Elara Caring

“Upon client record review, 1 of 5 records (Patient #1) did not have evidence that any changes in the hospice plan of care were discussed with the patient/family and SNF/NF or ICF/IID representatives, and are approved by the hospice before implementation. Patient #1: Several areas of documentation for new orders indicate that caregiver is in agreement with the plan of care, caregiver and MD in agreement with the plan of care, and caregiver to administer medications. It is not clear who the documentation is referring to as the patient is in a SNF, yet the Emergency contacts lists a friend as a caregiver and the patient’s son is listed as the primary caregiver. There is not evidence of specific detail that indicates that the hospice plan of care were discussed with the patient/family and SNF/NF or ICF/IID representatives, and are approved by the hospice before implementation. On 11/12/24, documentation indicated that the hospice called the friend who was listed as a contact but not listed as a Healthcare representative (Indiana Appointment of Healthcare Representative) that was signed by the patient on 11/24/23.”

“Based on record review and interview, the agency failed to ensure all patients received information regarding covered hospice services for 2 of 3 active records reviewed who needed respite services (Patients #43, 46). Findings include: 1. Review of an agency policy titled “;Levels of Care-Inpatient Respite Care” indicated “;short-term inpatient respite is available ... on an occasional basis.” Situations which could indicate a need for respite included “;injury or impairment of the caregiver” and “;the caregiver requires or requests an interval (5 days or less) of rest or relief from providing care” to the patient. The policy indicated the social worker or designee was to assess “;the need for respite care and arranges the clients admission for inpatient respite care ....” 2. Review of an agency policy titled “;Clients Rights and Responsibilities – Indiana” indicated the patient had the right to receive information about the services covered under the hospice benefit. 3. Review of a document provided by the alternate administrator used for employee training indicated more than one respite period is allowable in a single billing period with no written guidance from the Centers for Medicare & Medicaid Services (CMS) which restricts the use of respite to one stay. 4. Review of the clinical record of Patient #43 indicated a hospice election date of 12/17/2023. Patient received inpatient respite services at Entity 9, a skilled nursing facility, from 08/12/2024 – 08/16/2024 to “;provide [schedule] break for caregiver.” Patient returned home on 8/19/24. Registered Nurse (RN) 7 conducted a skilled nurse visit on 8/20/24 and noted both Patient and Person 18, primary caregiver, reported feeling ill. Person 18 reportedly informed the nurse he/she would be “;testing for COVID” later that day. The record included a coordination note, documented on 8/23/24 by Medical Social Worker (SW) 3, which indicated she received a call from Person 18 “;requesting up to 5-day private pay respite due to both [Person 18] and [Person 19] being ill at this time.” The record failed to evidence SW 3 informed Person 18 of the option for inpatient respite services covered by Patients hospice benefit. Review of a visit note report entered on 08/23/2024 by RN 29 indicated Patient #43 was re-admitted to Entity 9 for a “;5 day stay” as his/her caregivers tested positive for COVID. The note indicated Patient had also tested positive for COVID. Review of an agency document titled “;Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report” dated 08/28/2024 indicated Patient #43 was currently at Entity 9 “;on private pay due to being COVID +. [Persons 18 and 19] is COVID + as well and [Person 18] just got home from hospital on 8/26/24. During an interview on 08/30/2024 at 10:44 AM, when asked what level of care Patient #43 was currently receiving, SW 3 indicated routine level of care. SW 3 indicated Patient #43 had been in respite at Entity 9 and returned home. After returning home, his/her caregivers became ill and were unable to care for Patient #43, so SW 3 contacted Entity 9 about the caregivers of Patient #43 private paying for stay. When asked when a respite stay covered by hospice would be utilized for a patient, SW 3 indicated when a caregiver is ill or worn out. SW 3 indicated she had been told by the “;higher ups” about respite and told this patient would have to go into Entity 9 as a private pay patient. During an interview on 08/30/2024 at 11:25 AM, when asked who the caregivers were for Patient #43, Person 18 indicated his/herself and Person 19. When asked for the location of Patient #43 today, Person 18 reported Patient was currently at Entity 9 as Persons 18 and 19 were recovering from COVID and could not care for Patient. When asked what options the hospice agency provided for Patients current stay at Entity 9, Person 18 indicated he/she had been previously told by hospice staff that respite was only allowed every 90 days, so when him/herself and Person 19 were ill with COVID and were too ill to provide care, they thought they would have to private pay for Patient 43s stay at Entity 9. During a follow up interview on 08/30/2024 at 11:58 AM, when asked what was meant when you mentioned a higher up said the current stay for Patient #43 at Entity 9 would be private pay, not respite, SW 3 indicated that was not specific to this circumstance and she had been told in the past by her superiors that hospice does not pay for back-to-back respite stays. During an interview on 08/30/2024 at 1:45 PM, when asked what respite training the agency had provided regarding the frequency of respite use, RN 7 indicated she had not been told there was a limit on number of stays and understood when there was a need, respite would be available. When asked how he/she was involved with the current nursing facility stay for Patient #43, RN 7 indicated Patient #43 was ill when returned home from a respite stay at Entity 9 a few weeks previous. Patient #43s caregivers, Person 18 and Person 19, then became ill with COVID. Person 19 contacted RN 7 regarding what to do because both caregivers were ill, Person 18 had to be hospitalized, and the caregivers hadnt been able to contact SW 3 regarding return of Patient #43 to Entity 9. When asked if anyone from the hospice agency spoke to the family about respite services, RN 7 indicated she did not because the family contacted Entity 9 to set up care. 5. Review of the clinical record for Patient #46 indicated an order dated 07/12/2024 for respite care to begin on 07/12/2024 for family needing relief. During an interview on 08/30/2024 at 3:16 PM, when asked why the family of Patient #46 used respite level of care, Person 20 indicated the family was under distress. When asked what the hospice agency had discussed with family for future respite needs, Person 20 indicated they were told they would have to wait for 30 days from the last date of respite to qualify for respite again.”

“Based on observation, record review, and interview, the registered nurse (RN) failed to assess per hospice policy and/or accepted practices and/or failed to document an assessment; the RN failed to assess wounds for 2 of 6 discharged patients; and the RN used tap water to flush a suprapubic catheter and failed to obtain an order to flush or insert a suprapubic catheter(See L591). The scope and severity of the deficiencies evidenced the hospice agencys inability to ensure the provision of quality health care in a safe environment which resulted in Elara Caring being found out of compliance with the condition of participation 42 CFR 418.64 Condition of participation: Core services.”

“Based on record review and interview, the hospice agency failed to ensure a complaint was logged, investigated, and resolved (See L505), failed to document communication with the patient that a discharge for cause was being considered, failed to make efforts to resolve the problem, and failed to properly notify patient of discharge for cause (See L517). Findings include: The severity of this deficiency evidenced the agency failed to protect and promote all patients rights, which resulted in Elara Caring being found out of compliance with Condition of Participation 42 CFR 418.52 Patients rights.”

“Based on observation, record review, and interview, the hospice agency failed to perform an accurate and complete initial comprehensive assessment (See L0524); failed to ensure all medications were reviewed during the comprehensive assessment and failed to ensure an accurate medication list was maintained (See L0530); failed to complete the initial bereavement assessment (See L0531) and failed to include data elements in the comprehensive assessment that allow for measurement of outcomes (See L0534). Findings include: The cumulative effect of these systemic problems had the potential to impact all 229 active patients which resulted in the agency being found out of compliance with Condition of Participation 42 CFR 418.54 for Initial and Comprehensive assessment of the patient.”

“Based on record review and interview, the hospice agency failed to establish an individualized written plan of care which addressed all patient needs (See L543); failed to ensure the primary caregiver was trained and/or educated on wound care orders (See L544); failed to ensure the patients problems and goals were included on the plan of care (POC) (See L548); failed to note the patients progress towards outcomes and goals within the revised POC (See L553); failed to ensure hospice aide services were provided according to the plan of care (See L555); and failed to ensure the on-going sharing of information, specific to the status of an as-needed (PRN) visit, between all disciplines providing care and services in all settings (See L557). The scope and severity of the deficiencies evidenced the hospice agencys inability to ensure the provision of quality health care in a safe environment which resulted in Elara Caring being found out of compliance with the condition of participation 42 CFR 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.”

“Based on observation, record review, and interview, the hospice agency failed to follow its own policies and procedures and accepted standards of practice related to infection control (See L579) and failed to provide infection control education, specific to the use of a catheter securement device to decrease the risk of urinary tract infection (UTI), to family members and other caregivers (See L582). Findings include: The scope and severity of the deficiencies evidenced the hospice agency failed to maintain an effective infection control program that protected patients, families, and employees, which resulted in Elara Caring being found out of compliance with Condition of Participation 42 CFR 418.60 Infection control.”

“Based on record review and interview, the hospice agency failed to ensure a complaint was logged, investigated, and resolved for 1 of 3 patients reviewed who were discharged due to death (Patient #19). Findings include: 1. The Complaint Resolution policy, effective 4/27/20, indicated “;Complaints/concerns brought to the direct attention of any hospice team member or volunteer are addressed immediately whenever possible and brought to the attention of the Administrator/Designee ... Documented investigation is conducted within 5 working days by appropriate personnel of all written or verbal complaints received by the Hospice... To resolve complaints, a minimum of three attempts are made to contact the person filing the complaint by telephone. If telephone contact is unsuccessful, a letter is sent. Each contact, attempted contact, or action taken to resolve the issue is documented with the original complaint. All complaints will have full resolution or attempts to resolve including effective action taken to include the outcome reported back to the complainant....” 2. On 5/26/24 at 7:28 PM, Person 1, an employee of Entity 1, called the hospice agency and reported a lack of care for Patient #19 and requested to speak with an administrator. Person 1 was transferred to Corporate Staff Person 3, the administrator on call that evening. 3. During an interview on 7/09/24 at 2:55 PM, Corporate Staff Person 3 relayed she took the complaint from Person 1 and forwarded it via email to the Administrator, the Alternate Administrator, and Branch Director 1. 4. During an interview on 7/02/24 at 3:56 PM, Branch Director 1 indicated any complaint the agency receives should be entered, documented, and followed up on and that she did not see the complaint regarding Patient #19 in the electronic medical record system.”

“Based on record review and interview, the hospice agency failed to document communication with the patient that a discharge for cause was being considered; failed to make efforts to resolve the problem and failed to properly notify patient of discharge for cause for 1 of 1 discharged for noncompliance records reviewed (Patient #24). Findings include: 1. The agency policy “;Clients Rights and Responsibilities-Indiana” indicated the client has the right to be fully informed in advance about care/service to be provided, as well as any modifications to the plan of care. 2. The agency policy “;Discharge from Hospice Care” indicated before the client can be discharged for cause, the hospice advises the client that a discharge for cause is being considered; makes a serious effort to resolve the problem caused by the clients behavior or the situation and document in the clients clinical record the problem(s) and the efforts made to resolve the problem. 3. The review of the patient admission packet included patient rights stating the client will be given a timely advance notice of discharge and if the client is discharged to another organization, the hospice agency will provide the client with a list of current medications and information necessary for continued care, including pain management and indicated when a discharge occurs, an assessment will be completed and instructions will be provided for any needed ongoing care or treatment. 4. Patient #24s clinical record evidenced skilled nurse (SN) visits were performed on 12/14/23, 12/15/23, 12/18/23, 12/20/23, 12/26/23 and 12/28/23. The SN visit notes for these dates failed to include any discussion of a possible discharge for cause; failed to include narcotic medication counts were performed during the SN visits and failed to include any documentation of efforts made to resolve the problem of possible missing medications. The clinical record evidenced social worker (SW) visits were performed on 12/15/23 and 12/27/23. The SW visit notes failed to include any documentation of a possible discharge for cause. Patient #24s clinical record evidenced a hospice discharge for cause without a visit made was completed by the Administrator on 12/29/23. The discharge report failed to evidence communication with Patient #24 or the attending physician for Patient #24. 5. During an interview on 7/15/24 beginning at 3:29 PM, RN 10 relayed they thought Patient #24 had been discharged due to being out of the service and were unaware Patient #24 was discharged for cause. RN 10 also relayed they document the narcotic counts in the narrative section of the skilled nurse visit note and relayed the hospice agency did not have a lockbox in place at Patient #24s home. 6. During an interview on 7/15/24 beginning at 4:21 PM, the Administrator indicated narcotic counts should have been performed at least weekly but ideally during every nurse visit and the count should have been documented in the narrative section of the skilled nurse note. They relayed they thought Patient #24 had been advised of a possible discharge for cause and it should have been documented in a coordination note and stated they left Patient #24 a voicemail stating the patient had been discharged from the hospice agency for cause on 12/29/23. When asked if leaving a voicemail notifying a patient of discharge is standard agency practice, the Administrator relayed that when the patient is unavailable by phone, the agency usually attempts to make an in-person visit to discharge and relayed the hospice agency did not attempt to do an in-person discharge visit with Patient #24.”

“Based on record review and interview, the registered nurse (RN) failed to perform a complete and accurate skin assessment for 1 of 1 discharged patient records reviewed with wounds (Patient #24) and failed to perform a suicide risk assessment during the initial comprehensive assessment for 1 of 1 patient records reviewed with suicidal ideation (Patient #19). 4. The agency policy “;Suicide” indicated the hospices interdisciplinary group (IDG) members were to “;respond to suicidal ideation (thoughts of harming oneself) and/or actual suicide attempts in a proactive and compassionate manner aimed at protecting the safety of all involved parties.” The policy indicated “;suicide risk factors are included in the comprehensive assessment of each client. Risk for hospice clients may include, but are not limited to: “;making statements about helplessness, hopelessness, worthlessness, uselessness ... threatening suicide or to harm oneself in some way ....” When the IDG determined a patient was a possible suicide risk, “;additional screening is conducted by a hospice clinician that includes asking the client the following questions: ... Have [you] thought about killing yourself? ... Do you have a plan of how to kill yourself? ....” 5. Patient #14s clinical record indicated a hospice benefit election date of 6/16/24 and Patient’s terminal diagnosis was Amyotrophic Lateral Sclerosis (ALS, a progressive neurological disorder). The hospice record included medical records from Patients visits to Entity 5, a doctors office, prior to electing hospice benefits. Entity 5s records indicated on 2/15/24, Patient reported suicidal thoughts to the entitys staff. Patient had a plan of how to kill himself/herself but did not currently intend to commit suicide. Patient reported if his/her ALS symptoms worsened, then he/she “;may” commit suicide. Patient was upset about “;how much [he/she] drools and needs [a] feeding tube.” Registered Nurse (RN) 4 conducted an admission comprehensive assessment on 6/16/24. The assessment indicated Patient was alert, oriented, and had a history of suicidal ideation reported to Entity 5 staff. The record failed to evidence RN 4 assessed Patients current suicide risk. The record indicated Patient declined social work services. The record indicated nursing visits were conducted on 6/18/24, 6/20/24, and 6/26/24 at 10:25 AM, which failed to evidence the nurses assessed Patients suicide risk. During the 6/20/24 visit, RN 3 noted Patient became upset after the nurse informed Patient the hospice had changed a medication from pill form to liquid form. Patient began “;throwing things” at the nurse. During the 6/26/24 visit at 10:25 AM, Entity 4 staff informed RN 6 that Patient would intermittently refuse medications and tube feedings, and would tell staff he/she “;wants to live and then that [he/she] is ready to die.” Patient asked RN 6 “;how long will I live?” The nurse attended a care conference with Entity 4 staff and Person 8, a family member and Patient-elected Power of Attorney (POA), during which Person 8 reported Patient had recently cried for “;most of 2 days.” The attended members agreed that Patient seemed “;very depressed,” and Entity 4 was to have its psychiatrist and therapist assess Patient. The record included a Clinical Coordination Note, documented on 6/26/24 by RN 6, which indicated the nurse was informed by Entity 4 staff of Patients attempted suicide. Patient was found by facility staff with a trash bag tied around his/her neck and reported he/she was “;trying to hurt” him/herself. Patient was sent to a local hospital, where he/she was admitted. During an interview on 7/16/24 beginning at 9:14 AM, RN 3 reported she was Patient #14s RN case manager from admission until 6/21/24, at which time Patient was transferred from Entity 6 to Entity 4 and RN 6 took over as nurse case manager. RN 3 was aware of Patients history of suicidal ideation and stated she notified Medical Social Worker (MSW) 2 and Branch Director 1 of this history, as she was “;newer” with the hospice agency and “;wasnt sure what to do.” MSW 2 advised RN 3 to conduct a care conference meeting to create a “;safety plan” with Patient and Entity 6, an assisted living facility where Patient resided between 6/16/24 – 6/21/24. RN 3 reported the care conference had not been conducted nor had a safety plan been created when Patient transferred to Entity 4. The nurse reported she did not conduct a suicide risk assessment on Patient. During an interview on 7/15/24 beginning at 2:45 PM, RN 6 reported she was Patients RN case manager beginning 6/21/24, when Patient transferred from Entity 6 to Entity 4. The nurse reported she saw Patient a few hours prior to his/her suicide attempt, and the care conference meeting conducted was a routine conference held due to Patient being admitted to Entity 4. RN 6 reported she had not performed a suicide risk assessment of Patient, as this was the social workers responsibility. During an interview on 7/15/24 beginning at 4:48 PM, MSW 2 reported Patient and his/her family initially declined social work services, so MSW did not evaluate Patient. The social worker did assist with Patients transfer from Entity 14 to Entity 4, however this was all conducted via phone. During an interview on 7/16/24 beginning at 9:25 AM, Branch Director 1 reported RN 4 was on vacation and was not available for interview. Branch Director 1 thought there was a suicide risk assessment that the nurse could conduct during the admission visit. Branch Director 1 confirmed it was the nurses responsibility to assess Patients suicide risk if Patient had declined social work services. Findings include: 1. The agency policy “;Comprehensive Assessment-Content” indicated the comprehensive assessment identifies the physical, psychosocial, emotional and spiritual needs of the client related to the terminal illness that must be addressed in order to promote the clients well-being, comfort and dignity throughout the dying process. 2. The review of the Registered Nurse (RN) Job Description indicated the RN makes the initial evaluation and assesses patient needs and obtains data on physical, psychological, social and spiritual factors that may influence patient health status and incorporate that data into the plan of care. 3. Patient #24s clinical record evidenced a start of care (SOC) and an initial comprehensive assessment completed by RN 9 on 12/13/23. The 12/13/23 initial comprehensive assessment visit note included documentation of a Stage IV wound to Patient #24s left lower buttock. A skilled nurse (SN) visit note completed by RN 10 on 12/18/23 evidenced a 10 centimeter (cm) x 10 cm x 5 cm surgical wound to Patient #24s left hip. RN 10 included documentation in the SN visit note that the left hip wound was not documented during the 12/13/23 SOC initial assessment and Patient #24 reported having the left hip surgical wound for 3 months. RN 9 failed to assess and document all wounds during the 12/13/23 SOC initial assessment. During an interview on 7/15/24 beginning at 3:29 PM, RN 10 verified Patient #24 had a surgical wound to the left hip since SOC on 12/13/23. During an interview on 7/15/24 beginning at 4:21 PM, the Administrator relayed RN 9 is no longer employed by the hospice agency and would not be available for an interview during the survey. They also relayed a complete skin assessment should have been performed during the initial SOC visit. During an interview on 7/16/24 beginning at 10:14 AM, the Alternate Administrator relayed a skin assessment should be performed every nursing visit.”

“Based on record review and interview, the hospice agency failed to ensure the patients drug profile was reviewed for accuracy for 3 of 4 patients with home visit observations in a facility (Patients #3, #5, and #6). Findings include: 4. The review of Patient #3s clinical record included a list of Patients current medications, which indicated Patient was to take Buspirone (a medication used to treat anxiety) twice a day and Lasix (a diuretic medication used to decrease excess fluid in the body). The Buspirones ordered frequency was decreased from 3 times a day to 2 times a day on 5/02/24, and Lasix was ordered on 7/12/23. Registered Nurse (RN) 6 conducted a recertification nursing assessment on 6/26/24 and noted “;no medication issues identified” during a review of Patients medications. RN 6 also conducted a skilled nursing visit on 7/03/24 and noted Patient had “;worsening” edema (swelling caused by a buildup of fluid), to both lower extremities, which was “;rare” for Patient. During an interview with RN 6 on 7/11/24 beginning at 11:19 AM, the nurse confirmed she was Patient #3s RN case manager. RN 6 reported she would ask Entity 2 staff if there were any medication changes at each visit and would reconcile the facilitys medication list against the hospices medication list during Patients recertification visits. The review of Entity 2s medication list for Patient #3, obtained 7/03/24, evidenced Patient had been taking Buspirone three times a day and failed to evidence Patient was currently taking Lasix. During an interview with Person 5, an employee of Entity 2, on 7/11/24 beginning at 10:41 AM, he/she reported Patient had been taking Buspirone 5 mg three times a day since 6/05/24 and Patient had not taken Lasix since 9/27/23. The medication changes were ordered by Entity 2s medical director. 5. During a home visit observation with Patient #6 on 7/03/24 beginning at 2:08 PM, Hospice Aide (HA) 1 was observed assisting Patient with a bed bath. Patient appeared to be restless and agitated throughout the visit. HA 1 reported this was Patients baseline behavior and the hospice had recently changed Patients medications after Patient had been observed hitting HA 1. The aide reported since patients medications were changed, Patient has been less physically aggressive but “;still puts up a fight.” The review of Patient #6s clinical record indicated Patient had a history of dementia with “;mood disturb[ance] and depression.” On 6/26/24, RN 15 conducted an as-needed (PRN) visit for “;aggressive and violent behaviors.” Patient had “;several violent outbursts and had to be secluded from other patients” within Entity 7, an assisted living facility. The hospice ordered Patients Depakote (a medication used to treat a variety of psychiatric disorders) be restarted and the frequency of Patients as-needed (PRN) Lorazepam (a medication used to treat anxiety) be increased from every 6 hours to every 4 hours as needed. On 6/28/24, RN 15 conducted a skilled nurse visit and noted Patient was “;agitated.” The nurse documented she “;confirmed with nursing staff that all medications have been given,” however the record failed to evidence the nurse reconciled the hospice medication list against Entity 7s medication list. On 6/29/24, Patient had a fall with injury. The hospice did not conduct a visit after facility staff declined. RN 16 conducted Patient’s next skilled nurse visit on 07/06/24 and failed to document she had reconciled Patients medications. The review of Entity 7s medication list for Patient #6, obtained 7/08/24, failed to evidence an active order for Depakote. The list also indicated Patients as-needed Lorazepam was ordered to be given every 6 hours. During an interview with Person 9, an employee of Entity 7, on 7/08/24 beginning at 1:07 PM, he/she reported Patients Depakote had been discontinued on 5/08/24 and Patient did not have an active order. Person 9 confirmed Patients as-needed Lorazepam was ordered to be given every 6 hours. During an interview with RN 15 on 7/08/24 beginning at 3:04 PM, the nurse confirmed she was Patients RN case manager. The nurse reported she reconciled the hospice medication list against the facilitys medication list “;weekly” to ensure there were no discrepancies, as she had observed instances of hospice medication orders not being entered into the facilitys medical record, and Patient would not receive the medications. RN 15 reported she had last reconciled Patients medications the week of 6/23/24 – 6/29/24. The nurse reported Patient had some falls “;due to worsening mental status” and had been more agitated, so on 6/26/24 the hospice had restarted Patients Depakote and increased Patients Lorazepam. RN 15 reported during her visit on 6/28/24, a nurse at Entity 7 had shown her Patients medication bottles and Patients medication administration record. During an interview with RN 16 on 7/11/24 beginning at 8:29 PM, she reported during skilled nurse visits performed at an assisted living facility, she would compare the hospice agency’s medication list against the facility’s medication list to ensure accuracy. RN 16 reported when she conducted Patient #6’s visit on 7/06/24, she was unable to review the facility’s medication list as there was no nurse available. RN 16 reported she would generally notify the agency’s “branch management” when she was unable to reconcile medications during a visit, so the RN case manager could follow up at the next nursing visit. RN 16 reported she did not notify the case manager nor anyone else at the agency that she was unable to reconcile Patient’s medications. The nurse reported Entity 7’s staff had reported Patient had been agitated, however the nurse did not observe any agitation during the visit. 1. The Medication Management policy, effective 4/27/20, indicated “;A Medication Profile is maintained for every client and includes a listing of the current medication orders for each client... includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements...” 2. The Medication Profile policy, effective 4/29/21, indicated “;A client-specific medication profile is maintained for each client and reviewed, at a minimum, every fifteen days... The clients medication profile review includes, but is not limited to... determining accuracy and completeness of the profile...” 3. The review of Patient #5s clinical record included a list of Patients current medications. A review of Patient #5s assisted living facility medication list included Melatonin (a medication used to treat insomnia) at bedtime, Glycerin adult suppository (a medication used to treat constipation) once per day as needed, and Tramadol (a medication used to treat pain) every 6 hours as needed. The agency medication list failed to include Melatonin, Glycerin adult suppositories, or Tramadol. On 7/05/24 at 1:45 PM during a home visit observation, both facility staff and RN 7 indicated the assisted facility was responsible for administering medications to Patient #5. During an interview with RN 7 on 7/11/24 beginning at 12:01 PM, the nurse indicated she was Patient #5s RN case manager. RN 7 reported she had checked the agencys medication list against the facility medication list earlier that day and had found that . RN 7 further relayed she had last compared the medication lists against each other approximately 6 weeks prior.”

“Based on record review and interview, the hospice agency failed to ensure a bereavement assessment was completed for the patients family for 1 of 5 patients reviewed residing in an Assisted Living Facility (Patient #5). Findings include: 1. The Comprehensive Assessment – Content policy, effective 4/27/2, indicated “;The comprehensive assessment of the client consists of... an initial assessment of the bereavement needs of the clients family and other involved individuals...” 2. Review of Patient #5s clinical record indicated an election date of 2/15/24 and failed to include an initial assessment of the bereavement needs of the patients family. 3. During an interview on 7/12/24 at 10:44 AM, RN 11 indicated when she does a bereavement assessment, she asks the family questions and pulls up the questionnaire and answers it accordingly. RN 11 relayed she could not see far enough back in the patients clinical record to determine whether a bereavement assessment had been documented. 4. On 7/12/24 at 2:00 PM, the Alternate Administrator relayed there was no initial bereavement assessment in Patient #5s clinical record.”

“Based on record review and interview, the hospice agency failed to include more than one data element in the comprehensive assessment that allowed for measurement of outcomes for 1 of 1 agency. Findings include: 1. The Clinical Records policy, effective 4/27/20, indicated “;Each clients clinical record includes, at a minimum... Outcome measure data elements.” 2. The Comprehensive Assessment – Client Outcome Measures policy, effective 4/27/20, indicated “;The comprehensive assessment includes data elements that allow for the measurement of client outcomes.” 3. Review of the agencys Quality Assessment and Performance Improvement (QAPI) documents included a quality indicator labeled Comprehensive Assessment Data Element – Dyspnea. The documentation failed to indicate how the data was being collected and measured. 4. During an interview on 7/16/24 at 11:42 AM, the Alternate Administrator indicated the data was collected using hospice item set (HIS) questions that populate in the comprehensive assessment. The Alternate Administrator further indicated she would have to seek clarification on whether the data was collected only at admission or during each comprehensive assessment. 5. During an interview on 7/16/24 at 1:18 PM, Corporate Person 2, when asked if there were any other data elements being used, indicated dyspnea was the data element that the agency chose to focus on.”

“Based on record review and interview, the hospice interdisciplinary group (IDG) failed to establish an individualized written plan of care which addressed all patient needs for 1 of 1 active patient records reviewed with a patient-reported history of suicidal ideation and suicide attempt (Patient #14), 1 of 1 discharge patient record reviewed with wounds (Patient #24), and 1 of 1 discharge patient record reviewed with a urinary catheter (Patient #19). 2. The agency policy “;Nursing Services” indicated Registered nurses who are designated as the RN Case Manager are responsible for coordinating and implementing the clients plan of care. 3. The agency policy “;Plan of Care-Content” indicated the plan of care includes but is not limited to drugs and treatments, medical supplies, equipment and appliances necessary to meet the needs of the client. 6. Patient #24s clinical record included a start of care (SOC) on 12/13/23 and included a plan of care (POC) for benefit period 12/13/23 to 3/11/24. The POC failed to include orders for wound care. During an interview on 7/16/24 beginning at 3:29 PM, RN 10 relayed the POC is initiated by the start of care RN and the RN case manager is responsible for updates to the POC. During an interview on 7/16/24 beginning at 1:14 PM, the Alternate Administrator relayed the POC for Patient #24 was missing wound care orders. 3. Review of Patient #19s clinical record included a POC which indicated the patient had a suprapubic catheter. The POC failed to include orders for catheter irrigation or flushing and failed to include orders for catheter insertion. During an interview on 7/2/24 at 2:38 PM, RN 1 indicated she had flushed Patient #19s suprapubic catheter on 5/21/24 and had attempted to change but could not remember the date she attempted to change it. During an interview on 7/09/24 at 1:43 PM, the Branch Director for the Lafayette Branch indicated there were no orders for the attempted suprapubic catheter insertion on 5/26/24. Findings include: 1. The review of facility policy #HOS.114 titled “;Suicide,” dated 4/27/20, indicated “;suicide risk factors” were included in the comprehensive assessment of each patient. When the IDG determined a patient was a possible suicide risk, a hospice clinician was to conduct additional screening, which including asking if the patient had thoughts about killing him/herself and if the patient had a plan on how to kill him/herself. If the patient answered “;yes” to any of the additional screening questions, the patient was to be considered “;a high risk for a suicide attempt and further action is warranted.” If the clinician felt there was “;no immediate danger,” interventions the clinician could include to address the patients suicide risk included but were not limited to “;... enlist the support of the clients family, caregivers, and significant others to engage the client and actively listen to his/her expressed concerns ... suggest a suicide watch until the crisis subsides.” 2. The review of Patient #14s record indicated Patient elected hospice benefits on 6/16/24 with a terminal diagnosis of Amyotrophic Lateral Sclerosis (ALS, a progressive neurological disorder). The hospice record included historical medical records from Patients visits to Entity 5, a doctors office. Entity 5s records indicated on 2/15/24, Patient reported suicidal thoughts to the entitys staff. Patient had a plan of how to kill himself/herself but did not currently intend to commit suicide. Patient reported if his/her ALS symptoms worsened, then he/she “;may” commit suicide. Patient was upset about “;how much [he/she] drools and needs [a] feeding tube.” Registered Nurse (RN) 4 conducted an admission comprehensive assessment on 6/16/24. The assessment indicated Patient was alert, oriented, and had a history of suicidal ideation reported to Entity 5 staff. The record failed to evidence RN 4 assessed Patients current suicide risk. The record included a plan of care for the initial benefit period of 6/16/24 – 9/13/24 which failed to evidence interventions that addressed Patients suicidal ideation. The record included a Clinical Coordination Note, documented on 6/26/24 by RN 6, which indicated Patient was found by staff of Entity 4, a skilled nursing facility, with a trash bag tied around his/her neck. Patient had told Entity 4 staff that he/she was “;trying to hurt” him/herself. Patient was sent to a local hospital, where he/she was admitted, and was discharged from the hospice agency. Patient was re-admitted to the hospice agency on 7/09/24 after discharge from the hospital. A new plan of care was created by the IDG which failed to evidence interventions that addressed Patients suicide risk. During an interview with RN 3 on 7/16/24 beginning at 9:14 AM, she reported she was Patient #14s RN case manager from admission until 6/21/24, at which time Patient was transferred to Entity 4 and RN 6 took over as nurse case manager. RN 3 reported she was aware of Patients history of suicidal ideation. The nurse was unsure what interventions were included in Patients plan of care to address Patients suicide risk.”

“Based on record review and interview, the hospice agency failed to ensure the primary caregiver was trained and/or educated on wound care orders for 1 of 1 discharged record reviewed with wounds (Patient #24). Findings include: 1. The agency policy “;Nursing Services” indicated Registered nurses who are designated as the RN Case Manager are responsible for coordinating and implementing the clients plan of care and the hospice shall ensure that the nursing needs of the client are met as identified in the clients initial assessment. 2. The agency policy “;Coordination of Services” indicated coordination of services and continuity of care is facilitated by established formal and informal communication mechanisms between all disciplines providing care. These communication mechanisms include but are not limited to family meetings as appropriate. 3. Patient #24s clinical record included physician orders for wound care to the left hip wound to be completed every 3 days and as needed for soilage effective 12/18/23. The clinical record failed to include documentation of education to the caregiver for Patient #24 on how to provide wound care when hospice staff was not present. 4. During an interview on 7/15/24 beginning at 3:29 PM, RN 10 relayed they should have documented the wound care education given to Person 6 in the skilled nurse visit note. 5. During an interview on 7/15/24 beginning at 4:21 PM, the Administrator relayed the hospice agency is responsible for wound care and education and this should have been documented in the narrative section of the skilled nurse visit note. 6. During an interview on 7/16/24 beginning at 10:14 AM, the Alternate Administrator relayed the hospice nurse is responsible for wound care and should have educated the family/caregiver on how to provide wound care as needed.”

“Based on record review and interview, the hospice agency failed to ensure the patients problems and goals were included on the plan of care (POC) for 1 of 1 discharged patient records reviewed with wounds (Patient #24). Findings include: 1. The agency policy “;Plan of Care-Content” indicated the plan of care reflects client goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments and the plan of care includes but is not limited to measurable outcomes anticipated from implementing and coordinating the plan of care. 2. Patient #24s clinical record included a POC for the benefit period 12/13/23 to 3/11/24. The POC failed to evidence patient individual measurable goals for wounds. 3. During an interview on 7/16/24 beginning at 3:29 PM, RN 10 relayed the POC is initiated by the start of care RN and the RN case manager is responsible for updates to the POC. 4. During an interview on 7/16/24 beginning at 1:14 PM, the Alternate Administrator relayed the POC for Patient #24 does not have measurable goals and specific interventions related to wounds.”

“Based on record review and interview, the hospice interdisciplinary groups (IDG) revised plan of care (POC) failed to note the patients progress towards outcomes and goals for 1 of 4 active records reviewed of patients serviced from the parent location (Patient #7). Findings include: 1. The review of Patient #7s clinical record indicated a current hospice benefit period of 6/22/24 – 9/19/24. The record indicated an IDG meeting was held on 7/03/24, during which Patients POC was revised. The plan of care failed to evidence Patients progress towards his/her outcomes and goals were evaluated by the Registered Nurse (RN) Case Manager. During an interview with RN 17 on 7/11/24 beginning at 3:01 PM, she confirmed she was Patients RN Case Manager. The nurse reported she reviewed Patients progress towards his/her goals during IDG meetings and documented Patients progress within her IDG note under the section “;Progress to goals and plan for the next 2 weeks.””

“Based on record review and interview, the agency failed to ensure hospice aide services were provided according to the plan of care for 1 of 3 active records reviewed of a patient with hospice aide services ordered and assigned to the parent location (Patient #7). Findings include: The review of Patient #7s record included a plan of care for the benefit election period 6/22/24 – 9/19/24, which indicated Patient was to receive hospice aide services. The hospice aide was to conduct 2 visits per week for 12 weeks. The record indicated Patient received only 1 hospice aide visit the week of 6/23/24 – 6/29/24 and failed to evidence documentation of a reason the second visit was not conducted. During an interview with Registered Nurse (RN) 17 on 7/11/24 beginning at 3:01 PM, she confirmed she was Patients RN case manager. The nurse was unsure of the reason Patient had only received 1 aide visit the week of 6/23/24 – 6/29/24. During an interview with Person 10, caregiver for Patient, on 7/11/24 beginning at 3:08 PM, he/she reported if Patients regular hospice aide was unavailable, it was hard for the agency to find a replacement. Person 10 reported when a hospice aide visit was missed, the agency would often fail to communicate to the caregiver that no aide was available to perform a visit.”

“Based on record review and interview, the hospice agency failed to ensure the on-going sharing of information, specific to the status of an as-needed (PRN) visit, between all disciplines providing care and services in all settings, for 3 of 4 active records reviewed which evidenced an after-hours PRN visit was requested by family and/or facility caregivers (Patients #2, 10, 12). Findings include: 1. The review of facility policy #HOS.034 titled “;Coordination of Services,” dated 4/27/20, indicated the interdisciplinary group (IDG) would ensure “;there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers and in all settings.” To coordinate services and ensure continuity of care, the IDG would establish “;formal and informal communication mechanisms between all disciplines providing care,” which included but was not limited to “;... telephone communications ... report to and from on-call staff ....” 2. The review of facility policy #HOS.082 titled “;Nursing Services,” dated 4/27/20, indicated the hospice would “;ensure the nursing needs of the client are met ....” 3. The review of Patient #2s clinical record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 3/27/24, which indicated Patient was to receive skilled nursing services and nursing interventions included inserting and/or changing Patients indwelling urinary catheter every 30 days and as needed (PRN) “;for catheter malfunction/dislodgement.” Patient lived with Person 11, family member and primary caregiver. The record indicated on 4/06/24 at 9:04 AM, Registered Nurse (RN) 18 documented Person 11 contacted the agencys after-hours phone line to report Patients urinary catheter had been dislodged and needed replaced. RN 18 documented she advised Person 11 that a nurse would perform a visit and then informed RN 4 of the need for a nurse visit. The record indicated on 4/06/24 at 3:10 PM, RN 19 documented Person 11 called the after-hours phone line to report a hospice visit had not yet been made nor had the caregiver been contacted by the agency with the nurses estimated time of arrival (ETA). At 3:55 PM, RN 20 documented she spoke with RN 4, who reported she had not received a visit assignment for Patient. At 5:20 PM, RN 4 documented she would “;follow-up and address this patients needs.” The record indicated RN 4 conducted a skilled nurse visit on 4/06/24 beginning at 6:50 PM. The nurse documented Patients urinary catheter “;came out earlier today” and RN 4 inserted a new urinary catheter. During an interview with Person 11 on 7/03/24 beginning at 9:48 AM, he/she reported on the morning of 4/06/24, the caregiver discovered Patients urinary catheter had come out and he/she reported this to the agencys after-hours phone line. Person 11 reported he/she was not contacted by hospice staff nor did a nurse attempt a visit, so at approximately 3:00 PM, the caregiver called the after-hours line again to check on the visit status. The caregiver reported RN 4 contacted him/her at approximately 5:00 PM and said she was just now notified of Patients visit need. Person 11 reported RN 4 arrived for the visit at approximately 6:30 PM. During an interview with RN 4 on 7/11/24 beginning at 5:40 PM, she reported the need for an after-hours visit was determined by the agencys triage nurses, who would then notify her of the visit. RN 4 would notify the patient and/or caregiver if there would be a delay of more than 1 hour in her arrival for the visit. The nurse reported on 4/06/24, she had multiple end-of-life visits to conduct, which are highest priority, when she was notified of Patient #2s PRN visit need. RN 4 reported she did inform Person 11 of the anticipated delay in her arrival. RN 4 did not recall a delay in being notified by the triage nurse of Patient #2s need for a visit. 4. The review of Patient #10s clinical record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 6/28/24, which indicated Patient was to receive skilled nursing services. The plan of care included nursing interventions, dated 5/31/24, which indicated the nurse was to “;instruct Patient/caregiver on ... when to contact Elara Caring” and “;coordinate with facility staff to ... establish methods to communicate changes to meet the Patients needs ....” Patient resided at Entity 8, an assisted living facility. The record indicated on 6/15/24 at 2:22 PM, RN 24 documented Person 13, an employee of Entity 8, contacted the agencys after-hours line to report Patient had “;redness to [his/her] right eye and [was] coughing up mucus. Mucus is mostly clear with green or yellow tinge at times.” RN 24 documented she “;inquired about familys wishes,” and Person 13 reported he/she was “;getting ready to call them to inform them [of Patients symptoms].” RN 24 documented she “;proposed since [Patient] has a nurse visit scheduled on [6/17/24] and is not currently having [shortness of breath] or discomfort or complaints, that if [Patients] family does not want a nurse visit, and [Patient] had no changes,” then no PRN visit would be conducted, and Patient would be assessed by the hospice nurse at the scheduled visit on 6/17/24. If Patients family wanted Patient to be seen during the weekend, a PRN visit would be conducted. RN 24 documented Person 13 agreed and was to call back with the familys decision. The record indicated on 6/15/24 at 2:41 PM, RN 24 documented Person 13 called the agencys after-hours line to report he/she spoke with Patients family, informed them of the symptoms observed, and Patients family was requesting a PRN visit be completed that weekend. Patients family was concerned Patient may have a contagious illness and had reported a family member was scheduled to move in with Patient. The message was sent to RN 8 at 2:54 PM. The record included a “;Missed Visit” coordination note, dated 6/17/24 and documented by RN 8, which indicated a PRN nursing visit was missed on 6/15/24. The nurse documented Entity 8s staff “;did not advise Patient needed a visit,” and Person 15s, Patients family member, concern was related to the family members “;risk of [catching] something from” Patient, as Person 15 had an upcoming medical procedure. RN 25 documented she advised Person 15 to “;wear a mask when at [Entity 9].” The record indicated on 6/16/24 at 1:46 PM, RN 25 documented Person 13 called the agencys after-hours line to follow-up on the “;status” of the visit requested 6/15/24. Person 13 reported he/she had called on 6/15/24 “;to request a visit from hospice to due to an overall change and increased cough [,] congestion [,] and redness to [Patients] right eye,” yet no visit had been made by the hospice. Person 13 reported Person 15, Patients family member, “;also wanted to know [the] status of [the hospices] visit to assess Patient.” The message was sent to RN 8, and she responded she would “;follow-up and address this patients needs” on 6/16/24 at 2:05 PM. The record indicated on 6/16/24 at 2:37 PM, RN 26 documented Person 13 called the agencys after-hours line to report he/she had spoken with RN 8 and Patients family. Person 13 reported a PRN visit was no longer needed, as Patients family had agreed to Patient waiting to be seen by the hospice nurse at his/her scheduled nurse visit on 6/17/27. The record indicated RN 10 conducted the scheduled nursing visit on 6/17/24, during which an antibiotic ointment was ordered for an eye infection and nebulizer treatments were ordered for “;congestion.” During an interview with RN 10 on 7/15/24 beginning at 5:30 PM, she reported she was notified of the visit request on 6/15/24 and contacted Person 15. The family member was reportedly only concerned if Patients symptoms were contagious. The nurse informed Person 15 that she could conduct a visit, but would be unable to say if Patient was contagious or not, and recommended Person 15 wear a mask, as the family member had an upcoming medical procedure. RN 10 stated Person 15 declined the need for a nurse to assess Patient. The nurse stated Person 13 called the after-hours line again on 6/16/24 after he/she saw that no visit had been performed by hospice. RN 10 then informed the facility staff of her discussion with Person 15, and the facility staff agreed to wait for a nurse visit until 6/17/24. RN 10 stated she asked Person 13 to call the hospice after-hours line to report a PRN visit was no longer needed. During an interview with Person 14, an employee of Entity 8, on 7/16/24 beginning at 2:38 PM, he/she reported Person 13 was not available for interview. Person 14 reported per the Entitys records, Person 13 had contacted the hospice agency to request a visit on 6/15/24 for redness to Patients eye. Person 13 contacted the hospice agency again on 6/16/24 to check on the visit status, as hospice had not yet come. The facility staff documented RN 10 reported she spoke with Person 15, who declined the need for a PRN visit. During an interview with Person 15 on 7/16/24 beginning at 2:25 PM, he/she recalled the hospice had been called by Entity 8 staff in June 2024 regarding a concern for an eye infection. Person 15 could not recall if he/she was contacted by the hospice staff or when a nurse visit was conducted. 5. The review of Patient #12s clinical record included a “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report,” dated 7/05/24, which indicated Patient was to receive skilled nursing services. The plan of care included nursing interventions, dated 11/27/23, which indicated the nurse was to “;instruct patient/caregiver on causes of constipation ... instruct patient/caregiver regarding medications (dosage/route/frequency) used for prevention and treatment of constipation ... assess Patients pain level and instruct Patient/caregiver to notify hospice nurse of pain that exceeds Patients comfort level/goal and/or ineffective pain management ....” The record indicated on 5/26/24 at 2:46 PM, After-Hours Triage Supervisor 1 documented Person 12, family member and caregiver to Patient, contacted the agencys after-hours phone line to report Patient #12 had abdominal and back pain, was vomiting, and had not had a bowel movement in 4 days. The caregiver reported he/she had attempted to give Patient a rectal suppository, however it “;fell out” after 1 hour “;with no stool.” Person 12 wanted to know if he/she could administer an enema. After-Hours Triage Supervisor 1 documented she advised Person 12 to administer an enema and call the hospice back “;if not effective and [Patient was] still having pain so we can send out a nurse to see [Patient].” The record indicated on 5/26/24 at 7:36 PM, RN 21 documented Person 12 contacted the agency a second time to report Patient had still not had a bowel movement, his/her abdomen was distended, and Patient was complaining of abdominal pain and nausea. Patient was “;laying on [the] bathroom floor with a blanket.” Patient had fallen and Person 12 was unsure if Patients pain was related to the fall or constipation. The record indicated at 7:54 PM, a message was sent to RN 22 and at 7:59 PM, RN 22 responded she would “;follow-up and address this patients needs.” The record indicated on 5/26/24 at 8:04 PM, RN 23 documented RN 22 reported to the after-hours triage staff that the message she received regarding Patient was “;unclear if a visit was needed.” RN 23 contacted After-Hours Triage Supervisor 1, who advised no visit was needed unless Patients caregivers called the after-hours line and requested a visit after an enema was administered. RN 23 documented she updated RN 22. The record indicated on 5/26/24 at 10:01 PM, RN 23 documented Person 12 contacted the agency a third time “;for visit request for bowels and [obtain the nurses] ETA.” RN 23 contacted RN 22, who then headed to Patients home to conduct a visit. The record included a “;Client Coordination Note,” dated 5/27/24 and documented by RN 22, which indicated the nurse had documented her visit with Patient on paper, however the record failed to evidence the visit note. During an interview with RN 22 on 7/15/24 beginning at 4:38 PM, the nurse reported the agencys after-hours triage nurses were responsible for evaluating calls from patients and caregivers to determine if a visit was needed. The after-hours triage nurses would then notify RN 22 when a visit was needed. The nurse reported on 5/26/24, the after-hours triage nurse had initially reported Person 12 was unsure if a visit was needed, and Person 12 had called the after-hours phone line “;more than once,” however RN 22 was unsure how many times the caregiver had called nor what the caregiver had reported during the calls. RN 22 stated once the after-hours triage nurses determined a visit was needed, RN 22 was notified and conducted a visit.”

“Based on observation, record review, and interview, the hospice agency failed to follow its own policies and procedures and accepted standards of practice related to infection control for 5 of 6 patients with home visit observations (Patient #1, #2, #3, #5, and #6). Findings include: 5. During a home visit observation with Patient #1 on 7/02/24 beginning at 5:08 PM, Registered Nurse (RN) 1 was observed performing a skilled nurse visit. The nurse performed hand hygiene by washing her hands on 2 occasions during the visit. During the hand washings, RN 1 scrubbed her hands under running water for 12 seconds and 7 seconds, respectively. On 1 occasion, RN 1 failed to perform hand hygiene prior to entering her nursing bag with dirty hands. After using an automatic blood pressure cuff, thermometer, and oxygen saturation (SpO2) probe with Patient #1, the nurse cleaned the equipment with an alcohol pad and immediately returned the still-wet equipment to the nursing bag, failing to allow it to dry. During an interview with RN 1 on 7/02/24 beginning at 5:59 PM, the nurse reported she washed her hands for the duration of the “;Happy Birthday” song and also knew how many “;motions” it took to wash all parts of her hands. RN 1 reported the alcohol would “;evaporate quickly” from the equipment. 6. During a home visit observation with Patient #2 on 7/03/24 beginning at 8:27 AM, RN 2 was observed performing a skilled nurse visit. During the visit, the nurse failed to perform hand hygiene in between glove changes on 2 occasions. For 1 of these occasions, RN 2 had unsuccessfully attempted to insert a Foley catheter. The nurse threw away her used catheter insertion supplies, removed her gloves, obtained new catheter insertion supplies, then performed hand hygiene. When inserting the Foley catheter, RN 2 used sterile gloves which had been stored without the outer plastic packing which ensured the gloves remained sterile. RN 2 was also observed using hand sanitizer on a paper towel to disinfect reusable vital sign equipment. During an interview with RN 2 on 7/03/24 beginning at 9:31 AM, she reported hand hygiene should be performed after removing dirty gloves. The nurse reported the sterile gloves were delivered and stored to Patients home without the outer plastic packaging. RN 2 also reported she disinfected her reusable equipment with hand sanitizer on a paper towel. 7. During a home visit observation with Patient #3 on 7/03/24 beginning at 2:08 PM, Hospice Aide (HA) 1 was observed assisting Patient #3 with a shower at Entity 6, a skilled nursing facility. The aide performed hand hygiene by washing her hands on 3 occasions during the visit. During 2 of the hand washings, HA 1 scrubbed her hands for 13 seconds and 10 seconds, respectively. The aide placed her supply bag on the shower floor without a barrier between the floor and the bag. HA 1 could not find Patients hairbrush, and obtained a hairbrush stored at Entity 6s nurse station. The aide was observed removing another patients hair from the brush prior to using it on Patient #3. During an interview with HA 1 on 7/03/24 beginning at 3:31 PM, she reported she washed her hands for the duration of the “;Happy Birthday” song. 9. During a home visit observation with Patient #6 on 7/08/24 beginning at 9:42 AM, HA 2 was observed assisting Patient with a bed bath at Entity 7, an assisted-living facility. At the beginning of the visit, the aide placed her supply bag directly on Patients bedroom floor without a barrier between the floor and the bag. During the visit, HA 2 failed to perform hand hygiene in between glove changes on 3 occasions. During an interview with HA 2 on 7/08/24 beginning at 10:50 AM, she reported hand hygiene should be performed between glove changes. 10. During an interview with Person 5, caregiver for Patient #19, on 7/10/24 beginning at 11:30 AM, he/she reported when RN 1 came to Patients home on 5/20/24, she asked where Patients supply of sterile water was stored, and Person 5 informed the nurse there was no supply of sterile water. Person 5 reported he/she stayed at Patients bedside while RN 1 went to the kitchen. When the nurse returned to Patients bedside, she had a canning jar filled with a clear solution and used the solution to irrigate Patients catheter. The caregiver reported during a subsequent visit, RN 1 told Person 5 she had filled the canning jar with sterile saline from syringes, however Person 5 reported he/she had not heard the nurse opening any packaging that day while in the kitchen. Person 5 reported he/she then reviewed camera footage from an in-home security camera which overlooked Patients kitchen and observed RN 1 filling the canning jar with “;well water” from Patients sink. The nurse then took the fluid-filled jar to Patients bedside. Person 5 reported he/she was present for RN 5s nurse visit on 5/26/24. When the nurse removed Patients suprapubic catheter, the caregiver observed only a few milliliters of “;foggy” water was removed from the balloon and stated he/she could tell the balloon had been “;punctured.” 11. During an interview with Administrator and Alternate Administrator on 7/08/24 beginning at 4:35 PM, Administrator reported staff should wash their hands for 15 – 20 seconds or the duration of singing the “;Happy Birthday” song twice, and hands should be scrubbed outside of running water. Administrator reported staff should perform hand hygiene in between changing gloves and prior to entering their nursing or supply bag. When staff were disinfecting reusable equipment, Administrator reported staff should use either Sani-wipes or alcohol pads to disinfect and should allow the disinfectant to dry prior to returning the equipment to the nursing bag. Administrator reported a barrier should be placed between the nursing or supply bag and the home surface. 1. The Infection Control Plan policy, effective 3/18/24, indicated “;Hand hygiene must be performed... Prior to direct contact with any patient... Prior to donning sterile or non-sterile gloves... After removing gloves... Hand hygiene is performed at a sink with soap and water... Wet hands with warm water and apply to hands enough soap to cover the front and back of your hands and in between fingers... Rub hands together vigorously for at least 20 seconds, covering all surfaces of hands and fingers thoroughly... Rinse with water.” 2. The Clinician Bag/ Box Technique policy, effective 12/04/19, indicated “;The inside of the bag and its contents are considered clean... All items removed from the clinician bag should be cleansed with a disinfectant ... before returning to the bag... When in a clients home, place a disposable protective barrier on a clean and dry surface, then place the bag on the barrier. Never place the bag on the floor.” 3. The Care of the Suprapubic Catheter policy, effective 12/14/19, indicated a sterile container should be used to hold the irrigation fluid that is to be drawn up. 4. The Aseptic Technique in the Home policy, effective 12/4/19, indicated “;Never use opened items or items that have questionable sterility.” 8. During a home visit observation of RN 7 providing care to Patient #5 on 7/05/24 beginning at 1:11 PM, RN 1 wiped thermometer, pulse oximeter, wrist blood pressure cuff, and stethoscope and immediately placed the items into the nursing bag. RN 7 failed to follow the manufacturer recommendations for disinfecting equipment used on patients. During an interview on 7/11/24 at 12:36 PM, RN 7 indicated she used Sani-wipes to disinfect the vital signs equipment during the home visit on 7/05/24. RN 7 initially relayed she thought the wipes had a manufacturer recommended wet time of 30 seconds to one minute but then found the package of Sani-wipes in her car and relayed the manufacturer recommended wet time was two minutes. 10. Review of Patient #19s clinical record included a coordination note that indicated it was an addendum for a nurse visit on 5/21/24. The coordination note indicated RN 1 used a canning jar found in the patients kitchen and emptied four 10-milliliter (ml) flushes into before using a 50 ml syringe to draw up the liquid and use it to flush Patient #19s suprapubic catheter. RN 1 failed to follow hospice agency policies and procedures and accepted standards of practice for flushing a catheter. During an interview on 7/2/24 at 2:38 PM, RN 1 indicated she washed a canning jar she found in the patients kitchen and used it as a container to hold water used to flush Patient #19s catheter.”

“Based on observation, record review, and interview, the hospice Registered Nurse (RN) failed to provide infection control education, specific to the use of a catheter securement device to decrease the risk of urinary tract infection (UTI), to family members and other caregivers, for 1 of 1 home visit observation of a patient with a Foley catheter (Patient #2). Findings include: The review of Patient #2s clinical record included a plan of care (POC) for the current benefit period of 6/05/24 – 8/03/24. The POC indicated Patient had a Foley catheter (indwelling urinary catheter placed through the urethra into the bladder) and nursing interventions related to the catheter included but were not limited to “;instruct Patient/caregiver on care of indwelling urinary catheter ... instruct Patient/caregiver on [signs and symptoms] and methods to prevent urinary tract infections ....” During a home visit observation with Patient #2 on 7/03/24 beginning at 8:27 AM, RN 2 was observed performing a skilled nurse visit. Person 11, family member and primary caregiver, reported Patient had just completed a round of antibiotics to treat a UTI. During the visit, RN 2 removed Patients brief, and his/her external catheter was positioned in between the Patients buttocks. Patients catheter securement device was not in place. The securement device was observed on Patients bedside table. When the nurse performed catheter care, stool was observed on the catheter. Person 17, a caregiver for Patient, was in the room with RN 2 while she performed the visit. RN 2 asked Person 17 “;we decided we didnt like the [catheter securement device]?” Person 17 shook his/her head “;no,” stated he/she had removed the securement device on 7/02/24 but did not know why. Person 17 stated he/she could put the securement device back on if needed. During the visit, RN 2 failed to educate Patients caregivers on the importance of using the catheter securement device to prevent UTIs. During an interview with RN 2 on 7/03/24 beginning at 9:31 AM, she reported Patient usually had a catheter securement device covered by an ACE bandage to keep his/her Foley catheter secure and in place. The nurse reported she had forgotten to instruct Person 17 to put on the catheter securement device back on Patient. During an interview with Person 11 and Person 17 on 7/03/24 beginning at 9:55 AM, Person 17 reported he/she had given Patient a bed bath after RN 2s visit but had not placed the catheter securement device back on Patient. Person 11 and Person 17 reported the securement device did not seem to bother Patient and was not causing skin breakdown.”

“Based on observation, record review, and interview, the registered nurse (RN) failed to assess per hospice policy and/or accepted practices and/or failed to document an assessment for 5 of 18 active patient records reviewed (Patient #1, #2, #5, #6, and #9); the RN failed to assess wounds for 2 of 6 discharged patients (Patient #19 and #24); and the RN used tap water to flush a suprapubic catheter and failed to obtain an order to flush or insert a suprapubic catheter for 1 of 3 patients reviewed who were discharged due to death (Patient #19). 14. Patient #24s clinical record evidenced a start of care (SOC) and an initial comprehensive assessment completed by RN 9 on 12/13/23. The 12/13/23 initial comprehensive assessment visit note included documentation of a Stage IV wound to Patient #24s left lower buttock. The visit note stated the patient refused wound care and measurements. A skilled nurse (SN) visit note completed by RN 10 on 12/14/23 failed to evidence a skin assessment was performed during the SN visit and included documentation that RN 10 was not comfortable removing the wound dressing due to not having supplies in the home and wound supplies were ordered for wound care. A SN visit note completed by RN 9 on 12/15/23 evidenced RN 9 provided wound care to the left buttock wound. The SN visit note failed to include wound measurements. A SN visit note completed by RN 10 on 12/18/23 evidenced a 10 centimeter (cm) x 10 cm x 5 cm surgical wound to Patient #24s left hip. RN 10 included documentation in the SN visit note that the left hip wound was not documented during the 12/13/23 SOC initial assessment and Patient #24 reported having the left hip surgical wound for at least 3 months. RN 9 failed to assess and document all wounds during the 12/13/23 SOC initial assessment. The visit note also included documentation of the left lower buttock wound being healed. A SN visit note completed by RN 10 on 12/20/23 evidenced RN 10 provided wound care and measurements during the visit. A SN visit note completed by RN 10 on 12/26/23 evidenced RN 10 provided wound care and measurements during the visit. A SN visit note completed by RN 10 on 12/28/23 evidenced RN 10 provided wound care during the visit. During an interview on 7/15/24 beginning at 3:29 PM, RN 10 verified Patient #24 had a surgical wound to the left hip since SOC on 12/13/23. During an interview on 7/15/24 beginning at 4:21 PM, the Administrator relayed RN 9 is no longer employed by the hospice agency and would not be available for an interview during the survey. They also relayed a complete skin assessment should have been performed during the initial SOC visit. During an interview on 7/16/24 beginning at 10:14 AM, the Alternate Administrator relayed a skin assessment should be performed every nursing visit. 10. During a home visit observation of RN 7 providing care for Patient #5 on 7/05/24 at 1:11 PM, Patient #5 voiced lower back pain. RN 7 failed to perform a complete pain assessment. Review of Patient #5s clinical record included a nurse visit note from RN 7s visit on 7/05/24. The nurse visit note indicated the patient had no pain. During an interview on 7/11/24 at 12:36 PM, RN 7 relayed Patient #5 had reported back pain and that RN 7 had asked if it was upper or lower back and the patient had said lower. RN 7 indicated she asked if it was lingering pain from and earlier fall and maybe asked if the pain was all the time when RN 7 was asked whether she had asked follow up questions about Patient #5s pain. 15. Review of Patient #19s clinical record included an RN recertification note by RN 1 in which RN 1 indicated the patient was alert and oriented times two with intelligible speech; the note failed to include wound assessments for four documented wounds, three with a recorded onset of 2/15/24 and one with an onset date of 3/28/24. In a nurse visit note on 5/02/24, RN 1 indicated Patient #19s skin was pink around the catheter with no discussion of urine appearance; the note failed to include wound assessments. In a nurse visit note from 5/10/24, RN 1 indicated the patient was alert and oriented times two and that urine was clear without odor and the quantity was sufficient; the note failed to include wound assessments. A coordination note from 5/13/24 indicated a relative of the patient called the after-hours line and reported the patient was talking to people who werent there and was anxious. The relative reported they though the patient might have a UTI, and the on-call nurse obtained an order for a urine dipstick. A nurse visit note from 5/13/24 indicated RN 1 visited and reported Patient #19 was nonsensical and had developed quivering movements with the hands and torso and was reaching in the air and grabbing at things. The note indicated RN 1 educated the family regarding antibiotics and C. difficile (a bacterium that causes infection of the colon and leads to diarrhea) and that the patient needed a nap. The note failed to include an assessment of the suprapubic catheter, urine dipstick results, or wound assessment. A nurse note from 5/16/24 indicated RN 1 visited just after the patient had vomited. The note indicated the patient was back to baseline cognitively. The note failed to include a description of the appearance of the emesis, suprapubic catheter assessment, or wound assessment. A nurse note from 5/18/24 indicated RN 4 completed a PRN visit for a change in mental status where the patient was agitated and restless and Morphine, Haldol, and Ativan had been ineffective at controlling the patients symptoms. A nurse note from 5/20/24 indicated RN 1completed a nurse visit and indicated Patient #19 was alert only to self and was lethargic with hallucinations. RN 1 further indicated the suprapubic catheter was not draining and she had flushed it; the note failed to include assessment of the catheter site, the urine, or wound assessment. A coordination note added 6/01/24 indicated it was an addendum to a nurse visit on 5/21/24 for which there is no nurse visit note. The coordination note indicated RN 1 had flushed the catheter but had no pull back and indicated she had manipulated the catheter site to get urine to drain around the catheter and had contacted Physician 1 who told her it was okay to leave the catheter in place even though it wasnt draining and to let urine drain from site. The coordination note failed to include wound assessment. Orders from 5/21/24 indicate Physician 1 ordered oral Vancomycin and Oxybutynin. In a nurse visit note from 5/24/24, RN 1 indicated Patient #19 was confused and cold even with blankets and a sweatshirt in a warm house. A nurse note from 5/25/24 indicated RN 5 completed a “;By Your Side” (end of life) visit in which the caregiver reported the patient was back to baseline. The note failed to include assessment of the suprapubic catheter. A nurse note on 5/26/24 indicated RN 5 completed another “;By Your Side” visit in which she reported the catheter was not draining properly and the bag, which the caregiver reported had not been emptied in four to five days, had about 400 milliliters of dark amber urine. The note further indicated RN 5 could not find appropriate fluid to flush the catheter and that the caregiver reported RN 1 had used tap water to flush it. RN 5 attempted to insert a new catheter five times unsuccessfully and sent Patient #19 to the emergency department via ambulance after consulting with the administrator on call. A coordination note from 5/31/24 indicated the patient died that day. -Interview with Sandi - she overheard that Vanc was $1000 and knew family would not pick up. She did not f/u with caregiver or MD Second addendum added 6/1 - On 5/20, RN “knew something was different because he was leaking urine around his catheter site now.” RN “knew” cath was patent on 5/16. Pt didn’t have any syringes to check balloon, so RN left home and returned on 5/21. During this visit, RN washed out canning jar, used this to hold sterile water, flushed 40 ml, only 10 ml returned. Leaking around catheter. Belly at the cath site “appeared like a bag of fluid lying on a table.” Cath balloon had 7 mls removed, RN reinstilled 10 ml. MD ordered cath to be “left as is, pt could have diaper changes as if he voided without a cath.” -Video shows RN with tap water in container Review of a video on 7/09/24 dated 5/21/24 and provided by Person 2, a relative of Patient #19, evidenced RN rinsing out a canning jar in the patients kitchen and taking it to the patient’s bedside. The video further evidenced RN 1 returned to the kitchen with the canning jar, rinsed it, filled it partially with water from the tap and took the jar containing the tap water to the patients bedside. Person 1, an employee at Entity 1, relayed she received report from medics regarding Patient #19 the suprapubic catheter had been displaced since the previous Tuesday, the home nurses had been squeezing urine manually from the site, the home nurse had tried to reinsert the catheter but it came out of the patients penis, and prior to the catheter becoming displaced the home nurses had been irrigating the catheter with tap water or well water. Person 1 indicated there was no dressing or urinary diversion device, just a hole in the abdomen that was leaking. RN 5 indicated that during a nurse visit on 5/26/24, Patient #19s caregiver relayed the catheter wasnt draining. RN 5 relayed she asked the caregiver for sterile water or acetic acid to flush the catheter, and the caregiver indicated the other RN used water from the sink to flush the patients catheter. RN 5 indicated she attempted multiple times to insert a new suprapubic catheter, but it came out through a hole under the patients penis. Physician 1 indicated he didnt know how to answer the question when asked if it was acceptable practice to use a canning jar from the patients kitchen to hold fluid to draw up for catheter irrigation and indicated leaving a catheter in when urine was leaking around it from the site was certainly an option depending on the circumstances. During an interview on 7/2/24 at 3:56 PM the Branch Director for the Lafayette Branch indicated wounds should be assessed at least weekly by the nurse. 1. The review of agency policy #D-120 titled “;Care of Suprapubic Catheter,” dated 12/04/19, indicated a suprapubic catheter was a urinary catheter “;inserted into the bladder surgically through the abdominal wall.” Changing of the catheter could be done by nursing once the stoma site had healed. When performing catheter care, the nurse was to use a “;sterile irrigation kit with sterile bulb syringe and container for irrigation. Sterile normal saline solution.” The policy indicated the nurses documentation should include “;Condition of the stoma site. Characteristics of the urinary drainage ... Any urine specimens collected ... Teaching done and client/caregiver response. The clients tolerance of the procedure ....” 2. The review of agency policy #D-170 titled “;Intermittent Irrigation Of Indwelling Urinary Catheter,” dated 12/04/19, indicated a urinary catheter could be irrigated “;to maintain catheter patency.” Supplies to be used for open intermittent irrigation (type of catheter irrigation which breaks the seal of a closed drainage system) included “;sterile irrigation tray and set ... ordered irrigating solution ....” When performing open intermittent irrigation, “;the nurse maintains asepsis [technique to prevent the spread of germs] throughout the procedure.” The procedure for open intermittent irrigation included the tasks “;Open sterile irrigation tray and establish sterile field [designated work area that is sterile (free of germs)]. Pour required amount of sterile irrigating solution into sterile container ....” The policy indicated the nurses documentation of the procedure should include “;Urine characteristics before and after procedure. Type and amount of irrigating solution instilled. The clients tolerance of the procedure ....” 3. The review of agency policy #J-125 titled “;In Home Urine Testing,” dated 12/04/19, indicated in-home urine testing was to be performed “;when signs and symptoms of UTI [urinary tract infection] are identified.” When an in-home urine test was performed, the nurses documentation should include “;How urine was collected. Assessment of urine (color, odor, etc). Patient symptoms (pain, burning, frequency, etc). Patient tolerance to procedure. Results of urine test. Notification to physician. Orders received, if any ....” 4. The review of agency policy #HOS.027 titled “;Comprehensive Assessment – Content,” dated 4/27/20, indicated the comprehensive assessment “;identifies the physical, psychological, emotional, and spiritual needs of the client ....” The comprehensive assessment consisted of “;discipline-specific assessment tools” which addressed “;... complications and risk factors that affect care planning ... severity of symptoms ... the need for referrals and further evaluation by appropriate health professionals ....” 5. The review of agency policy #HOS.082 titled “;Nursing Services,” dated 4/27/20, indicated the hospice should “;ensure that the nursing needs of the client are met as identified in the clients initial assessment, comprehensive assessment, and updated assessments ....” Nursing services were to be provided “;in accordance with accepted standards of practice ....” The policy also indicated the RN Case Manager was “;responsible for coordinating and implementing the clients plan of care ....” 6. The review of agency policy #HOS.084 titled “;Pain and Symptom Management,” dated 4/27/20, indicated the hospice nurses pain assessment should include “;History of pain and its treatment (pharmacologic & nonpharmacological). Characteristics of the pain [including:] Intensity (measured with a standardized scale). Descriptors (e.g., burning, stabbing, aching). Pattern (constant or intermitted [sic]). Location and radiation of pain. Frequency, timing, and duration of pain. Impact of pain on availability of life (e.g., sleeping, function, appetite, mood). Precipitations of pain. Strategies and factors that reduce pain ... Client/familys goals for pain management and their satisfaction with the current level of pain control. Assessment of the availability of medications in the home ....” The policy indicated a “;0-10 pain assessment scale” (standardized scale where the patient rated his/her pain from “;0” to “;10,” with “;0” meaning no pain and “;10” meaning the worst pain) would be used for patients “;who can verbally rate pain.” The Pain Assessment in Advanced Dementia pain assessment scale (PAINAD, standardized scale where patients are assessed for pain based on the presence and degree of behaviors, including breathing, negative vocalization, facial expression, body language, and consolability) would be used for patients “;that are nonverbal.” Patients would be asked to “;identify their comfort goal rating if able.” The nurse was to re-assess the patients pain “;during every home visit, any time a client states that his/her pain level has changed ...” and would document this in the clinical record. 7. The review of agency policy #HOS.093 titled “;Physician Orders,” dated 4/27/20, indicated reasons to obtain a physician order included but were not limited to “;... care, treatment, and services ... dressing changes/wound care ... added disciplines or services or equipment to meet the needs of the client ....” 8. During a home visit observation with Patient #1 on 7/02/24 beginning at 5:08 PM, Registered Nurse (RN) 1 was observed performing a skilled nurse visit. Patient resided at Entity 8, an assisted living facility. The nurse obtained Patients blood pressure (BP) using an automatic wrist BP machine. RN 1 placed the BP machine on Patients right wrist and lowered Patients arm down, below the level of his/her heart. RN 1 failed to assess all of Patients bony prominences for the presence or absence of wounds and failed to coordinate with Entity 8 staff to identify the date of Patients last bowel movement and if there were any patient changes, including falls or new medications. During an interview with RN 1 on 7/02/24 beginning at 5:59 PM, she reported she did not position the automatic BP machine at the level of Patients heart because Patient was sleeping, and the machine may have had an error if Patient was straining to hold his/her arm up. RN 1 reported she knew prior conducting the visit that Patient did not have any falls or medication changes, as the facility staff would have notified her via text message or through the agencys after-hours line. During an interview with Administrator and Alternate Administrator on 7/08/24 beginning at 4:35 PM, Administrator reported when obtaining a blood pressure using an automatic wrist BP monitor, the nurse should position the patients wrist according to the manufacturer’s instructions, which was usually at the level of the patients heart. Administrator reported the nurse should assess the patients skin at every visit if the patients skilled nurse visit frequency was ordered to be 1 time a week. Administrator also reported during each visit, the nurse should coordinate with facility staff to determine if any changes had occurred since the last visit, including any new orders. 9. The review of Patient #2s clinical record indicated Patients terminal diagnosis was Alzheimer’s disease and Patients secondary diagnoses included but were not limited to Alpha-1-Antitrypsin Deficiency (a genetic disease which can affect the lungs and/or liver). The record indicated Patient was bedbound and had a history of his/her heels being reddened and “;boggy” (observation of the tissue feeling soft and sponge-like, which could indicate the beginning stage of a pressure ulcer or deep tissue injury). During a home visit observation with Patient #2 on 7/03/24 beginning at 8:27 AM, RN 2 was observed performing a skilled nurse visit. During the visit, RN 2 failed to assess all of Patients bony prominences, including his/her heels, for the presence or absence of wounds, and failed to assess Patients lung sounds, heart tones, and bowel sounds. After completing her assessment of Patient, the nurse spoke with Person 11, family member and primary caregiver for Patient. Person 11 queried if RN 2 assessed Patients heels, to which the nurse responded she did assess the heels and there were no skin abnormalities. During an interview with RN 2 on 7/08/24 beginning at 4:21 PM, the nurse reported she usually assessed a patients lung sounds and heart tones at each visit. RN 2 confirmed she failed to assess Patients lung sounds and heart tones during the 7/03/24 visit. During an interview with Administrator and Alternate Administrator on 7/08/24 beginning at 4:35 PM, Administrator reported the nurse should assess the patients lung sounds and heart tones at every visit if the patients skilled nurse visit frequency was ordered to be 1 time a week. 11. The review of Patient #6s clinical record indicated Patients terminal diagnosis was Chronic Obstructive Pulmonary Disease (COPD) and Patients secondary diagnoses included but were not limited to history of falling and dementia. Patient resided at Entity 7, an assisted living facility. The record indicated on 6/29/24 at 3:21 PM, RN 26 documented Person 16, an employee at Entity 7, called the agencys after-hours line to report Patient had fallen “;and was noted with an abrasion to [his/her] forehead.” RN 26 documented an as-needed (PRN) visit would be conducted. The record indicated on 6/29/24 at 3:30 PM, RN 26 “;cancelled” a message to RN 27 regarding Patient. RN 26 then “;recalled” the message at 7:30 PM. RN 8 documented at 7:40 PM she would “;follow-up and address this patients needs.” The record included a “;Missed Visit” coordination note, documented on 6/30/24 by RN 8, which indicated the PRN visit on 6/29/24 was missed after the nurse contacted Person 24 to provide an Estimated Time of Arrival (ETA), but Person 16 declined the visit. During an interview with RN 8 on 7/11/24 beginning at 9:48 AM, she reported her duties included conducting after-hours visits for patients. RN 8 indicated a patient fall would indicate the need for a PRN visit. She reported the after-hours triage nurses determined if a visit was needed then would notify RN 8 of the visit details. The nurse reported a PRN visit was not conducted with Patient on 6/29/24 because Person 16 had refused the visit. RN 8 identified Person 16 as a family member rather than employee of Entity 7. Person 16 reportedly informed RN 8 that Patient had a “;scuff mark” on his/her forehead, was “;fine,” and Person 16 had only called the after-hours line because he/she was “;required” to notify the hospice agency of the fall. The record indicated a skilled nurse visit was not conducted until 7/06/24, 7 days after Patients fall. The record included a skilled nurse visit, documented on 7/09/24 by RN 15, Patients RN Case Manager. The note indicated RN 15 spoke with Person 16 and he/she was identified as an employee of Entity 6. During an interview with Alternate Administrator on 7/11/24 beginning at 4:51 PM, she confirmed “;best practice” was for the hospice nurse to conduct a PRN visit to assess a patient who had fallen. 12. The review of Patient #8s clinical record indicated on 6/22/24, Patient had a fall with injury. Patients injuries included a skin tear to the left forearm. The record indicated skilled nursing visits were conducted on 6/24/24 and 7/01/24 but failed to evidence the nurse documented an assessment of Patients skin tear wound. During an interview with RN 17 on 7/12/24 beginning at 9:24 AM, the nurse confirmed she was Patient #8s RN case manager. The nurse reported she assessed Patients skin tear wound during her weekly visits; but she did not typically document the wound assessment unless there was anything “;abnormal” observed. 13. During an interview with Person 5, caregiver for Patient #19, on 7/10/24 beginning at 11:30 AM, he/she reported Patient had issues with his/her suprapubic catheter not draining intermittently for 3-4 weeks prior to Patient going to Entity 1. Person 5 reported Patients abdomen became distended, and the caregiver was concerned Patient was uncomfortable due to a buildup of urine. Patients suprapubic stoma would frequently leak urine from around the catheter and Person 5 had difficulty keeping Patients skin clean and dry. The caregiver reported he/she repeatedly told RN 1 of his/her concerns regarding the malfunctioning catheter. The nurse reportedly advised the caregiver to “;keep changing” Patients bedding and dressings but failed to perform any further interventions to address Patients malfunctioning catheter until 5/20/24. Person 5 reported an antibiotic had been ordered by the hospice agency, but when the caregiver went to pick up the medication from a local pharmacy, he/she was told it would cost $1000. Person 5 reported Patients family was unable to pay for the medication. When the caregiver spoke with RN 1 regarding the cost of the antibiotic, the nurse reportedly stated the medication was not covered by the agency and no alternate medication was ordered. When RN 1 came to Patients home on 5/20/24, she asked where Patients supply of sterile water was stored, and Person 5 informed the nurse there was no supply of sterile water. Person 5 reported he/she stayed at Patients bedside while RN 1 went to the kitchen. When the nurse returned to Patients bedside, she had a canning jar filled with a clear solution and used the solution to irrigate Patients catheter. The caregiver reported during a subsequent visit, RN 1 told Person 5 she had filled the canning jar with sterile saline from syringes, however Person 5 reported he/she had not heard the nurse opening any packaging that day while in the kitchen. Person 5 reported he/she then reviewed camera footage from an in-home security camera which overlooked Patients kitchen and observed RN 1 filling the canning jar with “;well water” from Patients sink. The nurse then took the fluid-filled jar to Patients bedside. Person 5 reported he/she was present for RN 5s nurse visit on 5/26/24. When the nurse removed Patients suprapubic catheter, the caregiver observed only a few milliliters of “;foggy” water was removed from the balloon and stated he/she could tell the balloon had been “;punctured.” Person 5 reported when Patient returned home from Entity 1, he/she was in severe pain, which RN 1 attributed to the multiple attempts made by the hospice and Entity 1 staff to re-insert the suprapubic catheter.”

“Based on record review, personnel file review, and interview, the hospice agency failed to ensure the hospice aide had successfully completed a competency evaluation program which included the transfer of a patient with a Hoyer mechanical lift for 1 of 1 hospice aide personnel files reviewed of an aide who performed transfer of a patient with a Hoyer lift (Hospice Aide (HA) 4), which had the potential to affect 17 active patients identified by the agency as having a Hoyer lift ordered (Patients #2, 9, 10, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38). Findings include: The review of agency policy #ED.011 titled “;Team Member On-Boarding and Orientation,” dated 11/12/20, indicated home health aides would complete “;competency testing prior to providing client care.” The review of agency policy #ED.012 titled “;Hospice Aide Competency Assessment,” dated 8/20/21, indicated tasks the hospice aide was to perform as part of the competency evaluation program included “;Safe transfer techniques and ambulation,” which was to be evaluated “;while the aide is performing the tasks with a client.” The review of HA 4s personnel file evidenced a hire date of 10/18/23. Registered Nurse (RN) 9 documented the aide completed a competency evaluation on 10/20/23 which included the task of “;Safe Transfer Techniques.” During an interview with HA 4 on 7/16/24 beginning at 1:17 PM, she reported she completed a Hoyer transfer competency check off with HA 2. The aide stated she did not perform a Hoyer competency check with a nurse. HA 4 reported she had obtained her Certified Nursing Assistant certification prior to hiring on at the hospice agency and had worked as a “;scheduler.” HA 4 reported Patient #10 required the use of a Hoyer lift for transfer. The review of Patient #10s clinical record included a plan of care (POC) for the current benefit period of 5/31/24 – 8/28/24. The POC indicated Patient required the use of a Hoyer lift for transfer. The record indicated HA 4 conducted aide visits with Patient #10 on 6/05/24, 6/12/24, 6/19/24, 6/26/24, and 7/05/24. The aide documented tasks completed during the visit included transferring Patient to and from the bed and chair. During an interview with RN 14 on 7/16/24 beginning at 11:12 AM, the nurse reported she had done “;a couple” of hospice aide competency checkoffs. RN 14 reported she did not observe a patient transfer with a Hoyer lift for all aides she had competency checked. The nurse reported whether the aide performed a transfer with a Hoyer lift as part of the competency check-off depended on if there was a hospice patient on the nurse and aides schedule at the time of the competency check who required a Hoyer lift transfer.”

“Based on observation, record review, and interview, the hospice aide (HA) failed to provide all services according to the aide care plan for 2 of 2 home visit observations conducted with a hospice aide (Hospice Aide 1, 2). Findings include: 1. The review of agency policy #HOS.047 titled “;Hospice Aide Assignments and Duties,” dated 4/27/20, indicated the hospice aide was to “;report changes in the clients medical, nursing ... needs to a registered nurse ....” 2. During a home visit observation with Patient #3 on 7/03/24 beginning at 2:08 PM, Hospice Aide (HA) 1 was observed clipping Patients nails. Hospice aide informed a facility aide that Patient had reported pain to his/her shoulder during the “;last few” aide visits. The aide also noted Patient appeared to be having pain to his/her knee. During Patients toileting and shower, the aide had to frequently redirect Patient from scratching their perineum (area between the sexual organ and anus), as it was causing Patient to bleed. The aide reported this scratching was common for Patient. The review of Patient #3s clinical record included an aide care plan, effective 7/18/23. The aide care plan included the task “;Nail Care” and indicated this included cleaning and/or filing of the nails. The aide care plan failed to evidence the aide was to clip Patients nails. During an interview with HA 1 on 7/03/24 beginning at 3:31 PM, HA 1 reported clipping of Patients nails fell under the “;Nail Care” task. The aide stated Patient had been reporting pain to his/her shoulder and knee intermittently. HA 1 stated she had not yet reported the pain to the hospice Registered Nurse (RN) case manager, nor had she reported Patients frequent perineal scratching which had caused bleeding. 3. During a home visit observation with Patient #6 on 7/08/24 beginning at 9:42 AM, HA 2 was assisting Patient with a bed bath. Patient resided at Entity 7, an assisted living facility. During the bath, Patient repeatedly stated he/she had to go to the bathroom. HA 2 told Patient he/she had a brief on, and to void in the brief if needed. The aide failed to toilet Patient and failed to perform oral care during the visit. HA 2 was also observed applying barrier cream to Patients inner buttocks and tailbone area. The review of Patients clinical record included an aide care plan, effective 7/03/24. The care plan indicated tasks the aide was to perform “;every visit” included “;assist [Patient] to toilet” and “;oral care,” which included brushing Patients teeth and applying Chapstick. The aide care plan failed to evidence the aide was to apply barrier cream to a specific area and/or wound. During an interview with HA 2 on 7/08/24 beginning at 10:50 AM, she reported Patients RN Case Manager had ordered the barrier cream shortly after HA 2 began providing services to Patient and had observed an area that was “;real pink” on Patients buttocks/tailbone area. The aide stated she typically performed Patients visit earlier in the day, and Entity 7 staff would have already toileted and performed oral care for Patient. HA 2 reported Patient was difficult to transfer on and off the toilet, as Patient could be agitated and combative, and the aide did not want Patient to be “;more agitated” during the visit. The aide stated Patient often would say he/she had to void but “;doesnt go very much.” HA 2 reported Patient had upper dentures which were already in place. The aide was unsure if the facility removed Patients dentures to clean, but the aide did not perform oral care during the visit as she was worried Patient would “;bite down” while the aide was trying to perform the task. HA 2 then stated Entity 7 staff should have already brushed Patients teeth. 4. During an interview with Administrator and Alternate Administrator on 7/08/24 beginning at 4:35 PM, Administrator stated the hospice aide should notify the RN Case Manager of a patients report of pain as soon as the aide knows that the pain is “;not controlled.” Administrator reported the aide should be performing all tasks according to the aide care plan, unless the patient and/or caregiver refused. If the patient or caregiver requested tasks not included on the aide care plan, Administrator reported the aide should notify the RN Case Manager prior to performing the task. Administrator reported the task of “;nail care” did not include clipping of the nails, and hospice aides should only clip a patients nails if they were specifically instructed to do so within the aide care plan.”

“Based on personnel review, policy review, and interview, the hospice agency failed to document an orientation which addressed the employees specific job duties for 1 of 1 administrative staff personnel file reviewed (Employee L). Findings include: The review of agency policy #ED.011 titled “;Team Member On-Boarding and Orientation,” dated 11/12/20, indicated each employee would “;participate in an orientation program specific to ... [their] roles and responsibilities.” Once orientation was completed, the employee was to “;sign the orientation checklist and a copy will be retained in the personnel record.” During an interview with Branch Director 1 on 7/01/24 at 11:16 AM, she reported Employee L had been recently elected to the role of administrator. The review of Employee Ls personnel file indicated a hire date of 11/07/22. The employees title upon hire was Branch Director. Employee L was elected administrator of the agency effective 5/23/24. The file failed to evidence documentation of Employee Ls orientation to the role of administrator. During an interview with Employee L on 6/17/24 beginning at 11:57 AM, he reported he had completed orientation to the role of administrator with Employee Q, the agencys previous administrator. Employee L reported he thought he completed an orientation checklist but was unsure.”

“Based on record review and interview, the home health agency failed to collaborate with the primary care physician (PCP) and failed to obtain physician orders for discharge for 2 of 2 live discharge records reviewed (Patient #22 and 24). Findings include: 1. The agency policy “;Discharge from Hospice Care” indicated prior to discharge, the hospice obtains a written discharge order from the hospice physician or allowed practitioner and consults with the clients attending physician or allowed practitioner, documenting his/her review of the discharge decision in the discharge note or summary and the policy also indicated if the client no longer meets the hospices eligibility requirements, the hospice nurse consults with the clients attending physician or allowed practitioner regarding the need for other health care services and obtains appropriate discharge and referral orders. 2. Patient #22s clinical record included a Plan of Care (POC) for the benefit period 2/20/24 to 4/18/24. The clinical record failed to evidence collaboration with the PCP regarding the planned discharge for achieving goals and failed to evidence a written physician order for discharge. During an interview on 7/16/24 beginning at 10:14 AM, the Alternate Administrator relayed the clinical record for Patient #22 failed to include documentation that the PCP was notified and agreed to the planned discharge and failed to evidence a written order for discharge. 3. Patient #24s clinical record included a POC for the benefit period 12/13/23 to 3/11/24. The clinical record failed to evidence any collaboration with the PCP regarding a possible discharge for cause and failed to evidence a written physician order for discharge. During an interview on 7/15/24 beginning at 3:29 PM, RN 10 relayed they did not collaborate with the PCP for Patient #24 regarding a possible discharge for cause. During an interview on 7/15/24 beginning at 4:21 PM, the Administrator relayed they were unsure if they collaborated with the PCP regarding the discharge for cause. During an interview on 7/16/24 beginning at 10:14 AM, the Alternate Administrator relayed the clinical record for Patient #24 failed to include documentation that the PCP was notified regarding the discharge for cause and failed to evidence a written order for discharge.”

“Based on observation, record review, and interview, the hospice agency failed to ensure all entries in the clinical record were correct and per hospice policy for 3 of 24 clinical records reviewed (Patient #1, #4, and #19). 3. During a home visit observation with Patient #1 on 7/02/24 beginning at 5:08 PM, Registered Nurse (RN) 1 was observed performing a skilled nurse visit. A hospice aide was not present during the visit. The review of RN 1s visit note from 7/02/24 indicated the nurse conducted “;supervisory functions” of the hospice aide during the visit, which included indicating Patient/caregiver was “;satisfied with the aide care delivered” and the aide services were meeting the Patients needs. During the visit observation, RN 1 failed to ask Patient or his/her caregivers questions about the hospice aide services provided. During an interview with Branch Director 1 on 7/11/24 beginning at 3:22 PM, she confirmed RN 1 was no longer an active employee of the agency, effective 7/05/24. Branch Director 1 reported when performing a hospice aide supervisory visit, the nurse should ask the patient and/or caregiver(s) questions regarding the care provided by the aide(s) to determine how to answer the assessments “;supervisory functions” questions. Branch Director also reported the nurse assessment should be accurate and should not include documentation of something that had not been done. 1. The Clinical Records policy, effective 4/27/20, indicated “;Entries are made in the clinical record for all services provided... in a standardized format and are... complete... Each clients clinical record includes, at a minimum... clinical notes...” 2. The Documentation Requirements policy, effective 4/27/20, indicated “;Documentation is completed by all hospice staff and volunteers whenever... client/family visits occur... Documentation must be... accurate, and timely... All documentation contains complete, factual, essential, and accurate information.” 3. Review of Patient #4s clinical record with an election date of 4/25/24 included registered nurse (RN) visit notes for 5/08/24, 5/30/24, and 6/07/24. These nurse visit notes completed by RN 12 included documentation of licensed practical nurse (LPN) supervisory visits for LPN 1. The clinical record failed to evidence LPN nurse visit notes for Patient #4 prior to 6/13/24. During an interview on 7/12/24 at 11:07 AM, RN 12 relayed that the first LPN visit for Patient #4 was on 6/13/24. RN 12 further indicated the LPN supervisory visits were entered in error. 4. Review of Patient #19s clinical record included a coordination note that indicated it was an addendum for a nurse visit on 5/21/24. The coordination note indicated RN 1 completed a nurse visit on 5/21/24. The clinical record failed to evidence a nurse visit note for 5/21/24. During an interview on 7/2/24 at beginning at 2:38, RN 1 first indicated she did not know whether she completed a nurse visit for Patient #19 on 5/21/24 and then indicated she saw him on 5/20/24 so she guessed she went back on 5/21/24.”

“Based on record review and interview, the home health agency failed to send the discharge summary to the attending physician who will be responsible for providing care after discharge for 2 of 2 live discharged clinical records reviewed (Patient #22 and 24). Findings include: 1. The agency policy “;Discharge from Hospice Care” indicated when the client is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the clients attending physician or allowed practitioner. 2. The agency policy “;Documentation Requirements” indicated documentation must be legible, grammatically correct, accurate and timely. 3. Patient #22s clinical record included a Discharge-Transfer Summary Report which evidenced a discharge date of 2/28/24. The clinical record failed to evidence documentation that the discharge summary was sent to the receiving attending physician. During an interview on 7/16/24 beginning at 10:14 AM, the Alternate Administrator relayed the clinical record for Patient #22 failed to include evidence that the Discharge Summary was sent to the primary care physician after Patient #22 was discharged for meeting goals. 4. Patient #24s clinical record included a Discharge-Transfer Summary Report which evidenced a discharge date of 12/29/23. The clinical record failed to evidence documentation that the discharge summary was sent to the receiving attending physician. During an interview on 7/16/24 beginning at 10:14 AM, the Alternate Administrator relayed the clinical record for Patient #24 failed to include evidence that the Discharge Summary was sent to the primary care physician after Patient #24 was discharged for cause.”

“Based on record review, policy review, and interview, the hospice agency failed to obtain a copy of an inpatient facilitys clinical record and discharge summary from a patients inpatient respite stay, for 1 of 1 record reviewed of a patient who had completed a respite stay (Patient #2). Findings include: 1. The review of a respite contact between the hospice agency and Entity 2, a skilled nursing facility (SNF), dated 3/18/20, indicated at the time of a patients discharge from Entity 2, the SNF was to provide the agency “;with a copy of the [facilitys] discharge summary and, if requested by Hospice, a copy of its clinical records regarding the Respite Care provided.” 2. The review of Patient #2s clinical record indicated Patient receiving respite hospice services for caregiver strain at Entity 2, a skilled nursing facility, from 6/12/24 – 6/17/24. The hospice record failed to evidence the hospice agency had obtained a copy of Entity 2s clinical record and discharge summary from Patients inpatient respite stay. During an interview with Person 11, family member and primary caregiver for Patient #2, on 7/03/24 beginning at 9:55 AM, the caregiver reported Patient had gone to Entity 2 for a 5 day respite stay on multiple occasions while on hospice services. Person 11 reported whenever Patient returned home from the inpatient stay, he/she would develop a urinary tract infection. Person 11 felt it was due to poor care provided by Entity 2s staff but reported he/she had no other option for nearby inpatient respite facilities. The caregiver reported the hospice had started to order an antibiotic prophylactically to prevent infection prior to Patient going in the SNF. 3. During an interview with Alternate Administrator on 7/15/24 beginning at 10:10 AM, she reported it was not the agencys practice to obtain records from an inpatient facility after a patients respite stay.”

“Based on record review and interview, the hospice agency failed to provide hospice training to skilled nursing facility (SNF) staff for 1 of 2 SNFs reviewed for training (Entity 4). Findings include: 1. The review of the “;Hospice Collaboration Reference Guide-Indiana” failed to include orientation and education was provided to the contracted Entity 4 regarding the hospice philosophy. 2. During an interview on 7/16/24 beginning at 3:56 PM, Person 7 from Entity 4 relayed the hospice agency has not provided any education to the staff of Entity 4. 3. During an interview on 7/16/24 beginning at 5:10 PM, the Alternate Administrator relayed the Account Executive (AE) is responsible for visiting the SNF and the AE goes to Entity 4 weekly to educate staff. 4. During an interview on 7/16/24 beginning at 5:21 PM, AE 1 relayed they provide hospice education to SNF staff and relayed that Entity 4 has not accepted their verbal offer to provide hospice education to the staff.”