Harmony Home Health Services, LLC

“Based on interview and review of the facility’s Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the use of federal and/or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect the current 32 patients receiving care from the hospice agency. Findings include:Review of the facility’s EPP on 04/23/25 at 3:35 PM with the Director of Nursing (DON) revealed no policy inclusion regarding the use of State and/or Federal healthcare professional volunteers in an emergency or other emergency staffing strategies.During an interview on 11/08/23 at 4:09 PM regarding federal and state healthcare volunteers, the DON stated, “No, it’s not in there.””

“Based on interview, record review, and policy review, the facility failed (1) to ensure one of 16 sampled patients (Patient (P) 10) was assessed by the Social Worker (SW) and Chaplain within five days of the election of Hospice benefits, and (2) the documentation of the Physician involvement in the comprehensive assessment was not included in three of 16 sampled patients (P6, P11, and P14). These failures had the potential to delay medically needed social services and spiritual service provision to the patient. Findings include:1. Review of P10’s facility printed “Intake Referral Sheet” showed a start of care date of 02/01/25 with a primary medical diagnosis of adult failure to thrive.Review of P10’s electronic medical record (EMR) on 04/24/25 with the Executive Director (ED) revealed the SW assessment was completed on 02/13/25. This was 12 days after the start of care date. It was also revealed that the Chaplain assessment was completed on 02/14/25. This was 13 days after the start of care date.The ED reviewed the EMR for documentation of earlier contact or documented patient preference in regard to the SW assessment and stated at 2:03 PM that there was “nothing.” The ED reviewed the EMR for documentation of earlier contact or documented patient preference in regard to the Chaplain assessment and stated at 2:04 PM, “[He/She] [Chaplain] always gets in there so it was probably a scheduling issue, but nothing is documented.”2. Review of P6’s facility printed “Intake Referral Sheet” showed a start of care date of 09/05/23 with a diagnosis of repeated falls.Review of P11’s facility printed “Intake Referral Sheet” showed a start of care date of 01/28/25 with a diagnosis of primary spontaneous pneumothorax.Review of P14’s facility printed “Intake Referral Sheet” showed a start of care date of 04/02/24 with a diagnosis of toxic effects of other halogen derivatives.Review of the four EMR’s on 04/24/25 with the ED revealed the section on the comprehensive assessment for “Attending Physician” had areas to be checked of the following:”-Reporting patient status-Reported on plan of care problems, interventions, goals & patient response-Received new ordersConsultation results [blank line for comment]”The assessments for P6, P11, and P14 did not contain any documentation the physician was involved.During an interview on 04/24/25 at 5:31 PM, the ED stated, “They [SW and Chaplain] normally do a fantastic job. I feel there is a reason, but the documentation is not there.” The ED stated the expectation was for assessments to be completed within five days or less or that there is documentation regarding the delay. The ED stated physician involvement was “probably done via their messaging system,” but the expectation was for there to be documentation of the physician involvement in the comprehensive assessment. Review of the facility policy titled “Comprehensive Assessment – Hospice,” reviewed 11/2024, revealed:”. . . 3. The comprehensive assessment is completed, as appropriate to the patient’s needs, or within the following time frames:a. There is a 5-day window to complete the whole comprehensive assessment . . . “”

“Based on interview and review of the agency documentation, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services equaling a minimum of 5 percent of the total patient care hours of all paid hospice employees and contract staff. This had the potential to cause 32 of 32 residents to have unmet needs. Findings include:Review of the agency provided “Volunteer Time” report for the time period of 01/01/24 – 12/31/24 showed:”Volunteer Total Time 10.5Total Hospice Visit Time: 10,938.13 hoursPercentage [of Volunteer Hours]: 0.10%”Review of the agency provided “Volunteer Time” report for the time period 01/01/25 – 12/31/25 (printed on 04/22/25) showed:”Volunteer Total Time 30.58Total Hospice Visit Time: 3604.95Percentage [of Volunteer Hours]: 0.85%In an interview on 04/24/25 at 5:28 PM, the Executive Director (ED) confirmed the volunteer hours did not reach 5%. The ED stated, “When I look at volunteers I don’t look at cost savings benefits for patient and families, but I don’t look at it as a cost aspect. I know it’s supposed to be at 5% and I would like to have more.”Review of the undated agency policy titled, “Value of Volunteer Service/Cost Saving,” revealed, “. . . -Quarterly reports on volunteer services are present to the Governing Board. The agency volunteers provide a minimum of 5 percent of the total patient care hours of all paid employees and contract staff.-Each office will strive towards a minimum of 5 percent of the total patient care hours . . .””

“Based on observation, interview, and policy review, the Hospice Agency failed to ensure that supplies kept for patient use were not expired. This had the potential to negatively affect 32 of 32 patients receiving services. Expired products may not perform as intended, leading to ineffective treatment, and/or increase the risk of infection. Findings include:During an observation on 04/22/25 at 4:10 PM, the following were observed in one of two supply rooms:9 Wound Vacuum Dressings:Granufoam large – 4, expired 5/31/24Medela medium – 2, expired 2/27/25Dermatec medium – 3, expired 12/31/2410 Foley catheters:26 French (F, size) 30 milliliter (ml, retention bulb size) – 4, expired 7/28/2322F 30ml – 2, expired 8/28/2424F 5ml – 1, expired 11/20/2430F 30ml – 2, expired 4/28/24300ml cannisters for wound vacuums – expired 11/30/2433 red top blood vacutainer tubes expired 04/01/25Medline Latex Surgical gloves, size 8 – 6, expired 11/28/24Versatel Silicone Wound contact layers – 1, expired 06/2024 During an interview on 04/22/25 at 4:30 PM, the Executive Director reviewed all products found, confirmed the expiration dates, and stated all the products were expired. Review of the facility policy titled “Supply Inventory,” revised 06/2024, revealed, “. . . -Please keep in mind, [sic] that Medical Supplies are for client use and when those supplies become either damaged, contaminated or their effectiveness is diminished through an effective date, those supplies need to be discarded.. . . Inventory Disposal-If a Branch has any Medical Supply item that becomes damaged, contaminated or obsolete and need to be discarded from inventory, they should use the Medical Supply checkout form to discard those items and mark on the form – Inventory Disposal . . .””

“Based on interview, record review, and policy review, the facility failed to ensure the Skilled Nursing Facility (SNF) received the original certification of terminal illness and other admission documentation for one of one patient (Patient (P) 5) reviewed who lived at a SNF out of a total sample of 16. This had the potential to affect the care and services provided to the patient. Findings include:Review of P5’s hospice “Intake Referral Sheet” revealed a hospice start of care date of 04/08/25.During a home SNF visit on 04/23/25 at 10:00 AM, a review of the Hospice notebook for P5 did not reveal a certification of terminal illness (CTI), election of hospice benefits, or hospice plan of care.During an interview on 04/23/25 at 11:00 AM, the SNF Director of Nursing (DON) stated P5’s hospice information would be in a notebook at the Nurse’s Station.Review of P5’s hospice notebook on 04/23/25 at 11:07 AM revealed a three-ring binder with dividers that were empty for the CTI, hospice election form, and plan of care sections.During an interview on 04/23/25 at 11:25 AM, the Minimum Data Set (MDS, a federally mandated assessment) Coordinator (MDSC) reviewed the facility electronic medical record (EMR) for a hospice plan of care and CTI. The MDSC stated “I let medical records know and talked to the Business Office Manager regarding not having documentation.”During an interview on 04/23/25 at 4:55 PM, the Hospice Executive Director (ED) confirmed that the documentation had not been sent and provided an email with attachments that was verified as received by the facility on 04/23/25 at 3:54 PM. It was noted that the CTI was unsigned by the physician. During a follow-up interview on 04/24/25 at 5:30 PM, the ED stated, “It [documentation] should be to them [SNF] right away. Our timing of document delivery and signing documents could be improved. They [SNF] should have [the documents] withing the first 24 – 48 hours.”Review of the facility policy titled, “Facility Admission Process,” dated 05/2024, revealed, “. . . CMA (Care Coordinatory [sic]) will fax required paperwork to facility including:--Face Sheet--Order (POC [Plan of Care])--Medication Sheet--POLST [Cardiopulmonary Resuscitation directive]--Hospice Election--Most recent nursing assessment--Current History and Physical (must be within 30 days, if available)-Case Manager is responsible for facility packet. (Fill out completely, put in facility chart and attach all stickers according to facility protocol.””