Agrace Hospicecare

“Based on record review and interview, agency staff failed to communicate and offer alternative routes for adequate pain/symptom management at end of life for 1 of 5 deceased patient records reviewed (Patient #2) out of a total of 10 patient records reviewed. Findings include: Review of policy “;INFUSION PUMPS FOR CONTROLLED SUBSTANCES FOR HOMECARE PATIENTS” last reviewed 3/12/2024 revealed in part, “;Protocol: Infusion pumps are used in homecare for control of symptoms not managed with the dosing of scheduled medications. The infusion pump settings are checked regularly by homecare RNs to verify they reflect the current orders when the pump is initiated, at each RN visit, whenever pump/infusion parameters change and when a new cassette is started.” Review of policy “;Pain and Symptom Management” last reviewed 7/9/2024 revealed in part, “;The [agency name] IDT ensures that patients receive effective pain management and symptom control. The pain and symptom protocols are to be used as guidelines for the assessment of pain and symptoms and selection, implementation, and monitoring of possible interventions in the plan of care.” Further review revealed, “;3. The patient/caregiver is informed and encouraged to call [agency name] at any time should any pain and/or symptom management needs arise...5. If the patient is not receiving pain/symptom relief from the current medications and non-pharmacological interventions as identified in the plan of care, the RN notifies the attending physician (if any) and/or the agency provider and carries out the recommended action(s) ordered by the provider.” Review of Patient #2s medical record revealed that Patient #2 was admitted to hospice care on 6/17/2024 with a primary diagnosis of breast cancer with metastases (spread) to brain, lungs, and bones. Patient #2 had previously been receiving palliative care services prior to admission to hospice. Review of the medical record revealed due to cultural preferences, Patient #2’s family refused inpatient care, a Macy catheter (a tube inserted into the rectum for medication administration) and other non-pharmacologic pain interventions offered by the agency (including aide or longer nursing visits). Review of Patient #2s medical record revealed Patient #2s condition declined on 7/22/2024 and the following calls were made to the agency to inform them of the decline. Review of Patient #2’s medical record revealed pain assessments were documented for each nursing visit conducted from 7/22/2024 through 7/23/2024. Pain assessment documentation revealed no signs of pain. On 7/22/2024 at 10:57 a.m. by Patient #2s former palliative care nurse called to inform the agency that patient was no longer able to swallow the extended-release morphine (an opioid pain reliever). Family Member A was crushing oxycodone (an opioid pain reliever) with water and placing under tongue, but Patient #2 was no longer getting relief. Family was wondering about doing a CAAD pump (Continuous Ambulatory Drug Delivery) or subq (subcutaneous-into the subcutaneous tissue) medications. On 7/22/2024 at 1:09 p.m. Family Member A contacted the agency requesting Tylenol suppositories (a pain reliever and fever reducer) for Patient #2 displaying signs and symptoms of a fever. On 7/22/2024 at 1:40 p.m. a skilled nurse visit was conducted by the hospice RN (Registered Nurse). The hospice RN documented that “;the patient is now actively dying.” The RN offered IPU (Inpatient Unit), but family refused. Family very private and wanted to care for patient at home. RN informed family that comfort medications via IV (intravenously) via the patients implanted port would be discussed with the hospice NP (Nurse Practitioner).” Further review revealed caregiver reported worsening pain with physical activity (turning and repositioning). The nurse documentation revealed no pain at rest. On 7/22/202 following the skilled nurse visit, the hospice RN documented discussion with hospice NP about a pain pump in the home. The hospice RN then documented a discussion with the pharmacist regarding the pump in which the pharmacist stated that a pain pump “;not ideal in-home.” Further review of the documentation revealed on 7/22/2024 at 2:04 p.m., the hospice NP ordered a high-concentrate morphine solution (50 milligrams per milliliter), which would need to be obtained out of state and would take a day more to be delivered, and fentanyl (an opioid pain reliever) patch (placed on the skin to release the medication). On 7/22/2024 at 9:30 p.m. Family Member A called to inform the agency that Patient #2 is almost out of oxycodone and that fentanyl patches were supposed to arrive that day. Family Member A was not notified that the patch “;wont get there tonight.” The hospice RN spoke with MD at 10:40 p.m. and ordered 1 patch locally. On 7/22/2024 at 11:26 p.m. The agency contacted Family Member A to inform that medications (fentanyl patch and Tylenol suppositories) would be ready for pick up at 11:40 p.m. Family Member A voiced frustration at that time regarding not receiving medications timely. There was no documentation found regarding the delay in filling the Tylenol suppositories (over 10 hours). Review of Patient #2s medical record revealed documentation by the hospice NP that noted the NP ordered a higher dose of oxycodone more frequently until the morphine concentrate arrived. On 7/23/2024 at 12:19 p.m. Patient #2s previous palliative care nurse contacted the agency to inform them that Family Member A was distressed as Patient #2 was thrashing, moaning, and running a fever. The hospice RN “;confirmed that we cannot initiate a pump in the home.” On 7/23/2024 at 1:10 p.m. Palliative care nurse contacted the agency to inform them that he/she contacted Family Member A and calling to report that Patient #2 was cachexic (physical wasting with loss of muscle mass), so Family Member A was not sure the fentanyl patch is doing anything, and patient was sweating so patch has been coming off. Wondering about continuous care at this time. A skilled nurse revisit dated 7/23/2024 at 4:31 p.m. revealed Family Member A was very upset that the morphine solution had not arrived. A lower strength morphine solution (20mg/ml 50mg every 4 hours scheduled with 20-50mg every 1 hour as needed) was ordered. The family was not informed that the high-concentration morphine could not be ordered electronically, resulting in the order being cancelled. The family was not offered other routes of medication other than the one time they refused the Macy catheter. On 7/24/2024 at 6:31 a.m. Family Member A contacted agency to inform them that Patient #2 had passed. Review of agencys complaint log revealed a complaint by Family Member A on 7/23/2024 at 5:26 p.m. and on 7/30/2024 at 10:02 p.m. by the palliative care nurse; both with concerns of ineffective pain/symptom management at end-of-life for Patient #2. The agency response to the 7/30/2024 complaint revealed “;Right now with a shortage of meds, pumps arent always possible in the home.” There was no documentation within Patient #2s medical record to indicate that a discussion regarding the availability of a pain pump for Patient #2s end of life symptoms was ever held. There was no documentation within Patient #2s medical record that the IDT (Interdisciplinary Team) discussed the possibility of a pain pump. During an interview with Chief Quality Officer B on 8/27/2024 at 1:15 p.m., Chief Quality Officer B was asked why Patient #2 did not receive a pain pump for end-of-life symptom management. Chief Quality Officer B stated that the nurse assessments on 7/22/2024 and 7/23/2024 indicated that the patient wasnt having any pain. Quality Officer B was asked if these assessments were conducted during patient cares. Quality Officer B stated no. Quality Officer B then stated that there are other things to consider when doing an in-home pump such as availability of equipment and medication. When asked if this information was shared with the family members Quality Officer B stated that the agency offered IPU care, which the family declined.”

“Based on record review and interview, the agency staff failed to develop plans of care that were individualized to meet the patients needs in 22 of 27 patient records reviewed (Patients #3, #4, #5, #6, #9 #10, #11, #12 #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, and #27.) Record review for Patient #3 revealed Patient #3 was admitted to the hospice 10/11/2021 with a primary diagnosis of Senile Degeneration of Brain. Patient #3s POC update dated 11/21/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goal: Goals of Care: Patients unique goals of care will be identified and supported through end of life. Goal: Wound Management Goal: Manage wounds per physician orders based on patients goal through end of life.” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #3. Record review for Patient #16 revealed Patient #16 was admitted to the hospice 02/11/2022 with a primary diagnosis of Huntington Disease. Patient #16s POC update dated 11/21/2023 revealed “;Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goal: Goals of Care: Patients unique goals of care will be identified and supported through end of life. Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Plan for Maintaining Comfort: Patients symptoms will be managed and treated for comfort as evidenced by verbalization satisfaction of management through end of life.” The goals stated on the POC were generic and not individualized to meet the specific needs for Patient #16. Findings Include: Review of agencys Policy and Procedure titled “;Plan of Care Primary Interdisciplinary Team (IDT)” revealed under Policy “;Hospice care and services are provided to patients and their families in accordance with an individualized, written plan of care (POC). The POC is prepared by the IDT team in consultation with the patients hospice attending, the patient/legal representative and the primary caregiver. It reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated interdisciplinary assessments.” Record review for Patient #4 revealed Patient #4 was admitted to the hospice 03/24/2023 with a primary diagnosis of Chronic Heart Failure. Patient #4s POC update dated 11/19/2023-01/17/2023 revealed “;Goal: Manage Anticoagulation Goal: Patient’s anticoagulation will be addressed as needed through end of life. Antihypertensive Goal: Patient’s hypertension will be managed as needed through end of life. Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #4. Record review for Patient #5 revealed Patient #5 was admitted to the hospice 03/13/2023 with a primary diagnosis of Dementia. Patient #5s POC update dated 11/08/2023-01/06/2024 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #5. Record review for Patient #6 revealed Patient #6 was admitted to the hospice 10/21/2023 with a primary diagnosis of Parkinsons Disease. Patient #6s POC update dated 10/22/2023-12/20/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #6. Record review for Patient #9 revealed Patient #9 was admitted to the hospice 12/22/2022 with a primary diagnosis of Senile Degeneration of Brain. Patient #9s POC update dated 10/18/2023-12/16/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #9. Record review for Patient #10 revealed Patient #10 was admitted to the hospice 06/26/2023 with a primary diagnosis of Heart Failure. Patient #10s POC update dated 09/24/2023-12/22/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #10. Record review for Patient #11 revealed Patient #11 was admitted to the hospice 06/05/2022 with a primary diagnosis of Heart Failure Stage 5. Patient #11s POC update dated 09/28/2023-11/26/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #11. Record review for Patient #12 revealed Patient #12 was admitted to the hospice 05/15/2023 with a primary diagnosis of Glioblastoma. Patient #12s POC update dated 08/13/2023-11/10/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #12. Record review for Patient #13 revealed Patient #13 was admitted to the hospice 11/18/2022 with a primary diagnosis of Chronic Obstructed Pulmonary Disease (COPD). Patient #13s POC update dated 10/18/2023-12/16/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #13. Record review for Patient #14 revealed Patient #14 was admitted to the hospice 08/28/2023 with a primary diagnosis of Stage 4 Pressure Ulcer/Cellulitis. Patient #14s POC update dated 11/26/2023-02/23/2024 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #14. Record review for Patient #15 revealed Patient #15 was admitted to the hospice 07/27/2023 with a primary diagnosis of Chronic Kidney Disease Stage 4. Patient #15s POC update dated 10/25/2023-01/22/2024 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #15. Record review for Patient #17 revealed Patient #17 was admitted to the hospice 07/31/2023 with a primary diagnosis of Amyotrophic Lateral Sclerosis (ALS). Patient #17s POC update dated 11/29/2023-01/26/2024 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #17. Record review for Patient #18 revealed Patient #18 was admitted to the hospice 09/22/2023 with a primary diagnosis of Dementia/Parkinsons. Patient #18s POC update dated 09/22/2023-12/20/2023 revealed “;Goal: Antihypertensive Plan Goal: Patient’s hypertension will be managed as needed through end of life. Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #18. Record review for Patient #19 revealed Patient #19 was admitted to the hospice 08/02/2021 with a primary diagnosis of coronary artery disease. Patient #19s POC update dated 11/20/2023-01/18/2024 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #19. Record review for Patient #20 revealed Patient #20 was admitted to the hospice 06/14/2022 with a primary diagnosis of Congestive Heart Failure (CHF). Patient #20s POC update dated 10/07/2023-12/05/2023 revealed “;Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #20. Record review for Patient #22 revealed Patient #22 was admitted to the hospice 01/02/2023 with a primary diagnosis of Pneumonia. Patient #22s POC update dated 07/01/2023-08/29/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #22. Record review for Patient #23 revealed Patient #23 was admitted to the hospice 08/31/2022 with a primary diagnosis of COPD. Patient #23s POC update dated 10/25/2023-12/23/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #23. Record review for Patient #24 revealed Patient #24 was admitted to the hospice 05/09/2023 with a primary diagnosis of Recurrent non-small Cell Lung Cancer. Patient #24s POC update dated 11/05/2023-01/03/2024 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #24. Record review for Patient #25 revealed Patient #25 was admitted to the hospice 06/12/2023 with a primary diagnosis of Senile Degeneration of Brain. Patient #25s POC update dated 09/10/2023-12/08/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #25. Record review for Patient #26 revealed Patient #26 was admitted to the hospice 08/09/2023 with a primary diagnosis of Angiosarcoma. Patient #26s POC update dated 08/09/2023-11/06/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Fall Risk Goal: Minimize risk of falls that cause harm to the patient through end of life. Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #26. Record review for Patient #27 revealed Patient #27 was admitted to the hospice 10/12/2023 with a primary diagnosis of Alzheimer’s. Patient #27s POC update dated 10/12/2023-11/15/2023 revealed “;Goal: Communication Goal: Unique patient communication needs to be addressed/honored through end of life. Goal: Goals of Care: Patients unique goals of care will be identified and supported through end of life. Patient Goals: Patient’s unique goals will be identified and honored through goal completion or end of life” The goals stated on the POC were generic not individualized to meet the specific needs of Patient #27. During an interview with Director of Quality A on 02/08/2023 at 11:45 AM, when asked the expectation for individualizing auto-generated goals in the electronic medical record Director of Quality A stated, “some places are auto-generated, but yes it’s to be individualized.””

“A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 11/27/2023 – 11/28/2023. Based on observation, staff interviews, and review of maintenance records, Agrace Hospicecare did NOT construct, install and maintain the building systems to ensure physical environment to inpatients. 42 CFR 418.110(c) Condition of Participation: Physical Environment was NOT MET Findings include: The facility was found to contain the following deficiencies: Building 01 - Don & Marilyn Anderson Agrace Hospicecare Ctr K311 Vertical Separation K321 Hazardous Area - Enclosure Citation K-321 was found to have been incorrectly cited and has been removed. K343 Fire Alarm - Notification K351 Sprinkler System – Installation K353 Sprinkler System - Maintenance and Testing K362 Corridors - Construction of Walls K363 Corridor - Doors K374 Subdivision of Building Spaces - Smoke Barrier Doors K911 Electrical Systems – Other K912 Electrical Systems - Receptacles K914 Electrical Systems - Maintenance and Testing Citation K-914 was found to have been incorrectly cited and has been removed. Building 02 - Agrace Center for Hospice and Palliative Care K321 Hazardous Area - Enclosure Citation K-321 was found to have been incorrectly cited and has been removed. K353 Sprinkler System - Maintenance and Testing K363 Corridor Doors K374 Subdivision of Building Spaces - Smoke Barrier Doors K761 Maintenance, Inspection & Testing – Doors K911 Electrical Systems - Other K914 Electrical Systems - Maintenance and Testing Citation K-914 was found to have been incorrectly cited and has been removed. Refer to the full description at the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice’s inability to ensure a safe environment for inpatients, visitors, and staff was not maintained in accordance with the Life Safety Code (NFPA 101-2012).”

“A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 11/27/2023-11/28/2023. Based on observation, staff interviews, and review of maintenance records, Agrace Hospicecare did NOT construct, install and maintain the building systems to ensure fire protection for inpatients. 42 CFR 418.110(d) Standard: Life Safety Fire Protection was NOT MET Findings include: The facility was found to contain the following deficiencies: Building 01 - Don & Marilyn Anderson Agrace Hospicecare Ctr K311 Vertical Separation K321 Hazardous Area - Enclosure Citation K-321 was found to have been incorrectly cited and has been removed. K343 Fire Alarm - Notification K351 Sprinkler System – Installation K353 Sprinkler System - Maintenance and Testing K362 Corridors - Construction of Walls K363 Corridor - Doors K374 Subdivision of Building Spaces - Smoke Barrier Doors K911 Electrical Systems – Other K912 Electrical Systems - Receptacles K914 Electrical Systems - Maintenance and Testing Citation K-914 was found to have been incorrectly cited and has been removed. Building 02 - Agrace Center for Hospice and Palliative Care K321 Hazardous Area - Enclosure Citation K-321 was found to have been incorrectly cited and has been removed. K353 Sprinkler System - Maintenance and Testing K363 Corridor Doors K374 Subdivision of Building Spaces - Smoke Barrier Doors K761 Maintenance, Inspection & Testing – Doors K911 Electrical Systems - Other K914 Electrical Systems - Maintenance and Testing Citation K-914 was found to have been incorrectly cited and has been removed. Refer to the full description at the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice’s inability to ensure fire protection for inpatients, visitors, and staff was not maintained in accordance with the Life Safety Code (NFPA 101-2012).”

“Based on record review and interview, the agency staff failed to ensure that the hospice plans of care for patients residing in skilled nursing facilities (SNF) and Assisted Living Facilities (ALF) clearly delineated which provider was responsible for which functions within the plan of care in 8 out 8 patients (Patient’s #3, #4, #5, #9, #14, #18, #24, and #25) receiving hospice care in skilled nursing facilities, in a total of 27 patient records reviewed. Findings include: Record review for Patient #3 revealed Patient #3 was admitted to the hospice 10/11/2021 with a primary diagnosis of Senile Degeneration of Brain and resides in a SNF. Patient #3s POC (Plan of Care) did not delineate which provider was responsible for which interventions on the POC. Record review of Patient #3’s IDG (Interdisciplinary Group) POC update dated 11/21/2023 revealed “;Patients toe on left foot opened back up. Wound care is in place.” Review of POC orders starting 11/16/2023 revealed “;Wound care to left second toe to consist of cleansing, apply bacitracin, cover with non-adherent pad, wrap with gauze daily and as needed. Discontinue once healed.” Review of #3’s POC revealed no delineation for the NHs responsibility to conduct wound care interventions. During an interview with RN (Registered Nurse) G on 11/28/2023 at 12:00 PM, when ask how often the agency completes wound care on Patient #3, RN G replied, “;I do wound care weekly. The NH (Nursing Home) staff does it every day.” During an interview with Director of Quality Compliance A on 11/29/2023 at 10:25 AM, when asked about what the agencys expectation is related to POC interventions when a patient resides in a SNF, Cara replied, “;For contracted facilities, facilities continue to provide care as they would routine unless something is specific to the patient, ours is supplemental on top of that.” Findings Include: The agency’s contract titled “Hospice Assisted Living Facility Agreement” dated 1/28/2022, revealed in Agreements “Plan of Care (g.) the Plan of Care shall identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care.” The agency’s policies and procedure titled “Hospice Care for Facility Residents - Hospice Plan of Care” dated 03/09/2011 and revised date 08/24/2023, revealed under Procedure “3. The plan of care for facility patient identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon.” Record review of Patient #4s Plan of Care dated 11/19/2023-1/17/2024 revealed Patient #4 was admitted to the hospice 03/24/2023 with a diagnosis of Chronic Heart Failure and resides in an ALF. Patient #4s Plan of Care did not delineate which provider was responsible for which interventions on the (POC) Plan of Care. Record review of Patient #5s Plan of Care dated 11/08/2023-01/06/2024 revealed Patient #5 was admitted to the hospice 03/13/2023 with a diagnosis of Dementia and resides in an ALF. Patient #5s Plan of Care did not delineate which provider was responsible for which interventions on the POC. Record review of Patient #9s Plan of Care dated 10/18/2023-12/16/2023 revealed Patient #9 was admitted to the hospice 12/22/2023 with a diagnosis of Senile Degeneration of the Brain and resides in an ALF. Patient #9s Plan of Care did not delineate which provider was responsible for which interventions on the POC. Record review of Patient #14s Plan of Care dated 11/26/2023-02/23/2024 revealed Patient #14 was admitted to the hospice 08/28/2023 with a diagnosis of Stage 4 pressure ulcer and resides in an ALF. Patient #14s Plan of Care did not delineate which provider was responsible for which interventions on the POC. Record review of Patient #18’s Plan of Care dated 09/22/2023-12/20/2023 revealed Patient #18 was admitted to the hospice 09/22/2023 with a diagnosis of Dementia and resides in an ALF. Patient #18s Plan of Care did not delineate which provider was responsible for which interventions on the POC. Record review of Patient #24s Plan of Care dated 11/05/2023-01/03/2024 revealed Patient #24 was admitted to the hospice 05/09/2023 with a diagnosis of Recurrent non-small cell lung cancer and resides in an ALF. Patient #24s Plan of Care did not delineate which provider was responsible for which interventions on the POC. Record review of Patient #25s Plan of Care dated 09/10/2023-12/08/2023 revealed Patient #25 was admitted to the hospice 06/12/2023 with a diagnosis of Dementia and resides in a Skilled Nursing Facility. Patient #25s Plan of Care did not delineate which provider was responsible for which interventions on the POC.”

“Building 01 Based on observation and interview, the facility did not provide protection of vertical openings and shafts in accordance with NFPA 101, 2012 edition, Sections 19.3.1, 8.6.1, 8.6.3(1), 8.6.5, 8.3.5, 8.3.5.1, and 8.5.6. This deficient practice could affect all 32 patients, as well as an undetermined number of staff and visitors. Building 01 Findings include: On 11/28/2023 at 9:06 AM, observation in the Electric Room C1775 revealed a 2 1/2 inch diameter sprinkler pipe that penetrated the adjacent, fire rated stair wall which was not fire-stopped according to an approved method. This deficient practice was confirmed by Staff C and D at the time of discovery.”

“Building 01 Based on observation and interview, the facility did not provide occupant notification in spaces in accordance with NFPA 101, 2012 edition, Sections 19.3.4.1, 19.3.4.3, 9.6.3.1, 9.6.3.5, and 9.6.3.6.3; as well as NFPA 72, 2010 edition, Sections 18.2, 18.5.4, 18.5.4.5, 18.6, and 18.4.1. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Building 01 Findings include: On 11/28/2023 at 8:25 AM, observation in Room D2029, a conference room with five chairs, revealed that there was no audible and/or visual fire alarm device installed to provide notification to occupants. This deficient practice was confirmed by Staff C and D at the time of discovery.”

“Building 01 Based on observation and staff interview, the facility did not install an automatic fire sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5, 19.3.5.7, and 9.7.1, as well as NFPA 13, 2010 edition, Sections 7.2.6.2, 7.2.6.5, and 7.2.6.6. This deficient practice could affect all 32 patients, as well as an undetermined number of staff and visitors. Building 01 Findings include: On 11/27/2023 at 11:57 PM, observation of the Fire Sprinkler Room in the Johnson Basement, adjacent to the Garage, revealed a dry sprinkler system with a compressor that did not have a reliable power source able to restore normal air pressure to the system within 30 minutes. No backup power for the dry system compressor was evident and the compressor was connected a standard wall switch without any safeguards for the switch. When was asked if the compressor was connected a generator or other backup power system, Staff C responded with “;no.” This deficient practice was confirmed by Staff C and D at the time of discovery.”

“Building 01 Based on observation and interview, the facility did not provide an automatic fire sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.1, 19.3.6.2.4, 19.3.6.2.6, 9.7.1.1, 9.7.5, 8.3.5.6.2 (4), 8.4.2, and 8.4.4; NFPA 13, 2010 edition, 6.2.7, 8.3.1.1, 8.6.5.3, 22.1.2, 22.1.3, and 26.1; as well as NFPA 25, 2011 edition, Sections 4.7 and 5.1.1.2. This deficient practice could affect an undetermined number of staff and visitors. Building 02 Based on observation and interview, the facility did not provide an automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.1, 9.7.1.1, 9.7.5, and 8.3.5.6.2 (4); NFPA 13, 2010 edition, 6.2.7, 8.3.1.1, 22.1.2, 22.1.3, and 26.1; as well as NFPA 25, 2011 edition, Sections 4.3, 4.7 and 5.1.1.2. This deficient practice could affect an undetermined number of staff and visitors. This deficient practice could affect 1 patient, as well as an undetermined number of staff and visitors. Building 01 Findings include: 1. On 11/27/2023 at 12:15 PM, observation in the Anderson First Floor Trash Room revealed the sprinkler head cover plate, an escutcheon plate, was missing, thereby not completing the sprinkler assembly listing. 2. On 11/28/2023 at 8:31 AM, observation in the D2033 Storage Room revealed the sprinkler head cover plate, an escutcheon plate, was missing, thereby not completing the sprinkler assembly listing. 3. On 11/28/2023 at 8:57 AM, observation in Room D2018 revealed a ceiling tile that was not flush with the ceiling plane due to (2) ½ inch diameter conduits protruding out of the ceiling. This installation does not duplicate the smoke tight conditions that were used in the sprinkler UL certification test, creating a heat escape pathway, and invalidating the sprinkler assembly listing. 4. On 11/28/2023 at 9:34 AM, observation in the northside of the exterior veranda revealed the sprinkler head cover plate, an escutcheon plate, had fallen and thereby not completing the sprinkler assembly listing. 5. On 11/28/2023 at 10:17 AM, observation in the Nursing Room A1524 revealed the sprinkler head cover plate, an escutcheon plate, had fallen and thereby not completing the sprinkler assembly listing. 6. On 11/28/2023 at 11:39 AM, observation in the Soiled Linen Room D1061 revealed the sprinkler head cover plate, an escutcheon plate, was missing, thereby not completing the sprinkler assembly listing. 7. On 11/28/2023 at 11:50 AM, observation in the Anderson Building Vending Room revealed the sprinkler head cover plate, an escutcheon plate, was missing, thereby not completing the sprinkler assembly listing. These deficient practices were confirmed by Staff C and D at the time of discovery. Building 02 Findings include: 1. On 11/28/2023 at 2:54 PM, observation in the Administrative Work Room revealed the sprinkler head cover plate, an escutcheon plate, was not in place, thereby not completing the sprinkler assembly listing. 2. On 11/28/2023 at 3:35 PM, observation in Resident Room 12 revealed the sprinkler head cover plate, an escutcheon plate, was not in place, thereby not completing the sprinkler assembly listing. 3. On 11/28/2023 at 3:50 PM, observation in the Vase Storage Room revealed the sprinkler head cover plate, an escutcheon plate, was not in place, thereby not completing the sprinkler assembly listing. These deficient practices were confirmed by Staff C and Staff D at the time of discovery.”

“Building 01 Based on observation and interview, the facility did not provide smoke barrier corridor wall separations as required in NFPA 101, 2012 edition, Sections 19.3.6.2, 19.3.6.2.5, 19.3.6.2.6, 19.3.7.3, 8.4.4, and 8.4.5. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Building 01 Findings include: 1. On 10/28/2023 at 9:51 AM, observation in Electrical Room B1487 revealed the corridor wall included a (6) 1/2 inch diameter conduits within a 1 inch by 10 inch opening on the wall that were not properly sealed to limit the transfer of smoke according to an approved method. 2. On 10/28/2023 at 11:21 AM, observation in the IT Room D1141 revealed the corridor wall had (2) 3 inch diameter conduits and (1) 1 1/2 inch diameter conduit that were not properly sealed to limit the transfer of smoke according to an approved method. 3. On 10/28/2023 at 11:56 AM, observation above the ceiling in the Former Anderson Kitchen revealed the corridor wall to the Receiving Area had (2) 1/4 inch diameter copper pipes that were not properly sealed to limit the transfer of smoke according to an approved method. These deficient practices were confirmed by Staff C and Staff D at the time of discovery.”

“Building 01 Based on observation and staff interview, the facility did not maintain corridor doors in accordance with NFPA 101, 2012 edition, Section 19.3.6.3, 19.3.6.3.10, and 19.3.6.3.11. This deficient practice could affect all 32 patients, as well as an undetermined number of staff and visitors. Building 02 Based on observation and staff interview, the facility failed to ensure corridor doors would resist the passage of smoke in accordance with NFPA 101, 2012 edition, Sections 19.3.6.3.2(2), 19.3.6.3.10, and 8.4.3. This deficient practice could affect undetermined number of staff and visitors. Building 01 Findings include: On 11/28/2023 at 10:59 AM, observation revealed that the corridor door to the Prayer and Meditation Room did not fully close after three attempts. This deficient practice was confirmed by Staff C and Staff D at the time of discovery. Building 02 Findings include: On 11/28/2023 at 3:56 PM, observation at the Meditation Room revealed that the double corridor doors had a 1/4 inch gap between the meeting edges of the swinging double doors that prevented them from being smoke resisting. This deficient practice was confirmed by Staff C and Staff D at the time of discovery.”

“Building 01 Based on observation and interview, the facility did not maintain doors in smoke barrier doors in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.2.2.7, 19.3.7.8, 19.3.6.3.10, 8.5.4, 7.2.1.8, and 7.2.1; as well as NFPA 80, 2010 edition, Section 6.3.1.7.1. This deficient practice could affect all 32 patients, as well as an undetermined number of staff and visitors. Building 02 Based on observation and interview, the facility did not maintain doors in smoke barrier doors in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.2.2.7, 19.3.7.8, 19.3.6.3.10, 8.5.4, 7.2.1.8 and 7.2.1; as well as NFPA 80, 2010 edition, Section 6.3.1.7.1. This deficient practice could affect all 8 patients, as well as an undetermined number of staff and visitors. Building 01 Findings include: On 11/28/2023 at 10:28 AM, observation revealed that the double, smoke doors at the entrance to the Memory Care Unit, adjacent to Patient Room 1508, did not fully close after 3 attempts and left greater than a 1/8” gap between the self closing doors. This deficient practice was confirmed by Staff C and Staff D at the time of discovery. Building 02 Findings include: On 11/28/2023 at 3:25 PM, observation at the double acting, smoke barrier doors between the Smoke Compartment 1 and Smoke Compartment 2, adjacent to the Roof Access Room, revealed the doors did not fully close after three attempts. This deficient practice was confirmed by Staff C and Staff D at the time of discovery.”

“Building 02 Based on record review and interview, the facility failed to inspect door assemblies at least annually with a written record of inspection and testing in accordance with NFPA 101, 2012 edition, Sections 19.7.6, 4.6.12, 7.2.1.15, 8.2.2.4, and 8.3.3.4; as well as NFPA 80, 2010 edition, Section 5.2, 5.2.4, and 5.2.5. This deficient practice could affect all 8 patients, as well as an undetermined number of staff and visitors. Building 02 Findings include: On 11/27/2023 at 3:24 PM, record review revealed that the facility did not have a record that fire rated door assemblies, including any corridor, combination smoke and fire barrier, horizontally siding, vertically sliding, and rolling doors, had been inspected and tested within the past 12 months. In addition, there was no policy on which doors should be annually inspected and what criteria should be verified during testing of the door assemblies. This deficient practice was confirmed by Staff C and Staff D at the time of discovery.”

“Building 01 Based on observation and interview, the facility did not provide an emergency electrical generator with a remote stop in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.5.1.1, 19.5.1.2, 9.1.2, 9.1.3.1, and 4.6.12.2; NFPA 70, 2011 edition, Section 445.18; NFPA 99, 2012 edition, Sections 6.1 6.5.1, 6.4.1.1.6.1, 6.4.1.1.16.2, and 15.5.1.3; as well as NFPA 110, 2010 edition, Section 5.6.5.6, and 1.3. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Building 02 Based on observation and interview, the facility did not provide an emergency electrical generator with a remote stop in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.5.1.1, 19.5.1.2, 9.1.2, and 9.1.3.1, and 4.6.12.2; NFPA 70, 2011 edition, Section 445.18; NFPA 99, 2012 edition, Sections 6.1 6.5.1, 6.4.1.1.6.1, 6.4.1.1.16.2, and 15.5.1.3; as well as NFPA 110, 2010 edition, Section 5.6.5.6, and 1.3. This deficiency could affect an undetermined number of staff and visitors. Building 01 Findings include: On 11/27/2023 at 11:30 AM, observation at the interior mounted, generator located in the Johnson Lower Level revealed the manual stop station with a label was located within the generator housing and not provided elsewhere on the premises. When asked if an emergency stop station could be found inside the facility or outside the enclosure Staff C agreed that there was no additional stop station. This deficient practice was confirmed by Staff C and Staff D at the time of discovery. Building 02 Findings include: On 11/28/2023 at 4:06 PM, observation at the exterior mounted generator located outside of Resident Room 09 revealed the manual stop station with a label was located within the generator housing and not provided elsewhere on the premises. When asked if an emergency stop station could be found inside the facility or outside the enclosure Staff C agreed that there was no additional stop station. This deficient practice was confirmed by Staff C at the time of discovery.”

“Building 02 Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 19.5.1.1, and 9.1.2; NFPA 99, 2012 edition, Section 6.3.2.1, 6.3.2.1.1, and 6.3.2.2.4.2; as well as NFPA 70, edition 2011, Articles 110.8 and 210.8(B). This deficient practice could affect all 32 patients, as well as an undetermined number of staff and visitors. Building 02 Findings Include: On 11/28/2023 at 10:13 AM, observation in the Staff Breakroom revealed an electrical receptacle was located approximately five foot from the sink. The facility was not able to confirm that listed, ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the outside edge of a sink. This deficient practice was confirmed by Staff C and Staff D at the time of discovery.”