discharge records).” Audits were to be performed quarterly by the administrator or designee. The review of the agencys QAPI meeting minutes for the meeting held 2/14/24 indicated the committee reviewed data collected for Quarter 4 2023. The meeting notes indicated 0 “;comprehensive chart” audits had been completed for the period reviewed. The meeting minutes failed to evidence the agencys QAPI program incorporated and aggregated data elements from all patients comprehensive assessments and allowed for the measurement of outcomes. During an interview with Administrator and Corporate Staff 3 on 5/15/24 beginning at 4:19 PM, when queried what data elements the agency collected from comprehensive assessments and analyzed as part of its QAPI program, Administrator reported the agency completed chart audits of 10% of active and discharge records quarterly. The chart audits included review of the comprehensive assessment.”

“Based on record review and interview, the hospice agency failed to evidence the plan of care was individualized and included measurable outcomes anticipated from implementing and coordinating the plan of care, for 2 of 4 records reviewed of patients who had a home visit observation (Patient #1, 2). Findings include: 1. The review of Patient #1s clinical record included a “;Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report,” dated 5/02/24, which evidenced the agencys goals for Patient included but were not limited to “;Patient will achieve maximal wound healing and comfort within disease process ... Patient will maintain optimal skin integrity within disease process ... Anxiety will be reduced/controlled ... Patient will achieve optimal cardiac/circulatory function and comfort within disease process ... Patient will achieve optimal management of [col]ostomy [surgically created opening to the colon through the abdomen] ... Patient/caregiver will verbalize/demonstrate adequate knowledge of urostomy [surgically created opening in the abdomen that diverts urine from the bladder] and its management ... Pain will be relieved/reduced to meet Patients intensity goal ... Patient will achieve optimal respiratory function and comfort within disease process ....” During an interview with Registered Nurse (RN) 2 on 5/08/24 beginning at 5:55 PM, the nurse reported she was Patients RN case manager. When queried how the nurse measured the Patients progress towards the following goals, RN 2 reported: a. For the goal “;Anxiety will be reduced/controlled,” RN 2 would ask Patient if he/she was feeling anxious. If Patient reported shortness of breath, RN 2 would assess if Patient also felt “;overwhelmed.” b. For the goal “;Patient will achieve optimal cardiac/circulatory function and comfort within disease process,” RN 2 would assess Patients lung sounds, energy level, and presence or absence of shortness of breath and swelling of the lower extremities. c. For the goal “;Patient will achieve optimal management of [col]ostomy,” RN 2 would assess the appearance of the colostomy stoma (external portion of the ostomy) and surrounding skin, presence or absence of pain at the site, and if the colostomy was “;draining appropriately.” d. For the goal “;Patient/caregiver will verbalize/demonstrate adequate knowledge of urostomy,” RN 2 would assess the appearance of the skin surrounding the stoma, the appearance of Patients urine, and if the ostomy was “;draining appropriately.” e. For the goal “;Pain will be relieved/reduced to meet Patients intensity goal,” RN 2 would assess Patients pain using a 0-10 verbal pain scale (standardized method of assessing pain by having the patient rate their pain from 0-10, with “;0” meaning no pain and “;10” meaning the worst pain). RN 2 reported Patient “;always” rated his/her pain as a “;4-6” on a 0-10 verbal pain scale. f. For the goal “;Patient will achieve optimal respiratory function and comfort within disease process,” RN 2 would assess Patients oxygen saturation level (percentage of red blood cells with oxygen attached), lung sounds, and presence or absence of shortness of breath at rest and with exertion. 2. The review of Patient #2s clinical record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 5/02/24, which evidenced the agencys goals for Patient included but were not limited to “;... Patient will achieve optimal cardiac/circulatory function and comfort within disease process ... Patient/caregiver will achieve optimal communication ... Patient will achieve optimal genitourinary function and comfort within disease process ... Patient/caregiver will verbalize/demonstrate adequate knowledge of the urinary incontinence care ... Patient will achieve maximal wound healing and comfort within disease process ... Patient will maintain optimal mobility within disease process ... Pain will be relieved/reduced to meet Patients intensity goal ... Patient will achieve optimal respiratory function and comfort within disease process ... Patient/caregiver will understand safety and care requirements to ensure patient safety and care needs are met ....” During an interview with RN 3 on 5/13/24 beginning at 3:29 PM, the nurse reported she was Patients RN case manager. When queried how the nurse would evaluate a patients progress towards the following goals, RN 3 reported: a. For the goal “;Patient will achieve optimal cardiac/circulatory function and comfort within disease process,” RN 3 would assess the patients blood pressure and heart rate, heart tones, energy levels, and for the presence or absence of shortness of breath, swelling, cyanosis (bluish color of the skin or body part due to lack of oxygen), and difficulty urinating. b. For the goal “;Patient will achieve optimal genitourinary function and comfort within disease process,” RN 3 would assess the frequency the patient was urinating and for the presence or absence of incontinence (loss of bladder control) episodes, burning with urination, and blood or foul smell to the urine. c. For the goal “;Patient/caregiver will verbalize/demonstrate adequate knowledge of the urinary incontinence care,” RN 3 would assess for the presence or absence of difficulty initiating a urine stream, bladder still feeling full after urination, and blood in the urine. d. For the goal “;Patient will achieve maximal wound healing and comfort within disease process,” RN 3 would assess the appearance of the wound, measurement of the wound, and for the presence or absence of skin irritation caused by the type of wound dressing ordered. e. For the goal “;Patient will maintain optimal mobility within disease process,” RN 3 would assess the patients mobility while ambulating, including how “;steady” the patient was when walking. f. For the goal “;Pain will be relieved/reduced to meet Patients intensity goal,” RN 3 would assess the patients current pain level and tolerable pain level using a standardized pain scale, location of pain, and if Patients pain management interventions were effective. g. For the goal “;Patient will achieve optimal respiratory function and comfort within disease process,” RN 3 would assess the patients lung sounds, oxygen saturation level, and for the presence or absence of shortness of breath. If the patient was wearing oxygen, RN 3 would assess if the oxygen was effective. h. For the goal “;Patient/caregiver will understand safety and care requirements to ensure patient safety and care needs are met,” RN 3 would assess the patient and/or caregivers ability to comprehend any safety concerns in the home.”

“Based on record review and interview, the hospice agency failed to ensure the plan of care included a complete physician order for all drugs and included all treatments necessary to meet the patients needs for 2 of 14 active records reviewed (Patients #4, 9). Findings include: 1. The review of Patient #4s clinical record included a skilled nurse visit note, dated 5/03/24 by Registered Nurse (RN) 3, which indicated Patient had a “;reddened area to the groin.” The record included a physician order dated 5/03/24 for “;antifungal powder [used to treat fungal infections] and barrier cream [non-medication cream used to protect the skins outermost layers].” During an interview with RN 3 on 5/13/24 beginning at 12:55 PM, the nurse reported she observed redness to Patients groin while Patient was showering on 5/03/24. RN 3 stated the nurse at Facility M, an assisted living facility where Patient resided, was concerned for Patient having a possible yeast infection, so RN 3 ordered an antifungal powder and barrier cream to be used as needed. During a follow-up interview with RN 3 on 5/14/24 beginning at 10:53 AM, the nurse reported she entered a physician order for “;antifungal powder and barrier cream” to initiate delivery of the items. The nurse did not write a complete order for use of the antifungal powder, including dosage, frequency of use, etc, because the powder had not been used. During an interview with Person L, an employee at Patients skilled nursing facility, on 5/13/24 beginning at 4:51 PM, the employee reported a bottle of Miconazole antifungal powder was present in Patients room. Person L reported the bottle was unlabeled and the facility did not have an order for its use. 2. The review of Patient #9s clinical record included an RN start of care visit conducted on 4/22/24 by RN 2. The nurse noted Patient lived at a private residence alone and had multiple caregivers. Patient had a colostomy (surgically created opening for the colon through the abdomen) and used a Purewick catheter (an external catheter which uses suction to draw urine away from the body). The record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 5/02/24, which indicated the IDGs goals for Patient included but were not limited to “;... Patient will achieve optimal management of ostomy ... external catheter/Purewick will remain patent: Caregiver(s) will understand care of ... external catheter.” The plan of care failed to evidence interventions for the management of Patients colostomy, including frequency and directions for site care, and Purewick catheter, including suction setting (if present) and frequency of catheter change. During an interview with RN 2 on 5/15/24 beginning at 9:53 AM, the nurse reported Patients colostomy appliance was to be changed “;every couple of days” and as needed for leakage. RN 2 was unsure how often Patients Purewick catheter was to be changed. The nurse stated the Purewick catheter was connected to a low intermittent suction but was unsure if there was an option for different suction settings.”

“Based on observation, record review, and interview, the hospice agency failed to ensure the individualized plan of care included all medical supplies and appliances to meet the needs of the patient for 1 of 1 home visit observation of a patient with an ostomy (Patient #1). Findings include: During a home visit observation with Patient #1 on 5/08/24 beginning at 7:30 AM, Licensed Practical Nurse (LPN) 1 was observed changing the appliances for Patients colostomy (surgically created opening to the colon through the abdomen) and urostomy (surgically created opening in the abdomen that diverts urine from the bladder). The nurse also changed Patients abdominal wound dressing. Patient used a 2-piece appliance for both ostomies, which consisted of a flange unit (the part of the appliance which attached to the patients skin) and a pouch (the part of the appliance which collected the urine or feces). Due to the close proximity of the ostomies and wound, the nurse applied the ostomy flange units and wound dressing to where they were overlapping each other. During the visit, Patient reported the wound dressing and ostomies had to be changed 3 times a day due to drainage from wound and/or leaking from the ostomies seeping into one another. During an interview with Patient #1 on 5/08/24 beginning at 8:48 AM, he/she reported for the past 6 months, the agency had not provided enough ostomy supplies, including the flange units and pouches. Patient reported he/she had to purchase additional supplies out-of-pocket. Patient reported he/she was currently out of ostomy supplies provided by the hospice agency and was using his/her own personal supply. During an interview with Registered Nurse (RN) 2 on 5/08/24 beginning at 5:55 PM, the nurse reported she was Patients RN case manager and Patient received skilled nurse visits 5 days a week. RN 2 reported hospice staff changed Patients ostomy appliances and wound dressing at each visit. Additionally, Patient and his/her caregivers would change the ostomy appliances and wound dressing 2-3 times a day. RN 2 reported the increased need to change the appliances and wound dressing was due to the abdominal wound having a large amount of drainage, which would seep into the adhesive on the ostomy flange units. The nurse would place supply orders for Patients ostomy weekly, however Patient had to intermittently purchase ostomy supplies out-of-pocket to supplement his/her supply. During an interview with Administrator on 5/10/24 beginning at 10:55 AM, she reported Patients supplies and appliances were ordered by RN 2 once a week. The order would go to Administer to review for approval and she would add on any non-formulary supplies needed. The review of Patient #1s clinical record included a “;Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report,” dated 2/22/24, which indicated Patient and his/her caregivers were changing his/her ostomy appliances “;3 or 4 times daily due to leakage or drainage from a fistula.” The record included a plan of care for the benefit election period of 4/11/24 – 6/09/24 which indicated the hospice nurse was to perform site care to Patients colostomy and urostomy twice a week and as needed for soilage. “;Site care” included removing the 2-piece appliance, cleansing the skin, applying skin prep (protective film that prevents skin from breaking down), then applying a new 2-piece appliance. Patients abdominal wound dressing was to be changed once a day. The hospice nurse was to perform the dressing change once a week and Patients caregiver was to perform on all other days. The record evidenced the following ostomy supplies were ordered during the current benefit period: a. On 4/17/24, the agency ordered 10 flange units and 20 pouches. b. On 4/23/24, the agency ordered 10 flange units and 20 pouches. c. On 5/01/24, the agency ordered 20 pouches. d. On 5/08/24, the agency ordered 20 flange units and 20 pouches. The record evidenced between 4/11/24 – 5/10/24 (the date of record review), a total of 40 flange units and 80 pouches were ordered by the hospice. If Patients ostomy appliance had been changed a minimum three times a day during the 30-day period reviewed, 90 flange units and 90 pouches would be needed.”

“Based on observation, record review, and interview, the hospice interdisciplinary group (IDG) failed to revise the patients plan of care to include information from the patients updated comprehensive assessment for 2 of 4 home visit observations (Patient #1, 4). Findings include: 1. During a home visit observation with Patient #1 conducted on 5/08/24 beginning at 7:30 AM, Patient expressed he/she was worried regarding Person Ks, a family member, health status. Person K had a sudden change in health status approximately 2 months prior and was now in a rehabilitation facility. The family member had been living with Patient and assisting with his/her care prior to the medical event. Patient was concerned if Person K would be able to return home. During an interview with Patient #1 conducted on 5/08/24 beginning at 8:48 AM, Patient appeared depressed and became tearful at multiple points during the interview. Patient reported he/she was often tearful and felt lonely at times, stating “;it gets so quiet” at his/her house. Patient also reported feeling sad about his/her decreased ability to perform tasks he/she enjoyed, such as driving and gardening. The review of Patient #1s clinical record included a face-to-face visit conducted on 3/20/24 by Hospice Nurse Practitioner (NP) 3. The NP noted Patient was “;upset and depressed” regarding Person Ks health status. The record included a “;Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report,” dated 4/04/24, which indicated Patient had a history of anxiety disorder. Registered Nurse (RN) 2 documented Patient had “;experienced mild depression since [Person K] placed in nursing home.” The record included skilled nurse visits conducted on 4/25/24 and 4/26/24 by Registered Nurse (RN) 2 which indicated the nurse answered “;yes” to the assessment question “;Does patient exhibit/report depression and/or have a history of depression?” RN 2 documented Patient had “;little interest or pleasure in doing things” and “;felt down, depressed, or hopeless” for “;several days” over the last 2 weeks. The nurse documented Patients depression symptom score was a “;2” out of 10 on the Edmonton Symptom Assessment System (ESAS, a standardized scale used to assess symptoms commonly experienced by hospice patients, including depression. The symptoms are rated from 0-10, with a depression score of 0 meaning “;no depression” and 10 meaning “;worst possible depression”). RN 2 documented Patients goal for his/her depression score was 0. The record included skilled nurse visits conducted on 4/29/24, 4/30/24, and 5/01/24 by Licensed Practical Nurse (LPN) 1 which indicated the nurse answered “;yes” to the assessment question “Does patient exhibit/report depression and/or have a history of depression?” LPN 1 documented Patient had “;little interest or pleasure in doing things” and “;felt down, depressed, or hopeless” for “;several days” over the last 2 weeks. The visit notes failed to evidence a depression score for Patient using the ESAS scale. The record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update,” dated 05/02/24, which indicated RN 2 documented Patient denied feeling anxious or depressed. The revised plan of care failed to evidence the IDG discussed Patients depression symptoms or possible interventions. During an interview with RN 2 on 5/08/24 beginning at 5:55 PM, the nurse reported Patient began to feel down and depressed after Person K’s change in health status. RN 2 stated Patient “;gets emotional” when speaking with the nurse regarding Person K. 2. During a home visit observation with Patient #3 conducted on 5/09/24 beginning at 10:56 AM, HA 2 was observed assisting Patient with a shower and dressing. Patient was observed to have a red, slightly raised circular rash to his/her right lower back, hip, and buttocks. The rash appeared similar to bug bites. Patient also had scattered scratches and bruising, including a large bruise on his/her left anterior shin. HA 2 reported Patient had a rash for several weeks which had started on Patients arms and spread to his/her legs. HA 2 reminded Patient to not scratch several times throughout the visit. The aide reported the scattered bruising and scratches on Patients arms and legs were due to him/her scratching at the rash. The review of Patient #3s clinical record included a skilled nurse visit conducted on 4/30/24 by RN 3. The nurse noted Patient had a “;small itchy rash” on his/her trunk and legs. RN 1 advised Person J, Patients family member, to administer Benadryl as needed for itching. The record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 5/02/24, which failed to evidence the IDG discussed Patients rash nor RNs recommendations to take Benadryl as needed. The record included a skilled nurse visit conducted on 5/08/24 by RN 3. The nurse noted Patients rash continued, Interim Medical Director was notified, and the nurse received orders to take Benadryl as needed for itching and apply non-medicated lotion. During an interview with Patient #3 and Person J, family member for Patient #3, on 5/09/24 beginning at 12:09 PM, the family member reported Patient #3 had a generalized rash consisting of “;itchy bumps” for several weeks. During an interview with RN 3 on 5/13/24 beginning at 3:52 PM, the nurse reported Patient had reported an intermittent rash and itchiness for the past 1 month. RN 3 stated she did not observe a rash during her nurse visits until 5/08/24, where Patient had “;3 little dots,” similar in appearance to mosquito bites. During the visit, RN 3 also observed Patients left shin looked “;terrible ... like a bruise” and thought Patient may have developed it while he/she was scratching the area. RN 3 informed Interim Medical Director, who reportedly stated the area was likely an “;itchy bruise” and ordered Benadryl and a non-medicated moisturizer. RN 3 stated she did not discuss Patients rash during the 5/02/24 IDG meeting as the nurse had not observed the rash herself.”

“Based on observation, policy review, and interview, the hospice agency failed to ensure all staff followed standard precautions and agency policies and procedures specific to hand hygiene and bag technique for 4 of 4 home visit observations (Patients #1, 2, 3, 4). Findings include: 1. The review of agency policy #6-006 titled “;Hand Hygiene,” revised 12/2020, indicated hand hygiene should be performed “;before having direct contact with patients ... after contact with a patients intact skin ... After removing gloves.” When performing hand hygiene with an alcohol-based hand sanitizer, staff should apply the sanitizer and rub their hands together until dry. 2. The review of agency policy #6-013 titled “;Bag Technique” indicated hand hygiene was to be performed before entering the nursing bag. Patient-care devices, such as a blood pressure cuff and stethoscope, “;should be disinfected ... after each patient use.” 3. The review of manufacturers instructions for Sani-Cloth disinfectant wipes, dated 2021 and obtained from www.pdihc.com, evidenced equipment disinfected with a Sani-Cloth wipe should be allowed “;to remain wet for two (2) minutes” and air dry. 4. During a home visit observation with Patient #1 conducted on 5/08/24 beginning at 7:30 AM, Licensed Practical Nurse (LPN) 1 was observed using a blood pressure cuff, oxygen saturation probe, thermometer, and stethoscope. LPN 1 wiped each patient-care device with a Sani-Cloth disinfectant wipe then placed the equipment back in her nursing bag while the equipment was visibly wet. LPN 1 failed to allow the disinfectant to dry according to manufacturer’s instructions before returning the equipment to her nursing bag. During an interview with LPN 1 on 5/08/24 beginning at 8:43 AM, when queried how long the Sani-Cloth disinfectant wipes should be allowed to dry, LPN 1 was unable to state the dry time. 5. During a home visit observation with Patient #2 conducted on 5/08/24 beginning at 11:35 AM, Hospice Aide (HA) 1 was observed assisting Patient with a shower. During the shower, the aide failed to perform hand hygiene in between glove changes on 4 occasions. During an interview with HA 1 on 5/10/24 beginning at 8:49 AM, HA 1 reported she should perform hand hygiene in between glove changes. 6. During a home visit observation with Patient #3 conducted on 5/09/24 beginning at 10:56 AM, HA 2 was observed assisting Patient #3 with a shower. The aide failed to perform hand hygiene prior to donning gloves on 3 occasions. When performing hand hygiene with an alcohol-based hand sanitizer, the aide failed to rub the sanitizer in until her hands were dry on 1 occasion. During an interview with HA 2 on 5/09/24 beginning at 12:02 PM, the aide reported she should perform hand hygiene when her hands were “dirty.” HA 2 reported she should rub hand sanitizer in until her hands were dry. 7. During a home visit observation with Patient #4 conducted on 5/09/24 beginning at 4:05 PM, Registered Nurse (RN) 1 failed to perform hand hygiene prior to entering the nursing bag on 1 occasion and failed to perform hand hygiene after removing her gloves on 1 occasion. During the visit, RN 1 was observed using a blood pressure cuff, oxygen saturation probe, thermometer, and stethoscope. RN 1 wiped each patient-care device using a Sani-Cloth disinfectant wipe. After the nurse wiped the equipment and all items were visibly wet, the nurse stacked the equipment on top of each other. RN 1 failed to allow the disinfectant to dry prior to piling the equipment together. During an interview with RN 1 on 5/09/24 beginning at 4:57 PM, the nurse reported she performed hand hygiene before and after touching a patient, removing gloves, and performing invasive tasks, such as catheter care or wound care. RN 1 reported she used Sani-Cloth disinfectant wipes to disinfect her equipment and the dry time was 1 minute. 8. During an interview with Administrator and Clinical Supervisor 2 on 5/10/24 beginning at 3:33 PM, Clinical Supervisor 2 reported staff should perform hand hygiene in between glove changes and prior to entering the nursing bag. When performing hand hygiene with alcohol-based hand sanitizer, Clinical Supervisor 2 reported staff should rub their hands together until they are dry. Clinical Supervisor 2 reported staff should disinfect equipment used during a visit with Sani-Wipes and allow the disinfectant to dry prior to returning the equipment to the nursing bag. Administrator reported the dry time for Sani-Wipes was 2 minutes.”

“Based on record review and interview, the Registered Nurse (RN) failed to document an assessment of a patients pain using a standardized scale which accounted for patients decreased cognitive function, failed to document a complete assessment of an ostomy, failed to document education and training was provided to a patients caregivers regarding care and treatment of a colostomy and external urinary catheter, and failed to document physician notification of a patient fall with head injury for 3 of 14 active records reviewed (Patients #8, 9, 14). Findings include: 1. The review of agency policy #4-4046 titled “;Pain Assessment,” revised 11/15/23, indicated for patients who were “;cognitively impaired,” the nurse was to “;assess behavioral factors that signal pain or discomfort and include this information in the assessment.” 2. The review of Patient #8s clinical record evidenced a terminal diagnosis of cerebral vascular disease (decreased blood flow in the brain) and a secondary diagnosis of dementia. Patient resided in a memory care unit. The record included a skilled nurse visit note completed on 5/07/24 by RN 4. The nurse noted Patient was “;unable to understand and participate in [his/her] care” and had “;periods of confusion.” RN 4 documented she assessed Patients pain using a verbal 0-10 pain scale (standardized scale used to assess pain by asking a patient to rate his/her pain from 0-10, with “;0” meaning no pain and “;10” meaning the worst pain). The record included a skilled nurse visit completed on 5/09/24 by RN 4. The nurse noted Patient was “;unable to understand and participate in [his/her] care” and was confused. RN 4 documented she assessed Patients pain using a verbal pain scale. During an interview with RN 4 on 5/14/24 at 2:27 PM, she reported Patient was intermittently confused. The nurse assessed Patients pain using a verbal 0-10 pain scale and stated, “;sometimes [Patient] gets it, sometimes [Patient] doesnt.” RN 4 reported she also assessed Patient for signs of pain including facial grimacing and moaning. She did not document the assessment of these signs unless the patient was exhibiting them. RN 4 reported Patient had “;mild” pain. 2. The review of Patient #9s clinical record included an RN start of care visit conducted on 4/22/24 by RN 2. The nurse noted Patient lived at a private residence alone and had multiple family members serving as caregivers. Patient had a colostomy (surgically created opening for the colon through the abdomen) and used a Purewick catheter (an external urinary catheter which uses suction to draw urine away from the body). RN 2 documented a caregiver for Patient #8 reported Patient had “;skin irritation” to the area surrounding the colostomy. The visit note failed to evidence the nurses assessment of the colostomy surrounding skin. The note also failed to evidence RN 2 performed education and training to Patients multiple caregivers to ensure the caregivers could appropriately care for Patients colostomy and Purewick catheter. During an interview with RN 2 on 5/15/24 beginning at 9:53 AM, the nurse reported Patient had multiple caregivers who were primarily managing Patients colostomy and Purewick catheter. Patients colostomy appliance was to be changed “;every couple of days” and as needed for soilage or leakage. The hospice nurse was to change the appliance once a week and the caregivers were to change all other times. RN 2 stated Patients caregivers reported no concerns with the ostomys surrounding skin but could not recall if she removed Patients colostomy appliance to observe the area. The nurse reviewed verbally with Patient’s primary caregiver how to perform site care to Patients colostomy and the primary caregiver demonstrated how to change Patients Purewick catheter. RN 2 was unsure how often the Purewick catheter was to be changed. 3. The review of Patient #14s clinical record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 5/02/24, which indicated Patient had a history of repeated falls and medications included Eliquis (a blood thinner medication). The record included a skilled nurse visit note, dated 5/03/24 by RN 3, which indicated Patient had a fall prior to the nurses visit. RN 3 noted a “;goose egg bump” to Patients forehead. The record failed to evidence RN 3 notified Patients physician of the fall with head injury. During an interview with RN 3 on 5/15/24 beginning at 3:17 PM, the nurse reported Patients fall on 5/03/24 was unwitnessed and Patient did not recall what occurred prior to or during the fall. RN 3 stated Patient had a “;bump” to the head but no open wounds or lacerations. RN 3 reported she notified Interim Medical Director of the fall but could not recall if she documented the notification.”

“Based on record review and interview, the medical social worker (MSW) failed to conduct a timely social work evaluation for 2 of 2 active records reviewed which evidenced orders for MSW evaluation (Patients #2, 8). Findings include: 1. The review of Patient #2s clinical record indicated a hospice benefit election date of 7/28/23. The record included a physician order, dated 1/24/24, for social work visits to be conducted once every 2 months. The record evidenced a social work visit was last conducted on 3/05/24. The record included a physician order, dated 3/24/24, to recertify Patient for hospice services. The order failed to evidence the frequency of visits to be performed by social services for the new certification period. The record failed to evidence Patients social work services had been discontinued. The record included a “;Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report,” dated 3/27/24, which indicated Patient was to receive 1 social work visit per month for “;companionship.” The record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 4/24/24, which indicated MSW 1 was to complete a visit with Patient within the next 2 weeks. The plan of care indicated social services interventions included “;active reflexes/supportive listening ... provide companionship to Patient ... provide Patient with emotional support and reassurance ....” The record included a physician order, dated 4/26/24, which indicated Patient was to have a social work evaluation. The record included a “;Client Coordination Note Report,” dated 4/26/24 and documented by Former Employee F, which indicated Patients family was “;requesting MSW assistance.” During an interview with MSW 1 on 5/13/24 beginning at 12:36 PM, the social worker reported Patient had been receiving social work services, but the order had mistakenly not been continued at the time of Patients recertification on 3/24/24. The social worker had not made any visits since 3/05/24. MSW 1 reported the hospice IDG discovered the error during its meeting on 4/24/24 and an order for MSW evaluation was obtained. The social worker reported she had attempted to schedule the visit on 5/03/24 and 5/07/24, however the social worker had been unable to conduct the visit due to time constraints. The record indicated MSW 1 conducted a MSW evaluation of Patient #2 on 5/14/24. The record failed to evidence the reason for the delay in conducting the evaluation. 2. The review of Patient #8s clinical record evidenced a terminal diagnosis of cerebral vascular disease (decreased blood flow in the brain) and a secondary diagnosis of dementia. Patient resided on a memory care unit. The review of the agencys complaint log evidenced a complaint from Person N, caregiver to Patient #8, dated 4/13/24. Within the complaint, Person N reported concerns with care Patient was receiving from Entity O, an assisted living facility. Person N expressed interest in a care conference with the hospice and Entity Os staff “;to make sure everyone is on the same page.” During an interview with Person N on 5/15/24 beginning at 9:38 AM, he/she reported there had been several instances where the caregiver found Patient #8 with feces or urine on themselves. Person N reported a case conference was held with the caregiver, staff from Entity O, and Former Employee P. Since the case conference, Person N reported they suspected Patient was still urinating outside of his/her bathroom and Patient had several episodes where he/she removed all of his/her clothes in public. Person N was unsure of any further options for care for Patient. Patient #8s clinical record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 5/02/24, which Former Employee P documented “;Patient is now taking feces and putting it on items, will take clothes off, move objects and wander ....” MSW 1 documented Patient was not receiving social work services. The record included a physician order, dated 5/02/24, for a social work evaluation. During an interview with MSW 1 on 5/15/24 beginning at 9:34 AM, the social worker reported a social work evaluation was ordered for Patient #8 during the last IDG meeting due to Person Ns recent complaint regarding care provided by Entity O. The IDG thought a social worker should evaluate Patient to determine if social work services were needed. MSW 1 reported she had not yet conducted the evaluation due to time constraints.”

“Based on record review and interview, the hospice agency failed to ensure upon hire all hospice aides completed a return demonstration of a patient transfer using a Hoyer lift for 1 of 3 personnel files reviewed of hospice aides hired after 10/25/17 (Hospice Aide (HA) 2), which had the potential to affect 2 of 4 active patients who required the use of a Hoyer lift for transfer (Patients #6, 7). Findings include: 1. The review of agency policy #8-022 titled “;Orientation,” last revised 01/21, indicated “;all personnel will demonstrate knowledge and proficiency in skills appropriate to their assigned responsibilities during the orientation period.” The orientation content was to include a “;baseline skills assessment.” 2. The review of Hospice Aide 2s personnel file evidenced a hire date of 5/15/23. The file included a “;Skills Competency Checklist: Hospice Aide,” completed as part of the aides new hire orientation, on 6/20/23 with Former Employee H, a Registered Nurse (RN). The checklist failed to evidence HA 2 completed a return demonstration of a patient transfer using a Hoyer lift. The file also included a “;Skills Competency Checklist: Hospice Aide,” completed as part of an annual competency, on 10/26/23 by Former Employee I, a RN. The checklist failed to evidence HA 2 completed a return demonstration of a patient transfer using a Hoyer lift. 3. The review of Patient #6s clinical record evidenced a hospice benefit election date of 11/15/23. Patients plan of care for the benefit period of 2/13/24 – 5/12/24 evidenced Patient was to receive hospice aide visits 2 times a week for 1 week then 3 times a week for 12 weeks. Patients aide care plan evidenced aide tasks included but were not limited to showering and Patient was to be transferred with a Hoyer lift. Patient resided in a private home with his/her family members acting as primary caregivers. HA 2 documented she completed a transfer of Patient with a Hoyer lift for 30 of 38 hospice aide visits for the current benefit period (2/14/24, 2/16/24, 2/19/24, 2/23/24. 2/26/24, 3/01/24. 3/06/24, 3/08/24, 3/13/24, 3/15/24, 3/18/24, 3/22/24, 3/25/24, 3/27/24, 3/29/24, 4/01/24, 4/03/24, 4/05/24, 4/08/24, 4/10/24, 4/12/24, 4/15/24, 4/17/24, 4/19/24, 4/22/24, 4/26/24, 4/29/24, 5/03/24, 5/06/24, and 5/10/24). 4. The review of Patient #7s clinical record evidenced a hospice benefit election date of 8/10/23. Patients plan of care for the benefit period 4/06/24 – 6/04/24 evidenced Patient was to receive hospice aide visits 3 times a week for 8 weeks then 1 time a week for 1 week. Patients aide care plan evidenced aide tasks included but were not limited to showering and transferring to and from a bed/chair. Patient was to be transferred using a Hoyer lift and resided in a skilled nursing facility. HA 2 documented she completed a transfer of Patient with a Hoyer lift for 3 of 15 hospice aide visits for the current benefit period (4/10/24, 4/19/24, and 5/03/24). During an interview with HA 2 on 5/13/24 beginning at 2:24 PM, the aide reported she completed an aide competency checkoff with Former Employee H upon hire. The competency checkoff was performed in the agencys office. When queried if the aide had performed a return demonstration of a patient transfer with a Hoyer lift, HA 2 reported she performed a return demonstration with Volunteer Coordinator 1, who previously worked as a hospice aide. HA 2 reported she had 2 active patients who required the use of a Hoyer lift for transfers – Patients #6 and #7.”

“Based on observation, record review, and interview, the hospice aide failed to provide services which were included in the aide care plan and consistent with the hospice aide training for 2 of 2 home visit observations with a hospice aide (Patients #2, 3). Findings include: 1. During a home visit observation with Patient #2 on 5/08/24 beginning at 11:35 AM, Hospice Aide (HA) 1 was observed assisting Patient with showering. During the shower, HA 1 applied a barrier cream to a wound in between Patients buttocks. The wound appeared to be closed and approximately the size of a pencil eraser. HA 1 reported she had been applying the barrier cream to the area since she began working with Patient #2 at the request of Patients family member. The review of Patient #2s clinical record included a plan of care for the benefit period of 3/24/24 – 5/22/24 which indicated Patient was to receive hospice aide visits 5 times a week. The record included a hospice aide care plan which failed to evidence the task of applying a barrier cream to Patient’s inner buttock wound. 2. The review of Patient #3s clinical record included a plan of care for the benefit period of 5/06/24 – 7/04/24 which indicated Patient was to receive hospice aide visits 5 times a week. The record included a “;Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report,” dated 05/02/24, which indicated Patient had 2 falls in the last 3 months and required reminders to use his/her walker for ambulation. The record included a hospice aide care plan which indicated Patient was a fall risk and aide tasks included but were not limited to “;stand-by assistance with ambulation.” The aide care plan also indicated the aide should be “;aware of oxygen precautions needed,” however the care plan failed to evidence the interventions the aide was to perform related to Patients oxygen precautions. During a home visit observation with Patient #3 on 5/09/24 beginning at 10:56 AM, HA 2 was observed assisting Patient with showering and dressing. During the visit, Patient walked to and from his/her bedroom and bathroom without using his/her walker. HA 2 was unable to walk next to Patient while he/she was walking due to space limitations in Patients home. Patient was observed grabbing on to furniture to steady him/herself while walking. An oxygen concentrator was observed in Patient’s home. During an interview with HA 2 on 5/09/24 beginning at 12:02 PM, the aide reported Patient used his/her walker “;all the time” unless someone was with him/her. HA 2 stated interventions she performed to decrease Patients risk for falls included reminding Patient to use the walker or hold on to furniture while walking. When queried what interventions the aide performed for a patient on oxygen precautions, the aide could not list any interventions. During an interview with Patient #3 and Person J, family member for Patient #3, on 5/09/24 beginning at 12:09 PM, the family member reported Patient was to use his/her walker “;all the time” when ambulating. Person J reported Patient did not use oxygen continuously or as needed. 3. During an interview with Administrator and Clinical Supervisor 2 on 5/10/24 beginning at 3:33 PM, Clinical Supervisor 2 reported the aide care plan should indicate if the aide was to apply a barrier crème to a wound. Clinical Supervisor 2 stated interventions the aide should perform when a patient was on oxygen precautions included educating the patient and/or family not to smoke while wearing oxygen and avoid open flames or fires. The supervisor reported hospice aides were trained on these precautions and should be aware of the interventions to be performed.”