Every finding on record at Accentcare Hospice & Palliative Care of Houston - South, LLC

It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by document review, clinical record review, and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure accurate documentation of the intent of the patient's advanced directive was included in the plan of care as required by agency policy. Agency policy HOS 2-078 Advance Directives, effective 01/01/2013, revised 06/27/2025, required in part, "At admission, the patient is informed that Agency staff member documents the presence or absence of an Advance Directive and the intent of the patient's advance directive on the comprehensive assessment. The Agency shall request a copy of the patient's Advance Directive to ensure Agency staff understands the patient's wishes. The advance directive will be uploaded to their EMR. The Agency shall communicate the Advance Directive to all staff participating in patient care...Information related to the Advance Directive will be added to the individualized care plan...Advance Directive orders, including a Do Not Resuscitate (DNR) order, must be written and signed by the attending physician/qualified clinician primarily responsible for the patient's care ...The Advance Directive orders, including a DNR order, must be reviewed on each recertification." CLINICAL RECORD 2: The patient elected the hospice benefit on 12/14/2024 and resided in a nursing facility. The Registered Nurse (RN) documented on the nursing admission assessment dated 12/14/2024 that the patient wished to be a do-not-resuscitate (DNR). The initial plan of care dated 12/14/2024 to 03/13/2025 included documentation that the patient as a full code. The physician signed an out of hospital do not resuscitate document and uploaded into the EMR (electronic medical record) on 01/07/2025. The Interdisciplinary Group Meetings from 01/07/2025 through 08/07/2025 included documentation that the patient was listed as both a full code and a DNR. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/06/2025 and resided at home. The RN documented on the nursing admission assessment dated 02/06/2025 that the patient was a full code. The initial plan of care dated 02/06/2025 to 05/06/2025 included documentation that the patient as a full code. An out of hospital do not resuscitate document was signed by the physician on 04/30/2025 and uploaded into the EMR on 05/01/2025. The Interdisciplinary Group Meetings from 05/07/2025 through 07/30/2025 included documentation that the patient was listed as both a full code and a DNR. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/28/2025 and resided at home. The plan of care dated 03/28/2025 to 06/25/2025 included documentation that the patient’s code status was a full code. The physician signed an out of hospital do not resuscitate document on 05/05/2025. The Interdisciplinary Meetings and plan of care updates from 04/09/2025 through 07/30/2025 included documentation that the patient's code status was both a full code and a do-not-resuscitate. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/08/2025 and resided in a nursing facility. The RN documented on the nursing admission assessment dated 05/08/2025 that the patient's do not resuscitate (DNR) status was confirmed by the caregiver/responsible party and that the patient did have a DNR. There was no documented evidence in the clinical record of an out of hospital do not resuscitate document scanned into the clinical record. The Interdisciplinary Meeting and plan of care update dated 05/13/2025 included documentation that the patient's code status was do not resuscitate. However, the RN and the Social Worker listed the patient as a full code in their notes. The Interdisciplinary Meetings from 05/27/2025 through 08/05/2025 included documentation that the patient's code status was do not resuscitate. The RN documented that the patient was a DNR, however, the Social Worker continued to document that the patient was a full code. During a joint clinical record review and interview on 08/13/2025, the Director of Clinical Services (DCS) (Personnel Record 3) confirmed the documentation of the patient’s code status and DNR was inconsistent. The DCS had no explanation for the discrepancy about the patients documented resuscitation status.

It is required that the hospice designates a Registered Nurse member of the IDG (intradisciplinary group) to ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed, the agency did not ensure assessment of patients’ wound(s) was completed as required by agency policy. Agency policy Wound Care: 2005 Protocol, effective 03/18/2005, revised 12/14/2022, required in part "The Hospice nurse will assess wounds at least once per Medicare week." CLINICAL RECORD 9: The patient elected the hospice benefit on 03/28/2025 with diagnoses of hypertensive heart disease with heart failure, Alzheimer’s disease, and chronic respiratory failure with hypoxia. The Registered Nurse (RN) documented on the nursing visit note dated 06/26/2025 the patient had two new wounds, two stage 2 pressure wounds to each buttock measuring 2cm x 1cm x 0.25cm. A physician's order for wound care was documented the same day, to clean the wound with wound cleanser, pat dry, and apply comfort foam/silver. The nurse documented the next wound assessment on the nursing visit note dated 07/08/2025. The wound measured 2cm x 2cm x 0.12cm and the same wound care was performed. The nurse documented on the nursing visit notes dated 07/10/2025, 07/17/2025, 07/24/2025, 07/29/2025, 07/31/2025, and 08/05/2025 that the caregiver performed the wound care and did not document an assessment of the wound during these nursing visits. The nurse did not follow agency policy when the nurse did not document an assessment of the patient’s wound at least once per Medicare week. During a joint clinical record review and interview on 08/13/2025, the Director of Clinical Services (Personnel Record 3) confirmed the nurse had not documented a wound assessment every week as required.

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the plan of care included measurable goals anticipated from implementing and coordinating the plan of care. Agency policy HOS 2-030 The Plan of Care, effective 01/01/2013, revised 09/12/2023, required in part, "...Each patient shall be monitored for their response to care or services provided in relation to their established goals...The written care plan shall contain...Statement of treatment goals..." CLINICAL RECORD 12: The patient elected the hospice benefit on 07/24/2025 with diagnoses of malignant neoplasm of bronchus/lung and malignant neoplasm of the bone. The Registered Nurse documented on the nursing admission assessment dated 07/24/2025 that the patient had dyspnea (shortness of breath) with exertion and the physician ordered Oxygen at two liters per minute per nasal cannula continuously. The nurse documented on the nursing visit note dated 07/28/2025 that the patient had wheezes in the lower right and lower left lobes with a dyspnea score of 4 out of 10. The nurse noted on the Interdisciplinary Group Meeting dated 07/30/2025 that the patient had oxygen saturations of 83% on room air and was now dependent on oxygen at 2 liters per minute continuously. The plan of care dated 07/25/2025 to 10/21/2025 did not include a goal related to the patient’s shortness of breath. During a joint clinical record review and interview on 08/13/2025, the Director of Clinical Services (Personnel Record 3) confirmed that the record did not include measurable goals for the patient’s shortness of breath. MEASURABLE GOAL

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy Hand Hygiene: 4003 Protocol, effective 06/19/2008, revised 06/09/2021, required in part, "Decontaminate the hands using an alcohol-based hand rub, or wash hands with antimicrobial soap and water when the hands are not visibly soiled in the following circumstances...After contact with body fluids or excretions, mucous membranes...When performing patient care and moving from a contaminated body site to a clean-body site (e.g., when moving from the perineal area to the face)...After having contact with inanimate objects (e.g., medical equipment, used linens) ..." HOME VISIT 1: During the home visit observation with Registered Nurse (RN) (Personnel Record 4), the RN untaped the patient's incontinent brief with gloved hands to assess the patient's perineal area. The nurse then reattached the patient's brief and without removing gloves and sanitizing hands, the nurse moved to the patient's left hand for an assessment of skin turgor. The RN recognized this lapse and then removed the soiled gloves and sanitized hands, donned (applied) new gloves and continued with the assessment. HOME VISIT 2: During the home visit observation with the Hospice Aide (HA) (Personnel Record 8), the HA was observed at the end of visit to remove a dirty trash bag from the receptacle with gloved hands. The HA then placed the bag on the tile floor and inserted a new trash bag into the can. The aide did not remove gloves or sanitize hands until she left the patient’s house, and the aide was not observed to sanitize hands until this site visitor brought it up. During home visit observation with Registered Nurse (RN) (Personnel Record 4), the RN untaped the patient's incontinent brief with gloved hands to assess the patient's perineal area. The nurse then reattached the patient's brief and without removing gloves and sanitizing hands, the nurse moved to the patient's left hand for an assessment of skin turgor. The RN recognized this lapse and then removed the soiled gloves and sanitized hands, donned (applied) new gloves and continued with the assessment.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 13 (15%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse developed patient specific care instructions for the hospice aide. Agency policy Hospice Aide Plan of Care: 2112 Protocol, effective 03/22/2016, revised 06/10/2024, required in part, "Registered Nurse (RN)...Documents the Aide Care Plan, including interventions, frequency, and additional instructions, e.g., directions about Oxygen use. If the patient is on continuous oxygen, specific instructions need to be documented in the plan of care for the hospice aide. It is safe to use the oxygen while in the shower by draping the oxygen supply hose safely over the shower door, shower rod, or side of the tub. While washing the patient's face, it is safe to remove the nasal cannula while you do so unless specifically stated not to do so in the plan of care...If HA (hospice aide) POC (plan of care) does NOT meet patient needs: Nurse revises HA POC in EMR (electronic medical record), communicates changes to HA via phone, Documents this communication in EMR..." CLINICAL RECORD 9: The patient elected the hospice benefit on 03/28/2025 with diagnoses of Alzheimer’s disease and chronic respiratory failure with hypoxia. The plans of care dated 03/28/2025 to 06/25/2025 and 06/26/2025 to 09/23/2025 included orders for the Hospice Aide to provide visits to the patient twice a week. The plans of care also included a physician order for Oxygen to be administered to the patient continuously by nasal cannula at three liters per minute. The Hospice Aide plan of care assignment active at the time of the site visit was dated 03/28/2025. The aide was assigned to provide a bed bath and shampoo/hair care, perineal care, catheter care, oral care, clean the patient's nails, dress the patient, change the patient's linens, and turn and position in bed. The aide plan of care included oxygen precautions, but did not include instructions to the aide related to the patient’s oxygen therapy and if the oxygen could be removed while providing cares to the patient. The RN documented on the nursing visit note dated 05/07/2025 that the patient had a blister on the left ankle measuring 0.05cm x 0.05cm x 0.025cm. The nurse documented the site was cleaned with wound cleanser, patted dry, and triple antibiotic ointment was applied. The wound was wrapped with a Kerlix gauze dressing. The wound was active until it was documented as healed on 06/05/2025. Then on 06/25/2025, the RN documented two stage two pressure wounds to each buttock measuring 2.5cm x 3.5cm x 0.25cm. A physician's order for wound care was documented the same day and included to clean the wound with wound cleanser, pat dry, and apply comfort foam/silver. The aide care plan did not include instructions to the aide related to the patient’s wound dressings and did not include instructions for how to care for the dressings while providing cares or if the dressings became soiled, wet or dislodged. CLINICAL RECORD 12: The patient elected the hospice benefit on 07/24/2025 with diagnoses of malignant neoplasm of bronchus/lung and malignant neoplasm of the bone. The plan of care dated 07/25/2025 to 10/21/2025 included an order for the Hospice Aide to provide visits to the patient three times a week. The RN documented on the nursing admission assessment dated 07/24/2025 that the patient had a stage two pressure ulcer on the patient's left greater trochanter measuring 3cm x 3cm x 0cm and documented that the wound was cleansed with wound cleanser, pat dry, apply calcium alginate, and cover with an island dressing. A physician order dated 08/11/2025 included to provide the same treatment three times a week. The Hospice Aide plan of care dated 07/24/2025 and active at the time of review assigned the HA the following tasks to be performed every visit: provide the patient a bed bath, shampoo/hair care, deodorant, skin care (apply lotion, skin protectant, report any new skin breakdown skin tears/lacerations), perineal care, and to turn and position the patient. The aide care plan did not include instructions to the aide related to the patient’s wound dressing and did not include instructions for how to care for the dressing while providing cares or if the dressing became wet or dislodged. During a joint clinical record review and interview on 08/14/2025, the Director of Clinical Services (Personnel Record 3) confirmed the active aide care plans did not address the patients' wounds or the patient's continuous oxygen.

It is required that a Registered Nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 1 (100%) personnel record reviewed for the hospice aide, the agency did not ensure the hospice aide received an annual on-site visit with the Registered Nurse to observe and assess the aide while performing care. Agency policy Competency Assessment of Patient Care Staff: 8049, effective 04/15/2010, last revised 12/27/2024, required in part, "Competency evaluations will be required within the first 90 days for all patient care disciplines who have a license or certification required to do their clinical job. These evaluations will be repeated every three years. Hospice aides are the exception to triennial competencies, as they will receive a competency evaluation prior to providing solo patient care and annually thereafter." PERSONNEL RECORD 8: Hospice Aide date of hire 09/09/2019. Personnel record review revealed no documented evidence of annual aide competency evaluations for May through December of 2023 and for the year of 2024. The COVID-19 Public Health Emergency (PHE) ended on May 11, 2023, that exempted agencies from the requirement of an annual onsite visit by the RN to observe the aide perform care. The emergency waiver directed agencies that annual on-site visits must be completed within 60 days of the end date of the PHE, which was May 11, 2023. The record did include an annual aide competency evaluation dated 05/06/2025. During a joint personnel record review and interview on 08/14/2025, the Director of Business Operations confirmed that the personnel record did not include aide annual competency evaluations for 2023 and 2024.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice did not ensure hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours. During the review of the Volunteer Program and interviews with the Volunteer Services Manager and the Director of Patient Experience, the documentation showed that the agency’s average volunteer percentage rate for 2024 was 1%. The agency acknowledge that the percentage was well below the 5% required and explained that a Performance Improvement Project had been ongoing since January 2025 and remained active at the time of the site visit. Agency growth from an average daily census (ADC) in 2024 of 60 to an ADC of 95 in 2025 had contributed to the struggle to meet volunteer percentage. The Volunteer Services Manager stated that as of July 2025, the volunteer percentage was up to 4%. During the review of the Volunteer Program documents and interviews with the Volunteer Services Manager and the Director of Patient Experience, it was determined that the average volunteer percentage rate for 2024 was 1%. This falls below the targeted 5% volunteer requirement, which prompted the initiation of a Performance Improvement Project that had been ongoing since January 2024 and remained active at the time of the site visit. Agency growth from an average daily census (ADC) in 2024 of 60 to an ADC of 95 in 2025 has contributed to the struggle to meet volunteer numbers. Monthly numbers are reviewed with the recruitment and retention activities, which include using Volunteer Match, local recruiting activities at colleges, and specialty recruitment activities for music volunteers, seamstresses, etc. The agency has a very active retention program and now includes a quarterly volunteer meeting to ensure any news/updates, training, and fellowship. As of July 2025, the volunteer percentage was up to 4%.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure documentation of education provided to the family/caregivers for the safe use of durable medical equipment. Agency policy HOS 2-087 Patient Education Process, effective 01/01/2013, last revised 01/03/2025, required in part, "...the patient and family/caregiver will receive verbal and, as appropriate, written instructions on...Safe, effective use of equipment...Documentation of patient and family/caregiver education will consist of what was taught to the patient; The patient's and/or family/caregiver's response to the teaching; and additional learning needs..." CLINICAL RECORD 9/HOME VISIT 2: The patient elected the hospice benefit on 03/28/2025 with diagnoses of hypertensive heart disease with heart failure, Alzheimer’s disease, and chronic respiratory failure with hypoxia. The Registered Nurse documented on the admission comprehensive assessment that the patient needed a Hoyer lift. The plan of care dated 03/28/2025 to 06/25/2025 included in the durable medical equipment (DME) section an order for a manual lift with a sling. During the home visit observation #on 08/12/2025 with the Hospice Aide (HA) (Personnel Record 8), a Hoyer lift was observed to be present in the patient’s home. There was no documented evidence in the clinical record that the patient and/or caregiver had been instructed to the safe use of the Hoyer lift. During a joint clinical record review and interview on 08/13/2025, the Director of Clinical Services (Personnel Record 3) agreed the clinical record did not include documentation of patient or caregiver education on the Hoyer lift.

It is required that criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 2 (100%) personnel records reviewed for unlicensed staff, the agency did not ensure the staff received a state required background check prior to hire and annually. State regulation required in part, state "regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hiring an individual and on an annual basis to determine if the person is listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and is, therefore, unemployable." PERSONNEL RECORD 10: Volunteer date of hire 02/23/2023. Personnel record review revealed no documented evidence that the Volunteer had been checked against the Employee Misconduct Registry before hire and annually as required by state regulation. During a joint personnel record review and interview on 08/14/2025, the Director of Business Operations confirmed that the personnel record did not include the state required background check.

Based on record review and interview the hospice nurse (RN A) failed to ensure coordination of care with the IDG/IDT for 1 of 5 (Patient #1) patients reviewed whose medication was delayed for 3 days and who refused ADL care. This failure of the RN A to coordinate care with the IDG/IDT could affect any patient admitted with medications or receiving ADL care from the hospice and place them at risk of not having their needs met. --- RR of Intake Report for C#410339 read in part ";hospice is supposed to assist [patient #1] with showing and write out prescriptions, but they are not doing this. It can be three days later when [patient #1) gets her prescriptions... [patient #1] always smells because [patient #1] has accidents. These people (from hospice) are supposed to be going in at least three times a week to give [patient #1] a shower. Yesterday (03/03/23) [patient #1] smelled really bad and there were urine stains on [patient #1]s sheets..." RR policy titled ";Interdisciplinary Group Coordination of care" revised 02-15-23 read in part ";...4. Hospice personnel communicate changes promptly via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications is included in the clinical record on a communication note, interdisciplinary group meeting form, and /or clinical note..." RR of the computerized clinical record for patient #1 revealed a start of care date of 2-3-23. Primary diagnosis listed as Hypertensive Heart Disease without Heart Failure and Acute Kidney failure. RR of SOC assessment date 2-3-23 completed by RN A revealed SN frequency of 2w1,1w13, 3 PRN and HA frequency of 1w1, 2w12 and 1w1. Further review under the section ";Assessment: ADL requiring assistance – bathing, dressing, grooming and toileting" and under the section ";medication reconciliation" – medication review complete-yes, reviewed current medication regimen, interactions, side effects with pharmacy, hospice physician/attending physician patient/family/caregiver..." There was no documentation that medications were to be brought in by patient # 1 friends or family. Further review of SOC assessment revealed ";Provided an overview of Hospice Services/benefit...Hospice role in providing ...medications...Patient reporting pain to BLE knees and left shoulder with activity. Patient reporting insomnia alleviated with Seroquel that she had run out of." RR of skilled nurse visit note written by RN B report dated 2-4-23 revealed there was no documentation of any issues with medications or pain . Further review revealed patient #1 insomnia score was a 5 out of 10 with 5 being the worst level in the last 24 hours. RR of client episode coordination note dated 2-5-23 written by RN B documented "; late note for visit completed on 2-4-23-...reported no pain at time of visit, but reported insomnia alleviated with Seroquel. Comfort kit not at facility..." RR of skilled nurse visit note report dated 2-6-23 written by RN C documented under the section ";medication reconciliation- medications to be delivered today." Further review of visit note revealed a new order for Seroquel 25 mg for sleep. During an interview on 5-4-23 at 10:28 am the resident care coordinator at the assisted living where patient #1 lived stated when patient #1 was admitted to hospice the patient had no pain medication or sleep medication. The resident care coordinator further stated that the patient was requesting her sleeping medication and it took the Hospice three days to send the medications. The resident care coordinator stated when she talked to RN A about it, she said she forgot to order the medications. RR of IDG comprehensive assessment and plan of care update report dated 2-15-23 documented the medications the agency was responsible for providing was listed as follows: Acetaminophen 650 mg rectal suppository every 6 hours for fever or pain Aspirin 81 mg daily for heart Bisacodyl 10 mg rectally for constipation prn Furosemide 20 mg daily for edema Glycopyrrolate 1 mg every 6 hours for secretions prn Lisinopril 20 mg daily for hypertension Lorazepam 0.5 mg every 4 hours anxiety/insomnia prn Melatonin 10 mg at bedtime for insomnia Morphine concentrate 0.25 ml every 3 hours pain/dyspnea prn Haloperidol lactate 2 0.5ml every 6 hours agitation, hallucination, nausea prn Prochlorperazine Maleate 10 mg every 6 hours nausea, vomiting prn Tizanidine 2mg daily for pain Tramadol 50 mg every 8 hours pain prn Seroquel 25 mg at bedtime for sleep. During an interview with RN A on 5-4-23 at 11:01 AM. RN A stated she had to order patient #1 medications due to some extenuating circumstances because patient #1 told her that her landlord/neighbor was supposed to bring her medications [ from home]. The landlord/neighbor did not end up bringing the medications. RN A stated she could not remember how many days patient #1 went without medications. RN A stated the normal practice is to actually see the medications that the patient has in order to determine what medications are needed and either have the family member to pick up the needed medications from the pharmacy or order from the Hospice pharmacy to be delivered. When questioned further RN A stated she believed she admitted patient #1 on a Friday and patient #1 did not receive her medications for a few days. RR of IDG/IDT comprehensive assessment dated 2-15-23 and electronically signed by RN A revealed no evidence that the IDG/IDT was informed that there was a delay in patient #1 getting medications delivered. RR of Hospice aide care plan report dated 2-3-23 read HA frequency of 1w1, 2w12 and 1w1. HA to complete bathing, hair car, skin care , shampooing every visit. RR HA visit notes revealed visits were made on 2-14-23 and 2-16-23. Further review of the 2-16-23 visit note revealed patient #1 refused a bath that day. RR order dated 2-20-23 taken by RN A read ";DC aide per patient request...no visits requested/scheduled " During an interview on 5-4-23 at 10:28 am the resident care coordinator at the assisted living where patient #1 lived stated their facility did not get any notification that the HA was not going to come visit patient #1. The resident care coordinator further stated it took the facility complaining for 2 weeks for the hospice agency to send a HA. During an interview with RN A on 5-4-23 at 11:01 AM. The RN stated patient #1 refused every visit. RN A further stated that the first 2 weeks patient #1 did not shower at all with the HA or facility staff. RR of skilled nurse visit notes dated 2-4-23, 2-6-23, 2-14-23 and 2-20-23 revealed no evidence that patient #1 was refusing HA visits or baths. RR of IDG/IDT comprehensive assessment dated 2-15-23 and electronically signed by RN A revealed no evidence that the IDG/IDT was informed that patient #1 was refusing HA visits. RR of IDG/IDT comprehensive assessment dated 3-1-23 and electronically signed by RN A read ";D/C aide per patient request...aide care plan updated during past 2 weeks, if applicable (include missed visits, refusal of care, new needs identified):" There was no documentation of any refusals on IDG/IDT. During an interview 5-4-23 at 2:00 pm the supervising nurse stated that the hospice orders the hospice comfort kit depending on where they are being admitted from. When the hospice admits a patient the nurse will see what medications are on hand if there is anything the patient does not have the Hospice can order the medications and have it there the next day and the family or patient will be made aware that the med will not be there , if the patient needs the medication the Hospice will use a local pharmacy to have the medication there the same day. The supervising nurse stated she was not aware of what time patient #1 was admitted but whatever medications she was missing RN#1 could have called the facility pharmacy to see what their cut off time for delivery was [ and ordered the medications] or the medications could have been order from a local pharmacy. Concurrent review of HA visits on agency computerized system revealed 2 HA visits dated 2-9-23 and 2-10-23 without any notes attached. The supervising nurse stated the dates were green on the computer because the visits were not documented. The supervising nurse further stated if patient #1 was refusing care there should have been documentation of the refusals and the IDG/IDT should be informed.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, documents, observation and interviews. The Agency Plan of Care Policy Policy #214, "Plan of Care (Revised: 2/21/20)," stated in part, "Procedures: b. Based on the information gathered in the comprehensive assessment, the POC will be updated to reflect patient and family goals and will include all interventions needed to address the problems identified in the comprehensive assessment." 4 of 13 (31%) clinical records reviewed revealed the plan of care (POC) lacked patient goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 10: The patient was admitted on 2/11/22. The certificate of terminal illness (CTI) dated 2/11/22 for the certification period 2/11/22 - 8/9/22 stated the patient had a tracheotomy placed on 12/2021. The IDG POC dated 2/11/22 lacked a goal and interventions for the tracheotomy. Clinical Record 1: The patient was admitted on 6/21/22. The oxygen was noted in the home during the patient observation on 9/27/22. The IDG POC lacked a goal and interventions for oxygen. Clinical Record 8: The patient was admitted on 9/27/21. A physician order dated 7/25/22 gave wound care orders for three (3) wounds. The interdisciplinary group (IDG) POC dated 7/9/22 lacked the goals and interventions for the three (3) wounds. Clinical Record 3: The patient was admitted on 2/19/22. The CTI dated 8/3/22 for the certification period 8/18/22 - 10/16/22 stated the patient had bowel and bladder incontinence. The IDG POC dated 8/16/22 lacked a goal and interventions for bowel and bladder incontinence. Director of Clinical Services Interview During the interview on 9/27/22, the Director of Clinical Services reviewed and agreed with the above findings.