Hospice of Western Kentucky

“Based on record review and interview, the facility failed to establish a complete and comprehensive emergency program in accordance with the Code of Federal Regulations (CFR) State Operations Manual (SOM), Appendix Z. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 12 on the day of survey. The findings include: Record review, of the facility’s Emergency Preparedness Plan (EPP) on 09/18/2024 at 1:15 PM, revealed the facility failed to establish and maintain a complete and comprehensive emergency program that must comply with all applicable Federal, State, and local Emergency Preparedness requirements. Interview, with the Administrator on 09/18/2024 at 1:16 PM, revealed the facility was unaware the EPP was not a complete and comprehensive emergency program. The finding was verified by the Administrator at the time of record review and the Administrator at the exit conference on 09/18/2024.”

“Based on observation, interview, record review, and policy review, the Hospice Agency failed to meet the Condition of Participation Interdisciplinary Group, Care Planning, and Coordination of Services. The agency failed to 1.) develop individualized care plans; 2.) provide appropriate symptom management; and 3.) ensure that patient care plans incorporated measurable data elements in care plan goals. This deficient practice had the potential to affect all 98 patients receiving services from the Hospice Agency. The findings include: 1. Hospice Agency failed to develop individualized care plans for three of 18 (Patient (P) 9, P13, and P14) active sampled records. (See L543) 2. Hospice Agency failed to provide appropriate symptom management for three of 18 (Patient (P) 1, P8, and P11) active sampled records. This deficient practice had the potential to affect all three patients’ quality of life. (See L546) 3. The Hospice Agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for 18 of 18 sampled patients (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, and P18) reviewed for care plan development. (See L548)”

“Based on interview, record review, and policy review, the Hospice Agency failed to meet the Condition of Participation Core Services. The agency’s Registered Nurse (RN) failed to follow acceptable nursing standards of practice. This deficient practice had the potential to cause adverse effects to this patient. The findings include: The Hospice Agency failed to ensure a physician’s order was obtained for the Registered Nurse (RN) to drain a PleurX catheter (a flexible tube that drains excess fluid from the pleural space in the chest to help with breathing care) for one of one (Patient (P) 16) sampled patients with a PleurX catheter. (Refer to L591).”

“Based on observation, record review, and interview, it was determined the facility failed to install and maintain exit signage in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 12 on the day of the survey. The findings include: 1. Record review, of the exit sign inspection log on 09/18/2024 at 12:01 PM, revealed the facility failed to visually inspect exit signage for operation of illumination monthly. Interview, on 09/18/2024 at 12:02 PM with the Maintenance Director, revealed the facility was not aware of the requirement to visually inspect exit signs monthly. 2. Observation, during the building inspection tour on 09/18/2024 at 12:45 PM, revealed the door for the A Hall Patio was not equipped with a No Exit sign. The door would likely be mistaken for an exit in the event of an emergency. Interview, on 09/18/2024 at 12:46 PM with the Maintenance Director, revealed the facility was unaware No exit signage was required on doors to the outside if they could be confused as an exit. The findings were verified by the Maintenance Director at the time of observation/record review and the Administrator at the exit conference on 09/18/2024. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4 7.10.2 Directional Signs. 7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2. 7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2. 7.10.5 Illumination of Signs. 7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode. 7.10.5.2* Continuous Illumination. 7.10.5.2.1 Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2. 7.10.5.2.2* Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system. 7.10.8.3* No Exit. 7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT 7.10.8.3.2 The NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of 3⁄8 in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign. 7.10.9 Testing and Maintenance. 7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.”

“Based on observation and interview, it was determined the facility failed to have an approved design location under the Kitchen Hood Extinguishing System in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect one (1) of two (2) smoke compartments and kitchen staff. The facility had the capacity for 13 beds with a census of 12 on the day of the survey. The findings include: Observation, during the building inspection tour on 09/18/2024 at 12:18 PM, revealed the gas-fired stove, located on the cooking line in the kitchen, was not provided with an approved method that would ensure the appliance was returned to an approved design location after it had been moved for maintenance or cleaning. Interview, on 09/18/2024 at 12:19 PM with the Maintenance Director, revealed the facility was not aware of the requirement for an approved method to ensure that appliances were returned to an approved design location after maintenance or cleaning and did not have a system in place currently. The finding was verified by the Maintenance Director at the time of observation and the Administrator at the exit conference on 09/18/2024. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.3.2.5 Cooking Facilities. 19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4. 19.3.2.5.2* Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area. 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. Actual NFPA Standard: NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, (2011) 12.1.2 Installation. 12.1.2.1 All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer’s instructions. 12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire extinguishing system. 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer’s listed design manual. 12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.”

“Based on record review and interview, it was determined the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 12 on the day of the survey. The findings include: Record review, of the facilitys fire alarm inspection reports for the 12-month period prior to the survey on 09/18/2024 at 11:47 AM, revealed the backup batteries in the fire alarm panel failed testing on 06/18/2024. The fire alarm vendor stated on the report that the facility would address the batteries and at the time of the survey there was no documentation to show the batteries were replaced. Interview, on 09/18/2024 at 11:48 AM with the Maintenance Director, revealed the facility was not aware the fire alarm batteries failed the testing on 06/18/2024. The finding was verified by the Maintenance Director at the time of record review and the Administrator at the exit conference on 09/18/2024. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.3.4 Detection, Alarm, and Communications Systems. 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.”

“Based on observations and interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 12 on the day of the survey. The findings include: Observation, during the building inspection tour on 09/18/2024 at 12:15 PM, revealed the portable fire extinguishers were inspected annually in November of 2023 and since the annual inspection extinguishers located throughout the facility were missing all monthly inspections. Interview, on 09/18/2024 at 12:16 PM with the Maintenance Director, revealed the facility was unaware the monthly inspections werent being documented. Observation, during the building inspection tour on 09/18/2024 at 12:40 PM, revealed the portable fire extinguisher located in the Janitorial Room was last inspected annually in 2020. Interview, on 09/18/2024 at 12:41 PM with the Maintenance Director, revealed the facility was unaware the fire extinguisher had not been inspected annually. The findings were verified by the Maintenance Director at the time of observations and the Administrator at the exit conference on 09/18/2024. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Actual NFPA Standard: NFPA 10 Standard for Portable Fire Extinguishers, (2010) 7.2 Inspection. 7.2.1 Frequency. 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 7.3* Maintenance. 7.3.1 Frequency. 7.3.1.1 All Fire Extinguishers. 7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. 7.3.1.1.2 Fire extinguishers shall be internally examined at intervals not exceeding those specified in Table 7.3.1.1.2.”

“Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly for each shift in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 12 on the day of the survey. The findings include: Record review, of the facility’s fire drill records for the 12-month period prior to the survey on 09/18/2024 at 11:56 AM, revealed the facility only had two (2) documented fire drills for the previous 12 months one (1) on first (1st) shift completed 09/16/2024 and one (1) on second (2nd) shift completed 02/10/2024. Interview, on 09/18/2024 at 11:57 AM with the Maintenance Director, revealed the facility was not aware the fire drills were not documented. The finding was verified by the Maintenance Director at the time of record review and the Administrator at the exit conference on 09/18/2024. Actual NFPA Standard: NFPA 101 Life Safety Code, (2012) 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.”

“Based on record review and interview, the facility failed to perform testing for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 12 on the day of the survey. Findings include: Record review, of the emergency generator maintenance logs for the 12 months prior to the survey on 09/18/2024 at 11:50 AM, revealed the facility was unable to provide documentation for weekly generator inspections for the last 12 months. Interview, on 09/18/2024 at 11:51 AM with the Maintenance Director, revealed the facility was unaware the weekly generator checks were not being documented. Record review, of the emergency generator maintenance logs for the 12 months prior to the survey on 09/18/2024 at 11:53 AM, revealed the facility was unable to provide documentation that generator was exercised under load monthly. Interview, on 09/18/2024 at 11:54 AM with the Maintenance Director, revealed the facility did not have a system to transfer the generator to facility load that he felt comfortable completing. The findings were verified by the Maintenance Director at the time of record review and the Administrator at the exit conference on 09/18/2024. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) 6.5.4 Administration (Type 2 EES). 6.5.4.1 Maintenance and Testing of Essential Electrical System. 6.5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. 6.5.4.1.1.2 Inspection and Testing. Generator sets shall be inspected and tested in accordance with 6.4.4.1.1.3. 6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, Chapter 8. Actual NFPA Standard: NFPA 110 Standard for Emergency and Standby Power Systems, (2010) 8.3 Maintenance and Operational Testing. 8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 8.3.4.1 The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8.4.1.1 If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, providing the same record as required by 8.3.4. 8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating 8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations. 8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source. 8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.”

“Based on record review and interview, the facility failed to maintain documentation of inspections on the Patient Care Related Electrical Equipment (PCREE) in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 13 beds with a census of 12 on the day of the survey. The findings include: Record review, of the PCREE testing documentation on 09/18/2024 at 12:56 PM, revealed there was no documentation for the testing of the PCREE in use throughout the facility. Interview, on 09/18/2024 at 12:57 PM the Maintenance Director, revealed the facility was not aware of the PCREE testing requirements and did not have the documentation to present at the time of the survey. The finding was verified by the Maintenance Director at the time of record review and the Administrator at the exit conference on 09/18/2024. Actual NFPA Standard: NFPA 99 Health Care Facilities Code, (2012) 3.3.137 Patient-Care-Related Electrical Equipment. Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity. 10.5.2.1 Testing Intervals. 10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. 10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. 10.5.3 Servicing and Maintenance of Equipment. 10.5.3.1 The manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer. 10.5.3.1.1 The documents specified in 10.5.3.1 shall include the following, where applicable: (1) Illustrations that show the location of controls (2) Explanation of the function of each control (3) Illustrations of proper connection to the patient or other equipment, or both (4) Step-by-step procedures for testing and proper use of the appliance (5) Safety considerations in use and servicing of the appliance (6) Precautions to be taken if the appliance is used on a patient simultaneously with other electric appliances (7) Schematics, wiring diagrams, mechanical layouts, parts lists, and other pertinent data for the appliance (8) Instructions for cleaning, disinfection, or sterilization (9) Utility supply requirements (electrical, gas, ventilation, heating, cooling, and so forth) (10) Explanation of figures, symbols, and abbreviations on the appliance (11) Technical performance specifications (12) Instructions for unpacking, inspection, installation, adjustment, and alignment (13) Preventive and corrective maintenance and repair procedures 10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. 10.5.6 Record Keeping - Patient Care Appliances. 10.5.6.1 Instruction Manuals. 10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible. 10.5.6.2* Documentation. 10.5.6.2.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 10.5.6.2.2 At a minimum, the record shall contain all of the following: (1) Date (2) Unique identification of the equipment tested (3) Indication of which items have met or have failed to meet the performance requirements of 10.5.6.2 10.5.6.3 Test Logs. A log of test results and repairs shall be maintained and kept for a period of time in accordance with a health care facility’s record retention policy. 10.5.8 Qualification and Training of Personnel. 10.5.8.1* Personnel concerned for the application or maintenance of electric appliances shall be trained on the risks associated with their use. 10.5.8.1.1 The health care facilities shall provide programs of continuing education for its personnel. 10.5.8.1.2 Continuing education programs shall include periodic review of manufacturers’ safety guidelines and usage requirements for electrosurgical units and similar appliances. 10.5.8.2 Personnel involved in the use of energy-delivering devices including, but not limited to, electrosurgical, surgical laser, and fiberoptic devices shall receive periodic training in fire suppression. 10.5.8.3 Equipment shall be serviced by qualified personnel only.”

“Based on interview, record review, and policy review, the Hospice Agency failed to ensure that medications for managing the symptoms of pain, shortness of breath, and anxiety were available in a timely manner for one of 18 (Patient (P) 8) active sampled patients out of a total sample of 23. This deficient practice had the potential to affect this patient’s quality of life. The findings include: Review of the agency’s policy dated 01/01/10 and titled, “Medications – Management” indicated, “ . . . Medications are provided on a timely basis and are available 24 hours a day and seven days a week as needed . . .” Review of P8’s “Initial Comprehensive Assessment,” dated 09/07/24 and found in P8’s Electronic Medical Record (EMR) under the “Comprehensive Assessment” tab, indicated that P8 was admitted to hospice with a primary diagnosis of chronic respiratory failure. The Registered Nurse (RN) documented that P8 rated his/her pain at a level of seven out of 10 on a scale of zero to 10, with zero indicating no pain and 10 indicating the worst pain possible; described the duration of pain as “almost always;” and described the frequency as “constant.” The RN also documented that P8’s dyspnea (shortness of breath) was moderate, occurred without exertion, and caused P8 to experience increased anxiety. Review of P8’s “Medications List,” found in P8’s EMR under the “Medications” tab, indicated that the patient was not ordered comfort medications to manage his/her symptoms until 09/09/24, two days after identifying P8’s pain, dyspnea, and anxiety. During an interview on 09/16/24 at 11:30 AM, the Quality Administrator confirmed that the comfort medications should have been ordered and received by P8 on 09/07/24 and that it should not have taken two days for the patient to receive the medications.”

“Based on observation, interview, record review, and policy review, the Hospice Agency failed to identify and address potential drug side-effects from the use of anti-hypertensive (lowers blood pressure) medications at the end-of-life for one of three (Patient (P) 4) observed skilled nursing visits. This deficient practice had the potential to cause this patient adverse effects from the use of medications without addressing the potential drug side-effects. The findings include: Review of the agency’s policy dated 01/01/10 and titled, “Medications – Management” indicated, “ . . . The Hospice Nurse provides instruction to the patient/caregiver regarding the safe administration of medications including potential side effects and expected responses and evaluates the patient’s caregiver’s ability to safely administer medications . . .” Review of P4’s “Medication List,” located in P4’s Electronic Medical Record (EMR) under the “Medications” tab, indicated that P4 was taking atenolol and olmesartan medoxomil (lowers blood pressure). There were no blood pressure parameters (a guideline of when blood pressure medications should not be given due to the risk of lowering blood pressure beyond the normal level) ordered from the physician. During a skilled nursing visit observation on 09/17/24 at 12:30 PM, P4’s caregiver (an unlicensed aide) advised Registered Nurse (RN) 1 that the patient “stood up to go into the shower and appeared to have passed out.” The caregiver further advised RN1 that he/she “always takes P4’s blood pressure before giving the medications and, if [he/she] thinks the blood pressure is too low, [he/she] will not give the medications.” The RN did not take P4’s blood pressure during the visit and did not review the caregiver’s blood pressure logs to determine if P4’s blood pressure had been decreasing, or if the blood pressure medications needed to be adjusted by the physician. During an interview on 09/17/24 at 12:55 PM, RN1 confirmed that he/she did not assess P4’s blood pressure during the visit, did not review the patient’s blood pressure logs during the visit, and did not obtain orders from the physician for parameters on when to hold the two blood pressure medications. RN1 agreed that parameters for the blood pressure medications must be obtained from the physician, and he/she needs to educate the caregivers on the new parameters of when to hold the blood pressure medications. During an interview on 09/17/24 at 4:00 PM, the Quality Administrator confirmed that RN1 needed to assess P4’s blood pressure during the visit and that parameters must be obtained for the caregivers to safely administer the blood pressure medications.”

“Based on interview, record review, and policy review, the Hospice Agency failed to develop individualized care plans for three of 18 (Patient (P) 9, P13, and P14) active sampled records out of a total sample of 23. This deficient practice had the potential to affect all three patients’ quality of life. The findings include: Review of the agency’s policy titled “Plan of Care,” dated 10/14/13, indicated, “. . . Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDT (interdisciplinary team) in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver . . .” 1. Review of P9’s “Visit Note,” dated 07/22/24, completed by the Registered Nurse (RN), and located in P9’s Electronic Medical Record (EMR) under the “Visit Notes” tab, revealed “. . . [caregiver] states patient has had some seizures recently, and states this is not uncommon, and it happens a couple times every 3 weeks . . .” Review of P9’s “Care Plan Problem Details,” dated 7/22/24 and located in P9’s EMR under the “Care Plan” tab, revealed no documentation that a care plan for seizure activity was started by the RN. 2. Review of P13’s “Visit Note,” dated 08/09/24, completed by the RN, and located in P13’s EMR under the “Visit Notes” tab, revealed “. . . [the patient is] only smoking about 3/4 of a pack a day -17 cigarettes . . .” Review of P13’s “Vital Sign Measurement #1 – Oxygen,” dated 08/09/24, completed by the RN and located in P13’s EMR under the “Assessment” tab, indicated the patient was receiving supplemental oxygen at two liters per minute. Review of P13’s “Care Plan Problem Details,” dated 08/09/24 and located in P13’s EMR under the “Care Plan” tab, revealed no documentation that a care plan for oxygen safety regarding the dangers of smoking cigarettes near a supplemental oxygen source was started by the RN. 3. Review of P14’s “Visit Note,” dated 08/09/24, completed by the RN, and located in P14’s EMR under the “Visit Notes” tab, revealed, “. . . Patient stated has episodes at night where he can’t breathe. Educated [patient] on having oxygen in the home or when he does have those episodes and needs oxygen. Oxygen ordered . . ..” Review of P14’s “Visit Note,” dated 08/26/24, completed by the RN and located in P14’s EMR under the “Visit Notes” tab, revealed, “. . . Patient has SOA [shortness of air] with exertion . . .” Review of P14’s “Nursing Summary Notes,” dated 09/07/24, completed by the RN, and located in P14’s EMR under the “Nursing Visit Notes” tab, revealed, “. . . Visible SOA at rest with increased RR (respiration rate) noted at 24 bpm . . . Patient reports DOE [dyspnea on exertion] during activities . . . The patient sleeps with the HOB [head of bed] raised 4 inches. The patient states he leans forward to breathe easier and at night has to sit upon the side of the bed to breathe better . . .” Review of P14’s “Care Plan Problem Update,” dated 09/07/24 and located in P14’s EMR under the “Care Plan” tab, revealed no documentation that a care plan for shortness of breath was started by the RN. During an interview on 09/18/24 at 12:30 PM, the Quality Administrator confirmed that the RN’s for P9, P13, and P14 did not individualize the care plans to include seizure activity, oxygen safety, and shortness of breath.”

“Based on observation, interview, record review, and policy review, the Hospice Agency failed to provide appropriate symptom management for three of 18 (Patient (P) 1, P8, and P11) active sampled records out of a total sample of 23. This deficient practice had the potential to affect all three patients’ quality of life. The findings include: Review of the agency’s policy titled, “Medications – Management,”, dated 01/01/10, indicated, “. . . Monitoring Medications: “Medications are provided on a timely basis and are available 24 hours a day and seven days a week as needed . . . Patient response to medication is monitored according to individual clinical need and actual or potential related problem . . .” 1. Review of P1’s “Care Plan Problem Interventions,” dated 09/06/24 and located in P1’s Electronic Medical Record (EMR) under the “Care Plan” tab, indicated, “ . . . Collaborate with primary MD prn (as needed) – Titrate pain medicine to control pain prn – Adjust per MD’s orders . . .” Review of P1’s “Medications List,” located in P1’s EMR under the “Medications” tab, indicated the patient was ordered Colace (stool softener) twice a day on 11/02/23 and MiraLAX once a day as needed on 11/02/23. During a skilled nursing visit observation on 09/17/24 at 8:00 AM, P1 was unable to answer questions and had severely contracted legs. The patient’s caregiver reported to Licensed Practical Nurse (LPN) 1 that the patient had been experiencing “burning pain in the feet” and “runny stools.” The caregiver also stated that he/she gives P1 MiraLAX (a laxative) once a day. There were no interventions or education provided to the caregiver to alleviate the pain or diarrhea symptoms, and the LPN did not follow-up with a phone call to the patient’s physician for medication orders. During an interview on 09/17/24 at 9:00 AM, when asked why an intervention or education for P1’s burning feet pain and diarrhea was not made during the visit, the LPN stated that he/she “thinks the patient was on Gabapentin (medication for burning feet) in the past, and the family doesn’t like to medicate the patient.” 2. Review of P8’s “Comprehensive Assessment,” dated 09/27/24 and located in P8’s EMR under the “Comprehensive Assessment” tab, revealed the patient rated his/her pain a seven out of 10 on a scale of zero to 10, with zero indicating no pain and 10 indicating the worst pain possible. There was no documentation of P8’s acceptable pain level in the pain assessment. There was no documentation indicating that the RN provided education or an intervention to P8. 3. Review of P11’s “Visit Note,” dated 08/16/24 and located in P11’s EMR under the “Visit Notes” tab, revealed “the patient has been very anxious and not happy being here at the SNF (skilled nursing facility). Staff reports giving [him/her] Ativan [anti-anxiety medication] hoping that will be effective. Visit with pt [patient], pt is sitting up in bed on [his/her] phone trying to reach someone to try and get [him/her] out of this place. Pt says [he/she] does not want to be here, [he/she] wants to go back to [the hospice house] – Discussed with patient that is not an option and that I was sorry. [Pl1] does not except that and is trying to get someone to get [him/her] out. This nurse put order back in for Dilaudid [pain medication] 4 mg [milligrams] 1 tablet q4h [every 4 hours] for pain. No other needs at this time . . .” There was no documentation indicating that the LPN provided education or an intervention to P11. During an interview on 09/17/24 at 4:30 PM, the Quality Administrator confirmed that an intervention must be attempted for any patient reported symptom and agreed that interventions were not provided for P1, P8, and P11’s symptoms.”

“Based on interview, record review, and policy review, the Hospice Agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for 18 of 18 sampled patients (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, and P18) reviewed for care plan development out of a total sample of 23. This deficient practice had the potential to affect all 98 patients receiving services from the Hospice Agency. The findings include: Review of the agency’s policy titled, “Assessments – Patient Outcome Measures,” dated 08/20/22, indicated, “. . . The comprehensive assessment includes data elements that allow for the measurement of patient outcomes. The data collected from the patient’s comprehensive assessment is used to provide individualized care planning, appropriate interventions and for the coordination of services for each patient . . .” 1. Review of P1’s “Active Care Plan Problems,” found in P1’s Electronic Medical Record (EMR) under the “Care Plan” tab, indicated the Registered Nurse (RN) started P1’s care plans on 09/11/24. The care plan problems included altered mental status, altered respiratory status, altered genitourinary status, and altered skin integrity. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 2. Review of P2’s “Active Care Plan Problems,” found in P2’s EMR under the “Care Plan” tab, indicated the RN started P2’s care plans on 08/30/24. The care plan problems included altered safety, altered cardiac circulatory functions, altered comfort, and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 3. Review of P3’s “Active Care Plan Problems,” found in P3’s EMR under the “Care Plan” tab, indicated the RN started P3’s care plans on 08/16/24. The care plan problems included altered safety, altered skin integrity, altered respiratory status, altered comfort, and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 4. Review of P4’s “Active Care Plan Problems,” found in P4’s EMR under the “Care Plan” tab, indicated the RN started P4’s care plans on 09/16/24. The care plan problems included altered safety, altered mental status, altered skin integrity, altered comfort, altered gastrointestinal status, and altered genitourinary status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 5. Review of P5’s “Active Care Plan Problems,” found in P5’s EMR under the “Care Plan” tab, indicated the RN started P5’s care plans on 08/27/24. The care plan problems included altered safety, altered skin integrity, altered comfort, and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 6. Review of P6’s “Active Care Plan Problems,” found in P6’s EMR under the “Care Plan” tab, indicated the RN started P6’s care plans on 08/29/24. The care plan problems included altered safety, altered gastrointestinal status, and altered comfort. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 7. Review of P7’s “Active Care Plan Problems,” found in P7’s EMR under the “Care Plan” tab, indicated the RN started P7’s care plans on 06/06/24. The care plan problems included altered comfort, altered safety, altered gastrointestinal status, and altered respiratory status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 8. Review of P8’s “Active Care Plan Problems,” found in P8’s EMR under the “Care Plan” tab, indicated the RN started P8’s care plans on 09/27/24. The care plan problems included altered comfort, altered skin integrity, altered gastrointestinal status, and altered respiratory status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 9. Review of P9’s “Active Care Plan Problems,” found in P9’s EMR under the “Care Plan” tab, indicated the RN started P9’s care plans on 07/22/24. The care plan problems included altered mental status, altered respiratory status, altered genitourinary status, and altered comfort. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 10. Review of P10’s “Active Care Plan Problems,” found in P10’s EMR under the “Care Plan” tab, indicated the RN started P10’s care plans on 06/26/24. The care plan problems included altered comfort and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 11. Review of P11’s “Active Care Plan Problems,” found in P11’s EMR under the “Care Plan” tab, indicated the RN started P11’s care plans on 08/16/24. The care plan problems included altered gastrointestinal status, altered comfort, and altered safety. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 12. Review of P12’s “Active Care Plan Problems,” found in P12’s EMR under the “Care Plan” tab, indicated the RN started P12’s care plans on 09/12/24. The care plan problems included altered comfort, altered safety, and alterations in respiratory status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 13. Review of P13’s “Active Care Plan Problems,” found in P13’s EMR under the “Care Plan” tab, indicated the RN started P13’s care plans on 08/08/24. The care plan problems included altered comfort, altered respiratory status, and altered skin integrity. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 14. Review of P14’s “Active Care Plan Problems,” found in P14’s EMR under the “Care Plan” tab, indicated the RN started P14’s care plans on 08/23/24. The care plan problems included altered gastrointestinal status, altered comfort, altered respiratory status, altered skin integrity, and altered cardiopulmonary status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 15. Review of P15’s “Active Care Plan Problems,” found in P15’s EMR under the “Care Plan” tab, indicated the RN started P15’s care plans on 09/04/24. The care plan problems included altered mental status, altered safety, and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 16. Review of P16’s “Active Care Plan Problems,” found in P16’s EMR under the “Care Plan” tab, indicated the RN started P16’s care plans on 09/12/24. The care plan problems included altered skin integrity, altered safety, and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 17. Review of P17’s “Active Care Plan Problems,” found in P17’s EMR under the “Care Plan” tab, indicated the RN started P17’s care plans on 09/19/24. The care plan problems included altered comfort and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 18. Review of P18’s “Active Care Plan Problems,” found in P18’s EMR under the “Care Plan” tab, indicated the RN started P18’s care plans on 08/26/24. The care plan problems included altered comfort, altered genitourinary status, and altered gastrointestinal status. The “Active Care Plan Problems” did not include measurable data elements to monitor progress toward the expected outcomes and goals. During an interview on 09/18/24 at 4:00 PM, the Quality Administrator confirmed that the RNs were not creating “Active Care Plan Problems” that were measurable and included data elements to monitor progress toward the expected outcomes and goals.”

“Based on observation, interview, and policy review, the Hospice Agency failed to ensure one of three Registered Nurses observed (Registered Nurse (RN) 1) followed standards of practice for infection control during a skilled nursing visit. This deficient practice increased the risk of cross-contamination among patients. The findings include: Review of the agency’s policy titled, “Infection Control – Bag Technique,” dated 01/01/10, indicated, “. . . Hospice nurses and home health aides are required to maintain their bags containing equipment and supplies in a clean environment at all times . . . Upon arrival at the patient’s home, the bag is placed on a clean surface utilizing newspaper, paper towels, and/or a liner as a barrier. Alternatively, the bag may be hung on a doorknob if no liner is available. 3. Hand washing supplies are retrieved from the bag if needed and hands are washed before removing other items from the bag. 4. Clean and dirty items are kept separate within the bag. 5. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag. 6. The newspaper, paper towel and/or liner are disposed of upon completion of the visit. 7. All nurses and home health aides are required to have a home care bag . . .” During a skilled nursing observation on 09/17/24 at 12:00 PM, RN1 entered P4’s home without a home care bag. The RN had the equipment needed for the visit stored in his/her pockets. RN1 removed a pulse oximeter (measures the saturation of oxygen carried in blood) and placed the device on P4’s finger. RN1 obtained the results, removed the device from P4’s finger and placed the device back into his/her pocket without disinfecting it. RN1 then removed a stethoscope from his/her pocket, listened to P4’s heart and lung sounds, and then placed the stethoscope back into his/her pocket without disinfecting it. During an interview on 09/17/24 at 12:55 PM, RN1 stated, “I clean the equipment when I get into the car.” The RN confirmed that the equipment was not disinfected after use on P4, and that a home care bag must be used during home care visits. The RN also confirmed all multi-patient use equipment must be disinfected between patient use and that placing soiled patient use equipment in his/her pockets is not the standard of practice for infection control. During an interview on 09/17/24 at 4:00 PM, the Quality Administrator confirmed that it is the agency’s policy for all clinicians to carry a home care bag containing the equipment and supplies needed for the visit, and that all multi-use patient equipment must be disinfected after patient use.”

“Based on interview, record review, and policy review, the Hospice Agency failed to ensure a physician’s order was obtained for the Registered Nurse (RN) to drain a PleurX catheter (a flexible tube that drains excess fluid from the pleural space in the chest to help with breathing) for one of one (Patient (P) 16) sampled patients with a PleurX catheter. This deficient practice had the potential to cause adverse effects to this patient. The findings include: Review of the agency’s policy titled, “Pleurx Catheters,” dated 01/01/10, indicated, “. . . PURPOSE: For symptom management of pleural effusion and malignant ascites. FREQUENCY [for draining]: As ordered by the physician . . .” Review of P16’s “Visit Note,” dated 09/13/24 and located in P16’s Electronic Medical Record (EMR) under the “Visit Notes” tab, indicated that RN2 “Arrived at the home to assess drainage on pleurx dressing . . . Patient showed this RN drainage in tubing of pleurx drain. This RN drained and re-dressed the patient’s drain using sterile technique . . .” RN2 did not document how much was drained from the catheter. Review of P16’s entire EMR revealed no documentation that a physician’s order was obtained to drain the patient’s PleurX drain, including how much and how often to drain. During an interview on 09/18/24 at 11:35 AM, RN2 confirmed that on 09/13/24 he/she “drained 200 milliliters (ml.) from the PleurX catheter and did not have a physician’s order for draining the catheter.” During an interview on 09/18/24 at 11:40 AM, the Quality Administrator confirmed that there was no physician’s order to drain P16’s PleurX catheter; and that RN2 should not have drained P16’s PleurX catheter without an order from the physician for the amount to drain and the frequency for draining.”

“Based on observation, interview, and policy review, the Hospice Agency failed to have a physical therapy (PT) consultation performed for safe transfers for one of three patients (Patient (P) 4) observed during skilled nursing visits. This deficient practice had the potential to cause injury to the patient and the patient’s caregivers. The findings include: Review of the agency’s policy titled, “Assessments – Contents of the Comprehensive Assessment,” dated 08/22/22, indicated, “. . . The comprehensive assessment identifies the physical, psychosocial, emotional and spiritual needs of the patient related to the terminal illness that must be addressed in order to promote the patient’s well-being, comfort and dignity throughout the dying process. The comprehensive assessment of the patient consists of discipline-specific assessment tools that address the following factors . . . the need for referrals and further evaluation by appropriate health professionals . . .” During a skilled nursing visit observation on 09/17/24 at 12:35 PM, P4’s caregiver (an unlicensed aide) asked Registered Nurse (RN) 1 if he/she believed the patient could safely be transferred from the bed to the wheelchair so the patient could go into the living room. The RN replied by asking the caregiver if he/she felt comfortable transferring the patient to the wheelchair. The caregiver responded, “I’m not sure, I think so.” The patient was observed lying in the bed with contractures (deformity and rigidity) to the legs. The caregivers also advised the nurse that the patient “gets very agitated when moved or touched.” During an interview on 09/17/24 at 12:55 PM, RN1 agreed that for the safety of the patient and the caregivers, the RN needs to coordinate a PT visit for P4. During an interview on 09/17/24 at 5:00 PM, the Chief Executive Officer confirmed that it was the agency’s policy to obtain a PT consult for safe transfers when patient and caregiver safety was in question.”

“Based on interview, review of employee files, and policy review, the agency failed to provide documentation of an initial orientation for each employee that addressed the employee’s specific job duties for four of six employee files (State Registered Nurse Aide (SRNA)1, Spiritual Counselor (SP), Social Worker (SW), and Educator/Registered Nurse (RN) 1) reviewed. This increased the risk of patient needs not being met when staff members were not knowledgeable of their specific job duties. The findings include: Review of the agency’s policy titled, “New Hire Orientation,” revised 11/29/18, revealed, “. . . Upon hire each new employee of Hospice and Palliative Care of Western Kentucky will complete a 3-day general orientation. Upon completion of the 3-day general orientation a more specific orientation will be individualized for each specific job title. The length and content will be based on the new employee’s knowledge and experience . . .” 1. Review of the employee file for SRNA1 failed to reveal documentation that the agency had provided orientation about the hospice philosophy upon employment. Further review of SRNA1s employee file revealed three documents titled, “HC HOSPICE AIDE – ORIENTATION CHECKLIST.” The first orientation checklist located in the employee file for SRNA1 revealed several orientation check-off items with a preceptors initial and signature dated 06/03/24. The document contained neither the employees initials nor the employees signature acknowledging the orientation. A second Hospice Aide Orientation Checklist located in the employee file for SRNA1, dated 06/26/24, revealed several check-off items and a preceptor signature. The document contained neither the employees initials nor the employees signature acknowledging the orientation. A third Hospice Aide Orientation Checklist located in the employee file for SRNA1 revealed a preceptors initials in the orientation checklist with no dates on when the items were completed, and there was no employee signature acknowledging the orientation subjects. The document contained the preceptors signature, dated 06/26/24. During an interview on 09/18/24 at 3:50 PM, the Chief Executive Officer (CEO) acknowledged the above findings and stated it was his/her expectation that all items in the orientation checklist for staff be dated and initialed by both preceptor and staff. The CEO also stated that the SRNA1s immediate supervisor should have filled in the orientation checklist and that the checklist was not completed correctly. 2. Review of the personnel files for the SP, SW, and RN1 revealed no documentation of orientation information for any of them in their employee files. During an interview on 09/18/24 at 3:50 PM, the CEO acknowledged the orientation was missing for SP, SW, and RN1. The CEO stated that a schedule of orientation was initiated for each staff member when hired, but the actual training record could not be accessed due to a recent change in the facilitys trainer.”

“Based on interviews and personnel file review, the agency failed to provide documentation of competency and skills assessments for two of six (Licensed Practical Nurse (LPN) 2 and LPN1) personnel files reviewed. This had the potential to cause patients harm due to potential nursing incompetency. The findings include: 1. Review of the personnel file for LPN2 revealed LPN2 was hired by the agency on 01/24/24. Included in the file was a document titled, “Hospice Nurse Competency Checklist.” The competency checklist was undated and unsigned. 2. Review of the personnel file for LPN1 revealed LPN1 was hired by the agency on 06/07/22. Included in the file was a document titled, “Hospice Nurse Competency Checklist.” The competency checklist was undated and unsigned. During an interview on 09/18/24 at 3:50 PM, the Chief Executive Officer (CEO) acknowledged the above findings and stated the competency checklists were in progress. The CEO agreed that the competencies were not completed or dated, and it was his/her expectation that staff competencies be documented and completed.”