Tidelands Community Hospice/Tidelands Community Ho

“Based on record review, interview and review of facility policy and procedure, the hospice facility failed to ensure 24 hours 7 days a week service was provided to 2 of 20 patient charts reviewed. (Patient 13 and 16). The findings include: Record review on 3/13/24 at 1:13 PM of Pt 13 revealed Pt 13 was admitted on 10/16/23 for Chronic Obstructive Pulmonary Disease (COPD). Review of the chart revealed Pt 13s representative notified the Registered Nurse (RN) on 2/22/24 at 11:43 AM in reference to a noise with the oxygen concentrator and the patient with emesis after breakfast. The representative was advised to use “;nausea medication if more emesis” and a new concentrator to be ordered stat. A telephone contact note on 2/23/24 at 1:45 PM noted the patients representative was contacted regarding the patients wellness and was informed the patient “;had a little something to eat and threw it up, yesterday, he/she did not have any food, advised Ondansetron if more than one emesis”. Further review of the chart revealed no nursing visit offered and/or made for the signs and/or symptoms for Pt 13. During an interview on 3/14/24 at 1:25 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer stated, “;They (nursing) should increase visits if nausea”. Review of Patient #16’s record on 3/13/24 at 10:50 AM revealed Patient #16 was admitted to hospice care on 1/23/24 with a diagnosis of Lung Cancer. A Medical Social Worker (MSW) visit note dated 3/11/24 indicated Patient #16 was in the hospital. There was no other documentation in Patient #16’s record about the hospitalization. Review of the Answering Service Call Logs for Friday 3/8/24 through 3/10/24 revealed the following: >3/8/24 at 3:10 PM The family member/caregiver (FM/CG) called. There was no message. >3/8/24 at 6:46 PM The FM/CG called, “...has fever, needing advice...” >3/8/24 at 9:11 PM The FM/CG called, “...Trying to reach nurse, fever has gone up...” >3/9/24 at 7:55 AM The FM/CG called, “...pls (please) have her call me...” >3/9/24 at 10:23 AM The FM/CG called, “...RX (prescription medication) QUESTIONS...” >3/9/24 at 11:18 AM The FM/CG called, “...needs you to call her again...” >3/10/24 at 6:11 PM The FM/CG called, “...had to be hospitalized and wanting to speak with nurse...” Review of an email titled, “Weekend Report” dated 3/11/24 at 7:34 AM provided by the Clinical Director (CD) as part of the Hospice’s Call Log revealed the following: >”Friday, March 8, 2024...7:00pm (FM/CG name) called service regarding (Patient #16’s name) elevated temperature, Tylenol adm (administered) for fever, caregiver to continue to monitor...10:00pm (FM/CG name) called service, (Patient #16’s name) temp (temperature) elevated, cooling strategies discussed, ceiling fan, cool compress, Tylenol to be repeated, pt (patient)...” >”Saturday, March 9, 2024...7:56 am (FM/CG name) called service, (Patient #16’s name)...discussed Motrin and Tylenol for fever indications...12:00pm (FM/CG name) called service, (Patient #16’s name)...tolerated breakfast, temp elevated, pt taken to (name of hospital) for evaluation...” >Sunday, March 10, 2024...10:00 am Follow up call to (name of hospital) admitted...6:11pm (FM/CG name) called service updated on call RN (registered nurse) regarding pt’s status...” Review of Patient #16’s record and the Hospice’s Call Logs revealed no documented evidence the hospice nurse visited the patient or offered a visit despite six phone calls by the FM/CG over a two day and two night time period. In an interview with the CD on 3/14/24 at 10:24 AM, she/he reviewed Patient #16’s record, and reviewed the Call Logs and Weekend Report for 3/8/24 through 3/10/24 and confirmed there was no documentation indicating the hospice nurse on-call visited Patient #16 or offered to visit Patient #16. The CD stated, She should have made a visit. He died at the hospital. He didn’t make it to the Hospice House.” Review of the Hospice’s policy titled, “Patient Care...Availability 24/7” on 3/14/24 revealed, “...Care and services...are available 24 hours a day, 7 days a week, as needed to meet the needs of patients and their caregivers...””

“Based on interview and record review, the hospice facility failed to ensure the interdisciplinary team (IDT) completed a comprehensive assessment within 5 days of notice of election for 11 of 20 patient charts reviewed (Patients 2, 4, 7, 8, 9, 10, 11, 12, 13, 14 and 15) and disciplines performed late initial assessments for 2 of 20 patient charts reviewed. (Patients 8 and 16). The findings include: Record review on 3/12/24 at 4:03 PM of P 4 revealed P 4 was admitted on 5/08/23 for Senile degeneration of brain. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 5/19/23. During an interview on 3/14/24 at 12:06 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 9:46 AM of P 8 revealed P 8 was admitted on 6/01/23 for Atherosclerotic Heart Disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 6/08/23 with no initial chaplain assessment until 6/26/23. During an interview on 3/14/24 at 12:38 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 10:47 AM of P 9 revealed P 9 was admitted on 3/08/23 for Obstruction of bile duct. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 3/22/23. During an interview on 3/14/24 at 12:48 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 11:23 AM of P 10 revealed P 10 was admitted on 7/29/23 for malignant neoplasm of descending colon. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 8/09/23. During an interview on 3/14/24 at 12:53 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 12:06 PM of P 11 revealed P 11 was admitted on 9/06/23 for retroperitoneal abscess. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 9/13/23. During an interview on 3/14/24 at 1:00 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 12:35 PM of P 12 revealed P 12 was admitted on 9/29/23 for acute myeloblastic Leukemia. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 10/11/23. During an interview on 3/14/24 at 1:05 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 1:13 PM of P 13 revealed P 13 was admitted on 10/16/23 for Chronic Obstructive Pulmonary Disease (COPD). Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 10/25/23. During an interview on 3/14/24 at 1:20 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Review of Patient #2’s record on 3/12/24 at 11:20 AM revealed Patient #2 elected hospice care on 2/6/24 with a diagnosis of Senile Degeneration of the Brain (dementia). There was no documented evidence the IDT communicated about the comprehensive assessment and the development of the initial plan of care. The first IDT meeting was on 2/21/24 (15 days after the election of benefit). In an interview with the Clinical Director (CD) on 3/14/24 at 1:17 PM she/he reviewed Patient #2’s record and confirmed the findings. Review of Patient 7’s record on 3/12/24 at 3:04 PM revealed Patient #7 elected hospice care on 10/25/23 with a diagnosis of Chronic Osteomyelitis (infection in the bone). There was no documented evidence the IDT communicated about the comprehensive assessment and the development of the plan of care. The first IDT meeting was on 11/8/23 (14 days after election of benefit). In an interview with the CD on 3/14/24 at 9:50 AM she/he reviewed Patient #7’s record and confirmed the findings. Review of Patient #15’s record on 3/13/24 at 12:06 PM revealed Patient #15 elected hospice care on 10/4/23 with a diagnosis of Multiple Myeloma (cancer of the blood plasma cells in the bone marrow). There was no documented evidence the IDT communicated about the comprehensive assessment and development of the the plan of care. The first IDT meeting was on 10/18/23 (14 days after election of benefit). In an interview with the CD on 3/14/24 at 10:34 AM she/he reviewed Patient #15’s record and confirmed the findings. Review of Patient #14’s record on 3/13/24 at 12:47 PM revealed Patient #14 elected hospice care on 6/7/23 with a diagnosis of Atherosclerotic Heart Disease (plaque build up in the coronary arteries). There was no documented evidence the IDT communicated about the comprehensive assessment and the development of the plan of care. The first IDT meeting was on 6/14/23 (seven days after election of benefit). In an interview with the CD on 3/14/24 at 10:46 AM, she/he reviewed Patient #14’s record and confirmed the findings.”

“Based on record reviews, interview and review of facility policy, the hospice failed to ensure medication reconciliation (MAR) of the actual medications in the patient’s facility home that the patient takes for 2 of 3 facility visits. (Patients 3 and 4). The findings include: Facility observation on 3/12/24 at 9:00 AM to 10:30 AM of P 3 revealed the following listed medications on the hospice MAR which P 16 was not taking: Correctol, take 10 mg (milligrams) of bisacodyl (5 mg tablet) by mouth 1 time a day as needed, Ibuprofen, take 800 mg of ibuprofen (800 mg tablet) by mouth every 8 hours as needed, Geri-Mox antacid-antigas, take 10 suspension of alum-mag hydroxide-simeth (aluminum-mag hydroxide-simethicone 200mg-200 mg-20 mg/5 ml (milliter) suspension) by mouth, before meals and at bedtime as needed (for stomach), Powderlax, take 17 gram of polyethylene glycol 3350 (17 gram powder packet) by mouth 1 time day as needed, and Prilosec 20 mg, take 1 tablet every day. During an interview on 3/12/24 at 11:40 AM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Facility observation on 3/14/24 at 11:00 AM to 12:00 PM of P 4 revealed the facility MAR noted Tylenol 325 mg tablet (650 mg tablet) oral, as needed every six hours while the hospice MAR noted Acetaminophen Extra Strength, take 500 mg of Acetaminophen extra strength (500 mg tablet) by mouth every 6 hours as needed, and facility MAR noted Seroquel 25 mg tablet (0.5) tablet every 12 hours for 36 months while the hospice MAR noted Seroquel, take 25 mg of Seroquel (25 mg tablet) by mouth every 12 hours. The facility MAR revealed the following medication on the facility MAR and not on the hospice MAR: Hyoscyamine 0.125 mg sublingual tablet (2 tablets) as needed every four hours. The hospice MAR revealed the following medications not noted on the facility MAR: Voltaren Arthritis Pain, apply 1 gel of Voltaren Arthritis pain (1% (percent) gel) topically every 8 hours times 7 days and Bisacodyl, insert 10 mg of bisacodyl (10 mg suppository) rectally 1 time a day as needed. During an interview on 3/12/24 at 11:42 AM Registered Nurse (RN) 1 stated, “;I check meds once a week or every other week”. During an interview on 3/14/24 at 12:60 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Facility policy, entitled “;Medication Reconciliation” revealed, “;3. The medications should be reviewed with the patient and family on each visit to see if new medications have been added or deleted from their medication profile...”.”

“Based on record review, interview and review of the Hospice’s policies, the Hospice failed to ensure an Initial Bereavement Risk Assessment was completed for six of 20 records reviewed for an Initial Bereavement Risk Assessment (Patients #4, #6, #11, #16 and #19). The findings include: Record review on 3/12/24 at 4:03 PM of P 4 revealed P 4 was admitted on 5/08/23 for Senile Degeneration of Brain. Review of the chart revealed no initial bereavement assessment within 5 days of the notice of election. During an interview on 3/14/24 at 12:06 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/11/24 at 2:02 PM of P 6 revealed P 6 was admitted on 11/21/23 for Progressive Supranuclear Opthalmoplegia. Review of the chart revealed the initial bereavement assessment within 5 days was not fully completed by the social worker. During an interview on 4/14/24 at 12:28 PM, the CEO/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 12:06 PM of P 11 revealed P 11 was admitted on 9/06/23 for retroperitoneal abscess. Review of the chart revealed no initial bereavement risk assessment within 5 days of the notice of election. During an interview on 3/14/24 at 1:00 PM, the CEO/Clinical Director/Compliance Officer verified the findings. During an interview with the Bereavement Coordinator (BC) on 3/12/24 at 8:35 AM, he/she stated no Initial Bereavement Risk Assessment is done at admission for any patients. During review of records for Patients #1 through #20 during the survey, Initial Bereavement Risk Assessments were completed for some patients but not all patients and the BC was not aware the MSW’s completed any Initial Bereavement Risk Assessments. Review of Patient #19’s record on 3/13/24 at 9:50 AM revealed an Initial Bereavement Risk Assessment was not completed. During an interview with the Clinical Director (CD) on 3/14/24 at 9:32 AM she/he reviewed Patient #19’s record and confirmed the findings. Review of Patient #16’s record on 3/13/24 at 10:50 AM revealed an Initial Bereavement Risk Assessment was not completed. During an interview with the CD on 3/14/24 at 10:12 AM she/he confirmed the findings. Review of the Hospice’s policy titled, “Bereavement Risk Assessment” on 3/14/24 revealed, “During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient’s death.””

“Based on record review, interview and review of the Hospice’s policies, the hospice failed to train the caregivers in how to provide wound care and change the dressing for one of two patient records reviewed for wound care (Patient #14). The findings include: Review of Patient #14’s record on 3/13/24 at 12:47 PM revealed Patient #14 was admitted to hospice care on 6/7/23 with a diagnosis of Atherosclerotic Heart Disease (plaque build up in the coronary arteries). A nursing visit note dated 2/19/24 indicated, “wound care provided” but did not indicate what type of wound care was provided. A nursing visit note dated 2/19/24 indicated, “...family provides wound care in the absence of hospice nurse.” Review of the record including all of the nursing visit notes dated 1/30/24 through 3/11/24 (1/30/24, 2/6/24, 2/12/24, 2/19/24, 3/4/24, 3/11/24)revealed no documentation of any education or training in wound care and dressing changes to Patient #14’s family. In an interview with the CD on 3/14/24 at 11:00 AM she/he reviewed Patient #14’s record and confirmed the findings. Review of the Hospice’s policy titled, “PLAN OF CARE” on 3/14/24 revealed, “...Each patient and his or her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care...””

“Based on record review, interview and review of the Hospice’s policies, the Hospice failed to include all necessary services in the plan of care for four of 17 patient records review for plans of care (Patients #1, #2, #8, and #14). Record review on 3/13/24 at 9:46 AM of P 8 revealed P 8 was admitted on 6/01/23 for Atherosclerotic Heart Disease. Review of P 8s medication administration record (MAR) revealed the patient taking Plavix 75 milligrams (mg) one time a day and Aspirin 81 mg one time a day. Further review of P 8s POC revealed the patient was not care planned for bleeding precautions while on the medications. During an interview on 3/14/24 at 12:38 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer stated, “;The patient should have been care planned for it”. A home visit was made to Patient #1 on 3/12/24 at 1:00 PM with the Hospice Registered Nurse (RN). Patient #1 told the RN she was not getting up by herself because of previous falls. Review of Patient #1’s record on 3/13/24 at 3:05 PM revealed Patient #1 was admitted to hospice care on 1/22/24 with a diagnosis of Pancreatic Cancer. The Interdisciplinary Group Note dated 3/6/24 indicated, “...fell without injury” and the IDG Note dated 2/21/24 indicated, “...past falls in home due to weakness...” A RN visit note dated 3/5/24 indicated, “...Pt (patient) was nervous about ambulation due to a previous fall without injury...” Review of Patient #1’s plan of care (POC) for the period 1/22/24 to 4/20/24 did not include anything about Patient #1’s history of falls or prevention of future falls. In an interview with the Clinical Director (CD) on 3/14/24 at 11:08 AM she/he reviewed Patient #1’s record and confirmed the findings. The CD confirmed there should be a care plan for for falls/fall prevention.” A home visit was made to Patient #2 on 3/12/24 at 9:00 AM with the Hospice Aide (HA). Patient #2 was observed to require two people to complete a bed bath as she/he kept her/his arms and legs partially flexed all of the time and became stiff with all care. Patient #2 was observed to require total care and only answered two questions appropriately during the care. Patient #2 was somewhat thin in appearance. Review of Patient #2’s record on 3/12/24 at 2:42 PM revealed a registered nurse (RN) visit note dated 2/19/24 which read, “...skin integrity concern as pt (patient) is bedbound and not eating well...” Review of the Plan of Care (POC) revealed no care plan for skin integrity/potential for breakdown. In an interview with the CD on 3/14/24 at 11:34 AM, the CD reviewed Patient #2’s record and confirmed the findings and confirmed there should be a care plan regarding skin integrity. Review of Patient #14’s record on 3/13/24 at 12:47 PM revealed Patient #14 was admitted to hospice care on 6/7/23 with a diagnosis of Atherosclerotic Heart Disease (plaque build up in the coronary arteries). A nursing visit note dated 2/19/24 indicated, “wound care provided” but did not indicate what type of wound care was provided. A nursing visit note dated 3/4/24 indicated, “Wound care provided. No changes in wound care” but the type of wound care provided was not documented and there was no documented assessment of the wound. There was no physician’s order for wound care and review of the plan of care dated 2/2/24 to 4/1/24 revealed there was no care plan for the wound. In an interview with the CD on 3/14/24 at 11:00 AM she/he reviewed Patient #14’s record and confirmed there was no care plan for the wound and there should be. Review of the Hospice’s policy titled, “PLAN OF CARE” on 3/14/24 revealed, “...The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient..””

“Based on record review, interview and review of the Hospice’s policies, the hospice interdisciplinary group (IDG) failed to review and update the plan of care (POC) no less frequently than every 15 calendar days for six of 20 patient records reviewed (Patients #3, #6, #8, #12, #13 and #16). Review of Patient #16’s record on 3/13/24 at 10:50 AM and a document titled, “IDG Report” dated 3/6/24 revealed a note, “Pending.” The document did not include the plan of care (POC) and did not have any staff signatures. During an interview with the Clinical Director (CD) on 3/14/24 at 10:31 AM she/he reviewed Patient #16’s record and confirmed the findings. Review of the Hospice’s policy titled, “PLAN OF CARE” on 3/14/24 revealed, “...The plan of care is reviewed and updated by the IDG every 15 days or more frequently if needed...””

“Based on record review and interview, the hospice failed to ensure the physician plan of care (POC) was followed for frequency visits by hospice disciplines for 10 of 20 patient charts reviewed (Patients 2, 3, 4, 6, 8, 9, 12, 15, 16 and 20), urinalysis results obtained per POC for 2 of 20 patient charts reviewed and patient visit obtained per patient and/or patient representative request for 1 of 20 patient charts reviewed. (Pt 16). The findings include: Record review on 03/12/24 at 2:55 PM of P 3 revealed P3 was admitted on 6/30/23 for Senile Degeneration of Brain. Review of the physician POC for certification period 12/27/23 to 2/24/24 revealed Registered Nurse (RN) frequency of 1 time a week for 9 weeks and chaplain 1 time every 4 weeks starting 2/09/24 to 2/24/24. Review of the certification period revealed 1 missed RN visit the week of 12/27/23 to 12/30/23 and no order for (1) chaplain visit the week of 1/14/24 to 1/20/24 and 1/28/24 to 2/03/24 and (1) missed visit 2/09/24 to 2/24/24. During an interview on 3/14/24 at 11:40 AM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/12/24 at 4:03 PM of P 4 revealed P 4 was admitted on 5/08/23 for Senile Degeneration of Brain. Review of the physician POC for certification period 1/3/24 to 3/2/24 revealed RN frequency starting 1/03/24 to 3/02/24 for 1 time a week every other week for 2 weeks, Hospice Aide (HA) visit frequency for 5 times a week for 9 weeks and Chaplain visit frequency for 1 time every 4 weeks. Review of the certification period revealed a missed RN visit the week of 1/03/24 to 1/6/24 and one extra visit the week of 1/28/24 to 2/3/24 without a physicians order, two missed HA visits the week of 1/03/24 to 1/06/24 and (3) missed visits the week of 2/11/24 to 2/17/24 and one extra chaplain visit the week of 2/04/24 to 2/10/24 without a physicians order. During an interview on 3/14/24 at 12:06 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/11/24 at 2:02 PM of P 6 revealed P 6 was admitted on 11/21/23 for Progressive Supranuclear Opthalmoplegia. Review of the physician POC for certification period 11/21/23 to 2/18/24 revealed HA visit frequency for 5 times a week beginning 11/26/23 to 2/17/24. Review of the certification period revealed 1 missed visit the week of 12/24/23 to 12/30/23 and 1 missed visit the week of 12/31 23 to 1/06/24. During an interview on 3/14/24 at 12:28 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 9:46 AM of P 8 revealed P 8 was admitted on 6/01/23 for Atherosclerotic Heart Disease. Review of the physician POC for certification period 1/27/24 to 3/26/24 revealed chaplain visit for 1 time every 4 weeks. Review of the certification period revealed a missed visit the week of 1/27/24 to 2/3/24. During an interview on 3/14/24 at 12:38 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 10:47 AM of P 9 revealed P 9 was admitted on 3/8/23 for Obstruction of bile duct. Review of the physician POC for certification period 1/02/24 to 3/01/24 revealed the RN frequency for 1 time a week for 9 weeks and the HA frequency for 5 times a week for 9 weeks. Review of the certification period revealed 1 missed RN visit the week of 1/02/24 to 1/06/24 and 1missed HA visit the week of 1/02/24 to 1/06/24. During an interview on 3/14/24 at 12:48 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Record review on 3/13/24 at 12:35 PM of P 12 revealed P 12 was admitted on 9/29/23 for Acute Myeloblastic Leukemia. Review of the physician POC for certification period 12/28/23 to 3/26/24 revealed the RN visit frequency was 1 time a week for 14 weeks, HA visit frequency of 3 times a week for 14 weeks (12/28/23 to 3/26/24) then 4 times a week for 13 weeks beginning 1/02/24 to 3/26/24 and chaplain visits for 1 time every 4 weeks. Review of the certification period revealed 1 missed RN visit the week of 12/28/23 to 12/30/23 and 1 missed visit the week of 12/31/23 to 1/06/24; 2 missed HA visits the week of 12/28/23 to 12/30/23 and 2 missed visits the week of 12/31/23 to 1/06/24 and 1 extra chaplain visit the week of 1/21/24 to 1/27/24 without a physicians order. During an interview on 3/14/24 at 1:05 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer verified the findings. Review of Patient #20’s record on 3/11/24 at 1:30 PM revealed Patient #20 was admitted to hospice care on 1/19/24 with a diagnosis of Chronic Obstructive Pulmonary Disease (a disease of the lungs). The Plan of Care (POC) indicated the Hospice Aide (HA) was to visit Patient #20 five times a week. Review of the record revealed two missed HA visits the week of 1/21/24 and no HA visits the week of 1/28/24. There was no documentation indicating the reason for the missed visits. Patient #20 died on 1/30/24 (19 days after admission). During an interview with the Clinical Director (CD) on 3/14/24 at 9:25 AM, the CD reviewed Patient #20’s record and confirmed the findings. Review of Patient #2’s record on 3/12/24 at 11:20 AM revealed Patient #2 was admitted to hospice care on 2/6/24 with a diagnosis of Senile Degeneration of the Brain (dementia). The POC at admission indicated the HA was to visit Patient #2 five times a week. Review of the record revealed a missed HA visit the first week of services (2/6/24) and two missed HA visits the second week of services (the week of 2/11/24). There was no documentation indicating the reason for the missed visits. During an interview with the CD on 3/14/24 at 11:19 AM she/he reviewed Patient #2’s record and confirmed the findings. Review of Patient #16’s record on 3/13/24 at 10:50 AM revealed Patient #16 was admitted to hospice care on 1/23/24 with a diagnosis of Lung Cancer. The POC at admission indicated the HA was to visit Patient #16 five times a week. Review of Patient #16’s record revealed no HA visits the first three weeks of hospice services and one missed HA visit the fourth week of hospice (1/11/24). There was no documentation indicating the reason for the missed visits. Further review of Patient #16’s record revealed a Medical Social Worker (MSW) visit note dated 3/11/24 indicating Patient #16 was in the hospital. Review of an email titled, “Weekend Report” dated 3/11/24 at 7:34 AM provided by the Clinical Director (CD) as part of the Hospice’s Call Log revealed the family member/care giver (FM/CG) called the on-call hospice nurse on 3/8/24 at 7:00 PM regarding an “elevated temperature...Tylenol adm (administered) for fever, caregiver to continue to monitor...” The FM/CG called back at 10:00 PM regarding an elevated temperature and the on-call nurse instructed the FM/CG, “Tylenol to be repeated (three hours after last dose)...” The FM/CG called back on 3/9/24 at 7:56 AM and the on-call nurse “discussed Motrin and Tylenol for fever and indications...” Review of Patient #16’s plan of care medications list revealed Tylenol was ordered every 6 hours as needed and Motrin was not ordered. The hospice on-call nurse instructed Patient #16’s FM/CG to give medications not in accordance with the medications ordered by the physician. Review of Patient #15’s record on 3/13/24 at 12:06 PM revealed Patient #15 was admitted to hospice care on 10/4/23 with a diagnosis of Multiple Myeloma (cancer of the plasma blood cells in the bone marrow). The POC dated 2/1/24 to 3/31/24 indicated the HA was to visit Patient #15 five times a week. Review of Patient #15’s record revealed a missing HA visit the first week of the certification period (2/1/24) and two missing HA visits the week of 2/25/24. There was no documentation indicating the reason for the missed visits. During an interview with the CD on 3/14/24 at 10:34 AM she/he reviewed Patient #15’s record and confirmed the findings. Patient #5’s record was reviewed on 3/11/24 at 2:35 PM. Patient #5 was admitted to hospice care on 9/8/23 with a diagnosis of Alcoholic Liver Cirrhosis. Review of the IDG Report dated 12/13/23 revealed, “...Blood work drawn 12-07-23...” Review of the record revealed no documentation of the laboratory results. In an interview with the CD on 3/14/24 at 9:50 AM she/he reviewed Patient #5’s record and confirmed the findings. Review of Patient #7’s record on 3/12/24 at 3:04 PM revealed Patient #7 was admitted to hospice care on 10/25/23 with a diagnosis of Chronic Osteomyelitis (infection in the bone). The Physician’s Plan of Care (PPOC) dated 1/23/24 to 4/21/24 indicated, “...Obtain UA (urinalysis) C & S (culture and sensitivity)...” Review of Patient #7’s record revealed there was no documentation a UA C & S was done or any laboratory results. In an interview with the CD on 3/14/24 at 9:59 AM, he/she reviewed Patient #7’s record and confirmed the findings. The CD stated it was from the previous PPOC that was not deleted. When asked if there was documentation of UA C & S laboratory results from the previous certification period, the CD stated, “No.” Review of the Hospice’s policy titled, “PLAN OF CARE” on 3/14/24 revealed, “The care and services provided to patients and their families are in accordance with an individualized, written plan of care...””

“Based on record review and interview, the Hospice failed to provide Volunteer services as requested by the family member/care giver (FM/CG) at the time of the Medical Social Worker (MSW) Initial Assessment for one of three patient records reviewed for volunteer services (Patient #16) and failed to provide a nursing visit as requested by the family member/caregiver (FM/CG) for one of 17 records reviewed (Patient #20). The findings include: Review of Patient #16’s record on 3/13/24 at 10:50 AM revealed Patient #16 was admitted to hospice care on 1/23/24 with a diagnosis of Lung Cancer. The MSW Initial Assessment Visit Note dated 1/29/24 indicated, “...interested in volunteers...Volunteer Coordinator, to follow up...” Review of the Volunteer section of the record revealed there was no volunteer documentation. Review of the Interdisciplinary Group (IDG) Note dated 2/7/24 indicated, “...(FM/CG) is isolated from others with all the care of patient. Not many friends or community interaction...patient care keeps (FM/CG) home bound...” The IDG Note did not include any discussion of volunteer services. Review of the Physician’s Plan of Care (PPOC) for the period 1/23/24 to 4/21/24 revealed no indication of any volunteer services. In an interview with the Clinical Director (CD) on 3/14/24 at 10:10 AM she/he reviewed Patient #16’s record and confirmed the findings. Review of Patient #20’s record on 3/11/24 at 1:30 PM revealed Patient #20 was admitted to the hospice care on 1/19/24 with a diagnosis of Chronic Obstructive Pulmonary Disease. A Telephone Contact Note dated 1/21/24 indicated, “...daughter...asked that the nurse visit Monday...” Further review of Patient #20’s record revealed no nursing visit note for Monday (1/22/24) or any documentation to indicate why no nurse visit was made. In an interview with the CD on 3/14/24 at 9:21 AM, she/he reviewed Patient #20’s record and confirmed the findings, stating “I don’t see it.” Review of the Hospice’s policy titled, “Volunteers...Assignments” on 3/14/24 revealed, “...Volunteer Assignments...Companionship...Depending upon the level of support available to patient/family this has the potential to be the single most important service that the volunteer can provide to both patient and family. ...””

“Based on observation and interview, the hospice failed to ensure current information was available in 2 of 3 facility patient charts reviewed contained up to date information for the patients. (Patients 3 and 4). The findings include: Facility observation on 3/12/24 at 10:00 AM of P 3 revealed P 3 was admitted on 6/30/23 for Senile Degeneration of Brain. Review of the hospice book for P 3 at the facility revealed no current hospice plan of care, no advance directive form, no current physician certification and recertification form, and/or current medication profile. During an interview on 3/12/24 at 10:35 AM the facility Director of Nursing (DON) stated, “;They (the hospice) are to update their binders. They are to physically bring in their paperwork”. During an interview on 3/14/24 at 11:24 AM the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer stated, “;The charts are kept up by the hospice coordinator”. Facility observation on 3/12/24 at 11:30 AM of P 4 revealed P 4 was admitted on 5/08/23 for Senile Degeneration of Brain. Review of the hospice book for P 4 at the facility revealed no current hospice plan of care, physician certification and recertification and/or current medication profile. During an interview on 3/12/24 at 11:40 AM, RN 1 stated, “;Theres a lady that brings the information from the office to the facility”. During an interview on 3/14/24 at 12:06 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer stated, “;The charts are kept up by the hospice coordinator”.”

“Based on record review, interview and review of facility policy and procedure, the hospice failed to ensure the Quality Assessment Performance Improvement (QAPI) program included all facets of the hospice program including patient care and other relevant data. The findings include: Review of facility QAPI minutes on 3/14/24 at 10:05 AM revealed no documentation of review of all facets of the program including patient care for the hospice program during QAPI meeting minutes on 2/01/23, 05/17/23, 8/16/23 and 12/11/23. During an interview on 3/14/24 at 4:25 PM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer stated, “;We have discussion but its not documented in our meeting. The contracts and agreements are reviewed between myself and the CFO (Chief Financial Officer). I dont discuss them in the group”. Facility policy, entitled “;QAPI-Program Data” revealed, “;5. The QAPI Committee is responsible for reviewing and analyzing data that may impact patient/family care, which may include but not limited to: a. Physician, nursing, social work, counseling, volunteering and hospice aide services; b. Clinical records; c. Pharmaceutical services; d. Utilization of levels of care; e. Contracted services; f. Complaint and incident report logs; g. Infection surveillance data; h. CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys; and i. PEPPER (Program for Evaluating Payment Patterns Electronic Report) data...”.”

“Based on observation, interview and review of the Hospice’s policy, the Hospice failed to ensure staff used standard precautions and hand hygiene during patient care for one of four patient visits observed (Patient #2). The findings include: A home visit was made with the Hospice Aide (HA) #1 on 3/12/24 at 9:00 AM to Patient #2 who was residing at an Assisted Living Facility. The HA was observed with gloves on providing Patient #2 a bed bath. After washing Patient #2’s perineal area, genital area and buttocks, the HA did not remove the gloves. The HA proceeded to dry the patient, apply lotion, put clothes on the patient, touch the bedside table, the bed side rails, the bed remote control, and the supplies with the same gloves on before removing the gloves and performing hand hygiene. After the care was finished, HA #1 was interviewed. HA #1 confirmed the findings. During an interview with the Clinical Director on 3/14/24 at 11:38 AM, she/he confirmed the gloves should have been removed and hand hygiene performed after providing perineal/buttocks care. Review of the Hospice’s policy titled, “Hand Hygiene Policy and Compliance Program” on 3/14/24 revealed, “...Indications for hand hygiene are...after direct care...After using the bathroom...After any contact with any contaminated materials...All employees...are responsible for implementing hand hygiene procedures in an ongoing attempt to prevent...infectious processes and communicable diseases...””

“Based on interview and record review, the Hospice failed to develop a bereavement plan of care for three of three bereaved records reviewed (Patients #17, #18 and #19). The findings include: During an interview with the Bereavement Coordinator (BC) on 3/12/24 at 8:35 AM he/she stated, “I only do a bereavement plan of care if they require visits.” The BC stated, “I don’t have anybody right now that has a plan of care (POC).” The BC stated Patients #17, #18 and #19 are receiving bereavement mailings but do not have bereavement POC’s. On 3/13/24 at 9:50 AM Patient #19’s record was reviewed. Patient #19 was admitted to hospice care on 7/11/23 and died on 8/27/23. Patient #19 had a bereaved. There was no bereavement POC for Patient #19’s bereaved. On 3/13/24 at 10:05 AM Patient #18’s record was reviewed. Patient #18 was admitted to hospice care on 5/23/23 and died on 6/8/23. Patient #18 had a bereaved. There was no bereavement POC for Patient #18’s bereaved. On 3/13/24 at 10:20 AM Patient #17’s record was reviewed. Patient #17 was admitted to hospice on 4/3/23 and died on 4/27/23. Patient #17 had a bereaved. There was no bereavement POC for Patient #17’s bereaved.”

“Based on observation, interview, record review and review of the Hospice’s policies, the hospice failed to ensure a Hospice Aide reported signs of discomfort/pain to the Registered Nurse (RN) for one of two HA visits observed (Patient #2). A home visit was made to Patient #2 on 3/12/24 at 9:00 AM and Hospice Aide (HA) #1 was observed providing a bed bath. Patient #2 required two people to provide the bed bath and each time she/he was turned to the left side she/he said “Oh, ow, Oh Lord,” exhibited facial wincing and one time also placed her/his right hand on her/his right hip simultaneously. When Patient #2 was lying still she/he did not exhibit any signs of discomfort/pain. During an interview with HA #1 after the visit was finished he/she confirmed Patient #2 said “Oh, ow, Oh Lord,” exhibited facial wincing and one time also placed her right hand on her right hip simultaneously. When asked if she had reported these signs of discomfort/pain to the hospice nurse, he/she stated, “No.” HA #1 stated another HA told her/him Patient #2 “does this all the time but she’s not in pain.” During review of HA #1’s documentation for the visit 3/12/24, there was no documentation of notification to the nurse of Patient #2’s signs of discomfort/pain. During an interview with the Clinical Director (CD) on 3/14/24 at 11:10 AM she/he confirmed there was no documentation HA #1 reported Patient #2’s signs of discomfort/pain to the Hospice Nurse. The CD stated Hospice Aides are supposed to report signs of discomfort/pain to the Hospice Nurse.”

“Based on observation, interview and review of the Hospice’s policy, the Hospice failed to ensure expired patient medical supplies were not readily available for patient use and removed from the patient medical supplies cabinet. Observation on 3/11/24/at 11:48 AM to 12:15 PM revealed the following expired supplies in the patient supply room: (31) petroleum jelly skin protectant packets expired 8/21, (10) Sure prep protective wipes expired 2/23, (10) Sure prep protective wipes expired 3/23, (32) Sure prep protective wipes expired 10/22, (34) Cavilon no sting barrier wipes expired 4/16/23, (12) Quick N Clean antiseptic hand wipes expired 6/08, (25) Micro kill bleach germicidal bleach wipes expired 11/16, (17) Mesalt 7.5 by 7.5 cm (centimeter)/3.3inch pad expired 4/28/22, (5) Optifoam non-adhesive foam wound dressings expired 10/03/22, (2) suture removal trays expired 4/30/22, (4) Tegaderm film 6 inch by 8 inch expired 6/19 and (5) Xtrasorb super absorbent dressings expired 2/23/24. During an interview on 3/11/24 at 12:17 PM the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer. The findings include: During inspection of the patient care medical supplies cabinets on 3/11/24 at 12:12 PM the following expired supplies were found: One box of Reinforced Gelling Fiber dressing 4 x 4.75 inches, Quantity 10/box, six remaining, expired 2/28/24; One package of Sorba View 2000 4-1/2 x 4-1/2 inches window dressing, Quantity three; expired 3/2020; and Tegaderm Film Dressing, 4 x 4-3/4 inches; Quantity three, expired 6/18/22. These findings were confirmed with the Clinical Director (CD) on 3/11/24 at 12:18 PM. Review of the Hospice’s policy titled, “MEDICAL SUPPLIES” on 3/14/24 revealed, “...Expiration dates...are checked periodically by the hospice’s administrative support staff. Outdated medical supplies are discarded...””

“Based on interview and review of employee files, the Hospice failed to provide orientation about the hospice philosophy to 12 of 28 employee files reviewed. Review of personnel training on 3/14/24 at 9:20 AM revealed the following personnel with no documented training related to the hospice philosophy: Registered Nurse (RN) 1 hired on 2/26/24, RN 2 hired on 11/2/20, RN 3 hired 4/25/22, RN 4 hired 7/29/09, Hospice Aide (HA) 1 hired 3/4/24, HA 2 hired 9/25/15, HA 3 hired 11/13/23, HA 4 hired 10/03/19, HA 5 hired 5/08/23, HA 6 hired 11/29/23 and HA 7 hired 12/11/23. During an interview on 3/14/24 at 10:00 AM, the Chief Executive Officer (CEO)/Clinical Director/Compliance Officer stated, “;The trainings are done through HealthStream which we pay the hospital for. They make suggestions about what we take”. The findings include: A home visit was made to Patient #2 on 3/12/24 at 9:00 AM and Hospice Aide (HA) #1 was observed providing a bed bath. Patient #2 required two people to provide the bed bath and when she/he was turned to the left side she/he said “Oh, ow, Oh Lord,” exhibited facial wincing and one time also placed her/his right hand on her/his right hip simultaneously. When Patient #2 was lying still she/he did not exhibit any signs of discomfort. During an interview with HA #1 after the visit was finished he/she confirmed Patient #2 said “Oh, ow, Oh Lord,” exhibited facial wincing and one time also placed her right hand on her right hip simultaneously. HA #1 stated another HA told her Patient #2 “does this all the time but she’s not in pain.” When asked if she received orientation or training on the hospice philosophy of care HA #1 stated she/he did not know. On 3/13/24 at 3:26 PM HA #1’s employee file was reviewed. There was no documented evidence HA #1 received orientation to the hospice philosophy. In an interview with the Clinical Director (CD) on 3/14/24 at 11:15 AM she/he reviewed HA #1’s employee file and confirmed the findings. The CD stated the hospice does not provide orientation to the hospice philosophy for employees at the time of hire.”

“Based on record review and interview, the hospice failed to ensure responses to treatments and medications were recorded in the patients records for two of 20 records reviewed (Patients #2 and #14). A home visit was made to Patient #2 on 3/12/24 at 9:00 AM and a Hospice Aide was observed giving Patient #2 a bed bath. A white substance was observed on Patient #2’s right mons pubis (pubic area), consistent with a vaginal yeast infection, which resolved after bathing. Review of Patient #2’s record on 3/12/24 at 11:20 AM revealed Patient #2 was admitted to hospice care on 2/6/24 with a diagnosis of Senile Degeneration of the Brain (dementia). The medication list indicated Patient #2 was started on fluconazole (used to treat vaginal yeast infection) 150 mg tablet once daily for five days beginning 2/15/24. The Registered Nurse (RN) visited on 2/19/24 and 2/22/24 and there was no documented evidence the nurse assessed the effectiveness of the fluconazole. In an interview with the Clinical Director (CD) on 3/14/24 at 11:32 AM, she/he reviewed Patient #2’s record and stated she remembered this because the patient’s family member called and she spoke with him/her and the fluconazole was ordered that day. The CD stated the RN should have assessed the effectiveness of the fluconazole. Review of Patient #14’s record on 3/13/24 at 12:47 PM revealed Patient #14 was admitted to hospice care on 6/7/23 with a diagnosis of Atherosclerotic Heart Disease (plaque build up in the coronary arteries). A nursing visit note dated 2/19/24 indicated, “wound care provided” but did not indicate what type of wound care was provided. A nursing visit note dated 3/4/24 indicated, “Wound care provided. No changes in wound care” but the type of wound care provided was not documented and there was no documented assessment of the wound. In an interview with the CD on 3/14/24 at 11:00 AM she/he reviewed Patient #14’s record and confirmed the findings. The CD also stated an assessment of the wound should be done “every comprehensive visit” (i.e. every 15 days). Review of the Hospice’s policy titled, “Clinical Records” on 3/14/24 revealed, “...Each patient’s clinical record includes, at a minimu, the following...updated comprehensive assessments, documentation of the patient’s responses to medications, symptoms management, treatments and services...” Review of the Hospice’s policy titled, “Wound Care” on 3/14/24 revealed, “...The registered nurse will assess all patient wounds upon discovery and institute care/treatment until such time as the wound is resolved...Registered nurses will assess and document skin integrity until a wound is resolved...The wound should be measured and documented weekly...””

“Based on record review and interview, the Hospice failed to ensure there was a physician’s order in the patient record for one of 17 patient records reviewed for physician’s orders (Patient #14). The findings include: Review of Patient #14’s record on 3/13/24 at 12:47 PM revealed Patient #14 was admitted to hospice care on 6/7/23 with a diagnosis of Atherosclerotic Heart Disease (plaque build up in the coronary arteries). A nursing visit wound care note dated 1/30/24 indicated Patient #14 had a pressure ulcer wound to the left foot. A nursing visit note dated 2/19/24 indicated, “wound care provided...family provides wound care in the absence of hospice nurse.” There was no documentation of the type of wound care provided by the nurse or ordered by the physician. A nursing visit note dated 3/4/24 indicated, “...Wound care provided. No changes in wound care...” There was no documentation of the type of wound care provided by the nurse or ordered by the physician. Review of Patient #14’s record revealed there was no physician’s order for wound care to Patient #14’s left foot. In an interview with the CD on 3/14/24 at 11:00 AM she/he reviewed Patient #14’s record and confirmed the findings and stated there should be a physician’s order. Review of the Hospice’s policy titled, “Wound Care” on 3/14/24 revealed, “...Orders for wound care should be entered into the EMR (electronic medical record)...””