Survey Report for 461628

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	461628	A. BUILDING __________ B. WING ______________	07/21/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
TEMPLE VIEW HOSPICE	1611 EAST 2450 SOUTH #5A, ST GEORGE, UT, 84790
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0500
L0500	27237 Based on observation, interview and record review, it was determined the hospice agency failed to meet the Condition of Participation for Patient's Rights. This resulted in a finding of immediate threat to patient health and safety, immediate Jeopardy (IJ), which was confirmed on 7/15/2021, in the area of Patient Rights. The hospice agency was officially notified in writing of this finding on 7/15/2021. The hospice agency's plan for removal of IJ was as follows: a. Mandatory staff training on abuse/neglect, safety/fire, privacy/dignity during care, and home assessments. b. Social worker visits for home safety and abuse/neglect assessments for all patients. c. Communication thread established to notify all staff when state survey was in progress. d. Reported abuse to Adult Protective Services, local authorities, and family. e. Coordinated safe transfer of IJ patient and service to another hospice. f. The facility opted to remove the child locks and monitoring devices. The hospice agency alleged IJ removal on 7/17/2021. On 7/19/2021 surveyors were onsite and determined the IJ had been removed as of 7/17/2021. The hospice agency was notified of the IJ removal on the afternoon of 7/19/2021. Findings include: 1. The hospice agency failed to provide documented evidence the patient or their representative received written notice of patient's rights and responsibilities prior to furnishing care. (Refer to Tag L502) 2. The hospice agency failed to ensure patients were free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property. (Refer to Tag L517)
L0502
L0502	27237 Based on interview and record review, it was determined there was no documented evidence the hospice agency had provided the patient or their representative with written notice of patient's rights and responsibilities prior to furnishing care. Specifically, for 5 of 13 sampled patients notice of rights and responsibilities were either not located, or were for home health and not hospice. (Patient identifiers: 4, 5, 7, 8 and 13). Findings include: A complete or focused medical record review was completed for 13 sampled patients. For patients 4, 8 and 13, there was no documented evidence the patients or their representatives received written notice of patient's rights and responsibilities prior to care being furnished. For patients 5 and 7, the patients and or representative received written notice of patient rights and responsibilities for their affiliated home health agency but not from the hospice agency.
L0517
L0517	27237 Based on observation, interview and record review, it was determined the hospice agency did not ensure patients were free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property. Specifically, surveyors identified an abusive and neglectful situation for 2 of 2 hospice patients that resided at an unlicensed care facility (UCF). Additionally, the hospice's social worker (SW) did not address the allegations immediately. (Patient identifiers: 6 and 13) This resulted in a finding of immediate threat to patient health and safety, immediate Jeopardy (IJ), which was identified. The hospice agency was officially notified in writing of this finding on 7/15/2021. The hospice agency alleged IJ removal on 7/17/2021. On 7/19/2021 surveyors were onsite and determined the IJ had been removed as of 7/17/2021. The hospice agency was notified of the IJ removal on the afternoon of 7/19/2021. Findings include: 1. Patient 6 was admitted to the agency on 4/13/2021, with a terminal diagnosis of severe protein-calorie malnutrition. A review of patient 6's medical record was completed on 7/21/2021. A registered nurse (RN) completed a comprehensive nursing assessment on 4/13/2021. The nurse documented that patient 6 was bedbound and required maximum assistance with dressing, grooming, meal preparation, transfers, bathing and toileting. On 7/14/2021 at 2:05 PM, a home visit was attempted with patient 6 at the UCF. There was no answer to knocking or ringing of the doorbell. Surveyors went across the street to another building unit of the UCF and spoke with caregiver (CG) 1. CG 1 provided the surveyors with the phone number for CG 2 who was supposed to be taking care of patient 6. CG 2 was contacted by telephone and stated he was in the building next door taking care of another patient. He stated patient 6's full-time live-in CG had a day job so he would check on patient 6 throughout the day. CG 2 was asked if anyone was with patient 6 at the moment and he stated "no". CG 2 met the surveyors outside and accompanied the surveyors to patient 6's unit of the UCF at 2:11 PM. At 2:13 PM, the owner of the UCF, who was also the husband of one of the owners of the hospice agency that was being surveyed, came in the door and demanded to know who the surveyors were and what we were doing there. CG 2 proceeded to show the surveyors to patient 6's room with the UCF owner following close behind. CG 2 introduced the surveyors to patient 6 and patient 6 gave verbal consent for an interview. CG 2 left the room, the UCF owner tried to enter but the surveyors asked for privacy and closed the door at 2:14 PM. Patient 6 was observed lying in bed. There was a video camera observed on the wall at the foot of the bed facing patient 6. The surveyors asked patient 6 if he knew there was a camera and he stated he did not know what it was; the surveyors informed him it was a camera. The surveyors asked him if he knew that he was alone in the UCF unit, in which he stated he did not know that. The surveyors asked if he had a way to get ahold of someone if he needed something. He stated he did not have a phone or any way to get ahold of someone other than yelling out. During that point of the interview, at 2:17 PM, the UCF owner came into the room and in a very loud voice stated that patient 6 did not need to answer any questions. The UCF owner then turned to patient 6 and asked him if he wanted the surveyors to leave. Patient 6 appeared to be distressed and did not comment. The UCF owner repeated himself to patient 6 in a louder voice than before. Patient 6 was observed to recoil under his blanket. The surveyor informed patient 6 that it was up to him and the surveyors would leave if he wanted them to, but the surveyors still had a few more questions. The UCF owner repeated to patient 6 in a louder voice than previously heard, "Do you want them to leave because we can make them leave." At which point patient 6 was observed cowering with a fearful appearance and covered his face almost completely with his blanket, and stated, "Yeah, I guess that would be okay." At that point the surveyors left. As the surveyors exited the UCF unit, child locks were observed on the main exit door with an additional lock at the top of the door. On 7/14/2021 at 3:30 PM, an interview was conducted with the agency's SW. The surveyor asked her plan for addressing the abuse and neglect allegations observed by the survey team; she stated she planned on visiting the patient the next day. The surveyors asked her why she was not going to see the patients today, the SW stated, "I don't work after five PM." NOTE: it was 3:30 PM at time of the interview. 2. The IJ findings affected all patients who resided at the UCF, including patients 13. Patient 13 was admitted to the hospice agency on 7/12/2021. A home visit was conducted with patient 13 on 7/14/2021 at 3:51 PM. He was observed to be lying in bed. There was a camera observed in the room positioned towards patient 13. There was no phone or calling system observed in the room. Patient 13 stated he was there because, "I want to die." NOTE: patient 13 passed away on 7/17/2021. According to CG 2, patient 13 was left alone at times during the day when he would leave to attend to patient 6 housed in another building of the facility. 3. Both patients were to be receiving 24 hour care by a paid caregiver of the UCF. Based on observation, interview and/or record review, both patients 6 and 13 were bedbound and completely dependent for all cares. 4. On 7/14/2021 at 3:30 PM, an interview was conducted with the agency's SW. The surveyor asked her plan for addressing the abuse and neglect allegations observed by the survey team; she stated she planned on visiting the patient the next day. The surveyors asked her why she was not going to see the patients today, the SW stated, "I don't work after five PM." NOTE: it was 3:30 PM at time of the interview.
L0520
L0520	27237 Based on interview and record review, the hospice agency failed to meet the Condition of Participation for Initial and Comprehensive Assessment of the Patient. Findings include: 1. The hospice agency failed to ensure a registered nurse completed an initial assessment within 48 hours after the election of hospice. (Refer to Tag L522) 2. The hospice agency failed to ensure the comprehensive assessment was completed within 5 calendar days after the election of hospice benefit. (Refer to Tag L523) 3. The hospice agency failed to complete a drug profile for each patient. (Refer to Tag L530) 4. The hospice agency failed to ensure an initial bereavement assessment was appropriately completed for each patient/family/caregiver. (Refer to Tag L531)
L0522
L0522	19354 Based interview and record review, it was determined the hospice agency (HA) did not ensure a registered nurse completed an initial assessment within 48 hours after the election of hospice care for 1 of 10 sampled patients who had a full medical record review completed by the survey team. Specifically, a non-registered nurse completed the initial nursing assessment to determine immediate care needs. (Patient identifier: 4). Findings include: Patient 4 was admitted to the agency on 6/8/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 4's medical record was completed on 7/21/2021. An initial nursing assessment was completed on 6/8/2021 by a non-licensed nursing graduate. An interview was conducted with the Director of Clinical Services (DCS) on 7/13/2021 at 1:42 PM. The DCS was asked about the unlicensed nursing graduate completing patient assessments. The DCS stated that he was "under the impression" that a graduate from a nursing program could work as a nurse pending licensure.
L0523
L0523	33753 Based on interview and record review, it was determined the hospice agency did not ensure the interdisciplinary group, in consultation with the individual's attending physician, completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Specifically, spiritual counselor (SC) and social worker (SW) involvement in the comprehensive assessment could not be found for 8 of 10 sample patients who had a full medical record review completed by the survey team. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, and 11.) Findings include: 1. Patient 6 was admitted to the agency on 4/13/2021, with a terminal diagnosis of severe protein-calorie malnutrition. A review of patient 6's medical record was completed on 7/21/2021. No evidence of SC involvement in patient 6's comprehensive assessment could be found. On 7/20/2021 at 2:11 PM, an interview was conducted with the agency's SC. When asked why a spiritual assessment had not been completed for patient 6 the SC stated he did not recognize that patient name and that he did not visit every patient that was admitted to the agency. 2. Patient 11 was admitted to the agency on 11/13/2020, with a terminal diagnosis of multiple sclerosis. A review of patient 11's medical record was completed on 7/21/2021. No documented evidence of SW or SC involvement in patient 11's comprehensive assessment could be found in her medical record. On 7/20/2021 at 2:11 PM, an interview was conducted with the agency's SC. The SC stated he had been introduced to patient 11 but that he had not completed an assessment for her. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated prior to completing a home safety assessment the week before she had "never" seen patient 11. 3. Patient 4 was admitted to the agency on 6/8/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 4's medical record was completed on 7/21/2021. No documented evidence of SC involvement in patient 4's comprehensive assessment could be found in her medical record. 27237 4. Patient 3 was admitted to the hospice agency on 5/4/2021 with a terminal diagnosis of heart failure. He was discharged on 6/24/2021. A review of patient 3's medical record was completed on 7/20/2021. a. Patient 3's psychosocial assessment was completed on 5/17/2021; 13 days after election of hospice care. There was no documented evidence as to why the psychosocial assessment was not completed within the required timeframe. The skilled nurse assessments dated 5/4/2021, 5/7/2021, 5/11/2021 and 5/14/2021 all documented that a social work visit was needed. b. No evidence of SC involvement in patient 6's comprehensive assessment could be found. The skilled nurse assessments dated 5/4/2021, 5/7/2021, 5/11/2021, 5/14/2021, 5/17/2021, 5/19/2021, all documented that spiritual counseling was needed. The skilled nurse assessments dated 5/24/2021, 5/26/2021, 6/1/2021, 6/2/2021, 6/3/2021, 6/6/2021, 6/8/2021 and 6/16/2021 all documented that spiritual counseling was needed and that patient/family appear/indicate fear, hopelessness, and struggling with meaning of illness; "Spouse has dementia & struggles to remember the significance of pt's (patient's) illness." 5. Patient 5 was admitted to the hospice agency on 5/5/2021 with a terminal diagnosis of chronic combined systolic and diastolic heart failure. A review of patient 5's medical record was completed on 7/20/2021. Patient 5's spiritual assessment was completed on 6/14/2021; 43 days after the election of hospice care. There was no documented evidence as to why the spiritual assessment was not completed within the required timeframe. 6. Patient 1 was admitted to the agency on 3/25/2021 with a terminal diagnosis of restrictive cardiomyopathy. A review of patient 1's medical record was completed on 7/21/2021. No documented evidence of SW or SC involvement in patient 1's comprehensive assessment could be found in his medical record. 7. Patient 2 was admitted to the agency on 3/17/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 2's medical record was completed on 7/21/2021. No documented evidence of SC involvement in patient 2's comprehensive assessment could be found in her medical record. 8. Patient 7 was admitted to the agency on 3/29/2021 with a terminal diagnosis of chronic obstructive pulmonary disease. A review of patient 7's medical record was completed on 7/21/2021. No documented evidence of SC involvement in patient 7's comprehensive assessment could be found in his medical record. 9. On 7/20/2021 at 2:11 PM, an interview was conducted with the agency's SC. The SC indicated he had been working at the agency since June or July of 2020. He stated he completed spiritual assessments for patients once he was notified by the office a visit needed to be done. The SC stated he did not complete spiritual assessments on all patients and again stated the office informed him when he needed to go out to complete an assessment. The SC stated he was not sure when the spiritual assessment was supposed to be completed after a patient was admitted and stated there had been times he was out of town and was unable to complete visits. He further stated he did not know who covered for him when he was off. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated she had been at the agency for approximately two years. The SW stated she completed psychosocial assessments for agency patients to identify needs and support their families through the end of life process. The SW further stated she did not complete psychosocial assessments on all patients, only on those who did not decline social work. The SW then stated when the nurses completed their initial assessments they determined if a SW visit was needed.
L0530
L0530	27237 Based on interview and record review, it was determined that a drug profile was not accurate and completed timely for 3 of 10 sample patients who had a full medical record review completed by the survey team. Specifically, a review of all prescription and over-the-counter-drugs, herbal remedies and other alternative treatments that could affect drug therapy was not completed timely, did not contain all medications and treatments, and was not updated when new medications were added. (Patient identifiers: 3, 4, and 5.) Findings include: 1. Patient 3 was admitted to the hospice agency on 5/4/2021 with a terminal diagnosis of heart failure. A review of patient 3's medical record was completed on 7/20/2021. The first documented evidence of a drug profile review for medication interactions or duplicate therapies was dated 5/18/2021; 14 days after the election of hospice care. Review of nursing notes completed by an unlicensed nursing graduate (UNG) and interdisciplinary group (IDG) notes revealed that patient 3 was taking magnesium citrate for constipation upon admission, and was started on oxygen and Lasix after admission. None of these medications or treatments were listed or updated on to the drug profile. There was no documented evidence these medications and treatments were reviewed for medication interactions or duplicate therapies. There was evidence in the medical record that patient 3 went to the emergency department for acute cholecystitis (inflammation of the gallbladder) on 5/16/2021. On 5/17/2021, it was documented by the UNG, "I gathered up all of the mag (magnesium) citrate/stool softeners due to the pt (patient) calling 911 last night and being transported to the ER (emergency room). He felt like he had severe constipation and had a lot of 'tightness' in his belly. A CT (computerized tomography) was done and inflammation was shown along with some negative effects to his gall bladder, this is most likely due to the significant amounts of mag citrate that he drinks." 2. Patient 5 was admitted to the hospice agency on 5/5/2021 with a terminal diagnosis of chronic combined systolic and diastolic heart failure. A review of patient 5's medical record was completed on 7/20/2021. The first documented evidence of a drug profile review for medication interactions or duplicate therapies was dated 5/18/2021; 13 days after the election of hospice care 19354 3. Patient 4 was admitted to the hospice agency on 6/8/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 4's medical record was completed on 7/21/2021. The first documented evidence of a drug profile review for medication interactions or duplicate therapies was dated 6/16/2021; eight days after the election of hospice care. The drug profile review was completed by a non-registered nurse and was not signed by a registered nurse or physician. There was no documented evidence the medications and treatments were reviewed for medication interactions or duplicate therapies. 4. An interview was conducted with the Director of Clinical Service (DCS) on 7/19/2021 at 1:26 PM, related to the medication profiles. The DCS stated that medications, including medications at the time of discharge from other agencies, were to be reviewed with the patient at the time of admission. The DCS stated that any discrepancies were to be reported to the ordering physician for reconciliation.
L0531
L0531	33753 Based on interview and record review, it was determined the hospice agency did not ensure an initial bereavement assessment was completed. Specifically, for 4 of 10 sample patients who had a full medical record review completed by the survey team there was no documented evidence of an initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. (Patient identifiers: 1, 2, 4, and and 7.) Findings include: 1. Patient 1 was admitted to the agency on 3/25/2021 with a terminal diagnosis of restrictive cardiomyopathy. A review of patient 1's medical record was completed on 7/21/2021. No documented evidence of a bereavement assessment could be found in patient 1's medical record. 2. Patient 2 was admitted to the agency on 3/17/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 2's medical record was completed on 7/21/2021. No documented evidence of a bereavement assessment could be found in patient 2's medical record. 3. Patient 7 was admitted to the agency on 3/29/2021 with a terminal diagnosis of chronic obstructive pulmonary disease. A review of patient 7's medical record was completed on 7/21/2021. No documented evidence of a bereavement assessment could be found in patient 7's medical record. 19354 4. Patient 4 was admitted to the agency on 6/8/2021 with a terminal diagnosis of Alzheimer's. A review of patient 4's medical record was completed on 7/21/2021. No documented evidence of bereavement assessment could be found in patient 4's medical record. 5. On 7/20/2021 at 4:32 PM, an interview was conducted with the director of clinical services (DCS). The DCS stated the initial bereavement assessment was completed by the nurse and was not sure of a timeframe but believed it was to be completed within 48 hours of admission.
L0536
L0536	27237 Based on interview and record review, the hospice agency failed to meet the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services. Findings include: 1. The hospice agency failed to ensure that a written plan of care (POC) was developed with participation from the entire designated IDG. (Refer to Tag L537) 2. The hospice agency failed to ensure the POC included a detailed statement of the scope and frequency of services necessary to meet the patient and family needs. (Refer to Tag L547) 3. The hospice agency failed to ensure the IDG, in collaboration with the individual's attending physician, documented a review and revision of the individualized plan as frequently as the patient's condition required. (Refer to Tag L552) 4. The hospice agency failed to ensure the patients revised POC included information from their updated comprehensive assessments. (Refer to Tag L553) 5. The hospice agency failed to ensure the ongoing sharing of information between all disciplines. (Refer to Tag L557)
L0537
L0537	27237 Based on interview and record review, it was determined the hospice agency did not ensure that a written plan of care (POC) was developed with participation from the entire designated interdisciplinary group (IDG) for 6 of 10 sample patients who had a full medical record review completed by the survey team. (Patient identifiers: 1, 2, 3, 4, 5, and 7.) Findings include: 1. Patient 3 was admitted to the hospice agency on 5/4/2021 with a terminal diagnosis of heart failure. A review of patient 3's medical record was completed on 7/20/2021. The initial POC for the certification period 5/4/2021 through 8/1/2021 contained no documented evidence that it was developed in collaboration with the skilled nurse (SN), social worker (SW) and spiritual counselor (SC). 2. Patient 5 was admitted to the hospice agency on 5/5/2021 with a terminal diagnosis of chronic combined systolic and diastolic heart failure. A review of patient 5's medical record was completed on 7/20/2021. The initial POC for the certification period 5/5/2021 through 8/2/2021 contained no documented evidence that it was developed in collaboration with the SW and SC. 33753 3. Patient 1 was admitted to the agency on 3/25/2021 with a terminal diagnosis of restrictive cardiomyopathy. A review of patient 1's medical record was completed on 7/21/2021. The POC for the certification period 5/5/2021 through 8/2/2021 contained no documented evidence that it was developed in collaboration with the physician, SW, and SC. 4. Patient 2 was admitted to the agency on 3/17/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 2's medical record was completed on 7/21/2021. The POC for the certification period 6/15/2021 through 9/12/2021 contained no documented evidence that it was developed in collaboration with the physician, SN, SW and SC. 5. Patient 7 was admitted to the agency on 3/29/2021 with a terminal diagnosis of chronic obstructive pulmonary disease. A review of patient 7's medical record was completed on 7/21/2021. The POC for the certification period 3/29/2021 through 6/26/2021 contained no documented evidence that it was developed in collaboration with the physician, SN, SW and SC. 19354 6. Patient 4 was admitted to the agency on 6/8/2021 with a terminal diagnosis of Alzheimer's. A review of patient 4's medical record was completed on 7/21/2021. The initial POC for certification period 6/8/2021 through 9/5/2021 contained no documented evidence that it was developed in collaboration with the SN, SW and SC.
L0547
L0547	27237 Based on interview and record review, it was determined the hospice agency interdisciplinary group (IDG) did not ensure the plan of care (POC) included a detailed statement of the scope and frequency of services necessary to meet the patient and family needs for 2 of 10 sample patients who had a full medical record review completed by the survey team. (Patient identifiers: 3 and 5.) Findings include: 1. Patient 3 was admitted to the hospice agency on 5/4/2021 with a terminal diagnosis of heart failure. He was discharged on 6/24/2021. A review of patient 3's medical record was completed on 7/20/2021. The initial nursing assessment completed by an unlicenced nursing graduate (UNG) dated 5/4/2021 documented the following frequency of services: skilled nurse two times per week; aide three times per week; social worker (SW) one time per month; spiritual counselor (SC) one time per month. The same frequencies of services were documented in 13 other SN visit notes dated from 5/7/2021 through 6/16/2021. Patient 3 had documented visits by the social worker (SW) on 5/17/2021, 6/13/2021 and 6/22/2021. The initial POC and updates to the POC did not contain documented evidence of a detailed scope and frequency for the SW. Additionally, there were no physician orders found in the medical record for the SW visits. Beginning 5/18/2021, aide visits were documented approximately three times per week. The initial POC and updates to the POC did not contain documented evidence of a detailed scope and frequency for aide visits. Additionally, there were no physician orders found in the medical record for the aide visits. There were no documented visit notes by the SC found in the medical record, even though the the UNG documented in 14 of her visit notes that a SC visit was needed 1 time per month. 2. Patient 5 was admitted to the hospice agency on 5/5/2021, with a terminal diagnosis of chronic combined systolic and diastolic heart failure. A review of patient 5's medical record was completed on 7/20/2021 Patient 5 had documented visits by the social worker on 5/10/2021, 5/28/2021, 6/10/2021, and 6/24/2021. There was a SC visit documented of 6/14/2021. The initial POC and updates to the POC did not contain documented evidence of a detailed scope and frequencies for the SW or SC. Additionally, there were no physician orders found in the medical record for the SW or SC visits. 3. On 7/20/2021 at 2:11 PM, an interview was conducted with the agency's SC. The SC indicated he had been working at the agency since June or July of 2020. He stated he completed spiritual assessments for patients once he was notified by the office a visit needed to be done. The SC stated he did not complete spiritual assessments on all patients and again stated the office informed him when he needed to go out to complete an assessment. When asked about patient 3, the SC stated he did not remember getting notice to visit patient 3, and stated he may have been out of town. He further stated, he did not know who covered for him when he was off. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated she had been at the agency for approximately two years. The SW stated she completed psychosocial assessments for agency patients to identify needs and support their families through the end of life process. The SW further stated she did not complete psychosocial assessments on all patients, only on those who did not decline social work. The SW then stated when the nurses completed their initial assessments they determined if a SW visit was needed.
L0552
L0552	33753 Based on interview and record review, it was determined the hospice agency did not ensure the interdisciplinary group (IDG) in collaboration with the individual's attending physician documented a review and revision of the individualized plan as frequently as the patient's condition required, but no less frequently than every 15 calendar days for 6 of 10 sample patients who had a full medical record review completed by the survey team. (Patient identifiers: 1, 3, 5, 6, 8, and 11.) Findings include: 1. Patient 6 was admitted to the agency on 4/13/2021 with a terminal diagnosis of severe protein-calorie malnutrition. A review of patient 6's medical record was completed on 7/21/2021. A review of patient 6's plan of care (POC) updates were completed by the agency on 6/15/2021, 6/29/2021, and 7/13/2021. The review forms dated 6/15/2021 and 6/29/2021 were signed by the skilled nurse (SN) and social worker (SW). The review form dated 7/13/2021 was signed by the SN. No documented evidence could be found to indicate the physician or spiritual counselor (SC) collaborated in any of the reviews and revisions of patient 6's POC. 2. Patient 11 was admitted to the agency on 11/13/2020, with a terminal diagnosis of multiple sclerosis (MS). A review of patient 11's medical record was completed on 7/21/2021. a. A review of patient 11's POC updates were completed by the agency on 6/1/2021, 6/15/2021, and 6/29/2021. All review forms were signed by the SN but no other member of the IDG. No documented evidence could be found to indicate the physician, SW, or SC collaborated in any of the reviews and revisions of patient 11's POC. b. The following notes were documented in patient 11's medical record by registered nurse (RN) 1: i. On 6/10/2021 and 6/17/2021, "Of concern for (name of patient 11) is the loss of the ability to vocalize. (Name of patient 11's power of attorney (POA)) is to arrange a meeting with (name of patient 11's neurologist) to consult for possible solutions." ii. On 6/24/2021, "Of concern for (name of patient 11) is the loss of the ability to vocalize. (Name of patient 11's POA) is to arrange a meeting with (name of patient 11's neurologist) to consult for possible solutions. (Name of patient 11's POA) has been out of town, so appointment is delayed until he returns." iii. On 7/1/2021, "(Name of patient 11) stated this visit that she is worried that her vocalization is becoming more difficult. She whispers and mouths words, sometimes making sounds. She was able to vocalize 25% of the visit." iv. On 7/8/2021 it was documented that the agency's medical director attended the visit and, "(Name of patient 11) reports she would like to talk to her Neurologist, (name of patient 11's neurologist) about the progressive loss of her voice/ability to vocalize. When asked if she had difficulty taking in enough air to pass over her vocal cords to make sound, she said, 'Maybe.' She is desirous of answers. POA (name of POA) will make arrangements for a consult when he returns from vacation." v. On 7/15/2021, "Of concern for (name of patient 11) is the loss of the ability to vocalize. (Name of patient 11's POA) is to arrange follow up for physician consultation." Note: Per documentation patient 11 is alert and oriented but "completely immobile" due to her MS. Additionally, per documentation patient 11 complained of difficulty vocalizing for approximately 35 days. No documented evidence could be found to indicate the IDG discussed patient 11's difficulty vocalizing or attempted to assist patient 11 in coordinating a visit with her neurologist. On 7/20/2021 at 12:34 PM, an interview was conducted with RN 1. RN 1 stated patient 11's POA was supposed to make an appointment with her neurologist regarding her loss of ability to vocalize. RN 1 stated patient 11's POA had been having trouble getting a hold of patient 11's neurologist and then he had been out of town for approximately three weeks but had returned "last week." When asked why the SW or other IDG members had not been involved in assisting with making an appointment RN 1 stated patient 11's POA needed to "sign off" because he was the POA and he needed to make the arrangements. RN 1 confirmed patient 11 was alert and oriented and able to make her own decisions. RN 1 further stated, "It is unfortunate it has taken so long." On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated prior to completing a home safety assessment the week before she had "never" seen patient 11. The SW stated she had "never" been asked to assist patient 11 in setting up physician appointments. The SW confirmed her job duties could include assisting with physician appointments. 3. Patient 1 was admitted to the agency on 3/25/2021 with a terminal diagnosis of restrictive cardiomyopathy. A review of patient 1's medical record was completed on 7/21/2021. A review of patient 1's POC updates were completed by the agency on 6/1/2021 and 6/15/2021. The review form dated 6/15/2021 was signed by the SN. The review form dated 6/1/2021 was not signed by any member of the IDG. No documented evidence could be found to indicate the physician, SC, or SW collaborated in the reviews and revisions of patient 1's POC. 4. Patient 8 was admitted to the agency on 1/19/2021 with a terminal diagnosis of congestive heart failure. A review of patient 8's medical record was completed on 7/21/2021. A review of patient 8's POC updates were completed by the agency on 6/15/2021 and 6/29/2021. No documented evidence could be found to indicate the SC collaborated in the reviews and revisions of patient 8's POC. 27237 5. Patient 3 was admitted to the hospice agency on 5/4/2021 with a terminal diagnosis of heart failure. A review of patient 3's medical record was completed on 7/20/2021. POC updates occurred on 5/18/2021, 6/1/2021 and 6/15/2021. The POC update dated 5/18/2021 was essentially blank with no quantifying information. The POC update dated 6/1/2021 was incomplete. Neither contained documented evidence the IDG reviewed and/or updated the POC, including the medical director. The POC update dated 6/15/2021, was electronically signed by the SW, but contained not information or updates by the SW. There was no documented evidence that any of the other IDG members had reviewed and/or updated the POC, including the medical director. 6. Patient 5 was admitted to the hospice agency on 5/5/2021 with a terminal diagnosis of chronic combined systolic and diastolic heart failure. A review of patient 5's medical record was completed on 7/20/2021. POC updates occurred on 5/18/2021, 6/1/2021, 6/15/2021, 6/29/2021 and 7/13/2021. There was no documented evidence the medical director had reviewed the POC update or participated in any of the 5 IDG meetings. The POC update dated 5/18/2021 was electronically signed by the SC, but contained not information or updates by the SC. The POC update dated 6/1/2021 was electronically signed by the SC, but contained no information or updates by the SC. There was no documented evidence of participation by the SW. The POC updates dated 6/15/2021 and 6/29/2021, were electronically signed by the SW, but contained no information or updates by the SW. There was no documented evidence of participation by the SC. The POC update dated 7/13/2021 contained no documented evidence of participation by the SW or SC. 7. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated the nurse was the IDG member who documented on the POC update forms and if she was seeing the patient for SW visits she would sign the POC update form to acknowledge agreement with the plan of care. On 7/20/2021 at 4:32 PM, an interview was conducted with the Director of Clinical Services (DCS) reagrding IDG meetings and updates. The DSC stated, all disciplines involved in the patients care would attend the IDG, and it was his instinct that everyone was supposed add to the POC update but he was not certain. An interview was attempted with the medical director on 7/20/2021 and 7/21/2021 with no success.
L0553
L0553	27237 Based on interview and record review, it was determined the hospice agency did not ensure the patients revised plan of care (POC) included information from their updated comprehensive assessments for 2 of 10 sampled patients who had a full medical record review completed by the survey team. (Patient identifiers: 3 and 5.) Findings include: 1. Patient 3 was admitted to the hospice agency on 5/4/2021 with a terminal diagnosis of heart failure. He was discharged on 6/24/2021. A review of patient 3's medical record was completed on 7/20/2021. There was evidence in the medical record that patient 3 went to the emergency department (ED) for acute cholecystitis (inflammation of the gallbladder) on 5/16/2021. Instructions from the ED were to follow up with the primary care provider for additional treatment. On 5/18/2021, there was an interdisciplinary group (IDG) meeting held. There was no evidence patient 3's hospitalization was discussed during that IDG. There was no evidence the medical director was aware of patient 3's ED visit and was providing follow up treatment, and there were no physician orders found in the medical record that could show follow up treatment was being provided. In addition to the above, on 5/11/2021 and 5/14/2021 an unlicensed nursing graduate (UNG) documented patient 3 was struggling with constipation. On 5/24/2021, the UNG documented she ordered an oxygen concentrator for patient 3 to help with shortness of breath. On 6/1/2021, 6/2/2021, 6/3/2021, and 6/16/2021, the UNG documented patient 3 was still having discomfort from gall bladder inflammation. On 6/2/2021, the UNG also documented patient 3 was having a difficult time breathing so she turned up the oxygen. On 6/3/2021, it was documented by the UNG, "Pt (patient) spouse called 911 thinking they were being held hostage and (sic) their new home with the 24 hour care giver. Both the pt and the spouse are having a hard time with their memory and coming to terms with the declining process. We took both of their phones away so they aren't repeatedly calling 911 and other contacts in their phones." On 6/6/2021, the UNG documented that patient 3 and his spouse went missing from the unlicensed care facility they were residing at and, "A number of us went looking for them & they were located quickly." On 6/8/2021, the UNG again documented, "Pt spouse called 911 thinking they were being held hostage and (sic) their new home with the 24 hour care giver. Both the pt and the spouse are having a hard time with their memory and coming to terms with the declining process. We took both of their phones away so they aren't repeatedly calling 911 and other contacts in their phones." On 6/10/2021, the UNG again documented that patient 3 and his spouse went missing from the unlicensed care facility they were residing at and, "A number of us went looking for them & they were located quickly." There was no documented evidence the POC was revised and updated with measurable goals and outcomes and progress towards goals which addressed the concerns documented by the UNG. Additionally, there was no evidence the physician or social worker (SW) was aware of the concerns documented by the UNG. On 5/17/2021, the SW documented patient 3 did not have adequate support. On 6/13/2021, the SW documented there was a disagreement among family members and a meeting was held. There was no documented evidence the POC was revised and updated with measurable goals and outcomes and progress towards goals which addressed the concerns documented by the SW. Additionally, there was no evidence the physician was aware of the concerns documented by the SW. An interview was attempted with the medical director on 7/20/2021 and 7/21/2021 with no success. The UNG was no longer working for the hospice agency at the time of survey. 2. Patient 5 was admitted to the hospice agency on 5/5/2021 with a terminal diagnosis of chronic combined systolic and diastolic heart failure. A review of patient 5's medical record was completed on 7/20/2021. On 6/14/2021, the spiritual counselor (SC) documented patient 5 could benefit from " ...contemplating what he would like to have done as far as funeral arrangements." There was no documented evidence of involvement by the SC in the initial POC or any of the 5 IDG updates that were reviewed. An interview was conducted on 7/20/2021 at 2:11 PM, with the SC regarding no documented visits to patient 5 after charting on 6/14/2021 about the need for funeral arrangements. The SC confirmed he had not revisited patient 5 after 6/14/2021.
L0557
L0557	33753 Based on interview and record review, it was determined the hospice agency did not ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services were provided directly or under arrangement for 1 of 10 sample patients who had a full medical record review completed by the survey team. Specifically, the social worker (SW) did not document coordination with the skilled nurse (SN). Additionally, a patient was discharged from the hospice agency without involvement with the SW or the SN overseeing his care. (Patient identifier: 6.) Findings include: 1. Patient 6 was admitted to the agency on 4/13/2021 with a terminal diagnosis of severe protein-calorie malnutrition. A review of patient 6's medical record was completed on 7/21/2021. a. On 6/8/2021 the SW documented the following, " ...His eyes appeared puffy and somewhat goopy. He did not seem too concerned but I told him that he should mention it to the RN (registered nurse)..." No documented evidence could be found to indicate the SW shared the information regarding patient 6's eyes with the "RN." On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated she was "pretty sure" she brought up patient 6's eye issues in the interdisciplinary group meeting, which the "RN" attended, but that she did not know if the survey team would be able to find supporting documentation in his record. b. A physician order dated 7/16/2021 indicated patient 6 was to discharge to another hospice agency. There was no other documentation regarding the discharge in patient 6's medical record. On 7/20/2021 at 1:07 PM, an interview was conducted with SN 2 who was the case manager overseeing patient 6's care. SN 2 stated she had not been involved in patient 6's discharge. SN 2 stated, "All I did was hear about it after the fact; it all came from the state. They are the ones who orchestrated the whole thing." SN 2 further stated she knew "nothing about it," and the next thing she knew, patient 6 was discharged to another hospice agency. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated she was not involved in patient 6's discharge but did complete a home safety assessment on 7/15/2021 to determine if he was safe to stay at his current residence. The SW stated she asked patient 6 if he wanted to move to another facility, but patient 6 declined and said he felt safe and did not want to move. The SW stated she did not ask patient 6 about discharging from the hospice agency. The SW further stated she was not told anything about patient 6's discharge other than that he had been discharged and the name of the new agency he was discharged to.
L0559
L0559	27237 Based on interview and record review, it was determined the hospice agency failed to meet the Condition of participation for quality assurance and performance improvement (QAPI) Findings include: 1. The hospice agency failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven QAPI program. (Refer to Tag L560) 2. The hospice agency failed to ensure that licensed professional staff participated in the hospice's QAPI program, and in-service training program. (Refer to Tag L586)
L0560
L0560	27237 Based on interview and record review, it was determined the hospice agency did not develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement (QAPI) program. Specifically, the hospice agency and governing body did not maintain documentary evidence that could demonstrate operations of a functioning QAPI program that included: tracking, measuring, and analyzing quality indicators and adverse events, that was then implemented into performance improvement activities that would improve quality of care and patient safety. Findings include: On 7/12/2021, during entrance the agency's QAPI Plan, performance improvement projects (PIPs), evidence of QAPI meetings, adverse event log, and governing body minutes were requested. The surveyors reviewed all the information provided for the past 12 months, as follows: A document titled, "Owners Meeting 3/9/21". The document contained the following headings: Billing Recap, Charting/Compliance, Training, Cash Flow, Payroll, [name of person] Compensation, CEO (chief executive officer)/Administrator, Contributions. Other than the headings, there was no other information in the document. A document titled, "Templeview Home Health & Hospice 11/25/2020 Owner Meeting". The document contained the following headings: Update on Accreditation; Current Condition/Temp of Operation; Personnel; Financial; and Medical. Four of the headings contained sub-headings. Other than the headings and sub-headings, there was no other information in the document. A monthly expense document was provided with no date. Everything else provided was from the first quarter of 2020 and was business or financial in nature and did not contain any QAPI information. Additionally, the above documents did not show a separation between hospice and their affiliated home health agency. The hospice did not provide evidence of adverse event tracking or PIP's. On 7/21/2021, via text message the director of clinical services (DCS) was asked if he had provided everything requested during entrance, in which he stated he believed he had. On 7/21/2021 at 10:00 AM, the DCS was interviewed about the hospice's QAPI program. He stated that he just started with the agency and "self- identified" some areas that needed improvement, but that was the only thing he had done for QAPI. He was asked about the lack of documentation provided for QAPI and he stated the meeting minutes were the only thing he could find, and currently there was not a QAPI program in place. The DCS was asked about the commingling of hospice and home health and he stated until the survey he was not aware of the requirement for separation between the two entities. The hospice agency could not provide documented evidence that all of the components of a hospice-wide QAPI program, including program scope, program data, and program activities, were in place.
L0583
L0583	27237 Based on interview and record review, it was determined the hospice agency failed to meet the Condition of Participation for Licensed Professional Services. Findings Include: 1. The hospice agency failed to ensure licensed professional services were delivered only by health care professionals who met the appropriate qualifications. (Refer to Tag L584) 2. The hospice agency failed to ensure licensed professionals were actively participating in the coordination of all aspects of the patient's hospice care. (Refer to Tag L585) 3. The hospice agency failed to ensure licensed professional staff participated in the hospice's quality assessment and improvement program and hospice in-service training program. (Refer to Tag L586)
L0584
L0584	27237 Based on interview and record review, it was determined the hospice agency did not ensure that licensed professional services were delivered only by health care professionals who met the appropriate qualifications. Specifically, an unlicensed nursing graduate (UNG) was providing care to hospice patients. Findings include: 1. During review of patient medical records it was noted that a staff member was providing cares as a skilled nurse. The staff member had recently graduated and was not licensed as a registered nurse. 2. An interview was conducted with the Director of Clinical Services (DCS) on 7/13/2021 at 1:42 PM. The DCS was asked about the unlicensed nursing graduate completing patient assessments. The DCS stated that he was "under the impression" that a graduate from a nursing program could work as a nurse pending her licensure. 3. On 7/19/2021 at 9:07 AM, an interview was conducted with the UNG regarding her professional license status. She stated that she had worked at the hospice agency as a provisional nurse, recently graduated, and had not taken the state licensing exam to become a registered nurse and that it was scheduled for next month. When asked if she provided cares to patients' in their homes without another nurse present, she stated yes.
L0585
L0585	27237 Based on interview and record review, it was determined that licensed professionals were not actively participating in the coordination of all aspects of the patient's hospice care. Specifically, there was no documented evidence the medical director (MD), spiritual counselor (SC), and/or social worker (SW) were participating in ongoing interdisciplinary comprehensive assessments, and in developing and evaluating the plan of care (POC) for 8 of 10 patients who had a full medical record review completed by the survey team. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7 and 11. ) Finding include: 1. A medical record review was completed for 10 sampled patients on 7/21/2021. a. For 7 of 10 patients (1, 2, 3, 4, 6, 7, and 11), there was no documented evidence of a comprehensive assessment by the SC. b. For 2 of 10 patients (1 and 11), there was no documented evidence of a comprehensive assessment by the SW. c. For 6 of 10 patients (1, 2, 3, 4, 5, and 7), there was no documented evidence of involvement in the development of the POC by the MD, SC and SW. d. For 6 of 10 patients (1, 3, 4, 5, 6, and 11), there was no documented evidence of participation in ongoing interdisciplinary updates to the POC by the MD and SC. e. For 5 of 10 patients (1, 3, 4, 5, and 11), there was no documented evidence of participation in ongoing interdisciplinary updates to the POC by the SW. 2. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SW. The SW stated the nurse was the interdisciplinary group (IDG) member who documented on the POC updates and if she was seeing the patient for SW visits she would sign the POC update to acknowledge agreement with the POC. The SW also stated if the patient declined the SW she would not go out and do an assessment of the patient. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's SC. When asked about completing the initial assessment the SC stated he did not go and see every patient. When asked who does the spiritual assessment on the patients he did not make visits to he stated, he did not know. On 7/20/2021 at 4:32 PM, an interview was conducted with the director of clinical services (DCS) reagrding IDG meetings and updates. The DSC stated, all disciplines involved in the patients care would attend the IDG, and it was his instinct that everyone was supposed add to the POC update but he was not certain. An interview was attempted with the medical director on 7/20/2021 and 7/21/2021 with no success.
L0586
L0586	27237 Based on interview and record review, it was determined the hospice agency did not ensure that licensed professional staff participated in the hospice's quality assessment and improvement program (QAPI) and hospice in-service training program. Findings include: 1. On 7/12/2021, during entrance the agency's QAPI Plan, performance improvement projects (PIPs), evidence of QAPI meetings, and governing body minutes were requested. On 7/21/2021, via text message the director of clinical services (DCS) was asked if he had provided everything requested during entrance, in which he stated he believed he had. The provided information was reviewed. The hospice agency did not provide documented evidence that all of the components of a hospice-wide QAPI program were in place, with the participation of all licensed professionals. On 7/21/2021 at 10:00 AM, the DCS was interviewed about the hospice's QAPI program. He stated the meeting minutes were the only thing he could find, and currently there was not a QAPI program in place. 2. Review of a sampling of personnel files for staff revealed they had orientation, competencies and some inservices documented. However, over the course of the survey, the spiritual counselor, social worker and the unlicensed nursing graduate were asked about orientation, competencies and training. All three stated they had not received a specific orientation, did not recall anyone observing their skills and competencies, or recall being offered a specific inservice training program.
L0648
L0648	27237 Based on observation, interview and record review, it was determined the hospice agency failed to meet the Condition of Participation for Organizational Environment. Findings include: 1. The hospice agency failed to meet the Condition of Participation for Patient's Rights. This resulted in a finding of immediate threat to patient health and safety, immediate Jeopardy. (Refer to Tag L500) 2. The hospice agency failed meet the Condition of Participation for Initial and Comprehensive Assessment of the Patient. (Refer to Tag L520) 3. The hospice agency failed meet the Condition of Participation for Interdisciplinary Group, Care Planning, and Coordination of Services. (Refer to Tag L536) 4. The hospice agency failed to maintain a hospice-wide, data-driven quality assurance and performance improvement program. (Refer to Tag L559) 5. The hospice agency failed to meet the Condition of Participation for Licensed Professional Services. (Refer to Tag L583) 6. The hospice agency failed to ensure care provided was consistent with patient and family needs and goals. (Refer to Tag L650) 7. The hospice agency failed to provide nursing services in a manner that was consistent with accepted standards of practice. (Refer to Tag L652) 8. The hospice failed to ensure other covered services were made available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. (Refer to Tag L653) 9. The hospice agency failed to ensure signed copies of the notice of patient rights and/or election statements were complete and accurate. (Refer to Tag L673)
L0650
L0650	33753 Based on observation, interview, and record review, it was determined the hospice agency did not ensure care provided was consistent with patient and family needs and goals. Specifically, for 1 of 10 sample patients who had a full medical record review completed by the survey team, the social worker (SW) did not identify and address patient needs. (Patient identifier: 6.) Findings include: Patient 6 was admitted to the agency on 4/13/2021 with a terminal diagnosis of severe protein-calorie malnutrition. A review of patient 6's medical record was completed on 7/21/2021. A skilled nurse (SN) completed a comprehensive nursing assessment on 4/13/2021. The nurse documented that patient 6 was bedbound and required maximum assistance with dressing, grooming, meal preparation, transfers, bathing and toileting. On 4/16/2021 the SW completed her initial assessment of patient 6. She documented patient 6 was bedbound, required assistance with walking, and was incontinent. She also documented that patient 6 lived at home with a paid caregiver and she identified no safety concerns. On 7/14/2021 at 2:05 PM, a home visit was attempted with patient 6 at the unlicensed care facility (UCF). There was no answer to knocking or ringing of the doorbell. Surveyors went across the street to another building unit of the UCF and spoke with caregiver (CG) 1. CG 1 provided the surveyors with the phone number for CG 2 who was supposed to be taking care of patient 6. CG 2 was contacted by telephone and stated he was in the building next door taking care of another patient. He stated patient 6's full-time live-in CG had a day job so he would check on patient 6 throughout the day. CG 2 was asked if anyone was with patient 6 at the moment and he stated no. CG 2 met the surveyors outside and accompanied the surveyors to patient 6's unit of the UCF at 2:11 PM. CG 2 introduced the surveyors to patient 6 and patient 6 gave verbal consent for an interview. Patient 6 was observed lying in bed. There was a video camera observed on the wall at the foot of the bed facing patient 6. The surveyors asked patient 6 if he knew there was a camera and he stated, he did not know what it was; the surveyors informed him it was a camera. The surveyors asked him if he knew that he was alone in the UCF unit, in which he stated he did not know that. The surveyors asked if he had a way to get ahold of someone if he needed something. He stated he did not have a phone or any way to get ahold of someone other than yelling out. Note: The social worker did not identify or address that patient 6's paid caregiver had a day job and was not available to assist him during the day, or that patient 6 had no way to call for help aside from yelling. Additionally, the SW did not investigate if patient 6 was being financially exploited by paying for services he may not have received.
L0652
L0652	19354 Based on interview and record review, it was determined the hospice agency did not provide services in a manner that was consistent with accepted standards of practice for 1 of 10 sampled patients who had a full medical record review completed by the survey team. Specifically, an unlicensed nursing graduate (UNG) wrote physician orders for assessment, treatment, and medication administration and it was not documented who accepted verbal orders and if they were authorized to do so. Additionally, the hospice agency did not ensure it had an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling as specified in 418.64(d). (Patient identifier: 4.) Findings include: 1. Patient 4 was admitted to the agency on 6/8/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 4's medical record was completed on 7/21/2021. The following physician orders were documented by the UNG: a. 6/8/2021: "Referred for admission" b. 6/8/2021: Admission Order: Acetaminophen 650 Milligram (mg) rectally as needed; Atropine 1.5% 2-4 drops every 4 hours (hrs) as needed (prn) for excess secretions; DiphenhydrAMINE HCl 25 mg 1-2 caps 4-6 hrs prn; Haloperidol Lactate 2 mg/milliliter (ml) 1-2 ml every 2 hrs prn; Loperamide A-D 2 mg 2 tabs after each loose stool; LORazepam 2 mg/ml 0.5-1 ml every 2-4 hrs prn; Morphine Sulfate 20 mg/25 ml give 0.25-1 ml every 1-4 hrs prn; Ondansetron 8 mg 1 tab SL (sublingually) every 4-6 hrs prn; Senna S 8.6-50 mg 1-2 tabs daily prn; and Sorbitol (70 %). c. Additional orders were documented as: Acetaminophen 500 mg 2 tablets in AM & PM; ARIPiprazole 5 mg every night at bedtime; Atorvastatin Calcium 40 mg; Celecoxib 200 mg twice per day (BID); Donepezil HCl 10 mg 1 tablet at bedtime; Lisinopril 40 mg every morning; LORazepam 2 mg 1 tablet at Breakfast, Lunch, & Dinner; and Warfarin Sodium 3 mg every morning. This order was not signed by the person receiving the order. d. 6/10/2021, an order was written to check a urinalysis by dip stick and a culture. e. 6/11/2021, an order was written to start Apirpipraxole 5 mg TID (three times per day). f. 6/15/2021, an order was written to start Pyridium 200 mg TID. Additionally, on 6/16/2021 and 6/18/2021 verbal orders were written to start Seroquel 50 mg BID and "Discontinue hospice services per patient request to no longer receive hospice care at this time". Neither order indicated who took the verbal orders and if they were authorized to do so. An interview was conducted with the Director of Clinical Services (DCS) on 7/13/2021 at 1:42 PM. The DCS was asked about the UNG providing care. The DCS stated that he was "under the impression" that a graduate from a nursing program could work as a nurse pending licensure. 2. On 7/20/2021 at 3:32 PM, an interview was conducted with the agency's social worker (SW). The SW stated the office manager was the bereavement coordinator. On 7/20/2021 at 4:32 PM, an interview was conducted with the DCS. The DCS stated the office manager was over the bereavement program. The DCS confirmed the office manager did not have experience or education in grief or loss counseling.
L0653
L0653	27237 Based on observation and interview, it was determined the hospice did not ensure other covered services were made available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. Specifically, the social worker (SW) was not available to complete emergency assessments of patients that resided at an unlicensed care facility (UCF) after the surveyors identified an abusive and neglectful situation for 3 of 3 hospice patients. Additionally, the hospice agency did not have backup coverage for the spiritual counselor (SC). (Patient identifiers: 6, 12, and 13) Findings include: 1. On 7/14/2021 at 2:14 PM, an interview was conducted with patient 6 at the facility he resided in. During the interview with patient 6, he was observed to be abused verbally by the facility owner when the owner used a loud and threatening voice to coerce patient 6 into stopping the interview with surveyors. The facility owner was the husband of one of the owners of the hospice being surveyed. Additionally, patient 6 was alone in the facility, with no way to call for help, and was being filmed without his knowledge or consent. Per interview with patient 6 and another care giver (CG) of the facility patient 6 was bedbound and was left alone for extended periods of time during the day. The camera footage was viewable to all employees of the facility including the owners, at any time from their phones. Also observed, was a child lock on the front door exiting the facility. As a result of the facility owner's behavior and actions, patient 6 was observed to cower and withdraw and appeared to be in distress, at which time the surveyors were forced to end the interview. Additionally, there was the potential for harm for invasion of privacy, isolation, and unsafe environment while being left unattended. Also, the lock on the front door has the potential to restrict access outside in the event of an emergency, especially when patient 6 was left alone. The situation identified resulted in an immediate jeopardy finding and affected all patients who resided at the facility, including patients 12 and 13. On 7/14/2021 at 3:30 PM, an interview was conducted with the agency's SW. The surveyor asked her plan for addressing the abuse and neglect allegations observed by the survey team; she stated she planned on visiting the patient the next day. The surveyors asked her why she was not going to see the patients today, the SW stated, "I don't work after five PM." NOTE: it was 3:30 PM at time of the interview. 2. On 7/20/2021 at 2:11 PM, an interview was conducted with the agency's SC. The SC indicated he had been working at the agency since June or July of 2020. He stated he completed spiritual assessments for patients once he was notified by the office a visit needed to be done. The SC stated he did not complete spiritual assessments on all patients and again stated the office informed him when he needed to go out to complete an assessment. The SC stated he was not sure when the spiritual assessment was supposed to be completed after a patient was admitted and stated there had been times he was out of town and was unable to complete visits. He further stated he did not know who covered for him when he was off. An interview was conducted with the Director of Clinical Services (DCS) 7/20/2021 at 4:32 PM regarding coverage when the SC not available. The DCS stated that it sounded like they had some issues with coverage and they need a backup plan.
L0673
L0673	33753 Based on interview and record review, it was determined the hospice agency did not ensure signed copies of the notice of patient rights and/or election statements were complete and accurate for 13 of 13 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6 ,7 ,8, 9 ,10, 11, 12 and 13). Findings include: A complete or focused medical record review was completed for 13 sampled patients. On 7/19/2021 at 12:54 PM, the director of clinical services (DCS) provided the survey team with all admission paperwork for the 13 sampled patients 1. Patient 11 was admitted to the agency on 11/13/2020 with a terminal diagnosis of multiple sclerosis. A review of patient 11's medical record was completed on 7/21/2021. The election statement provided by the agency for patient 11 was not signed by the patient until 3/12/2021. Note: Patient 11's start of care date was 11/13/2020. On 7/20/2021 at 4:32 PM, an interview was conducted with the DCS. The DCS confirmed the start of care date for patient 11 was 11/13/2020. The DCS then stated, "I am a little confused to be honest with you," because the notice of election in the record was dated 3/12/2021. The DCS then stated documentation at the agency had been "lacking," and he was in the process of trying to fix this issue. 27237 2. Additionally, for patients 3, 4, 8, 10, 11, 12 and 13, there was no documented evidence provided of a signed copy of the patient rights. Also, for patients 8 and 13, there was no documented evidence provided of a signed election statement. 3. For patients 1, 2, 5, 6, 7 and 9, the signed copy of patient rights on file was for a home health agency and not specific to the hospice being surveyed.