3hc

“Based on agency policy, clinical record review, and staff interviews the agency failed to communicate changes of condition for 2 of 3 patients with changes of condition. (patient’s #1 and 2) Findings included: A policy, Direction and Coordination of Services (revised 03/2024), received on 08/12/2024 at approximately 4:30 PM from the Hospice Quality Assurance and Performance Improvement (QAPI) nurse stated, “;Any changes in the patients status will be communicated with the other team members the same day.” 1. Patient #1 was admitted on 05/05/2024 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure. The plan of care for 05/05/2024- 08/02/2024 included orders for skilled nurse visits 1 time a week for 13 weeks with 6 PRN [as needed] and medical social worker (MSW) visits 1 time a month for 1 month, 2 times a month for 2 months with 3 PRN. Review of the clinical record revealed the following documentation by RN # 4 related to the SN visit on 5/10/24, “;No one contacted as a result of this visit... Requires continuous assistance...Needs assistance to prevent falling...Patient response: little to no understanding...unsafe ambulation... No one contacted as a result of this visit... appears sedated... Sits up on edge of bed and falls over... home alone most of the time. Does not know what meds [medications] he takes and when...” There was no evidence in the clinical record of the physician, MSW, or hospice administrator being notified. Further review of the clinical record revealed the following documentation on 5/20/24 by MSW # 5, “;No one contacted... PT [patient] focused a lot on his medications and feeling as if they were not “;straight”. SW [MSW] encouraged pt [patient] to discuss with his nurse at the next visit...” There was no evidence in the clinical record of the registered nurse case manager [RNCM] being notified. During an interview conducted on 08/12/2024 at approximately 4:00 PM RN#4 stated, “;Yes, I alerted the hospice team including the social worker, we discussed multiple times as well in out teams meeting.” During an interview on 08/12/2024 at approximately 3:04 PM the hospice QAPI nurse stated, “;All communication should be included in the patient chart.” MSW #5 was not available for an interview. During an interview conducted on 08/12/2024 at approximately 3:05 PM the Hospice Director stated, “;The expectation is for her [MSW] to notify the care manager about the medication concerns and document it.” 2. Patient #2 was admitted on 01/04/2024 with a diagnosis of hypertensive heart disease and chronic kidney disfunction with heart failure, The plan of care for 07/02/2024-08/30/2024 included orders for skilled nurse visits 2 times a week for 9 weeks with 6 PRN (as needed), Aide visits 2 times a week for 1 week, 3 times a week for 8 weeks, and medical social worker (MSW) visits 2 times a month for 2 months with 3 PRN. Review of the clinical record revealed the following documentation related to hospice aide (HHA) #7s visit on 07/15/2024, “;Decline in patient condition... Patient stated that he is declining to where he does not feel comfortable standing...” There was no evidence in the clinical record of the registered nurse case manager (RNCM) being notified. Further review of the clinical record revealed a MSW telephone call of 07/31/2024 stating, “;[spouses name] reports pt [patient] did not have a good night and was throwing up all night.” There was no evidence in the clinical record of the RNCM being notified. During an interview on 08/12/2024 at approximately 2:40 PM HHA #7 stated, “;I think I had e-mailed his nurse [RNCM]. I thought that I have put it in [a note].” MSW #5 was not available for an interview. During an interview conducted on 08/12/2024 at approximately 3:05 PM the Hospice Director stated, “;The expectation is for her [MSW] to notify the care manager about the symptoms and document it.””

“Based on clinical record review and staff interview, the agency failed to coordinate a patient’s discharge with a community-based primary care provider for 1 of 3 discharge records reviewed (Patient #1). Findings included: Patient #1 was admitted to the agency on 05/28/24 with a principal diagnosis of brain cancer. Patient #1 was initially admitted as a home hospice patient while he was living with his sister in her apartment. On admission, Patient #1 elected to use the agencys medical director as primary care practitioner (PCP). On 06/14/24, an emergency respite stay was coordinated for Patient #1 at the agencys inpatient unit due to his sister not having paid rent or the electricity bill. The apartment landlord would not allow the patient to continue to stay at the home without electricity and the patients sister was not able to be located or contacted. On 06/18/24, the agencys social worker documented that the agency had discussed Patient #1s discharge to a hotel, funded by the agency, and stated that she did not feel this was an appropriate discharge due to Patient #1s cognitive status. At that time, the plan was for the agency to have the patients cognitive status assessed. The agency’s social worker documented that the patient would be discharged if he “;has capacity” but would remain at the inpatient unit until a safe discharge could be coordinated if he “;lacks capacity” once assessed by the psychiatrist. On 06/19/24, a psychiatric evaluation was conducted. The physician documented that Patient #1 displayed cognitive impairment and that his ability to reliably and safely participate in his own medical care was significantly impacted by his limited comprehension, limited insight, limited judgement. On 06/22/24, Employee #3, an agency RN, documented that she was called into Patient #1s room because he wanted to show her the essential oils that he was using to “;protect him” from snakes, spiders and bedbugs. At that time, the patient was noted to be confused, moving his hands around “;theatrically” and was speaking in a Jamaican accent although he was not from Jamaica and had reportedly never traveled there. Patient #1 was noted to have refused medications earlier that day and to have gotten “;snippy” with one of the agencys aides. On 06/23/24, the inpatient unit contacted EMS and law enforcement because Patient #1 was ambulating through the facility hallways asking other family members for cigarettes and was unable to be redirected. The patient was stated to have been paranoid and hallucinating. EMS would not transport the patient to the hospital, because Patient #1 stated that he did not want to go. Patient #1 reportedly agreed to stay at the inpatient unit and to abide by their policies following this incident. On 06/24/24, the social worker spoke to the medical crisis unit who ultimately evaluated the patient and determined that he was not an immediate threat to himself or others. The social worker documented having sent a referral to a skilled nursing facility and left a message with the Department of Social Services regarding legal guardianship and having notified the mobile crisis unit. On 06/25/24 at 11:26 AM, the social worker documented that she and the agencys senior director of compliance contacted the patients healthcare power of attorney (POA) and stated that the POA was unwilling to become Patient #1’s caregiver and would not allow him to come to live at her home. At that point, the social worker contacted adult protective services and left a message regarding Patient #1s guardianship and the lack of medical necessity for him to remain at the agencys inpatient unit. At 2:33 PM on the same day, the social worker documented that after a discharge planning meeting, it was decided that the patient would be transported from the agencys inpatient unit to a hotel, funded by the agency. The patient was scheduled for transport via stretcher using the agencys contracted medical transportation company which occurred at 5:10 PM. At 5:29 PM the agency documented that the patients mother/POA signed him into the hotel due to the patient not having any identification. There was no evidence that the agency referred or coordinated care or treatment with any primary care provider in the community at the time of discharge. On 06/29/24, Patient #1 contacted the agency and stated he was low on his seizure medication. The agencys on-call nurse directed the patient to contact his pharmacy to see if he had refills and if he did not, he should contact his physician. On 07/01/24, Patient #1 contacted the agency and reported that the pharmacy had faxed a form to the agency so that the patient could get refills of his seizure medication. At that time, he was told by an administrative staff member that he was no longer a patient, and he should contact his physician. In an interview on 07/08/24 at 3:19 PM, the social worker stated that on 06/18/24 she had concerns about Patient #1s ability to get his debit card out to pay for a hotel room and check-in and said, “;He was having difficulty not knowing where his debit card was. I was concerned that he would not be able to physically get his debit card out to pay for a room, et cetera...” She stated that the agencys “;higher ups” [corporate staff] had been meeting to establish a discharge plan and “;The discharge to the hotel was the safe route...the medical crisis unit took report...and sent someone out to speak with him, due to him not being a harm to self or others he could not be involuntarily committed... adult protective services didnt pick him up because of no home plan... we didnt exercise taking him to the hospital because he didnt have a medical need to be there...he was not fit to be at [name of inpatient unit] and had been deemed incapacitated by a psychiatrist.” The social worker stated that she “;never heard from” the skilled nursing facilitys (SNF) admission coordinator regarding Patient #1 but did not attempt to contact the SNF again. She stated that she had also contacted two assisted living facilities (ALFs). One of the ALFs reportedly stated that they would not accept the patient (this information was relayed from an agency employee who works at the ALF), and the other ALF stated that they had a bed available but that the agency had reportedly conducted a meeting and determined that an ALF was not the appropriate level of care for the patient due to his behaviors. The social worker did not attempt further contact with either of the ALFs. In an interview on 07/08/24 at 3:45 PM, the inpatient unit director stated that the agency had called 9-1-1 one night while Patient #1 was in their facility but that he refused to go to the hospital and emergency services could not take him without his consent. She also stated that “;The motel was the right and safest place for him...we are not a lockdown unit... it [having Patient #1 at the inpatient unit] was becoming a safety issue for the patients...It got to the point where it was just really disruptive.” Regarding the plan for the patient to continue receiving medications following discharge, the inpatient unit director stated, “;We dont set them up unless they had a prior PCP.” At the time of survey, the inpatient unit director was unaware that Patient #1 had contacted the agency on 06/29/24 and 07/01/24 for medication refills and stated that she would have helped the patient with his medicines if she had been aware.”

“Based on clinical record review, Discharge for Cause report to the Division of Health Service Regulation (DHSR), facility room observation, and staff interview, the agency failed to implement safety measures following a patient elopement attempt. Immediate jeopardy was identified beginning 07/09/24 at 2:30 PM and was abated on 07/09/24 at 4:52 PM with an acceptable allegation of compliance. Findings included: Patient #1 was admitted to the agency on 05/28/24 with a principal diagnosis of brain cancer. Patient #1 was initially admitted as a home hospice patient while he was living with his sister in her apartment. On 06/14/24, an emergency respite stay was coordinated for Patient #1 at the agencys inpatient unit due to his sister not having paid rent or the electricity bill at that residence. The apartment landlord would not allow the patient to continue to stay at the home without electricity and the patients sister was not able to be located or contacted. On 06/25/24 the inpatient unit director documented, “;Patient has exited his room by climbing over his outside patio rail and ambulated to Wayne Memorial Drive and this author had to redirect patient to return to his room. When asked what he was doing he stated that he was wanting a cigarette.” In an interview on 07/09/24 at 10:00 AM, the inpatient unit director stated that the aforementioned incident occurred on 06/18/24 at approximately 6:45 PM. She was informed by one of her aides who was driving to the facility that Patient #1 was “;at the road”. The inpatient unit director went outside and located the patient by the stop sign, “;kind of wandering down the sidewalk”. The inpatient unit director talked to the patient, and he was able to be redirected to return to the facility with her. The patient stated that he had crawled over the bench (which was on the patio of his room) to get to the highway. The inpatient unit director stated that the agencys typical safety measures were not successful for Patient #1 because he had unplugged his bed (which would have alarmed if it were plugged in) due to the mattress inflation being uncomfortable and he refused to have a camera placed in his room for monitoring. In an interview on 07/09/24 at 10:30 AM, the inpatient unit director stated, “;...normally I dont have wanderers [at the inpatient unit]. If it is a demented patient on the home hospice side who is still ambulatory, I cant accept those patients here because I cant keep those patients safe in the building.” She also stated if a patient who was in the facility became confused during their stay and began with wandering behaviors, she would talk to the family and the patient would typically receive medication adjustments to try to control the behaviors chemically. The inpatient unit director stated that Patient #1’s room location was third room from the nurses station and “;within eyes view” which was why he went out through the patio instead of using the room door and walking through the facility’s hallways. She added that it was her opinion that Patient #1 would not have accepted a 1:1 volunteer or other staff member to monitor him for safety in his room due to his paranoia, however, this strategy was not attempted. The inpatient unit director stated that there were no safety measures put in place related to blocking or restricting access to the patio door for Patient #1 due to concerns that his agitated and/or paranoid behavior would have escalated if he was unable to independently access the patio outside of his room. This strategy was not attempted. CREDIBLE ALLEGATION OF COMPLIANCE THE PROCESS THAT LED TO THE DEFICIENCY: The process that led to the deficiency was that there was no patient elopement policy or procedure in place to identify patients at risk for elopement and appropriate interventions to prevent patient elopement. THE PLAN OF CORRECTING THE SPECIFIC DEFICIENCY AND PROCEDURE FOR IMPLEMENTING THE ACCEPTABLE PLAN OF CORRECTION FOR THE SPECIFIC DEFICIENCY CITED: An Inpatient Hospice procedure 28.32 will be developed and implemented immediately called “;Patient Elopement” effective 7/9/24. All facility staff on duty at the inpatient facility will be educated in person on 7/9/24 on the new procedure by the Director of Inpatient Services. This education will be logged in the online learning management system. On duty staff will be required to review and sign the Patient Elopement policy (28.32). The education and procedure review will be recorded and assigned via the online learning management system to staff who were not present at the live training on 7/9/24. They will be required to complete the education and procedure review before starting their next assigned shift. This will be logged in the online learning management platform. THE MONITORING PROCEDURE TO ENSURE THAT THE PLAN OF CORRECTION IS EFFECTIVE, AND THAT SPECIFIC DEFICIENCY CITED REMAINS CORRECTED AND/OR IN COMPLIANCE WITH THE REGULATORY REQUIREMENTS: The Education Manager and Sr Director of Quality, Regulation, and Compliance will validate all inpatient hospice staff have completed mandatory education and Elopement Policy review (28.32) and it is documented in the education record by 7/23/24. The QAPI and Clinical Department will audit a representative sampling of hospice patient charts on a weekly basis to determine if patient was identified as an elopement risk and if so were measures put in place per the 3HC Elopement Procedure. Once 100% compliance is achieved for 3 consecutive weeks there will be ongoing monitoring via the quarterly clinical record review to ensure continued compliance. Audit results will be reported to the Professional Management Team, and the Inpatient Hospice QAPI Team.”

“Upon patient record review, 1 of 5 (Patient #4 ) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Pt #4 - Documentation by nurse that the patient’s port a cath was flushed. There is no evidence of medications used to flush patients port a cath on the med profile. (Corrected on site)”

“Upon client record review, 2 of 5 (Patient #1, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #1 - wound care order states to clean wound with normal saline, skin prep to area, and apply hydrocolloid. RN note of 6/25 states she cleansed the wound with wound cleanser, covered with hydrocolloid gel. Pt #4 - RN note of 6/17 states that patient went to ED, got a shot of Rocephin and was sent home with antibiotics. No new medication in record. Pt also has PAC - no order for the flushing of the port - RN flushed port per her documentation using 5 or 10 ml of saline. (Corrected on site)”

“Upon patient record review 2 of 34 (Patient #9.10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 9: The pt was admitted 3/14/24. The MSW performed the comprehensive assessment 3/20/24. There is no evidence the RN completed the social workers assessment during the comprehensive assessment. Patient 10: The pt was admitted 4/16/24. The MSW performed the comprehensive assessment 4/23/24. There is no evidence the RN completed the social workers assessment during the comprehensive assessment.”

“Upon patient record review, 7 of 34 (Patient #1,3,4,5,18,26,33) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: SN documents on 4/3/24 and 4/5/24 “pt on 5 liters oxygen”. The Oxygen is not an order on the medication profile for 5 liters of O2. Patient 3: Citalopram,hydrocodone/acetaminophen found in home, not in POC. Corrected on site. Patient 4: The POC 4/10/24 contains orders for a patient with a gastrostomy tube. There is evidence the pt cannot take meds PO and they are given through the G tube. There are orders for Miralax, protonix, prochlorperazine, Immodium tablets all to be given PO on the medication profile. There is also a separate order for Polyethylene Glycol to be given via G tube with no diluent on the medication profile. Corrected on site. Patient 5: The nurse documented on 5/17/24 “Bactrim ds ordered for 2 weeks.” There is no evidence of an order on the medication profile. Corrected on site Patient 18: Upon home visit finding pt taking Carbidopa/levodopa and PO Tylenol that were not on the medication profile and not new per caregiver. Corrected on site. Patient 26: The medication profile includes duplicate orders for acetaminophen 650mg rectal suppository q4 hrs prn mild pain and temp >101, albuterol-ipratropium 2.5mg-0.5mg/3ml inhalation solution Q3 hrs prn cough/dyspnea/wheezing, Ativan 0.5mg -2mg, Benadryl 25-50mg Q4 hrs prn itching, soap suds enema PR once daily for constipation, and Tylenol 650 mg every 4 hours as needed for mild pain. Corrected on site Patient 33: The medication profile contains an order for Oxygen with no dose. Corrected on site.”

“Upon patient record review, 2 of 34 (Patient #9.10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 9: The pt was admitted 3/14/24. The Bereavement initial assessment was not completed until 3/20/24. There is no evidence the RN completed the Bereavement assessment in the initial comprehensive assessment. Patient 10: The pt was admitted 4/16/24. The Bereavement initial assessment was not completed until 4/23/24. There is no evidence the RN completed the Bereavement assessment in the initial comprehensive assessment.”

“Upon patient record review, 1 of 34 (Patient #34) 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 34: Pt record contains evidence of SN visits 5/10, 5/13, 5/17 where the urinary assessment contains documentation that the pt has a foley and it is patent. There is no documentation of description of the urine. The NP documented on 5/9 that pt has a UTI, ordered an ATB. The NP narrated in the documentation that the foley needed changed but did not order the foley to be changed. The standing orders are for the foley to be changed PRN for leakage or occludsion. The foley was changed on 5/21 and another ATB round was ordered as the UTI had not cleared.”

“Upon patient record review, 7 of 34 (Patient #4,5,6,8,26,29,34) 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 4: There is evidence the pt has a G tube for feedings and medication administration. The POC contains standing gastrostomy tube order only “may use G tube if needed” and are not specific to G tube care, flushing or site care. In addition, there are orders for Stage III and Stage IV pressure ulcers however, there is no evidence the pt has wounds. Patient 5: The initial comprehensive assessment the SN documents pt is bed bound, had a CVA. There is no evidence of goals or interventions in the care plan for at risk for impaired skin integrity or a CVA care plan. Patient 6: The comprehensive assessment contains evidence that pt uses a walker and there is no evidence of a fall care plan. Patient 8: The SN documented on the comprehensive assessment that “pt requires assist with ambulation at all times” and on 4/24/24 “pt sways but catches self”. There is no fall risk care plan implemented. Patient 26: The patients initial comprehensive assessment includes information that the patient has dysphagia with a peg-tube placement but continues to tolerate a soft mechanical diet. The plan of care does not include aspiration precautions or continued assessment of the patient’s ability to swallow. The patient’s medication profile includes Clopidogrel 75 mg daily, the plan of care does not include bleeding precautions. Patient 29: The patient is admitted with a biliary JP drain, the plan of care does not include a problem statement with interventions and goals to address the drain. Patient 34: There is evidence in the pt record foley inserted 3/23/24. There is no urinary/elimination care plan.”

“Upon patient record review, 23 of 34 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,15,16,17,18,19,21,26,28,33,34) 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 1: The POC contains orders for a gastrostomy tube, orders for Stage III and Stage IV pressure ulcers. There is no evidence the pt has wounds or a gastrostomy tube. SN documents on 4/3/24 and 4/5/24 “pt on 5 liters oxygen”. There is no order on the POC for 5 liters of oxygen. Patient 3: Upon home visit finding pt taking Citalopram and hydrocodone/acetaminophen these medications are not on the POC. Corrected on site. The SN documented on 5/16/24 she delivered Calzime paste to the pt. There are no orders for Calzime or barrier cream on the POC. Patient 4: The POC 4/10/24 contains orders for a patient with a gastrostomy tube. There is evidence the pt cannot take meds PO and they are given through the G tube. There are orders for Miralax, protonix, prochlorperazine, Imodium tablets all to be given PO. There is also a separate order for Polyethylene Glycol to be given via G tube with no diluent. SN documented pt has a 16fr 10cc foley in place on comprehensive assessment. Order is for 16fr 5cc foley. Patient 4,13,17,18,19,21,33,34:The POC’s contain orders for skin tears, stage I, stage II, stage III, stage IV pressure ulcers however, these patients do not have wounds. Patient 5: The nurse documented on 5/17/24 “Bactrim ds ordered for 2 weeks.” There is no evidence of an order on the POC. Patient 6: The POC 4/10/24 contains orders for May use condom catheter prn on male patients (patient is female). “May transfer to inpatient hospice center and transfer care to 3HC hospice MD while there for respite, acute and residential care.” which is a standing physician order however, an order is needed prior to changing level of care for acute inpatient level of care. Comprehensive assess contains a foley 16 fr 10cc. The POC order is for a 16 fr 5cc. Patient 8: The SN ordered and had delivered Hydraguard Remedy Phytoplex to the pt home. There is no evidence of an order on POC. Patient 2,4,5,7,8,9,10,11,12,13,16,18,19,28: initial POC’s have a standing orders “May transfer to inpatient hospice center and transfer care to 3HC hospice MD while there for respite, acute and residential care.” Pt will need a MD order for a change in LOC to GIP. Patient 2,4,5,7,8,9,10,11,12,13,28: Initial POC “May use condom catheter for males with urinary incontinence” (patients are female). Patient 15: SN documented 5/7/24 “Caregiver giving Ibuprofen for pain, declines morphine”. There is no order for Ibuprofen. Corrected on site. Patient 16: The SN documented on 5/1 “wound care to be performed to genitalia area per POC” There is no order for the wound care. 4/26 SN documented 4/26 pt has foley, there is no order for a foley. On 5/20 SN documented pt has suprapubic catheter. There is no order for suprapubic catheter. Pt is in facility. Catheter order corrected on site. Patient 17,21: The initial POC contain “May use G tube if available”. Neither pt has a G tube. Corrected on site Patient 18: Upon home visit finding pt taking Carbidopa/levodopa and PO Tylenol that were not on POC and not new per caregiver. Wound care order POC does not state who to perform. Corrected on site Patient 26: The patient has a RUQ colostomy in place with evidence of appliance changes documented at the time of admit for every 3 days, and updated documentation on 2/15/24 is written for appliance changes “as needed” with no indicator. The patient records does not include treatment orders for the colostomy or stoma care. Corrected on site Patient 33: The POC contains an order for Oxygen with no dose. Corrected on site.”

“Upon patient record review, 5 of 34 (Patient #2,3,8,16,26) 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 equipment and supply needs. Patient 2: The nurse documented on the comprehensive assessment pt uses CPAP at night. This was not included on the POC. Corrected on site Patient 3: The comprehensive assessment completed 4/10/24 the SN documented “hospital bed delivered to home” and “pt uses a rollater”. There was no hospital bed or rollator added to the POC. Corrected on site. Patient 8: The nurse documented on 5/15/24 “ pt ambulates with assistive device”. There are no orders for assistive devices on the POC. The SN documented ordering a BSC there is no evidence of an order for a BSC. Corrected on site Patient 16: The POC does not contain DME. There is evidence the patient has a hospice bed and OBT as pt is in a facility. Corrected on site Patient 26: There is evidence in the patient record that the patient uses albuterol-ipratropium 2.5mg-0.5mg/3ml inhaled via nebulizer every 3 hours as needed for cough/dyspnea/wheezing, the plan of care does not include the nebulizer. Corrected on site”

“Upon patient record review, 6 of 34 (Patient #3,17,26,27,29,33) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 3: The POC contains orders for a gastrostomy tube, orders for Stage III and Stage IV pressure ulcers. There is no evidence the pt has wounds or a gastrostomy tube. Patient 17: Admitted to IPU SN documented pt has IV 20guage in RFA with an occlusive dressing. There are no orders for this IV or care of the IV. The initial POC has order for may use gastrostomy tube if available. Pt does not have a gastrostomy tube. Corrected G tube removed from POC. Patient 26: The patient receives Volunteer services; the plan of care does not include a problem statement with interventions and goals for the volunteer needs. Patient 27: The medication profile includes orders for Eliquis (a blood thinner), the plan of care does not include a cardiac interventions and goals that include bleeding precautions. Patient 29: The patient was admitted on 5/7/24 with a biliary JP drain, the plan of care does not include orders for the care and management of the drain. The POC contains orders for a gastrostomy tube, orders for Stage III and Stage IV pressure ulcers. There is no evidence the pt has wounds or a gastrostomy tube. Patient 33: Pt is on Eliquis (a blood thinner), the POC does not include a cardiac interventions and goals to include bleeding precautions. The patient has orders on POC for Volunteer and has interventions listed for the volunteer though no goals or a problem statement.”

“Upon client record review, 7 of 34 (Patient #1,2,5,18,28,29,34) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The POC 3/26/24 does not contain a nursing frequency order. Pt is in their IPU as a residential hospice patient receiving nurse visits. Patient 2: The SN documented wound care on 5/9/24 “cleaned with Normal saline”. The order is to cleanse with NS, apply silver cell and cover with gauze. There is no evidence the nurse followed the order. Corrected on site. Patient 5: The SN documented on the comprehensive assessment 2/21/24 “Foley 18fr 10cc balloon in place” The POC order is for Foley 16fr 5 cc. The SN documented “Placed a 18fr foley using sterile technique on 3/20/24 and 4/22/24. The order on the POC is for a 16fr 5cc foley. Corrected on site Patient 18: Comp assess 5/18 SN documented “Cleansed with soap, water, wound cleanser, covered with transparent occlusive dressing. The order is for cleanse with soap/water, cover with foam and secure with tape. Patient 28: On 5/8/24 the SN documented under the buttocks wound section “no open area zinc and optifoam applied”. On 5/17, 5/15, 5/13 there was documentation of wound care performed to buttocks gluteal wound per POC. There is no evidence of an order for a buttocks gluteal wound. Patient 29: It was witnessed that the SN performed a dressing change to a stage II wound on patients spine. The LPN removed the old dressing, then reapplied new dressing without cleansing the wound or applying skin prep. The plan of care includes orders for stage II wounds; “clean with normal saline, apply skin prep, cover with 4x4 foam, secure with tape, change 2 times a week and as needed if soiled.” Patient 34:The POC 3/21/24 has standing order for may insert foley 16fr 5cc. The nurse placed a 16fr 10cc catheter on 3/23/24. SN documented 3/22 Pt on Oxygen at 4.5 liters. The order is for 2-4 liters on POC 3/21/24.”

“Upon patient record review, 24 of 34 (Patient #1,2,6,7,9,11,12,13,14,15,16,17,18,21,25,26,27,28,29,30,31,32,33,34) did not have evidence in the patient record that hospice aide assignments and duties are: Patients 1,2,6,7,9,11,12,13,14,15,16,17,18, 21,25,28,33,34: The aide POC’s do not contain frequencies for any of the tasks to be performed by the aide. The task assignments for bathing does not indicate if skill is to be performed for bed bath, shower or at sink. Patient 26: The patient record does not include frequency orders for hospice aide visits. The hospice aide task assignments for shaving, oral care, foot care, nail care, skin care, hair care/shampoo, change patient linen and bathing do not include a task frequency. The aide assignment for bathing does not indicate if skill is to be performed for bed bath, shower or at sink. There are no bleeding precautions indicated in the hospice task assignment related to shaving (the patient takes Clopidogrel daily.) Patient 27: The plan of care does not include frequency orders for hospice aide services, effective 3/7/24. The hospice aide task assignment does not include frequencies for incontinent care, bathing, denture/oral care, nail care, skin care, bathing, hair/shampoo care, dressing or changing linens. There is no assignment for the type of bathing task is to be performed (bedbath, shower, sink.) The hospice aide safety identification does not include bleeding precautions. Patient 29: The plan of care does not include frequency orders for hospice aide services, effective 5/7/24. The task assignments for catheter care, bathing and oral care do not include a task frequency. The assignment for bathing does not indicate if the care is to be provided via bed bath, tub, shower or sink. Patient 30: The patient was admitted on 5/17/24 to GIP care, the record does not contain frequency orders for hospice aide services. The hospice aide task assignments for oral care, empty foley catheter, change linen, assist with dressing, bath and incontinent care do not include a frequency. The task for bath does not specific for bedbath, tub, shower or sink. Patient 31: The patient was admitted on 5/17/24 to GIP care, the record does not contain frequency orders for hospice aide services. The hospice aide task assignments for bathing, and emptying foley catheter do not include a frequency. The task assignment for bathing does not indicate bedbath, shower or sink. The aide task assignment does not include oral care or hair care. Patient 32: The patient was admitted on 5/13/24 to GIP care, the record does not contain frequency orders for hospice aide services. The hospice aide task assignments for bathing, does not include a frequency. The task assignment for bathing does not indicate bedbath, shower or sink.”

“Upon patient record review 2 of 34 (Patient #21,28) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 21: The POC does not contain an order for aide visits. The pt was admitted to IPU and the POC had the tasks listed for the aide with no task frequency and no visit frequency for the aide visits. The aide visited the pt on 5/10, 5/12, 5/13 twice, 5/14, 5/15,5/17 without an aide order for visits. Patient 28: The medical record has evidence of missed visits by the aide on 5/17,5/18, 5/20 with no clear missed visit documentation pertaining to patient choice for visits not being completed.”

“Upon patient client record review, 8 of 34 (Patient #1,4,6,8,9,11,18,28) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The SN documented on 4/1/24 “call 3HC 2e/7”. Patient 4: The SN documented on 5/17/24 “using oxymoron often”. Patient 6: The SN documented on the POC “pt will maintain a pain score of ____ or less”. Patient 8: The SN documented on 4/4/24 “ Pt desires to remain a FC”. This is not an approved abbreviation. FC per their policy is a foley catheter. Patient 9: The SN documented on 5/15/24 “NADN” This is not an approved abbreviation per agency policy. Patient 11: POC order for foley 16fr 5cc balloon. The SN documented pt has 16fr 10cc balloon on 1/31, 2/5,5/15,5/19. I did not see evidence of when this size foley was placed. Patient 18: On 5/14 SN documented “wound care done per POC”. Patient 28: On 5/17/24, 5/13/24 SN documented “wound care to foot per POC”.”

“Upon patient record review, 1 of 34 (Patient #34) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 34: The NP made a visit to the pt on 5/9/24 for symptoms of depression. NP documented urine was discolored and foul smelling, pt being treated routinely for pain with fentanyl. The NP documented in the narrative pt has UTI, to change foley every 30 days, and Bactrim DS for 10 days. The order to change the foley was not transcribed. The pt was seen by nursing routinely twice weekly after with foley assessment documentation of foley patent and has drainage bag. 5/17 when visit was made it was reported that over night on 5/16 pt was “hollering out in pain that radiates up and down her rt hip and talking out of her head”. The SN called the NP and the NP increased the fentanyl patch, ordered ATB and ordered morphine. The foley was not changed until 5/21/24.”

“Upon client record review, 1 of 34 (Patient #16) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 16: POC 3/28/24 contains an order for wound care to decubitus ulcer to be changed daily and prn with no reason and does not state who will perform the wound care. Pt is in a facility.”

“Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. Location #1: The agency provided dates of 3/14/24, 3/17/24, 3/21/24, 4/25/24, 5/9/24 and 5/16/24 indicating that a remote transfer of power was performed but did not include evidence of a visual inspection of the generator, results of the testing are not documented. A written record of weekly, monthly, annual or tri-annual inspection, performance, exercising period and/or repairs/maintenance is not available for the alternate power source. NFPA 110 Part 8.3.7: A fuel quality test shall be performed at least annually using appropriate ASTM D975-2 standards. The agency is unable to provide evidence of annual fuel quality test. There is no evidence of a battery inspection, electrolyte specific gravity reading or conductive reading. Location #2: There is no evidence of a written record of weekly, monthly or tri-annual performance, exercising period and/or repairs/maintenance for the alternate power source. There is no evidence of a visual inspection. An annual inspection was performed and documented on 5/16/24. NFPA 110 Part 8.3.7: A fuel quality test shall be performed at least annually using appropriate ASTM D975-2 standards. The agency is unable to provide evidence of annual fuel quality test. There is no evidence of a battery inspection, electrolyte specific gravity reading or conductive reading.”

“Upon observation, there was no evidence of 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. Upon observation, there was no evidence the smoking regulations of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Crystal Coast Hospice House: -The doors located in the 200 hall do not prevent the passage of smoke, the automatic doors do not close completely when activated in the protected area. -Where vertical openings (holes in floors) exist, enclose the openings with fire barriers on each story exposed to the opening. It is observed that the ceiling openings in the riser/mechanical room are not enclosed or sealed. -The cross corridor door in the 200 hall and within the smoke barrier, does not completely close when triggered. -19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. A portable space-heating device was located under the nursing station at the Crystal Coast Hospice House. Item was permanently removed prior to the surveyor leaving the facility. Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. A power strip was in use for personal electronics by the patient in Room 101. -Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3.4.4.1, NFPA 110, 8.4.2 Upon review, documentation of weekly inspection of the generator located at Crystal Coast Hospice House was performed on 3/14/24, 3/17/24, 3/21/24, 4/25/24, 5/9/24, and 5/16/24, there is no documentation that the generator was exercised under load for 30 minutes per month, there is no evidence of a 90 minute annual load test, there is no evidence of a tri-year 4 hour load test. No additional documents were provided at this location for generator inspections. Kitty Askins Hospice Center: -Evidence of smoking (greater than 20 cigarette butts) are noted at the Veterans patio located at an entry way, there is no evidence of a “no smoking” sign. -Upon review, there is no documentation of a weekly inspection of the generator located at Kitty Askins Hospice Center. The records do not include evidence of a monthly 30 minute load test, there is no evidence of a 90 minute annual load test, there is no evidence of a tri-year 4 hour load test. No additional documents were provided at this location for generator inspections.”