Sharon S Richardson Community Hospice

“Based on observation, record review and interview the agency failed to ensure that each patients drug profile contained all ordered medications in 3 of 6 observation visits conducted (Patients #2, #8 and #9) out of a total of 6 observation visits and 4 of 17 (Patients #10, #11, #13, #15) patient medical records reviewed of a total of 23 records reviewed. Review of Patient #13’s medical record revealed Patient #13 was admitted to hospice service on 02/02/2024, Patient 13s plan of care dated 04/02/2024-05/31/2024 revealed oxygen was ordered at 2-6 liters via nasal cannula as needed for comfort. Review of Patient #13s medication profile revealed no orders for oxygen. Review of Patient #15’s medical record revealed Patient #15 was admitted to hospice service on 10/05/2023, Patient 15s plan of care dated 04/02/2024-05/31/2024 revealed oxygen was ordered for use. Review of Patient #15s medication profile revealed no orders for oxygen. During an interview with Director of Clinical Operations C and Inpatient Unit Manager F on 05/14/2024 at 4:15 PM, when findings of home visits and records reviewed regarding Oxygen not found on the patient medication list, Director of Clinical Operations C replied, “It’s forgotten but we need to be better about that.” Inpatient Unit Manager F stated, “We used to have Oxygen as part of the medication list but changed a few years ago with new software.” Record review of Patient #8’s medical record revealed Patient #8 was admitted to hospice services on 11/10/2022 with primary diagnosis of Chronic Obstructive Pulmonary Disease. During a home visit observation with RN (Registered Nurse) H on 05/14/2024 at 10:00 AM at the Skilled Nursing Facility for Patient #8, observed Patient #8 having oxygen on. Review of Patient #8s Plan of Care for certification period starting 04/18/2024 revealed “Deficit related to airway and breathing patterns: Care Plan Problem Interventions: Continuous O2 at 2.5L. Date Active 02/27/2023.” Review of Patient #8’s medication profile revealed there was no evidence that oxygen was listed on the medication profile. During an interview with RN H on 05/14/2024 at 10:10 AM, when asked about how long Patient #8 has been on oxygen and orders, RN H replied, “Patient #8 has been on oxygen for a long time, at least 6 months now. Was originally on 2L (Liters), then 3L, and now on 4L.” Record review of Patient #9’s medical record revealed Patient #9 was admitted to hospice services on 04/09/2023 with primary diagnosis of Heart Failure, unspecified. During a home visit observation with RN G on 05/14/2024 at 8:35 AM at the Assisted Living Facility for Patient #9, observed an oxygen concentrator in Patient #9’s room and 7 additional oxygen cylinders located in Patient #9’s bathroom. At the end of the patient visit, RN G applied the oxygen to Patient #9 while sitting in the chair. Record review of Patient #9’s last 4 IDG (Interdisciplinary Group) meeting notes dated 03/21/2024, 04/04/2024, 04/18/2024, 05/02/2024 revealed Patient #9 has used oxygen for symptom management. Review of Patient #9’s medication profile revealed there was no evidence that oxygen was listed on the medication profile. During an interview with RN G on 05/14/2024 at 9:10 AM, when asked about how long Patient #9 has been on oxygen and that orders were not on the medication profile or plan of care for Patient #9, RN G replied, “Patient #9 has been on oxygen about 4 months ago. Started as needed 2L, then 2 months ago it was continuous at 3L due to increased shortness of breath. We increased Patient #9’s Metalazone dose and got breathing under better control. Now back to as needed 2-6 L for shortness of breath. I didn’t know it had to be on the medication profile.” Record review of Patient #10’s medical record revealed Patient #10 was admitted to hospice services on 08/31/2023 with primary diagnosis of Malignant Neoplasm of colon, unspecified and secondary diagnosis of Emphysema. Record review of Patient #10’s last 3 IDG meeting notes dated 04/16/2024, 04/30/2024, and 05/14/2024 revealed Patient #10 has used oxygen for symptom management. Review of Patient #10s Plan of Care for certification period starting 03/25/2024 revealed “Altered breathing pattern related to dyspnea: Care Plan Problem Interventions: Monitor need for increase in oxygen. Date Active: 11/07/2023.” Review of Patient #10s medication profile revealed no orders for oxygen. Record review of Patient #11’s medical record revealed Patient #11 was admitted to hospice services on 03/12/2024 with primary diagnosis of Chronic Systolic Congestive Heart Failure. Record review of Patient #11’s last 3 IDG meeting notes dated 04/04/2024, 04/18/2024, 05/02/2024 revealed Patient #11 has used oxygen as needed for symptom management. Review of Patient #11s Plan of Care for certification period starting 03/12/2024 revealed “Care Plan Problem: Deficit related to airway and breathing patterns related to systolic heart failure. Interventions: Collaborate with physician, obtain order for oxygen: Oxygen 1-5L per nasal cannula as needed and continuous for dyspnea. Date Active 03/20/2024.” Review of Patient #11s medication profile revealed no orders for oxygen. Findings include: Review of agency policy titled “Medication Management” policy number PC.M50, last reviewed December 2022 revealed, “Procedure 5. A Medication Profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient’s terminal illness.” Record review of Patient #2’s medical record revealed Patient #2 was admitted to hospice services on 01/15/2024 with primary diagnosis of Congestive Heart Failure (CHF). Review of Patient #2s plan of care dated 04/30/2024-07/29/2024 revealed oxygen was ordered at 2-6 liters via nasal cannula as needed for comfort. Review of Patient #2s medication profile revealed oxygen was not listed. During a home visit observation with RN I on 05/13/2024 at 3:09 PM at the Assisted Living Facility (ALF) for Patient #2, observed Patient #2 using oxygen via nasal cannula with the oxygen concentrator set at a rate of 2 L. During an interview with RN I on 05/13/2024 at 3:42 PM, when asked how someone would know that Patient #2 was on oxygen as it was not listed on Patient #2’s medication profile, RN I replied, “It is in the computer as a standing admission order.” When RN I was asked if oxygen is usually on the medication profile, RN I replied, “That makes sense. I think it should be.” During an interview with Director of Clinical Operations C on 05/14/2024 at 11:35 AM, when asked agency expectations for Oxygen on the medication profile, Director of Clinical Operations C replied, “Oxygen should be on the plan of care and supposed to be on the medication list as well.””

“Based on record review and interview, the agency failed to obtain orders for a change in visit frequency for skilled nursing and aide services provided in 2 of 23 patient records reviewed (Patient #9 and #11). Findings include: Review of agency policy and procedure titled “Plan of Care-Content” dated 03/2023 revealed “2. The plan of care includes but is not limited to: b. a detailed statement of the scope and frequency of services necessary to meet the specific needs of the patients.” Record review of Patient #9 Plan of Care (start of care 04/20/2023) for certification period dated starting 03/21/2024 revealed “Staff Assignment orders: Hospice Aide 2 visits weekly.” Review of Patient #9’s hospice aide visits from 03/21/2024 to 05/11/2024 revealed visits were conducted weekly on 03/26/2024, 04/02/2024, 04/08/2024, 04/15/2024, 04/22/2024, 04/29/2024, and 05/09/2024. Findings for Patient #9’s hospice aide visits were confirmed during an interview with Director of Clinical Operations C on 05/15/2024 at 10:05 AM, Director of Clinical Operations C stated, “The nurse said it was a missed order and confirmed that the order should be for hospice aide 1 time per week.” Record review of Patient #11 Plan of Care (start of care 03/12/2024) for certification period dated starting 03/12/2024 revealed “Staff Assignment orders: Skilled Nurse 2 visits weekly.” Review of Patient #11’s skilled nurse visits from 03/12/2024 to 05/11/2024 revealed visits were conducted weekly on 03/12/2024, 03/20/2024, 03/26/2024, 04/05/2024, 04/11/2024, 04/24/2024, 05/01/2024, and 05/09/2024. The week of 04/14/2024, Patient #11 refused skilled nurse visits. Findings for Patient #11’s skilled nurse visits were confirmed during an interview with Director of Clinical Operations C on 05/15/2024 at 1:25 PM who stated, “The order should have been fixed but was not. The order should have been changed to weekly.””

“Based on record review and interview, the agency RN (Registered Nurse) failed to supervise the hospice aide for quality of care and services no less frequently than every 14 days in 1 of 15 patients receiving hospice aide services (Patients #13) in a total of 23 patient records in reviewed. Findings include: Review of agency policy titled “Hospice Aide Supervisory Visits-Wisconsin Policy No. 1-037.1” dated 05/11/2020 revealed “Procedure: 1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days in order to ensure that services ordered by the interdisciplinary group meeting are meeting the needs of the patient.” Record review of Patient #13’s “Hospice Plan of Care” with start of care date 02/02/2024 revealed “Orders: RN: 2 times per week. Aide: 2 times per week.” Review of RN documentation from 04/02/2024 to 05/15/2024 revealed no evidence of hospice aide supervision from 04/15/2024 to 05/15/2024. During an interview with Director of Clinical Operations C on 05/15/2024 at 1:24 PM, when asked about Patient #13 hospice aide supervisory documentation missing from 04/15/2024to 05/15/2024, Director of Clinical Operations C replied, “The nurse did the supervisory visit but didnt document it in the patients record.””

“Based on observation, record review and interview, the agency staff failed to identify which provider was responsible for which functions on the plan of care for patients residing in facilities in 9 of 15 medical records reviewed out of a total of 23 medical records reviewed (Patients #2, #4 #8, #9, #12, #13, #16, #17 and #19). Record review for Patient #19 with SOC 4/24/82024 revealed Patient #19 resided in a Skilled Nursing Facility (SNF). The Plan of care failed to delineate which provider was responsible for what interventions between the SNF and hospice. During an interview with Director of Clinical Operations on 05/14/2024 at 4:00 PM, when asked if agency expectations and policy require a plan of care that identifies who is responsible for performing functions or interventions, Director of Clinical Operations C replied, “Correct.” Record review for Patient #13 with Start of Care (SOC) 02/02/2024 revealed Patient #13 resided in an Assisting Living Facility (ALF). The Plan of care failed to delineate which provider was responsible for what interventions between the ALF and hospice. Record review for Patient #16 with Start of Care (SOC) 03/29/2024 revealed Patient #16 resided in a Skilled Nursing Facility (SNF). The plan of care failed to delineate which provider was responsible for what interventions between the SNF and hospice. Record review for Patient #17 with SOC 02/16/2023 revealed Patient #17 resided in an Assisted Living Facility (ALF). The plan of care failed to delineate which provider was responsible for what interventions between the SNF and hospice. Record review for Patient #8 with SOC 11/10/2022 revealed Patient #8 resided in a Skilled Nursing Facility (SNF). The Plan of Care failed to delineate which provider was responsible for what interventions between the SNF and hospice. Record review for Patient #9 with SOC 04/20/2023 revealed Patient #9 resided in an ALF. The Plan of Care failed to delineate which provider was responsible for what interventions between the ALF and hospice. Record review for Patient #12 with SOC 04/20/2024 revealed Patient #12 resided in an ALF. The Plan of Care failed to delineate which provider was responsible for what interventions between the ALF and hospice. Review of agency policy “Hospice Care for Nursing Facility Residents-Hospice Plan of Care” H45 last reviewed October 2023, revealed “Procedure 3. the plan of care for the 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 and included in the plan of care.” Record review for Patient #2 with start of care (SOC) 01/15/2024 revealed Patient #2 resided in an Assisted Living Facility (ALF). The Plan of Care failed to delineate which provider was responsible for what interventions between the ALF and hospice. Record review for Patient #4 with SOC 02/29/2024 revealed Patient #4 resided in an Assisted Living Facility (ALF). The Plan of Care failed to delineate which provider was responsible for what interventions between the ALF and hospice.”

“Based on record review and interview, the facility failed prepare a Hazard Vulnerability Assessment as part of an emergency preparedness plan in accordance with the requirements of 42 CFR 418.113(a)(1) and 42 CFR 418.113(a)(2). This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 5/14/2024 at 1:49 pm, record review of the Emergency Plan (EP), which was dated 8/9/2023, revealed that the EP had no record of a Hazard Vulnerability Assessment. When asked if the EP dated 8/9/2023 had documentation of a facility risk assessment and associated strategies, Staff D stated, “;No.” This finding was confirmed at the time of discovery by a concurrent interview with Staff A, Staff B, and Staff D.”

“Based on observation and interview, the facility failed to install supervised smoke detection and a supervised fire alarm system in accordance with the NFPA 101 (2012 edition) 19.3.4, 19.3.4.1, 4.6.1.1, 4.6.1.2, 9.6, and 9.6.5.1 and NFPA 72 (2010 edition) Sections 10.1.1, 10.12.5, 10.16.3, 10.16.3.2, 17.7.3, 17.7.3.1.2, 17.7.4, and 17.7.4.1. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 5/14/2024 at 4:07 pm, observation of the corridor in front of the entrance to the Cafe, adjacent the west wing nurse station, revealed a smoke detector located within 10-inches of an air supply diffuser for the ventilation system. 2. On 5/14/2024 at 4:32 pm, observation revealed that there was no fire alarm control panel or fire alarm remote annunciator panel located in an area that was staffed 24 hours a day. The fire alarm control panel (FACP) was located in a mechanical room on the Garden level. A remote fire alarm annunciator was located in the front entry vestibule, which was 17-feet from the reception desk. The front entry vestibule had glass doors, and the remote fire alarm annunciator was within view of staff and volunteers located at the reception desk. The front reception desk was staffed from 8 am to 7:30 pm seven days a week. These conditions were confirmed at the time of discovery by a concurrent interview with Staff B, Staff D and Staff E.”

“Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.4, 9.6.1.3, and 9.6.1.5 and NFPA 72 (2010 edition) Sections 14.3.1, 14.4.2.2, 14.4.5, 14.6, and 14.6.2.4. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 5/14/2024 10:41 am, review of fire alarm inspection and testing documents revealed that the semi-annual inspection of alarm initiating devices for heat detectors, duct detectors, electromechanical releasing devices (door hold opens), and fire alarm panel batteries had not been conducted in the past 18 months. An annual fire alarm inspection was completed on 7/10/2023 by Ahern. When asked if any records of the semi-annual testing and inspections of the fire alarm system were available for review for duct detectors, door hold opens, heat detectors, and fire alarm panel batteries, Staff D stated, “;No.” This condition was confirmed at the time of discovery by a concurrent interview with Staff D and Staff E.”

“Based on observation and staff interview, the facility did not provide an automatic sprinkler system in accordance with NFPA 101 (2012 edition) Section 19.3.5 and 9.7.1.1 and NFPA 13 (2010 edition) Section 7.2.6.3.1. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 5/14/2024 at 2:36 pm, observation of the Garden level mechanical room revealed two air compressors used for the dry fire sprinkler system. Each air compressor had a 3/8-inch diameter pipe being used to supply air to the dry pipe fire sprinkler system. Connection piping from the air supply to the dry pipe valve of not less than 1/2 inches in diameter is required. This condition was confirmed at the time of discovery by a concurrent interview with Staff B, Staff D, and Staff E.”

“Based on record review and staff interview, the facility did not provide a sprinkler outage plan initiating fire watch procedures for sprinkler outages in accordance with NFPA 101 (2012 edition) Section 9.7.6 and NFPA 25 (2011 edition) Sections 15.5.2 and 15.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 5/14/2024 at 1:05 pm, review of the “;Fire Watch” policy, labeled policy number IPU F10 8/2018, revealed the policy did not appropriately designate when a fire watch was to be initiated for a sprinkler outage. The policy called for a “;Plan of action should the fire alarm or sprinkler system be out of service for more than 4 hours in a 24-hour period. 2. On 5/14/2024 at 1:06 pm, review of the “;Fire Watch” policy, labeled policy number IPU F10 8/2018, revealed the policy did not require that the fire watch was to be continuously conducted. These conditions were confirmed at the time of discovery by a concurrent interview with Staff D and Staff E.”

“Based on record review, observation, and interview the facility failed to maintain a written fire safety plan in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.7.2, 19.7.2.1, 19.7.2.2, 19.7.2.3, and 4.6.1.1. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: On 5/14/2024 at 1:18 pm, review of the facilitys written fire safety plan, which was located in the Emergency Plan, revealed the fire safety plan did not include evacuation of smoke compartments. When asked if the written fire safety plan included a section for the evacuation of smoke compartments, Staff D stated, “;Nope.” This condition was confirmed at the time of discovery by concurrent interview with Staff D and Staff E.”

“Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 4.7.1, 4.7.2, 4.7.4, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 5/14/2024 at 11:19 am, review of the fire drill records for the last 12 months revealed that the fire drills were not conducted at varied times. The facility performed fire drills during the 2nd shift on 6/11/2023 at 8:17 pm and during the 2nd shift on 2/7/2024 at 8:44 pm. The facility also performed fire drills during the 3rd shift on 10/9/2023 at 5:55 am and during the 3rd shift on 1/26/2024 at 6:15 am. 2. On 5/14/2024 at 11:21 am, review of the fire drill records for the last 12 months revealed that the facility did not perform fire drills quarterly on each shift. No fire drills were performed during the 1st shift in the 3rd quarter of 2023 and 1st quarter of 2024. No fire drills were performed during the 2nd shift in the 3rd quarter of 2023 and 4th quarter of 2023. No fire drills were performed during the 3rd shift in the 2nd quarter of 2023 or the 2nd quarter of 2024. These conditions were confirmed at the time of discovery by a concurrent interview with Staff D and Staff E.”

“Based on record review and interview, the facility failed to perform maintenance and testing of the essential electrical system in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3, NFPA 110 (2010 edition) Sections 8.3, 8.3.4, 8.4, and 8.4.9, and NFPA 99 (2012 edition) Sections 6.4.4.1, 6.4.4.1.1, 6.4.4.1.1.2, 6.4.4.2, 6.5.4.1.1, and 6.5.4.2. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors. Findings include: 1. On 5/14/2024 at 12:10 pm, review of the monthly generator records, in the past 12 months, revealed the automatic transfer times to emergency power were not recorded during the monthly load tests. When asked if the facility had records of the automatic transfer times to emergency power, for the monthly emergency generator load tests over the past 12 months, Staff D stated, “;No.” 2. On 5/14/2024 at 12:11 pm, review of the monthly generator records, in the past 12 months, revealed the emergency generator cool down times were not recorded during the monthly load tests. When asked if the facility had records of the emergency generator cool down times, for the monthly emergency generator load tests over the past 12 months, Staff D stated, “;No.” 3. On 5/14/2024 at 12:12 pm, review of the emergency generator documentation revealed that the 36-month test, for a duration of four (4) continuous hours under load, was not performed in the past 36-months. There was no documentation of the most recent 36-month, 4-hour test under continuous load for the emergency generator. When asked if the facility had documentation from the past 3 years of a 36-month, 4-hour test under continuous load, Staff E stated, “;No.” This finding was confirmed at the time of discovery by concurrent interview with Staff D and Staff E.”