Bethesda Hospice Care

“Based on policy review, record review, home visit observation, and interview the hospice provider failed to complete a comprehensive assessment of the patient’s and familys goals for pain management in four of five full records reviewed (Records/Patients #1, #2, #3, and #4) and how pain impacted the patient’s quality of life in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to hospice services on 12/08/2024 with a primary diagnosis of senile degeneration of the brain not elsewhere classified (a group of conditions that cause a progressive decline in cognitive abilities such as memory, thinking, and reasoning). The patient resided in a long-term care facility. Review of the initial assessment, dated 12/08/2024, showed the following: - A pain screening was completed with the help of the patient and that the patient could verbalize pain; - The patients pain severity was “;mild;” - A comprehensive pain assessment was completed and showed: * The patient had pain in the left hip and described as chronic, intermittent daily, and aching; * Precipitating factors included: movement, weather changes, and stress; * Side effects of the pain included: moderate effects on physical functioning, mild effects on social interaction, mild effects on mood and emotions, moderate effects on nutrition and appetite, moderate effects on sleep patterns, and no effects on spirituality; * Relief measure included: cold, non-narcotic analgesics, over-the-counter pain relievers, and rest and relaxation; * There were no side effects of treatments reported; and The provider failed to ensure that the pain assessment included the patients acceptable level of pain. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 07/12/2024 with a primary diagnosis of cerebrovascular disease (a range of conditions that affect the brains blood flow). The patient resided in a long-term care facility. Review of the initial assessment, dated 07/12/2024, showed the following: - A pain screening was completed for the patient with the help of staff observation as the patient was unable to verbalize any information related to pain; - The staff observation scale used was the PAINAD scale (a tool used to assess pain in individuals with cognitive impairments that focuses on behaviors associated with pain. A score 1 to 3 indicates mild pain, a score of 4 to 6 indicates moderate pain, and a score of 7 to 10 indicates severe pain); - The patients PAINAD score was a “;4” which indicates the pain severity was “;moderate;” - A comprehensive pain assessment was completed and showed: * The patient had generalized pain related to gout (a type of inflammatory arthritis) and a pressure wound which was described as chronic, intermittent daily, and the patient was unable to describe the quality or character of the pain; * Precipitating factors included: movement; * Side effects of the pain included: severe effects on physical functioning, moderate effects on social interaction, moderate effects on mood and emotions, moderate effects on nutrition and appetite, mild effects on sleep patterns, and no effects on spirituality; * Relief measures included: over-the-counter pain relievers and rest and relaxation; * There were no side effects of treatments reported; and The provider failed to ensure that the pain assessment included the patients acceptable level of pain. During an interview on 03/13/2025 at 11:20 AM, the clinical manager stated that for patients that can verbalize a pain number the acceptable level of pain should be documented and for patients that are not able to verbalize a pain number a pain scale such as the FLACC scale (a behavioral observation tool used to assess pain in patients who are unable to communicate) should be used. He/she stated that with the electronic medical record (EMR) they are unable to see documentation of what an acceptable pain level for the patient is. The expectation would be that the nurse would look at the last pain assessment that was documented to see if the patient has a change in the level of pain. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/01/2022 with a terminal diagnosis of Parkinsons disease with dyskinesia, without fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and resided at a skilled nursing facility. Review of the comprehensive assessment, dated 06/01/2022, showed in part: - The pain management section: A comprehensive pain assessment was not completed; - The patient was able to verbalize pain; - The pain assessment section: Pain was an active problem for the patient; - In the pain and comfort assessment: The patient was unable to describe pain; - In the fall risk assessment tool: Pain is affecting the patients level of function; - The section plan for next visit: comfort and symptom control; and - The communication section stated the patient reported severe painful muscle spasms in his/her legs two to three times a day, had sharp pains on the left side of his/her body, and migraine headaches one time a month. Observation on 03/28/2025 from 8:45 AM to 10:15 AM, showed the patient was able to have a conversation and was able to answer questions when asked. The patient stated the following: - He/She had an open sore on his/her buttocks; - The facility, and hospice, had ignored his/her requests for help with the pain; - The patient stated the “;white pills” (Tylenol) and the “;blue pill” (naproxen) was not helping to control the pain; - Pain medication was often slow in coming, and the facility runs out on the weekends. The POC for Patient #1 failed to be individualized regarding: - Acceptable level of pain; - Offering morphine, or prescription pain medication, after continued reports of pain; and - Communication methods for reporting pain. Findings included: Review of the providers policy titled, “;Pain Management,” last revised 10/25/2023, showed in part: - Upon admission, all patients were screened for pain within 24 hours and documented in the medical record: and - If pain was identified or the patient was on a routine pain medication, the plan of care will be updated to identify individualized interventions and goals. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service on 10/18/2023 with a primary diagnosis of Type II Diabetes (a group of diseases that results in too much sugar in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long term care facility (LTCF). Review of the skilled nurse (SN) initial assessment, dated 10/19/2023, showed in part: - Problem of pain management; - Pain in back and left hip; - Acute and chronic pain; and - Precipitating factor of osteomyelitis. The SN initial assessment, dated 10/19/2023, failed to show the patients goal for pain management. Review of the SN recertification assessment, dated 01/27/2025, showed in part, pain interferes with the patients “;activity or movement.” The assessment failed to show side effects of pain for the following: - - Physical functioning; - - Social interaction; - - Mood and emotions; - - Nutrition and appetite; - - Sleep patterns; and - - Spirituality. During an interview on 03/12/2025 at 1:38 PM, the registered nurse coordinator (RNC: known at the agency as clinical manager) stated that the SN assessment should include “;all aspects” of the pain assessment.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the providers policy titled, “;Medication Management Program,” last reviewed 07/17/2024, showed in part, the following: - Administration of medication is of high-risk and therapeutic benefit to the patient; - Medication management processes are measured on an ongoing basis; - Performance measures for data to be collected, aggregated, reviewed and analyzed in an effort to identify risk points and areas to improve patient safety; and - Measures for medication errors for rate of administration, omission, and administration without an order. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service on 10/18/2023 with a primary diagnosis of Type II Diabetes (a group of diseases that results in too much sugar in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long term care facility (LTCF). Review of the skilled nurse (SN) recertification assessment, dated 01/27/2025, showed the patients sacral area was treated “;daily” with Clavida (a zinc oxide based cream used to protect skin exposed to moisture due to incontinence). Review of the skilled nurse (SN) visits, dated 01/27/2025, 02/03/2025, 02/10/2025, 02/18/2025, 02/24/2025, 02/26/2025, 03/03/2025, 03/10/2025, showed in part, the medication profile review with “;no issues identified.” Observation on 03/11/2025 starting at 11:30 AM, during the patients LTCF home visit, showed the following discrepancies between the agencys medication profile provided 03/10/2025: - Colace (a brand-name stool softener that contains the active ingredient docusate sodium) 100 milligrams (mg) oral capsule, once a day for constipation. The LTCFs medication list showed docusate sodium 100 mg oral capsule every 24 hours as needed; - Miralax (a brand-name laxative that contains the active ingredient polyethylene glycol) 17 grams (g), once a day to prevent constipation. The LTCFs medication list showed polyethylene glycol 17 g every 24 hours as needed; - The hospice providers medication profile and LTCFs medication list failed to show Clavida; and - The LTCFs medication list showed ammonium lactate external cream (used to treat dry or scaly skin), applied to the heels. The agencys medication profile list did not list ammonium lactate cream. During an interview on 03/12/2025 at 1:38 PM, the registered nurse coordinator (RNC: known at the agency as clinical manager) stated that the skilled nurse was expected to reconcile the medication list at every visit. The RNC stated that if the nurse visited weekly, then the medication list would be reconciled every week. Review of the provider’s policy titled, “Comprehensive and Ongoing Assessment,” dated 02/2024 showed, in part: -The comprehensive assessment shall take into account the drug profile; -A review of all the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: * Effectiveness of drug therapy; * Drug side effects; * Actual or potential drug interactions; * Duplicate drug therapy; * Drug therapy currently associated with laboratory monitoring; and * Compliance with treatments and medication regimen.”

“Based on policy review, record review, and interview the hospice provider failed to ensure that each patients plan of care (POC) was individualized to their needs in three of five full records reviewed (Records/Patients #2, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the providers policy titled, “;Plan of Care,” reviewed 01/2023, showed in part that: - The comprehensive POC will be based on the initial comprehensive and ongoing assessments by all team members; - The plan of care must include an assessment of the patients needs and identification of the services, including the management of discomfort and symptom relief. The plan of care shall state in detail the scope and frequency of services to meet the patients and familys needs; and - The analysis of data obtained during assessments should facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service on 10/18/2023 with a terminal diagnosis of type II (two) diabetes (a group of diseases that results in too much sugar in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long-term care facility (LTCF). Review of the skilled nurse (SN) initial assessment, dated 10/19/2023, showed in part, the following: - A diagnosis of type II diabetes; and - The patient took insulin (used to lower blood sugar levels). Review of the SN recertification assessment, dated 01/27/2025, showed in part, the following: - A diagnosis of type II diabetes; and - Assessment of the endocrine and metabolic status showed within normal limits with no problem noted or reported. Review of the patients plan of care, dated 02/03/2025, showed the provider failed to include monitoring of the patient’s diabetes. Review of the LTCFs medication administration record (MAR) dated 03/12/2025, showed blood glucose monitoring as needed for signs and symptoms of hypo/hyperglycemia (low/high blood sugar). RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to hospice services on 12/08/2024 with a terminal diagnosis of senile degeneration of the brain not elsewhere classified (a group of conditions that cause a progressive decline in cognitive abilities such as memory, thinking, and reasoning) and secondary diagnoses of type II diabetes without complications (a group of diseases that results in too much sugar in the blood), chronic atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular heartbeat), and long-term (current) use of anticoagulants (a medication group that thins the blood). The patient resided in a LTCF. Review of the initial assessment, dated 12/08/2024, showed that the patient had type I diabetes (the patient’s diagnosis was type II diabetes) that was diet controlled and failed to assess the patients history of anticoagulant medications. Review of the POC, dated 12/8/2024 to 03/07/2025, failed to show diabetes or interventions related to diabetes. The POC included an order for apixaban (a medication used to thin the blood) 5 milligrams (mg) twice per day and failed to include any bleeding precautions related to anticoagulant use. Review of the LTCF physician order sheet showed an order, dated 11/01/2024, to monitor blood glucose as needed (PRN) when signs and symptoms of hypo/hyperglycemia were present. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 07/12/2024 with a terminal diagnosis of cerebrovascular disease (a range of conditions that affect the brains blood flow) and secondary diagnoses of type II diabetes with diabetic chronic kidney disease (a type of kidney disease that occurs when high blood sugar levels damage the kidneys), long-term (current) use of aspirin (a medication used to reduce the formation of blood clots with heart disease), and long-term (current) use of antithrombotics/antiplatelets (medications that prevent blood clots from forming). The patient resided in a LTCF. Review of the initial assessment, dated 07/12/2024, showed that the patient had type I diabetes (the patient’s diagnosis was type II diabetes) that was diet-controlled and was receiving anticoagulation therapy. Review of the POC, dated 07/12/2024 to 10/09/2024, showed an order for empagliflozin (a medication used to control blood sugar in type II diabetes) 10 mg daily in the morning and failed to include interventions related to diabetes. The POC also showed an order for aspirin l 81 mg daily and Plavix (an antiplatelet medication) 75 mg daily. The POC failed to include bleeding precautions related to aspirin and Plavix treatment. Review of the physician order sheet from the LTCF, dated 03/11/2025, showed the patient had an order to monitor blood glucose PRN when signs and symptoms of hypoglycemia are present dated 02/26/2021. During an interview on 03/12/2025, beginning at 1:35 PM, the registered nurse (RN) coordinator stated that he/she would expect the plan of care to be individualized for each patient and to include interventions for diabetes and bleeding precautions. He/she further stated that each discipline should be individualizing the plan of care.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop interventions to effectively manage individual symptoms of pain in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service on 10/18/2023 with a primary diagnosis of Type II Diabetes (a group of diseases that results in too much sugar in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long term care facility (LTCF). Review of the patients bowel movement (BM) record, provided by the LTC facility, dated from 01/31/2025 to 03/11/2025, showed in part, the following: - One bowel movement on 03/08/2025 at 5:40 AM; - No bowel movement on 03/9/2025 and 03/10/2025; and - One bowel movement on 03/11/2025 at 2:38 PM. Review of the patients plan of care, dated 02/03/2025, showed in part, the following: - Colace (a brand-name stool softener that contains the active ingredient docusate sodium) 100 milligrams (mg) oral capsule once a day for constipation; and - Miralax (a brand-name laxative that contains the active ingredient polyethylene glycol) 17 grams (g) every 24 hours to prevent constipation. Review of the chaplain visit notes, dated 03/11/2025, showed in part, the patient stated that he/she had not had a BM in several days and experienced “;passing” pains. The chaplains notes showed the patient verbally denied pain and showed no signs of pain or discomfort. Observation during the chaplain visit on 03/11/2025 from 11:40 AM to 12:30 PM, showed the patient stated that he/she was “;constipated.” The patient stated that he/she had not had a BM in “;weeks” and stated, two times, “;Im stopped up with pooping.” The chaplain asked the patient, if he/she was having pain. The patient stated that the nurse had given him/her three pills. The patient pointed to his/her shake container and asked the chaplain if the shake had something to help him/her “;poop.” The patient stated that he/she had pain and felt pressure like “;it” (the poop) was coming out. The patient closed his/her eyes and scowled. During an interview on 03/12/2025 at 1:38 PM, the registered nurse coordinator (RNC: known at the agency as clinical manager) stated that the chaplain was expected to report any changes in condition or indications of pain to the facility nurse and the hospice nurse. Review of the provider’s policy titled, “;Pain Management,” revised date 10/25/2023, showed in part the following: - Nursing staff were to inquire, recognize, and report all patient reports of pain; - Patients were to be reassessed with routine nursing assessments for pain management; - Pain was to be communicated by numeric scale, and faces pain scale; - Non-verbal patients were to be assessed based on physical indicators; and - Nursing staff were to monitor pain symptoms at every shift and document in the nursing notes. Review of the providers policy titled, “;Plan of Care,” (POC) revised date 01/2023, showed in part the following: -The plan of care must include the management of discomfort and symptom relief; and -The plan of care must include initial and ongoing assessment of patient needs and goals. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/01/2022 with a terminal diagnosis of Parkinsons disease with dyskinesia, without fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and resided at a long-term care facility (LTCF). Review of the comprehensive assessment, dated 06/01/2022, showed in part: - The patient was able to verbalize pain; - Pain was an active problem for the patient; - The patient was unable to describe pain; - Pain was affecting the patients level of function; - Interventions included comfort and symptom control; - The plan for the next visit included comfort and symptom control; - Communication notes showed the patient reported severe painful muscle spasms in his/her legs two to three times a day, had sharp pains on the left side of his/her body, and migraine headaches one time a month; and - The clinician failed to perform a comprehensive pain assessment that included interventions to manage pain and symptoms. Review of the interdisciplinary group (IDG) update POC, dated 03/06/2025, showed in part: - - On 09/09/2024, the patient’s pain was rated at a “0” (zero- on a numerical pain scale in which zero indicated no pain and 10 indicated the worst possible pain) and fatigue rated at a “6” (six), however there was not a scale shown to indicate what a fatigue level score of six meant; - The patient would be pain free or verbalize an acceptable pain level with his/her current pain medications; - Management and severity of pain had not been updated since 06/01/2022; and - The IDG narrative know at the facility as “;prep notes” section showed, the patient reported no pain, current pain medication routine was Tylenol, routine topicals, and Morphine as needed, however the patient had not needed Morphine. - The IDG/POC update failed to include updated individualized interventions for the management and severity of the patient’s pain (the last update was on 06/01/2022). Observation on 03/11/2025 at 8:45 AM during the patient’s home visit, showed the patient was able to have a conversation and was able to answer questions when asked. Per interview conducted during observation, the patient stated that: - He/She had an open sore on his/her buttocks; - The LTCF, and hospice had ignored his/her requests for help with the pain; - The patient stated the “;white pills” (Tylenol) and the “;blue pill” (naproxen; a class of medications called NSAIDs give to reduce pain and fever) was not helping to control the pain; and - Pain medication was often slow in coming, and the LTCF runs out on the weekends. Review of the POC, dated 03/05/2025, showed the POC: - The pain management section: A comprehensive pain assessment was not completed; - Failed to include the patient’s acceptable level of pain; - Failed to contain individualized guidance on pain and symptom management which included offering morphine or prescription pain medication after patient reported pain unrelieved by scheduled Tylenol; and - Failed to include individualized communication methods for reporting pain. During an interview on 03/11/2025 at 10:20 AM, the hospice registered nurse stated that: - The patient has a prescription order for regular doses of Tylenol and an as needed dose of Tylenol; - The patient had an order for naproxen 500 mg every 4 hours as needed (prn); - The patient was assessed and did not have open pressure ulcers. He/she had a red area that was treated with a moisture barrier cream; - The patient had an air mattress for pressure relief, positioning wedges in the bed, and a pressure-relieving cushion for the wheelchair; - The patient was often dramatic with visitors and would deny pain when staff check on him/her; and - He/she would expect the facility staff nurse to give pain medications when requested and utilize the morphine prescribed if the Tylenol and naproxen did not control the pain. During an interview on 03/12/2025 at 10:50 AM, the clinical manager stated that all patient reports of pain should be addressed immediately, and the patient should be as comfortable as possible. During an interview on 03/13/2025 at 11:00 AM, the clinical manager stated that a pressure ulcer was discovered on the buttocks of Patient #1 and a treatment plan was being established during the interdisciplinary group meeting.”

“Based on policy review, record review, and interview the hospice provider failed to ensure that the plan of care (POC) was updated in two of five full charts reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/CLIENT #2: Review of the clinical record showed the patient was admitted to hospice service on 10/18/2023 with a primary diagnosis of Type II Diabetes (a group of diseases that results in too much sugar in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long term care facility (LTCF). Review of the skilled nurse (SN) visit, dated 02/18/2025, showed the wound care frequency, for the left buttock, every Monday, Wednesday, and Friday. Review of the interdisciplinary group (IDG) meeting, dated 02/20/2025, showed in part, the following: - The left buttock wound had not shown signs of improving in the past week; - Cleanse left buttock wound, apply foam border dressing, and change every seven days; and - The IDG notes failed to change wound care frequency to Monday, Wednesday, and Friday. Findings included: Review of the providers policy titled, “;Plan of Care,” revised 01/2023, showed, in part: - The comprehensive plan of care will be based on the initial comprehensive and ongoing assessments by all team members; - All hospice interdisciplinary team members involved in the patients care will contribute to the written plan of care, in coordination with the patients attending physician, the patient/patient representative and the primary caregiver; - The plan of care should include: * Patient, family or caregiver needs; * Goals; * Dates problems identified/onset; * Resolution date; and -Hospice updates the plan of care as often as the condition of the patient indicates by the attending physician, the medical director of physician designee and interdisciplinary group. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to hospice services on 12/08/2024 with a primary diagnosis of senile degeneration of the brain not elsewhere classified (a group of conditions that cause a progressive decline in cognitive abilities such as memory, thinking, and reasoning). The patient resided in a long-term care facility. Review of the initial assessment dated 12/08/2025, showed that the patient was admitted with an unstageable pressure ulcer (an area with full-thickness tissue loss where the base of the wound is obscured making it impossible to determine the stage) to the left heel that measured 1.5 centimeters (cm) in length by 1.3 cm in width and had a depth of 0 cm. Review of the initial plan of care dated 12/08/2024 to 03/07/2025, showed an order to apply skin prep to the left heel twice per day. Review of a skilled nurses (SN) note dated 01/14/2025, showed that the unstageable pressure ulcer was healed. Review of the interdisciplinary group meeting note dated 01/23/2025, showed that the patient had no active wounds. Review of the physician order sheet, medication administration record, and treatment administration record from the long-term care facility dated 03/11/2025, failed to show any orders for skin treatments for a pressure ulcer. Review of the POC dated 03/08/2025 to 06/05/2025 showed an order to clean the area with wound cleanser, pat dry and apply skin prep daily starting 12/19/2024. The provider failed to ensure that the POC was updated based on the needs of the patient and orders from the physician.”

“Based on nationally recognized standards, home visit observation, and interview the hospice provider failed to ensure that infection control guidelines were followed to prevent the transmission of infections in one of four home visit observations completed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the Centers for Disease Control (CDC) policy titled, “Hand Hygiene Guidance,” dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient’s immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. RECORD/PATIENT #4: Observation on 03/11/2025, beginning at 8:45 AM, during the patients long-term care facility home visit, showed the nurse did the following during a dressing change: - Donned gloves and measured the wound on the patients scalp; - Wore the soiled gloves and dug through a box of supplies located in the patients room; - Removed his/her gloves and failed to perform hand hygiene; - Left the room for approximately two minutes to search for more supplies then returned with the supplies; - Sanitized his/her hands with alcohol hand gel and cleaned his/her dirty equipment (wrist blood pressure cuff, stethoscope, thermometer, pulse oximeter, and measuring tape) without gloves then washed his/her hands with soap and water; - Donned gloves and opened a package of gauze to clean the scalp wound with wound cleanser spray; - Removed the glove on his/her right hand that was used to clean the wound and donned a clean glove and failed to perform hand hygiene; - Opened a package of gauze to dry the scalp wound and proceeded to dry the wound and failed to remove his/her gloves or perform hand hygiene; - Wore soiled gloves and opened a dressing to apply to the wound; - Picked up trash from the table, removed his/her gloves and used alcohol hand gel to sanitize his/her hands; - Left the room for supplies, returned and used alcohol hand gel to sanitize his/her hands; - Donned gloves and placed the dressing on the patients wound; and - Removed his/her gloves and used alcohol hand gel to sanitize his/her hands. During an interview on 03/12/2025, beginning at 1:35 PM, the registered nurse (RN) coordinator stated that he/she would expect the skilled nurse to wash or sanitize his/her hands before contact with the patient, if they touched the patient, if they touched equipment that had touched the patient, and when they removed their gloves.”

“Based on policy review, record review, and interview the hospice provider failed to ensure that wounds were measured in accordance with standards of practice in two of three applicable full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice service on 10/18/2023 with a primary diagnosis of Type II Diabetes (a group of diseases that results in too much sugar in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long term care facility (LTCF). Review of the skilled nurse (SN) recertification assessment, dated 01/27/2025, showed in part, the following: - Braden Scale Score (pressure ulcer risk assessment) of 10 (a score of from 10 to 12 required increased vigilance and preventative measures); - Urine and bowel incontinence; - Inability to change positions; and - Stage I ulcer on left buttock, measured 5 centimeters (cm) by 2.5 cm. Review of the patients plan of care, dated 02/03/2025, for the certification period from 02/09/2025 to 04/09/2025, showed in part, the nurse would do the following: - Assess the status of the left buttock wound every visit; and - Make recommendations as necessary to the facility staff for treatment. Review of the interdisciplinary group (IDG) meeting, dated 03/06/2025, showed the nurse failed to document the measurement of the left buttock wound on 02/24/2025. Review of the SN visit, dated 02/24/2025, showed the nurse failed to document the measurement of the left buttock wound. During an interview on 03/12/2025 at 1:38 PM, the registered nurse coordinator (RNC: known at the agency as clinical manager) stated that measurements of the patients wound would be completed weekly, unless the wound had already been dressed and covered. The RNC stated that if the wound was covered the nurse would be expected to get the wound measurements from the LTCFs nurses notes. Findings included: Review of the providers policy titled, “;Wounds: Treatment of Pressure and Non-Pressure Injuries, including Staging and Documentation,” revised 10/2023 showed, in part: - Any wound is to be assessed by a licensed nurse or licensed practitioner. The location, stage, size, odor, undermining, tunneling, exudates, necrotic tissue, and presence or absence of granulation tissue, peri-wound, and wound edge description should be noted and documented in the patients medical record at least weekly. Wound assessment documentation should be completed for pressure injuries and recommended for any other skin issues of concern; - Document presence or absence of skin impairment of any kind on admission, transfer, and discharge. If present, describe the condition or wound thoroughly; and - All patients skin conditions are to be documented at least weekly. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 07/12/2024 with a primary diagnosis of cerebrovascular disease (a range of conditions that affect the brains blood flow) and a secondary diagnosis of unspecified malignant neoplasm (a cancerous lesion) of the skin of the scalp and neck. The patient resided in a long-term care facility. Review of the initial assessment, dated 07/12/2024, showed that the patient had a non-healing scalp wound requiring daily dressing changes due to skin/scalp cancer and the assessment failed to show any measurements of the area. Review of the skilled nurses (SN) note, dated 01/15/2025, showed no documentation regarding an assessment or measurements of the patients scalp wound. Review of the SN note, dated 01/24/2025, showed under the wound assessment that the wound on the scalp had a dry wound bed and the wound cleaning and dressing change were completed per care plan. No other assessment or measurements were provided. Review of the SN note, dated 01/29/2025, showed under the wound assessment that the wound on the scalp had a dry wound bed, wound edges were attached, the peri-wound was denuded (the loss of the outermost layer of skin often caused by moisture, friction, or body fluids), there was no drainage or odor, and the wound cleansing and dressing change were completed per care plan. No measurements were provided. Review of the SN note, dated 02/06/2025, showed under wound assessment that the wound on the scalp had a wound bed that contained eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed) and slough (dead tissue in a wound bed), the wound bed was 40% red, 20% yellow, and 40% black (a healing wound bed should be pink or red in color), the peri-wound was denuded, and there was a moderate amount of sanguinous (blood- tinged drainage)/bloody drainage. No measurements were provided. Review of the SN note, dated 02/12/2025, showed under wound assessment that the wound had a dry wound bed and the wound cleaning and dressing change were completed per care plan. No other assessment or measurements were provided. Review of the SN note, dated 03/05/2025, showed under wound assessment that the wound had a moist wound bed, the peri-wound was denuded, there was a moderate amount of sanguinous/bloody drainage, there was no odor, and the wound cleaning and dressing change were completed per care plan. No measurements were provided. During an interview on 03/12/2025, beginning at 1:35 PM, the clinical manager stated that wound measurements and assessments should be done once a week on the visit unless there is a timing issue with the facility. He/She would expect the hospice nurse to get measurements from the facility and document those if they are unable to complete measurements themselves on the visit and that every wound should be measured regardless of type. Findings included: Review of the providers policy titled, “;Wounds: Treatment of Pressure and Non-Pressure Injuries, including Staging and Documentation,” revised 10/2023, showed in part: - Any wound is to be assessed by a licensed nurse or licensed practitioner. The location, stage, size, odor, undermining, tunneling, exudates, necrotic tissue, and presence or absence of granulation tissue, peri-wound, and wound edge description should be noted and documented in the patients medical record at least weekly. Wound assessment documentation should be completed for pressure injuries (skin injury caused by unrelieved pressure) and recommended for any other skin issues of concern; - Document presence or absence of skin impairment of any kind on admission, transfer, and discharge. If present, describe the condition or wound thoroughly; and - All patients skin conditions are to be documented at least weekly. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/18/2023 with a terminal diagnosis of type II (two) diabetes (a group of diseases that results in too much sugar in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long-term care facility (LTCF). Review of the skilled nurse (SN) recertification assessment, dated 01/27/2025, showed in part, the following: - A Braden Scale Score (pressure ulcer risk assessment) of 10 (a score of from 10 to 12 required increased vigilance and preventative measures); - Urine and bowel incontinence; - Inability to change positions; and - A stage I (one) ulcer (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved) on left buttock, measured 5 centimeters (cm) by 2.5 cm. Review of the patients plan of care, dated 02/03/2025, for the certification period from 02/09/2025 to 04/09/2025, showed in part, the nurse would do the following: - Visit once per week for nine weeks with 10 visits as needed for pain and symptom management; - Assess the status of the left buttock wound every visit; and - Make recommendations as necessary to the facility staff for treatment. Review of the SN visit, dated 02/24/2025, showed the nurse failed to document the measurement of the left buttock wound. Review of the interdisciplinary group (IDG) meeting, dated 03/06/2025, showed the nurse failed to document the measurement of the left buttock wound on 02/24/2025. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 07/12/2024 with a terminal diagnosis of cerebrovascular disease (a range of conditions that affect the brains blood flow) and a secondary diagnosis of unspecified malignant neoplasm (a cancerous lesion) of the skin of the scalp and neck. The patient resided in a LTCF. Review of the initial assessment, dated 07/12/2024, showed that the patient had a non-healing scalp wound requiring daily dressing changes due to skin/scalp cancer. The initial assessment failed to show any measurements of the area. Review of the SN note, dated 01/15/2025, showed no documentation regarding an assessment or measurements of the patients scalp wound. Review of the SN note, dated 01/24/2025, showed under the wound assessment that the wound on the scalp had a dry wound bed and the wound cleaning and dressing change were completed per care plan. No other assessment or measurements were provided. Review of the SN note, dated 01/29/2025, showed under the wound assessment that the wound on the scalp had a dry wound bed, wound edges were attached, the peri-wound was denuded (the loss of the outermost layer of skin often caused by moisture, friction, or body fluids), there was no drainage or odor, and the wound cleansing and dressing change were completed per care plan. No measurements were provided. Review of the SN note, dated 02/06/2025, showed under wound assessment that the wound on the scalp had a wound bed that contained eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed) and slough (dead tissue in a wound bed), the wound bed was 40% red, 20% yellow, and 40% black (a healing wound bed should be pink or red in color), the peri-wound was denuded, and there was a moderate amount of sanguinous (blood- tinged drainage)/bloody drainage. No measurements were provided. Review of the SN note, dated 02/12/2025, showed under wound assessment that the wound had a dry wound bed and the wound cleaning and dressing change were completed per care plan. No other assessment or measurements were provided. Review of the SN note, dated 03/05/2025, showed under wound assessment that the wound had a moist wound bed, the peri-wound was denuded, there was a moderate amount of sanguinous/bloody drainage, there was no odor, and the wound cleaning and dressing change were completed per care plan. No measurements were provided. During an interview on 03/12/2025, beginning at 1:35 PM, the registered nurse (RN) coordinator stated that wound measurements and assessments should be done once a week on the visit unless there is a timing issue with the facility. He/She would expect the hospice nurse to get measurements from the facility and document those if they are unable to complete measurements themselves on the visit and that every wound should be measured regardless of type.”

“Based on job summary review, clinical record review, and interview the hospice aide failed to report changes in the patients medical needs to a registered nurse (RN) in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the providers job summary for the certified nurse assistant (CNA) titled, “;Job Description/Performance Appraisal,” last revised March 2003, showed in part, the CNA kept the charge nurse informed of pertinent information that may require follow-up. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 10/18/2023 with a primary diagnosis of type II (two) diabetes (a group of diseases that results in too much suage in the blood) and chronic osteomyelitis (an infection in the bone) of the vertebral spine with past medical history of chronic pain. The patient resided in a long-term care facility (LTCF). Review of the patients plan of care for the recertification period from 02/09/2025 to 04/09/2025, showed in part, the following interventions for the aide: - Weigh the patient monthly during the first visit of each month, with each recertification, and as requested by the RN or the RN coordinator (known at the provider as the clinical manager (CM)); - Report all bowel movements and or lack of bowel movements; - Report to the RN or CM if there was no bowel movement in three days; and - Notify LTCF staff and RN or CM of any patient complaint of pain or nonverbal signs of pain. Review of the hospice aide visit notes for the recertification visit, dated 02/10/2025, and the first visit of the month, dated 03/03/2025, showed the hospice aide failed to obtain the patients weight. Review of the LTCF’s bowel movement (BM) record for the patient, dated from 01/31/2025 to 03/11/2025, showed in part, the patient had no BM from 02/26/2025 to 03/03/2025. Review of the hospice aide visit notes, dated 03/03/2025, showed the hospice aide failed to notify the RN the patient had no BM for the previous five days. During an interview on 03/12/2025 at 1:38 PM, the RN coordinator (RNC) stated that the aide was expected to report any changes in condition to the nurse and document the change on the aide sheet. The RNC stated that the aide was expected to follow the plan of care.”

“Based on policy review, record review, and interview the hospice provider failed to ensure that the discharge summary was sent to the attending physician in two of three live discharge records reviewed (Records/Patients #7 and #10) and in one of two revocation records reviewed (Record/Patient #9). This deficient practice has the potential to affect all the patients discharged by the provider. Findings included: Review of the providers policy titled, “;Discharge from Hospice,” dated 10/2022, showed in part: - Hospice Manager provides that the necessary paperwork is completed at the time of discharge. This will include a signed Revocation Form, if necessary, and completion of a discharge summary; - Hospice staff will file the appropriate discharge documentation in the clinical record; and - If a patient is transferring to an acute facility or another hospice, the patients medical record shall be copied and sent to the receiving organization along with a discharge summary. RECORD/PATIENT #7: Review of the clinical record showed that the patient was admitted to hospice services on 04/20/2023 and discharged from hospice services on 12/18/2024 for no longer meeting eligibility requirements for hospice care. A discharge summary was completed on 12/19/2024 and the provider failed to ensure that a copy of the discharge summary was sent to the attending physician. RECORD/PATIENT #9: Review of the clinical record showed that the patient was admitted to hospice services on 03/04/2023 and revoked hospice services on 01/17/2024 due to the patients caregiver requesting an evaluation in the emergency room. A discharge summary was completed on 01/17/2024 and the provider failed to ensure that a copy of the discharge summary was sent to the attending physician. RECORD/PATIENT #10: Review of the clinical record showed that the patient was admitted to hospice services on 05/25/2024 and discharged from hospice services on 11/20/2024 for no longer meeting eligibility requirements for hospice care. A discharge summary was completed on 11/22/2024 and the provider failed to ensure that a copy of the discharge summary was sent to the attending physician. During an interview on 03/13/2025 at 8:35 AM, the registered nurse (RN) coordinator stated that he/she would expect a discharge summary to be completed and sent to the medical director. He/she stated that he/she was unsure if the attending physician received a discharge summary. During an interview on 03/13/2025 at 9:10 AM, the RN coordinator stated that the electronic medical record (EMR) was only set up to send the discharge summary to the medical director at that time.”

“Based on policy review, employee file review, and interview, the hospice provider failed to ensure that a criminal background check (CBC) was performed prior to first patient contact, in two of six employee files reviewed (Employees #2 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Client/Resident Mistreatment, Neglect and Abuse,” revised date 05/2019, showed in part, the facility screens potential employees with the employee disqualification list (EDL) and conducts a criminal background check (CBC) prior to an applicant being offered employment by [named hospice]. Review of the providers policy titled, “;Sanction Screening-State/Federal Health Care Programs,” revised date 04/2019, showed in part, the facility to ensure that all employees, medical staff, and others are not ineligible for a business relationship due to an exclusion by federal or state enforcement agency, or criminal conviction, and should be screened by the human resources department for criminal back ground check and employee disqualification list, with other registries as necessary. EMPLOYEE #2: Review of the employee file showed the following: - Date of hire: 12/26/2023; and - The employee file failed to include a CBC as of 03/12/2025. During an interview on 03/12/2025 at 3:25 PM, the human resource director stated that there was no CBC available prior to employee #2s date of hire. EMPLOYEE #4: Review of the employee file showed the following: - Date of hire: 09/01/2021; and - The employee file failed to include a CBC as of 03/13/2025. During an interview on 03/12/2025 at 1:40 PM, the registered nurse (RN) coordinator stated that the CBC should be completed for all staff whether a contract staff or direct hire, before the first patient contact.”