Hospice and Palliative Care Inc. New Hartford

“Based on a review of clinical records and interviews with the Administrator, Director of Patient Services, and Director of Quality and Compliance it was determined in 2 of 18 active records (patients #11 and 14), the comprehensive assessments were incomplete and failed to identify all of the patient’s needs. Evidence as follows: 1. Patient #11 was admitted to the hospice on 08/15/24 with a terminal diagnosis of Parkinsons disease. On 09/06/24 the interdisciplinary team noted new wounds, orders included: - “;Patient/caregiver verbalize/demonstrate knowledge of wound care and what to report to RN/MD”.- “;Red areas on the top of R foot and L outer ankle. Clean with soap and water, apply sure prep. LPN [licensed practical nurse] to do 2x week at each visit. May cover with an optifoam for extra protection. Apply heel boots. Family proficient at doing this daily.”- “;Small stage 2 left buttocks-cleanse with wound cleanser, pat dry, cover with optifoam. Change every 7 days and prn [as needed]. Family proficient at wound care.”- “;Wash peri-area/thighs with soap and water, pat dry, apply barrier cream to area for excoriated area. LPN to apply 2x week at visit. Family proficient at applying daily and prn.” On 09/06/24 the registered nurse performed a home visit and completed wound care. The visit notes included “;red areas noted to top of right foot/ankle areas and left outer ankle. No open area noted. Optifoam was covering right ankle area. Sure prep applied to bilateral ankles and heels. [caregiver] watched me apply this and says [they are] able to do so daily to prevent further break down.” There was no evidence the nurse:- provided instruction on the stage 2 pressure sore site- provided wound care instructions on peri-area and thighs- assessed if the caregiver was performing wound care correctly as ordered through a return demonstration 2. Patient #14 was admitted to the hospice on 05/16/24 with a terminal diagnosis of malignant neoplasm of the lung and bone.The 05/16/24 plan of care included skilled nursing 1-2 times a week for 13 weeks and wound care orders that included:- “;May apply skin prep to right hand 5th digit outer aspect where blood collection is seen in form of blood blister.”- “;Place form fitting band aid to first finger right hand to protect top of fingers and fingernail from possible infection.”- “;Keep all R hand fingers dry, but cleanse middle finger with saline, apply hydrogel, cover with 2x2 gauze, then wrap with gauze every 3 days and PRN [as needed] if wet, soiled, or falling off, performed by HCPI staff.”. On 05/29/24 verbal orders included “;Cleanse middle finger with saline, apply iodine and cover with gauze, secure with tape. Change daily and prn [as needed].” On 08/15/24 verbal orders for change in wound care included “;cleanse second finger and third finger on right hand daily with saline, pat dry, apply betadine and allow to dry. May leave open to air unless leaving the family home. If out of the home cover with gauze and secure with tape until arriving back at the home. May be completed by patient and spouse who are proficient in task.” The 09/18/24 plan of care included wound care may be completed by patient and spouse who are proficient in task. There was no evidence the nurse assessed the patient and caregivers ability to provide wound care through:- teaching and education of new wound care orders- evidence of a return demonstration with wound care to right hand On 10/07/24 at 12:40 p.m., the records were reviewed the Administrator, Director of Patient Services, and Director of Quality and Compliance. The surveyor requested any evidence in the record related to how the nurse assessed the patient and/or caregiver to determine whether they were proficient with wound care. The Administrator stated they were unable to provide any evidence of teaching to support this determination. Failure to conduct a comprehensive assessment of the patient and/or caregivers ability to provide all ordered care and treatments has the potential for the development of an incomplete plan of care and unmet patient needs.”

“Based on clinical record review and interviews with the Administrator, Director of Patient Services, and Director of Quality and Compliance, it was determined in 2 of 18 active records (patients #4 and 10), the hospice nurse failed to conduct a comprehensive assessment of the patient’s medications. Evidence as follows: 3. Patient #4 was admitted to the Hospice residence on 07/10/24 with a terminal diagnosis of malignant neoplasm (cancer), primary unknown and additional diagnoses of abdominal mass, hydronephrosis (increased fluid in the kidney), stroke, and developmental delay. The patients “;Medication Profile”, printed 10/03/24, included:- acetaminophen 650 mg rectal suppository; 1 suppository every 4 hours as needed for pain/fever- acetaminophen 325 mg tablet; take 2 tabs orally every 4 hours as needed for pain/fever- senna s 8.6-50 mg tablet; take 1-4 tabs orally up to 3 times daily as needed for constipation The hospice nurse failed to:- document when to use the oral acetaminophen versus the rectal acetaminophen- a maximum daily dose for the acetaminophen ensuring both the oral and rectal dose were included- document if the senna s is currently in use and if so, the current dose being used On 10/07/24 the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. Failure to ensure a comprehensive assessment of the patient’s medication is completed has the potential for negative drug effects and unmet patient needs. 1. Patient #10 was admitted to the Hospice on 07/08/24 with a terminal diagnosis of cerebrovascular disease and an additional diagnosis of status post resection of brain tumor with residual left sided weakness and blindness. Morphine AllergyThe patients 07/01/24 referral document from the hospital documented the patient had an allergy to morphine. The 07/08/24 Plan of Care documented the patient had an allergy to morphine. Morphine 20mg/ml concentrate, take 5-10 milligrams orally every 2 hours as needed for pain or shortness of breath; current dose 0.25mL every 2 hours as needed, was ordered and listed on the patients plan of care and medication list. On 07/08/24, the hospice nurse went and performed an initial assessment on the patient. The nurse documented they encouraged the patient and caregiver to begin using morphine concentrate 0.25 mL every 2 hours as needed and the patient and caregiver verbally understood. The nurse failed to document whether they discussed why morphine was listed as an allergy for the patient and what the patients reaction to it was. There is also no evidence the nurse called the physician to ensure that it was ok for the patient to have morphine. On 07/09/24 a different hospice nurse visited the patient and documented the patients caregiver reported giving the patient a dose of morphine on 07/08/24. The nurse documented that morphine was listed as an allergy, but the caregiver stated it was not a “;true allergy and is from the patient not liking it in the past while hospitalized.” The nurse documented the patient had no adverse reaction to the morphine and encouraged the caregiver to administer it as needed. There is no evidence the nurse called the physician to discuss the patient had a morphine allergy listed however was ordered and using morphine. On 07/11/24, the pharmacist documented in the electronic medical record the medication profile was reviewed for adverse reactions, drug interactions, and significant side effects. They noted that morphine was listed as an allergy with unknown reaction and there was active morphine orders. The pharmacist documented to monitor for any adverse effects when administered. Senna DoseAccording to the patients medication profile printed 10/07/24, they were taking senna s 8.6-50mg tablet, take 1-4 tab(s) orally up to 3 times per day as needed for constipation. The current dose the patient was taking was blank; making it unclear whether the patient was using the medication and how much. On 10/07/24 the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. 2. Patient #5 was admitted to the Hospice on 07/29/24 with a terminal diagnosis of malignant neoplasm of the brain and additional diagnoses of encephalopathy and adult failure to thrive. On 08/27/24 the Plan of Care was updated to include an order to “;apply a small dash of antifungal powder under right side abdominal fold daily.” The order failed to include the specific type of antifungal powder to use and how long it should be used for. On 10/03/24 the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information.”

“Based on clinical record review and interviews with the Administrator, Director of Patient Services, and Director of Quality and Compliance, it was determined in 1 of 21 (patient #1), the agency failed to ensure an initial bereavement risk assessment was conducted to identify the needs of the family and caregivers. Evidence as follows: 1. Patient #1 was admitted to the hospice on 08/27/24 with a terminal diagnosis of chronic respiratory failure with hypoxia, and additional diagnoses of anxiety, hepatomegaly, cerebral palsy, and severe intellectual disabilities. The patient was a resident of a residential alternative group home. On 8/31/24 the social worker visited the patient and documented the following:- the patient was non-verbal therefore their support system was not assessed- a call was placed to the patients sister, who was listed as the primary bereaved, but there was no answer, so a message was left- a full social work assessment was pending because the primary bereaved was unavailable On 9/26/24 the social worker visited the patient for a routine visit. There was no evidence the social worker attempted to reach the patients sister again to complete a bereavement assessment. The social worker did document they had a “;chat about how long [they have] been working with the patient” however, there was no evidence of an assessment completed with the facility staff to identify their bereavement needs. On 10/03/24 at 2:50 p.m. the surveyor reviewed the record with the Administrator and Director of Patient Services. They acknowledged the findings, and no additional information was provided. On 10/04/24 at 9:30 a.m. the surveyor reviewed the record with the Bereavement Coordinator who acknowledged the lack of follow through to complete full social work assessment and stated that the social worker assigned to the patients case had resigned. Failure to conduct an initial bereavement risk assessment has the potential to delay the development of a comprehensive bereavement plan of care leading to unmet family and caregiver needs.”

“Based on clinical record review and interviews with the Administrator, Director of Patient Services, and Director of Quality and Compliance, it was determined in 5 of 18 active records (patients #3, 6, 10, 13, and 17), the hospice nurse failed to develop and/or update the plan of care based on the patients comprehensive assessment. Evidence as follows: 4. Patient #10 was admitted to the agency on 07/08/24 with a terminal diagnosis of cerebrovascular disease and an additional diagnosis of status post resection of brain tumor with residual left sided weakness and blindness. Failure to Update Plan of Care In the initial assessment on 07/08/24, under review of symptoms, the hospice nurse noted the patient had a stage 1 pressure injury to their thoracic spine/kyphosis, a stage 2 pressure injury to their coccyx, and a scabbed area to the right skull. On the weekly visit to assess the patient on 07/09/24, the nurse documented they assessed the scabbed area on the skull and they were unable to assess the stage 2 coccyx pressure injury due to the patient not wanting to be moved while eating breakfast. There is no evidence the nurse attempted to assess the stage 1 pressure injury on the thoracic spine at the 07/09/24 visit or at any subsequent visits. The 07/08/24 Plan of Care failed to include any interventions regarding the stage 1 pressure injury. On 10/07/24 at 12:40 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. Change in Treatment The 07/08/24 Plan of Care there includes the following wound care order: Stage 2 pressure ulcer on the medial buttocks/coccyx to cleanse with wound cleanser, apply skin prep to surrounding skin, place a sacral optifoam (cushioned bandage) and change every 5 days or as needed. In the hospice nurses note from their visit on 09/11/24, they document that the coccyx pressure injury has healed and that the caregiver is keeping the site clean and dry and applying barrier cream with changing/bathing. The Plan of Care, reviewed and updated on 09/11/24 and 10/03/24, continued to include the wound care orders. The nurse failed to update the plan of care to reflect that the pressure injury on the coccyx had healed and did not obtain new orders for the barrier cream. On 10/07/24 the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. 5. Patient #17 was admitted to the hospice on 09/04/24 with a terminal diagnosis of lung cancer and additional diagnoses of malignant pleural effusion, chronic respiratory failure, chronic obstructive pulmonary disease, and hypertensive heart disease with heart failure. Blood PressureOn 09/11/24 the hospice nurse visited the patient and documented the patients blood pressure was 110/74 and informed the patient caregiver:- to “;keep an eye” on the patients blood pressure because it was soft (low)- the patient is on medications that lower their blood pressure- the patient caregiver should check the patients blood pressure prior to giving blood pressure medications and call the agency if the blood pressure is less than 100 to get further instructions- patient caregiver verbalized understanding The hospice nurse failed to update the plan of care to include:- patient caregiver to check patients blood pressure prior to administering blood pressure medications- blood pressure parameters - teach and assess patient caregivers ability to perform blood pressure monitoring Heat/IceOn 10/02/24 the hospice nurse visited the patient and documented the patient complained of left sided chest pain and based on assessment believed it was a pulled muscle. The nurse recommended to the patient and patient caregiver to use ibuprofen and alternate using heat and ice. The patient and patient caregiver were agreeable. The hospice nurse failed to update the plan of care to include:- the use of heat and/or ice including the length of time and frequency to use each treatment- teach and assess the patient/patient caregivers understanding for the use of heat and ice On 10/07/24 at 12:40 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. Failure to ensure a Plan of Care is developed and updated based on a comprehensive assessment has the potential for unmet patient needs and possible negative patient outcomes. Home visit 1. Patient #3 was admitted to the hospice on 07/12/24 with terminal diagnosis heart failure and additional diagnosis of vascular dementia.On 10/02/24, the surveyor conducted an observational home visit with the social worker who made a routine home visit at a skilled nursing facility where the patient was temporarily receiving respite care.During the visit, the surveyor requested a copy of the patients medication administration record, and this was provided by the assistant director of nursing at the skilled nursing facility. The following discrepancies were noted:The Hospice Medication Profile printed on 10/01/24 included the following orders:- potassium citrate 10 milliequivalent once daily- acetaminophen 500 mg take 1 tablet every 6 hours as needed for pain or fever- vitamin B 12 100 mg take 1 tablet once a day- ferrous sulfate 325 mg take 1 tablet every other dayThe 10/02/24 skilled nursing facility medication administration record included:- potassium chloride (rather than potassium citrate) 10 milliequivalent once daily- acetaminophen 325 mg (rather than acetaminophen 500 mg) take 2 tablets every 6 hours as needed for mild painThe 10/02/24 skilled nursing facility medication administration record did not include:- vitamin B 12 100 mg take 1 tablet once a day- ferrous sulfate 325 mg take 1 tablet every other day The 12/2023 Medication Reconciliation policy states that the medication reconciliation will “occur with any transition of care when a patient is moved from one setting (hospital, home care, respite, and long-term care) to another.”On 10/03/24 at 2:50 p.m. the surveyor reviewed the findings with the Administrator, Director of Patient Services, and the Director of Quality and Compliance. The Director of Patient Services stated that sometimes the facility has changes such as standing orders that are added to the medication administration record, however, the nurse should be reconciling the medications at each visit. The registered nurse had visited on 09/27/24 for a routine weekly visit.They acknowledged the findings and provided no additional information. 2. Patient #6 was admitted to the hospice on 04/04/24 with a terminal diagnosis of Alzheimers disease with anxiety and mood disorder.Diet orderThe 09/25/2024 Interdisciplinary Group Meeting/Care Plan had multiple conflicting diet orders:- Page 3 stated “;regular diet soft pureed consistency with nectar thick liquids” (start date 08/27/24)- page 5 stated “;soft foods, thin liquids” (start date 04/19/24)- page 6 stated “;pureed/soft food diet, thin liquids” (start date 04/10/24)The 09/24/24 Plan of Care included the following diet orders:- page 2 stated “;regular diet, other: thin liquids” (no start date listed)- page 3 stated “;regular diet soft pureed consistency with nectar thick liquids” (start date 08/27/24)None of these orders were end dated. Urinary catheterThe 09/25/2024 Interdisciplinary Group Meeting/Care Plan included an order to “;irrigate catheter with normal saline as needed for sediment, leaking, or obstruction” and did not include the volume of normal saline to irrigate with.On 10/02/24 the registered nurse documented the urinary catheter was irrigated with 10 ml of sterile water; however, the order was to irrigate with (unspecified amount of) normal saline. On 10/07/24 at 12:40 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and the Director of Quality and Compliance. They acknowledged the findings and provided no additional information.3. Patient #13 was admitted to the hospice on 06/27/24 with terminal diagnosis of cerebral atherosclerosis and additional diagnoses of dementia and dysphagia (difficulty swallowing).Thickened liquidsThe 09/25/24 Interdisciplinary Group Meeting/Care Plan contained conflicting diet orders.- page 5 stated “;pureed diet, nectar thickened liquids” (start date 07/11/24)- page 7 stated “;current diet pureed pudding thick, consistent carb medium” (start date 07/04/24)- page 7 also stated “;use simply thick or “;thick it” for honey thick liquids” (start date 08/28/24)- page 9 stated “;previously on puree diet with pudding thick liquids. Family is OK to pleasure feed to her tolerance & preferences. Family is aware of aspiration risk and signs/symptoms of aspiration.” (start date 06/27/24)The 09/25/24 Plan of Care included the following order:- soft diet, diet as tolerated; other: drinks 1 ensure daily (no start date)On 10/07/24 at 12:40 pm the surveyor reviewed the record with the Administrator, Director of Patient Services, and the Director of Quality and Compliance. They acknowledged the findings and provided no additional information. 4. Patient #10 was admitted to the agency on 07/08/24 with a terminal diagnosis of cerebrovascular disease and an additional diagnosis of status post resection of brain tumor with residual left sided weakness and blindness. On 07/08/24, in the initial assessment under review of symptoms, the hospice nurse documented the patient had a stage 1 pressure injury to their thoracic spine/kyphosis, a stage 2 pressure injury to their coccyx, and a scabbed area to the right skull. The 07/08/24 Plan of Care included: Stage 2 pressure ulcer on the medial buttocks/coccyx, cleanse with wound cleanser, apply skin prep to surrounding skin, place a sacral optifoam (cushioned bandage) and change every 5 days or as needed; and failed to include any interventions regarding the stage 1 pressure injury. On 07/09/24, the nurse documented they assessed the scabbed area on the skull and were unable to assess the stage 2 coccyx pressure injury due to the patient not wanting to be moved while eating breakfast. There was no evidence the nurse attempted to assess the stage 1 pressure injury on the thoracic spine at that or at any subsequent visits. On 09/11/24, the nurse document that the coccyx pressure injury had healed and that the caregiver was keeping the site clean and dry and applying barrier cream with changing/bathing. The Plan of Care, reviewed and updated on 09/11/24 and 10/03/24, continued to include the original wound care orders which were no longer relevant. The nurse failed to update the plan of care to reflect that the pressure injury on the coccyx had healed and did not obtain new orders for the barrier cream. On 10/07/24 the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. 5. Patient #17 was admitted to the hospice on 09/04/24 with a terminal diagnosis of lung cancer and additional diagnoses of malignant pleural effusion, chronic respiratory failure, chronic obstructive pulmonary disease, and hypertensive heart disease with heart failure. Blood PressureOn 09/11/24 the hospice nurse visited the patient and documented the patients blood pressure was 110/74 and informed the patient caregiver:- to “;keep an eye” on the patients blood pressure because it was soft (low)- the patient is on medications that lower their blood pressure- the patient caregiver should check the patients blood pressure prior to giving blood pressure medications and call the agency if the blood pressure is less than 100 to get further instructions- patient caregiver verbalized understanding The hospice nurse failed to update the plan of care to include:- patient caregiver to check patients blood pressure prior to administering blood pressure medications- blood pressure parameters - teach and assess patient caregivers ability to perform blood pressure monitoring Heat/IceOn 10/02/24 the hospice nurse visited the patient and documented the patient complained of left sided chest pain and based on assessment believed it was a pulled muscle. The nurse recommended to the patient and patient caregiver to use ibuprofen and alternate using heat and ice. The patient and patient caregiver were agreeable. The hospice nurse failed to update the plan of care to include:- the use of heat and/or ice including the length of time and frequency to use each treatment- teach and assess the patient/patient caregivers understanding for the use of heat and ice On 10/07/24 at 12:40 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. Failure to ensure a Plan of Care is developed and updated based on a comprehensive assessment has the potential for unmet patient needs and possible negative patient outcomes.”

“Based on a review of the agencys Quality Assurance Performance Improvement (QAPI) Plan, an interview with the Director of Quality and Compliance, and review of the QAPI meeting minutes, it was determined the agency failed to adequately review records of patients with adverse events, analyze their causes, and implement preventative actions. Evidence as follows: On 10/01/24, during the entrance conference, the surveyor requested the quality assurance plan and meeting minutes for the past 12 months. On 10/07/24 the surveyor reviewed the binder provided by the Director of Patient Services, which included the 2024 “;Quality Assurance Performance Improvement Plan,” the internal quality assurance meeting minutes for the previous year, and the executive quality assurance meeting minutes for the previous year. The 2024 QAPI Plan stated that all incidents are:- logged into a database- the data is assembled into reports- benchmarked against other hospice users at the national level- analyzed for areas of risk and improving outcomes On 10/07/24 at 2:00 p.m. the surveyor interviewed the Director of Quality and Compliance about the process of analyzing adverse events. The Director reported that at the time there was no analysis being conducted related to adverse events or determination of the root cause of adverse events to identify areas of risk. The Director reported the agency logged adverse events which allowed counting of how many adverse events occurred, however, there was no ongoing review of records for patients who experienced adverse events unless there were multiple events for the same patient. The Director reported they used to conduct record reviews for patients that experienced adverse events, however, this practice was stopped due to time constraints. On 10/07/24 at 5:00 p.m. pm the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance. The acknowledged the findings and provided no additional information. Failure to adequately review and analyze adverse events prevents the hospice from identifying systemic issues and may lead to negative outcomes for the patient population.”

“Based on 3 of 6 observational home visits (patients #1, 5, and 6), a review of the hospice’s policies and procedures, and interviews with Director of Quality and Compliance it was determined the staff failed to adhere to accepted standards and practices to prevent the transmission of infection. Evidence as follows: Home visit3. Patient #6 was admitted to the hospice on 04/04/24 with a terminal diagnosis of Alzheimers disease with anxiety and mood disorder. The 02/01/24 “;Bag Technique” policy states:- Hospice nurses and home health aides are required to maintain their bags containing equipment and supplies in a clean environment at all times.- All nurses and home health aides are required to have a home care bag. The 02/01/24 “;Standard and Transmission-Based Precautions” policy states:- Hospice staff are required to use standard precautions in the care of all hospice patients, including hand hygiene before and after patient contact. On 10/03/24, the surveyor conducted an observational home visit with the aide. The aide met the surveyor in the patients driveway and upon entering the home, immediately began assisting the caregiver with transferring the patient out of bed and into the bathroom. Prior to initiating the shower, the aide informed the surveyor that they did not perform hand hygiene upon entering the patients home as they knew they would be changing the patients briefs and would be performing hand hygiene following this task. The aide did not carry a bag into the patients home, however, the aide had gloves and hand sanitizer in their pockets.The aide did not perform hand hygiene prior to leaving the patients home. On 10/07/24 at 12:40 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. Policy and ProcedureThe 02/01/24 “;Infection Control Responsibilities: stated the Chief Clinical Officer and the Compliance and Quality Director:- implement written policies and procedures for prevention and control of infectious, contagious, or communicable diseases- implement written policies and procedures for the care of patients who have contagious, infections, or communicable diseases On 10/07/24 at 2 p.m., the surveyor interviewed the Director of Quality and Compliance about the infection control program and requested the policies or procedures for the prevention of infection from airborne pathogens, infusion therapy, urinary tract care, respiratory tract care, wound care, multi-drug resistant organism, and blood-borne pathogens. The surveyor also requested information about a policy or procedure that addressed the transmission of infectious agents in all settings where the patients reside (e.g. home, inpatient, skilled nursing facility, et cetera). On 10/07/24 at 2:50 p.m., the Director of Quality and Compliance gave the surveyor copies of the policy titled Standard and Transmission-Based Precautions (dated 02/01/24). The policy failed to address protocols for preventing infection from:- infusion therapy- urinary tract care- wound care- multi-drug resistant organism The policy also failed to address transmission of infectious agents in all settings where patients reside. Failure to follow accepted standards of practice for infection control has the potential of increased transmission of infections and communicable diseases. Home Visit 2. Patient #5 was admitted to the agency on 07/29/24 with a terminal diagnosis of malignant neoplasm of the brain and additional diagnoses of encephalopathy, and adult failure to thrive. On 10/2/24 during the observational home visit, the hospice nurse was observed going into their bag and retrieving her blood pressure cuff. After taking the patients blood pressure, the nurse placed the blood pressure cuff on the barrier and without cleaning their hands, went back into their bag and retrieved a thermometer. After taking the patients temperature, the hospice nurse placed the thermometer on the barrier and without cleaning their hands, went back into their bag and retrieved a pulse oximeter. According to the policy titled “;Bag Technique” reviewed 02/01/24, “;hands are washed before removing other items from the bag.” The hospice nurse failed to wash their hands before re-entering their bag multiple times during the visit. On 10/03/24 at 2:50 p.m. the findings were reviewed with the Administrator, Director of Patient Services, and Director of Quality and Compliance who acknowledged the findings and provided no additional information. Home Visit 1. Patient #1 was admitted to the hospice on 08/27/24 with a terminal diagnosis of chronic respiratory failure with hypoxia, and additional diagnoses of anxiety, hepatomegaly, cerebral palsy, and severe intellectual disabilities. The patient was a resident of an Individualized Residential Alternative group home. On 10/02/24 at 3:00 p.m. the surveyor completed an observational home visit with the hospice nurse and licensed practical nurse from the group home and observed the following: Bag TechniqueUpon entry, the hospice nurse placed a barrier on the floor and the nursing supply bag on top of it. On 10/03/24, surveyor requested the agencys bag technique policy; the Director of Patient Services provided the surveyor with the “;Bag Technique” policy dated 02/01/24. The policy stated that the nursing bag was to be placed on a clean surface utilizing a barrier. * Floors are not considered clean and should be used as a last resort. There were other clean options for bag placement within the patients room. *Per Lippincott’s Home HealthCare Now Journal: 35(9):p 478-484, October 2017 “Best Practices for Home Care ‘Bag Technique’ and the Use of Surface Barriers”, the nurses bag should be placed on a clean, dry, flat surface. If no such surfaces are available, then a bag barrier should be used, or the bag should be hung on a doorknob. Nephrostomy CareThe hospice nurse performed hand hygiene and donned clean gloves. The surveyor observed the hospice nurse remove the protective outer dressing to the patients right nephrostomy tube insertion site. A stayfix securement device was in place. The nurse did not reapply the outer dressing leaving the insertion site open. The patient was then rolled on to right side which caused the nephrostomy insertion site to come in contact with the bed linens. At the end of the visit the licensed practical nurse reported that they would replace the dressing to the nephrostomy tube insertion site. The patients care plan stated that the hospice nurse was to assess wounds during weekly visits and that wound care was completed by group home nursing staff. The hospice nurse removed the outer dressing from the nephrostomy tube to visualize the area but failed to replace the outer protective dressing thus exposing the insertion site to contamination. Wound Care and Hand HygieneWhen rolled to the right side the surveyor observed that the patient had a bowel movement, the hospice nurse and licensed practical nurse cleaned the patient. Without changing gloves, the hospice nurse then removed the foam dressing from the patients stage two pressure ulcer on the left hip. The hospice nurse then removed the gloves and left the room to locate a trash receptacle. The hospice nurse failed to ensure a trash container or plastic bag was available to discard the contaminated dressing. The hospice nurse returned to the room, cleansed their hands with hand sanitizer and donned a clean pair of gloves. The hospice nurse arranged wound care supplies directly on the patients bed and did not utilize a barrier. The hospice nurse cleansed the wound with normal saline and then held the tube of medihoney in their right hand and spread the medihoney onto the wound directly from the bottle. The hospice nurse then wiped the bottle tip on the peri skin thus contaminating the bottle. The hospice nurse covered the wound with a foam dressing and removed their gloves. The surveyor then observed the hospice nurse reach into their bag without cleansing their hands. At the end of the visit the licensed practical nurse cleaned up and disposed of the wound care supplies. The Director of Patient Services provided the surveyor with the following policies on 10/03/24: - Policy titled “Biohazardous Waste Management” dated 02/01/24 included that any waste containing blood or body fluid was segregated, handled, labeled, and stored in accordance with local, State and Federal regulations. The policy failed to provide specific instructions on the handling of biohazardous waste. - Policy titled “;Hand Hygiene” revised 02/01/24 states that staff must wash hands before touching a patient, before clean/aseptic procedures, after performing tasks that involve a risk of exposure to body fluids, after touching a patient, before and after wearing gloves and after an activity involving physical contact with a patients immediate environment. The hospice nurse failed to follow the agency’s policy and procedure for hand hygiene. - Policy titled “;Wound and Skin Care” revised 12/1/23 did not provide specific guidance for performing wound care. Surveyor requested additional information specific to performing wound care and was provided with patient education which did not provide specific steps to practitioner when performing wound care. On 10/03/24 at 2:50 p.m. the surveyor interviewed the Director of Patient Services and asked for specific steps for wound care. Director stated that the expectation was that the hospice nurse “;wash hands and get supplies ready on a barrier, cleanse hands and don gloves to remove dressing, remove soiled gloves and perform hand hygiene, don new gloves and cleanse wound, remove soiled gloves, perform hand hygiene, don clean gloves and redress wound”. The surveyor reviewed findings from visit and record with the Administrator and Director of Patient Service. They acknowledged the findings, and no additional information was provided.”

“The hospice failed to maintain a coordinated infection control program. Evidence as follows: On 10/01/24 at 09:45 a.m., during the entrance conference, the surveyor requested the hospices infection control policy. On 10/07/24 at 2:10 p.m., the surveyor interviewed the Director of Quality and Compliance about the infection control program including the process for investigating patient infections. The Director reported they collect the number of infections for monitoring and reporting and do not investigate unless a sudden increase in infections was identified. During the interview, the surveyor requested the policies and procedures for the prevention of infection from airborne pathogens, infusion therapy, urinary tract care, wound care, multi-drug resistant organisms, and blood-borne pathogens. The Director of Quality and Compliance reported that they did not believe they had policies that addressed these issues but would give the surveyor copies of any related policies or procedures if available. On 10/07/24 at 2:50 p.m., the Director of Quality and Compliance gave the surveyor a copy of the policy titled “;Standard and Transmission-Based Precautions” (dated 02/01/24). The policy failed to address protocols for preventing infection from infusion therapy, urinary tract care, wound care, and multi-drug resistant organisms On 10/07/24 at 5 p.m., the above findings were reviewed with the Administrator, Director of Quality and Compliance, and Clinical Supervisor. No further information was provided at that time. On 10/17/24 at 1:30 p. m., the surveyors program manager contacted the Director of Quality and Compliance who then faxed the surveyor the following: - “;Infection Control Program for Hospice and Palliative Care” (dated 02/01/24) - “;Personal Protective Equipment” (dated 02/01/24) - “;Respiratory Protection Policy (N95 Respirator Mask)” (dated 02/01/24) - “;Multi-drug Resistant Organisms” (dated 02/01/24) - “;Wound and skin care” (dated 12/01/23) - “;Quick sheets” references for prevention of catheter-associated urinary tract infection and hand hygiene (undated) The 02/01/24 “;Infection Control Program for Hospice and Palliative Care” details the role of the Infection Control Officer (ICO), which includes: - coordinating the infection control activities and services as the primary resource for staff - investigates infection incidents and implements corrective actions - manages data collection, monitoring, and reporting The Director of Quality and Compliance did not mention this role during the interview or request the Infection Control Officer join the interview to answer surveyor questions about infection control on 10/07/24. Although the hospice eventually produced the policies that addressed their protocols for preventing infection from infusion therapy, urinary tract care, wound care, and multi-drug resistant organisms, the hospice failed to demonstrate a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases.”

“Based on review of 5 clinical records of live discharges from the agency and interviews with agency staff, it was determined for 3 of 5 patients the agency failed to ensure an adequate discharge plan was in place and/or a complete discharge summary was prepared and sent to the patients providers to ensure continuity of care. Evidence as follows: 1. Patient #23 was admitted to the hospice on 08/19/22 with a terminal diagnosis of chronic obstructive pulmonary disease. The patient was discharged 05/12/23 for no longer continuing to meet hospice criteria. On 05/09/23 the hospice nurse visited the patient and documented the patient reported being sick with a cold and chronic cough for the past 6 weeks, had thick green sputum, lung sounds were diminished in the bases and clear in the upper lobes, and cough was wet sounding as if produced by postnasal drip. The patient reported using their nebulizer and inhaler 4 to 8 times daily, but also reported only using it only once that day at 6 p.m. The nurse documented they were going to collect a sputum sample for analysis; however the patient was unable to produce any sputum at the time of the visit and only had a productive cough in the morning. The nurse left a specimen cup for the licensed practical nurse to collect the sample (at next visit). On 05/10/23 an interdisciplinary group conference (IDG) communication note included the above information. On 05/10/23 the social worker documented that following the IDG collaboration they and the nurse made a home visit to discuss the decision to discharge the patient as they no longer met medical criteria. It was documented the patient had no signs of distress and no visible shortness of breath or pain. The social worker documented the patient was visibly upset with the outcome and stated they were unable to do things or get around like in the past. The patient stated they were going to appeal the discharge and was provided with paperwork to do so. The patient was provided with information on palliative programs in the local area and stated they would be self-referring.The hospice nurse documented similar information in their note, including the patient was able to speak in full sentences with no signs of shortness of breath as well as that the sputum culture was unable to be obtained that day. A review of the patients vital signs record indicated the patient had not had any change in vital signs, temperature, pulse, respirations, blood pressure, or oxygen saturation during the weeks that proceeded this visit. On 05/11/23 the hospice nurse documented that on 05/10/23 they spoke with the primary care physician and pulmonologist offices to inform them of IDG recommendation to discharge the patient. The physicians offices agreed to follow the patient and would send prescriptions to the equipment supply company for durable medical equipment and oxygen, were aware of all medications, and would order all prescriptions. On 05/11/23 a licensed practical nurse documented in a visit note the client notified the nurse there was a specimen sample that needed to be dropped off at the lab, they visited the patient, and then dropped off the sample at the lab. On 05/12/23 the patient was discharged from the agency. There was no evidence the results from the sputum specimen were obtained and reviewed prior to the patients discharge. The discharge summary and letter to the primary care physician dated 05/17/23, 5 days after discharge, failed to include any information about patient illness or outstanding labs to be followed up on. The discharge summary included the patient had self-referred to palliative services, however, failed to include any information provided to palliative services for continuity of care. On 10/03/24 at 2:50 p.m. the above findings were reviewed with Administrator, Director of Patient Services, and Director of Quality and Compliance. The Director of Patient Services stated that no sputum specimen was ever obtained. The surveyor informed the agency that the licensed practical nurse documented obtaining a sputum specimen on 05/11/23. On 10/07/24 at approximately 9 a.m., the Director of Quality and Compliance provided the surveyor with lab results that were obtained by the agency on 10/04/24. Results included growth of organisms indicative of a pulmonary infection. On 10/07/24 at 9:50 a.m. the surveyor interviewed the hospice nurse regarding agency communication, follow up care with the palliative care program, and the sputum specimen. The nurse stated that the hospice was unable to provide the referral to palliative care because the same entity operated both which could be construed as a conflict. The nurse also stated that to their knowledge no sputum specimen was ever obtained. On 10/07/24 at 11:55 a.m. the surveyor interviewed the agency provider (nurse practitioner) who ordered the sputum specimen. The provider stated they were unaware the specimen was obtained or they would have followed up with the lab to obtain results. Furthermore, they stated that the lab had not provided the results to the agency, which was not uncommon with this lab, and that the lab and patients primary care physician were part of the same medical group as the lab therefore the physician may have been informed/aware. 2. Patient #22 was admitted to the hospice on 12/18/23 with a terminal diagnosis of cerebral atherosclerosis and was discharged on 12/23/23 due to being hospitalized outside of the catchment area. The patient resided in a nursing home. On 12/23/23 the hospice nurse documented at 8 a.m. they received a call from the patients wife stating the patient fell out of their chair and was being transferred to an emergency department outside of catchment area. The nurse documented a call was placed to the emergency department and they would provide an update after the patient was examined. The same nurse documented at 10:18 a.m. they received a call from patients spouse stating the patient fractured their hip and was being transferred to another hospital, also outside of catchment area. The nurse informed the spouse the patient would be discharged from the agency as the hospital was out of the catchment area. The nurse placed a call to the hospital and nursing home to make them aware of same. There was no evidence the nurse confirmed the patients admission to the hospital or that they discussed clinical issues and/or hospice services. Later that same day (12/23/23 5:43 p.m.), the on-call nurse documented a call from the patients sibling stating the patient wanted to go back to the nursing home. The sibling was advised that the patient had been discharged from the hospice and would need to be re-referred to the agency on Tuesday (12/26/23). On 12/23/23 a letter was sent to the patient’s primary care physician stating the patient was discharged from the agency after refracturing their hip and was being admitted to a hospital outside of the catchment area. The letter erroneously stated the agency offered information to the patient on other services available in the community. The patient was readmitted to the agency on 12/29/23 and remained on service until they expired 01/06/24. 3. Patient #26 was admitted to the hospice on 05/17/24 with a terminal diagnosis of Alzheimers dementia and was discharged 09/16/24 due to moving outside the catchment area. The patient previously received services from this agency during the summer of 2023. The patient and family spend their summer months in upstate New York and receive services from another hospice out of area the remainder of the year. On 9/10/24 the social worker documented they contacted the hospice in the other catchment area and informed them of the patients planned discharged. The social worker further documented they confirmed with the out of area hospice that they intended to evaluate and admit the patient the same day of discharge from the current hospice. On 09/10/24, the current agency provider completed a face-to-face encounter and documented the that clinical findings were made available to the out of area certifying for use in determining eligibility for ongoing certification of hospice care services. The revocation/transfer/discharge summary, signed by the hospice nurse, social worker, and spiritual services, indicated the reason for discharge was that the patient moved out of the service area, and the disposition was noted as “;self”. The discharge summary failed to include any information regarding the patients plan for future care. On 09/16/24 the agency social worker sent a letter to the patients primary care physician advising the patient moved out of the catchment area and was discharged. The letter was generic in nature, erroneously stated the agency offered information to the patient on other services available in the community, and failed to include any specific information regarding the patients plan for ongoing services by another hospice agency. Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and possible unmet patient needs upon discharge/transfer from the hospice.”