Wellspring Lutheran Services

“Based on record review and interview, the agency failed to ensure the emergency plan was tested annually; and failed to ensure participation in a full-scale or facility based functional exercise every 2 years, resulting in the potential for an unprepared agency response in the event of an actual emergency. Findings include: **Policy titled “;Emergency Preparedness Plan, Policies and Procedures” (revised 10/2024) stated under “;Drills and Exercises” on page 23 that, “;1. The Agency will: A. Review the emergency plan no less than annually (paper review); B. Conduct evaluation drills or exercises; and C. Update the plan based on results of those evaluations.” The policy also stated, “;2. Agency staff members will participate in a minimum of one drill or exercise annually to determine the effectiveness and efficiency of the current policy and any forms developed for use in a disaster.” The agencys Emergency Preparedness (EP) binder was reviewed on 2/27/25. During review of the binder, it was determined the drill for 2023 contained documentation regarding a table top drill for a heatwave. Upon further review of the documentation, it was determined the documentation contained general information on how to perform the drill and 3 exercise modules with follow-up discussion questions. However, the drill documentation lacked information regarding who participated in the drill as well as proof of any post-exercise discussion or detailed after action report. There was a short form labeled “Appendix C: AAR (after action report) Documentation” located in the binder, however, this form specifically stated it was not the final AAR document, and that facility-specific information would be entered on a different form. Upon review of the documentation for the drill in 2024, it was determined a table top drill for a winter storm/blizzard was performed. The documentation in the binder contained general information on how to perform the drill and 3 exercise modules with follow-up discussion questions. However, the drill documentation lacked information regarding what occurred during the drill as well as proof of any post-exercise discussion or detailed after action report. There was a short form labeled “Appendix C: AAR (after action report) Documentation” located in the binder, however, this form specifically stated it was not the final AAR document, and that facility-specific information would be entered on a different form. Additionally, it was determined the last full-scale or facility-based functional EP exercise was performed in 2022. During an interview with the Administrator (Adm #1) on 2/27/25 at 1:00 PM, Adm #1 confirmed the drills in 2023 and 2024 were both table top drills. Adm #1 confirmed, there was no full-scale or facility based functional exercise performed in 2024. Adm #1 was also asked for records of who attended, what occurred during the drills, discussion that took place following the scenarios, and an after-action report. Adm #1 stated she did not have that information for the above drills and acknowledged the findings.”

“Based on observation, record review and interview, the hospice failed to include pain interventions on the plan of care for 1 of 12 patients (P-7) receiving home health aide services from a total of 14 sampled patients, resulting in patient pain and discomfort during bathing. Findings include: P-7: The Start of Care (SOC) was dated 1/22/25. The Plan of Care (POC) for the certification period 1/22/25 through 4/21/25, identified diagnoses of cerebral atherosclerosis, dementia, hypertensive heart disease, and heart failure. During record review on 2/25/25, it was discovered that the plan of care (POC) documented the patient had a fractured femur at the hip with surgical intervention. The POC also documented pain control assessment at each visit. During a joint surveyor/home health aide (HHa) visit on 2/26/25, two surveyors observed the HHa performing a bed bath and dressing on P-7. The HHa asked the patient about her pain level prior to the bed bath and the patient stated she had a small amount of pain but not enough to need pain but declined pain medication. The patient did not appear to be in any pain, however, during the bath the patient moaned and verbally expressed pain including facial grimacing. The patient was in obvious distress. There was no evidence in the record that the patient had premedication orders for bathing and dressing or that the patient was premedicated prior to the bath with the patient having a fractured femur. There was surveyor observed ineffective pain management. After the bath HHa was questioned about premedication and the HHa said it is something she will discuss with the facility staff. During an interview on 2/28/25, at 10:20 a.m., the Clinical Manager (CM-1) acknowledged the above findings and said, “The patient had as needed pain medicine ordered, and they will communicate with the facility staff regarding premedicating for the patient’s bath.””

“Based on record review and interview, it was determined the hospice failed to ensure the plan of care (POC) included patient specific measurable goals in 2 (P-6, P-8) of 14 records reviewed, which resulted in the potential for failure to meet the patient’s needs, and unmet patient goals. Findings include: P-6: The Start of Care (SOC) was dated 4/13/24. The Plan of Care (POC) for the certification period 4/13/24 through 6/11/24, identified diagnoses of hypertension and angina. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Energy conservation techniques utilized, increased activity and endurance; patient will have satisfaction with socialization.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-8: The Start of Care (SOC) was dated 2/8/25. The Plan of Care (POC) for the certification period 2/8/25 through 4/8/25, identified diagnoses of hemiplegia & hemiparesis, dysphagia, and heart disease. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, “Aspiration prevented, increased safety in swallowing, patient/family aware of aspiration risk; patient displays effective coping with feelings of depression.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 2/28/25 at 10:20 a.m., the Clinical Manager (CM-1) acknowledged the above findings.”

“Based on record review and interview, it was determined the Hospice failed to ensure the plan of care (POC) included ordered interventions to meet patient needs in 1 (P-10) 4 records with oxygen ordered out of a total sample of 14 records reviewed, resulting in the increased potential for dyspnea (difficulty in breathing) and subsequent feelings of an unpeaceful death. Findings include: P-10: The SOC date to Hospice was 1/21/25 with diagnoses which included chronic systolic (congestive) heart failure, chronic kidney disease, and history of falls. On 2/26/25, record review noted under “Admission Orders” on 1/21/25 that O2 (oxygen) was to be administered at 2-4 LPM (liters-per-minute) via nasal cannula as needed for shortness of breath/dyspnea. However, review of P-10’s POC noted the oxygen order above failed to be included under the problem of “Shortness of breath”. No oxygen administration was found in any of the ordered interventions within the entire POC. The findings above were reviewed and acknowledged by the Clinical Manager (CM-1) and Administrator (Adm-1) during an interview on 2/28/25 at 9:18 AM. Both CM-1 and Adm-1 noted this did not meet agency expectations or its policy referenced below. Agency Policy: “Plan of Care” (revised 1/2023) under Section 0080 stated, “Nursing services ensures the nursing needs of the patient are met as identified in the patient’s comprehensive assessment and updated assessments.” Section 0440 stated, “As each patient is discussed, each team member provides appropriate input for updating the plan of care.””

“Based on record review and interview, the hospice failed to provide infection control education to 2 (Vol-1, Vol-2) of 2 pet therapy volunteers, resulting in a lack of infection control education for these two volunteers. Findings include: On 2/26/25, the personnel files for the following pet therapy volunteers were reviewed. Vol-1: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of infection control education in 2024 or 2025. Vol-2: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of infection control education in 2024 or 2025. The hospice policy titled, Volunteer Handbook (no date) states, volunteers will receive training appropriate to the task assigned. Training will include orientation and basic hospice training as a minimum. The policy failed to indicate volunteers would receive infection control education. The findings were reviewed with the Volunteer Coordinator (VC-1) during an interview on 2/26/25 at 3:30 p.m. VC-1 explained that since these volunteers are for pet therapy they were not trained the same as someone who sits with patients. VC-1 acknowledged there was no infection control education for Vol-1 or Vol-2.”

“Based on record review and interview, the Hospice failed to ensure the registered nurse prepared written care instructions specific to the needs of the patient in 2 (P-2, P-10) of 12 records reviewed in which aide services were provided, failed to include safety precautions for 1 (P-7) of 12 records with aide services provided, and failed to provide direct instructions which enabled the aide to make clinical decisions concerning patient care in 1 (P-10) of 12 records with aide services, out of a total sample of 14 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-2: This patient elected hospice care on 8/23/24 with diagnoses of cerebral atherosclerosis (a buildup of plaque in the arteries of the brain) and liver failure. The referral documentation indicates the patient was hospitalized from 8/12/24 to 8/19/24 due to right-sided abdominal pain. The patient underwent a percutaneous cholecystostomy (a surgical procedure to place a tube into the gallbladder to drain bile and relieve inflammation) on 8/14/24. During record review on 2/25/25, it was noted that the hospice registered nurse documented on the 8/23/24 start of care assessment that the patient has a bile drain to the right upper quadrant with minimal bilious output. The 8/23/24 aide care plan instructed the aide to provide a bed bath or shower once a week for 13 weeks. The aide care plan failed to alert the aide to the presence of the bile drain on the patient’s right upper quadrant and failed to include any instructions for the aide regarding the care/cleaning of the bile drain during bathing. The findings were reviewed with the clinical manager (CM-1), during an interview on 2/28/25 at 8:30 a.m. CM-1 stated there should have been mention of the drain bag on the aide care plan. P-7: This patient elected hospice care on 1/22/25, with diagnoses of cerebral atherosclerosis, dementia, and hypertensive heart disease with heart failure. During record review on 2/26/25, it was noted that the aide care plan failed to include low bed position safety precautions for a fall risk patient. During a joint surveyor/home health aide visit on 2/26/25, two surveyors observed the home health aide performing a bed bath and dressing on P-7. The home health aide elevated the bed (The bed had no safety rails) prior to the bed bath and left the patient bed in the elevated position while the aide washed her hands in the bathroom, approximately 12 feet away, numerous times. During an interview on 2/28/25, at 10:20 a.m., the Clinical Manager (CM-1) acknowledged the above findings. P-10: The start of care date to Hospice was 1/21/25 with diagnoses which included chronic systolic (congestive) heart failure, chronic kidney disease, and history of falls. On 2/26/25, record review of the Hospice aide’s plan of care (POC) effective 1/21/25, failed to incorporate an admitting order (1/21/25) that O2 (oxygen) was to be administered at 2-4 LPM (liters-per-minute) via nasal cannula as needed for shortness of breath/dyspnea. The aide POC under DME (durable medical equipment) failed to acknowledge that P-10 had oxygen ordered. In addition, the POC instructed that the aide “May apply moisture barrier to buttocks and groin as needed.” This level of intervention by the aide contradicts CMS (Centers for Medicare and Medicaid Services) language which states an aide is authorized in “Recognizing and reporting changes in skin condition...” but not to treat skin conditions. The findings above were reviewed and acknowledged by the Clinical Manager (CM-1) and Administrator (Adm-1) during an interview on 2/28/25 at 9:22 AM.”

“Based on record review and interview, it was determined the Hospice failed to ensure that ordered interventions were appropriate and optimized to meet patient care goals in 2 (P-10, P-11) of 14 records reviewed, resulting in the increased potential for an unpeaceful transition towards death. Findings include: P-10: The start of care (SOC) date to Hospice was 1/21/25 with diagnoses which included chronic systolic (congestive) heart failure, chronic kidney disease, and history of falls. On 2/26/25, record review noted the plan of care (POC) under the problem “Shortness of breath” had a goal that “Patient will have managed shortness of breath as evidenced by an RDOS (Respiratory Distress Observation Scale) of less than 4.” Additional review of the Hospice’s RDOS scale noted the following: “An RDOS score greater than or equal to 3 (out of 16) signifies respiratory distress and need for palliation (increased comfort measures).” This finding was brought to the attention of the Clinical Manager (CM-1) and Administrator (Adm-1) during an interview on 2/28/25 at 9:42 AM. Both acknowledged that the goal of less than 4 was inappropriate since a level 3 signified respiratory distress, which is not a desirable goal for the patient/family. P-11: The SOC date to Hospice was 1/21/25 with diagnoses which included atherosclerosis (plaque buildup reducing blood flow) to arterial left and right lower extremities, hypertension, and chronic respiratory failure. On 2/26/25, record review noted the POC under the problem “Shortness of breath” had a goal that “Patient will have managed shortness of breath as evidenced by an RDOS of less than 4.” Review of the Hospice’s RDOS scale noted the following: “An RDOS score greater than or equal to 3 signifies respiratory distress and need for palliation.” This finding was brought to the attention of the CM-1 and Adm-1 during an interview on 2/28/25 at 9:46 AM. Both noted again that the goal of less than 4 was inappropriate due to a level 3 signifying respiratory distress. The Hospice failed to interpret the RDOS scale correctly to meet the needs of the patient and failed to adhere to its policy referenced below. Agency Policy: “Plan of Care” (revised 1/2023) under Section 0400 stated, “The following areas are reviewed and approved by the patient/family: ... 6. Realistic and achievable goals and objectives; 8. Agreed-upon outcomes.””

“Based on record review and interview, the hospice failed to ensure 2 (Vol-1, Vol-2) of 2 pet therapy volunteers received orientation about the hospice philosophy, resulting in a lack of education regarding the hospice philosophy for these two volunteers. Findings include: On 2/26/25, the personnel files for the following pet therapy volunteers were reviewed. Vol-1: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of orientation about the hospice philosophy. Vol-2: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of orientation about the hospice philosophy. The hospice policy titled, Volunteer Handbook (no date) states, volunteers will receive training appropriate to the task assigned. Training will include orientation and basic hospice training as a minimum. The hospice failed to follow its own policy and ensure pet therapy volunteers received orientation about the hospice philosophy. The findings were reviewed with the Volunteer Coordinator (VC-1) during an interview on 2/26/25 at 3:30 p.m. VC-1 explained that since these volunteers are for pet therapy they were not trained the same as someone who sits with patients. VC-1 acknowledged that these two volunteers had not received orientation about the hospice philosophy.”