Adoray Home Health and Hospice

“Based on observation, record review and interview the agency failed to ensure that each patients drug profile was reviewed and accurate in 2 of 3 observation visits conducted with Registered Nurses out of a total of 4 observation visits (Patients #3 and #4). Findings include: Review of policy “;Medication Reconciliation” last dated 10/18/2021 revealed in part, “;Medication Reconciliation is the process of identifying the most accurate list of all medications that the patient is taking.” Further review revealed in part “;1. The clinician will reconcile meds (medications) at each visit.” An observation visit was conducted at Patient #3s place of residence on 3/5/2024 at 9:00 a.m. with RN (Registered Nurse) C. Quality Supervisor B was also in attendance. There was no medication reconciliation performed by RN C. Upon surveyor review of the medication list at the facility, the facility had 2 medications that were not on the hospice medication list: “;Milk of Magnesia 1200mg (milligrams)/15ml (milliliters) suspension, 30ml/2400mg by mouth daily as needed for constipation (start date of 2/5/2023). Dulcolax 10mg suppository, 10mg rectal daily as needed for constipation-give every fourth day for no bowel movement (start date of 2/6/2023).” An observation visit was conducted at Patient #4s place of residence on 3/5/2024 at 1:00 p.m. with RN F. Quality Supervisor B was also in attendance. There was no medication reconciliation performed by RN F. Upon surveyor review of the medication list at the facility, the facility had 2 medications that were not on the hospice medication list: “;Calazime Paste, apply topically as needed for heavy incontinence with peri-area or groin apply as needed after incontinence care (start date of 1/16/2024). Phytoplex Hydraguard, apply topically for heavy incontinence, dry skin, and to prevent reddened peri-area or groin as needed (start date of 1/16/2024).” There was 1 medication on the hospice medication list that the facility medication did not have: “;Bacitracin ointment: after cleansing wound/abrasion with saline, apply small amount ointment and cover with sterile dressing for wound healing-use mepilex dressing (start date of 3/31/2023).” During an interview with Quality and Compliance Supervisor B on 03/05/2024 at 2:30 PM, when asked how often staff are expected to reconcile medications. Quality and Compliance Supervisor B stated, “I know every two weeks for sure, I believe every visit.” During an interview with Director of Hospice E on 03/05/2024 at 2:41 PM, when asked how often staff are expected to reconcile medications, Director of Hospice E stated, “Should be done every visit.””

“Based on record review, the agency staff failed to develop plans of care that were individualized to include measurable goals to meet the patients needs in 19 of 19 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 #10, #11, #12 #13, #14, #15, #16, #17, #18, & #19) patient records reviewed. Record review for Patient #16 revealed Patient #16 was admitted to the hospice 01/24/2024 with a primary diagnosis of Malignant neoplasm of prostate. Patient #16’s POC dated 01/24/2024 - 04/22/2024, revealed Patient #16 resided in a SNF. “Goals: SN: Patient receives level of care appropriate to patient care needs; Target Date: 4/22/2024. SN: Patient/Family will express satisfactory control of symptoms; Target Date: 4/22/2024. SN: Patient symptoms will be managed; Target Date: 4/22/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #16. Review of Patient #17s medical record “;Hospice Plan of Care” dated 10/28/2023 revealed Patient #17 was admitted to hospice on 7/5/2022 with a primary diagnosis of chronic lymphocytic leukemia. Secondary diagnoses included dementia with agitation/anxiety/mood disturbance and history of lung cancer. Goals on the Plan of Care included: Aide: “;Promote safe personal care and hygiene. Maintain clean, safe environment.” MSW: “;Patient/caregiver demonstrates ability to cope with limitations. Continuity of care will be maintained as appropriate to patient/primary caregiver needs.” SN: “;Patient/Caregiver will demonstrate safe and effective use of recommended DME and assistive devices. Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process. Family/Caregiver will have mechanisms to cope appropriately.” These goals were not measurable and/or individualized to meet the patients specific needs. Record review for Patient #18 revealed Patient #18 was admitted to the hospice 12/15/2023 with a primary diagnosis of Alzheimer’s disease. Patient #18’s POC dated 12/15/2023 - 03/13/2024, revealed Patient #18 resided in a Assisted Living Facility (ALF). “Goals: SN: Patient will verbalize understanding of pain management regimen; Target Date: 3/13/2024. SN: Patient will remain comfortable; Target Date: 3/13/2024. SN: Patient symptoms will be managed; Target Date: 3/13/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #18. Review of Patient #19s medical record “;Hospice Plan of Care” dated 1/25/2024 revealed Patient #19 was admitted to hospice on 1/25/2024 with a primary diagnosis of aphasia following a stroke. Secondary diagnoses included vascular dementia, essential hypertension and chronic obstructive pulmonary disease. Goals on the Plan of Care included: Aide: “;Patients personal care needs will be met. Provide effective control measures to prevent spread of COVID 19. MSW: Patient/caregiver will cope with change in lifestyle from disease. Continuity of care will be maintained as appropriate to patient/primary caregiver needs.” SN: “;Patient symptoms will be managed. Patient will remain comfortable. Patient/caregiver will be able to demonstrate safe and effective use of recommended DME and assistive devices. Patient receives level of care appropriate to patient care needs.” These goals were not measurable and/or individualized to meet the patients specific needs. During an interview with Quality and Compliance Supervisor B on 03/05/2024 at 4:09 PM, Quality and Compliance Supervisor B confirmed the above findings and stated, “It is currently one of our QAPI PIP’S (Quality Assessment and Performance Improvement Performance Improvement Projects).” Review of Patient #7s medical record “;Hospice Plan of Care” dated 1/10/2024 revealed Patient #7 was admitted to hospice on 1/10/2024 with a primary diagnosis of Malignant neoplasm of colon. Secondary diagnoses included malignant neoplasm of unspecified adrenal gland, malignant neoplasm of unspecified lung, hypertensive chronic kidney disease. Goals on the Plan of Care included “;Aide: Provide effective infection control measures to prevent spread of COVID 19. Patients personal care needs will be met. Patient/caregiver can describe measures to reduce/prevent fatigue. SN: Patient will remain comfortable. Patient will verbalize understanding of pain management regimen. Patient symptoms will be managed.” These goals were not measurable and/or individualized to meet the patients specific needs. Record review for Patient #8 revealed Patient #8 was admitted to the hospice 10/20/2023 with a primary diagnosis of Alzheimer’s disease. Patient #8’s POC dated 01/18/2024 - 04/16/2024, revealed Patient #8 resided in a home. “Goals: SN: Patient will remain comfortable; Target Date: 4/16/2024. SN: Patient symptoms will be managed; Target Date: 4/16/2024. SN: Patient/Family will express satisfactory control of symptoms; Target Date: 4/16/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #8. Record review for Patient #9 revealed Patient #9 was admitted to the hospice 08/08/2023 with a primary diagnosis of Type 2 diabetes with diabetic peripheral angiopath without gangrene. Patient #9’s POC dated 02/04/2024 - 04/03/2024, revealed Patient #9 resided in a home. “Goals: SN: Patient receives level of care appropriate to patient care needs; Target Date: 4/3/2024. SN: Patient/Family will express satisfactory control of symptoms; Target Date: 4/3/2024. SN: Patient free of any signs/symptoms of infection; Target Date: 4/3/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #9. Review of Patient #10s medical record “;Hospice Plan of Care” dated 02/01/2024 revealed Patient #10 was admitted to hospice on 02/01/2024 with a primary diagnosis of Malignant neoplasm of head of pancreas. Secondary diagnoses included anemia in chronic kidney disease, hypertensive heart disease with heart failure. Goals on the Plan of Care included: “;Aide: Provide effective infection control measure to prevent spread of COVID 19. Chaplain: Patient/caregiver will feel more connected to the religious or spiritual community. Chaplain: Patient achieves feelings of spiritual comfort. Chaplain: Patient and family will have spiritual needs met. SN: Patient/family will express satisfactory control of symptoms. SN: Patient will be able to eat/drink to his/her satisfaction. SN: Patient will be pain free or verbalize an acceptable pain level with current pain management regimen. SN: Patient/caregiver can describe measures to reduce/prevent fatigue.” These goals were not measurable and/or individualized to meet the patients specific needs. Review of Patient #11s medical record “;Hospice Plan of Care dated 12/12/2023 revealed Patient #11 was admitted to hospice on 12/12/2023 with a primary diagnosis of Multiple Sclerosis. Secondary diagnoses included mild cognitive impairment, insomnia, major depressive disorder, and neuralgia and neuritis. Goals on Plan of Care included: “;Aide: Provide effective infection control measures to prevent spread of COVID 19. MSW: Patient/caregiver will cope with change in lifestyle from disease. SN: Patient symptoms will be managed. SN: Patient will remain comfortable. SN: Patient/caregiver will verbalize understanding of pain management regimen. SN: Patient/caregiver will verbalize understanding of medications in Comfort Pak. SN: Patient/family will express satisfactory control of symptoms. SN: Patient receives level of care appropriate to patient care needs.” These goals were not measurable and/or individualized to meet the patients specific needs. Record review for Patient #12 revealed Patient #12 was admitted to the hospice 12/01/2023 with a primary diagnosis of Hypertensive chronic kidney disease. Patient #12’s POC dated 02/29/2024 - 05/28/2024, revealed Patient #12 resided in a home. “Goals: SN: Patient receives level of care appropriate to patient care needs; Target Date: 5/28/2024. SN: Patient/Family will express satisfactory control of symptoms; Target Date: 5/28/2024. SN: Patient will demonstrate understanding of appropriate use of meds for pain management; Target Date: 5/28/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #12. Record review for Patient #13 revealed Patient #13 was admitted to the hospice 01/22/2024 with a primary diagnosis of Sjogren syndrome. Patient #13’s POC dated 01/22/2024 - 04/20/2024, revealed Patient #13 resided in a home. “Goals: SN: Patient receives level of care appropriate to patient care needs; Target Date: 4/20/2024. SN: Patient/Family will express satisfactory control of symptoms; Target Date: 4/20/2024. SN: Patient symptoms will be managed; Target Date: 4/20/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #13. Review of Patient #14s medical record “;Hospice Plan of Care” dated 1/17/2024 revealed Patient #14 was admitted to hospice on 1/17/2024 with a primary diagnosis of cancer of the spleen. Secondary diagnoses included metastasis to abdominal lymph nodes, acute on chronic cancer related pain and essential hypertension. Goals on the Plan of Care included: Aide: “;Provide effective infection control measures to prevent spread of COVID 19. Chaplain: Patient/caregiver will feel needs are being met as they have defined. SN: Patients symptoms will be managed. Patient/caregiver will verbalize understanding of pain regimen. Patient will remain comfortable. Patient receives level of care appropriate to patient care needs. Patient/Caregiver will be able to demonstrate safe and effective use of recommended DME (Durable Medical Equipment) and assistive devices.” These goals were not measurable and/or individualized to the meet the patients specific needs. Review of Patient #15s medical record “;Hospice Plan of Care” dated 06/27/2023 revealed Patient #15 was admitted to hospice on 10/25/2022 with a primary diagnosis of Alzheimers disease. Secondary diagnoses included depression, mood disturbance, hypertensive heart disease with heart failure and heart failure. Goals on the Plan of Care included: “;Aide: Patients personal care needs will be met. Provide effective control measures to prevent spread of COVID19. Aide: Maintain clean, safe environment. Chaplain: Patient/Family will feel heard and feeling validated. MSW (Medical Social Worker): Family/Care Giver will have mechanisms to cope appropriately. MSW: Patient/caregiver will cope with change in lifestyle. MSW: Work through anger. SN: Patient caregiver will verbalize understanding of pain management regimen. Patient/caregiver will verbalize understanding of falls/injury prevention and home safety measures. SN: Family/caregiver can verbalize realistic expectations in performance of role. SN: Family/caregiver able to verbalize/demonstrate effective coping skills. SN: Patient receives level of care appropriate to patient care needs. SN: Patient will demonstrate understanding of appropriate use of meds for pain management. SN: Patient/family will express satisfactory control of symptoms. SN: Family/caregiver can identify safety concerns.” These goals were not measurable and/or individualized to meet the patients specific needs. Findings include: Review of policy “;Plan of Care Hospice” dated 1/4/23 revealed in part, “;3. The Plan of Care will be established by the hospice interdisciplinary group in collaboration with the attending physician, the patient, the patient representative, and the primary caregiver in accordance with the patients needs. 4. The Plan of Care will include: c. Measurable outcomes.” Review of Patient #1s medical record “;Hospice Plan of Care” dated 2/16/2024 revealed Patient #1 was admitted to hospice on 2/16/2024 with a primary diagnosis of interstitial pulmonary disease (a lung disease that affects breathing and oxygenation). Secondary diagnoses included hypertensive heart and chronic kidney disease, acute on chronic congestive heart failure and Type 2 diabetes. Goals on the Plan of Care included Aide: “;Provide effective infection control measures to prevent spread of COVID 19.” SN (Skilled Nursing): Patient will be pain free or verbalize an acceptable pain level with current pain management regimen. Patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/or injury. Patient/Caregiver can identify potential complications; actions to take; when to call Hospice. Family/Caregiver will verbalize understanding of s/s (signs/symptoms) of impending death.” These goals were not measurable and/or individualized to meet the patients specific needs. Review of Patient #2s medical record “;Hospice Plan of Care” dated 2/13/2024 revealed Patient #2 was admitted to hospice on 8/17/2023 with a primary diagnosis of a mass partially obstructing the ureter. Secondary diagnoses included heart failure, chronic kidney disease stage 3 and unspecified dementia. Goals on the Plan of Care included Aide: “;Provide effective infection control measures to prevent spread of COVID 19. Maintain clean, safe environment. Promote safe personal care and hygiene. SN: Patient/Caregiver will identify s/s to report to hospice; actions to take. Family/Caregiver will verbalize understanding of impending death. Patients symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow.” These goals were not measurable and/or individualized to meet the patients specific needs. Review of Patient #3s medical record “;Hospice Plan of Care” dated 2/26/2024 revealed Patient #3 was admitted to hospice on 11/3/2022 with a primary diagnosis of Alzheimers disease. Secondary diagnoses included essential hypertension and with dementia with mood disturbance. Goals on the Plan of Care included: Aide: “;Promote safe personal care and hygiene. Provide effective infection control measures to prevent spread of COVID 19. Promote healthful environment. MSW: Family/Caregiver will have mechanisms to cope appropriately. Patient/Caregiver will cope with change in lifestyle from disease. SN: Patient will be pain free or verbalize an acceptable pain level with current pain management regime. Anxiety/agitation reduction with use of robotic cat.” These goals were not measurable and/or individualized to meet the patients specific needs. Review of Patient #4s medical record “;Hospice Plan of Care” dated 1/23/2024 revealed Patient #4 was admitted to hospice on 3/29/2023 with a primary diagnosis of cognitive function decline following a stroke. Secondary diagnoses included dysphagia, past heart attack and essential hypertension. Goals on the Plan of Care included: Aide: “;Provide effective infection control measures to prevent spread of COVID 19. Promote skin integrity. Patients personal care needs will be met. MSW: Patient will maintain optimal coping through hospice care. SN: Patient receives level of care appropriate to patient care needs. Family/caregiver will verbalize understanding of impending death. Patient will demonstrate safe mobility with use of assistive device.” These goals were not measurable and/or individualized to meet the patients specific needs. Record review for Patient #5 revealed Patient #5 was admitted to the hospice 02/05/2024 with a primary diagnosis of hypertensive heart disease with heart failure. Patient #5’s “Hospice Plan of Care” (POC) dated 02/05/2024 - 04/04/2024, revealed Patient #5 resided in a SNF (Skilled Nursing Facility). “Goals: SN (Skilled Nursing) Patient will remain comfortable; Target Date: 4/4/2024. SN: Patient symptoms will be managed; Target Date: 4/4/2024. SN: Patient/Family will express satisfactory control of symptoms; Target Date: 4/4/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #5. Record review for Patient #6 revealed Patient #6 was admitted to the hospice 08/01/2023 with a primary diagnosis of Neurocognitive disorder with Lewy bodies. Patient #6’s POC dated 01/28/2024 - 03/27/2024, revealed Patient #6 resided in a home. “Goals: SN: Patient will remain safe at home; Target Date: 3/27/2024. SN: Patient receives level of care appropriate to patient care needs; Target Date: 3/27/2024. SN: Patient/Family will express satisfactory control of symptoms; Target Date: 3/27/2024.” The goals stated on the POC were not measurable, generic and not individualized to meet the specific needs of Patient #6.”

“Based on observation, record review and interview agency staff failed to follow accepted standards of practice for hand hygiene and bag technique in 3 of 4 patient observation visits (Patients #2, #3, #4) Findings include: Review of policy “;Hand Washing, Hand Hygiene, and Gloving Guidelines” last dated 9/3/2021 revealed in part, “;To maintain an environment free from potential contamination to patients and to prevent the transfer of disease-producing organisms from person to person or place to place. To maintain compliance with infection control principles and standard precautions. Hand washing/hand hygiene must be performed: e. After handling an individuals belongings. g. Before putting on gloves. h. After removing gloves.” Review of policy “;Equipment Cleaning and Bag Technique” last dated 10/16/2023 revealed in part, “;Any equipment and/or supplies that are soiled during the visit will not be returned to the clinicians bag unless cleaned using an antibacterial germicidal alcohol wipe.” An observation visit was conducted at Patient #2s place of residence on 3/5/2024 at 8:00 a.m. with Hospice Aide D. Quality Supervisor B was also in attendance. Throughout the visit, Hospice Aide D had one instance of donning gloves without performing hand hygiene prior and one instance of glove changes without performing hand hygiene in between. An observation visit was conducted at Patient #3s place of residence on 3/5/2024 at 9:00 a.m. with RN (Registered Nurse) C. Quality Supervisor B was also in attendance. Throughout the visit, RN C had two instances of donning gloves without performing hand hygiene prior. An observation visit was conducted at Patient #4s place of residence on 3/5/2024 at 1:00 p.m. with RN F. Quality Supervisor B was also in attendance. After cleaning equipment used during the visit and prior to returning equipment to the nursing bag, RN F placed the clean equipment on top of the patients wheelchair to dry; thereby re-contaminating the equipment. The dirty equipment was then placed back into the clean section of the nursing bag. An interview was conducted with Quality Supervisor B on 3/5/2024 at 3:30 p.m. regarding the above findings. When asked what was observed on the visits, Quality Manager B confirmed the above findings for each patient.”

“Based on record review and interview, agency staff failed to identify which provider is responsible for performing the respective function on the Plan of Care for patients residing in a facility in 13 of 19 patient records reviewed (Patients #2, #3, #4, #5, #7, #10, #11, #14, #15, #16, #17, #18, #19). Findings include: The agency had no policy addressing the formulation of the Plan of Care for patients residing in facilities. Review of Patient #2s medical record revealed Patient #2 was admitted to hospice service on 8/17/2023 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #3s medical record revealed Patient #3 was admitted to hospice service on 11/3/2022 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #4s medical record revealed Patient #4 was admitted to hospice service on 3/29/2023 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #5s medical record revealed Patient #5 was admitted to hospice service on 2/5/2024 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #7s medical record revealed Patient #7 was admitted to hospice service on 1/10/2024 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #10s medical record revealed Patient #10 was admitted to hospice service on 2/1/2024 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #11s medical record revealed Patient #11 was admitted to hospice service 12/12/2023 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #14s medical record revealed Patient #14 was admitted to hospice service on 1/17/2024 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #15s medical record revealed Patient #15 was admitted to hospice service on 10/25/2022 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #16s medical record revealed Patient #16 was admitted to hospice service on 1/24/2024 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #17s medical record revealed Patient #17 was admitted to hospice service on 7/5/2022 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review Patient #18s medical record revealed Patient #18 was admitted to hospice service on 12/15/2023 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. Review of Patient #19s medical record revealed Patient #19 was admitted to hospice service on 1/25/2024 and resided in a facility. The hospice Plan of Care did not indicate which provider was responsible for performing which functions. During an interview with Director of Hospice E on 03/05/2024 at 2:41 PM, when asked if the agency’s current plan of care delineates who’s responsible for for regarding patient care between hospice and facilities, Director of Hospice E stated, “Some aspects of it does, only with specific cares. We report to facility staff and have a facility binder for the (facility) staff to reference.” During an interview with Director of Hospice E on 03/05/2024 at 3:40 PM, when asked if the agency could provide a policy, Director of Hospice E stated, “We don’t have one.””