Interim Healthcare Hospice of Western Wisconsin

“Based on observation, record review, and interview, the agency nurse failed to conduct a full medication review to ensure that the patient record contained an accurate medication profile in 1 of 4 home visits conducted (Patient #3) in a total of 19 patient records reviewed. Findings include: Review of agency policy titled “;Drugs and Biologicals- Administration, Use and Disposal” dated 11/29/2019 revealed, “;Responsibility: The Hospice ensures that processes are in place to support the designated RNs (Registered Nurse) documentation and ongoing update of the medications used in the hospice patients care, including ongoing review of the patients needs versus the findings of an updated comprehensive assessment and noted revisions to the IDG (Interdisciplinary Group) plan of care. Procedure: 1. The designated RN is responsible for maintaining a current medication profile that includes prescription drugs and biologicals, over-the-counter drugs, herbal remedies, and alternative treatments used by each patient, as well as the current dosage, frequency, and route of administration. 8. The designated RN is responsible for verifying any changes in medication, dose, frequency or route with the patients attending physician or the Hospice Medical Director or physician designee and obtaining appropriate revised physician orders.” Record review for Patient #3 revealed Patient #3 resided in the SNF (Skilled Nursing Facility) since 04/14/2023 and was admitted to this hospice agency 04/26/2023 with primary diagnosis of Cerebrovascular Disease. A home visit observation was conducted with RN D on 01/24/2024 at 1:00 PM to 1:30 PM at the SNF in which Patient #3 resided. RN D performed a comprehensive head to toe assessment on Patient #3. RN D left Patient #3s room and observed RN D discuss with SNF RN Case Manager E regarding a need to order additional Sarna medicated cream for Patient #3 and observed no other medications discussed or reviewed. During an interview with RN D on 01/24/2024 at 1:30 PM, when asked if there were any other tasks for RN D to complete for Patient #3, RN D replied, “;No.” RN D left the SNF building. Record review of Patient #3s hospice medication profile as compared to SNF medication profile revealed the following medication order discrepancies: -Hospice order revealed, “;Acetaminophen 325mg (milligram) oral 2 tablets 4 times per day, start 04/26/2023.” SNF order revealed, “;Acetaminophen 325mg oral 2 tablets 3 times per day, start 06/06/2023.” There was a discrepancy in the frequency for this medication. -Hospice order revealed, “;Morphine 0.25mg/mL (milliliter). 0.25 mL as needed every 4 hours, start 04/26/2023.” SNF order revealed, “;Morphine 0.25mg/mL. 0.25 mL as needed every 2 hours, start 05/02/2023.” There was a discrepancy in the frequency for this medication. -Hospice order revealed, “;Clopidogrel 75mg oral 1 tablet daily, start 04/26/2023.” SNF orders revealed Clopidogrel was discontinued on 05/02/2023. -SNF orders revealed, “;Hyoscyamine Sulfate 0.125mg 1 tablet sublingual every 2 hours as needed for excessive secretions, start 05/02/2023. Sarna/Camphor-Menthol 0.5% lotion topical 4 times per day as needed for itching. Standing orders (start date 05/03/2023): Tums 500mg 2 tablets by mouth every 4 hours as needed for heartburn. Simethicone 80mg 1 tablet by mouth every 4 hours as need for upset stomach, gas, or heartburn. Magnesium Hydroxide 400mg/5mL by mouth daily as needed for constipation. Docusate Sodium 100mg 1 capsule by mouth up to twice a day as needed for stool softening. Sennoside-Docusate Sodium 8.6mg-50mg 1 tablet by mouth daily as needed for constipation. Standing orders (start date 05/03/2023): Guaifenesin 100mg/5mL by mouth every 4 hours as needed for cough. Standing orders (start date 05/15/2023): Bisacodyl 10mg suppository daily as needed for constipation. Docusate Sodium 283mg/5mL enema daily as needed for constipation. “ The hospice medication profile did not contain medication orders for Hyoscyamine Sulfate, Sarna/Camphor-Menthol, Tums, Simethicone, Magnesium Hydroxide, Docusate Sodium, or Sennoside-Docusate Sodium. During an interview with SNF RN Case Manager E on 01/24/2024 at 1:35 PM, when asked how often the hospice nurse reviews and reconciles medications, SNF RN Case Manager E replied, “;I dont know if they have a set schedule.” The above findings were reviewed with Director of Nursing B regarding Patient #3s medication profile discrepancies between the hospice agency and SNF. During an interview with Director of Nursing B on 1/24/2024 at 2:35 PM, when asked what the process or expectation is for medication review for patients that reside in facilities, Director of Nursing B replied, “;My preference is weekly or with each visit reconciling.””

“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 18 of 19 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 #10, #11, #12 #13, #14, #16, #17, #18, & #19) patient records reviewed. Review of Patient #1s medical record revealed Patient #1 was admitted to hospice service on 12/29/2023 with a primary diagnosis of frontotemporal neurocognitive disorder. Review of Patient #1s “;Initial Plan of Care” dated 12/29/2023 revealed the following goals: “;Patient will have optimal symptom management through end of life; Patient will have all ADL (Activities of Daily Living), safety, and activity needs met; Patient will awaken rested and not be fatigued during day most of time; Patient will receive coordinated care from hospice IDG (Interdisciplinary Group) and facility staff.” These goals were not measurable and/or specific to the patients needs. Review of Patient #4s medical record revealed Patient #4 was admitted to hospice service on 12/29/2023 with a primary diagnosis of CHF (congestive heart failure). Review of Patient #4s “;Initial Plan of Care” dated 12/29/2023 revealed the following goal: “;Patient will maintain maximum safety and independence in ADLs within the limits of disease process.” This goal was not measurable nor specific to the patients needs. Review of Patient #10s medical record revealed Patient #10 was admitted to hospice service on 8/3/2023 with a primary diagnosis of Alzheimers Disease. Review of Patient #10s “;Comprehensive Plan of Care” dated 1/15/2024 revealed the following goals: “;Patient will have acute confusion/agitated behaviors reduced to manageable level within the limits of the disease; Patient will have all ADL, safety, and activity needs met through anticipation.” These goals were not measurable and/or specific to the patients needs. Review of Patient #12s medical record revealed Patient #12 was admitted to hospice service on 9/26/2021 with a primary diagnosis of Dementia with Lewy Bodies. Review of Patient #12s “;Comprehensive Plan of Care” dated 1/2/2024 revealed the following goals: “;Patient will have optimal symptom management through end of life; Patient/caregiver will verbalize/demonstrate feeling supported by hospice team, family, and/or friends and will adapt to changes, challenges and crises; Patient will verbalize/demonstrate feeling supported by hospice team, family, and/or friends and will adapt to changes and increasing care needs; Patient will have all ADL, safety, and activity needs met; Patient will maintain maximum safety and independence in ADLs within the limits of the disease process.” These goals were not measurable and/or specific to the patients needs. Review of Patient #13s medical record revealed Patient #13 was admitted to hospice service on 12/14/2023 with a primary diagnosis of Alzheimers Disease. Review of Patient #13s “;Comprehensive Plan of Care” dated 12/14/2023 revealed the following goals: “;Patient will have all ADL, safety, and activity needs met; Patient will be able to participate in ADLs and diversional activities with environmental adaptations made for visual loss; Patient will verbalize that symptoms of decreased cardiac output are adequately managed within limits of disease process; Patient will receive coordinated care from hospice IDG and facility staff.” These goals were not measurable and/or specific to the patients needs. Record review for Patient #7 revealed Patient #7 was admitted to the hospice 12/22/2023 with a primary diagnosis of Alzheimers. Patient #7’s Comprehensive POC dated 12/22/2023-03/20/2024, last review date 01/17/2024, revealed “;Patient #7 resided in an ALF (Assisted Living Facility). Problems/Goals/Interventions, Goals: Safety Needs Met: Patient will have all ADL, safety, and activity needs met. Goal Length: Ongoing. Goals: Incontinence managed: caregivers will manage Incontinence of bladder. Goal Length: Ongoing. Goals: No Falls: Patient will have no falls. Goal Length: Ongoing.” The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #7. Record review for Patient #8 revealed Patient #8 was admitted to the hospice 12/05/2023 with a primary diagnosis of Cerebral Infarction. Patient #8’s Comprehensive POC dated 01/18/2024-04/16/2024, last review date 01/17/2024, revealed “;Patient #8 resided at home. Problems/Goals/Interventions, Alteration in Neurological Status: Goals: Maintain ability to perform ADLs as independently as possible. Goal Length: Ongoing.” Dyspnea/Sleep Deprivation: Goals: Patient will verbalize understanding of energy conversation measures. Goal Length: Ongoing. Alteration in Cardiac Status: Goals: Control Fluid Overload: Patient will have symptoms of fluid volume overload controlled within limits of disease. Goal Length: Ongoing. Alteration in Elimination Status: Goals: Catheter Remain Patent. Goal Length: Ongoing. Goals: No infection in Suprapubic site. Goal Length: (none.) Alteration in Functional status: Goals: Patient will maintain maximum safety and independence in ADLs within the limits of disease process. Goal Length: Ongoing. Need for Fall Prevention Plan: Goals Patient will have no injury from falls. Goal Length: Ongoing. The goals stated on the POC were 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 11/07/2023 with a primary diagnosis of Heart Disease of Coronary Artery. Patient #9’s Comprehensive POC dated 10/20/2023-01/17/2024, last review date 01/17/2024, revealed “;Patient #9 resided at home. Problems/Goals/Interventions, Goals: Understanding Bleeding Precautions: Patient/caregiver will verbalize understanding of precautions to prevent bleeding. Until end of current benefit period. Goal Length: Ongoing. Goals: Verbalize Symptom Control: Patient will verbalize that symptoms of decreased cardiac output are adequately managed within limits of disease process. Until end of benefit period. Goal Length: Ongoing. Goals: Control fluid overload: Patient will have symptoms of fluid volume overload controlled within limits of disease. Until end of current benefit period. Goal Length: Ongoing. Goals: Maintain maximum independence: Patient will maintain maximum safety and independence in ADLs within the limits of disease process. Until end of current benefit period. Goals: No Injury from Falls: Patient will have no injury from falls. Until end of benefit period. Goal Length: Ongoing. Goals: Verbalize Understanding of Medications: Patient/caregiver will verbalize understanding of administration, dosing, and indication for each comfort kit medication. Goal Length: Ongoing. The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #9. Record review for Patient #11 revealed Patient #11 was admitted to the hospice 06/08/2021 with a primary diagnosis of Vascular Dementia. Patient #11’s Comprehensive POC dated 11/25/2023-01/23/2024, last review date 01/17/2024, revealed “;Patient #11 resided in an ALF (Assisted Living Facility). Problems/Goals/Intervention: Goals: Anxiety/Depression Reduced: Patient/caregiver will verbalize that anxiety/depression is absent or reduced to an acceptable level. Goal Length: Ongoing. Goals: Needs met through Anticipation: Patient will have all ADLs, safety, and activity needs met through anticipation. Goals: No signs of UTI. Patient will have no signs of urinary tract infection. Goal Length: Ongoing. Goals: No Falls: Patient will have no falls. Goal Length: Ongoing. Goals: Plan to Prevent Skin Injury: Patient/caregiver will verbalize a plan for preventing impaired skin integrity. Goal Length: Ongoing. Goals: No New Breakdown: Patient will have no new skin breakdown. Goal Length: Ongoing. Goals: Anorexia: Patient/caregiver will verbalize understanding of changing nutritional need with disease progression. Goal Length: Ongoing. Goals: Verbalize understanding of Medications: Patient/caregiver will verbalize understanding of administration, dosing, and indication for each comfort kit medication. Goal Length: Ongoing. The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #11. Record review for Patient #14 revealed Patient #14 was admitted to the hospice 09/18/2023 with a primary diagnosis of Symptoms and Signs with Cognitive Functions & Awareness. Patient #14’s Comprehensive POC dated 12/17/2023-03/15/2024, last review date 01/17/2024, revealed “;Patient #14 resided in an SNF (Skilled Nursing Facility). Problems/Goals/Intervention: Goals: Reduce Acute Confusion/Delirium/Agitation: Patient will have acute confusion/agitated behaviors reduced to manageable level within the limits of the disease. Goal Length: Ongoing. Goals: Understand Energy Conservation: Patient will verbalize understanding of energy conservation measures. Goal Length: Ongoing. Goals: Incontinence Managed: Incontinence of bowel will be managed by caregivers. Goal Length: Ongoing. Catheter Remain Patent: Patient will have catheter remain patent. Goal Length: Ongoing. Goals: No signs of UTI. Patient will have no signs of urinary tract infection. Goal Length: Ongoing. Goals: No Falls: Patient will have no falls. Goal Length: Ongoing. Goals: Patient will have no injury from falls. Goal Length: Ongoing. Goals: No New Breakdown: Patient will have no new skin breakdown. Goal Length: Ongoing. Goals: Understand Changing Nutritional needs: Patient/caregiver will verbalize understanding of changing nutritional needs with disease progression. The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #14. Record review for Patient #3 revealed Patient #3 was admitted to the hospice 04/26/2023 with a primary diagnosis of Cerebrovascular Disease, unspecified. Patient #3’s POC dated 12/22/2023 – 02/19/2024, last review date 12/18/2023, revealed “;Patient #3 resided in an SNF (Skilled Nursing Facility). Problems/Goals/Interventions: Goals: Pain Management: Patient will report pain using a standardized pain scale, establish a self-identified pain goal, and report/demonstrate that pain is managed at or below a manageable level. Goal Length: Ongoing. Dyspnea Managed: Patient will remain free of signs of respiratory distress and/or report dyspnea is managed at acceptable level of manageable. Goal Length: Ongoing. Safe ADL (Activities of Daily Living) Care: Caregivers will demonstrate safe and effective ADL care for patient needs. Goal Length: Ongoing. Plan to Prevent Skin Injury: Patient/caregiver will verbalize a plan for preventing impaired skin integrity. Goal Length: 30 days. The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #3. Record review for Patient #5 revealed Patient #5 was admitted to the hospice 12/27/2023 with a primary diagnosis of Moderate Protein-Calorie Malnutrition. Patient #5’s POC dated 12/27/2023 – 03/25/2024, last review date 12/28/2023, revealed “;Patient #5 resided at home. Problems/Goals/Interventions: Goals: Pain Management: Patient will report pain using a standardized pain scale, establish a self-identified pain goal, and report/demonstrate that pain is managed at or below a manageable level. Goal Length: Ongoing. Perineal/Perianal Skin Intact: Patient will maintain perineal and perianal skin integrity. Goal Length: Ongoing. Safe ADL Care: Caregivers will demonstrate safe and effective ADL care for patient needs. Goal Length: Ongoing. Plan to Prevent Skin Injury: Patient will have no new skin breakdown. Goal Length: Ongoing. Adequate Oral Intake for Comfort: Patient will report adequate oral intake for comfort. Goal Length: Ongoing. The goals stated on the POC were 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 11/22/2023 with a primary diagnosis of Alzheimers Disease with Late Onset. Patient #6s POC dated 11/22/2023 – 02/19/2024, last review date 11/22/2023, revealed “;Patient #6 resided at home. Problems/Goals/Interventions: Goals: Needs Met through Anticipation: Patient will have all ADL, safety and activity needs met through anticipation. Goal Length: Ongoing. Safe ADL Care: Caregivers will demonstrate safe and effective ADL care for patient needs. Goal Length: Ongoing. Skin Healing: Skin will heal to maximum potential. Goal Length: Ongoing. The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #6. Findings include: Review of agency policy titled, “Care Delivery Addendum B” dated 12/21/2021 revealed, examples of individualized measurable goals and “The elements of the goal should relate to the individual need of the patient/client.” Record review for Patient #2 revealed Patient #2 was admitted to the hospice 07/20/2023 with a primary diagnosis of hemiplegia following a cerebral vascular accident. Patient #2’s Comprehensive POC dated 01/16/2024-03/15/2024, last review date 01/02/2024, revealed “;Patient #2 resided in an ALF (Assisted Living Facility). Problems/Goals/Interventions, Goals: Safety DME (Durable Medical Equipment) use: Patient/caregiver will verbalize and demonstrate safe use of DME. Goal Length: Ongoing. Goals: Perineal/Perineal Skin Intact: Patient will maintain perineal and perineal skin integrity. Goal Length: Ongoing. Goals: No Injury from Falls: Patient will have no injury from falls. Goal Length: 30 days.” The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #2. Record review for Patient #16 revealed Patient #16 was admitted to the hospice 12/07/2022 with a primary diagnosis of congestive heart failure. Patient #16’s Comprehensive POC dated 12/07/2022-03/06/2023, last review date 02/06/2023, revealed “;Patient #16 resided in an ALF. Problems/Goals/Interventions, Goals: Safety DME (Durable Medical Equipment) use: Patient/caregiver will verbalize and demonstrate safe use of DME. Goal Length: Ongoing. Goals: Perineal/Perineal Skin Intact: Patient will maintain perineal and perineal skin integrity. Goal Length: Ongoing. Goals: No Injury from Falls: Patient will have no injury from falls. Goal Length: Ongoing.” The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #16. Record review for Patient #17 revealed Patient #17 was admitted to the hospice 04/10/2023 with a primary diagnosis of lung cancer. Patient #17’s Comprehensive POC dated 12/06/2023-12/18/2023, last review date 12/06/2023, revealed “;Patient #17 resided in an ALF. Problems/Goals/Interventions, Goals: Safety DME (Durable Medical Equipment) use: Patient/caregiver will verbalize and demonstrate safe use of DME. Goal Length: Ongoing. Goals: Perineal/Perineal Skin Intact: Patient will maintain perineal and perineal skin integrity. Goal Length: Ongoing. Goals: No Injury from Falls: Patient will have no injury from falls. Goal Length: Ongoing.” The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #17. Record review for Patient #18 revealed Patient #18 was admitted to the hospice 09/13/2022 with a primary diagnosis congestive heart failure. Patient #18’s Comprehensive POC dated 01/06/2024-01/17/2024, last review date 12/20/2023, revealed “;Patient #18 resided in an ALF. Problems/Goals/Interventions, Goals: Safety DME (Durable Medical Equipment) use: Patient/caregiver will verbalize and demonstrate safe use of DME. Goal Length: Ongoing. Goals: Perineal/Perineal Skin Intact: Patient will maintain perineal and perineal skin integrity. Goal Length: Ongoing. Goals: No Injury from Falls: Patient will have no injury from falls. Goal Length: Ongoing.” The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #18. Record review for Patient #19 revealed Patient #19 was admitted to the hospice 10/12/2023 with a primary diagnosis of hypertensive heart disease with heart failure. Patient #19’s Comprehensive POC dated 10/12/2023-11/10/2023, last review date 11/08/2023, revealed “;Patient #19 resided in an ALF. Problems/Goals/Interventions, Goals: Perineal/Perineal Skin Intact: Patient will maintain perineal and perineal skin integrity. Goal Length: Ongoing. Goals: No Injury from Falls: Patient will have no injury from falls. Goal Length: Ongoing.” The goals stated on the POC were generic and not individualized to meet the specific needs of Patient #19.”

“Based on record review and interview this agency’s Interdisciplinary group (IDG) failed to maintain a system of communication, and integration in the Plan of Care (POC) to show patient’s progress towards outcomes and goals in 10 of 19 (Patients #4, #6, #7, #8, #9, #10, #11, #12, #13, and #14) patient records reviewed. Record review for Patient #7 revealed Patient #7 was admitted to hospice 12/22/2023 with a primary diagnosis of Alzheimer’s and had services of Skilled Nurse, Social Worker, Chaplain, and Hospice Aide. Patient #7s POC dated 12/22/2023-03/20/2024 revealed IDG meetings were conducted on 01/03/2024 and 01/17/2024 and have no documentation present to show updates provided by the SN, SW, Chaplin, and Aide services and how they collaborated towards Patient #7’s individualized POC. Record review for Patient #8 revealed Patient #8 was admitted to hospice 12/05/2023 with a primary diagnosis of Cerebral Infarction and had services of Skilled Nurse, Social Worker, Chaplain, and Hospice Aide. Patient #8s POC dated 12/5/2023-03/03/2024 revealed IDG meetings were conducted on 12/06/2023, 12/20/2023, (Patient #8 was not reported on 12/20/2023s meeting), 01/03/2024, and 01/17/2024 and have no documentation present to show updates provided by the SN, SW, Chaplin, and Aide services and how they collaborated towards Patient #8s individualized POC. Record review for Patient #9 revealed Patient #9 was admitted to hospice 11/07/2023 with a primary diagnosis of Heart Disease of Coronary Artery and had services of Skilled Nurse, Social Worker, Chaplain, and Hospice Aide. Patient #9s POC dated 10/20/2023-01/17/2024 revealed IDG meetings were conducted on 12/06/2023, 12/20/2023, (Patient #9 was not reported on 12/20/2023s meeting), 01/03/2024, and 01/17/2024 and have no documentation present to show updates provided by the SN, SW, Chaplin, and Aide services and how they collaborated towards Patient #9s individualized POC. Record review for Patient #11 revealed Patient #11 was admitted to hospice 06/08/2021 with a primary diagnosis of Vascular Dementia and had services of Skilled Nurse, Social Worker, Chaplain, and Hospice Aide. Patient #11s POC dated 11/25/2023-01/23/2024 revealed IDG meetings were conducted on 12/06/2023, 12/20/2023, 01/03/2024, and 01/17/2024 and have no documentation present to show updates provided by the SN, SW, Chaplin, and Aide services and how they collaborated towards Patient #11s individualized POC. Record review for Patient #14 revealed Patient #14 was admitted to hospice 09/18/2023 with a primary diagnosis of Symptoms and Signs with Cognitive Functions and Awareness and had services of Skilled Nurse, Social Worker, Chaplain, and Hospice Aide. Patient #14s POC dated 12/17/2023-03/15/2024 revealed IDG meetings were conducted on 12/06/2023, 12/20/2023, 01/03/2024, and 01/17/2024 and have no documentation present to show updates provided by the SN, SW, Chaplin, and Aide services and how they collaborated towards Patient #14s individualized POC. An interview was conducted with Director of Nursing C on 01/25/2024 at 9:20 AM. When asked about the agency’s IDG process for meetings and documentation, and if all disciplines provide an individual report, Director of Nursing C replied, “Yes”, then stated, “The Nurse reports off first and then every discipline contributes.” When asked if there is a way for the IDG to free text into the IDG conversation, Director of Nursing A replied, “The IDG summary note should capture the report/patient update Yes.” Director of Nursing C was asked if there was an issue with the IDG on 12/20/2023 that Patients were missing a IDG meeting on 12/20/2023, Director of Nursing C replied, “Yes.” Record review for Patient #6 revealed Patient #6 was admitted to hospice 11/22/2023 with a primary diagnosis of Alzheimers Disease with Late Onset and had services of SN (Skilled Nurse), SW (Social Work), Spiritual Counselor (SC) and Hospice Aide. Patient #6’s POC (Plan of Care) dated 11/22/2023 to 02/19/2024 revealed IDG meetings were conducted on 12/06/2023, 12/20/2023, 01/03/2024, and 01/17/2024, and revealed Patient #6 was not reported on for 12/20/2023s meeting. On 01/17/2024 IDG meeting, there was no documentation present to show updates provided by the SW and SC and how they collaborated towards Patient #6s individualized POC. Findings include: Review of policy tilted “Interdisciplinary Group (IDG) Plan of Care” dated 12/02/2008 revealed “Procedure, The IDG plan of care is developed, reviewed and revised based on the findings of the initial comprehensive assessments, as well as updated comprehensive assessments conducted throughout the patient’s/family’s care. a) the IDG plan of care is established, reviewed, and revised in consultation with the patient/family and attending physician, if any, as well as the Hospice Medical director and other members of the IDG.” Review of Patient #4s medical record revealed Patient #4 was admitted to hospice service on 12/29/2023 with a primary diagnosis of CHF (congestive heart failure). Further review revealed no review of the plan of care until 1/17/2024 which was 19 days after admission. Review of Patient #4s IDG meeting note dated 1/17/2024 revealed “;Discussion: Plan of care effective.” There was no documentation of each team members contribution to the plan of care review. Review of Patient #10s medical record revealed Patient #10s IDG meeting notes dated 12/20/2023, 1/3/2024 and 1/17/2024 revealed “;Discussion: Plan of care effective.” There was no documentation of each team members contribution to the plan of care review. Review of Patient #12s medical record revealed Patient #12s IDG meeting note dated 11/22/2023 revealed “;Discussion: POC (plan of care) sufficient and goals managed.” Review of Patient #12s IDG meeting notes dated 12/6/2023 and 12/20/2023 revealed “;Discussion: POC is effective.” Review of Patient #12s IDG meeting note dated 1/3/2024 revealed “;Discussion: RN (registered nurse) recertification completed.” There was no documentation of each team members contribution to the plan of care review in these IDG notes. Review of Patient #13s medical record revealed Patient #13s IDG meeting note dated 1/3/2024 revealed “;Discussion: Plan of care remains appropriate for patient.” Review of Patient #13s IDG meeting note dated 1/17/2024 revealed “;Discussion: Plan of Care effective.” There was no documentation of each team members contribution to the plan of care review in these IDG notes.”

“Based on record review and interview agency staff failed to supervise Hospice Aide services every two weeks in 3 of 19 (Patients #4, #8, & #13) patient records reviewed. Record review of Patient #8’s “Comprehensive Plan of Care” with a start of care date 12/05/2023 revealed “Visit Frequency: Hospice Aide: 3 times per week x 12 weeks.” Review of RN documentation for the Hospice Benefit Period 12/05/2023-1/25/2024 revealed no evidence of hospice aide supervision. During an interview on 01/25/2024 at 9:15 AM, when asked if there had been any RN supervisory visits for Patients #4 and #8, Administrator A stated, “None.” Findings include: Review of agency policy titled, “Supervision of Employees Who Provide Patient/Family Care” dated 05/11/2008 revealed “Hospice Aide 1. The Hospice Hospice Director of Health Care Services (DHCS) designates a registered nurse to conduct hospice aide employee supervision. 4. The designated supervisor. a) Documents the results of the supervision of the employee...” Review of Patient #4s medical record revealed Patient #4 was admitted to hospice service on 12/29/2023 with a primary diagnosis of CHF (congestive heart failure). Review of Patient #4s “;Initial Plan of Care” dated 12/29/2023 – 3/27/2024 revealed hospice aide ordered at 2 times per week. Further review of Patient #4s medical record revealed no documentation of any aide supervisory visits made. Review of Patient #13s medical record revealed Patient #13 was admitted to hospice service on 12/14/2023 with a primary diagnosis of Alzheimers Disease. Review of Patient #13s “;Comprehensive Plan of Care” dated 12/14/2023 – 3/12/2024 revealed hospice aide ordered at 2 times per week. Further review of Patient #13s medical record revealed no aide supervisory visit was made until 12/31/2023,17 days later.”

“Based on record review and interview the agency staff failed to document an assessment for volunteer services in 18 of 19 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, & #19) patient records reviewed. Record review of Patient #7s Initial Skilled Nursing Visit Assessment dated 12/22/2023 (with a start of care dated 12/22/2023) revealed no evidence that the volunteer needs of Patient #8 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #7 was offered and declined volunteer services. Record review of Patient #8s Initial Skilled Nursing Visit Assessment dated 12/5/2023 (with a start of care dated 12/5/2023) revealed no evidence that the volunteer needs of Patient #8 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #8 was offered and declined volunteer services. Record review of Patient #9s Initial Skilled Nursing Visit Assessment dated 11/07/2023 (with a start of care dated 11/07/2023) revealed no evidence that the volunteer needs of Patient #9 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #9 was offered and declined volunteer services. Record review of Patient #11s Initial Skilled Nursing Visit Assessment dated 06/08/2021 (with a start of care dated 06/08/2021) revealed no evidence that the volunteer needs of Patient #11 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #11 was offered and declined volunteer services. Record review of Patient #14s Initial Skilled Nursing Visit Assessment dated 09/18/2023 (with a start of care dated 09/18/2023) revealed no evidence that the volunteer needs of Patient #14 were assessed. The checkbox for Volunteer services accepted was blank. Patient #14 was offered volunteer services and assigned a volunteer for 1 time per month to start on 09/18/2023-11/30/2023. Patient #14 never received volunteer services. Record review of Patient #15s Initial Skilled Nursing Visit Assessment dated 07/21/2023 (with a start of care dated 07/21/2023) revealed no evidence that the volunteer needs of Patient #15 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #15 was offered and declined volunteer services. In an interview with Hospice Director B on 01/23/2024 at 3:35 PM, when asked what the expectation was for staff when assessing for or offering volunteer services, Hospice Director B stated, “The expectation is that staff document declined services in the visit narrative note” or complete the check box on the comprehensive assessment if services are requested. Review of Patient #1s medical record revealed Patient #1 was admitted to hospice service on 12/19/2023 with a primary diagnosis of frontotemporal neurocognitive disorder. Further review revealed no documentation within the medical record that Patient #1 was assessed for or offered volunteer services. Review of Patient #4s medical record revealed Patient #4 was admitted to hospice service on 12/29/2023 with a primary diagnosis of CHF (congestive heart failure). Further review revealed no documentation within the medical record that Patient #4 was assessed for or offered volunteer services. Review of Patient #10s medical record revealed Patient #10 was in the second hospice benefit period dated 11/1/2023 – 1/29/2024 with a primary diagnosis of Alzheimers Disease. Further review revealed no documentation within the medical record that Patient #10 was assessed for or offered volunteer services. Review of Patient #12s medical record revealed Patient #12 was in the 13th benefit period dated 11/12/2023 – 1/13/2024 with a primary diagnosis of dementia with lewy bodies. Further review revealed no documentation within the medical record that Patient #12 was assessed for or offered volunteer services. Review of Patient #13s medical record revealed Patient #13 was admitted to hospice service on 12/14/2023 with a primary diagnosis of Alzheimers Disease. Further review revealed no documentation within the medical record that Patient #13 was assessed for or offered volunteer services. Record review of Patient #3s Initial Skilled Nursing Visit Assessment dated 04/26/2023 (with a start of care dated 04/26/2023) revealed no evidence that the volunteer needs of Patient #3 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #3 was offered and declined volunteer services. Record review of Patient #5s Initial Skilled Nursing Visit Assessment dated 12/27/2023 (with a start of care dated 12/27/2023) revealed no evidence that the volunteer needs of Patient #5 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #5 was offered and declined volunteer services. Record review of Patient #6s Initial Skilled Nursing Visit Assessment dated 11/22/2023 (with a start of care dated 11/22/2023) revealed no evidence that the volunteer needs of Patient #6 were assessed. The checkbox for Volunteer services accepted was blank and no additional documentation that Patient #6 was offered and declined volunteer services. Findings include: Review of Patient #2s medical record revealed Patient #2 was admitted to hospice service on 07/20/2023 with a primary diagnosis of hemiplegia following cerebral infarction. Further review revealed no documentation within the medical record that Patient #2 was assessed for or offered volunteer services. Review of Patient #16s medical record revealed Patient #16 was admitted to hospice service on 12/07/2022 with a primary diagnosis of CHF (congestive heart failure). Further review revealed no documentation within the medical record that Patient #16 was assessed for or offered volunteer services. Review of Patient #17s medical record revealed Patient #17 was admitted to hospice service on 04/10/2023 with a primary diagnosis of lung cancer. Further review revealed no documentation within the medical record that Patient #17 was assessed for or offered volunteer services. Review of Patient #19s medical record revealed Patient #19 was admitted to hospice service on 10/12/2023 with a primary diagnosis of hypertensive heart disease with heart failure. Further review revealed no documentation within the medical record that Patient #19 was assessed for or offered volunteer services.”

“Based on record review and interview, the agency staff failed to ensure that the volunteer level of activity equaled at least 5 percent of the total patient care hours of paid hospice staff for the past year in 1 of 1 volunteer program reviewed. Findings include: Review of agency policy titled, “Volunteer Services” dated 04/25/2018 revealed “v. Standard: Level of Activity. Volunteers must provide day-to-day administration and/or direct patient services in an amount that at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contracted staff.” Review of the hospice’s volunteer program revealed a level of volunteer activity at 1.26 percent, below the 5 percent required. Percentage was calculated by agency through it’s computer system. During an interview conducted on 01/24/2024 at 1:00 PM with Administrator A, Administrator A explained that the agency’s Volunteer Coordinator left the agency in July of 2023 and it has been difficult trying to fill the position and that the agency is also finding it difficult to recruit volunteers. Administrator A stated that during the survey there were no active volunteers providing patient or clerical services, but that a patient care volunteer was starting services in the month of February.”

“Based on observation, record review and interview the agency staff failed to coordinate care between agency and facility in 1 of 4 (Patient #10) patient observations conducted. Findings include: Review of agency policy titled, “Provision of Hospice Services to Residents of a SNF/NF (Skilled Nursing Facility/Nursing Facility). “Dated 02/15/2013 revealed, “Policy: Interim Healthcare Hospice...maintains responsibility for professional management of hospice services in facility...” “The provisions of hospice services are stated in written agreement defining the responsibility of the facility and of Interim Healthcare Hospice in providing care to the patient.” Review of Patient #10s medical record revealed Patient #10 was recertified for a second benefit period dated 11/1/2023 – 1/29/2024. An observation visit was conducted at Patient #10s place of residence, which was a memory care facility, with RN C on 1/24/2024 at 8:34 a.m. Review of Patient #10s hospice binder at the facility revealed no documentation of the patients plan of care or any IDG updates. An interview was conducted with RN C on 1/24/2024 at 9:00 a.m. regarding the finding. When asked where the hospice keeps their plan of care and updates available for facility staff, RN C stated that there wasnt a copy of the plan of care or updates to the plan of care kept at the facility, that he/she wasnt aware it was required.”