Nursing Placement Hospice & Palliative Care, LLC

“Based on record review and staff interview, it has been determined that the hospice agency failed to develop, implement, and maintain an effective and ongoing hospice-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program. Findings are as follows: Review of the Quality Assurance Performance documents failed to reveal evidence that the hospice agency developed, implemented, and maintained an effective and ongoing hospice-wide, data-driven QAPI program. Further review of the Quality Assurance Performance documents failed to reveal evidence that included the following: - program objectives - all patient care disciplines involved - a description of how the program will be administered and coordinated - a methodology for monitoring and evaluating the quality of care - priorities for the resolution of problems - monitoring of any identified problems to determine the effectiveness of any action taken - who is responsible for the program oversight and reporting to the governing body, or any documentation relative to the review of the QAPI program itself During a surveyor interview on 2/17/2025 at approximately 10:30 AM with the Quality Control and Performance Improvement Nurse (as indicated by the Director of Nurses), Staff G, she revealed that she was new to the position, and that she is the “data” nurse. She further revealed that the quality improvement project that the hospice agency is working on improving is falls. Record review of the falls data collected revealed that patient falls have increased from quarter one to quarter four. During a surveyor interview with the Director of Operations on 2/17/2025 at approximately 11:30 AM, she was unable to provide evidence of what interventions have been put into place relative to the increase of falls and revealed that a QAPI plan relative to falls should have been implemented.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to maintain and document an infection control program that protects patients, families, staff, and visitors by preventing and controlling infections and communicable diseases. Findings are as follows: Review of an agency policy titled, “Infection Control Reporting” states in part, “;...purpose; a system is established for the evaluation, reporting, and maintenance of records of infection related to the care or services provided to clients and, as appropriate, among staff...” Review of an agency provided document for the tracking of patients’ infections failed to reveal documentation including, but not limited to, if the infection is being treated or not, if/when the infection was resolved, or any follow up information related to the infection and patient’s status. Additionally, there was no information relative to the analysis of the data collected or if any trends were noted. During a surveyor interview with the Infection Control Nurse (as identified by the Director of Nurses), Staff J, on 2/17/2025 at approximately 10:45 AM, she revealed that she is not the Infection Control Nurse and is not responsible for the hospice agency’s infection control program. She further revealed that she reviews patient information relative to infections in the agencys electronic medical record system then compiles a list of all documented infections monthly and presents the information quarterly. Additionally, she revealed that she only tracks patient infections and does not track infections among staff. During surveyor interview with Director of Nurses on 2/17/2025 at approximately 12:15 PM, she stated that Staff J is new to the role, and that it was her understanding that Staff J is the agency’s designated Infection Control Nurse. She was unable to provide evidence that the agency maintained an infection control program to protect patients, families, staff, and visitors by preventing and controlling infections and communicable diseases.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to use volunteers for the day-to-day administrative and/or direct patient care roles within defined roles and under the supervision of a designated hospice employee. Findings are as follows: Record review failed to reveal evidence that the facility utilizes any volunteers. During surveyor interview with the Director of Nurses and the Director of Operations (DOO) on 2/11/2025 at approximately 2:30 PM, they revealed that they do not utilize any volunteers, therefore they have no defined roles if they were to utilize them. The DOO acknowledged that they are unable to provide a volunteer for day-to-day administrative and/or direct patient care roles if a patient was to request one.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to develop and maintain an emergency preparedness plan that includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. Findings are as follows: Review of the hospice agency’s emergency binder failed to reveal evidence of any process for cooperation and/or collaboration with any local, state, or federal emergency preparedness officials in efforts to maintain an integrated response during a disaster or emergency situation. During a surveyor interview with the Director of Operations on 2/13/2025 at approximately 11:30 AM, she acknowledged that the hospice agency’s emergency binder failed to include a process for collaboration with any local, state, or federal emergency preparedness officials to discuss or maintain an integrated response during a disaster or emergency situation. She revealed that the hospice agency has never had any involvement with any emergency preparedness officials.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to conduct all required exercises to test the hospice agency’s emergency plan. Findings are as follows: Review of the hospice agencys emergency plan failed to reveal evidence that a hospice agency representative had participated in a full-scale community-based exercise or that the hospice agency had experienced a natural or man-made emergency that required the activation of their emergency plan. During a surveyor interview with the Director of Operations on 2/14/2025 during the emergency preparedness task, she revealed that a staff member attends the state-wide community-based exercise, however, she was unable to provide evidence that any staff member attended an exercise.”

“Based on surveyor observation, record review, and staff interview, it has been determined that the hospice agency failed to treat a patient with respect during a nurse assessment visit for 1 of 1 visit observed, Patient ID #3. Findings are as follows: Record review revealed that Patient ID #3 was admitted to the hospice agency with a diagnosis including, but not limited to, Picks disease (a form of dementia that affects behavior and language). Additionally, s/he is non-verbal. During a surveyor observation on 2/11/2025 at approximately 10:00 AM while visiting Patient ID #3, who resides in a Skilled Nursing Facility (SNF), the patient was observed wearing booties to his/her feet, had hand rolls in place to his/her hands, and was seated in the dining room with several other residents and visitors around. Registered Nurse, Staff B, entered the dining room and began to speak to Patient ID #3. She proceeded to obtain his/her vital signs, listened to his/her lungs and abdomen, and assessed his/her skin because his/her lower extremities have open areas. Staff B concluded her assessment of Patient ID #3 and exited the dining room. During a surveyor interview on 2/12/2025 at approximately 2:20 PM with Staff B, she indicated that she often assesses Patient ID #3 in the dining room. She informed the surveyor that most of the time when she visits, Patient ID #3 is in the dining room, so that is where she conducts her assessment. Additionally, she revealed that she does not return Patient ID #3 to his/her room to complete her assessment. During a surveyor interview with the Director of Nurses on 2/13/2025 at approximately 1:55 PM, she revealed that she was unaware that Staff B failed to return Patient ID #3 to his/her room to complete her assessment. She further revealed that staff should not be assessing patients in a common area and expects that staff would return a patient to his/her room or a private area to be assessed.”

“Based on record review and staff interview, it has been determined that the hospice agency’s initial comprehensive assessment for a patient failed to include an initial bereavement assessment for 7 of 12 patients reviewed, Patient IDs #s 1, 2, 3, 4, 5, 7, and 12. Findings are as follows: 1a. Record review revealed Patient ID #1 had a start of care date and initial assessment completed on 2/2/2025. Additional review failed to reveal evidence that a bereavement assessment was completed. 1b. Review of the record for Patient ID #2, reveals a start of care and initial assessment on 4/19/2024. Additional review failed to reveal evidence that a bereavement assessment was completed. 1c. Record review revealed Patient ID #3 had a start of care date and initial assessment completed on 10/17/2024. Additional review failed to reveal evidence that a bereavement assessment was completed. 1d. Record review revealed Patient ID #4 had a start of care date and initial assessment completed on 12/3/2024. Additional review failed to reveal evidence that a bereavement assessment was completed. 1e. Record review revealed Patient ID #5 had a start of care date and initial assessment completed on 8/10/2024. Additional review failed to reveal evidence that a bereavement assessment was completed. 1f. Record review revealed Patient ID #7 had a start of care date and initial assessment completed on 9/11/2024. Additional review failed to reveal evidence that a bereavement assessment was completed. 1g. Record review revealed Patient ID #12 had a start of care date and initial assessment completed on 11/8/2024. Additional review failed to reveal evidence that a bereavement assessment was completed. During a surveyor interview with the Director of Nurses on 2/13/2025 at approximately 1:45 PM, she was unable to provide evidence that the initial assessments included a bereavement assessment, as required, for Patient ID #s 1, 2, 3, 4, 5, 7, and 12.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to ensure that the plan of care includes all services necessary for the palliation (refers to medical care or treatments aimed at alleviating symptoms and improving the quality of life for individuals with serious, chronic, or terminal illnesses) and management of their terminal illness and related conditions including drugs and treatment necessary to meet the needs of the patients related to physicians’ orders and medications for 5 of 12 patients reviewed, Patient ID #s 1, 2, 3, 5, and 6. Findings are as follows: 1.Review of Patient ID #1s physicians orders revealed an order dated 2/3/2025 for a Scopolamine (helps to prevent nausea) base patch; 1 milligram (mg) over 3 days, and to apply to the skin. Further review of the physicians orders revealed an order dated 2/8/2025 for Silvadene (a topical antibiotic) 1% cream to be applied to the right knee wound daily. Record review of Patient ID #1’s Plan of Care (POC) dated 2/2/2025 through 5/2/2025 failed to reveal evidence that the patient is receiving the Scopolamine patch or the Silvadene cream to his/her wound. During a surveyor interview on 2/11/2025 at approximately 10:00 AM with the Director of Nurses, she was unable to provide evidence that the patients POC was followed to include all drugs and treatments prescribed for the patient. 2.Record review of Patient ID #2s physicians orders revealed an order dated 2/8/2025 for the patient to receive a nutritional supplement three times a day. Record review of Patient ID #2’s POC dated 12/15/2024 through 2/12/2025 failed to reveal evidence that the patient is receiving the nutritional supplement as ordered. During a surveyor interview with Registered Nurse, Staff B, on 2/13/2025 at approximately 12:30 PM, she was unable to provide evidence that the patients POC was followed to include all drugs and treatments prescribed for the patient. 3. Record review of Patient ID #3s physicians orders revealed an order dated 2/6/2025 for skin prep (a protective film) to apply to his/her right heel daily. Further review of the physicians orders revealed an order dated 1/24/2025 for Santyl (a wound ointment that removes dead tissue and aids in healing) 250 unit/gram to be applied to the right heel daily. Record review of Patient ID #3’s POC dated 1/15/2025 through 4/14/2025 failed to reveal evidence that the patient is receiving the Santyl ointment or the skin prep as ordered. During a surveyor interview on 2/12/2025 at 1:00 PM with the Director of Nurses, she was unable to provide evidence that the patients POC was followed to include all drugs and treatments prescribed for the patient. 4. Record review of Patient ID #5 revealed the following physicians orders: - 11/19/2024 Lidocaine (for pain relief) 4% patch, apply to both knees in the morning for pain for 12 hours and remove per the schedule - 11/19/2024 Multivitamin with minerals, give one tablet by mouth in the evening for wound healing - 1/19/2024 Ondansetron HCL (medication to help with nausea and vomiting) 4 mg, take one tablet by mouth every 6 hours as needed Record review of Patient ID #5’s POC dated 2/6/2025 through 4/6/2025 failed to reveal evidence that the patient is receiving the Lidocaine patch, multivitamin, or the Ondansetron, as ordered. During a surveyor interview on 2/12/2025 at approximately 12:30 PM with the Director of Nurses, she was unable to provide evidence that the patients POC was followed to include all drugs and treatments prescribed for the patient. 5.Record review of Patient ID #6s physicians orders revealed an order dated 1/16/2025 for Morphine (medication for pain relief) concentrate; 100 mg per 5 milliliters (mL), give 0.125 mL every hour as needed for pain, shortness of breath, or dyspnea. Record review of Patient ID #6’s POC dated 1/17/2025 through 4/16/2025 failed to reveal evidence that the patient is receiving his/her Morphine, as ordered. During a surveyor interview on 2/12/2025 at approximately 1:00 PM with the Director of Nurses, she was unable to provide evidence that the patients POC was followed to include all drugs and treatments prescribed for the patient.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to ensure that Durable Medical Equipment (DME) is identified in the hospice patients’ plan of care related to the palliation (refers to medical care or treatments aimed at alleviating symptoms and improving the quality of life for individuals with serious, chronic, or terminal illnesses) and management of the terminal illness for 13 of 19 patients reviewed, Patient IDs #s 2, 3, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, and 18. 1.Review of Patient ID #2’s Plan of Care (POC) dated 12/15/2024 through 2/12/2025 failed to reveal evidence how the patient transfers or ambulates, or if any DME is required to care for the patient. During a surveyor observation of Patient ID #2, who resides at a Skilled Nursing Facility, on 2/11/2025 at approximately 9:00 AM, Nursing Assistant, Staff A, was observed transferring the patient via a Hoyer lift (a mechanical lift device designed to assist individuals with limited mobility in transferring from one place to another) with another caregiver from his/her bed to a Broda chair (a type of specialized wheelchair designed to provide enhanced comfort and support for individuals with complex medical needs). During a surveyor interview with the Director of Nurses on 2/13/2025 at 1:20 PM, she was unable to provide evidence that Patient ID #2’s POC was updated to include all services and DME necessary for the palliation and management of his/her terminal illness including that the patient utilizes a Hoyer lift for transfers. 2. Record review of Patient ID #3’s POC dated 10/17/2024 through 1/14/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 3. Record review of Patient ID #4’s POC dated 2/1/2025 through 4/1/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 4. Record review of Patient ID #6’s POC dated 1/17/2025 through 4/16/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 5. Record review of Patient ID #7’s POC dated 12/10/2024 through 3/9/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 6. Record review of Patient ID #9’s POC dated 1/26/2025 through 3/26/2025 failed to reveal evidence that the Durable Medical Equipment and Supplies/Section 13 of the POC was completed. 7. Record review of Patient ID #10’s POC dated 2/17/2025 through 4/16/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 8. Record review of Patient ID #11’s POC dated 12/5/2024 through 3/4/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 9. Record review of Patient ID #12’s POC dated 2/6/2025 through 5/6/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 10. Record review of Patient ID #13’s POC dated 10/7/2034 through 1/4/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 11. Record Review of Patient ID #14’s POC dated 9/4/2024 through 12/2/2024 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 12. Record review of Patient ID #15’s POC dated 1/15/2025 through 4/14/2025 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. 13. Record review of Patient ID #18’s POC dated 8/26/2024 through 11/23/2024 failed to reveal evidence that the DME and Supplies/Section 13 of the POC was completed. During a surveyor interview on 2/12/2025 at approximately 2:00 PM with the Director of Nurses, she was unable to provide evidence that the DME and Supplies/Section 13 for Patient IDs #s 2, 3, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, and 18 were completed.”

“Based on record review and staff interview, it has been determined that the hospice agency’s governing body (Board of Directors) failed to ensure that the hospice agency has an ongoing program for quality improvement that is defined, implemented, maintained, and evaluated annually. Findings are as follows: Review of a governing body minutes document dated 2/22/2023 failed to reveal evidence that the governing body ensured an ongoing program for quality improvement and patient safety was implemented, maintained, and evaluated annually, as required. Record review failed to reveal evidence that the governing body met during the 2024 calendar year to ensure an ongoing program for quality improvement and patient safety was defined, implemented, maintained, and evaluated annually. During a surveyor interview with Registered Nurse, Staff G, on 2/14/2025 at approximately 11:00 AM, she was unable to provide evidence that the governing body ensured an ongoing program for quality improvement and patient safety was implemented, maintained, and evaluated during the 2023 and 2024 calendar years.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases relative to patients, families, staff, and visitors. Findings are as follows: Review of a hospice agency policy titled, “Infection Control Reporting” states in part, “;...purpose; a system is established for the evaluation, reporting, and maintenance of records of infection related to the care or services provided to clients and, as appropriate, among staff...” Review of an agency provided document for the tracking of patients’ infections failed to reveal documentation including, but not limited to, if the infection is being treated or not, if/when the infection was resolved, or any follow up information related to the infection and patient’s status. Additionally, there was no information relative to the analysis of the data collected or if any trends were noted. Further record review of the above-mentioned document failed to reveal evidence that appropriate corrective actions were taken based on the data analysis, or that the data was integrated into the agency’s Quality Assessment and Performance Improvement (QAPI) program, as required. During a surveyor interview with the Infection Control Nurse (as identified by the Director of Nurses), Staff J, on 2/17/2025 at approximately 10:45 AM, she revealed that she is not the Infection Control Nurse and is not responsible for the hospice agency’s infection control program. She further revealed that she reviews patient information relative to infections in the agencys electronic medical record system then compiles a list of all documented infections monthly and presents the information quarterly. Additionally, she revealed that she only tracks patient infections and does not track infections among staff. During surveyor interview with Director of Nurses on 2/17/2025 at approximately 12:15 PM, she stated that Staff J is new to the role, and that it was her understanding that Staff G is the agency’s designated Infection Control Nurse. She was unable to provide evidence that the hospice agency maintained an agency-wide infection control program that included all pertinent information relative to a patient’s infection status for data analysis, infections among staff are being tracked, or that the data was integrated into the agency’s QAPI program for ongoing review and monitoring.”

“Based on record review and staff interview it has been determined that the agency failed to use volunteers in day-to-day administrative and/or direct patient care roles. Findings are as follows: Record review failed to reveal evidence that the agency utilizes any volunteers. During a surveyor interview with the Director of Nurses on 2/13/2025 at approximately 11:00 AM, she revealed that the agency does not utilize volunteers because they do not have any. When informed that several patients’ records that were reviewed indicated that the patients had declined a volunteer, she revealed that she was unaware that the patients’ records indicate that a volunteer was declined although the agency currently has no volunteers to provide to the patient”

“Based on record review and staff interview, it has been determined that the hospice agency failed to document viable and ongoing efforts to recruit and retain volunteers. Findings are as follows: Record review failed to reveal evidence that the agency utilizes any hospice volunteers. During a surveyor interview with the Director of Operations on 2/11/2025 at approximately 2:30 PM, she revealed that the agency had reached out to the volunteers utilized in the past, but they declined to return to work as volunteers. She was unable to provide evidence of any ongoing efforts made to recruit and retain volunteers.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to use volunteers for the day-to-day administrative and/or direct patient care roles that equals, at a minimum, 5 percent of the total patient care hours provided by paid employees. Findings are as follows: Record review failed to reveal evidence that the facility utilizes any volunteers. During a surveyor interview with the Director of Nurses and the Director of Operations (DOO) on 2/11/2025 at approximately 2:30 PM, they revealed that they do not utilize any volunteers because they do not have any. They were unable to provide evidence that volunteers provide day-to-day and/or direct patient care services to equal, at a minimum, 5 percent of the total patient care hours provided by paid staff, or any associated documentation, as required.”

“Based on record review and staff interview, it has been determined that the hospice agency failed to ensure that all clinical record entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the agency policy and currently accepted standards of practice relative to physicians’ signatures for 2 of 18 records reviewed, Patient ID #s 6 and 14. Findings are as follows: Review of an agency’s policy titled, “Plan of Care” states in part, “;...the attending physician signs the plan of care...” Review of a document titled, “;Hospice Services Coverage Policy” by the Rhode Island Executive Office of Health and Human Services states in part, “...a copy of the initial care plan and subsequent care plans at each new period of Hospice Care, along with the signed physician certification form, must be sent to the fiscal agent within 30 days...” Record review for Patient ID #6 revealed a certification document for 1/17/2025 through 4/16/2025 that failed to reveal evidence of a physician signature as of 2/13/2025. Record review for Patient ID #14 revealed a certification document for 9/4/2024 through 12/2/2024 that was signed by the patient’s physician on 11/22/2024 which was 29 days after the patient had been discharged from the hospice agency, which was on 10/25/2024. During a surveyor interview with the Director of Nurses on 2/13/2025 at approximately 3:30 PM, she acknowledged the above-mentioned concerns for Patient ID #s 6 and 14 and revealed that the physicians are expected to sign the patient’s plan of care including their orders within 30 days.”

“Based on surveyor observation and staff interview, it has been determined that the hospice agency failed to ensure that the patient, their family and/or the caregiver(s), receive instruction in the safe use of durable medical equipment for 1 of 1 patient observed being transferred with a Hoyer lift (a mechanical lift device designed to assist individuals with limited mobility in transferring from one place to another), Patient ID #2. Findings are as follows: During a surveyor observation on 2/11/2025 at approximately 9:00 AM of Patient ID #2, who resides at a Skilled Nursing Facility (SNF), Nursing Assistant, Staff A, was observed transferring the patient via Hoyer lift with another caregiver from his/her bed to a Broda chair (a type of specialized wheelchair designed to provide enhanced comfort and support for individuals with complex medical needs). Staff A failed to lock the wheels of the Hoyer lift and Broda chair during the patient’s transfer from his/her bed to the Broda chair. Further, Staff A was observed placing her right foot on the base of Hoyer lift to stabilize it during the patient’s transfer. During a surveyor interview with Staff A immediately following the above observation, she acknowledged that she failed to lock the wheels on the Hoyer lift and the Broda chair during the patients transfer. During an interview with the Director of Nurses on 2/12/2025 at approximately 10:00 AM, she indicated that she would expect Staff A to lock the wheels on the Hoyer lift and the Broda chair during the patients transfer. She acknowledged that Staff A did not demonstrate the appropriate use of durable medical equipment.”