Franciscan Hospice Care

“Based on record review and interview, the hospice agency failed to maintain a system of communication to ensure the interdisciplinary group (IDG) coordinated care and services between the members of the IDG for 1 of 1 patient record reviewed which evidenced the Registered Nurse (RN) identified a potential need for spiritual care services (Patient #24). Findings include: The review of Patient #24s clinical record evidenced a benefit election date of 2/23/24. The record included an admission comprehensive assessment completed on 2/23/24 by RN 3. The nurse documented Patient had “;occasional” depression and difficulty sleeping due to anxiety. RN 3 completed a spiritual assessment of Patient during the visit, within which the nurse indicated Patient both declined spiritual care services and was “;unsure of [spiritual care] at this time.” The record included a Phone Call note documented on 2/24/24 by Chaplain 2. The note indicated the chaplain attempted to contact Patient #24s primary caregiver but was unsuccessful. Chaplain 2 documented he/she left a voice mail for the caregiver offering a spiritual support visit, and if he/she had not heard back by 2/26/24, the chaplain would attempt to contact the caregiver again. The record included an IDG Note dated 3/04/24 by Chaplain 2. The note indicated Patients spiritual care services were declined. The record indicated RN 3 conducted a skilled nurse visit on 2/26/24. The nurse documented he/she encouraged Patient #24 “;to consider using [the agencys] chaplain” because Patient verbalized “;needing someone to talk to but does not feel comfortable going to church.” The record failed to evidence RN 3 coordinated with the IDG to inform of Patients potential need for spiritual care services. During an interview with Chaplain 2 on 3/6/24 beginning at 5:28 PM, the chaplain reported when patients and/or caregivers declined spiritual care services during an admission visit, the employee would contact the patient and/or caregiver to offer spiritual care services and answer any questions regarding the service. Chaplain 2 reported he/she attempted to contact Patient #24s primary caregiver on 2/24/24 but had to leave a message. The chaplain reported he/she had no record of further follow-up with Patient #24 nor the primary caregiver regarding spiritual care services. Chaplain 2 stated he/she was not notified of the potential need for spiritual care services after RN 3s nurse visit on 2/26/24. Chaplain 2 stated he/she needed to reach out to Patient and/or the primary caregiver due to the nurses documented potential need for spiritual care services.”

“Based on observation, record review, and interview, the hospice failed to ensure all patients’ physical needs, including wounds and drains, were identified and assessed by the hospice nurse when completing the nursing portion of the admission comprehensive assessment (See L524) and failed to ensure the comprehensive assessment included data elements which allowed for measurement of outcomes, were measured and documented in the same way for all patients, and took into consideration aspects of care related to hospice and palliation (See L534). The administrator was notified of an Immediate Jeopardy on 01/12/24 at 4:30 PM at 42 CFR §418.54 Initial and comprehensive assessment of the patient. The Immediate Jeopardy was identified as beginning on 01/05/2024. The immediacy was abated on 01/18/24. The cumulative effects of these systemic problems resulted in the hospice agency failing to ensure all required elements of the comprehensive assessment were completed. Franciscan Hospice Care was found of compliance with 42 CFR 418.54 Initial and comprehensive assessment of the patient. *”

“Based on observation, record review, and interview, the hospice failed to ensure ensure spiritual care services were provided at the frequency ordered in the plan of care (See L543), failed to ensure the primary caregiver was educated and trained on performing wound care (See L544), failed to ensure the interdisciplinary group [IDG] plan of care included interventions to address a patients pain and poor appetite (See L546), failed to ensure the individualized plan of care included measurable outcomes (See L548), failed to ensure the plan of care included drugs and/or treatments for all patient wounds and drains (See L549), failed to ensure the plan of care included all medical supplies and appliances necessary to meet the needs of the patient (See L550), the interdisciplinary group (IDG) reviewed all active patients plans of care during the biweekly IDG meeting, every 15 days at minimum, and failed to revise the individualized plan of care to reflect a change in patient condition (See L552), and failed to update the plan of care to reflect information from the patient’s updated comprehensive assessment (See L553). The cumulative effect of these systemic issues resulting in the hospice agency failing to ensure the IDG oversaw and directed the patients care and the plan of care included all required elements. Franciscan Hospice Care was found out of compliance with 42 CFR 418.56”

“Based on observation, record review, and interview, the hospice licensed professionals failed to conduct and document a complete assessment of all wounds and drains at every visit and according to best practice, failed to obtain a medication order prior to entering into the electronic medical record, and failed to notify the attending physician of a change in the patients wound bed appearance for 6 of 8 records reviewed of a patient with wounds and/or a drain (See L585). The scope and severity of the findings resulted in the hospice failed to ensure licensed professionals consistently and appropriately assessed, monitored, and treated patients’ wounds and/or drains, Franciscan Hospice Care was found out of compliance with 42 CFR 418.62 Licensed professional services.”

“Based on record review and interview, the hospice agency failed to protect the patients right to choose their own physician for 1 of 2 active records reviewed of patients who requested an attending physician other than the hospice physician (Patient #6). Findings include: The review of Patient #6s clinical record evidenced a hospice election benefit date of 01/05/24. The record indicated the patients attending physician was Hospice Physician 1. During an interview with Person E, the primary caregiver for Patient #6, on 01/10/24 beginning at 3:06 PM, the caregiver reported he/she and Patient #6 wanted Person J, the patients primary care physician, to be the hospice attending physician. During an interview with Registered Nurse (RN) 3 on 01/11/24 beginning at 3:40 PM, the nurse reported he/she conducted a meet-and-greet visit with Patient #6 and his/her family on 01/03/24. During the visit, the nurse reported Patient #6 and his/her family wanted Person J to be the hospice attending physician. The nurse reported if a patient elected an attending physician other than the hospice physician, the nurse would notify Office Employee 1 of this election. The nurse reported he/she did not inform the office employee of Patient #6s attending physician selection due to the office being closed at the time of the admission visit on 01/05/24. During an interview with Office Employee 1 on 01/11/24 beginning at 4:07 PM, the employee reported he/she was responsible for contacting physicians elected by patients and/or families to ensure they would follow the patients while on hospice. Office Employee 1 reported he/she was not informed of Patient #6s election of Person J as his/her attending physician.”

“Based on observation, record review, and interview, the hospice agency failed to ensure all patients’ physical needs, including wounds and drains, were identified and assessed by the hospice nurse when completing the nursing portion of the admission comprehensive assessment for 4 of 6 records reviewed of patients with a wound and/or drain on admission (Patients #2, 4, 6, and 12). *** Im assuming someone has something regarding the wound from the clinical record that will need to go here before my observation.*** During an interview on 1/10/2024, at 12:15 PM, at the home of Patient #6 during an observation of care, Registered Nurse (RN) 3 stated to the caregiver, “;Ill gladly look at the wounds if you want me to.” During an interview on 1/10/2024, at 12:15 PM, the patients caregiver indicated he/she would do the wound care to the patients feet if RN 3 would at least do the wound care on the buttocks. During an observation of care at the patients home on 1/10/2024, at 12:26 PM, RN 3 was observed removing a dressing on the lower back above the buttocks and 4 small red open areas were observed on the lower back above and around the crease of the buttocks: one open area was on the left side of the crease of the buttocks, two open areas were at the top of the crease of the buttocks, and one was on the right side of the crease of the buttocks. The base of all 4 open areas was observed to be red with no drainage noted and each was the size of a pinky fingernail. At 12:32 PM the caregiver shined a light onto the patients buttocks and RN 3 counted the open areas and indicated there were 4 wounds. RN 3 was not observed to have measured the open areas on the buttocks. At 12:35 PM the patients feet were observed to have an absorbent pad wrapped with gauze on both feet and ankles. Heel protectors were observed on both of the patients feet over the wrapped gauze. RN 3 was not observed to have removed the heel protectors and wrapped gauze to assess the feet. During an interview on 1/10/2024, at 12:35 PM, the patients caregiver indicated the patient had 5 wounds on the left foot and 3 wound on the right foot. The patients caregiver indicated the right foot had a “;big wound” on the heel and both feet had black areas on the wounds. At 1:01 PM, the patients caregiver he/she had never refused wound care by the hospice staff, and RN 3 usually seemed to be in a hurry and didnt offer to look at the patients feet. The patients caregiver indicated RN 3 had never looked at or completed the wound care on the patients feet and saw the buttocks wounds for the first time that day (1/10/24). *The record for Patient #12 included a undated summary indicating an election date of 10/18/23. Embedded in this document was an admission summary completed by Registered Nurse 9 (RN 9). The admission summary indicated scattered bruising of bilateral upper extremities, a wound to the lateral right upper extremity approximately 3 centimeters in diameter and a preventative foam dressing to coccyx. The record failed to indicate complete measurements of the lateral right upper extremity wound or bruising. During an interview on 1/17/24 at 2:30 pm with Clinical Manager 2 indicated they would expect length, width and depth measurements of all wounds, CM 2 indicated the is was not done for Patient #12. *The comprehensive assessment for Patient #2 dated 12/22/23 completed by Registered Nurse 11 (RN 11) indicated Patient #2 has an open area to the coccyx with a CDI dressing. The integumentary assessment reveals a decubitus ulcer, patient reported pain of 2 of 10. A skilled nurse visit note dated 12/23/23 revealed RN 11 completed a follow up visit with Patient #2 which indicated wound care was completed. The record failed to indicate a complete assessment of the wound including measurements. During an interview on 1/12/24 beginning at 10:55 am with RN 11 who indicated they did not complete the assessment of the coccyx because they did not have supplies to complete the dressing change. RN 11 indicated they should have completed the assessment on admission but due to not having supplies they did not. When they returned 12/23/23 there was no open area. During an interview with the Administrator, Clinical Manager 2 and Clinical Manager 3 beginning at 4:09 pm on 1/12/24, they concluded that a complete wound assessment should be completed at the time of admission. Clinical Manager 3 confirmed it was not completed for Patient #2. Findings include: 1. A review of agency policy #966511 titled “;Assessment and Care Plan Policy,” last reviewed 11/19/21, indicated the comprehensive assessment should be patient-specific and identify the patients physical care needs. 2. A review of agency education provided to all hospice nurses, dated 05/04/23, indicated the hospice comprehensive assessment should include all wounds and Aspira drains (catheter placed in the body and used to drain excess fluid accumulated around the lungs or abdomen). * 4. The review of Patient #4’s clinical record evidenced a hospice election benefit date of 11/07/23. RN 1 completed the nursing portion of the admission comprehensive assessment on 11/07/23. The visit note indicated the patient had a venous stasis ulcer (wound caused by decreased blood flow) to the “top of the left foot” which was covered by a foam dressing, but failed to evidence a complete assessment of the wound, including wound bed and surrounding skin appearance, wound measurement, presence or absence of signs and symptoms of infection, etc. During an interview with RN 1 on 01/18/24 beginning at 8:36 AM, the nurse reported during the 11/07/23 visit, he/she puled the foam dressing far back enough to “peak” at the wound. RN 1 reported the patient had been receiving home health nursing services prior to electing his/her hospice benefit and the home health nurse had placed the wound dressing on “recently.” The nurse was unsure of the date of the last home health nurse visit. RN 1 confirmed the 11/07/23 visit note failed to evidence a complete wound assessment of Patient #4’s venous stasis ulcer. 5. The review of Patient #6s clinical record evidenced a hospice election benefit date of 01/05/24 and the patient began receiving hospice services while he/she was inpatient at Facility I, a hospital. RN 3 completed the nursing portion of the admission comprehensive assessment on 01/05/24. The visit note indicated the patient had 9 wounds between both feet, which were a “;combination of diabetic and peripheral disease wounds,” The assessment evidenced the following: a. A wound to the left lateral ankle, measuring 1.9 centimeter (cm) in length by 1.9 cm in width x 0.2 cm in depth (1.9 x 1.9 x 0.2), with no noted type, description, or assessment b. A wound to the right medial heel, measuring 4.5 x 4.9 x 0.1 cm, with no noted type, description, or assessment c. A wound to the left lateral foot, measuring 1.8 x 2.7 x 0.4 cm, with no noted type, description, or assessment d. A wound to the left heel, measuring 2.0 x 4.5 x 0.2 cm, with no noted type, description, or assessment. e. A wound to the left medial ankle, measuring 4 x 4.2 x 0.4 cm, with no noted type, description, or assessment f. A wound to the left lateral lower leg, measuring 4.5 x 4.5 x 0.2 cm, with no noted type, description, or assessment g. A wound to the left anterior ankle, measuring 2.8 x 3.2 x 0.2 cm, with no noted type, description, or assessment h. A wound to the right medial ankle, measuring 1.6 x 2 x 0.2 cm, with no noted type, description, or assessment i. A wound to the right lateral ankle, measuring 1.2 x 1.2 x 0.2 cm, with no noted type, description, or assessment j. A pressure ulcer wound to the right heel which was noted to be “;dark, large, abnormal shaped.” The documentation failed to evidence the wounds measurement, pressure ulcer staging, nor a complete assessment of the wounds appearance The visit note indicated RN 3 did not assess the patients multiple foot wounds due to the dressings being changed earlier in the day by Facility I staff. The visit note failed to evidence any further wounds were noted. The record failed to evidence a nursing visit was completed on 01/06/24. Patient #6 was discharged from Facility I to their private residence on 01/07/24 and RN 4 conducted a PRN (as needed) visit that evening after Person E, the primary caregiver to Patient #6, reported the patient had fallen. The visit note failed to evidence the nurse assessed the patients foot wounds. RN 4 documented Patient #6 had an area of red, unblanchable (does not turn white when pressure applied) excoriation on his/her coccyx (bone at the base of the spine where the buttocks begin). RN 3 conducted a skilled nursing visit on 01/08/24. The visit note indicated prior to assessing the patient, Person E informed the nurse he/she was considering transferring the patient to another hospice agency. The note indicated after this discussion, the nurse left the home and failed to assess the patient, including assessing the patients multiple wounds. The record failed to evidence a nursing visit was conducted by hospice staff on 01/09/24. A review of the agencys on call log indicated the hospice received a call on 01/09/24 at 7:10 PM in which Person E reported the patient was complaining of pain to wounds “;on [his/her] behind.” The log indicated Patient #6s caregiver declined a visit be made that evening but requested the patients nurse case manager “;come and assess wounds” on 01/10/24. During an interview with Person E on 01/10/24 beginning at 9:59 AM, the caregiver reported up until the time of the interview, no hospice staff had assessed Patient #6s multiple foot wounds. During an interview with RN 3 on 01/10/24 beginning at 11:03 AM, the nurse reported he/she did not assess Patient #6s foot wounds on 01/15/24 because the wound care had already been performed by the hospital podiatrist. The nurse reported he/she obtained wound measurements from the hospital record. RN 3 reported he/she was not on-call on 01/06/24 (a Saturday) and the record indicated no skilled nursing visit was made to Patient #6. During the visit on 01/08/24, Person E reported to the nurse that he/she performed Patient #6s wound care daily to the multiple foot wounds and it had not yet been done that day. The nurse reported neither the patient nor Person E refused the nurse assess the patients wounds, however the nurse did not perform an assessment during the visit because he/she thought the patient would be transferring to a new hospice agency the same day. The nurse stated he/she should have assessed the patients wounds during the visit. RN 3 reported he/she was planning to conduct a visit to Patient #6 on 01/10/24 to sign transfer paperwork, as the patient had been set up to transfer to another hospice agency. When queried if the nurse was planning to conduct any further assessment during the visit on 01/10/24, the nurse reported he/she was going to follow up regarding the patients pain and restlessness reported during the after-hours call on 01/09/24. During a follow-up interview with RN 3 on 01/11/24 beginning at 3:40 PM, the nurse reported he/she assessed Patient #6s coccyx area (bone at the base of the spine) during the 01/05/24 visit. RN 3 reported at the time of the visit, the patient had an area of unblanchable redness with excoriation to the coccyx. RN 3 also reported during the visit on 01/10/24, he/she noted “;a cluster” of “;4-5” open wounds on the patients coccyx/buttocks. The nurse reported he/she did not measure the buttocks wounds due to the patient asking the nurse to hurry and finish the assessment. During an interview with the Administrator and Clinical Supervisor 3 on 01/11/24 beginning at 2:34 PM, the Administrator confirmed the visit performed on 01/05/24 by RN 3 was the nursing portion of Patient #6s comprehensive assessment. The Administrator reported a nursing visit should have been conducted on 01/06/24 to assess the patients wounds. 7. Findings include: 1. A review of policy #966511 titled “;Assessment and Care Plan Policy,” last reviewed 11/19/21, indicated the comprehensive assessment should be patient-specific and identify the patients physical care needs. 2. A review of hospice education provided to all hospice nurses and dated 05/04/23, indicated the hospice comprehensive assessment should include all wounds and Aspira drains (catheter placed in the body and used to drain excess fluid accumulated around the lungs or abdomen). 3. Patient #2’s clinical record evidenced a hospice election date of 12/22/23 and that RN 11 completed the nursing portion of the admission comprehensive assessment on 12/22/23 which indicated Patient #2 had an “open area” to the coccyx (bone at the base of the spine where the buttocks begin) with a clean, dry, and intact foam dressing. The integumentary portion of the assessment indicated Patient had a decubitus ulcer (wound caused by prolonged pressure to a body site) but failed to evidence the location. The assessment indicated Patient reported pain to the coccyx area of 3 out of 10 on a 0-10 numeric scale (type of pain scale where a patient rates his/her pain from 0-10). The skilled nurse visit note dated 12/23/23 revealed RN 11 completed a follow up visit with Patient and indicated wound care was completed. The record failed to indicate a complete assessment of the wound including measurements was completed during the admission comprehensive assessment. During an interview with RN 11 on 01/12/24 beginning at 10:55 AM, the nurse indicated he/she did not complete the assessment of the coccyx on 12/22/23 because they did not have supplies to complete the dressing change. RN 11 indicated they should have completed the assessment on admission. When the nurse completed the follow-up visit on 12/23/23, the coccyx was red but there was no open area. During an interview with the Administrator, Hospice Manager 2 and Clinical Supervisor 3 on 01/12/24 beginning at 4:09 PM, the administrative staff reported a complete wound assessment should be completed at the time of admission. Clinical Supervisor 3 indicated the record failed to evidence a complete assessment of Patient not documented for Patient #2. 4. The review of Patient #4’s clinical record evidenced a hospice election benefit date of 11/07/23. RN 1 completed the nursing portion of the admission comprehensive assessment on 11/07/23. The visit note indicated the patient had a venous stasis ulcer (wound caused by decreased blood flow) to the “top of the left foot” which was covered by a foam dressing, but failed to evidence a complete assessment of the wound, including wound bed and surrounding skin appearance, wound measurement, presence or absence of signs and symptoms of infection, etc. During an interview with RN 1 on 01/18/24 beginning at 8:36 AM, the nurse reported during the 11/07/23 visit, he/she puled the foam dressing far back enough to “peak” at the wound. RN 1 reported the patient had been receiving home health nursing services prior to electing his/her hospice benefit and the home health nurse had placed the wound dressing on “recently.” The nurse was unsure of the date of the last home health nurse visit. RN 1 confirmed the 11/07/23 visit note failed to evidence a complete wound assessment of Patient #4’s venous stasis ulcer. 5. The review of Patient #6s clinical record evidenced a hospice election benefit date of 01/05/24 and the patient began receiving hospice services while he/she was inpatient at Facility I, a hospital. RN 3 completed the nursing portion of the admission comprehensive assessment on 01/05/24. The visit note indicated the patient had 9 wounds between both feet, which were a “;combination of diabetic and peripheral disease wounds,” The assessment evidenced the following: a. A wound to the left lateral ankle, measuring 1.9 centimeter (cm) in length by 1.9 cm in width x 0.2 cm in depth (1.9 x 1.9 x 0.2), with no noted type, description, or assessment b. A wound to the right medial heel, measuring 4.5 x 4.9 x 0.1 cm, with no noted type, description, or assessment c. A wound to the left lateral foot, measuring 1.8 x 2.7 x 0.4 cm, with no noted type, description, or assessment d. A wound to the left heel, measuring 2.0 x 4.5 x 0.2 cm, with no noted type, description, or assessment. e. A wound to the left medial ankle, measuring 4 x 4.2 x 0.4 cm, with no noted type, description, or assessment f. A wound to the left lateral lower leg, measuring 4.5 x 4.5 x 0.2 cm, with no noted type, description, or assessment g. A wound to the left anterior ankle, measuring 2.8 x 3.2 x 0.2 cm, with no noted type, description, or assessment h. A wound to the right medial ankle, measuring 1.6 x 2 x 0.2 cm, with no noted type, description, or assessment i. A wound to the right lateral ankle, measuring 1.2 x 1.2 x 0.2 cm, with no noted type, description, or assessment j. A pressure ulcer wound to the right heel which was noted to be “;dark, large, abnormal shaped.” The documentation failed to evidence the wounds measurement, pressure ulcer staging, nor a complete assessment of the wounds appearance The visit note indicated RN 3 did not assess the patients multiple foot wounds due to the dressings being changed earlier in the day by Facility I staff. The visit note failed to evidence any further wounds were noted. The record failed to evidence a nursing visit was completed on 01/06/24. Patient #6 was discharged from Facility I to their private residence on 01/07/24 and RN 4 conducted a PRN (as needed) visit that evening after Person E, the primary caregiver to Patient #6, reported the patient had fallen. The visit note failed to evidence the nurse assessed the patients foot wounds. RN 4 documented Patient #6 had an area of red, unblanchable (does not turn white when pressure applied) excoriation on his/her coccyx. RN 3 conducted a skilled nursing visit on 01/08/24. The visit note indicated prior to assessing the patient, Person E informed the nurse he/she was considering transferring the patient to another hospice agency. The note indicated after this discussion, the nurse left the home and failed to assess the patient, including assessing the patients multiple wounds. The record failed to evidence a nursing visit was conducted by hospice staff on 01/09/24. A review of the agencys on call log indicated the hospice received a call on 01/09/24 at 7:10 PM in which Person E reported the patient was complaining of pain to wounds “;on [his/her] behind.” The log indicated Patient #6s caregiver declined a visit be made that evening but requested the patients nurse case manager “;come and assess wounds” on 01/10/24. During an interview with Person E on 01/10/24 beginning at 9:59 AM, the caregiver reported up until the time of the interview, no hospice staff had assessed Patient #6s multiple foot wounds. During an interview with RN 3 on 01/10/24 beginning at 11:03 AM, the nurse reported he/she did not assess Patient #6s foot wounds on 01/15/24 because the wound care had already been performed by the hospital podiatrist. The nurse reported he/she obtained wound measurements from the hospital record. RN 3 reported he/she was not on-call on 01/06/24 (a Saturday) and the record indicated no skilled nursing visit was made to Patient #6. During the visit on 01/08/24, Person E reported to the nurse that he/she performed Patient #6s wound care daily to the multiple foot wounds and it had not yet been done that day. The nurse reported neither the patient nor Person E refused the nurse assess the patients wounds, however the nurse did not perform an assessment during the visit because he/she thought the patient would be transferring to a new hospice agency the same day. The nurse stated he/she should have assessed the patients wounds during the visit. RN 3 reported he/she was planning to conduct a visit to Patient #6 on 01/10/24 to sign transfer paperwork, as the patient had been set up to transfer to another hospice agency. When queried if the nurse was planning to conduct any further assessment during the visit on 01/10/24, the nurse reported he/she was going to follow up regarding the patients pain and restlessness reported during the after-hours call on 01/09/24. During an interview on 1/10/2024, at 12:15 PM, at the home of Patient #6 during an observation of care, RN 3 stated to the caregiver, “;Ill gladly look at the wounds if you want me to.” In response, the patients caregiver indicated he/she would do the wound care to the patients feet if RN 3 would at least do the wound care on the buttocks. During an observation of care at the patients home on 1/10/2024, at 12:26 PM, RN 3 was observed removing a dressing on the lower back above the buttocks and 4 small red open areas were observed on the lower back above and around the crease of the buttocks: one open area was on the left side of the crease of the buttocks, two open areas were at the top of the crease of the buttocks, and one was on the right side of the crease of the buttocks. The base of all 4 open areas was observed to be red with no drainage noted and each was the size of a pinky fingernail. At 12:32 PM the caregiver shined a light onto the patients buttocks and RN 3 counted the open areas and indicated there were 4 wounds. RN 3 was not observed to have measured the open areas on the buttocks. At 12:35 PM the patients feet were observed to have an absorbent pad wrapped with gauze on both feet and ankles. Heel protectors were observed on both of the patients feet over the wrapped gauze. RN 3 was not observed to have removed the heel protectors and wrapped gauze to assess the feet. During an interview on 1/10/2024, at 12:35 PM, Person E indicated the patient had 5 wounds on the left foot and 3 wound on the right foot. The patients caregiver indicated the right foot had a “;big wound” on the heel and both feet had black areas on the wounds. At 1:01 PM, the patients caregiver he/she had never refused wound care by the hospice staff, and RN 3 usually seemed to be in a hurry and didnt offer to look at the patients feet. Person E indicated RN 3 had never looked at or completed the wound care on the patients feet and saw the buttocks wounds for the first time that day (1/10/24). During a follow-up interview with RN 3 on 01/11/24 beginning at 3:40 PM, the nurse reported he/she assessed Patient #6s coccyx (bone at the base of the spine)/buttocks area during the 01/05/24 visit. RN 3 reported at the time of the visit, the patient had an area of unblanchable redness with excoriation. RN 3 also reported during the visit on 01/10/24, he/she noted “;a cluster” of “;4-5” open wounds on the patients coccyx/buttocks. The nurse reported he/she did not measure the buttocks wounds due to the patient asking the nurse to hurry and finish the assessment. During an interview with the Administrator and Clinical Supervisor 3 on 01/11/24 beginning at 2:34 PM, the Administrator confirmed the visit performed on 01/05/24 by RN 3 was the nursing portion of Patient #6s comprehensive assessment. The Administrator reported a nursing visit should have been conducted on 01/06/24 to assess the patients wounds. 7. The review of Patient #12’s clinical record indicated a benefit election date of 10/18/23 and RN 9 completed the nursing portion of the admission comprehensive assessment. The admission summary indicated scattered bruising of bilateral upper extremities, a wound to the lateral right upper extremity approximately 3 centimeters in diameter and a preventative foam dressing to coccyx. The record failed to indicate complete measurements of the lateral right upper extremity wound or bruising. During an interview with Clinical Manager 2 on 1/17/24 at 2:30 PM, the employee indicated he/she would expect length, width and depth measurements of all wounds. Clinical Manager indicated this was not done for Patient #12.”

“Based on record review and interview, the hospice agency failed to ensure the comprehensive assessment included data elements which allowed for measurement of outcomes, were measured and documented in the same way for all patients, and took into consideration aspects of care related to hospice and palliation, which had the potential to affect all agency patients. Findings include: The review of the agencys QAPI program documentation failed to evidence the agency collected data elements from all comprehensive assessments, documented and measured the data in the same way for all patients, and the agency’s QAPI program tracked and analyzed the data elements for the measurement of outcomes. During an interview with QAPI Coordinator 4 on 01/19/24 beginning at 4:45 PM, when queried on which data elements were embedded within the comprehensive assessment and tracked as part of the agencys QAPI program, the QAPI coordinator was unable to identify any data elements pulled from the comprehensive assessment. During a follow-up interview with QAPI Coordinator 4 on 01/22/24 beginning at 2:10 PM, when queried what data was embedded within all comprehensive assessments and tracked as part of the QAPI program, the employee reported he/she reviewed 100% of all admission comprehensive assessments monthly to ensure the spiritual assessment and bereavement risk assessments were completed and 20% of all comprehensive assessments monthly to ensure the assessment was completed and reflected up-to-date information on the patients status. The employee also reported as part of the agencys performance improvement project (PIP) for a complete pain assessment to be completed, the QAPI coordinator would review 100% of all admission comprehensive assessments and subsequent visits to ensure all aspects of the pain assessment were completed. QAPI Coordinator 4 reported no further data from all comprehensive assessments were used within the agencys QAPI program. During an interview on 01/22/24 beginning at 3:05 PM, the Administrator reported the agencys QAPI program included data from the Hospice Item Set (HIS) measures, which were obtained from the admission comprehensive assessment only. The Administrator reported he/she was responsible for presenting the agency’s QAPI program for review and approval to the agency’s Governing Body. The Administrator was unable to name any further data elements, embedded within all comprehensive assessments and tracked by the QAPI program, which had been approved by the Governing Body.”

“Based on record review and interview the hospice failed to ensure spiritual care services were provided at the frequency ordered in the plan of care for 1 of 7 active patients receiving spiritual care services (Patient #15). 1. The record for Patient #15 indicated orders for spiritual service visits once a week for two weeks, with the addition of 1 as needed visit followed by in increase to twice weekly for 13 weeks. The record indicated a spiritual service visit was made 12/19/23 with the next visit being made 1/2/24. The record failed to indicate the IDG was notified of spiritual care frequency not being met. In an interview on 1/19/24 at 3:47 pm Clinical Manager 3 (CM 3) indicated IDG should have been notified of the missed visit. CM 3 confirmed no record of notification to IDG of spiritual care frequency not being met for Patient #15. *”

“Based on record review and interview, the hospice agency failed to ensure the primary caregiver was educated and trained on performing wound care for 1 of 8 active records reviewed of patients with a wound requiring treatment (Patient #6). Findings include: The review of Patient #6s clinical record evidenced a hospice election benefit date of 01/05/24 and the nursing portion of the admission comprehensive assessment on 01/05/24. The visit note indicated the patient had 9 wounds between both feet, which were a “;combination of diabetic and peripheral disease wounds.” The visit note indicated the patients wounds were covered by an unknown dressing and the nurse did not perform a wound assessment nor wound care due to the wound care being performed earlier in the day. The visit note failed to evidence RN 3 ensured Person E, the primary caregiver to Patient #6, was competent to perform wound care to the patients foot wounds. On 01/05/24, the nurse entered the following interventions into the patients plan of care: a. Instruct the patient and Person E, the primary caregiver, “;on wound care procedures including preparation, dressing removal, wound cleansing, and dressing the wound. b. Perform wound care to the “;left foot” three times a week. Wound care was to include removing the old dressing, cleansing, applying petroleum gauze (wound dressing with petroleum jelly), and securing the wound with gauze roll. The record indicated a PRN (as needed) visit was conducted by RN 4 on 01/06/24. The nurse noted the patients foot wounds were covered with an ABD pad (large absorbent dressing) and secured with gauze roll. The visit note failed to evidence RN 4 ensured Person E was competent to perform wound care to the patients foot wounds. The record indicated a nurse visit was conducted by RN 3 on 01/07/24. The visit note failed to evidence RN 3 ensured Person E was competent to perform wound care to the patients foot wounds. During an interview with Person E on 01/10/24 beginning at 9:59 AM, the caregiver confirmed he/she provided wound care to Patient #6s multiple foot wounds. The caregiver reported he/she was performing wound care according to orders placed by the patients previous wound care clinic, which included applying Gentamicin ointment (an antibiotic), Adaptic (a non-adherent dressing), Alginate (a wound dressing), covering with an ABD pad, and securing with a gauze roll. During an interview with RN 3 on 01/11/24 beginning at 3:40 PM, the nurse reported Person E was not performing wound care to the patients foot wounds according to the hospice wound care order. The nurse was unsure of the specific wound care Person E was performing to the foot wounds. RN 3 reported he/she ensured Person E could provide appropriate wound care by speaking with the caregiver and discussing what wound care he/she had performed prior to hospice admission. The nurse confirmed he/she did not observe Person E perform wound care to Patient #6s foot wounds.”

“Based on record review and interview, the hospice agencys interdisciplinary group (IDG) failed to ensure the plan of care included interventions to address a patients pain and poor appetite for 1 of 1 active record reviewed of a patient with noted pain and decreased appetite due to a cheek mass (Patient #10). Findings include: An agency policy #9665111 titled “;Assessment and Care Plan Policy,” last reviewed 11/19/21, indicated the hospice plan of care would include interventions to manage the patients pain and symptoms. An agency policy #8095669 titled “;Hospice Interdisciplinary Group,” last revised 12/16/21, indicated the IDG would meet every 15 days at minimum to “;update the plan of care and comprehensive assessment, to evaluate the patient status ... and to plan for patients care needs.” The review of Patient #10s clinical record indicated a terminal diagnosis of breast cancer. The record included a skilled nursing visit on 11/21/23 by Registered Nurse (RN) 4 which indicated the patient had a swollen, hardened mass to the patients left cheek and jaw. Patient #10 reported he/she was having trouble eating due to pain when chewing. RN 4 documented he/she notified Hospice Physician 1 and received an order for warm compresses to be applied to the mass every 4 hours. The nurse also documented the physician reported the mass “;may be” the patients cancer spreading “;but we will try the warm compresses.” The plan of care failed to evidence an order for the warm compresses. The record indicated an IDG meeting was held 11/30/23 and RN 4 noted Patient #10s left cheek mass was present and warm compresses had not helped reduce the pain to the area. The note also indicated the patients appetite had decreased. The record failed to evidence the IDG implemented further interventions for the patients left cheek mass and related pain and decreased appetite. The record included a skilled nurse visit completed on 12/12/23 by RN 4. The nurse noted the patient appeared “;very thin” and the hardened area to the patients left check was still present. Patient #10 reported he/she had “;not been eating as much” due to painful chewing. The record indicated an IDG meeting was held on 12/14/23 during which RN 4 noted the presence of Patient #10s left cheek mass and decreased appetite. The record failed to evidence the IDG implemented further interventions for the patients left cheek mass and related pain and decreased appetite. The record included skilled nurse visits completed on 12/15/23 and 12/19/23 by RN 4. The nurse noted the patients left cheek mass remained, the patient reported pain to the mass when chewing, and the patients appetite was decreased. The record included a skilled nurse visit completed on 12/22/23 by RN 4. The nurse noted the patient was having difficulty opening his/her mouth due to the painful left cheek and jaw mass. The record indicated an IDG meeting was held 12/28/23 and RN 4 noted the presence of Patient #10s left cheek mass and decreased appetite. The record failed to evidence the IDG implemented further interventions for the patients left cheek mass and related pain and decreased appetite. The record included a skilled nurse visit completed on 01/05/24 by RN 4. The nurse noted the patients appetite had decreased due to pain in his/her left cheek and jaw mass while chewing and Patient #10 and his/her caregiver asked the nurse if the patient could be taken to an Emergency Department to have the mass evaluated. RN 4 informed the patient and caregiver that they would need to revoke his/her hospice benefit to do this and the caregiver stated he/she would speak with Office Employee 1 to “;see what [his/her] options are.” The record included a skilled nurse visit completed on 01/10/24 by RN 4. The nurse noted Patient #10 appeared to have lost weight, his/her arms were “;very thin,” and the patients left cheek and jaw mas had spread “;down into [his/her] neck.” Patient #10 reported his/her appetite had decreased due to painful chewing and the mass was inhibiting his/her ability to open his/her mouth wide. The record failed to evidence the nurse notified the IDG of the increase in mass size. The record included a skilled nurse visit completed on 01/12/23 by RN 4. The nurse noted Patient #10s left cheek mass continued as well as the pain, decreased appetite, and inability to open his/her mouth wide. RN 4 documented the patients caregiver was planning to schedule an appointment with the patients oncologist to assess the mass. The record indicated an IDG meeting was held 01/11/24 and RN 4 noted Patient #10s appetite had been “;so-so to poor” and the patient ate “;very little due to the pain caused by the lump on [his/her] left cheek when [he/she] chews.” The record failed to evidence the IDG implemented further interventions for the patients left cheek mass and related pain and decreased appetite. The record included a skilled nurse visit completed on 01/14/23 by RN 4. The nurse noted he/she informed the Medical Director of the patients cheek, jaw, and neck mass prior to the visit and the physician suspected a salivary gland infection. The Medical Director ordered for the patient to start Levaquin, an antibiotic. During an interview with RN 4 on 01/17/24 beginning at 9:35 AM, the nurse reported Patient #10s left cheek mas was first noted on 11/21/23. RN 4 stated Hospice Physician 1 thought the mass was due to the patients cancer spreading and ordered warm compresses to the site. The nurse reported no further orders were placed related to the patients mass until 01/14/24 when the Medical Director ordered Levaquin for a suspected blocked salivary gland.”

“Based on record review and interview, the hospice agency failed to ensure the individualized plan of care included measurable outcomes for 1 of 13 complete records reviewed (Patients #4). Findings include: An agency policy #9665111 titled “Assessment and Care Plan,” last reviewed 11/19/21, indicated the plan of care should include “goals with measurable outcomes.” The review of Patient #4s clinical record evidenced an election of hospice benefit date of 11/07/23. The patients plan of care evidenced the following goals: a. For pain - “;[Patient #4] and/or [the patients caregivers] will verbalize satisfaction with the patients level of comfort and symptom control while under hospice care. Uncontrolled pain will be resolved within 2 hours of exacerbation.” b. For anxiety – “;[Patient #4] and /or [the patients caregivers] will verbalize and demonstrate ability to manage the patients anxiety while under hospice care.” During an interview with Hospice Manager 2 on 01/15/24 beginning at 1:42 PM, when queried how the interdisciplinary group (IDG) would measure Patient #4’s pain goal, the manager reported the nurse case manager would know the individual’s pain goal and assess if the patient was above or below this number. Hospice Manager 2 reported this was not included within the goal as written. Hospice Manager 2 also reported Patient #4’s goal for anxiety was not measurable.”

“Based on observation, record review, and interview, the hospice interdisciplinary group (IDG) failed to ensure the plan of care included drugs and/or treatments for all patient wounds and drains for 3 of 9 records reviewed of patients with a wound and/or drain (Patients #2, 4, and 6). *The plan of care for Patient #2 for period 12/29/23 through 1/11/24 indicated the presence of an indwelling drain with care instructions to perform an assessment of the drain, including surrounding skin. The order includes changing the drain dressing weekly or as needed for soilage or dislodgment. The record failed to indicate the frequency of emptying the drain, the amount of fluid to be drained nor who would provide the drain care. During an interview conducted on 1/11/24 beginning at 4:48 pm which included the Administrator, Clinical Manager 2 and Clinical Manager 3, who concluded together the drain was an Aspira drain (a tunneled, long-term catheter used to drain accumulated fluid from the pleural or peritoneal cavity to relieve symptoms associated with malignant ascites). They concluded the plan of care should include the frequency of emptying a drain and amount of fluid to be drained. They were in agreement this was not included in the plan of care for Patient #2. The record for Patient #2 included communication note dated 12/25/23 which indicated the Person H; caregiver for Patient #2, called the agency to obtain clarification of Riley’s Butt Paste (a topical cream to be used) on Patient #2. The communication note indicated Registered Nurse 10 instructed to use the topical cream as directed. The record failed to indicate the medication or indications for use. During an interview on 1/19/24 beginning at 11:30 am Clinical Manager 2 indicated all medications, including topicals and over the counter medications should be included on the plan of care. Clinical Manager 2 further indicated it was not on the plan of care for Patient #2 and they would add it to the plan of care. Findings include: 1. An agency policy #9665111 titled “;Assessment and Care Plan Policy,” last reviewed 11/19/21, indicated the plan of care should include all medications and treatments. 2. The review of Patient #4’s clinical record evidenced a hospice election benefit date of 11/07/23. RN 1 completed the nursing portion of the admission comprehensive assessment on 11/07/23. The visit note indicated the patient had a venous stasis ulcer (wound caused by decreased blood flow) to the “top of the left foot” which was covered by a foam dressing, The plan of care indicated the patient was to receive skilled nursing visits 2 times per week and failed to evidence an order for the foam dressing to be applied to the foot wound. The record indicated RN 1 conducted a skilled nursing visit on 11/13/23. The visit note indicated the patient had “;multiple new open wounds” to his/her second and third left toes, “;new orders [were] received,” and the nurse performed wound care. The visit note failed to evidence the specific wound care provided. The plan of care evidenced 2 orders for wound care to the left toe wounds were documented by RN 1 on 11/13/23. The orders were: a. Cleanse the wounds with wound spray, pat dry, apply gauze to “;space toes apart,” and keep open to air. The wound care was to be performed at each skilled nursing visit. b. Cleanse with wound cleanser, apply MediHoney (a wound ointment), and cover with gauze. The wound care was to be performed “;each visit” and Person B, the primary caregiver, was to perform wound care on days the hospice staff was not present. The record indicated RN 1 conducted a skilled nursing visit on 11/16/23. The visit note indicated the nurse performed wound care to the patients toe wounds but failed to evidence the specific wound care provided. The record indicated RN 8 conducted a skilled nursing visit on 11/20/23. The visit note indicated the nurse provided wound care to the patients toe wounds by applying Medihoney, covering with a non-adherent dressing, and securing with roll gauze. The record indicated RN 1 conducted a skilled nursing visit on 11/27/23. The visit note indicated the patients left toe wounds were “;much worse” than the last assessment (documented 11/20/23). The note indicated the wounds were edematous (swollen), red, and had black eschar (dead tissue). RN 1 documented he/she educated Person B to keep the wounds open to air “;as much as possible and to soak to foot in soapy water twice a day. The record failed to evidence an updated wound care order. During an interview with RN 1 on 01/18/24 beginning at 8:36 AM, the nurse could not recall the date the first order for wound care to the patients left toe wounds was obtained. RN 1 reported he/she thought the initial wound care order was to leave the wound open to air. When queried as to which wound care order obtained on 11/13/23 was to be performed, the nurse reported the order to cleanse and leave the wound open to air was the order being performed. 5. The review of Patient #6s clinical record evidenced a hospice election benefit date of 01/05/24 and the patient began receiving hospice services while he/she was inpatient at Facility I, a hospital. RN 3 completed the nursing portion of the admission comprehensive assessment on 01/05/24. The visit note indicated the patient had 10 wounds between both feet, including 4 wounds to the right foot and ankle, which were a “;combination of diabetic and peripheral disease wounds.” The visit note indicated the patients wounds were covered by an unknown dressing and the nurse did not perform a wound assessment nor wound care due to the treatment being performed earlier in the day. On 01/05/24, the nurse entered the following intervention into the patients plan of care: a. Perform wound care to the “;left foot” three times a week. Wound care was to include removing the old dressing, cleansing, applying petroleum gauze (wound dressing with petroleum jelly), and securing the wound with gauze roll. The plan of care failed to evidence orders for the patients wounds to the coccyx and/or right foot. The record indicated Patient #6 was discharged to their private residence on 01/07/24. Review of Patient #6s discharge paperwork from Facility I failed to evidence wound care orders for the patients multiple wounds. During an interview with RN 3 on 01/11/24 beginning at 3:40 PM, the nurse reported he/she assessed Patient #6s coccyx area (bone at the base of the spine) during the 01/05/24 visit. RN 3 reported the patient had an area of unblanchable redness with excoriation to the coccyx. The nurse reported Patient #6 had a foam dressing on the area which had been placed by Facility I staff. When queried how the 01/05/24 “;left leg” wound care order was obtained, RN 3 reported it was not based on hospital orders or an assessment of the patients wounds but rather a wound treatment the hospice used often for wounds and didnt need done daily. RN 3 reported he/she conducted a visit with Patient #6 on 01/07/24, a day after the patient was discharged after Facility I. During the visit the nurse asked Person E, the primary caregiver, for the patients hospital discharge records to obtain wound care orders. The nurse reported Person E could not find the hospital discharge records or any written wound care orders. RN 3 was unsure of the specific wound care Person E was providing to Patient #6s bilateral foot wounds. During an interview with Person E on 01/10/24 beginning at 9:59 AM, the caregiver confirmed he/she provided wound care to Patient #6s multiple foot wounds. The caregiver reported he/she was performing wound care according to orders placed by the patients previous wound care clinic, which included applying Gentamicin ointment (an antibiotic), Adaptic (a non-adherent dressing), Alginate (a wound dressing), covering with an ABD pad, and securing with a gauze roll. During an interview with the Administrator on 01/11/24 beginning at 4:48 PM, the Administrator reported if a patient was discharged from a hospital with a wound, the nurse should review discharge records to obtain wound care orders. If the discharge records are not available or do not include wound care orders, the Administrator reported the nurse should assess the wound(s) and obtain orders from the attending physician.”

“Based on observation, record review and interview, the hospice failed to ensure the plan of care included all medical supplies and appliances necessary to meet the needs of the patient for 2 of 9 records reviewed of patients receiving hospice aide services (Patient #8 and #13). 1. A comprehensive assessment dated 12/11/24 completed by Registered Nurse 9 (RN 9) for Patient #13 indicated the use of a compression sleeve for treatment of lymphedema (swelling in an arm or leg caused by a lymphatic blockage). A review of the plan of care failed to evidence the compression sleeve or indications for use. During an interview on 1/19/24 beginning at 1:30 pm Clinical Manager 2 (CM 2) indicated the compression sleeve and indications for use should be on the plan of care (POC), CM 2 further indicated it was not on the POC for Patient #13. 2. During a home visit conducted on 1/16/24 beginning at 10:14 am with Hospice Aide 1(HA1) it was observed Patient #8 required assistance with transfer by use of a stand lift; when showering, a shower chair and assistance to don a torso shell brace for diagnosis of Scoliosis (a sideways curvature of the spine). The plan of care dated 1/12/24 for Patient #8 failed to evidence the stand lift, shower chair or use of a brace. During an interview on 1/17/24 beginning at 1:30 pm Clinical Manager 2 confirmed the stand lift nor shower chair were not on the Plan of Care for Patient #8 and further indicated goals or interventions related to the use of the brace should be on the plan of care, but were not present for Patient #8. Findings include:”

“Based on observation, record review, and interview, the hospice interdisciplinary group (IDG) failed to review all active patients plans of care during the biweekly IDG meeting for 1 of 1 IDG meeting observed and failed to revise the individualized plan of care to reflect a change in patient condition for 1 of 1 active record reviewed of a patient whose level of care went from General Inpatient to Respite (Patient #6). Findings include: 1. An agency policy #8095669 titled “;Hospice Interdisciplinary Group,” last revised 12/16/21, indicated the IDG would meet every 15 days at minimum to “;update the plan of care and comprehensive assessment, to evaluate the patient status ... and to plan for patients care needs.” 2. An agency policy #8095787 titled “;Respite Care Policy,” last revised 12/16/21, indicated when a patients level of care was to go to respite, the hospice nurse would obtain an order for change in level of care from the attending physician. 3. An agency policy #9665111 titled “;Assessment and Care Plan Policy,” last reviewed 11/19/21, indicated the hospice clinician were to inform the attending physician of “;any changes that suggest a need to alter the plan of care and orders will be obtained from the physician ... and documented ....” 4. An observation of the hospices interdisciplinary group meeting was conducted on 01/11/24 beginning at 7:02 AM. The IDG reviewed and discussed all new admissions and patients due for recertification, then broke off into 2 groups, separated between the parent and branch locations, to discuss the remaining patients. During observation of the parent locations IDG meeting, the IDG failed to review the spiritual and social services portions for all patients plans of care during its biweekly meeting. During an interview with Employee A, a member of the IDG, on 01/22/24 beginning at 4:40 PM, the employee reported he/she would review his/her patients plans of care prior to the IDG meeting and during IDG meetings, he/she would review the plans of care with the group only there were “;relevant” changes. The employee reported the IDG meeting the surveyor observed on 01/11/24 lasted longer than the typical meeting, as normally the IDG would only review the plans of care for patients who are new or due for recertification. During an interview with Hospice Manager 2 on 01/22/24 beginning at 4:55 PM, the hospice manager reported all portions of the plans of care should be reviewed during the IDG meeting. 5. The review of Patient #6s clinical record evidenced a hospice election benefit date of 01/05/24 and the patient began receiving hospice services while he/she was inpatient at Facility I, a hospital, as General Inpatient (GIP) level of care. Registered Nurse (RN) 3 completed the nursing portion of the admission comprehensive assessment on 01/05/24. The visit note indicated the patient currently required high flow oxygen and the plan was to wean Patient #6s oxygen down and discharge from Facility I on 01/07/24. The record indicated no hospice visits were conducted on 01/06/24 and Patient #6 was discharged from Facility I on 01/07/24. During an interview with Hospice Manager 2 on 01/10/24 beginning at 11:55 AM, the manager reported Patient #6s level of care was changed from GIP to respite on 01/06/24 due to the patient no longer requiring high flow oxygen. When queried how the hospice determined the patient could go from GIP to respite level of care, Hospice Manager 2 reported he/she “;assumed” the hospice physician was notified of the patients decreased oxygen needs and then provided an order. During a follow-up interview with Hospice Manager 2 on 01/10/24 beginning at 1:17 PM, the manager reported on 01/06/24, RN 4 received a report from Facility Is staff on the patients status via phone and relayed this to Hospice Manager 2. The manager reported he/she obtained a physician order to change Patient #6s level of care to respite, however the order for this change was not “;synced” to the agencys electronic medical record. During an interview with RN 4 on 01/11/24 beginning at 4:37 PM, the nurse stated he/she called Facility I on 01/06/24 and a facility nurse reported Patient #6 had been weaned off high flow oxygen and was to be discharged home on 01/07/24. RN 4 reported he/she did not document this call, did not relay Patient #6s update to any IDG members, and did not obtain an order to change the patients level of care.”

“Based on observation, record review, and interview, the hospice failed to update the plan of care to reflect information from the patient’s updated comprehensive assessment for 1 of 2 home visit observations with a patient receiving skilled nurse services for wound and drain care (Patient #2) and for 1 of 1 active records reviewed of a patient who was documented to have a sudden decrease in appetite (Patient #15). 1. The plan of care for Patient #2 dated 12/29/23 indicated wound care orders to remove dressing from coccyx (a triangular arrangement of bone that makes up the final segment of the spine) wound, cleanse wound with wound cleanser, apply medihoney (a specialized honey created to aid in the treatment of wounds), cover with foam dressing. The dressing change was to be performed weekly or as needed for soilage. During home visit with Registered Nurse 5 (RN 5) on 1/11/24 beginning at 11:00 am for Patient #2 it was observed RN 5 performed wound care to the coccyx wound. RN 5 removed the foam dressing to reveal Patient #2’s coccyx which appeared reddened in color and the skin intact. RN 5 wiped the site with gauze and a applied clean foam dressing. During an interview with RN 5 on 1/11/24 beginning at 2:55 pm RN 5 indicated on 1/11/24 they had changed the wound care orders to remove the medihoney from the order and continue with the foam dressing for protection. The visit note dated 1/11/24 completed by RN 5 noted a foam dressing had been applied for protection due to reddened area. The visit note dated 1/11/24 revealed the previous wound care order remained. In an interview on 1/12/24 beginning at 4:09 pm with the Administrator, Clinical Manager 2 and Clinical Manager 3 who indicated the plan of care should be updated when the change of condition for the patient is noted. They concluded this was not completed for Patient #2 2. The record for Patient #15 contained an IDG note dated 1/11/24 completed by Registered Nurse 5 which indicated Patient #15 s roommate died after which the patient reported a 50% decrease in appetite where they had been eating well before. The record failed to indicate goals or interventions related to nutritional needs. In an interview on 1/22/24 beginning at 9:42 am with Clinical Manager 2 and Hospice Educator 5, they indicated there should be interventions for nutrition on the plan of care, CM 2 confirmed there were no goals or interventions related to nutrition on the plan of care for Patient #15. Findings include:”

“Based on observation, record review, and interview, the hospice agency failed to ensure all employees followed agency policy and standard precautions to prevent the spread of infectious and communicable diseases for 4 of 4 home visit observations conducted with a Registered Nurse (RNs 2, 3, 5, and 6). * During an observation of care at the home of Patient #6 on 1/10/2024, at 12:23 PM, Registered Nurse (RN) 3 was observed wiping in between the patients buttocks with gloved hands with a disposable wipe. A brown substance was observed on the disposable wipe. RN 3 was observed removing gloves from both hands and then applying new gloves. RN 3 was then observed removing a dressing on the lower back above the buttocks and 4 small red open areas were observed on the lower back above and around the crease of the buttocks. RN 3 was observed wiping the open areas with a gauze pad moistened with what was identified as normal saline (a wound wash solution). RN 3 was not observed performing hand hygiene after removing gloves used to clean in between the patients buttocks and before applying new gloves and cleansing the open areas on the skin. *During a home visit conducted on 1/11/24 beginning at 11:00 am with Registered Nurse 5 (RN) who was to perform a dressing change of an abdominal drain. It was determined this dressing change was to be conducted in a sterile (a patient safety principle that reduces the risk of microbial transmission to the patient) manner. It was observed while RN 5 was replacing the clear dressing to the top of the drain site, the dressing became twisted, sticking to RN 5’s glove and unusable. RN 5 removed gloves, left the sterile field to obtain a new sterile dressing kit, obtained a new package from behind a recliner, opened package and donned sterile gloves, removed the clear dressing cover and applied dressing cover to the drain dressing. RN 5 failed to perform hand hygiene and maintain a sterile field. During an interview conducted on 1/11/24 beginning at 2:55 pm RN 5 indicated the dressing change for Patient #2’s drain was sterile when applying a new dressing. During an interview on 1/12/24 with the Administrator, Clinical Manager 2 and Clinical manager 3 whom concluded the dressing change for Patient #2 should be performed using a sterile technique. Clinical Manager 3 concluded sterile technique was not maintained for Patient #2 dressing change. Findings include: 1. An agency policy #8090283 titled “;Standard and Transmission Based Precautions,” last revised 12/16/21, indicated hand hygiene should be performed immediately prior to donning gloves and after removing gloves. Gloves should be removed when moving from a potentially soiled area to a clean area or procedure. When disinfecting used equipment, staff should allow the disinfectant to dwell on the equipment for the length of time recommend by the manufacturer and prior to placing the equipment back in his/her clinical bag. 2. During a home visit observation with Patient #1 on 01/09/24 beginning at 2:17 PM, RN 2 was observed removing 1 glove, entering the nursing bag with the ungloved dirty hand to obtain supplies, then donned a new glove. At the end of the visit, RN 2 cleaned their used stethoscope and vital sign equipment with a 70% alcohol swap then placing the equipment immediately into his/her nursing bag. During an interview with RN 2 on 01/09/24 beginning at 2:54 PM, when queried when to change gloves during a skilled nurse visit, the nurse reported he/she “;probably” didnt remove gloves correctly during the visit. The nurse also reported he/she wanted to return the used equipment back to the bag when it was still wet with disinfectant. 3. 4. 5. During a home visit observation with Patient #9 on 01/17/24 beginning at 12:01 PM, RN 6 was observed removing 1 glove, obtaining a barrier from his/her nursing bag, placing the barrier at the patients feet, and donning a new glove without performing hand hygiene. After the nurse obtained the patients vital signs and listened to the patients lung and bowel sounds, RN 6 wiped his stethoscope and blood pressure cuff with a disinfectant wipe then placed the cuff on top of the stethoscope to dry. Later in the visit, the nurse was observed preparing wound care supplies, wiping his/her bandage scissors with a disinfectant wipe, then donned gloves without performing hand hygiene. RN 6 began to assess and treat the patients multiple wounds. While assessing and treating Patient #9s wound to the medial (towards the middle of the body) knee, the nurse noted the presence of slough (dead wound tissue) to the wound. RN 6 cleansed the wound with a soaked gauze, wiping from the inner wound (clean) to the surrounding skin (dirty) multiple times using the same gauze pad. RN 6 also used the same measuring tape to measure multiple open wounds. 6. During an interview with the Administrator, Hospice Manager 2, and Clinical Supervisor 3 on 01/11/24 beginning at 4:48 PM, the Administrator reported staff should perform hand hygiene after removing gloves, staff should enter his/her supply bag with clean hands, and should allow their equipment to dry after disinfecting.”

“Based on observation, record review, and interview, the hospice licensed professionals failed to conduct and document a complete assessment of all wounds and drains at every visit and according to best practice, failed to obtain a medication order prior to entering into the electronic medical record, and failed to notify the attending physician of a change in the patients wound bed appearance for 6 of 8 records reviewed of a patient with wounds and/or a drain (Patients #2, 4, 8, 9, 12, and 13). *The record for Patient #12 included a wound documentation record with date of 1/10/24 for open wounds to Patient #12s middle lower back and a wound to middle left leg. The record failed to identify depth measurements. Five days after the wounds were noted, the record indicated treatment orders for the wounds were entered into the record 1/15/24. The record further indicated an assessment completed on 1/15/24 the record failed to indicate depth measurements were completed. During an interview with Clinical Manager 2 (CM 2) on 1/17/24 during an interview 2:30 pm, CM 2 confirmed depth measurements should be obtained during assessment of wounds and this was not completed for Patient #12. *An admission assessment for Patient #13 completed by Registered Nurse 9 dated 12/11/23 indicated the presence of a wound to the right axilla measured at 3 cm x 8 cm x 6 cm. The indicated the next wound assessment including measurements was completed on 1/09/24. An untitled document containing wound measurements for Patient #13 indicated five wounds with an assessment date of 1/14/24. The record did not reveal depth measurements for any of the wounds. During a record review conducted with Clinical Manager 2 (CM 2) on 1/17/24 beginning at 10:30 am the CM 2 indicated there were not measurements taken for wounds after 12/11/23 until 1/9/24 and measurements should have occurred weekly and depth should have been completed for all wound measurements. Clinical Manager 2 confirmed this was not completed for Patient #13. *The record for Patient #8 included a skilled nurse visit dated 3/17/23 completed by Registered Nurse 13 (RN 13) which indicated Entity G placed a foam dressing to the coccyx. It was reported to RN 13 Patient skin was intact, no identified reason for treatment. The record failed to indicate an assessment of the coccyx was completed by the nurse on 3/17/23. RN 13 entered an order for a dressing to the coccyx be changed every 3 days beginning on 3/17/23. On 3/23/23 RN 5 indicated the presence of a stage 1 wound (pressure related non-blanchable redness to intact skin) to the coccyx. The record failed to indicate an assessment of the coccyx was completed for Patient #8 on 3/27/23, 3/30/23, 4/13/23 and 4/24/23. During an interview on 1/17/24 beginning at 1:30 pm Clinical Manager 2 confirmed the record has no complete assessment of the coccyx wound documented for Patient #8. Findings include: 1. An agency policy #9665111 titled “;Assessment and Care Plan,” last reviewed 11/19/21, indicated the skilled professional should inform the attending physician “;of any changes that suggest a need to alter the plan of care,” orders would by obtained by a skilled professional, and the orders would be documented in the electronic medical record (EMR). 2. The review of Patient #4’s clinical record evidenced a hospice election benefit date of 11/07/23 and a plan of care which indicated the patient was to receive skilled nursing visits twice a week. Registered Nurse (RN) 1 completed the nursing portion of the admission comprehensive assessment on 11/07/23. The visit note indicated the patient had a venous stasis ulcer (wound caused by decreased blood flow) to the “top of the left foot” which was covered by a foam dressing, but failed to evidence a complete assessment of the wound, including wound bed and surrounding skin appearance, wound measurement, presence or absence of signs and symptoms of infection, etc. The record indicated RN 1 completed a skilled nursing visit on 11/08/23. The visit note failed to evidence a complete assessment of Patient #4s venous stasis ulcer. The record indicated RN 1 conducted a skilled nursing visit on 11/13/23. The visit note indicated the patient had “;multiple new open wounds” to his/her second and third left toes but failed to evidence a complete assessment of the new toe wounds. The record indicated RN 1 conducted a skilled nursing visit on 11/16/23. The visit note failed to evidence a complete assessment of the patients toe wounds. The record indicated RN 8 conducted a skilled nursing visit on 11/20/23. The nurse noted the presence of yellow-green slough (a type of dead tissue found in a wound bed) and pain to the left big toe. The visit note indicated the nurse ordered a “;gout” (a type of inflammatory arthritis) and the record indicated RN 8 entered an order for Allopurinol (a medication used to treat gout, a type of inflammatory arthritis). The record failed to evidence RN 8 notified the patients attending physician of the presence of slough nor obtained a verbal order for the Allopurinol prior to placing the order. The record indicated RN 1 conducted a PRN (as needed) skilled nursing visit on 11/23/23 due to a patient fall. The record failed to evidence the nurse assessed Patient #4s toe wounds during the visit. The record indicated RN 1 conducted a skilled nursing visit on 11/27/23, during which the nurse noted the patients toe wounds had worsened since the previous assessment (11/20/23). The toe wounds were noted to have 75% eschar (a type of dead tissue found in a wound bed) and a “;mild” odor. The record evidenced this was the first visit in which a complete assessment of the patients toe wounds was documented, 2 weeks after the “;multiple new open wounds” were first noted. The record indicated RN 1 conducted a skilled nursing visit on 11/30/23. The visit note failed to evidence the nurse completed an assessment of the patients toe wounds. The record indicated RN 1 conducted a skilled nursing visit on 12/04/23. The nurse noted the toe wounds were “;improving” however the visit note failed to evidence any further assessment of the wounds. The record indicated RN 1 conducted a skilled nursing visit on 12/07/23. The nurse noted Patient #4s left toes had become cold to touch and gangrenous (death of tissue due to lack of blood flow and/or infection), “;especially to [the] second toe which is nearly completely blue in color.” RN 1 noted the toe wounds had 100% eschar and were “;very odorous.” The record indicated RN 8 conducted a discharge nursing visit on 12/09/23. The nurse noted the patient had revoked his/her hospice benefit to seek aggressive treatment. A review of Patient #4s records from Facility C, a hospital, indicated the patient presented to Facility Cs Emergency Department (ED) on 12/9/23 reporting “;uncontrolled” left foot pain. The hospital records indicated 2 of the patients left toes were “;black.” Redness and swelling was also noted to the left foot. Facility Cs records indicated Patient #4 was admitted to the hospital and underwent an amputation of the 2nd and 3rd left toes. The patient was made “;comfort care” on 12/13/23 and died in the hospital on 12/14/23. During an interview with RN 8 on 01/16/24 beginning at 9:42 AM, the nurse reported he/she sent a case communication note through the agencys electronic medical record (EMR) to RN 1, the patients case manager, regarding the presence of slough in the toe wounds. RN 8 reported he/she “;assumed” the patients pain to the left big toe was due to gout, input the Allopurinol order into the clinical record, then sent the order to the hospice physician for signature. The nurse confirmed he/she did not obtain a verbal order for the Allopurinol prior to entering it into the clinical record. During an interview with RN 1 on 01/18/23 beginning at 8:36 AM, the nurse reported the following: a. During the admission comprehensive assessment on 11/07/23, the nurse pulled the foam dressing covering the venous stasis ulcer far back enough to “;peak” at the wound. RN 1 reported the patient had been receiving home health nursing services prior to electing their hospice benefit and the home health nurse had placed the wound dressing “;recently.” The nurse was unsure of the date of the last home health nurse visit. RN 1 confirmed the 11/07/23 visit note failed to evidence a complete wound assessment. b. During the visit on 11/08/23, the nurse reported he/she again pulled the foam dressing covering the venous stasis ulcer far back enough to “;peak” at the wound. RN 1 confirmed the 11/08/23 visit note failed to evidence a complete wound assessment. c. During the visit on 11/13/23, Patient #4s new toe wounds were “;scabbed” and the surrounding skin was red and “;yellow-y” in color. d. During the visit on 11/16/23, the nurse reported the toe wounds “;hadnt changed much.” RN 1 confirmed the visit note failed to evidence an assessment of the patients active wounds. e. The nurse had reviewed the case communication sent by RN 8 from the 11/20/23 visit, however the agencys EMR had no method to evidence the nurse reviewed the note. RN 1 reported he/she was going to conduct a visit “;the next day or shortly after,” however the next nursing visit in which a wound assessment was documented was 11/27/23. f. The visit note on 12/4/23 failed to evidence a complete wound assessment. 3. The review of Patient #9s clinical record evidenced an election of hospice benefit date of 11/14/23 and a plan of care which indicated the patient was to receive skilled nursing visits twice a week. RN 9 completed the nursing portion of the admission comprehensive assessment on 11/14/23 which failed to evidence a wound to the patients coccyx. The record indicated RN 9 conducted a skilled nursing visit on 12/11/23, which evidenced Patient #9 had a “;significant” wound to the coccyx which was “;large, back [sic], and peeling.” RN 9 documented he/she was unable to stage or assess the wound completely due to the presence of eschar (dead wound tissue). RN 9 documented he/she applied Medihoney and a foam dressing to the wound. The record failed to evidence the presence of the coccyx wound prior to 12/11/23 visit nor an order for the wound care provided. The record indicated skilled nursing visits were conducted on 12/14/23 and 12/21/23 by RN 7. The visit notes failed to evidence the nurse completed an assessment of the patients coccyx wound. The record indicated RN 9 received a call from Family Member K on 12/22/23 requesting to have a nurse assess Patient #9s coccyx wound due to tissue “;falling” off. RN 9 conducted a visit and noted the coccyx wound had eschar, tunneling (opening underneath the skin), and a mild odor. The nurse documented Therahoney gel (a wound treatment) was applied, and the wound was covered with a foam dressing. The record failed to evidence an order for the wound care provided. The record indicated skilled nursing visits were conducted on 12/28/23 and 01/02/24 by RN 7. The visit notes failed to evidence the nurse completed an assessment of the patients coccyx wound. The record indicated RN 7 conducted a skilled nursing visit on 01/04/24 and noted a “;new” wound to the coccyx. The nurse documented the wound had eschar and necrotic tissue and bone was exposed. The record indicated RN 9 conducted a skilled nursing visit on 01/13/24 and noted when performing wound care to the coccyx wound, the dressing was saturated with “;copious, purulent, brown, malodorous drainage.” The nurse noted the wound measured 11 centimeters (cm) in width by 14 cm in length by 4 cm in depth (11 x 14 x 4). The visit note indicated Patient #9 had a “;small scabbed area” to the medial left knee and an area of blanchable redness to the medial right knee. The record failed to evidence the patients physician was notified of the copious brown drainage with odor (a potential sign of infection). During an interview with RN 9 on 01/18/24 beginning at 8:30 AM, the nurse reported Patient #9 had wounds noted to the coccyx and bilateral medial knees during the visit on 01/13/24. The nurse reported he/she assessed only the skin exposed when turning the patient on their side to perform wound care, not a complete head-to-toe assessment. When queried if the patient had any wounds to the heels, the nurse reported he/she did not assess Patient #9s heels. The record indicated RN 7 conducted a skilled nursing visit on 01/15/24 and noted the wound measured 24.4 x 30.35 x 8.6 cm with brown, tan, and green purulent drainage. The record failed to evidence any other wounds. During an interview with RN 7 on 01/17/24 beginning at 4:26 PM, the nurse reported Patient #9s coccyx wound had developed within the “;last few weeks.” When queried how the nurse was obtaining wound measurements to the 100th decimal point, RN 7 reported he/she had been measuring the wound in inches then converting to centimeters. The nurse reported he/she had planned to “;follow up” with RN 9 regarding the significant change in wound measurements between the visits on 01/13/24 and 01/15/24 but had not yet done so. RN 7 reported he/she conducted a complete head-to-toe skin assessment during the visit and the patient had no further wounds observed. The nurse also reported he/she obtained an order an antibiotic after the visit due to the signs and symptoms of infection observed. During a follow-up interview with RN 7 on 01/17/24 beginning at 4:56 PM, the nurse reported he/she had erroneously converted the patients coccyx wound measurements from centimeters to centimeters during the 01/15/24 visit. During a home visit observation with Patient #9 on 01/17/24 beginning at 12:01 PM, RN 6 was observed assessing the patients multiple wounds. Patient #9 was observed to have a unstageable pressure ulcer to the right medial knee which RN 6 noted was “;scabbed” and a Stage 2 pressure ulcer to the left medial knee. While assessing the patients open wound to the left posterior leg, RN 6 measured the length and width, cleansed, then began to dress the wound. When queried on the depth of the wound, RN 6 reported it appeared to be 0.2 centimeters (cm) then measured the wounds depth. An unstageable pressure ulcer with eschar was noted to the right heel and a deep tissue injury was noted to the left heel was also observed. RN 6 stated during the visit the left heel wound had “;eschar” which was not observed. During an interview with RN 6 on 01/17/24 beginning at 4:2 PM, the nurse reported he/she assessed Patient #9s left heel wound to be an unstageable pressure ulcer, not a deep tissue injury. The nurse reported the heel wound was not open or scabbed. During an interview with Person K, the primary caregiver for Patient #9, on 01/17/24 beginning at 1:35 PM, the caregiver reported the patient had wound to his/her bilateral heels “;around the time” the patient began receiving hospice services and the coccyx wound developed shortly afterward. During a follow-up interview with Person K on 01/17/24 beginning at 2:30 PM, the family member reported he/she first observed wound to the bilateral medial knees on 01/14/24.”

“Based on observation, record review and interview the hospice failed to notify the physician of abnormal assessment findings for 2 of 2 records reviewed with elevated blood pressure (Patient #12 and #17). 1. The record for Patient #12 revealed admitting diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and co-morbidities of pulmonary hypertension (high blood pressure in the arteries of the lungs affecting the right side of the heart), chronic kidney disease stage III (decreased kidney function), hypertension (high blood pressure), atrial fibrillation (irregular heart rate). A skilled nurse visit note dated 12/18/23 completed by Registered Nurse 8 (RN 8) indicated a blood pressure of 163/102, pulse of 98, and 3 + pitting edema (swelling that leaves an indention on the skin when pressure is applied, graded on a +1 to + 4 scale) to bilateral lower extremities. RN 8 completed written communication of assessment findings to Registered Nurse 2, the patient’s case manager. The record failed to evidence communication to the Interdisciplinary Team (IDG) nor further follow up of assessment findings. In an interview on 1/18/24 at 11:33 am with Clinical Manager 2 (CM 2) indicated they would have expected the nurse to notify the physician of Patient #12 assessment findings. CM indicated that was not done for Patient #12. 2. An observation of a home visit with Registered Nurse 5 (RN 5) for Patient #2 included RN 5 performed care of an indwelling abdominal drain for Patient #2. The record for Patient #2 included a visit note dated 1/11/24 in which Registered Nurse 5 (RN 5) included measurements of 0.5 cm x 0.5 cm for the drain site opening with suture in place. It was not observed during the home visit conducted 1/11/24 that RN 5 performed measurements of the drain site. In an interview conducted on 1/12/24 at 2:30 pm Registered Nurse 5 indicated they “eyeballed the measurements as I have been a nurse for 20 years and know what 0.5 cm x 0.5 cm looks likes.” In an interview on 1/11/24 beginning at 4:48 pm the Administrator indicated it is “never appropriate to eyeball measurements of drains or wounds.” 3. The record for Patient #17 completed by Registered Nurse 8 on 1/1/24 indicated a blood pressure of 154/118 and a pulse of 102 with patient reports of feeling extra tired. The record indicated communication was shared with Registered Nurse 12. The record failed to indicate further follow up notification to the IDG team, or physician. In an interview on 1/22/24 beginning at 9:50 am Clinical Manager 2 indicated a blood pressure of 154/118 should have been followed up on with the physician and it was not done for Patient #17. Findings include:”

“Based on record review and interview, the social worker failed to provide medical social services based on the patient and caregivers needs for 2 of 12 records reviewed of patients receiving medical social services (Patients #4, 13). *The comprehensive assessment dated 12/11/23 for Patient #13 indicated the caregiver was seeking assistance with other resources for themselves and Patient #13. The note indicated communication was relayed to the Interdisciplinary team (IDG), including Medical Social Worker 1 (MSW 1) on 12/11/23. The record failed to indicate follow up by MSW 1. During an interview on 1/17/24 beginning at 10:30 am, Clinical Manager 2 (CM2) indicated there should have been follow up by MSW 1. CM 2 confirmed no follow up was completed for Patient #13 by any MSW. The review of Patient #4’s clinical record evidenced a hospice election benefit date of 11/07/23. The record indicated the patient had a venous stasis ulcer to the “top of the left foot” on admission and developed “multiple” open wounds to the left 2nd and 3rd toes, first noted during the nursing visit on 11/13/23. The plan of care evidenced an order for wound care to the left toe wounds which included cleansing with wound spray, pat dry, apply gauze to “space toes apart,” and keep open to air. The order indicated wound care was to be performed at each skilled nursing visit. The record indicated Social Worker (MSW) 2 conducted the social work portion of the admission comprehensive assessment on 11/09/23. The visit note indicated the hospice social worker was to conduct monthly visits for “;emotional support and assessment of caregiver needs.” The record indicated RN 1 conducted a skilled nursing visit on 11/27/23. During the visit, the nurse noted the wounds to the left toes were “;much worse” than the previous assessment, including having eschar to the wound beds. The patient was noted to be having pain in the toes, was feeling weak, and was no longer able to ambulate. RN 1 documented new orders to soak the patients foot in soapy water twice a day. The nurse noted Person B, the patients primary caregiver, would “;do [his/her] best” to perform the wound care, but the caregiver was “;exhausted” caring for Patient #4 and another ill family member. The caregiver reported he/she had been having difficulty placing the gauze between the patients toes “;so he/she just stopped doing it.” The visit note indicated RN 1 contacted MSW 1 “;to express concerns about [Person E] not being able to care for [Patient #4] as [he/she] needs.” The nurse documented MSW 1 was to contact Person E to “;discuss care options.” The record indicated RN 1 called Person B on 11/28/23 and the caregiver reported there were “;no needs.” The record failed to evidence further documentation of the nature of the call. During an interview with RN 1 on 1/18/24 beginning at 8:36 AM, the nurse could not recall the nature of the call made to Person B on 11/28/23. The record indicated Person B placed two calls to the agencys after-hours line on 12/02/23 requesting assistance as he/she could not awaken Patient #4 nor ambulate him/her. The record indicated RN 8 conducted a PRN visit later that day, during which the caregiver “;expressed frustration and the need for more help” and reported he/she was overwhelmed. RN 8 documented Person B needed a social worker to follow up with him/her on 12/04/23 “;with information about caregivers assistance and companies.” The record evidenced after RN 1 noted Patient #4’s need for social work services on 11/27/23, the first documented social work contact was on 12/04/23 by MSW 1. The note indicated the social worker attempted to contact Person B via phone, however another family member answered and reported the caregiver was currently unavailable. MSW 1 reported he/she would follow up with Person B the next day (12/05/23). The record indicated Person B placed a call to the agency on 12/06/23 and spoke with RN 13. The caregiver called to request assistance with transferring the patient and getting him/her dressed. RN 13 noted he/she informed RN 1 and MSW 1 of the call and the employees reported they were “;developing a plan for increased care, such as in-home paid caregivers or placement in an [extended care facility].” The record indicated RN 1 conducted a skilled nursing visit on 12/07/23. The nurse noted Patient #4s left toes had become cold to touch and gangrenous (death of tissue due to lack of blood flow and/or infection), “;especially to [the] second toe which is nearly completely blue in color.” RN 1 noted when speaking with Hospice Physician 1 regarding the patients wounds, the nurse and MD discussed the “;inability for [Person B] to care for [the patients] current wound.” RN 1 also documented he/she encouraged Person B to “;hire private caregivers” to assist with Patient #4s care. The record failed to evidence any further assistance was provided to the patient and/or family in obtaining additional caregiving assistance. The record failed to evidence any further social work documentation of contact attempts or visits after 12/04/23. Patient #4 revoked his/her hospice benefit on 12/09/23 to seek amputation of his/her left toes. The review of the records from Facility C, a hospital, evidenced after Patient #4 underwent a toe amputation, the patient was made “;comfort care” and died in the hospital on 12/14/23. During an interview with MSW 1 on 01/16/23 beginning at 3:01 PM, the social worker reported he/she was contacted by RN 1 on 11/27/23 and informed Person B needed assistance with the patients care. MSW 1 reported he/she would typically attempt to contact the patient and/or caregivers the “;same day” that hear a patient or caregiver needed social work assistance. The social worker could not recall the reason he/she did not attempt to contact Person B on 11/27/23. MSW 1 reported he/she reviewed RN 1s note on 11/28/23 and interpreted it as the caregiver no longer needed additional help. MSW 1 stated he/she attempted to contact Person B on 12/04/23 after being contacted again by hospice staff regarding concerns with the caregiver feeling overwhelmed. The social worker confirmed on 12/04/23, he/she spoke with another family member to try to discuss caregiving options. MSW 1 reported he/she did not perform any further follow-up with Patient #4s caregivers and the caregivers did not obtain any additional assistance prior to the patients death.”

“Based on observation, record review, and interview, the hospice agency failed to ensure all hospice aides successfully completed a competency evaluation which included the use of mechanical lifts for 1 of 1 home visit observations of a hospice aide (Hospice Aide (HA) 1). Findings include: 1. An agency policy #8095902 titled “;... Hospice Aide Competency ...” indicated the hospice agency would ensure all hospice aides were competent by conducting a competency evaluation on hire. The competency evaluation was to be performed by direct observation with a Registered Nurse (RN) and include “;transfer techniques.” 2. A review of the personnel file for Hospice Aide 1 indicated a start date of 02/19/19. The file included a “;Patient Lift Competency” dated 04/17. The file failed to evidence Hospice Aide 1 successfully completed a competency for mechanical lifts after being hired at the hospice agency nor the aide completed a competency for the mechanical lift used at Entity G. During an interview with Hospice Educator 5 on 01/22/24 beginning at 1:30 PM, the educator reported HAs mechanical lift competency was completed prior to the employees hiring at the agency by Entity C, a hospital owned by the same health care corporation as the hospice agency. Hospice Educator 5 also reported the agency had no record HA 1 completed a competency evaluation with the mechanical lift used at Entity G. The educator when a patient resided at an assisted living or extended care facility and required transfer with a mechanical lift, the hospice did not require the aide to successfully compete a competency evaluation of the facilitys lift(s). 3. A review of the personnel file for Hospice Aide 2 indicated a start date of 10/10/22. The file failed to evidence the aide completed a competency for mechanical lifts. 4. A review of the personnel file for Hospice Aide 3 indicated a start date of 12/19/22. The file failed to evidence the aide completed a competency for mechanical lifts. 5. A review of the personnel file for Hospice Aide 5 indicated a start date of 01/16/23. The file failed to evidence the aide completed a competency for mechanical lifts. 6. A review of the personnel file for Hospice Aide 6 indicated a start date of 02/26/01. The file failed to evidence the aide completed a competency for mechanical lifts. 7. A review of the personnel file for Hospice Aide 7 indicated a start date of 07/31/23. The file failed to evidence the aide completed a competency for mechanical lifts. 8. A review of the personnel file for Hospice Aide 8 indicated a start date of 08/25/20. The file failed to evidence the aide completed a competency for mechanical lifts. 9. During a follow-up interview with Hospice Educator 5 on 01/22/24 beginning at 4:15 PM, the educator confirmed the agency had no record of Hospice Aides 2, 3, 4, 5, 6, 7, or 8 completing a competency for mechanical lifts. * During a home visit conducted on 1/16/24 beginning at 10:14 am, it was observed Hospice Aide 1 (HA 1) using Entity G stand lift to complete the transfer of Patient 8 from their wheelchair to Entity G shower chair to complete a shower. During an interview on 1/16/24 beginning at 11:15 am Hospice Aide 1 indicated she knew how to use the stand lift because she had taken care of Patient #8 for a long time.”

“Based on observation, record review, and interview, the hospice agency failed to create an individualized aide care plan for 2 of 9 records reviewed of patients receiving aide services (Patients #4, 8). *During a home visit conducted on 1/16/24 beginning at 10:14 am with Hospice Aide 1 (HA 1) it was observed Patient #8 request a towel roll be placed on their left side to aide in positioning by HA 1. It was observed HA 1 rolled a towel and placed longways behind Patient #8s left shoulder and side. During an interview on 1/16/24 beginning at 11:15 am Hospice Aide 1 (HA 1) indicated she knew how Patient #8 wanted the towel because of the length of time HA 1 has taken care of Patient #8. During an interview on 1/17/24 beginning at 1:30 pm Clinical Manager 2 indicated the towel used for positioning is not on the Plan of Care for Patient #8 The review of Patient #4s clinical record included a plan of care for the initial benefit period of 11/07/23 – 02/04/24 which indicated the patient was to receive hospice aide services. The record included an aide care plan which indicated aide tasks included assisting the patient was showering. The aide care plan failed to evidence how the aide was to ambulate and/or transfer Patient #4 to and from the shower.”

“Based on record review and interview, the hospice agency failed to ensure the patients plan of care specified the services to be provided by a contracted inpatient facility for 1 of 1 active record reviewed of a patient who received hospice services at Facility I (Patient #6). Findings include: The review of agency policy #8095844 titled “;General Inpatient Care Policy,” last revised 12/16/21, indicated the agency would “;retain responsibility for ensuring that the personnel will provide quality care ...,” the hospice plan of care would be provided to the inpatient facility within 24 hours of admission, and the hospice interdisciplinary group would monitor the patients care and “;ensure that all care rendered is according to the Hospice Plan of Care.” The review of Patient #6s clinical record evidenced a hospice election benefit date of 01/05/24 and the patient began receiving hospice services while he/she was inpatient at Facility I, a hospital, as General Inpatient (GIP) level of care. RN 3 completed the nursing portion of the admission comprehensive assessment on 01/05/24. The visit note indicated the patient had 10 wounds between both feet, which were a “;combination of diabetic and peripheral disease wounds,” and were covered with an unknown dressing. RN 3 documented he/she did not perform wound care to the multiple foot wounds due to the wound care being performed earlier in the day by hospital staff. The record indicated the patient was discharged to his/her personal residence on 01/07/24. Patient #6s plan of care failed to evidence the services which were to be provided by Facility I staff, including wound care treatments. During an interview with the Administrator and Clinical Supervisor 3 on 01/11/24 beginning at 4:25 PM, the Administrator reported when a hospice patient was receiving hospice services at a contracted inpatient facility, the inpatient facility was responsible for “;everything.” Clinical Supervisor 3 reported Patient #6s plan of care did not evidence which services were to be provided by Facility I staff.”