Transcend Hospice and Palliative Care

“Based on interview, record review and facility document review, the Hospice agency failed to meet the Condition of Participation (CoP) for L500 Patient’s Right when they failed to 1.) comply with mandatory reporting requirements to immediately report suspicions of neglect to Adult Protective Services (APS) for one of 14 patients (Patient (P) 9) whose records were reviewed out of a total sample of 14. P9 was noted to be a vulnerable adult on 12/09/24, and the case was not filed with APS and law enforcement until 02/07/24. These failures had the potential to place P9 at risk of serious injury, harm, or impairment, up to and including death, and 2.) identify, document, and have a functional working grievance program from November 2023 until 12/03/24. This had the potential to cause patient and caregiver concerns to be unaddressed. The agency was notified of the Immediate Jeopardy (IJ) at L517 on 02/07/25 at 5:25 PM related to the failure to comply with mandatory reporting requirements. In concurrence with Centers for Medicare and Medicaid Services (CMS) review, the removal plan was approved on 02/08/25 at 1:52 PM. The survey team verified implementation of the facility’s IJ removal plan on 02/08/25/25 at 7:30 PM. Findings include: 1. The agency failed to immediately notify APS of suspicions of neglect for one of 10 active patients (P9) when the patient was first assessed to be vulnerable and unsafe living in his home without caregivers present. (Refer to L517) 2. The agency failed to identify, document, and have a functional grievance program from November 2023 until 12/03/24. (Refer to L505)”

“Based on record review, documentation review, policy review, and interview, the facility failed to ensure “Plans of Care” contained measurable goals for three of 10 active record reviews (Patients (P)3, P2, and P9) out of 14 records reviewed. This had the potential for the inability for staff to assess progress or lack of progress in a patient’s status related to improvement in health status. The agency also failed to follow the “Plan of Care” for skilled nursing visits for one of 14 record reviews (P6) and failed to reconcile medications with the nursing home in which P3 resides. These failures had the potential for patients not to receive the services the hospice “Plan of Care” had developed and for a patient that resides in a nursing facility to receive unnecessary medications or not receive the correct dosages or frequencies of the prescribed medications the physician has ordered. Findings include: 1. Review of the “Care Plans” for three of 10 active record reviewed out of 14 sampled patients revealed there was no documentation to indicate that goals includsed in their “Hospice Plan of Care” were measurable. (Refer to L548). 2. Review of the “Hospice Nursing Clinical Note” for one out of 10 active records reviewed out of 14 sampled patients revealed documentation the last skilled nursing visit completed was on 01/14/25. The “Physician Orders” located under the “Patient Chart” in the electronic medical record (EMR) revealed skilled nursing visits were ordered once a week on 12/20/24. There was no documentation of skilled nursing visits performed after 01/14/25 (Refer to L543). 3. During a home visit on 02/06/25 for P3, Registered Nurse (RN)1 did not reconcile P3’s medication list with the nursing facility’s medication list with the facility staff (Refer to L530).”

“Based on record review and interview, the agency failed to have a complete and accurate record in regard to paperwork signed by the patient and/or patient representative for a DNR (Do Not Resuscitate) for three of 10 patient’s records reviewed for DNR (Patient (P) 6, P7, and P9) out of a total sample of 14 patients. Findings include: 1. Review of P6’s “Patient Profile,” located under the “Patient Profile” tab in the electronic medical record (EMR), revealed P6 was admitted to hospice services on 12/05/24 with a terminal illness of senile degeneration of the brain. Review of P6’s “Hospice Nursing Initial Comprehensive Admission Assessment,” located under the “Nursing Clinical Note” tab in the EMR, revealed a note dated 12/06/24 which provided documentation the patient and the family wished for P6 to have a DNR status. P6 resided in a nursing facility and had a DNR order in place; however, there was no paperwork in the hospice clinical record which indicated the DNR order. 2. Review of P7’s “Patient Profile,” located under the “Patient Profile” tab in the EMR, revealed P7 was admitted to hospice services on 01/21/25 with a terminal illness of moderate protein calorie malnutrition. Review of P7’s “Hospice Nursing Initial Comprehensive Admission Assessment,” located under the “Nursing Clinical Note” tab in the EMR, revealed a note dated 01/21/25 which provided documentation of the patient and the patient’s family wishes for P7 to have a DNR status. P7 resided in a nursing facility and had a DNR order in place; however, there was no paperwork in the hospice clinical record which indicated the DNR order. 3.Review of P9’s “Patient Profile” located under the “Patient Profile” tab in the EMR revealed P9 was admitted to hospice services on 12/06/24 with the terminal illness of ischemic cardiomyopathy. Review of P9’s “Hospice Nursing Initial Comprehensive Admission Assessment” located under the “Nursing Clinical Note” tab in the EMR revealed a note dated 12/06/24 which provided documentation of the patient’s wishes to have a DNR status. On the consents signed by the patient on 12/06/24, it was marked by the patient “Advance Directive/DNR.” There was no other paperwork in the clinical record to reflect these wishes. During an interview on 02/08/25 at 7:00 PM, the Clinical Manager stated, “We recognized this was a problem area with the nurses having the discussions of a DNR code status with the patients and families on admissions, but they were not following up to either get the signed paperwork for our records or have the patients or patient’s families to sign the DNR paperwork. We in-serviced each nurse last week, and we have placed these forms in all the admission packets for them to begin using with their new admissions.””

“Based on interview, record review, and review of agency policy, the hospice agency failed to identify, document, and have a functional grievance program from November 2023 until 12/03/24. This failure had the potential to cause patient and caregiver concerns to be unaddressed for 23 of 23 active patients. Findings include: Review of the facility’s “Concern Log,” provided by the facility, revealed grievances/concerns began on 12/03/24. There was no documentation of a “Concern Log” from November 2023 when the new management company took over until 12/03/24. During an interview on 02/06/25 at 3:30 PM, the Director of Nursing (DON) stated, “This log began on 12/03/24. I didn’t realize that we needed one until then.” The DON also stated he/she did not begin working at the hospice agency until March 2024. During an interview on 02/08/24 at 4:00 PM, the DON stated, “The new management company began in November 2023. I do not have any records until when I started this on 12/03/24.” Review of the agency’s policy titled, “Complaint Resolution,” dated June 2019 revealed, “. . . Hospice maintains records of grievances/complaints and their outcomes and includes this information in the annual program review/evaluation. A summary of the grievances/complaints will be reported quarterly to the governing body/owner . . .””

“Based on interview, record review, agency policy review, and review of the New Jersey Adult Protective Services (APS) website, the hospice agency failed to comply with mandatory reporting requirements to immediately report suspicions of neglect to APS for one of 14 patients (Patient (P) 9) whose records were reviewed out of a total sample of 14. P9 was noted to be unsafe and a vulnerable adult on 12/09/24, and the case was not filed with APS and law enforcement until 02/07/25. This placed P9 at continued risk of serious injury, harm, and impairment. Findings include: Review of P9’s “Patient Profile,” provided by the agency., revealed P9 was admitted to hospice services on 12/06/24 with a terminal diagnosis of ischemic cardiomyopathy. Review of P9’s “Hospice Nursing Clinical Notes” revealed the following: 12/09/24 and untimed - It was recorded P9 was eating approximately two child size meals per day. It was also recorded, “. . . Pt [patient] has a large, painful bruising to chest wall which [he] she [P9] stated was from a fall. [He/She] was unwilling to go downstairs as [he/she] stated [he/she] cannot get back upstairs. Educated [family member] . . . and pt that it is not safe for [him/her] remain alone as [he/she] is a high fall risk and unable to get [himself/herself] to the bathroom or kitchen. [Family Member] stated ‘we’re not ready to hire help at this time.’ Reported safety concerns to MSW [Medical Social Worker], SC [Spiritual Counselor] and DON [Director of Nursing] . . .” 12/16/24 and untimed - “... Discussed with pt and [family member] . . . the need for help in the home and reiterated pt should not be left alone. Both pt and [family member] refused to discuss.” 12/23/24 and untimed - “. . . Routine SN [skilled nurse] visit. Door was left unlocked and TN [the nurse] found pt upstairs in [his/her] bed not wearing any clothing. [He/she] stated [he/she] was hot in the night so [he/she] took [his/her] nightgown off. Helped [him/her] dress and sit on side of the bed. AAO x 2 [Awake, Alert and Oriented], very forgetful. Reminded pt [he/she] should have someone with [him/ her] 24/7 [24 hours per 7 days of week] for safety reasons . . .” 01/06/25 and untimed - “. . . Reported safety concerns to DON . . .”[family member] that it is unsafe with [him/her] being alone . . . Educated on the possible safety issues with [him/her] being alone . . .” 01/27/25 and untimed - “. . . Noted [he/ she] (P9) did not have [his/her] life alert on nor phone nearby . . . Gave [him/her] life alert and educated on safety concerns of [him/her] being alone . . . [family member] made aware of safety concerns . . .” 01/30/25 and untimed, -“. . . PRN [as needed] visit for reported chest pain . . . patient was complaining of chest pain and requesting aspirin. TN (the nurse) called patient [family member] and route [sic] and let [him/her] know of the situation. Requested a family member come and stay with patient and was told no one was available . . . Patient hypertensive at 157/103, pulse of 120 and irregular, respiratory rate of 24 and shallow, SPO2 [saturation of oxygen] reading of 89%. TN suggested that [he/she] put on supplemental O2 [oxygen] and [he/she] refused. TN contacted clinical manager, who stayed on the phone while TN informed patient we advise [him/her] to go to the hospital due to hypertension and tachycardia. Patient adamantly refused, clinical manager and HHA [home health aide] . . . both witnessed refusal. [He/She] denied having any pain and stated [he/she] was ‘fine’ and did not need any further assistance. Advised patient of the risks of not going to ER and [he/she] stated [he/she] was OK with the risks. TN stayed for one hour to ensure patient had no further symptoms. Patient asked TN to leave stating [he/she] was fine advised [him/her] if [he/ she] continue to refuse treatment [he/she] may be discharged from service for continued refusal to follow POC (Plan of Care) . . .” 02/03/25 and untimed - “. . . Patient is unable to recall instructions provided after 1 minute . . . [He/She] agreed to follow safety instructions and to use oxygen when instructed to do so. However, within 1 minute [he/she] was asking what TN had just told [him/her] [he/she] should do . . .” Review of P9’s “Medication Profile” revealed P9 was supposed to receive Aspirin (Aspirin Children’s) 81 mg by mouth daily and Digoxin (a cardiac medication) 125 micrograms(mcg) by mouth daily. During a home visit on 02/07/24 at 10:25 AM, P9 was asked what medications he/she took. P9 stated, “I don’t take any medicines.” P9 was asked if he/she took an aspirin and his/her heart pill, Digoxin each day. P9 stated, “I don’t have to take any medicine like that.” It was noted that P9’s bedroom was upstairs, and her food was downstairs in the kitchen refrigerator. P9 would be required to navigate five steep stairs with a walker in order to get her food. During an interview on 02/07/25 at 11:10 AM, the MSW was asked if other community resources had been contacted to see if other options were available for P9. MSW stated, “I think I did.” When asked if this contact was documented in the medical record, the MSW stated, “I wouldn’t document anything like that.” During an interview on 02/07/25 at 11:20 AM, the Hospice aide (HA)1 stated, “The patient only has family that will drop in to put groceries in the refrigerator. “ HA1 stated family brought the food once a week. HA1 stated, “He/She] [P9] has a friend of the family that comes about three times a week to help [him/her] with supper and then leaves. [He/She] is here all the time by [himself/ herself], and I don’t feel it is safe for [him/ her] to be here alone.” When asked who would be here over the weekend to ensure P9 received something to eat, HA1 stated, “Nobody that I know of.” During an interview on 02/07/25 at 12:06 PM, Registered Nurse (RN)1 was asked if the patient was safe to be at home by herself. RN1 stated, “Not entirely, but I have talked to the family and to the office about the safety concerns of leaving the patient alone.” When asked if anything else has been done with the safety concerns of P9, RN1 replied, “Education of the patient and then to the family every visit is all that I know of.” RN1 was asked if she reconciled the medication profile with what the patient was taking, and RN1 stated, “Not every visit. Her family tells me [he/she] is taking [his/her] medicine.” Review of P9’s “IDG [Interdisciplinary Group] Meeting Review,” beginning 12/18/24 and completed every 2 weeks, revealed safety concerns of P9 being a high fall risk and concerns that P9 needed 24-hour care were discussed. It was recorded education had been provided by the hospice staff members to the patient and family, but they were reluctant and refused any further care for the patient at the time. There were no documented action plans, and no discussions documented that these failures were suspicious for neglect. Review of P9’s entire clinical record revealed no documented evidence APS (Adult Protection Services) had been notified of P9’s unsafe living situation and vulnerability from 12/09/24 until 02/07/25, when contact was first made with APS and law enforcement. During an interview on 02/07/25 at 1:31 PM, the DON stated, “There is definitely a concern for [his/ her] [P9] safety, but we cannot get the family to agree with extra help.” During an interview on 02/07/25 at 2:45 PM, the DON was asked if the safety concerns of P9 had been reported to anyone. The DON stated, “No, definitely if we thought it was abuse or neglect, we would have reported it to APS.” Review of New Jerseys APS law (N.J.S.A. 52:27D-406 to 426) website, located at https://apps.rainn.org/policy/policy-state-laws.cfm?state=New%20Jersey&group=5, revealed, “. . . requires health care professionals, law enforcement officers, firefighters, paramedics or emergency medical technicians who have reasonable cause to believe that a vulnerable adult is the subject of abuse, neglect or exploitation to report that information to the county Adult Protection Services office . . .” Review of the agency’s policy titled, “Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect, or Exploitation,” dated February 2021 and provided by the agency, revealed, “. . . all violations involving mistreatment, neglect . . . are reported immediately . . . to the Hospice Administrator . . .” Review of “Mandatory Reporting Requirements: The Elderly New Jersey,” dated April 2023, which was provided by the agency, revealed, “. . . When is a report required and where does it go . . . For a Vulnerable Adult: The relevant county adult protection services office . . . Neglect means an act or failure to act by a vulnerable adult or his caregiver which results in the inadequate provision of care or services necessary to maintain the physical or mental health of the vulnerable adult, and which places the vulnerable adult in a situation which can result in serious injury or which is life threatening . . . Reports for a . . . Vulnerable Adult [sic] must be made in a timely manner . . .””

“Based on interview, record review, and policy review, the agency failed to ensure that medications listed on the hospice agencys medication list were the same medications listed on the nursing facility’s medication list for one of 10 patients (Patient (P) 3) whose medications were reviewed out of a total sample of 14. This had the potential to cause P3 to suffer adverse drug events. Findings include: During a review of P3’s “Order Summary Report” of active orders as of 02/06/25, in P3’s nursing facility, it was revealed the patient was being given docusate sodium (a stool softener) 100 milligrams (mg) two tablets by mouth one time a day for constipation, morphine sulfate (a pain medication) oral solution 10 mg/0.5 ml (milliliter) 0.5 ml sublingually (under the tongue) every 6 hours as needed (PRN) for moderate to severe pain with a pain level of 5-10 or for shortness of breath (SOB), Percocet 5-325 mg (a pain medication) one tablet by mouth every four hours for pain, hold when asleep, and Trazodone (used for sleep) 50 mg one tablet by mouth at bedtime related to insomnia. Review of P3’s “Hospice Medication Profile,” dated for the certification period of 01/10/25 to 03/10/25 and provided by the agency, revealed docusate sodium 100 mg one tablet by mouth two times a day, morphine sulfate (Concentrate) 20 mg/ml Give 5 mg every three hours as needed for pain/SOB, and Trazodone 50 mg Give 1 tablet prn/as needed. There was no documentation of Percocet being on the Hospice Medication Profile. During an interview on 02/06/25 at 3:30 PM, the Clinical Manager (CM) was provided with P3’s “Order Summary Report” of active orders and the “Hospice Medication Profile” to review. The CM confirmed orders on the hospice profile did not match the nursing facility’s list for docusate sodium, morphine sulfate, and Trazodone. The Clinical Manager stated, “The Percocet isn’t on our profile, but it should be.” The Clinical Manager was asked how often the nurse should reconcile the medications for P3 and he/she stated, “With every visit.” During an interview on 02/07/25 at 3:15 PM, Registered Nurse (RN)1 stated, “I didn’t reconcile [P3’s] medications when I made the visit yesterday. I only asked the nurse taking care of [P3] if there had been any medication changes.” Review of the agency’s policy titled, “Medication Reconciliation,” dated June 2019, revealed, “Hospice will reconcile patient’s medications at time of admission and on an ongoing basis . . . Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication . . .””

“Based on record review and interview, the agency failed to follow the physician orders for skilled nursing visits for one of 10 patients (Patient (P) 6) whose records were reviewed for visit frequencies out of a total sample of 14. This failure had the potential for P6 to have a decline in condition that otherwise could had been recognized earlier if the skilled nursing visits had been made as ordered by the physician. Findings include: Review of P6’s “Patient Profile,” located under the “Patient Chart” tab in the electronic medical record (EMR), revealed P6 was admitted to hospice services on 12/05/24 with the terminal illness of senile degeneration of the brain. Review of P6’s “Hospice Physician Order,” located under the “Patient Chart” in the EMR, revealed an order dated 12/20/24 for “decrease SN [skilled nurse visit] to 1XW [sic] [one time a week] . . .” Review of P6’s “Hospice Nursing Clinical Note,” located under the “Patient Chart” in the EMR, revealed the last skilled nursing note was dated 01/14/25. There was no further documentation in the EMR to reveal P6 was seen by the nurse one time a week after 01/14/25. During an interview on 02/08/25 at 4:30 PM, the Director of Nursing (DON) stated, “I believe the nurse made the visits but [he/she] is not a good time manager.” When asked if the agency had verified that the skilled nursing visits had been made by the nurse, the DON replied, “The nurses have to sign in the nursing facility every time they go into make a visit and when they leave. I guess I could call and ask to see if I could get a record of the kiosk if I needed to.” The DON was asked when the nurse was supposed to document the nursing visit. The DON stated, “After the visit is made.””

“Based on policy review, record review, and interview, the agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for three of 10 patients (Patient (P)3, P2, and P9) out of a total sample of 14. This deficient practice had the potential to affect all 23 patients receiving services from the Hospice Agency. Findings include: Review of the agency’s policy titled, “IDG Care Planning Process,” provided by the agency and dated 2014 stated, “. . . The care of plan [sic] specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions [sic] . . . Measurable outcomes anticipated from implementing and coordinating the plan of care . . . and notes the patient’s progress toward outcomes and goals specified in the plan of care . . .” 1. Review of P3’s “Hospice Plan of Care,” located under the “Hospice Plan of Care” tab in the electronic medical record (EMR), indicated the Registered Nurse (RN) started P3’s care plan on 07/14/24 that included intermittent “SOB” (shortness of breath), [P3] is bed/chair bound with muscle weakness, and complains of abdominal pain.” The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals. 2. Review of P2’s “Hospice Plan of Care,” located under the “Hospice Plan of Care” tab in the EMR, indicated the RN started P2’s care plan on 09/06/24 that included at risk for pain due to generalized pain, osteoarthritis, limited mobility, history of left femur fracture, at risk for respiratory complications related to end of life respiratory changes, risk of aspiration, at risk for falls due to advanced age, polypharmacy, dementia, and decreased mobility. The care plan did not include measurable elements to monitor the progress toward the expected outcomes and goals. 3. Review of P9’s “Hospice Plan of Care,” located under the “Hospice Plan of Care” tab in the EMR, indicated the RN started P9’s care plan on 12/09/24 that included patient is at risk for pain as disease progresses, patient has dyspnea at rest, patient has heart disease and atrial fibrillation, patient has had multiple falls in the past three months, patient has bladder incontinence, and patient is at risk for moisture associated skin breakdown. The care plan did not include measurable elements to monitor the progress toward the expected outcomes and goals. During an interview on 02/06/25 at 11:15 AM, RN1 was asked if the goals for P3 were measurable. RN1 stated, “This one says pain will not interfere with sleep, activities, time with family and friends, appetite or mood.” RN1 was asked how the goal is measurable, and RN1 replied, “Well, putting it that way, the goals are not measurable.” During an interview on 02/06/24 at 3:30 PM, the Clinical Manager confirmed the goals in the patients’ care plans were not measurable.”

“Based on interview, record review, and review of agency policy, the hospice agency failed to regularly monitor quality indicators so that opportunities for improvement could be identified and prioritized. This had the potential to cause unmet care needs for 23 of 23 active patients served by the agency. Findings include: On 02/05/25, upon entrance to the agency, the agency was asked to provide evidence of the Quality Assurance and Performance Improvement (QAPI) activities for the period of 02/05/24 through 02/05/25. On 02/08/25, the agency provided “QAPI Report” for the dates of 05/08/24 and 11/20/24. The 05/08/24 meeting consisted of infection control as it pertained to hand hygiene compliance, medical record review for the compliance of the required documentation pertaining to the admission process, fall prevention, patient/family satisfaction, and employee files as it pertained to ensuing the mandatory components were completed. All of these areas had documentation under the “Data Collection Period/Finding/Conclusions” section which stated “Quarter 2 [sic] (April, May. June) data collection initiated. Findings will be discussed at the July 2024 QAPI Meeting.” There was no documented evidence provided that a July 2024 meeting took place. The 11/20/24 meeting consisted of infection control as it pertained to hand hygiene with the report of the data collection being, “All staff educated and demonstrated Hand Hygiene on 05/09/24. Monitoring of HHA (Home Health Aide) Hand Hygiene during supervision visits revealed 100% compliance.” Medical records, as it pertained to the required documentation pertaining to the admission process was reported as being in 100% compliance. Fall Prevention as it pertained to identify risks/trends of patient falls in an effort to prevent falls stated, “Quarter 2 [sic] (July, August, September) data collection will be discussed at the November 2024 QAPI meeting.” There was no further evidence of a discussion of the data on this 11/20/24 QAPI meeting minutes. There were also “QAPI AD HOC Committee Meeting Minutes,” dated 08/19/24, which revealed the issue of “Families were not made aware of non-covered items.” The Discussion/Action/Follow-Up” was documented, “Education was provided to team [sic]. Audit will be done of all new admissions and reviewed during IDG [Inter-Disciplinary Group] for follow-up as needed.” There were also the issues of “Facility/Community PCP [Primary Care Physician] and CTIs [Certification of Terminal Illness] not being signed” and “Bereavement process not in place for patients that expired prior to March 2024.” There was no further discussion from the 08/19/24 meeting on the non-covered items or bereavement concerns. The January 2025 “QAPI” meeting agenda was also provided. This did not have a sign-in sheet provided with the agenda. The following areas were included on the agenda Falls and Incident with having one fall with injury and two falls without injury reported, Urinary Infections were three with all being treated with antibiotics and no trends noted with the caregivers. During an interview on 02/08/25 at 8:00 PM, the Director of Nursing stated, “No one told me what needed to be covered in the QAPI meetings. So, I went and tackled the issues we found in our chart reviews first and then moved on to the other issues that were identified. I have had to learn this process as I went along.” Review of the agency policy “Quality Assessment and Performance Improvement (QAPI) Plan dated 2015 indicated “. . . Hospice has established an ongoing program of quality assessment and performance improvement . . . Data collection includes developing indicators, criteria or performance levels for each process determined to be improved. Data collection will be ongoing and frequency will be determined by the process improvement activity and approved by the Governing Body. Data collection will be used to monitor the effectiveness and safety of services and quality of care . . .””

“Based on observation and interviews, the agency failed to provide care in a manner to prevent cross contamination for two of three patients (Patient (P) 3 and P4) observed during home visits. This deficient practice had the potential to affect all 23 patients who are currently receiving hospice services and increased the risk of the spread of infection. Findings include: 1. During a home visit on 02/06/25 at 10:30 AM, Registered Nurse (RN)1 used the thermometer, pulse oximetry, and a blood pressure cuff on P3. After each piece of equipment was used, RN1 placed it on a barrier to be cleaned. At the end of the visit, RN1 began cleaning the thermometer with a cleaning wipe and placed the clean thermometer on the dirty side of the barrier where the other dirty equipment was lying. RN1 continued to clean the remaining pieces of equipment and once cleaned, placed each piece of clean equipment on the dirty side of the barrier. After all the dirty equipment was cleaned, RN1 placed the equipment back into his/her bag for storage. During an interview on 02/06/25 at 11:15 AM, RN1 stated, “I should have placed the clean equipment on a clean area on the barrier instead of placing it back down on the dirty side.” 2. During a home visit on 02/06/25 at 12:30 PM, Hospice Aide (HA)1 donned a clean pair of gloves and performed incontinence care for P4. HA1 then assisted P4 in pulling up his/her brief and assisted P4 to sit in the wheelchair. Without changing gloves or performing hand hygiene, HA1 propelled the wheelchair into the patient’s bedroom. During an interview on 02/06/25 at 2:30 PM, HA1 stated, “I should have pulled off my gloves and washed my hands before touching and moving the patient’s wheelchair.” During an interview on 02/06/25 at 3:30 PM, the Clinical Manager stated, “[RN1] should have made a clean and dirty side of the barrier and never put clean equipment down on the dirty side of the barrier. [HA1] should have removed [his/her] gloves and washed [his/her] hands before touching the wheelchair to move it.””

“Based on record review, interview and agency policy review, the hospice agency failed to provide new hires with a two-step PPD (Purified Protein Derivative) TB (Tuberculosis) testing for six out of six newly hired employees. This failure had the potential to have staff that were exposed to Mycobacterium tuberculosis to be undiagnosed and not treated appropriately. Findings include: 1. Review of Registered Nurse (RN)1’s personnel record revealed RN1 was hired on 06/28/24 and received a PPD on 08/02/24. There was no documentation that RN1 received a two-step PPD. 2. Review of the Director of Nursing’s (DON) personnel record revealed the DON was hired on 03/18/24. There was no documentation the DON received the two-step PPD. 3. Review of the Medical Social Worker (MSW) personnel record revealed the MSW was hired on 11/23/23. There was no documentation the MSW received a two-step PPD. 4. Review of Hospice Aide (HA)1 personnel record revealed HA1 was hired on 02/05/24 and received a PPD on 06/25/24. There was no documentation HA1 received a two-step PPD. 5. Review of HA2 personnel record revealed HA2 was hired on 07/08/24 and received a PPD on 04/09/24 prior to being hired at the hospice agency. There was no documentation HA2 received a two-step PPD. 6. Review of RN3 personnel record revealed RN3 was hired on 11/15/24. There was no documentation RN3 received a two-step PPD. During an interview on 02/08/24 at 7:45 PM, the DON stated, “We didn’t do the two step PPD for the new hires that we reviewed.” Review of the hospice agency policy titled, “Occupational Exposure to Tuberculosis/Prevention of Transmission of TB Plan” revealed, “. . . During pre-employment physical, employees and patient care volunteers who have the potential for exposure to M. tuberculosis . . . will have the baseline PPD skin testing performed . . . the baseline PPD testing will include the two-step method . . .””

“Based on interview and record review, the hospice agency failed to develop and implement effective volunteer recruiting efforts from November 2023 until the first hospice volunteer was available to provide services to the hospice patients. This failure had the potential for hospice patients not to receive the services they might need that could be provided by volunteers. Findings include: During an interview on 02/07/25 at 5:40 PM, the Volunteer Coordinator (VC) stated the recruiting efforts for hospice volunteers did not occur until July 2024 with the first volunteer service hours began in September 2024. The VC stated, “I am part of the [name of county] volunteer services. We post on Facebook, go to area colleges and promote or recruit for volunteers on social media.” The VC did not state that the hospice agency used online websites such as Volunteer Match. When asked if in-services were provided for the volunteers, the VC replied, “No, I do not.” The VC stated, “Pretty much I cannot get them together in the same spot and four of them are full time students.” The VC was asked what the hospice agency did for retention of volunteers and the VC stated, “I answer any questions that they may have. I send them cards and keep an open dialogue with them. They were also invited to our holiday party.” During an interview with the Director of Nursing (DON) on 02/07/25 at 7:00 PM, the DON stated, “The agency didn’t have many residents from November 2023 until March 2024. I became the DON in March 2024 and our census was low. Gradually we began to increase the number of patients that we had.” The surveyor requested a copy of the Volunteer Services policy but was not provided with such information.”

“Based on interview and record review, the hospice agency failed to have volunteer hours that equaled five percent of total patient hours from November 2023 until September 2024. This failure had the potential to cause the hospice patients to have unmet needs. Findings include: Review of the untitled documentation of the volunteer hours, provided by the agency, revealed the hospice agency had volunteer hours that equaled five percent of patient hours beginning in September of 2024. There was no documentation of volunteer hours prior to September 2024. During an interview on 02/07/24 at 5:40 PM, the Volunteer Coordinator stated the volunteer service hours began in September 2024. During an interview on 02/07/24 at 7:00 PM, the Director of Nursing stated, “The agency didn’t have many residents from November 2023 until March 2024. I became the DON in March 2024 and our census was low. Gradually we began to increase the number of patients that we had.” The surveyor did request a copy of the Volunteer Services but was not provided with this information.”

“Based on interview and record review, the hospice agency failed to have a signed written statement of revocation of hospice benefits for two of two patients (Patient (P)13 and P14) reviewed for revocation out of a total sample of 14. This failure had the potential to cause disruption of the patient’s Medicare benefits. Findings include: 1. Review of P13’s “Patient Profile,” located under the “Patient Profile” tab in the electronic medical record (EMR), revealed P13 had been admitted to hospice services on 11/27/23 with the terminal diagnosis of Alzheimer’s dementia. Review of P13’s entire EMR revealed no documented evidence of a signed written revocation of hospice benefits. However, there was documentation of a “Notice of Medicare Non-Coverage (NOMNC)” which stated “The effective Date Coverage of Your Current [name of hospice agency] Services Will End: March 2, 2024.” This notice was signed by the patient representative on 02/29/24. P13 was discharged from hospice services on 03/01/24 due to his/her condition being stable and no longer terminally ill. 2. Review of P14’s “Patient Profile,” located under the “Patient Profile” tab in the EMR, revealed P14 was admitted to hospice services on 06/28/24 with the terminal illness of Alzheimer’s Disease. Review of P14’s entire EMR revealed no documented evidence of a signed written revocation of hospice benefits. However, there was documentation of “Notice of Medicare Non-Coverage (NOMNC)” which stated “The effective Date Coverage of Your Current [name of hospice agency] Services Will End: 12/9/24.” This notice was signed by the patient representative on 12/06/24. P14 was discharged from hospice services on 12/09/24 due to his/her condition being stable and no longer terminally ill. During an interview on 02/08/24 at 6:00 PM, the Director of Nursing stated, “Both patient’s condition improved, and they were discharged from hospice services. I believe that we got the NONMC, and the revocation of hospice benefits mixed up and got the wrong one signed.””

“Based on record review, interview, and agency policy review, the hospice agency failed to document in the patient’s clinical record that the discussion of written policies and procedures for managing controlled drugs was provided and discussed with the patient and the patient’s family for one of 10 patients (Patient (P) 9) reviewed for medications out of a total sample of 14 patients. Findings include: Review of P9’s undated “Patient Profile,” located under the “Patient Profile” tab in the electronic medical record (EMR), revealed P9 had been admitted to hospice services on 12/06/24 with a terminal diagnosis of ischemic cardiomyopathy. Review of P9’s entire clinical record revealed no documented evidence that staff provided a discussion of written policies and procedures of managing controlled drugs to P9 or to his/her family. During an interview on 02/08/25 at 7:00 PM, the Clinical Manager (CM) stated, “I think they are discussing this with the patient and families.” Review of the agency’s policy “Hospice Comfort Kits,” dated 04/15/19, did not indicate the written policies and procedures for controlled drugs or a discussion of the policies would be provided to the patient and/or patient’s family.”