Swan Hospice

“Based on observation, interview, record review, and agency policy review, the agency failed to provide the patient and/or representative with written notice of the patient’s rights and responsibilities for one patient (Patient (P) 4) of three patients whose home folders were reviewed. This failure had the potential to result in the patient and/or representative not knowing, or understanding, their rights under the hospice benefit. Findings include: Review of P4’s “Face Sheet” located in the “Face Sheet” tab of the electronic medical record (EMR) revealed a “Start of Care (SOC)” date of 04/10/26 for a diagnosis of multiple sclerosis. During a home visit observation and interview on 05/27/26 at 9:32 AM at P4’s home, the hospice folder was reviewed with P4’s caregiver (CG). There was no documentation to show that P4 or his/her representative was provided with a written copy of the patient’s rights and responsibilities under the hospice benefit. The CG stated he/she was not there at the time of the signing of the election of benefits (EOB) and did not receive a copy of the signed EOB and rights and responsibilities. “I would have liked to be able to read it and know what it said.” During the home visit, Registered Nurse (RN) 1 also reviewed the home folder and confirmed the written copy of the patient’s rights and responsibilities was not in the folder. During an interview on 05/27/26 at 2:30 PM, the Administrator confirmed that the signed copy of the patient’s rights and responsibilities should be in the home folders. Review of an undated agency policy titled, “Patient Rights and Responsibilities in Hospice,” revealed, “. . . Upon admission to [Hospice Agency] and prior to care, the [State Agency] and [Federal Agency] requires that patients receive a verbal and written copy of their rights and responsibilities and have it reviewed with them during the initial assessment . . .””

“Based on interview, document review, and agency policy review, the hospice agency failed to ensure volunteer hours equaled five (5) percent (%) of the total patient care hours. This had the potential to cause all 108 patients currently receiving hospice services to have unmet needs. Findings include: Review of the hospice agency’s document titled, “Volunteer Information for 2025” provided by the Volunteer Coordinator (VC) revealed the agency’s monthly volunteer hour percentages were: January- 1%February-1%March-1%April-3%May-2%June-0%July-0%August-0%September-1%October-1%November-2%December-1% The average volunteer hour percentage for 2025 was 1%. During an interview on 05/28/26 at 8:15 AM, the VC acknowledged the average volunteer hour percentage of 1% for 2025 and stated, “I had just started working here in July 2025 and we had only three volunteers. I have been working on making improvements and finding good people, but it’s difficult.” Review of an undated agency policy titled, “Volunteers-Documentation,” revealed, “. . . The hospice must document cost savings achieved through the use of volunteers and include . . . Identification of necessary positions which are occupied by volunteers . . . The work time spent by volunteers occupying those positions . . . Estimates of the dollar costs which the hospice would have incurred if paid employees occupied the positions . . .” The policy did not address volunteer hours equaling or exceeding 5% of the total patient care hours.”

“Based on interviews, record review, and agency policy review, the agency failed to complete the discharge summary of care for two of two patients (Patients (P) 11 and P12) reviewed for hospice discharge. This had the potential for continuity of care not being met. Findings include: 1. Review of P11’s “Face Sheet” located in the “Face Sheet” tab of the electronic medical record (EMR) revealed a “Start of Care (SOC)” date of 01/16/26 for a diagnosis of malignant neoplasm of the left ovary. Review of a 01/26/26 “Discharge Summary” located in the “Clinical Documents” tab of the EMR revealed it was blank with no evidence to show a summary of care was documented in P11’s clinical record when P11 discharged to another hospice. 2. Review of P12’s “Face Sheet” located in the “Face Sheet” tab of the EMR revealed a “SOC” date of 12/22/25 for a diagnosis of hypertensive heart disease with chronic kidney failure. Review of the 01/16/26 “Discharge Summary” located in the “Clinical Documents” tab of the EMR revealed it was blank with no evidence to show a summary of care was documented in P12’s clinical record when P12 discharged to receive aggressive treatment. During an interview on 05/28/26 at 2:30 PM, the Director of Clinical Services (DCS) confirmed that he/she did not include the summary of stay when completing the “Discharge Summary.” Review of an undated agency policy titled, “Transfer of a Hospice Patient,” revealed, “. . . A written transfer summary includes, at a minimum . . . A brief description of services provided and ongoing needs that cannot be met . . . A summary of the patient’s care including treatments, symptoms and pain management . . .””

“Upon patient record review, 6 of 19 (Patients #1, 2, 3, 6, 10, 13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: The patient was seen twice on 12/02/24. the daughter had called regarding a fall, and when after hours nurse arrived patient also had coughing and “stuffy nose” with O2 sat of 89%. Medrol dose pack, Zithromax, and Delsym cough syrup was ordered. Later that morning, the RN visited. Patient with high BP at 166/88, Temp 99.9 with coarse lung sounds and thick green sputum. Duoneb and another nebulized medication were ordered. No further follow up call for 9 days. Patient #2: Patient was seen on 02/27/25 for increased anxiety per staff at skilled facility. Scheduled Ativan ordered. No follow up visit or call for 7 days and there was no mention of the efficacy of the Ativan at the next RN visit. Patient #3: Patient was seen 02/19/25 and started on Keflex for a UTI. There was no follow up call or visit for 8 days. Patient #6: Patient seen on 12/30/24. Was positive for Covid 19 and had a fever of 100.2. Started Mucinex. No follow up nursing visit for 8 days. Patient #10: Patient was started on Zithromax for a possible URI. No follow up nursing visit or call for 7 days. Patient #13: Patient seen 04/23/25 for an infection at the site of an old suprapubic catheter on the abdomen. There was drainage described as pus. No follow up visit or call for 5 days.”

“Upon patient record review, 10 of 19 (Patients #1, 2, 3, 4, 7, 9, 10, 11, 12, 13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: There were no interventions or goals for infection created when patient prescribed multiple medications for a URI. There were no interventions or goals for use of nebulized medications. Patient #2: There were no interventions or goals for anxiety and depression despite numerous changes in anxiety and depression medications including adding scheduled Ativan. Patient #3: The patient is receiving thick it due to dysphagia. There are no interventions or goals for dysphagia on POC. Patient is on Aspirin, though there are no interventions or goals for bleeding and use of anticoagulants. Patient #4: The patient is taking Sertraline and Quetiapine, both ordered by Hospice. There are no interventions or goals for anxiety or depression. Patient #7: There was no added POC problem for infection when patient started on antibiotics. The patient has nebulized medications ordered, but no interventions or goals for the nebulizer. Patient #9: The patient is on hospice with Non Hodgkin’s Lymphoma. there are no interventions or goals for cancer as the primary diagnosis. The patient is on daily scheduled narcotics. There are no specific interventions or goals on narcotic use for pain. Patient #10: The patient is on several medications for anxiety and depression. There are no interventions or goals for this. Patient #11: The patient is on multiple medications for depression and anxiety, however, there are no interventions or goals for anxiety and depression on the POC. Patient #12: The patient is on Methotrexate for auto immune issues. There are no interventions or goals on the plan of care related to immunology. Patient #13: The patient is on service with MS. There is not a plan of care for Neurology. The patient is also quadriplegic. There are no interventions or goals for this on the POC.”

“Upon patient record review, 2 of 19 (Patients #3, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3: Patient has what is described as an arterial ulcer on the anterior left foot. The order reads: “Wound cleanser, pat dry, put sure prep around edges, put small piece of Megasorb in the center of wound, cover with Optifoam. It states to change daily and prn. It does not specify a reason for prn dressing changes. Patient #13: This patient has 2 wounds. There is a stage 2 sacral wound that they had upon admission. There is also a chronic wound at the opening of an old suprapubic site. There is a wound order in the chart that reads, “Cleanse with soap and water, pat dry. Apply barrier cream every visit. Caregivers to perform wound care other days and as needed.” This order does not specify location. This order does not specify reason for prn dressing changes nor specify what the actual frequency of Hospice nurse dressing changes that will occur each week. There is no other order in the record for the second wound.”

“Upon patient record review, 13 of 19 (Patient #1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #3: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #4: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #5: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. The patient is ordered to have nail care every visit but does not specify type of nail care. Patient #6: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #7: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #8: The aide plan of care orders to assist with ambulation each visit but does not specify how the patient ambulates (w/c, walker, cane, Hoyer). The HHA plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #9: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #10: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #11: The aide plan of care orders to assist with ambulation each visit but does not specify how the patient ambulates.. There is ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #12: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. Patient #13: The aide plan of care ordered skin care every visit but does not specify what type of skin care is to be done. Patient has oral care ordered every visit but does not specify what kind of oral care is to be done. The patient is ordered to have nail care every visit but does not specify what the care needed is. Patient #14: The aide plan of care orders to assist with ambulation each visit but does not specify how.”

“Upon patient client record review, 6 of 19 (Patients #1, 6, 7, 11, 12, 14) did not have evidence that each patient record contains Advance Directives. Patient #1: Patient is alert and oriented x 1-2. The DNR was signed by the son. He is the Durable POA, however, that document states that it is not for healthcare purposes. there was not a Medical POA. Patient #6: Patient is on service with Alzheimer’s disease. Her daughter signed the DNR. There is no MDPOA in the record.. Patient #7: Patient has dementia. Daughter signed the DNR. There is no MDPOA in the record. Patient #11: Patient on service with Lewy Bodied dementia. The son signed the DNR. There is no MDPOA in the record. Patient #12: Patient on service with COPD. She signed all of her own consents except the DNR which was signed by the son. There is no documentation of why the son signed and there is no MDPOA in the record. Patient #14: Patient has dementia. the daughter signed the DNR. There is no MDPOA in the record.”

“Upon personnel record review, 2 of 13 (Personnel #9, 12) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state’s Social Work Practice Act, the hospice’s policies and procedures and/or job descriptions. Personnel #9 and #12: Each have a Bachelor’s in Social work. Although the agency has a Masters in Social work employed, and the social work does inservices with the BSW’s, there is no evidence of any supervision of patients, the Plan of care, including interventions and goals.”

“Based on record review and interview, the Hospice agency failed to provide documentation that it had participated in the community based full-scale exercise required every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 3/28/24 at 1:40 PM., review of the Agency’s Emergency Preparedness binder found no evidence the Hospice agency had participated the required full-scale community-based exercise every two years. No communication or effort was evidenced that the agency had reached out to the local incident command center (Region 3) to participate in the community-based exercise. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:50 PM.”

“Based on record review and interview, the agency failed during the review of the medication reconciliation to involve the physician in considering the ramifications of severe and major level drug interactions on the well-being of the patient in 5 (P-1, P-2, P-3, P-6, P-15) of 16 total sampled records and failed to ensure the comprehensive assessment included a review of all medications for identification of actual or potential drug interactions in 3 (P-12, P-13, P-14) of 5 records with recertification reviewed resulting in the potential for adverse medication effects and poor patient outcomes. Findings include: Agency policy titled “;PC.C55 Comprehensive Assessment -Content” (undated) was reviewed on 4/2/24. On page 1.-3., it stated “;The comprehensive assessment must include: ... x. Drug profile, including prescriptions... which includes identification of: 3) Actual/potential drug interactions...” P-12: This 76-year-old was admitted to the agency on 6/2/23 with a terminal diagnosis of alcoholic Cirrhosis of the liver (condition in which the liver gets damaged due to alcohol use), with ascites (abnormal fluid in the abdominal cavity). The medical record was reviewed on 4/1/24. During review, it was noted that a comprehensive assessment for recertification was completed by the nurse on 3/5/24 for the benefit period covering 3/11/24- 5/9/24. Under “;Medication Profile Review”, the nurse documented: please refer to intervention documentation. Under “;Medication Interventions Performed this Visit”, the nurse documented: teach regarding medications. It was also noted that changes were made to the medication profile since the previous comprehensive assessment (completed by the nurse on 12/28/23). There were no additional comments regarding a drug review. Using the agencys electronic medical record (EMAR) software, interactions were printed for surveyor review on 4/1/24 and it was noted there were 15 severe and 39 major interactions listed for the medications entered on this patients profile. There was no documentation found in the medical record that the drug interactions were identified by the agency staff. P-13: This 85-year-old was admitted to the agency on 12/12/23 with a terminal diagnosis of Alzheimer’s disease (brain disorder which gets worse over time). The medical record was reviewed on 4/1/24. During review, it was noted that a comprehensive assessment for recertification was completed by the nurse on 3/7/24 for the benefit period covering 3/11/24- 6/8/24. Under “;Medication Profile Review”, the nurse documented: no evidence of change since last review. It was also noted that changes were made to the medication profile since the previous comprehensive assessment (completed by the nurse on 12/12/23). Using the agencys EMAR software, interactions were printed for surveyor review on 4/1/24 and it was noted there were 3 severe and 24 major interactions listed for this patients medications. There was no documentation found in the medical record that the drug interactions were identified by agency staff. P-14: This 71-year-old was admitted to the agency on 12/21/23 with a terminal diagnosis of hypertensive heart disease (heart problems that occur due to high blood pressure), and chronic kidney disease. The medical record was reviewed on 4/1/24. During review, it was noted that a comprehensive assessment for recertification was completed by the nurse on 3/11/24 for the benefit period covering 3/20/24- 6/17/24. Under “;Medication Profile Review”, the nurse documented: no evidence of change since last review. It was also noted that changes were made to the medication profile since the previous comprehensive assessment (completed by the nurse on 12/21/23). Using the agencys EMAR software, interactions were printed for surveyor review on 4/1/24 and it was noted there were 10 severe and 50 major interactions for this patients medications. There was no documentation found in the medical record that the drug interactions were identified by agency staff. P-15: This 65-year-old was admitted to the agency on 1/6/24 with a terminal diagnosis of Multiple Sclerosis (disease affecting brain and spinal cord). The medical record was reviewed on 4/1/24. During review, it was noted that a comprehensive assessment was completed by the nurse on 1/6/24. Under “;Medication Profile Review”, the nurse documented: no issues identified. Using the agencys EMAR software, interactions were printed for surveyor review on 4/1/24 and it was noted there were 2 major interactions listed for the medications entered on this patients profile. There was no documentation found in the medical record that the drug interactions were identified by agency staff or reported to the physician. These findings were reviewed and acknowledged by the Administrator (Staff A) and the Quality Assurance Nurse (Staff B) during interview on 4/2/24 at 2:10 p.m. P-1: This 97-year-old patient had a hospice start of care (SOC) date of 7/3/2023, with terminal diagnoses of hypertensive heart disease with heart failure. During record review on 3/28/24, it was noted that Skilled Nursing (SN) at the SOC had used the Agency’s EMR (Electronic Medical Record) software to run a medication reconciliation report. This report revealed three severe (highest level) drug interactions, and 11 major drug interactions. However, under “Medication Profile Review” it was noted “No issues identified” was documented by SN. No evidence was found in the medical record that the physician was made aware of these significant drug interactions with subsequent guidance from the physician if it was safe to continue or not with the current drug regimen. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:42 PM. P-2: This patient was admitted to hospice on 6/28/2023 with terminal diagnoses of hypertensive heart disease with heart failure and Alzheimer’s disease. During record review on 3/28/24, it was noted that Skilled Nursing (SN) at the SOC had used the Agency’s EMR (Electronic Medical Record) software to run a medication reconciliation report. This report revealed 8 severe drug interactions, and 57 major drug interactions. Further review under “Medication Profile Review” it was noted “No issues identified” was documented by SN. No evidence was found in the medical record that the physician was made aware of these significant drug interactions with subsequent guidance from the physician if it was safe to continue or not with the current drug regimen. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:50 PM. P-3: This patient was admitted to hospice on 2/21/2024 with terminal diagnoses of hypertensive heart disease with heart failure, diabetes-type 2, dementia, and peripheral vascular disease. During record review on 3/28/24, it was noted that Skilled Nursing (SN) at the SOC had used the Agency’s EMR (Electronic Medical Record) software to run a medication reconciliation report. This report revealed two severe drug interactions, and 17 major drug interactions. Under “Medication Profile Review” it was noted “No issues identified” was documented by SN. No evidence was found in the medical record that the physician was made aware of these significant drug interactions with subsequent guidance from the physician if it was safe to continue or not with the current drug regimen. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:56 PM. P-6: This patient was admitted to hospice on 2/3/2024 with terminal diagnoses of hypertensive heart disease with heart failure, and HIV (human immunodeficiency virus). During record review on 3/28/24, it was noted that Skilled Nursing (SN) at the SOC had used the Agency’s EMR (Electronic Medical Record) software to run a medication reconciliation report. This report revealed three severe drug interactions, and 16 major drug interactions. However, under “Medication Profile Review” it was noted “No issues identified” was documented by SN. No evidence was found in the medical record that the physician was made aware of these significant drug interactions with subsequent guidance from the physician if it was safe to continue or not with the current drug regimen. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 2:14 PM. The Hospice agency failed to ensure that SN had appropriately reviewed medication reconciliation findings to the physician which alerted for a potential danger to the above patients and failed to adhere to its policy referenced below. Agency Policy: “Adverse Drug Reactions” Section 4.0 HH-HOS-FED (Revised 4Q/2021) stated, “As part of the patient’s drug regimen review, the clinician will assess for potential and actual adverse events related to medication including possible drug-drug and drug-food interactions. The physician/allowed practitioner who ordered the medication(s) ...will be notified of possible or actual drug interactions and adverse drug reactions.””

“Based on record review and interview, the agency failed to ensure the comprehensive assessment included an initial bereavement assessment for the needs of the patients family and other individuals who are involved in the care of the patient in 2 (P-1, and P-2) of 19 sample records reviewed resulting in the potential lack of bereavement support for individuals that may be affected upon the patient’s death. Findings include: P-1: This 97-year-old patient was admitted to hospice on 7/3/2023 with terminal diagnoses of hypertensive heart disease with heart failure. During a joint home visit with Skilled Nursing on 3/28/24, it was observed P-1 was very close to his wife of 75 years, son, daughters, and many grand-children as evidenced through conversations and the numerous family photos prominently displayed. However, on 3/28/24 review the initial comprehensive assessment dated 7/3/23, noted the Bereavement Risk Assessment (BRA) on page 8 of 21 only listed the wife. No other family members were assessed. Under “Personal Contacts” the patient’s son and two daughters were listed. Further record review noted strong relations with family outside of just P-1’s wife. For example, the Social Work’s visit note date 1/28/2024, documented, “(Wife) takes a call from a granddaughter, with great-grand-daughter, on FaceTime. They all blow kisses and talk to each other. (Wife) explains the kids are still coming to visit regularly... They looked through pictures on their digitized photo frame and told stories about most of them.” No updates or additions to the BRA were evidenced from admission through the home visit on 3/28/24. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:50 PM. Both were noted that the Hospice agency would review and update its procedure(s) concerning a more comprehensive BRA as required and stipulated in its policy below. P-2: This patient was admitted to hospice on 6/28/2023 with terminal diagnoses of hypertensive heart disease with heart failure and Alzheimer’s disease. During a joint home visit with the Hospice’s Chaplain on 3/28/24, it was noted through interview that P-2 had very close family relations. His children were planning a ceremonial party commemorating his career as the township’s sheriff of many years in a few weeks. During an interview with the Chaplain who is also the Bereavement Coordinator on 3/28/24 at 1:15 PM., it was discovered the standard practice is to only include one individual in the BRA. Further, it was revealed the standard practice was not to assess from the patient’s perspective (when possible) of who would significantly mourn upon their passing. Under “Personal Contacts” the patient’s three sons and daughter were listed but were not assessed in P-2 BRA. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:57 PM. Both recognized the significance of including the patient’s perspective of who would grieve at their passing, if possible, to have a more comprehensive BRA assessment. Agency policy titled “;PC.C55 Comprehensive Assessment -Content” (undated) was reviewed on 4/2/24. On page 1.-2., it stated “;The comprehensive assessment must include: ... v... Bereavement component that includes: -A bereavement assessment that considers the needs of the patients family and other individuals... that may impact their ability to cope with the patients death...””

“Based on record review and interview, the Hospice agency failed to incorporate any quantitative infection control data that could be tracked and trended to monitor progress towards pre-established goals concerning the containment or spread of infectious diseases, resulting in the potential for poor palliative outcomes and services for the 65 hospice patients currently receiving services. Findings include: During review of the Hospice’s QAPI (Quality Assessment and Performance Improvement) Program on 3/28/24, it was noted the Infection Control portion of the QAPI program had failed to be converted into a quantitative means that could be tracked and trended. In addition, no evidence was found of any pre-established baseline or ending goal values in which to evaluate potential progress made or lack of concerning any aspects of infection control. These findings were reviewed with and acknowledged by the Administrator (Staff A), and the Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:40 PM. The Hospice agency failed to meet this requirement and adhere to its policy referenced below. Agency Policy: “Quality Assessment/Performance Improvement Policies and Procedures” Policy # QAPI-1.0 (Effective February 15, 2023) stated, “This program (QAPI) is designed so that the hospice program may be managed and coordinated utilizing measurable performance standards based on organizational objectives. Surveillance techniques to identify infections and develop systems to reduce risk...””

“Based on record review and interview, the Hospice agency failed to ensure the information in the clinical record was accurate and complete in 2 (P-1, and P-2) of 5 records reviewed with re-certification episodes, out of a total sample of 16 records reviewed, resulting in pertinent information to be missing within the clinical record and the potential for patient needs not being met. Findings included: P-1: The patient was admitted to hospice on 7/3/2023 with terminal diagnoses of hypertensive heart disease with heart failure. On 3/28/24, review of the P-1’s Plan of Care (POC) revealed the following concerns for each POC identified below: Certification episode 2/28/2024 through 4/27/2024 noted under “Orders/Treatments” a failure to have the discipline and visit frequencies for the required services of Master of Social Work (MSW) and Chaplain services. Certification episode 12/30/2023 through 2/27/2024 noted under “Orders/Treatments” a failure to have the discipline and visit frequencies for the required services of Skilled Nursing (SN), Hospice Aide (HA), and MSW services. Certification episode 10/1/2023 through 12/29/2023 noted under “Orders/Treatments” a failure to have the discipline and visit frequencies for the required services of SN, HA, MSW, and Chaplain services. P-2: This patient was admitted to hospice on 6/28/2023 with terminal diagnoses of hypertensive heart disease with heart failure and Alzheimer’s disease. On 3/28/24, review of the P-2’s POC revealed the following concerns for each POC: Certification episode 3/16/2024 through 5/14/2024 noted under “Orders/Treatments” a failure to have the discipline and visit frequencies for the required services of SN, HA, MSW, and Chaplain services. Certification episode 1/16/2024 through 3/15/2024 noted under “Orders/Treatments” a failure to have the discipline and visit frequencies for the required service of MSW services. Certification episode 11/17/2023 through 1/15/2024 noted under “Orders/Treatments” a failure to have the discipline and visit frequencies for the required services of SN, HA, MSW, and Chaplain services. Certification episode 7/20/2023 through 9/17/2023 noted under “Orders/Treatments” a failure to have the discipline and visit frequencies for the required services of SN, HA, MSW, and Chaplain services. No patient or legal representative refusal of the above services was evidenced in the medical record. Further review of the record noted the above services were appropriately furnished under “Verbal Orders” but failed to be listed on the patient’s POC. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Quality Assurance manager (Staff B) during an interview on 4/2/24 at 1:50 PM. In addition, a request was made to review the Hospice agency’s chart audit tool used to verify that pertinent elements of the medical record are accurately maintained. Review of the chart audit tool revealed a failure to acknowledge and review any aspects concerning patient POC’s. Staff A and B were noted that the audit tool would be revised to incorporate a review of all patient POC’s. The Hospice agency failed to adhere to its policy as stipulated below. Agency Policy “Clinical Records” No. PC.C30 (undated) stated, “A clinical record is established and maintained for every patient receiving care and services from Swan Hospice. The record is complete, promptly, and accurately documented...””

“Based on record review and interview, the agency failed to ensure that a determination of eligibility for each employee criminal background check was completed within 3 months of hire for 5 of 10 employee records reviewed resulting in patient care being provided by persons with unknown criminal histories. Findings include: On 4/3/24, 10 personnel files of current staff were reviewed. It was noted that the agency had requested the process of a criminal background check to begin for all 10 staff members. It was also noted that the background check process request form for 5 clinical staff (Staff A, B, C, D, F) hired between April and May of 2023 indicated that the check was still “;processing”, and that the agency would receive an email notification when the check was completed. At 2:18 p.m., the office manager (Staff E) was queried to whether the agency received the email regarding criminal background eligibility status for the 5 staff members. Staff E stated that she was not an employee at the time of the criminal background checks for those 5 staff members and the email would have been received at the agency corporate level. Staff E stated that the staff member who originally requested the information at the corporate level was no longer currently employed by the agency. It was not clear when or if an email had been received by the agency indicating that the 5 criminal background checks were completed. It is unknown if the agency became aware of the criminal background eligibility determination for those 5 clinical staff members within 3 months of hire as the personnel files had not been updated. These findings were reviewed and acknowledged by the Administrator (Staff A) and the Quality Assurance Nurse (Staff B) during interview on 4/2/24 at 2:10 p.m.”