Viaquest Hospice of Indiana, LLC

“Based on record review, observation and interview, the hospice agency failed to ensure the plan of care was individualized for each patient and addressed the patient’s specific needs as identified in the comprehensive assessment and included all services necessary for the palliation and management of the terminal illness and related conditions and included the bereavement and emergency preparedness plan (See L0545), failed to ensure measurable outcomes were anticipated from implementing and coordinating the plan of care (See L0548), failed to ensure to include all services necessary for the palliation and management of the terminal illness to include drugs and treatments to meet the needs of the patient (See L0549), failed to ensure all medical supplies and appliances necessary to meet the needs of the patient (See L0550), failed to revise the plan of care to include information from the patients updated comprehensive assessment to note the patients progress toward outcomes and goals (See L0553), and failed to ensure ongoing sharing of information between all disciplines providing care and services in all settings (See L0557). The cumulative effect of these systemic problems has resulted in the hospice agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.”

“Based on record review and interview, the agency failed to evidence a full scale community - based drill was completed for 1 of 1 agency’s emergency preparedness plan reviewed. The findings include: The Emergency Preparedness Plan [EPP] was reviewed with the hospice administrator on 6/28/24, beginning at 11:45 AM. The EPP failed to evidence a full scale agency based exercise was completed nor a community based drill was completed within the last 24 months. The administrator presented for review after action reports for evidence of full scale drills. No further information was provided by survey exit on 7/02/2024. The after action documents presented included: 1) a report dated 9/30/22, when their hospice electronic medical record was hacked 2) a report dated 12/23/22 for a branch, when they prepared for and their area had an loss of electricity 3) a report dated 01/23/23 for a branch which prepared for inclement weather.”

“Based on record review and interview, the hospice failed to evidence their emergency preparedness plan addressed their patient population, including, those who resided in residential and group settings, and their ability to provide in an emergency and the continuity of operations, including delegations of authority and succession plan for 1 of 1 hospice emergency plan reviewed. Findings include: During an interview on 6/28/2024, beginning at 11:45 AM, the hospice administrator relayed their plan did not address their patient populations and indicated for those who reside in facilities, that are not their personal home, the hospice would follow the facility’s’ emergency plan; the administrator was not able to evidence this information within their plan.”

“Based on record review and interview, the hospice failed to ensure their emergency preparedness plan included a process for collaboration with local, regional, state and federal emergency preparedness officials for 1 of 1 hospice plan reviewed. Findings include: During an interview and review of the hospice emergency preparedness plan with the administrator on 6/28/2024, beginning at 11:45 AM, the administrator provided a list of county emergency officials for each county in which they provide care to patients. The hospice plan failed to evidence coordination with these officials nor coordination with federal and state emergency officials nor participation in their planning. The administrator relayed their corporate VP stayed in contact with these offices and officials yet the plan did not evidence this contact.”

“Based on record review and interview, the hospice agency failed to ensure all patients received a comprehensive assessment that identified the physical, psychosocial, emotional, and spiritual needs of the patients, related to their terminal illness, for 1 of 4 active records reviewed from the parent location (Patient 5). The Findings Include: The clinical record for Patient #5 was reviewed on 6/27/24, indicated an election of benefit date of 3/7/24; the comprehensive assessment failed to evidence a spiritual assessment was completed. During an interview on 6/27/24 beginning at 1:30 p.m. with Clinical Manager 2, indicated the spiritual assessment was not completed because Patient had declined spiritual services.”

“Based on record review and interview, the hospice interdisciplinary group failed to update the comprehensive assessment to consider changes that have taken place since the initial assessment to include information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care as frequently as the condition of the patient requires in 5 of 14 active clinical records reviewed. (Patient #2, 5, 10, 11, 14). Findings include: On 6/28/2024, beginning at 2:35 PM, the administrator relayed Patient #2’s pain goal was not located in the comprehensive assessment A Start of Care Comprehensive Assessment dated 06/21/2024 indicated Patient #2s pain level was 8 out of 10 (on a pain scale where 0 was no pain and 10 was worst pain) described as intermittent pressure and stabbing to the abdomen. A Nurse Visit Note Dated 06/23/2024 indicated the Patient had intermittent back pain with a pain level of 9 out of 10 on a pain scale with occasional aching back pain and relieved with Norco (pain reliever) to control the pain to a pain level of 7 out of 10. A Nurse Visit Note dated 06/25/2024 indicated the Patient complained of pain 10 out of 10 on a pain scale, had constant pressure, aching to neck, left ankle and shoulders and Norco was discontinued and Morphine (pain reliever) was started on 06/24/2024. A Nurse Visit Note dated 06/27/2024 indicated the Patient complained of constant neck with a pain level 10 out of 10 on a pain scale, was alert and oriented x3 and was able to answer appropriately. A clinical record review on 06/27/2024 failed to include an updated comprehensive assessment by the hospice interdisciplinary group to include the patients pain level being 9 out of 10, and 10 out of 10 since the initial assessment on 06/21/2024. The record for Patient #5, reviewed on 6/27/24 included a comprehensive assessment dated 6/19/24 for the second benefit period dated 6/5/24 to 9/2/24 which identified the patient as a moderate risk for skin breakdown using the Braden Scale. The comprehensive assessment indicated the patient as not having pain also indicated the patient was using medications Tylenol and gabapentin for pain. The record failed to evidence skin interventions, patient pain goal or progress toward the goals. During an interview on 7/1/24 beginning at 10:30 a.m. the administrator indicated the there was no documentation of goals, interventions or progress toward goals for skin or pain. The record for Patient #10, reviewed on 7/1/24 included a comprehensive assessment dated 6/26/24 for the third benefit period dated 6/3/24-8/1/24 which identified the use of a left-hand brace and use of knee braces when in bed. The record failed to evidence interventions, goals or progress toward goals. During an interview on 7/2/24 beginning at 11:00 a.m., the administrator indicated braces should be part of the assessment and there was no documentation of interventions, goals or progress toward goals for the braces. The record for Patient #11, reviewed on 7/2/24 included a comprehensive assessment for the seventh benefit period dated 5/8/24 to 7/6/24 which identified the patient as a high risk for skin breakdown using the Braden Scale. The comprehensive assessment identified a score of 10 on the MACH fall risk assessment scale, indicating a high fall risk. The record failed to evidence patient goals, interventions or progress toward goals related to fall risk. During an interview on 7/2/24 beginning at 1:30 p.m. the administrator indicated there was no documentation of skin or fall interventions or progress towards goals. The record for Patient #14 reviewed on 7/2/24 included a comprehensive assessment for the benefit period 4/8/24 – 7/6/24 which identified a score of 10 on the MACH fall risk assessment, indicating a high fall risk. The record failed to evidence patient fall goals, interventions or progress toward goals related to fall risk. During an interview on 7/2/24 beginning at 2:00 p.m. the administrator indicated there was no documentation of fall risk or pain interventions or progress towards goals.”

“Based on record review and interview, the hospice agency failed to ensure they identified their data elements, incorporated into the comprehensive assessment, that allowed for measurement of outcomes, were measured and documented in the same way for all patients for 14 of 14 (Patients #1 through #14) active clinical records reviewed. The Findings Include: During the entrance conference on 6/25/24 beginning at 11:30 a.m. the Administrator was unable to identify what data elements were being measured with outcomes. During an interview on 6/26/24 beginning at 10:30 a.m. Clinical Manager 2 was unable to identify what data elements were being measured with outcomes. The active clinical records numbered 1 through 14 evidenced the hospice had used the same standardized assessments for each Patient for the completion of the comprehensive assessments and updates to the assessments. The comprehensive assessments failed to evidence measurable outcome data elements had been incorporated into the assessments. The clinical record for Patient #5 with an election of benefit date of 3/7/24, and a comprehensive assessment dated 6/19/24 included a Plan of Care for the second benefit period dated 6/5/24 to 9/2/24. The record failed to evidence the data elements being measured for outcomes nor how the data elements were taken into consideration for the aspects of care on the plan of care. The clinical record for Patient # 9 with an election of benefit date of 4/20/24, and a comprehensive assessment dated 6/26/24 included a Plan of Care for the fourth benefit period dated 6/19/24-8/17/24. The record failed to evidence the data elements being measured for outcomes nor how the data elements were being taken into consideration for the aspects of care on the plan of care. The clinical record for Patient #10 with an election of benefit date of 12/6/23, and a comprehensive assessment dated 6/26/24included a Plan of Care for the third benefit period dated 6/3/24-8/1/24. The record failed to evidence the data elements being measured for the outcomes nor how the data elements were being taken into consideration for the aspects of care on the plan of care. The clinical record for Patient #11 with an election of benefit date of 3/15/24, included a Plan of Care for the seventh benefit period dated 5/8/24 to 7/6/24. The record failed to evidence the data elements being measured for outcomes nor how the data elements were being taken into consideration for the aspects of care on the plan of care. The clinical record for Patient #14 with an election of benefit date of 1/9/24, included a Plan of Care for the second benefit period dated 4/8/24 to 7/6/24. The record failed to evidence the data elements being measured for outcomes nor how the data elements were being taken into consideration for the aspects of care on the plan of care.”

“Based on record review and interview the hospice agency failed to ensure the data elements were an integral part of the comprehensive assessment and documented in a systematic and retrievable way for each patient. The agency failed to evidence the data elements for each patient were used in individual care planning and coordination of services, nor used in the aggregate for the hospices quality assessment and performance improvement program, which had the potential to affect all agency patients. The Findings Include: On 7/01/2024, beginning at 1 PM, the quality assessment and performance improvement [QAPI] program was reviewed with he administrator. When asked to identify the data elements from the patients comprehensive assessments, and used in the aggregate of the hospices QAPI, the administrator relayed she was not knowledgeable of the information. The administrator relayed that they audit their comprehensive and recertification assessments and various other documents and provided audit forms which included audits that asked if items were completed or present. No furhter information was provided by survey exit. During the entrance conference on 6/25/24 beginning at 11:30 a.m. the Administrator was unable to identify the data elements collected as part of the comprehensive assessment, which were being measured with outcomes. No further information regarding the data elements were provided by survey exit on 7/02/2024. During an interview on 6/26/24 beginning at 10:30 a.m. Clinical Manager 2 was unable to identify what data elements were being measured with outcomes. The review of the agencys Quality Assurance and Performance Improvement (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.”

“Based on record review and interview, the hospice failed to ensure the plan of care was individualized for each patient and addressed the patient’s specific needs as identified in the comprehensive assessment and included all services necessary for the palliation and management of the terminal illness and related conditions and included the bereavement and emergency preparedness plan in 11 of 14 active patients (Patient #2, 3, 4, 5, 6, 7, 8, 11, 12, 13, and 14). The Findings Include: On 7/01/2024, beginning at 12:45 PM, the administrator relayed they now realized that the plans of care, for their Patients on benefit period 2 and on, do not include the patient’s emergency plan nor their bereavement plan. The clinical record of Patient #4 revealed a plan of care for benefit period 4 and dates 6/1/24 to 7/30/24. A bereavement assessment was noted on 10/27/23. The plan of care failed to evidence information gathered from the initial bereavement assessment nor a bereavement plan of care. The clinical record of Patient #3 revealed a plan of care for benefit period 5 and dates 6/4/25 to 8/2/24. A Bereavement assessment was noted on 3/12/24. The plan of care failed to evidence information gathered from the initial bereavement assessment nor a bereavement plan of care. The last bereavement assessment completed. The clinical record of Patient #6 revealed a plan of care for benefit period 3 and dates 5/15/24 to 7/13/24. A bereavement assessment was noted on 11/21/23. The plan of care failed to evidence information gathered from the initial bereavement assessment nor a bereavement plan of care. The record reviewed on 6/27/24 for Patient #5 included a plan of care for the benefit period 6/5/24 – 9/2/24 which failed to evidence Patient’s emergency preparedness plan and a bereavement plan. The record reviewed on 7/2/24 for Patient #11 included a plan of care for the benefit period 5/8/24 – 7/6/24 which failed to evidence Patient’s emergency preparedness plan and a bereavement plan. The record reviewed on 7/2/24 for Patient #14 included a plan of care for the benefit period 4/8/24 – 7/6/24 which failed to evidence Patient’s emergency preparedness plan and a bereavement plan. During an interview on 7/2/24 beginning at 10:30 a.m. the administrator indicated the initial bereavement plan, does not appear on any plan of care after the initial plan of care. 1. A policy revised on 05/2021, titled, “;Bereavement Services,” indicated the plan of care would reflect family needs. 2. A Plan of Care for initial benefit period 06/21/2024 – 09/18/2024, for Patient #2 failed to evidence the initial bereavement assessment was incorporated into the plan of care. 3. A Plan of Care for initial benefit period 05/30/2024 – 08/27/2024, for Patient #7 failed to evidence the initial bereavement assessment was incorporated into the plan of care. 4. A Plan of Care for initial benefit period 06/06/2024 – 09/03/2024, for Patient #8 failed to evidence the initial bereavement assessment was incorporated into the plan of care. 5. A Plan of Care for benefit period 05/23/2024 – 07/21/2024, for Patient #12 failed to evidence the initial bereavement assessment was incorporated into the plan of care. 6. A Plan of Care for initial benefit period 06/25/2024 – 09/22/2024 for Patient #13 failed to evidence the initial bereavement assessment was incorporated into the plan of care.”

“Based on record review and interview the hospice agency failed to ensure measurable outcomes were anticipated from implementing and coordinating the plan of care for 9 of 14 active clinical records reviewed. (Patient # 2, 3, 4, 5, 6, 10, 11, 12, and 14) Findings include: The clinical record of Patient #3 revealed a plan of care for benefit period 5 and dates 6/4/25 to 8/2/24 that included goals “;Patient will have safety needs met” and “;Patient will follow an effective bowel program to prevent/relieve constipation.” The clinical record of Patient #4 evidenced a plan of care for care for benefit period 4 and dates 6/1/25 to 7/30/24 that included goals “;Pain will be managed at a level acceptable to patient”, “;Changes in neurological status will be addressed appropriately”, and “;Patient will follow an effective bowel program to prevent/relieve constipation.” The clinical record of Patient #6 evidenced a plan of care for benefit period 3 and dates 5/15/24 to 7/13/24 that included goals “;Changes in neurologic status will be addressed appropriately” and “;Patient will follow an effective bowel program to prevent/relieve constipation.” During an interview on 7/2/24 beginning at 2:45 PM, Branch Director 3 revealed goals such as “;changes in neurological status will be addressed appropriately”, “;Patient will have safety needs met”, “;Patient will follow an effective bowel program to prevent/relieve constipation”, and “;Pain managed at level acceptable to patient” are immeasurable goals and relayed the agencys goals and interventions need to be more patient centered. She indicated there is not a specific bowel program nor policy. The record reviewed on 6/27/24 for Patient #5 with an election of benefit date of 3/7/24 and a comprehensive assessment dated 6/19/24 included a plan of care for the second benefit period 6/5/24– 9/2/24 which indicated an order to instruct appropriate bowel protocol as needed with a goal to follow an effective bowel program to prevent/relieve constipation. The clinical record for Patient #10 with an election of benefit date of 12/6/23, and a comprehensive assessment dated 6/26/24 included a plan of care for the third benefit period dated 6/3/24-8/1/24 which indicated an order to instruct appropriate bowel protocol as needed with a goal to follow an effective bowel program to prevent/relieve constipation. The clinical record for Patient #11 with an election of benefit date of 3/15/24, included a plan of care for the seventh benefit period dated 5/8/24 to 7/6/24 which indicated an order to instruct appropriate bowel protocol as needed with a goal to follow an effective bowel program to prevent/relieve constipation. The clinical record for Patient #14 with an election of benefit date of 1/9/24, included a plan of care for the second benefit period dated 4/8/24 to 7/6/24 which indicated an order to instruct appropriate bowel protocol as needed with a goal to follow an effective bowel program to prevent/relieve constipation. During an interview on 7/2/24 beginning at 10:30 a.m. the administrator indicated the agency did not have a bowel protocol. During an interview on 6/28/24, beginning at 2:35 PM, the administrator relayed Patient #2’s plan of care did not reveal Patients measurable pain goal. During an interview on 7/01/24, beginning at 12:25 PM, the administrator relayed Patient #12’s plan of care did not include bleeding precautions or safety measures in place related to the use of Plavix and that the plan of care did not evidence patients measurable goals. 1. A Plan of Care for initial benefit period 06/21/2024 – 09/18/2024, for Patient #2 indicated goals would include the patients pain would be managed at a level acceptable to the patient. The Start of Care Comprehensive Assessment dated 06/21/2024 indicated the patients reported goal pain score was zero (0). A Nurse Visit Note dated 06/27/2024 indicated the Patient complained of a pain level of 9 out of 10 (pain scale where 0 was no pain and 10 was worst pain), the Nurse Visit Note indicated the patients pain goals were met and managed at a level acceptable to the patient. The Plan of Care failed to evidence a measurable outcome to ensure the patients pain level was managed. 2. An Updated Plan of Care for benefit period 05/23/2024 – 07/21/2024, for Patient #12 indicated goals would include instruction on safety measures. The Patient was on Plavix (antiplatelet medication to prevent blood clots) and the plan of care failed to evidence safety measures to include bleeding precautions and failed to evidence a measurable outcome to ensure the safety measures were met. 3. During an interview on 06/28/2024,”

“Based on record review and interview, the hospice plan of care failed include all services necessary for the palliation and management of the terminal illness to include drugs and treatments to meet the needs of the patient for 4 of 5 active clinical records review that received their services from the parent location (Patient’s #5, 8, 11, and 13). Findings include: The record reviewed on 6/27/24 for Patient #5 included a recertification plan of care for the benefit period 6/5/24 – 9/2/24 which indicated orders for acetaminophen 500 mg tablet (a medication used in the treatment of pain), take 2 tablets by mouth daily; gabapentin 400 mg capsule (a medication used for the treatment of nerve pain), take 1 capsule by mouth 3 times a day; hydrocodone – acetaminophen 5 mg/325mg ( a narcotic medication used for the treatment of pain), take 1 tablet by mouth every 6 hours as needed for pain; and morphine concentrate 100 mg/5 ml oral solution ( a narcotic medication used in the treatment of pain, shortness of breath or anxiety) give 0.25 ml by mouth every hour as needed. The record failed to evidence what medication should be used for what amount of pain. During an interview on 7/1/24 beginning at 11:30 a.m the administrator indicated the agency uses a mild, moderate or severe measurement for pain, however it was not indicated on the record for Patient #5. The record reviewed on 7/2/24 for Patient #11 included a recertification plan of care for the benefit period 5/8/24 – 7/6/24 which included a medication list. Within the medication list were medication orders for lisinopril 5 mg tablet ( a medication used in the treatment of high blood pressure), loperamide 2 mg tablet (a medication used for the treatment of diarrhea) and ondansetron 4 mg orally disintegrating tablet (used for the treatment of nausea or vomiting). The plan of care failed to evidence instructions for use of these medications. During an interview on 7/2/24 beginning at 2:30 p.m. the administrator indicated the instructions for the medications were not on the plan of care. During an interview on 7/01/2024, beginning at 11:30 AM, branch manager 2 was interviewed by phone and relayed that the plans of care for Patient # 8 and #13 did not include oxygen orders, to include the prescribed flow rate nor the method of delivery. 1. A Plan of Care for 1st benefit period 06/06/2024-09/03/2024, for Patient #8 indicated the patient had a diagnosis of heart disease with heart failure (impairment of the heart to fill and pump blood), oxygen supplies, oxygen precautions and failed to evidence the prescribed oxygen liters per minute and how the patient received the oxygen via mask, cannula or other source. A RN Visit Note dated 06/24/2024 indicated the Patient was on oxygen 2 Liters per minute. 2. A Plan of care for 1st benefit period 06/25/2024-09/22/2024, for Patient #13 indicated the patient had a diagnosis of lung cancer, oxygen supplies and was on oxygen precautions but the plan of care failed to evidence the prescribed oxygen liters per minute and how the patient received oxygen via mask, cannula or other source. A Skilled Nurse Visit dated 06/26/2024 indicated the patient had oxygen supplies in the home. 3. During an interview on 07/01/2024,”

“Based on record review, observation and interview the hospice agency failed to ensure all medical supplies and appliances necessary to meet the needs of the patient were included on the plan of care for 1 of 1 patients observed for home health aide services. (Patient # 4) The agency policy “;IDG Care Planning Process,” revised October of 2020, indicates the plan of care should be individualized for each patient and includes all medical supplies and appliances necessary to meet the needs of the patient. In an observation of a home visit with Patient #4 on 6/26/24 beginning at 1:00 PM, Patient was observed in a Broda Chair (reclining wheelchair). While Home Health Aide (HHA) 1 provided Patient with a shower, a Hoyer lift (a patient sling lift) was used to transfer Patient to a shower chair. HHA 1 relayed the Hoyer lift is necessary every time Patient is transferred between a chair and the bed. The clinical record of Patient #4 evidenced a plan of care for care for benefit period 4 and dates 6/1/25 to 7/30/24. The list of supplies needed to care for Patient included support surfaces, gloves, skin care, and incontinence supplies. The record failed to evidence a Hoyer Lift nor the Broda chair. During an interview on 6/27/24 beginning at 2:00 PM, Branch Director 2 indicated the plan of care should include all equipment needed to care for a patient and relayed the Broda Chair and Hoyer Lift should be included and are not on the plan of care for Patient #4.”

“Based on record review and interview, the hospice failed to revise the plan of care to include information from the patients updated comprehensive assessment to note the patients progress toward outcomes and goals in 1 of 5 active clinical records reviewed from the parent location (Patient #8). Findings include: Skilled Nurse Visit Notes, for Patient #8, dated 06/10/2024, 06/14/2024, and 06/17/2024 indicated the Patient complained of nausea. The Comprehensive Assessment/Plan of Care Update/Interdisciplinary Meeting Note dated 06/19/2024 indicated the patient complained of nausea. A Skilled Nurse Visit Note dated 06/24/2024 indicated Patient had complaints of nausea prior, food intake had decreased to 25%, and goals were met included the Patient verbalized need for adequate nutrition. The Plan of Care Update dated 06/19/2024 failed to be revised to update the measurable goals/outcomes and interventions to include the nausea was assessed for adequate nutrition intake.”

“Based on observation, record review and interview, the hospice failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings in 1 of 2 Patients with a start of care on or after 06/21/2024 (Patient #2). Findings include: During an interview on 6/28/24, beginning at 2:35 PM, the administrator relayed that the Patients record did not evidence documentation that the attending was notified of Patients continued complaints of uncontrolled pain. A Nurse Visit Note dated 06/27/2024 indicated Patient #2 was on scheduled Morphine 100 milligrams/5 milliliters, 0.25 milliliters every 4 hours started on 06/24/2024. The Nurse Visit Note indicated the patient complained of constant pain to the neck with a pain level 9 out of 10 on a pain scale (0 was no pain, 10 was worst pain). The Nurse Visit Note indicated the patient had a diagnosis of dysphagia (difficulty swallowing) after a cerebral infarction (brain stroke). A Start of Care Comprehensive Assessment dated 06/21/2024 indicated the patients pain goal was 0 and was unable to use his/her left arm/left leg and was non-ambulatory due to the cerebral infarction. A Plan of Care for initial benefit period 06/21/2024 – 09/18/2024, indicated orders to include the hospice nurse to monitor patients pain level and report ineffective pain control to the physician. An Aide Visit Coordination Note dated 06/27/2024 indicated the patient refused a shower because he/she was in too much pain. During an observation at a skilled nursing facility on 06/27/2024, beginning at 9:07 AM, the Patient indicated pain to neck, back and ankles all the time, and morphine (pain medication) was not really helping, and felt like neck was breaking. During the observation the hospice Registered Nurse asked the facility Qualified Medication Assistant (QMA) if the morphine was helping the patient and the QMA indicated the patient received morphine at 4 o’clock and did not have any complaints until 6 o’clock. A review of the clinical record failed to evidence on 06/27/2024 the nurse reported the patients ongoing pain to the physician and failed to evidence the aide notified the nurse of the patients refusal of care due to pain.”

“Based on record review and observation, the agency failed to ensure the registered nurse followed accepted standards of practice to prevent the transmission of infection in one of one clinical record reviewed with a home visit that included wound care (Patient #3). Findings include: The agency policy titled “;Infection Prevention and Control Plan”, revised 10/2020, indicates the agency will provide cleaning procedures for all equipment and a training program for all employees to understand work practices to prevent the transmission of an infection. In an observation of a home visit with Patient # 3 on 6/26/24 beginning at 9:15 AM, RN 1 wiped supplies after patient use (stethoscope, blood pressure cuff, thermometer, bandage scissors) with an antibacterial cloth. After wiping supplies, RN placed the items directly into her supply bag with a dry time of less than 15 seconds for each item. The antibacterial wipe (Sani-Cloth) directions for use indicated a full 2-minute dry time to disinfect surfaces. During an interview on 6/27/24 starting at 4:00 PM, RN 1 relayed she did not know the dry time of the antibacterial wipes. During an interview of 6/27/24 starting 9:00 AM, Branch Director 2 relayed the antibacterial wipes were provided to staff by the agency and the registered nurse was trained on indicated dry time.”

“Based on record review and interview, the hospice plan of care failed to specifically identify which provider was responsible for the care and services that are needed in 3 of 6 clinical records reviewed of a patient that resided in a skilled nursing facility (Patient #2, 7, 12). Findings include: During an interview on6/28/2024, beginning at 2:35 PM, the administrator relayed the RN for Patient #2, coordinated care with the qualified medication aide at the facility. When asked, the administrator relayed that the plan of care for Patient #2 did not delineate the care to be provided by the facility staff and the hospice staff. During an interview on 7/01/2024, beginning at 11:30 AM, the administrator contacted the branch manager by phone, to review; branch manager 2 relayed that the plan of care for Patient #7 and Patient #12 did not include the delineation of care between the hospice and the skilled nursing facility. 1. A Coordination Note dated 06/24/2024 indicated Patient #2 resided in entity 1, a skilled nursing facility. A Registered Nurse (RN) Start of Care dated 06/21/2024, indicated the patient was unable to use left arm and left, had contraction (muscle tissue that was stiffer than normal and difficult to stretch) to left hand, and required 1 assist for bathing, dressing, toileting, grooming, transferring to wheelchair and set up for eating. A Plan of Care for 1st benefit period 06/21/2024-09/18/2024, indicated the hospice nurse to coordinate plan of care with facility staff and failed to evidence the delineation of care required for the patient between the hospice and the skilled nursing facility. 2. A RN Visit Note dated 06/25/2024 indicated Patient #7 resided in a long-term care nursing facility, had a diagnosis of senile degeneration of the brain (mental deterioration), and required total care for activities of daily living to include bathing, dressing, and eating. A Plan of Care for 1st benefit period 05/30/2024-08/27/2024 failed to evidence the delineation of care required for the patient between the hospice and the skilled nursing facility. 3. A RN Visit Note dated 06/25/2024 indicated Patient #12 resided in a long-term care nursing facility, had a diagnosis of dementia (memory impairment), required 1 assist for activities of daily living to include bathing, dressing, and ambulating. An Updated Plan of Care for benefit period 05/23/2024-07/21/2024 failed to evidence the delineation of care required for the patient between the hospice and the skilled nursing facility.”