Lakeland Area Hospice, LP

“Based on a review of agency policy/procedure, a review of the agency emergency preparedness plan, and an interview with the agency Executive Director (EMP1), agency failed to ensure the emergency preparedness plan was reviewed and updated at least every 2 years, for one (1) of one (1) emergency preparedness plan documentation (EPP) reviewed (EPP#1). Findings:Agency EPP reviewed on September 5, 2025, at approximately 10:00am. This policy does not include reviewing/updating the emergency preparedness plan at least every two years. The EPP was reviewed on September 5 at approximately 10:00am.EPP#1: No documentation provided of the agency reviewing/updating the emergency preparedness plan at least every two years. Per the Executive Director (EMP1) on September 5, 2025, at approximately 10:00am, the emergency preparedness plan has not been reviewed at least every two years. An interview conducted with the agency Executive Director on September 5, 2025, at approximately 12:30pm confirmed the above findings.”

“Based on a review of the emergency preparedness program (EPP) documents and an interview with the administrator, the hospice agency failed to ensure that the EPP was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: A review of EPP program documents on September 5, 2025, at approximately 11:00am found that the hazard vulnerability/risk assessment (HVA) was not completed or included within the EPP. An interview conducted with the administrator and director of clinical services on September 5, 2025, starting at approximately 12:30pm confirmed the above findings.”

“Based on observation, review of agency policy and procedure, and staff (EMP) interview, the agency failed to ensure two (2) of two (2) registered nurses followed agency policy and procedure for infection control (PF#1 and PF#2). Findings:Review of agency “Bag Technique” PowerPoint in-service for staff reviewed on September 3, 2025, at approximately 2:00pm, section titled ‘Hand Hygiene’ states per CDC guidance “Hand hygiene is also required to be performed after contact with the intact patient’s kin (e.g., when taking a pulse or blood pressure with equipment taken from the nursing bag) and after contact with inanimate objects in the immediate vicinity of the patient (e.g., the nursing bag.) The interior of the bag can become contaminated when hand hygiene is not routinely performed prior to entering the nursing bag. List of tasks related to ‘Bag Technique’ includes: Plan where you will discard disposable items and sharps ahead of time; remove hand washing supplies first. Wash and dry hands thoroughly, following proper hand washing technique; remove any items needed for patient care, including any necessary personal protective equipment; close the bag before performing patient care; wash your hands again if you need to re-enter the bag for additional supplies during patient care; wash your hands, then repack and close the healthcare bag. Policy Number PC.I50 “Infection Control - Standard and Transmission-Based Precautions reviewed on September 3, 2025, at approximately 1:30pm. Procedures section states: Hospice staff are required to use standard precautions in the care of all hospice patients, regardless of diagnosis or presumed infection status. Standard precautions include, but are not limited to: Hand hygiene before and after patient contact. Policy Number: PC.I25 “Infection Control - Hand Hygiene” reviewed September 3, 2025, at approximately 1:45pm. Policy states: Lakeland Area Hospice follows hand hygiene guidelines recommended by the Centers for Disease control and the World Health Organization. Procedure states: When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry. Observation#1 (OBS#1) during home visit on September 2, 2025, at approximately 1:15pm, at a skilled nursing facility, Observed PF#2 performed tasks utilizing BP cuff, stethoscope, thermometer, and pulse oximeter. After contact with patient to perform tasks, no hand hygiene was performed by PF#2 prior to reentering supply bag. Observation#2 (OBS#2) during home visit on September 2, 2025, at approximately 1:25pm, at a skilled nursing facility, Observed PF#2 utilizing “Sani-Cloth Plus” Germicidal Disposable Wipes -expiration date 06/2023. After used equipment was wiped down no dry time was observed. Equipment visibly soiled placed immediately into a bag and bag was then placed directly into the utility bag. Observation#3 (OBS#3) during home visit on September 2, 2025, at approximately 2:10pm, at a skilled nursing facility, Observed PF#2 performed tasks utilizing BP cuff, stethoscope, thermometer, and pulse oximeter. After contact with patient to perform tasks, no hand hygiene was performed by PF#2 prior to reentering supply bag. Observation#4 (OBS#4) during home visit on September 2, 2025, at approximately 1:25pm, at a skilled nursing facility, Observed PF#2 utilizing “Sani-Cloth Plus” Germicidal Disposable Wipes -expiration date 06/2023. After used equipment was wiped down no dry time was observed. Equipment visibly soiled placed immediately into a bag and bag was then placed directly into the utility bag. Observation#5 (OBS#5) during home visit on September 3, 2025, at approximately 9:40am, at a skilled nursing facility, Observed PF#1 performed tasks utilizing BP cuff, stethoscope, thermometer, and pulse oximeter. After contact with patient to perform tasks, no hand hygiene was performed by PF#1 prior to reentering supply bag. Observation#6 (OBS#6) during home visit on September 3, 2025, at approximately 9:45am, at a skilled nursing facility, Observed PF#1 utilizing “Sani-Cloth Plus” Germicidal Disposable Wipes -expiration date 06/2023. After used equipment was wiped down no dry time was observed. Equipment visibly soiled placed immediately into a bag and bag was then placed directly into the utility bag. Interview with Director of Clinical Services EMP2 on September 5, at approximately 12:00pm confirmed above findings.”

“Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the nursing staff failed to document review of medication profile at minimum, every fifteen days for seven (7) of ten (10) active records reviewed (CR#1, CR#2, CR#3, CR#6, CR#7, CR#8, and CR#9). Findings included: Review of Policy Number PC.M50 “Medications - Management on September 5, 2025, at approximately 11:15am. Procedure states: ‘A medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient’s terminal illness. The medication profile includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements/remedies including cannabis. A review of Policy PC.M60 Medications - Profile on September 5, 2025, at approximately 11:30am. Policy states: “A patient specific medication profile is maintained for each patient and is reviewed, at a minimum, every fifteen days.” CR#1 Start of Services (SOS) 06/26/2025 Certification period 06/26/2025 through 09/23/2025. Documentation of medication review completed on 07/22/2025, 07/29/2025, and 08/22/2025. There was no documentation of medication review from 06/26/2025 through 07/21/2025; and 07/29/2025 through date of survey record review on 08/22/2025. CR#2 Start of Services (SOS) 10/16/2024 Certification period 08/12/2025 through 10/10/2025. Period reviewed from 06/10/2025 through 09/04/2025. There was no documentation of medication review from 06/10/2025 through 06/29/2025; and 07/29/2025 through 08/19/2025. CR#3, start of services (SOS) 08/19/2025, Certification period reviewed 08/19/2025 to 10/17/2025. There was no documentation of medication review from SOS 08/19/2025 through date of survey record review on 09/04/2025. CR#6 Start of Services (SOS) 08/22/2024 Certification period 08/17/2025 through 10/15/2025. Period reviewed from 06/10/2025 through 09/04/2025. Documentation of medication review completed on 06/24/2025, 07/15/2025, 07/31/2025, and 08/02/2025.There was no documentation of medication review from 06/25/2025 through 07/15/2025; and 08/02/2025 through date of survey record review on 09/04/2025. CR#7 Start of Services (SOS) 09/24/2024 Certification period 07/12/2025 through 09/18/2025. Period reviewed from 06/10/2025 through 09/04/2025. Documentation of medication review completed on 06/17/2025, 08/12/2025, 08/24/2025, and 09/01/2025.There was no documentation of medication review from 06/18/2025 through 08/12/2025. CR#8, start of services (SOS) 07/16/2025, Certification period reviewed 07/16/2025 to 10/17/2025. There was no documentation of medication review from SOS 07/16/2025 through date of survey record review on 09/04/2025. CR#9 Start of Services (SOS) 08/06/2025 Certification period 08/06/2025 through 11/03/2025. Documentation of medication review completed on 08/07/2025. There was no documentation of medication review from 08/05/2025 through date of survey record review on 09/04/2025. Interviews with Executive Director (EMP!) and Director of Clinical Services (EMP2) on September 5, 2025, at approximately 12:00pm. confirmed above findings.”

“Based on a review of clinical records (CR) and staff/employee (EMP) interviews, the hospice failed to ensure that a registered nurse (RN) documented an on-site supervisory visit to the patient’s home no less frequently than every 14 days (two weeks) to assess the quality of care and services provided by the home hospice aide (HHA) for three (3) of ten (10) active consumer records (CR) reviewed (CR#3, CR #6, and CR#9). Findings include:Review of clinical records (CR) on September 3, 2025, from approximately 12:00pm to 3:30pm; September 4, 2025 from approximately 9:45am to 12:00pm; and September 5 from approximately 10:45 to 11:30am revealed: CR#3, start of services (SOS) 08/19/2025, certification period reviewed 08/19/2025 to 10/17/2025. POC (plan of care) included order for HHA services two (2) times per week effective 8/19/2025. There was no documentation of HHA supervision visits conducted every fourteen (14) days between SOS 08/19/2025 through date of survey 09/04/2025. CR#6, start of services (SOS) 08/22/2024, certification period was from 08/17/2025 to 10/15/2025; record reviewed from 06/10/2025 through 09/05/2025. POC (plan of care) included order for HHA services two (2) times per week. The registered nurse conducted skilled nursing supervisory visits on 07/15/2025; and 07/31/2025. There was no documentation of HHA supervision visits conducted every fourteen (14) days for the days between 06/10/2025 through 07/14/2025; and 08/01/2025 through 09/04/2025. CR#9, start of services (SOS) 08/06/2025, certification period reviewed 08/06/2025 to 11/03/2025. POC (plan of care) included order for HHA services two (2) times per week. There was no documentation of HHA supervision visits conducted every fourteen (14) days from the start of HHA services on 08/14/2025 through 09/04/2025. An interview with EMP2 (Director of Clinical Services) on September 5, 2025, at approximately 12:00pm confirmed the above findings.”