Three Rivers Hospice South

“Based on review of the emergency preparedness manual provided by the administrator, policy review, and interview the hospice provider failed to ensure emergency preparedness policies and procedures were developed for the providers specific location and its branches and failed to ensure that on-duty staff and patients would be followed up with in the case of an emergency. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the emergency preparedness manual provided by the administrator showed the hospice provider failed to develop emergency preparedness policies and procedures that were location specific to the parent office and its branches. Review of the provider’s policy titled, “Disaster Plan,” dated 2018, failed to show that on-duty staff and patients would be followed up with in the case of an emergency. During an interview on 07/23/2024 at 4:15 PM, the hospice administrator stated that each agency uses the same emergency preparedness policy and the parent office and branches do not have agency specific policies and procedures.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure a medication review identified duplicate drug therapy in one record (Record/Patient #3) and failed to ensure medications were reconciled in one record (Record/Patient #4) of of five records reviewed. This deficient practice has the potential to affect all of the provider’s patients. Findings included: RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 04/12/2024 with a terminal diagnosis of cachexia (a general state of ill health involving great weight loss and muscle loss). The patient had a secondary diagnosis of insulin dependent diabetes. The patient resided in a skilled nursing facility. Review of the document titled, “Physician Orders Medication Profile,” showed the following orders: -Lantus Solostar (used to treat diabetes) Insulin subcutaneous pen- Inject 10 units subcutaneous at 8:00 PM. The skilled nursing facility’s (SNF) medication record failed to contain this medication; and -Skin prep (protects skin from friction) apply to left heel twice daily. The SNF’s medication record stated to apply to bilateral (both) heels twice daily. During an interview on 07/24/2024 at 11:45 AM, the hospice administrator stated that he/she would expect medications and orders to match between the agency and the facility. Review of the providers policy titled, “;Medication,” dated 2018, showed that:- A medication list shall be maintained for each client;- The medical director will review the complete medication profile upon admission and every 14 days, as new medications are added or patients condition changes, to ensure medication effectiveness, actual or potential medication related effects, duplicate therapy, and untoward interactions. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/02/2023 with a terminal diagnosis of hypertensive heart disease (structural and functional changes in the heart as a result of chronic high blood pressure). The patient had a secondary diagnosis of insulin dependent diabetes (a problem in the way the body regulates and uses sugar as a fuel). The patient resided in a skilled nursing facility. Review of the document titled, “;Physician Orders Medication Profile,” dated 07/24/2024 showed the document contained the following duplicated medications as currently active for the patient:- Acid reducer (famotidine) 20mg tablet, take one tablet by mouth two times daily with an order date of 07/12/2023;- Famotidine 20mg tablet, take one tablet by mouth two times daily with an order date of 07/12/2024; - Zofran 4 mg tablet, take one tablet by mouth every six hours as needed for nausea with an order date of 07/12/2023; and- Ondansetron (the generic form of Zofran) 4mg disintegrating tablet, take one tablet by mouth every six hours as needed for nausea with an order date of 07/12/2024. During an interview on 07/24/2024 at 11:34 AM, the director of clinical services stated that they would expect the medication profile to be free of duplicate therapy, and the plan of care document did contain duplicate orders.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure there was proof of collaboration with the patient’s attending physician in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Physician Orders,” dated 2018, showed admission orders shall be counter-signed by both the Attending Physician and the Hospice Medical Director within 7 days of the receipt of the telephone order. Review of the provider’s policy titled, “ Comprehensive Assessment/Care Plan Development,” dated 2018, showed the members of the Interdisciplinary Group will approve the plan of care within five days. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 07/03/2024 with a terminal diagnosis of Creutzfeldt-Jakob disease (a degenerative brain disorder that leads to dementia and death). The patient resided in a skilled nursing facility. Review of the document titled, “Combined Disciplinary Plan of Care,” reviewed by State agency (SA) on 07/23/2024 and dated 07/03/2024 failed to show a physician’s signature. During an interview on 07/23/2024 at 3:00 PM, the director of clinical services (DCS; Governing body designee-A) stated that the provider did not have proof the patient’s plan of care (POC) was sent to the attending physician for signature. The DCS also stated that they did not have a signed copy of the POC back from the attending physician.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure that the patients’ plan of care (POC) was individualized in, but not limited to, five of eleven records reviewed (Records/Patients #1, #2, #3, #4, & #5). This deficient practice has the potential to affect everyone served by the provider. Findings included: Review of the provider’s policy titled, “Comprehensive Assessment/Care Plan Development,” dated 2018, showed, in part, the following: -Care plan will be completed by all members of the interdisciplinary group (IDG) with information gathered from the comprehensive assessment as such needed relate to the terminal illness and related conditions of the client/family; -The plan of care (POC) clearly identifies each problem individualized to the client/family with measurable goals and outcome criteria, and the scope and frequency of services to be provided; and -Interventions related to each problem, including specific actions with frequency and duration, are included in the POC. RECORD/PATIENT #4: Review of the clinical record showed the patient admitted to hospice services on 04/12/2024 with a terminal diagnosis of cachexia (a general state of ill health involving great weight loss and muscle loss). The patient resided in a skilled nursing facility. Review of the document titled, “Nurse Progress Note Initial Assessment,” dated 04/12/2024, showed the patient has the following: -Weakness and is bed/wheelchair bound; -Lost six percent of total body weight in the last six months; and -Increased risk for falls. Review of the document titled, “Combined Disciplinary Plan of Care,” dated 04/17/2024, failed to show that the patient needed interventions for falls or needed interventions for weight loss. RECORD/PATIENT #5: Review of the clinical record showed the patient admitted to hospice services on 07/03/2024 with a terminal diagnosis of Creutzfeldt-Jakob Disease (a degenerative brain disorder that leads to dementia and death). The patient resided in a skilled nursing facility. Review of the document titled, “Nurse Progress Note Routine Visit,” dated 07/15/2024, showed that: -Patient was a two person assist and had tonic jerking movements; -Patient required thickened liquids; -Patient would be started on mechanical soft diet; and -Patient was guided to use chin tuck to safely swallow foods. Review of the document titled, “Combined Disciplinary Plan of Care,” dated 07/17/2024, failed to show interventions for fall risk or nutritional/diet interventions. During an interview on 07/23/2024 at 12:20 PM, the director of clinical services stated that he/she would expect patient specific interventions to be included in the plan of care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/28/2024 with a terminal diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity). The patient resided in their own home with the assistance of an adult child. Review of the document titled, “;Combined Disciplinary Plan of Care,” with creation date of 07/17/202, showed the document failed to contain specific and individualized goals, including, but not limited to:- Cardiopulmonary goal: * The patient will verbalize satisfactory control of shortness of breath episodes; * The plan of care failed to define the parameters for “;satisfactory control”;- Immunological/Infection goal: * Patient infection will be resolved; * Review of the plan of care showed the patient’s infection was resolved in May 2024; - Nutrition/Hydration goal: * Patient will have adequate food and fluids as tolerated to maintain comfort; * The plan of care failed to define the parameters for “;adequate food and fluids as tolerated”;- The plan of care failed to contain specific, individualized goals for the identified problems of gastrointestinal issues, genitourinary issues, and financial issues. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/02/2023 with a terminal diagnosis of hypertensive heart disease (structural and functional changes in the heart as a result of chronic high blood pressure). The patient had a secondary diagnosis of insulin dependent diabetes (a problem in the way the body regulates and uses sugar as a fuel). The patient resided in a skilled nursing facility. Review of the document titled, “;Combined Disciplinary Plan of Care,” with creation date of 07/16/2024 showed the document failed to contain specific and individualized goals, including, but not limited to:- Cardiopulmonary goal: * The patient will verbalize an acceptable level of cardio-related pain; * The plan of care failed to define the parameters for “;acceptable level”;- The plan of care failed to contain specific, individualized goals for the identified problems of infection, nutrition, gastrointestinal issues, and financial issues. During an interview on 07/24/2024 at 11:34 AM, the director of clinical services stated that:- The electronic medical record system would not let the clinicians remove problems, and goal progression for items not related to the patient from the plan of care; and- The plan of care did contain problems and goal progression items not related to the patient. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice care on 12/29/2022 with a terminal diagnosis of biventricular heart failure (a condition that affects both the left and right sides of the heart) and a secondary diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood flow to the heart) and a history of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with caregiver assistance. Review of the Physician Orders Visit Frequency showed the Volunteer Visit Frequency was ordered 12/24/2023, at one visit every 4 weeks. Review of the Volunteer Progress Notes showed that a volunteer was visiting the patient and caregiver two times per month, as documented on 06/05/28, 06/28/2024, 07/05/2024, and 07/12/2024. Record review of the Nurse Progress Note Routine Visits dated 07/02/2024, 07/05/2024, 07/09/2024, 07/11/2024, and 07/16/2024, showed edema (swelling) in the lower extremities, shortness of breath and generalized pain had been listed as issues in each of the summaries of the progress notes. Record review of the Combined Disciplinary Plan of Care (POC) revised on 07/17/2024, failed to be individualized and include goals and interventions for the following:- Edema in the patients lower extremities (legs and feet); - Shortness of breath (SOB); and- Volunteer. Observation and interview on 07/22/2024, at 4:30 PM, during a home visit, showed the patient became short of breath during normal conversation with the Social Worker and State Auditor (SA). The patient had to visibly stop talking after three to four words, to allow time for his/her breathing to become normalized. An oxygen compressor with tubing was sitting at the foot of his/her hospital bed, not running, with the tubing laying across the walkway of the living room floor. The patient and his/her caregiver also talked about the volunteer coming to the house to relieve the caregiver. The patient complained of knee pain, but did not need any medicine, he/she stated that heat helped to relieve the pain. The POC failed to be individualized and include any interventions for non-medicinal related treatments for pain. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice care on 12/29/2022 with a terminal diagnosis of biventricular heart failure (a condition that affects both the left and right sides of the heart) and a secondary diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood flow to the heart) and a history of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with caregiver assistance. Review of the Physician Orders Visit Frequency showed the Volunteer Visit Frequency was ordered 12/24/2023, at one visit every 4 weeks. Review of the Volunteer Progress Notes showed that a volunteer was visiting the patient and caregiver two times per month, as documented on 06/05/28, 06/28/2024, 07/05/2024, and 07/12/2024. Record review of the Nurse Progress Note Routine Visits dated 07/02/2024, 07/05/2024, 07/09/2024, 07/11/2024, and 07/16/2024, showed edema (swelling) in the lower extremities, shortness of breath and generalized pain had been listed as issues in each of the summaries of the progress notes. Record review of the Combined Disciplinary Plan of Care (POC) revised on 07/17/2024, failed to be individualized and include goals and interventions for the following:- Edema in the patients lower extremities (legs and feet); - Shortness of breath (SOB); and- Volunteer. Observation and interview on 07/22/2024 at 4:30 PM, during a home visit, showed the patient became short of breath during normal conversation with the Social Worker and State Auditor (SA). The patient had to visibly stop talking after three to four words, to allow time for his/her breathing to become normalized. An oxygen compressor with tubing was sitting at the foot of his/her hospital bed, not running, with the tubing laying across the walkway of the living room floor. The patient and his/her caregiver also talked about the volunteer coming to the house to relieve the caregiver. The patient complained of knee pain, but did not need any medicine, he/she stated that heat helped to relieve the pain. The POC failed to be individualized and include any interventions for non-medicinal related treatments for pain. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice care on 12/29/2022 with a terminal diagnosis of biventricular heart failure (a condition that affects both the left and right sides of the heart) and a secondary diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood flow to the heart) and a history of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with caregiver assistance. Review of the Physician Orders Visit Frequency showed the Volunteer Visit Frequency was ordered 12/24/2023, at one visit every 4 weeks. Review of the Volunteer Progress Notes showed that a volunteer was visiting the patient and caregiver two times per month, as documented on 06/05/28, 06/28/2024, 07/05/2024, and 07/12/2024. Record review of the Nurse Progress Note Routine Visits dated 07/02/2024, 07/05/2024, 07/09/2024, 07/11/2024, and 07/16/2024, showed edema (swelling) in the lower extremities, shortness of breath and generalized pain had been listed as issues in each of the summaries of the progress notes. Record review of the Combined Disciplinary Plan of Care (POC) revised on 07/17/2024, failed to be individualized and include goals and interventions for the following:- Edema in the patients lower extremities (legs and feet); - Shortness of breath (SOB); and- Volunteer. Observation and interview on 07/22/2024 at 4:30 PM, during a home visit, showed the patient became short of breath during normal conversation with the Social Worker and State Auditor (SA). The patient had to visibly stop talking after three to four words, to allow time for his/her breathing to become normalized. An oxygen compressor with tubing was sitting at the foot of his/her hospital bed, not running, with the tubing laying across the walkway of the living room floor. The patient and his/her caregiver also talked about the volunteer coming to the house to relieve the caregiver. The patient complained of knee pain, but did not need any medicine, he/she stated that heat helped to relieve the pain. The POC failed to be individualized and include any interventions for non-medicinal related treatments for pain.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that routine orders were individualized to meet the needs of the patient in three of five full records reviewed (Records/Patients #1, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, “;Comprehensive Assessment/Care Plan Development,” updated 2018, showed in part: - Interventions related to each problem, including specific actions with frequency and duration, are included in the plan of care; and - The plan of care will address such items as the following; Medications and treatments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice care on 12/29/2022 with a terminal diagnosis of biventricular heart failure (a condition that affects both the left and right sides of the heart) and a secondary diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood flow to the heart). The patient lived at home with caregiver assistance. Review of the document titled, “;Physician Orders for Hospice Patient,” dated 07/22/2024, showed the following: - Adult Aspirin (nonsteroidal anti-inflammatory and blood thinner), 1-2 tablets daily by mouth for clot prevention; - Gas Relief (simethicone helps break up the bubbles in gas and may help gas pass through your digestive tract), 1-2 capsules as needed up to four times per day for gas pain; - Refresh Tears (artificial tears used to lubricate the eye), 1-2 drops in affected eye as needed up to four times daily; - Benadryl Allergy (antihistamine used to relieve symptoms of allergy), 1-2 tablets every 4 to 6 hours as needed for itching; - Colace (laxative), 1-2 capsules once daily for constipation; - Oxygen, 2 to 4 liters per nasal cannula as needed for dyspnea (shortness of breath); - Atropine eye drops (used to treat inflammation in the eye and before certain eye exams, also used to treat excessive saliva production), 2-4 drops per mouth every hour as needed for excess secretions; - Lorazepam (controlled substance sedative), 0.25-1 milliliter (ml) every hour as needed for anxiety or restlessness; and - Roxanol (controlled substance narcotic), 0.25-1 ml every hour as need for pain or air hunger. Review of the clinical record failed to contain: - Individualized written orders for the medications listed above; - Specific instructions in each order on when to give the lowest dose and when to give the maximum dose; and - On the Refresh Tears which eye to administer the drops in. Review of the provider’s policy titled, “Medication,” dated 2018, showed that medication orders shall include the medication name, dose, frequency, and route of administration. Orders with variable doses or frequencies shall specify a maximum dose or frequency and the reason for administration. RECORD/PATIENT #4: Review of the clinical record showed the patient admitted to hospice services on 04/12/2024 with a terminal diagnosis of cachexia (a general state of ill health involving great weight loss and muscle loss). The patient resided in a skilled nursing facility (SNF). Review of the document titled, “Physician Orders Medication Profile,” dated 07/23/2024, showed an order for Morphine Concentrate (used to treat severe pain) 20 milligrams (mg) per milliliter (mL). Give 0.25-1 mL sublingual every hour as needed for pain/air hunger. Review of the clinical record failed to contain: -Individualized written orders for the medication listed above; and -Specific instructions in each order on when to give the lowest dose and when to give the maximum dose. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 07/03/2024 with a terminal diagnosis of Creutzfeldt-Jakob Disease (a degenerative brain disorder that leads to dementia and death). The patient resided in a SNF. Review of the document titled, “Physician Orders Medication Profile,” dated 07/22/2023, showed the following orders: -Oxygen apply 2-4 liters via nasal cannula as needed for shortness of breath; -Lorazepam (used to relieve anxiety) 2 mg/mL oral concentrate. Give 0.25-1 mL by mouth every hour as needed for anxiety/restlessness; and -Roxanol (used to relieve severe pain) 20 milligrams mg/mL. Give 0.25-1 mL sublingual every hour as needed for pain/air hunger. Review of the clinical record failed to contain: -Individualized written orders for the medication listed above; and -Specific instructions in each order on when to give the lowest dose and when to give the maximum dose. During an interview on 07/24/2024 at 11:45 AM, the director of clinical services stated that he/she would expect parameters for ranged doses.”

“Based on policy review, record review, observation, and interview the hospice provider failed to address the use of durable medical equipment in the patients plan of care (POC) in, but not limited to, three of five full records reviewed (Records/Patients #1, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Durable Medical Equipment Authorization & Ordering,” updated 2018, showed the Durable Medical Equipment (DME) provider was responsible for training the patient and family/caregiver on the safe and proper use of equipment and the DME provider would observe and verify the patient and family/caregiver could use the equipment appropriately to satisfy the Hospice’s staff. Review of the provider’s policy titled, “Equipment and Supplies, “ updated 2018, showed the provider would provide education for patient and family/caregiver, employees, and volunteers on the safe use of medical equipment. Review of the providers policy titled, “;Medical Supplies and Appliances,” updated 2018, showed the provision of medical supplies and appliances shall be coordinated as needed, as identified in the hospice plan of care. Review of the providers policy titled, “;Comprehensive Assessment/Care Plan- Development,” updated 2018, showed in part, the following: - Durable medical equipment and supplies required; - The plan of care (POC) is available to all Hospice Staff involved in the clients care; and - All employees will be familiar with the POC before providing care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice care on 12/29/2022 with a terminal diagnosis of biventricular heart failure (a condition that affects both the left and right sides of the heart), and a secondary diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood flow to the heart), and abnormal result of other cardiovascular function study, as well as several other conditions. The patient lived at home with caregiver assistance. Review of the initial, “;Nurse Progress Note Comprehensive Assessment,” completed on 12/29/2022 showed the following: - A decrease in Activities of Daily Living (ADL); - Increased shortness of breath (SOB) with moderate exertion; - Increased episodes of bowel incontinence; and - Intervention equipment was listed as a hospital bed and bedside commode. Review of the “;Combined Disciplinary Comprehensive Assessment,” dated 07/16/2024 showed, SOB with mild exertion/speech: Oxygen four (4) liters per minute (L/m). Review of the “;Combined Disciplinary Plan of Care,” dated 07/17/2024, showed the following: - Fall risk; and - Use assistive devices as appropriate: Walker. Review of the “;Nurse Progress Note Routine Visit,” dated 07/18/2024, showed the following: - Required assistance with all ADLs. - Increased SOB with mild exertion; - Walking unsteadiness had increased, using a wheeled (Rollator) walker and one person assist; - Fall precautions; and - Using oxygen intermittently and increased need for supplemental oxygen. Observation on 07/22/2024 at 4:15 PM, showed an oxygen concentrator with oxygen tubing laying across the walkway of the living room, the hospital bed had a low loss air mattress, and a rollator walker was sitting beside the bed. The POC failed to include this equipment. RECORD/PATIENT #4: Review of the clinical record showed the patient admitted to hospice services on 04/12/2024 with a terminal diagnosis of cachexia (a general state of ill health involving great weight loss and muscle loss). The patient resided in a skilled nursing facility. Observation on 07/23/2024 at 9:00 AM, during the patient’s home visit, showed the patient had the following DME placed in his/her room: -Pressure relief boots; -Pressure relief mattress in the wheelchair; -Fall mats beside to bed; and -Incontinence briefs. Review of the document titled, “Physician Orders Durable Medical Equipment,” dated 07/23/2024, failed to show the DME listed above. RECORD/PATIENT #5: Review of the clinical record showed the patient admitted to hospice services on 07/03/2024 with a terminal diagnosis of Creutzfeldt-Jakob Disease (a degenerative brain disorder that leads to dementia and death). The patient resided in a skilled nursing facility. Review of the skilled nurse note, dated 07/10/2024, showed the patient was in bed with bolsters present and a mat on the right side of the bed on the floor. Review of the skilled nurse note, dated 07/15/2024, showed the patient was up in a high back, reclining wheelchair. Review of document titled, “Physician Orders Durable Medical Equipment,” dated 07/22/2024, failed to show the DME listed above. During an interview on 07/23/2024, at 1:00 PM, the director of clinical services stated that he/she would expect all DME that a patient has to be on the DME order list and interventions specific to the DME on the plan of care.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that services were provided in accordance with the plan of care in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Physicians Orders,” dated 2018, showed the plan of treatment services shall include the specific procedures and modalities to be used and the amount, frequency, and duration of the treatments. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 04/12/2024 with a terminal diagnosis of cachexia (a general state of ill health involving great weight loss and muscle loss). The patient resided in a skilled nursing facility. Review of the document titled, “Physician Orders Visit Frequency,” showed an order dated 04/12/2024 for a volunteer coordinator visit one time a week until discontinued. Review of the clinical record failed to show any visits completed by the volunteer coordinator. During an interview on 07/24/2024 at 9:00 AM, the director of clinical services (Governing body designee-A) stated that the volunteer coordinator frequency was an error. An order was put in to discontinue the frequency on 07/24/2024.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the aide provided services as included in the plan of care (POC) in one of four full records reviewed that received aide services (Record/Patient #2). This deficient practice has the potential to affect all of the provider’s patients that receive aide services. Findings included: Review of the providers policy titled, “;Home Health Aide Services,” updated in 2018, showed that aide services are approved by the interdisciplinary group as palliative measures and are included in the POC. Review of the providers policy titled, “;Home Health Aide Services,” updated in 2018, showed that the aide would perform services:- According to the POC; and- The POC for hospice aide services is specific to frequency and services provided. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/28/2024 with a terminal diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity). The patient resided in their own home with the assistance of an adult child. Review of the aide visit documentation for the visit 07/03/2024 showed the aide performed nail care. Review of the aide assignment sheet reviewed on 07/23/2024 by State Agency (SA) and dated 05/09/2024, showed the document failed to contain the assigned task of the provision of nail care. During an interview on 07/24/2024 at 11:34 AM, the director of clinical services (Governing body designee-A) stated that:- They would expect the aide to perform only the tasks assigned by the supervising registered nurse on the aide assignment sheet; and - The aide assignment sheet dated 05/09/2024 failed to contain an assignment for the aide to provide nail care.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the aide reported changes in the patient’s condition to a registered nurse in three of four full records reviewed that received aide services (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all of the provider’s patients that receives aide services. Findings included: Review of the providers policy titled, “;Home Health Aide Services,” updated in 2018, showed that the aide would perform services:- According to the plan of care (POC); and- The POC for hospice aide services is specific to frequency and services provided. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 12/29/2022 with a terminal diagnosis of biventricular heart failure (a condition that affects both the left and right sides of the heart) and a secondary diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood flow to the heart) and a history of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with caregiver assistance. Review of the aide visits dated 07/03/2024, 07/08/2024, 07/15/2024, 07/18/2024, and 07/22/2024, showed the visits failed to contain documentation that the aide had notified the supervising registered nurse of the patients refusal of oral care, shaving, skin care, feeding, and linen change. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/28/2024 with a terminal diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity). The patient resided in their own home with the assistance of an adult child. Review of the aide visits dated 07/03/2024, 07/08/2024, 07/15/2024, 07/18/2024, and 07/22/2024, showed the visits failed to contain documentation that the aide had notified the supervising registered nurse of the patients refusal of oral care, feeding, and linen change. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/02/2023 with a terminal diagnosis of hypertensive heart disease (structural and functional changes in the heart as a result of chronic high blood pressure). The patient had a secondary diagnosis of insulin dependent diabetes (a problem in the way the body regulates and uses sugar as a fuel). The patient resided in a skilled nursing facility. Review of the aide visits dated 06/04/2024, 06/18/2024, 06/25/2024, and 07/02/2024, showed the visits failed to contain documentation that the aide had notified the supervising registered nurse of the patients refusal of oral care. During an interview on 07/24/2024 at 11:34 AM, the director of clinical services (Governing body designee-A) stated that:- They would expect the aide to report any patient care refusals to the supervising registered nurse, and- They were unable to provide documentation that the aide had reported patient care refusals to the supervising registered nurse.”

“Based on policy review, record review, and interview, the provider failed to ensure the hospice aide supervisory visits included all the required components in four records (Records/Patients #1, #2, #3, and #4) and were accurate in three records (Records/Patients #1, #2, and #3) of four full records reviewed that received aide services. This deficient practice has the potential to affect all patients that receive aide services. RECORD/PATIENT #4: Review of the clinical record showed the patient admitted to hospice services on 04/12/2024 with a terminal diagnosis of cachexia (a general state of ill health involving great weight loss and muscle loss). The patient resided in a skilled nursing facility. Review of the documents titled, “;Home Health Aide Supervisory Visit,” dated 06/25/2024, 07/09/2024, and 07/16/2024 showed that:- The aide was providing services according to the patients plan of care; -Patient/caregiver was satisfied with the quality of care and services provided; and- The aide reports problems/concerns to the registered nurse promptly. The supervisory visit documentation failed to address the aides correct or incorrect use of infection control practices RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/28/2024 with a terminal diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity). The patient resided in their own home with the assistance of an adult child. Review of the aide visits dated 07/03/2024, 07/08/2024, 07/15/2024, 07/18/2024, and 07/22/2024, showed the visits failed to contain documentation that the aide had notified the supervising registered nurse of the patients refusal of oral care, feeding, and linen change. Review of the documents titled, “;Home Health Aide Supervisory Visit,” dated 07/01/2024, 07/08/2024, and 07/15/2024 showed that:- The aide was providing services according to the patients plan of care; - The aide reports problems/concerns to the registered nurse promptly; and- The supervisory visit documentation failed to address: * The aides correct or incorrect use of infection control practices, * The patients refusal of care; and * The aides failure to communicate the patients refusals of care to the supervising registered nurse. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/02/2023 with a terminal diagnosis of hypertensive heart disease (structural and functional changes in the heart as a result of chronic high blood pressure). The patient had a secondary diagnosis of insulin dependent diabetes (a problem in the way the body regulates and uses sugar as a fuel). The patient resided in a skilled nursing facility. Review of the aide visits dated 06/04/2024, 06/18/2024, 06/25/2024, and 07/02/2024, showed the visits failed to contain documentation that the aide had notified the supervising registered nurse of the patients refusal of oral care. Review of the documents titled, “;Home Health Aide Supervisory Visit,” dated 07/02/2024, 07/12/2024, and 07/16/2024 showed that:- The aide was providing services according to the patients plan of care; - The aid reports problems/concerns to the registered nurse promptly; and- The supervisory visit documentation failed to address: * The aides correct or incorrect use of infection control practices, * The patients refusal of care; and * The aides failure to communicate the patients refusals of care to the supervising registered nurse. During an interview on 07/24/2024 at 11:34 AM, the director of clinical services stated that they would expect the aide supervisory visit to address a patients refusal of care, and the aides infection control practices Findings included: Review of the providers policy titled, “;Home Health Aide Services,” updated 2018, showed in part, the following: - Supervision of the aide is required every 14 days by a Registered Nurse. If the Licensed Practice Nurse is providing services, supervision of the services provided continues at 14 day intervals; and - Written documentation shall show that the aide is providing services in accordance with the plan of care and acceptable standards of practice. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice care on 12/29/2022 with a terminal diagnosis of biventricular heart failure (a condition that affects both the left and right sides of the heart), and a secondary diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood flow to the heart), and abnormal result of other cardiovascular function study, as well as several other conditions. The patient lived at home with caregiver assistance. Review of the aide supervisory assessments titled, “;Home Health Aide Supervisory Visit,” dated 06/27/2024, 07/11/2024, and 07/18/2024 failed to address complying with infection control policies and procedures.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff provide the skilled nursing facility (SNF) with the most recent hospice plan of care (POC) in one of two applicable records (Record/Patient #3). This deficient practice has the potential to affect the coordination of care with all of the hospice patients residing in skilled nursing facilities. Findings included: Review of the providers policy titled, “;Coordinating Provider,” updated 2018, showed that when the hospice client resides in, or is a client of an acute health care, skilled care or residential care facility, which is not providing services under arrangement with hospice, or if the hospice has an arrangement with a coordinating provider, the hospice collaborates with the other organizations and individuals providing care to the client/family to ensure coordination of services. Collaboration activities shall include the following: - The provider will use the state approved coordinated task plan of care (POC) in all long-term care facilities;- A current copy of the hospice POC is placed in the facility patient record; and- A narrative note will be placed in the facility record with each skilled nursing visit documenting the visit and any pertinent findings. Review of the document titled, “;Coordinated Task Plan – Instructions,” dated 06/2009 showed that:- The coordinated task plan will be initiated by the provider upon start of care in the long-term care and will be continuously updated with any changes as needed; and- At a minimum, the coordinated task plan will be reviewed with recertification of the hospice resident. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/02/2023 with a terminal diagnosis of hypertensive heart disease (structural and functional changes in the heart as a result of chronic high blood pressure). The patient had a secondary diagnosis of insulin dependent diabetes (a problem in the way the body regulates and uses sugar as a fuel). The patient resided in a SNF. During a home visit observation on 07/23/2024 at 9:00 AM, a review of the hospice providers binder, left at the nursing facility, showed that: - The coordinated task plan in the providers binder at the facility was last updated on 11/21/2023;- The current POC in the providers binder at the facility was dated 07/02/2024; - The binder failed to contain a copy of the current, updated POC dated 07/17/2024;- The current POC in the providers binder contained the documents titled, “;Combined Disciplinary Comprehensive Assessment,” and, “;Combined Disciplinary Plan of Care;” and - The binder failed to contain copies of the current, updated physicians orders for durable medical equipment, treatment profile, visit frequency, and medication profile. During an interview on 07/23/2024 at 09:20 AM, Facility Nurse A confirmed that:- The coordinated task plan in the providers binder at the facility was last updated on 11/21/2023;- The current POC in the providers binder at the facility was dated 07/02/2024; and- The POC dated 07/02/2024, in the providers binder contained only the documents titled, “;Combined Disciplinary Comprehensive Assessment,” and, “;Combined Disciplinary Plan of Care.” During an interview on 07/24/2024 at 11:34 AM, the director of clinical services (Governing body designee-A) stated that:- The complete, updated hospice POC contained multiple documents including the combined disciplinary comprehensive assessment, combined disciplinary POC, and the physicians orders for durable medical equipment, treatment profile, visit frequency, and medication profile; and- They would expect the coordinated task plan to be updated since 11/21/2023.”