Andwell Health Partners

“Based on document reviews, and interviews, the hospice failed to obtain consent from the patient or legal representative prior to disclosing medical information and delegating medication administration to Unqualified Caregiver #1 for one (1) out of ten (10) patients reviewed (Patient #2). Findings:Andwell Health Partner’s Corporate Compliance Policy, last revised 11/01/2023, states in part, “…the OIG [Office of Inspector General] identified…high risk compliance areas for hospice…Improper relinquishment of care services and to nursing homes, volunteers, and privately paid professionals…” A review of Andwell Partner’s Authorization to Use or Disclose PHI, last revised 01/03/2025 states in part, “…On admission, the patient or their legal representative may also use the Authorization to Release Healthcare Information form to authorize additional disclosures of PHI [protected health information] and a copy of the original, signed copy will be kept in the patient’s electronic medical record…Identity or description of persons (name, specific identification of the person(s), or class of persons) authorized to disclose information to…Nature of information to be disclosed must be a specific and meaningful description…. Release by Telephone: In general, no confidential patient information will be released over the telephone. Information will be provided over the telephone by professionals only in emergency situations or under conditions as stated in the permission for release of information and giving treatment…The person authorized to release this information is the Chief Clinical Officer or designee…Documentation will be made in the electronic medical record that will include the following: Name of the person releasing the information; Name and credentials of the person receiving the information, Date of disclosure, Purpose of disclosure, Information that was disclosed…” Andwell Health Partner’s Form titled “ALL programs: Pay agreement and consent form with the patient” in part states “…I give consent for Andwell to share limited information about my medical condition with the people listed below…”. A review of a document in Patient #2’s record titled “ALL programs: Pay agreement and consent form with the patient” dated 7/16/2026 and signed failed to include the name of Unqualified Paid Care Giver #1. A review of Patient #2’s medical record revealed the following entries:An entry made by Answering Service Agent #1 on 07/20/2025 at 10:17 PM indicating Unqualified Paid Care Giver #1 called Andwell Health Partners regarding Patient #2. A subsequent entry was entered by RN #1 on 7/20/2025 at 10:24 PM indicating RN #1 returned Unqualified Paid Care Giver #1’s call, and RN #1 instructed Unqualified Paid Care Giver #1 to “give comfort medications “until [Patient #2] is comfortable…” Unqualified Paid Caregiver #1 was not listed in Patient #2’s medical record as a contact. RN #1 failed to confirm whether Unqualified Paid Caregiver #1 was listed in Patient #2’s chart as an “Emergency Contact”. An entry by Answering Service Agent #2 on 8/2/2025 at 1:45 AM indicating Unqualified Paid Care Giver #1 a called Andwell Health Partners regarding Patient #2. A subsequent entry was entered by RN #1 on 7/20/2025 at 10:24 PM indicating RN #1 returned Unqualified Paid Care Giver #1’s call. The medical record revealed RN #1 instructed Unqualified Paid Caregiver #1 to “administer 1 mg Haldol w/ [with] 10 mg morphine now…repeat lorazepam/morphine dose at 2:50 if symptoms continue…” RN#1 failed to confirm and document that Unqualified Paid Caregiver #1 was listed in Patient #2’s chart as an “Emergency Contact”.”

“Based on document reviews and interviews, it was determined that the agency failed to ensure that services, by the Home Hospice Aide, were provided in accordance to orders written by the physician and the written plan of care for one (1) of twenty-one (21) records reviewed (Patient #18). Findings:The “Care Planning Process” policy, last revised 01/07/2025 states in part, “The plan of care/treatment will be based upon the physician’s orders and encompasses the equipment, supplies, and services required to meet the patient’s needs... .”On 5/27/2025 at approximately 1:45 PM, clinical records were reviewed with the Clinical Manager of Hospice Services, which indicated the following:- Patient #18 had a plan of care that required a Home Health Aide three (3) times per week from 11/21/2024 through 5/29/2025. The following scheduled home health visits were documented as missed with no reason documented: 11/29/2024; 12/11/2024;12/24/2024;12/25/2024; 12/27/2024; 12/31/2024; 1/1/2025; 1/29/2025; 1/31/2025 2/11/2025; 2/14/2025; 2/19/2025; 2/21/2025; 2/27/2025; 3/12/2025; 4/15/2025; 4/22/2025; 5/9/2025; 5/12/2025; 5/19/2025; and 5/29/2025.These findings were confirmed by the Clinical Manager of Hospice Services.”

“Based on document reviews and interviews, the hospice failed to ensure that a Registered Nurse (“RN”) was given a competency assessment to ensure they are qualified to care for patients for one (1) of ten (10) personnel files reviewed (RN #8). Findings:The “Human Resources Policy Manual”, dated 01/2021, it states in part, “The competency of all staff will be assessed at particular times during the first year of employment starting at recruitment and continuing with orientation/training and the initial employment period. Formal evaluations will take place at the end of six (6) months and annually. Assessment may take place periodically as needed. Educational activities will be based, in part, on performance improvement and documented on the annual Staff Development Plan, Staff Evaluation, or Review form.”On 05/28/2025 from 9:32 AM to 1:17 PM, ten (10) personnel files were reviewed with the Learning and Professional Development Specialist and the Chief Human Resources Director. The following was identified:- RN #8 was hired on 07/10/2023; and- As of 05/29/2025, there was no documented evidence that a competency assessment was completed.On 05/28/2025 from 9:32 AM to 1:17 PM, this finding was confirmed during the review by the Chief Human Resources Director.”

“Based on document reviews, interviews and observations, the agency failed to ensure nursing staff followed the agency’s Medication Management policy for all patients admitted between 12/01/2024 through 03/31/2025. Findings:The “Medication Management” policy, last revised 11/1/2022, states in part, “Controlled substances will be counted at the change of shift by two nurses. The oncoming and outgoing nurses will count all patient-specific controlled substances and compare the count with the amount remaining as documented on the Perpetual Medication Sheet. Both nurses will sign the Perpetual Medication Sheet. The signatures will verify and affirm that no discrepancies exist between the documented quantity remaining as designated on the Perpetual Medication Sheet and the actual count remaining in the medication drawers... .”On 5/29/2025 at approximately 10:30 AM, this review revealed the following: - The following shift to shift counts, there was only one (1) set of initials documented, rather than the two (2) sets of initials that are required: 12/28/2024, 01/06/2025, 01/14/2025, 01/15/2025, 01/15/2025, 01/19/2025, 01/19/2025, 01/26/2025, 01/26/2025, 01/29/2025, 01/29/2025, 01/31/2025, 02/03/2025, 02/11/2025, 02/15/2025, 02/19/2025, 02/22/2025, 02/22/2025, 02/24/2025, 02/28/2025, and 03/06/2025; a total of twenty-one (21) missed shift counts. - The following shift to shift counts, there was no time documented: 01/15/2025, 02/15/2025 and 02/19/2025.On 05/28/2025 at 1:00 PM, the Director of Hospice Services confirmed the above findings. On 05/29/2025 at approximately 8:40 AM, the Chief Clinical Officer confirmed the policy was not followed.”

“Based on document reviews, interviews and observations, the hospital failed to ensure nursing staff followed the hospital’s Medication Management policy for one (1) of two (2) registered nurses observed. (RN #1). Findings:The agency’s “Medication Management” policy, last revised 11/1/2022, states in part, “The components of the medication assessment/drug regimen review to determine patient/family/caregiver knowledge and skill related to medication administration may include but are not limited to ... . Safeguards for handling medications to prevent microbial contamination.”On 5/28/2025 at 8:55 AM, surveyors observed Registered Nurse (“RN”) #1 entering the medication room to prepare medications . This observation revealed the following:- RN #1 was observed to be carrying three (3) unwrapped prefilled syringes in the right scrub jacket pocket .On 5/28/2025 at 9:30 AM, the Director of Hospice Services confirmed that RN #1 was carrying prefilled syringes in the right pocket on her scrub jacket . On 5/29/2025 at 8:40 AM, Chief Clinical Officer, confirmed that carrying unwrapped syringes in a scrub jacket pocket was not “safeguarding medications to prevent microbial contamination”.”

“Based on Observations the facility failed to ensure doors at the means of egress meet the requirement of NFPA 101 life safety code 2012 edition 7.2.1.6.1 for requirements for delayed egress in 2 of 3 smoke compartments. Findings: On 05.27.2025, between 11:30 AM and 2:30 PM, the surveyor with the Manager of Facilities and Assistant Manager of Facilities present, observed the following: Exit door outside patient room 13 and patient room 6 were equipped with delayed egress and not signed. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTIL ALARM SOUNDSDOOR CAN BE OPENED IN 15 SECONDS. These findings were verified by the Manager of Facilities and Assistant Manager of Facilities at the time of the observation.”

“Based on observation and interview, the facility failed to ensure that the commercial cooking equipment was in accordance to NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 10.2.2. NFPA 101, The Life Safety Code, sections 19.3.2.5.1 and 9.2.3 Finding:On 05/27/2025, between 11:30 AM and 2:30 PM, a surveyor, with the Manager of Facilities and the Assistant Manager of Facilities present, observed the following:1. There was no placard posted by the portable class K extinguisher, stating that the fire protection system shall be activated prior to using the fire extinguisher. This deficient practice could affect all occupants including residents, employees, and visitors to the facility. The surveyor confirmed this finding with the Manager of Facilities and the Assistant Manager of Facilities at the time of the observation and record review.”

“Based on observation, interview, and documentation review the long-term care facility failed to ensure that the fire alarm was maintained in accordance with NFPA 101, Life Safety Code, 2012 Edition, Sections 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72Finding:Based on interview and observation on 05/27/2025 between hours of 11:30 AM and 2:30 PM. this surveyor accompanied with the Manager of Facilities and Assistant Manager of Facilities observed the following:1. The facility had no documentation of the last known fire alarm system sensitivity testing, in the past 5 years. The surveyor confirmed this finding the Manager of Facilities and the Assistant Manager of Facilities at the time of the observation.”

“Based on observation and interview, the long-term care facility failed to install the water-based fire protection system throughout the premises in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, Sections NFPA 13: 8.15.1.2.18.2 as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.5. Finding: On 05.27.2025, between 11:30 AM and 2:30 PM, the surveyor with the Manager of Facilities and Assistant Manager of Facilities present observed the following:1. The exit door outside patient room 6 had a combustible overhang measuring 54”. Combustible soffits, eaves, overhangs, and decorative frame elements shall not exceed 4 ft 0 in. or shall be sprinkled This finding was verified by the Manager of Facilities and Assistant Manager of Facilities at the time of the observation.”

“Based on observations, interview and document review, the facility failed to ensure that Sprinkler System was inspected and maintained in 2 of 3 smoke compartments in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficiency does not meet the minimum requirements of maintaining a sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems, 2011 edition, sections 4.3.1 and 5.2.1.1.1 Finding: On 05/27/2025, between 11:30 AM and 2:30 PM a surveyor with the Manager of Facilities and the Assistant Manager of Facilities present observed the following: 1. During the walk-through sprinkler heads were observed covered with dust and debris. These sprinkler head locations include, but are not limited to:a. Room 8, over the bedb. Room 2, over the bed This finding was verified by the Manager of Facilities and the Assistant Manager of Facilities at the time of the observation.”

“Based on interview and documentation review, the long-term care facility failed to conduct an annual fire door inspection that ensures that all fire rated doors and hardware are inspected, tested, and maintained by individuals performing the door inspections that possess knowledge, training or experience that demonstrates ability in accordance with NFPA 80, Standard for Fire Door and Other Opening Protectives, 2010 edition Section 5.2 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 19.7.6, and 8.3.3.1 Finding: On 05.27.2025, between 10:30 AM and 2:30 PM, during documentation review the surveyor with the Manager of Facilities and Assistant Manager of Facilities present observed the following: 1. The facility had no documentation that the doors had been inspected by a trained employee or a qualified outside vendor in the last year. I asked the Manager of Facilities if he has any training or classes regarding the inspection of fire doors by his staff who are inspecting the fire doors and he told me that,” The staff that performed the inspections had no knowledge or special training to inspect fire doors. They have hired a 3rd party vendor to come in and inspect the doors this year.” These finding was verified by the Manager of Facilities and Assistant Manager of Facilities at the time of the observation.”

“Based on documentation review and interview the facility, failed to ensure that inspect the retention force of receptacles not listed as hospital-grade are tested at intervals not exceeding 12 months in accordance with NFPA 99, Healthcare Facilities Code, 2012 edition, Section 6.3.3.2.4. Finding: Documentation review and interview during a facility tour with the Manager of Facilities and Assistant Manager of Facilities present on 5/27/2025 from 11:30 AM to 2:30 PM identified: 1. The annual testing of the receptacles did not include the retention force of the grounding blade of each electrical receptacle to ensure it is not less than 4 oz. This deficient practice could affect all occupants including residents, employees, and visitors to the facility. The surveyor confirmed this finding with the Manager of Facilities and Assistant Manager of Facilities the time of the observation.”