Every finding on record at Alternative Hospice, LLC

Based on policy review, contract review, record review, and interview, the hospice provider failed to ensure:- The patient rights to receive effective pain management from the hospice for conditions related to the terminal illness (L0512).The cumulative effect of this deficient practice has the potential to affect all the patients served by the provider.

Based on policy review, contract review, record review and interview, the hospice failed to ensure patients’ rights to effective pain and symptom management by failing to provide timely access to medications, failing to ensure timely nursing response after hours, and failing to coordinate services necessary to prevent unnecessary pain and distress.  These failures resulted in unmanaged symptoms in, two of three patient records reviewed (RECORD/PATIENT #1 and #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings Included: Review of the provider's policy titled, "After Hours Accessibility," revised June 2019, showed in part the following:- Nursing services, physician services and drug and biologicals are routinely available on 24-hour basis 7 days a week; and- Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family.Review of the provider's policy titled, "Coordination of Patient Care," revised June 2019, showed in part the following:- Ensure that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs; and- Care will be coordinated with other involved external organizations such as pharmacy companies. Review of the provider's policy titled, "Nursing Services," revised February 2025, showed in part the following:- Patients receiving nursing services will have appropriate assessments and reassessments of the patient’s needs; and- Responsibilities include informing the physician, medical director, interdisciplinary group (IDG) and other staff of changes in the patient’s needs. Review of the provider's policy titled, "Medication Dispensing," revised June 2019, showed in part, the following:- Hospice staff will order medications from the contracted pharmacy in advance of patient’s need to assure timely delivery of medications; and- Hospice medications are to be available 24 hours per day, 7 days per week through contracted pharmacy providers. Review of the hospice’s contracted pharmacy agreements showed that the pharmacies’ hours of operation were limited to daytime and weekend hours.  None of the agreements included provisions for 24-hour medication dispensing or delivery.  The agreements included only 24-hour on-call pharmacist availability, which does not ensure 24-hour access to medications. RECORD/PATIENT #1:Review of the medical record showed the patient was admitted to hospice services on 02/26/2026 with a terminal diagnosis of heart failure (a decrease in the ability of the heart to pump blood).  The patient resided in a long-term care facility (LTCF) and died on 03/01/2026.Review of the physician orders dated 02/26/2026 showed morphine sulfate (Roxanol) (used to treat moderate to severe pain) 5 milligrams (mg) sublingual every 2 (two) hours as needed for pain or dyspnea (shortness of breath) and lorazepam (Ativan) (antianxiety) 0.5 mg sublingual every 4 (four) hours as needed for anxiety/restlessness.Review of the on-call log dated 2/27/2026 at 9:34 AM, documented events from the night of 02/26/2026, showed the following:- The LTCF was locked out of the stat (for immediate use) drug machine (the LTCF medication supply that was not provided by hospice. The hospice provider had the orders for the medication but had not delivered the medication to the patient);- The hospice nurse obtained temporary orders;- The family became upset and considered sending the patient to the emergency room (ER);- The hospice nurse believed the patient was anxious and “did not need morphine”; and- The LTCF eventually accessed the stat drug machine. Review of the on-call report dated 3/2/2026 at 8:45 AM, showed:- The patient’s daughter called on 02/27/2026 requesting an increase in morphine due to the patient was crying and had discomfort;- The hospice nurse relied on LTCF nurse’s assessment; and- Ativan was given and the hospice staff failed to assess the patient. During an interview on 03/18/2026 at 11:25 AM, the reporter stated that:- The LTCF medication system locked up;- The patient was in excruciating pain for several hours and the family also reported the patient was having chest pain;- The daughter called hospice around 9:00 PM or 10:00 PM, hospice did not send a nurse;- The hospice indicated they were not contracted with a 24-hour pharmacy;- The hospice offered no advice or follow-up;- The reporter advised the daughter to call emergency medical system (EMS);- The LTCF eventually accessed the medication and the patient became comfortable; and- The hospice nurse visited the next day (02/28/2026). During interview on 03/23/2026 at 12:29 PM, the on-call nurse stated that:- The patient was admitted after 4:00 PM and the comfort kit was delivered the next morning;- The physician sent the patient’s medication orders to the hospice’s usual contracted (named) pharmacy; and- There was a separate pharmacy identified as a potential 24-hour option. Review of the hospice’s contracted pharmacy agreements provided by the hospice provider showed that none of the pharmacies provided 24-hour medication dispensing or delivery. During an interview on 03/23/2026 at 1:12 PM, hospice registered nurse (RN) A stated that:- The patient arrived after 4:00 PM and the LTCF was busy;- The comfort kit was not delivered that night;- The family called at 9:30 PM reporting the LTCF could not access the emergency kit;- The nurse did not visit and relied on the LTCF assessment;- The family reported chest pain, and the nurse did not assess;- The nurse acknowledged he/she should have made a visit; and- There was no 24-hour pharmacy available locally. During interview on 03/24/2026 beginning at 10:35 AM, the clinical director stated that:- There was a 24-hour (named) pharmacy;- He/she was not made aware of the facility's inability to access the stat kit;- The pharmacy contract required a 90-minute delivery timeframe; and- He/she would expect a visit for uncontrolled pain. During an interview on 03/23/2026 at 12:29 PM, the administrator stated that:- After-hours nursing visits are often determined based on whether the facility or family requests a visit; and- The patient was admitted after 4:00 PM and the comfort kit was not delivered until the following morning.  RECORD/PATIENT #2;Review of the patient’s medical record showed the patient was admitted to hospice on 1/19/2026 with a terminal diagnosis of unspecified severe protein-calorie malnutrition.  Other diagnoses included heart disease and heart failure.  The patient lived in a LTCF and died on 03/21/2026.Review of the on-call record dated 02/16/2026 at 8:30 AM, showed that:- On 02/15/2026 (evening) the patient complained of chest pain;- The LTCF did not have any as needed (PRN) medications available to control symptoms; and- The hospice nurse instructed the LTCF to lay the patient down (there was no further follow up by the hospice nurse until the next day). Review of the nurse note dated 02/16/2026 at 8:10 AM, showed that:- The patient reported left-sided chest pain over the weekend;- Pain noted upon touch under the left arm/rib area; and- A chest x-ray was ordered. Review of a chaplain note dated 02/16/2026 at 11:10 AM showed the patient reported slight chest pain.  During interview on 03/26/2026 at 7:37 AM, the clinical director stated that he/she would have expected the nurse to have a made a visit.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the comprehensive assessment included an assessment of all the physical needs of the patient in one of five full records reviewed (Record/Patient # 5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider's policy titled, "Initial Assessment / Comprehensive Assessment," revised 02/2025, showed in part the following:- Each patient admitted will receive a comprehensive assessment; and- The comprehensive assessment will identify the patient’s physical care needs. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of bladder cancer. The patient resided at home with family support.Review of the registered nurse (RN) initial assessment, dated 01/30/2026, showed the following:- Hospice pain assessment section failed to include the location of the patient’s pain;- Hospice gastrointestinal assessment section showed the patient had a colostomy (a surgical opening in the abdominal wall (stoma - typically a red and moist opening on the surface of the abdomen) used to expel waste from the large intestines). The assessment failed to identify the location of the colostomy, the appearance of the stoma, if the colostomy was covered with a collection bag, or the appearance / absence of waste excreted from the colostomy; and- Hospice genitourinary assessment section showed the patient had an ileostomy (a surgical opening in the abdominal wall (stoma) that brings the small intestine (ileum) to the surface and produces continuous, liquid, and acidic waste). The assessment failed to include a location of the ileostomy, the appearance of the stoma, if the ileostomy was covered with a collection bag, or the consistency and appearance of the drainage coming from the ileostomy.During an interview on 02/19/2026 at 2:15 PM, the hospice administrator designee stated that he/she would expect the location of pain and a full assessment of the colostomy and ileostomy to be documented.

Based on policy review, record review, home visit observation, and interview the hospice provider failed to ensure an accurate/updated medication profile was maintained in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider.Findings included: --- During an interview on 02/18/2026 at 2:30 pm the registered nurse coordinator (RNC) stated that skilled nursing staff are responsible to follow the hospice provider's policy regarding medication reconciliation. The staff are directed to compare the patient's medication bottle(s) to the most current medication list to ensure accuracy once each week. This process is completed in the patient's home or nursing facility. If discrepancies are discovered, staff are directed to contact the patient's physician for resolution of the discrepancy.  Review of the provider’s policy titled, “Medication Reconciliation,” revised June 2019, showed in part:- Medications ordered while the patient is receiving care will be compared to the medication list/profile.  The medication list/profile will be updated with each new or changed medication; and- When a patient is transferred to another organization, Hospice will fax a copy of the patient’s current medication list/profile to the organization and inform the organization how to obtain clarification regarding the reconciled list of medications.  Such communication is documented. Review of the provider’s policy titled, “Care to Residents of SNF/NF or ICF/IID,” (skilled nursing facility/nursing facility or intermediate care facility for individuals with intellectual disabilities) revised February 2025, showed in part, the named hospice will provide to the SNF/NF the following information:- The most recent hospice plan of care specific to each patient; and- The hospice medication information specific to each patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 12/19/2025, with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient lived in a skilled nursing facility (SNF).  Review of the current hospice medication profile showed in part the following:- Atropine ophthalmic solution 1% 2 (two) drops SL (sublingual) every 4 (four) hours as needed for excess secretions;- Magnesium hydroxide (Milk of Magnesia Suspension) 400 mg/5mL 30 mls PO (by mouth) once per day;- Acetaminophen 325 mg (milligrams) 2 (two) tables PO (by mouth) every 6 (six) hours, do not exceed 3 grams/24 hours;- Barrier cream apply topically PRN (as needed) after peri-care for redness/irritation every 8 (eight) hours; and- Lotion apply topically prn for dry skin once a day. Review of the current SNF’s medication orders and Medication Administration Record (MAR) showed in part the following:- Atropine 1% eye drops (Atropine Sulfate) 1-2 (one to two) drops sublingually (medication placed under the tongue) every 4 (four) hours as needed for secretions (the facility list had 1-2 drop range instead of the 2-drop dose on the hospice list);- Milk of Magnesia 400 mg/5 milliliters (ml) oral suspension (Magnesium Hydroxide) 30 ml by mouth as needed constipation (the facility list failed to include the timeframe of once per day); and- Tylenol 325mg tablet (acetaminophen) 2 tablets by mouth as needed pain (the facility list failed to include timeframe of every 6 (six) hours). The provider failed to reconcile the medications, which showed three medications failed to have a time frame for administering prn medications on the SNF’s record, and failed to include two treatments listed on the providers record but not listed on the SNF’s record.

Based on policy review, record review, and interview, the provider failed to ensure that each patient received an individualized initial or revised plan of care (POC) in four of five full records reviewed (Records/Patients #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/12/2025 with a terminal diagnosis of protein-calorie malnutrition, and additional diagnoses of diabetes mellitus type 2 (a chronic disease that affects how the body uses sugar for energy), and depression. The patient resided with an adult sibling caregiver.Review of five skilled nurse visit notes with a date range of 01/19/2026 through 02/03/2026 showed the nurse documented that the patient's blood glucose was obtained.Review of the updated POC dated 01/20/2026 showed the care need (care plan) section failed to include an endocrine care need with goals and interventions related to the patient's diagnosis of diabetes; included a depression care need that failed to include a goal or intervention, and included an anticipatory grief care need that failed to include a goal or intervention. No additional orders were noted on the POC and no interim orders related to checking the patient's blood glucose were provided. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of bladder cancer. The patient resided at home with family support.Review of the Registered Nurse (RN) Initial Assessment, dated 01/30/2026, showed the following:- Patient had a colostomy (a surgical opening in the abdominal wall (stoma - typically a red and moist opening on the surface of the abdomen) used to expel waste from the large intestines),  an ileostomy (a surgical opening in the abdominal wall (stoma) that brings the small intestine (ileum) to the surface and produces continuous, liquid, and acidic waste), three pressure ulcers (one stage 1 and two stage 2), and had pain; and- The RN assessed the patient’s pain, but failed to assess/document the location of pain; and - The RN documented that wound care was provided to the three pressure ulcers.Review of the initial POC dated 01/30/2026 through 04/29/2026 showed the document included a colostomy/ileostomy care need that failed to include a goal or intervention, a pain care need that failed to include goals or interventions, and the document failed to include an integumentary care need with goals and interventions for the pressure ulcers. No additional orders were noted on the POC, and no interim orders were provided, for colostomy/ileostomy, pain, or wound care.Review of the updated plan of care dated 02/05/2026 failed to include any new orders or care needs with goals or interventions for the colostomy/ileostomy, pain, or integumentary/wounds.During an interview on 02/19/2026 at 2:15 PM, the hospice administrator designee stated that he/she would expect orders to be in the record. Findings included: Review of the provider’s policy titled, "Physician Orders" revised 02/2025, showed, in part:The plan of care (POC) may include:Types of services required;Specific procedures deemed essential;Medications and treatments;Equipment and supplies required (including flow rate, delivery device, hours of use etc.;Expected goals or outcomes to be achieved;Care and services provided will be provided according to physician orders; andOrders are current and updated.  RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 08/15/2024 with a terminal diagnosis of Alzheimer's disease (a disease marked by progressive loss of mental capacity). The patient lived in a specialized memory care unit of a Skilled Nursing Facility (SNF).Review of the Medication Administration Record dated 02/2026 showed hospice and facility staff shared the responsibility of wound care of the patient's wound located on the right cheek of the face. The treatment order dated 2/11/2026, showed staff were directed to clean the wound with wound cleanser, apply Mupirocin (an anti-bacterial ointment) to the wound bed, apply zinc oxide (an antiseptic ointment) to the peri-wound, then cover with a gauze dressing, and affix with adhesive tape once each day.Review of the patient's Plan of Care (POC) dated 02/06/2026 to 04/06/2026 failed to show the wound care treatment as an intervention as part of the POC for the problem of impaired skin integrity identified by the provider on 05/27/2025.During an interview on 02/18/2026 at 2:30 pm the registered nurse coordinator (RNC) stated that all interventions including the wound care treatment should be included in the patient's impaired skin integrity POC. The RN supervisory nurse stated the omission was probably hospice staff failing to save the order / intervention when updating the POC. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 12/18/2025 with a terminal diagnosis of vascular dementia (a decline in mental capacity). The patient lived at home with daughters as primary caregivers.Review of the Physician's Order Sheet (POS) dated 02/09/2026 showed an order for a urinary catheter to be placed for urinary incontinence. The order read as follows: May place foley (a brand of urinary catheter) 18 French for comfort. Change PRN (as needed) leaking or clogged. May flush PRN with 60 ml (milliliters) of normal saline if needed or clogged.Review of the patient's Plan of Care (POC) dated 12/18/2026 to 03/17/2026 showed the hospice staff identified the patient's problem of genitourinary / catheter. The intervention read as follows: SN (Skilled Nursing) will replace 18 French foley if clogged, flush with 60 cc (cubic centimeters) of sterile water PRN. The POC failed to show the intervention as the physician order as written.During an interview on 02/18/2026 at 2:30 pm the registered nurse coordinator (RNC) stated that all interventions and physician orders should match on the patient's POC.    Findings included:Review of the provider’s policy titled, "Physician Orders" revised 02/2025, showed in part the plan of care (POC) may include:- Types of services required;- Specific procedures deemed essential;- Medications and treatments;- Equipment and supplies required (including flow rate, delivery device, hours of use etc.);- Expected goals or outcomes to be achieved;- Care and services provided will be provided according to physician orders; and- Orders are current and updated.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 08/15/2024 with a terminal diagnosis of Alzheimer's disease (a disease marked by progressive loss of mental capacity). The patient lived in a specialized memory care unit of a skilled nursing facility (SNF).Review of the medication administration record dated 02/2026, showed hospice and facility staff shared the responsibility of wound care of the patient's wound located on the right cheek of the face. The treatment order dated 2/11/2026, showed staff were directed to clean the wound with wound cleanser, apply mupirocin (an anti-bacterial ointment) to the wound bed, apply zinc oxide (an antiseptic ointment) to the peri-wound, then cover with a gauze dressing, and affix with adhesive tape once each day.Review of the patient's POC, dated 02/06/2026 to 04/06/2026, failed to show the wound care treatment as an intervention as part of the POC for the problem of impaired skin integrity identified by the provider on 05/27/2025.During an interview on 02/18/2026 at 2:30 PM, the registered nurse coordinator (RNC) stated that all interventions, including the wound care treatment, should have been included in the patient's impaired skin integrity POC. The RNC stated that the omission was probably hospice staff failing to save the order / intervention when updating the POC.RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/12/2025 with a terminal diagnosis of protein-calorie malnutrition and additional diagnoses of diabetes mellitus type 2 (a chronic disease that affects how the body uses sugar for energy), and depression. The patient resided with an adult sibling caregiver.Review of five skilled nurse visit notes, with a date range of 01/19/2026 through 02/03/2026, showed the nurse documented that the patient's blood glucose was obtained.Review of the updated POC dated 01/20/2026, showed the care need (care plan) section failed to include an endocrine care need with goals and interventions related to the patient's diagnosis of diabetes; included a depression care need that failed to include a goal or intervention, and included an anticipatory grief care need that failed to include a goal or intervention. No additional orders were noted on the POC and no interim orders related to checking the patient's blood glucose were provided.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 12/18/2025 with a terminal diagnosis of vascular dementia (a decline in mental capacity). The patient lived at home with daughters as primary caregivers.Review of the physician's order sheet (POS), dated 02/09/2026, showed an order for a urinary catheter (a sterile tube placed in the bladder to drain urine) to be placed for urinary incontinence. The order read as follows: May place Foley (a brand of urinary catheter) 18 french for comfort. Change PRN (as needed) leaking or clogged. May flush PRN with 60 milliliters (ml) of normal saline if needed or clogged.Review of the patient's plan of care (POC) dated 12/18/2026 to 03/17/2026 showed the hospice staff identified the patient's problem of genitourinary / catheter. The intervention read as follows: SN (Skilled Nursing) will replace 18 French foley if clogged, flush with 60 cc (cubic centimeters) of sterile water PRN. The POC failed to show the intervention as the physician order was written.RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of bladder cancer. The patient resided at home with family support.Review of the Registered Nurse (RN) Initial Assessment, dated 01/30/2026, showed the following:- Patient had a colostomy (a surgical opening in the abdominal wall (stoma - typically a red and moist opening on the surface of the abdomen) used to expel waste from the large intestines),  an ileostomy (a surgical opening in the abdominal wall (stoma) that brings the small intestine (ileum) to the surface and produces continuous, liquid, and acidic waste), three pressure ulcers (one stage 1 and two stage 2), and had pain; and- The RN assessed the patient’s pain, but failed to assess/document the location of pain; and - The RN documented that wound care was provided to the three pressure ulcers.Review of the initial POC dated 01/30/2026 through 04/29/2026 showed the document included a colostomy/ileostomy care need that failed to include a goal or intervention, a pain care need that failed to include goals or interventions, and the document failed to include an integumentary care need with goals and interventions for the pressure ulcers. No additional orders were noted on the POC, and no interim orders were provided, for colostomy/ileostomy, pain, or wound care.Review of the updated plan of care dated 02/05/2026 failed to include any new orders or care needs with goals or interventions for the colostomy/ileostomy, pain, or integumentary/wounds.During an interview on 02/18/2026 at 2:30 PM the registered nurse coordinator (RNC) stated that all interventions and physician orders should match on the patient's POC.During an interview on 02/19/2026 at 2:15 PM, the hospice administrator designee stated that he/she would expect orders to be in the record.

Based on policy review, record review, and interview, the hospice provider failed to revise the hospice plan of care to reflect changes that occurred in the facility where respite care was provided in one of two respite records reviewed (Record/Patient #7). This deficient practice has the potential to affect all patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Physician Orders,” revised 02/2025, showed in part that orders would be current and updated. RECORD/PATIENT #7:Review of the clinical record showed the following:- A skilled nurse (SN) visit note, dated 11/17/2025, that showed the patient was transferring to a long-term care facility (LTCF) for respite care related to increased care needs and caregiver strain; - A SN visit note dated 11/18/2025, that showed the patient had a productive cough with green phlegm and the SN obtained an order for Levaquin (an antibiotic) 500 milligrams (mg) daily for five days; - A LTCF summary report that showed an order, dated 11/18/2025, for levofloxacin (another name for Levaquin) 500 mg daily for seven days; an order dated 11/20/2025 to increase Roxanol (narcotic pain medication) 20 mg/milliliter (ml) from 0.25 ml to 0.5 ml every two hours as needed for pain; and an order dated 11/20/2025 to increase lorazepam (antianxiety medication)  2 mg/ml from 0.25 ml to 0.5 ml every three hours as needed for restlessness or agitation; and- The hospice updated plan of care/IDG (interdisciplinary group known by the provider as interdisciplinary team, IDT) note dated 11/25/2025 failed to include the orders for Levaquin, the increased dose of Roxanol, or the increased dose of lorazepam.During an interview on 02/20/2026 at 10:00 AM, the hospice administrator designee stated that he/she agreed that the information was missing from the IDG note and he/she was unable to find additional clarifying information.

Based on policy review, record review, and interview, the hospice provider failed to ensure that care and services were provided in accordance with the plan of care in two of five full records reviewed (Records/Patients #3 and #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider's policy titled, "Nursing Services," revised 02/2025, showed in part, nursing care will be provided in accordance with the patient’s IDG (interdisciplinary group) plan of care.RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/12/2025 with a terminal diagnosis of protein-calorie malnutrition, and additional diagnoses of diabetes mellitus type 2 (a chronic disease that affects how the body uses sugar for energy), and depression. The patient resided with an adult sibling caregiver.Review of five (5) skilled nurse (SN) visit notes, with a date range of 01/19/2026 through 02/03/2026, showed the nurse obtained a blood glucose level at each visit.Review of the plan of care dated 11/10/2025 through 02/07/2025, the updated plan of care/ IDG (known by the provider as IDT-interdisciplinary team) note dated 01/20/2026, and the updated plan of care/IDG note dated 02/03/2026 showed the plan of care and updated plan of care/IDG notes failed to include an order for the SN to obtain a blood glucose level. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of bladder cancer. The patient resided at home with family support.Review of the registered nurse (RN) initial assessment, dated 01/30/2026, showed the following:- Patient had: * A colostomy (a surgical opening in the abdominal wall used to expel waste from the large intestines) * An ileostomy (a surgical opening in the abdominal wall that brings the small intestine (ileum) to the surface and produces continuous, liquid, and acidic waste) * One stage 1 pressure ulcer (skin injury caused by unrelieved pressure that presented as a persistent area of skin redness without a break in the skin and does not disappear when pressure is relieved * Two stage 2 (a partial thickness loss of skin) pressure ulcers * Pain - The RN assessed the patient’s pain, but failed to assess/document the location of pain; and - The RN documented that wound care was provided to the three pressure ulcers.Review of the initial POC dated 01/30/2026 through 04/29/2026, showed the document failed to include orders related the care of the colostomy, ileostomy, or the pressure ulcers. Review of the updated plan of care dated 02/05/2026 showed the document failed to include any orders for the colostomy, ileostomy, or wound care for pressure ulcers. No interim orders were provided for the colostomy, ileostomy, or wound care for pressure ulcers.During an interview on 02/19/2026 at 2:15 PM, the hospice administrator designee stated that he/she would expect orders to be in the record.

Based on policy review, record review, and interview, the hospice provider failed to show evidence/documentation that the hospice plan of care (POC) was provided to the long-term care facility (LTCF) in one of two respite records reviewed (Record/Patient #7). This deficient practice has the potential to affect all the patient's served by the provider. --- Findings included:Review of the provider's policy titled, "Inpatient Care and Respite," revised 02/2025, showed in part that the hospice provider would provide a copy of the patient's POC to the facility providing respite care to ensure care is furnished in accordance with the plan. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to the LTCF for a respite stay on 11/17/2025 due to increased care needs and caregiver strain. The clinical record failed to contain documentation to show that the hospice provided the patient's current POC to the LTCF.During an interview on 02/20/2026 at 10:00 AM, the hospice administrator designee agreed that the information was missing from the record, and the registered nurse coordinator stated that he/she called the LTCF, and they were unable to find a copy.

Based on review of the medical director contract, review of the medical director job description, record review and interview, the provider failed to ensure the medical director assumed overall responsibility for the medical component of the provider's patient care program, including all multiple locations.  This deficient practice has the potential to affect all patients the provider serves in all locations.  Findings included: --- Review of the medical director contract with the provider titled, “Associate Medical Directorship Agreement,” effective 05/01/2017, and signed by the designated medical director, showed that the named hospice contracts with the physician to assume responsibility for the medical component of hospice’s patient care program in accordance with the requisite of State law and the Medicare and Medicaid conditions of participation for hospice agencies.  Review of the medical director job description, dated 2009, showed in part the duties and responsibilities of the medical director included:- To oversee the implementation of the entire physician, nursing, social work, therapy and counseling areas within the named hospice to ensure that these areas consistently meet patient and family needs;- Assumes overall responsibility for the medical component of the named hospice patient care program;- Provides medical consultation and direction when the attending physician or their designee cannot be reached and there is a change in the patient’s condition requiring medical attention; and- When the medical director is not available, a physician designated by the named hospice assumes the same responsibilities and obligations as the medical director.   Review of the three patient lists for the provider's three locations, dated 02/17/2026, showed the medical director was not listed as a patient physician at two of the three hospice locations.  During an interview on 02/19/2026 at 2:50 PM, the administrator designee and the registered nurse coordinator stated that:- The medical director was not involved in the hospice multiple location-1 area or hospice multiple location-2 area, he/she was the physician for the patients served out of the main (parent) hospice location;-  Physicians A and B were contracted by the provider that served the patients in hospice multiple location-1, and physician C was contracted by the provider to serve the patients in the hospice multiple location-2; and- The medical director did not supervise the other contracted physicians, they operated autonomously.

Based on policy review, record review, and interview, the hospice provider failed to ensure that staff submitted complete documentation timely in two of five full records reviewed (Records/Patients #3 and #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider's policy titled, "Timely Submission of Patient Documentation," revised 06/2019, showed in part, that all visit reports must be submitted the next scheduled work day, not exceeding three business days.RECORD/PATIENT #3:Review of the clinical record showed the following late documentation:- Licensed practical nurse (LPN) conducted a visit on 01/19/2026. The documentation was completed 01/24/2026;- Chaplain conducted a visit on 01/19/2026. The documentation was completed 01/25/2026;- LPN conducted a visit on 01/20/2026. The documentation was completed on 01/25/2026;- LPN conducted a visit on 01/22/2026. The documentation was completed on 01/31/2026;- LPN conducted a visit on 01/27/2026. The documentation was completed on 02/03/2026;- LPN conducted a visit on 01/29/2026. The documentation was completed on 02/03/2026; and - LPN conducted a visit on 02/03/2026. The documentation was completed on 02/11/2026.RECORD/PATIENT #5:Review of the clinical record showed the following late documentation:- An aide visit was conducted 02/09/2026. The documentation was completed 02/16/2026.- There were three skilled nurse visits missing from the record. One during the week of 02/02/2026 and two during the week of 02/08/2026.During an interview on 02/20/2026 at 9:40 AM, the hospice registered nurse (RN) coordinator stated that the visits have been conducted by the RN but the documentation was late.

Based on policy review, home visit observation, and interview, the provider failed to ensure the skilled nursing facility (SNF) patient record contained a copy of all required hospice documents in one of two home visits of patients that resided in a SNF (Record/Patient #1).  This deficient practice has the potential to affect all the provider's patients who reside in a SNF. Findings included: --- Review of the provider’s policy titled, “Care to Residents of a SNF/NF or ICF/IID,” (SNF/nursing facility or intermediate care facility for individuals with intellectual disabilities) revised 02/2025, showed in part the (named hospice) will provide the SNF/NF with the most recent hospice plan of care specific to each patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 12/19/2025, with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient lived in a SNF.  Observation on 02/19/2026, at 11:30 AM, when reviewing the hospice's facility binder, showed the binder failed to contain the current hospice updated plan of care, but contained only the original plan of care dated 12/19/2025.  During an interview on 02/20/2026, at 11:03 AM, the registered nurse coordinator stated that he/she would expect the updated plan of care to be in the facility binder, as the updated plan of care was sent to the facility every two weeks.

Based on policy review, record review, observation, and interview the agency failed to ensure that the medication profile included all medications prescribed by the physician for three (Records/Patients #1, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- PATIENT/RECORD #4: Review of the clinical record showed the following: -The agency's medication list contained the following orders: *Atropine ophthalmic solution- 2 drops sublingually (under the tongue) every 4 hours as needed for excess secretions; and *Lorazepam concentrate- 2 milligrams/milliliter (mg/ml) 0.25ml sublingually every 3 hours as needed for restlessness/anxiety/nausea. -The facility's medication list contained the following orders: *Oxygen 2-5 liters per minute (lpm) nasally as needed for shortness of breath; *Lorazepam 0.5 mg tablet- take one tablet by mouth every 3 hours as needed for anxiety; *Loperamide (used to treat diarrhea) 2 mg tablet- take one tablet by mouth every 3 hours as needed for loose stool; and *Atropine ophthalmic solution- 1-2 drops sublingually every 4 hours as needed for secretions. -The agency failed to ensure the medication lists were updated and accurate. Findings included: Review of the agency's policy titled, "Patient Record Content," dated 2017, showed in part that each patient record will contain a current medication profile to include medication/allergies/sensitivities and every medication, dose, frequency and route of administration for prescription and non-prescription medications, herbal products and home remedies. Review of the agency's policy titled, "Initial Assessment/Comprehensive Assessment," dated 2017, showed that each patient's comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, or other alternative treatments). RECORD/PATIENT #1: Observation on 02/22/2023 beginning at 9:00 AM, during the patient's home visit, showed the interdisciplinary team review (IDG) dated 02/07/2023 and the medication profile dated 02/21/2023 failed to include the following medications: - Gabapentin (a medication used to treat nerve pain) 100 milligrams (mg) two capsules twice per day; - Meclizine (a medication used to treat dizziness) 25 mg one tablet three times per day; - Potassium chloride (a medication used as a supplement for potassium) 20 milliequivalents (mEq) one tablet daily; - Miralax (a medication used for constipation) one scoop daily as needed; - Zyrtec (a medication used for allergies) 10mg one tablet daily; and - Dulcolax (a medication used for constipation) 5mg daily as needed. Further clinical record review showed the IDG and the medication profile included the following medications which the patient stated he/she was no longer taking: - Hydrocodone/Acetaminophen (a medication used for pain) 7.5mg/325mg one tablet four times per day; - Xanax (a medication used for anxiety) 0.25mg one tablet as needed daily; and - Compazine (a medication used for nausea) 10mg one tablet every 6 hours as needed. RECORD/PATIENT #3: Observation on 02/22/2023 beginning at 1:00 PM, during the patient's home visit, showed the medication profile dated 02/20/2023 contained the following medications with incorrect dosages: - Lorazepam (a medication used for anxiety) 2mg/milliliter (ml) 0.25 mg every 2 hours as needed; * Patient reports taking every 3 hours as needed; - Hydrocodone/Acetaminophen (a medication used for pain) 7.5mg/325mg one tablet every 12 hours as needed; * Patient had a bottle that contained Hydrocodone/Acetaminophen 10mg/325mg with directions for one tablet every 6 hours as needed; - Diazepam (a medication for anxiety) 5mg one tablet three times per day; and * Patient had a bottle that contained Diazepam 5mg with directions for one tablet four times per day. During an interview on 02/23/2023 beginning at 12:30 PM, the administrator stated that he/she would expect medication profiles to match what is in the home.

Based on policy review, record review, and interview, the agency failed to ensure that the plan of care (POC) was individualized in, but not limited to, five (Records/Patients #1, #2, #3, #4, & #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted to services on 07/31/2022; - The patient's most recent plan of care, dated 02/21/2023, included a care goal of decreased diarrhea and loose stools; - The patient's medication profile, dated 02/21/2023, included two medications for constipation with start dates of 08/01/2022; and - The agency failed to update the plan of care when the patient's needs changed. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to services for malignant neoplasm of the right kidney (a cancer that affects the right kidney); - The patient's plan of care, dated 02/07/2023, showed a care plan goal for decreased cardiac output; and - The agency failed to include any interventions to monitor cardiac output. RECORD/PATIENT #5: - The patient was admitted to services with secondary diagnoses of chronic obstructive pulmonary disease (COPD) (a disease that affects the airways of the lungs) and dysphagia (an inability to swallow) on 02/05/2023; - The patient's plan of care, dated 02/07/2023, failed to include goals or interventions related to COPD or dysphagia. During an interview on 02/23/2023, beginning at 12:30 PM, the administrator stated that he/she would expect care plans to be individualized for each patient. Findings included: Review of the agency's policy titled, "Assessment and Plan of Care Policy," dated 11/2021, showed, in part, the following: -The admission nurse/registered nurse develops and documents an individualized initial plan of care (IPOC) within 48 hours of election of hospice care to address immediate patient/family needs. RECORD/PATIENT #2: Review of the clinical record showed the following: -Patient was a fall risk and used devices to help with mobility; and -The agency failed to include specific individualized interventions for the patient's fall risk. RECORD/PATIENT #4: Review of the clinical record showed the following: -Patient was a fall risk; -Patient had wounds; and -The agency failed to include interventions for these identified problems on the patient's plan of care.

Based on policy review, record review, and interview the agency failed to ensure that documentation was completed in a timely manner in five (Records/Patients #1, #2, #3, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #2: Review of the clinical record showed the following: -A SN with a service date of 01/10/2023 and a signed date of 01/25/2023; -A SN with a service date of 01/13/2023 and a signed date of 01/25/2023; -A SN with a service date of 01/17/2023 and a signed date of 02/01/2023; -A SN with a service date of 01/24/2023 and a signed date of 02/03/2023; -A SN with a service date of 01/27/2023 and a signed date of 02/04/2023; -A SN with a service date of 01/31/2023 and a signed date of 02/04/2023; -A SN with a service date of 02/03/2023 and a signed date of 02/20/2023; -A SN with a service date of 02/07/2023 and a signed date of 02/15/2023; -A SN with a service date of 02/14/2023 and a signed date of 02/21/2023; -An aide note with a service date of 01/10/2023 and a signed date of 01/30/2023; -An aide note with a service date of 01/13/2023 and a signed date of 01/30/2023; -An aide note with a service date of 01/24/2023 and a signed date of 01/31/2023; -An aide note with a service date of 01/20/2023 and a signed date of 01/30/2023; -An aide note with a service date of 02/03/2023 and a signed date of 02/19/2023; and -An aide note with a service date of 02/10/2023 and a signed date of 02/19/2023. RECORD/PATIENT #4: -A SN with a service date of 02/06/2023 and a signed date of 02/22/2023; -A SN with a service date of 02/09/2023 and a signed date of 02/22/2023; -A SN with a service date of 02/13/2023 and a signed date of 02/22/2023; and -A SN with a service date of 02/17/2023 and a signed date of 02/22/2023. Findings included: Review of the agency's policy titled, "Timely Submission of Patient Documentation," dated 2017, showed in part that itineraries, with all visit reports attached, must be electronically charted or submitted the next scheduled work day, or not exceeding three (3) business days. RECORD/PATIENT #1: Review of the clinical record showed the following: - A skilled nurse's note (SN) with a service date of 01/03/2023 and a signed date of 01/09/2023; - A SN with a service date of 01/10/2023 and a signed date of 01/15/2023; - A SN with a service date of 01/17/2023 and a signed date of 01/26/2023; - A SN with a service date of 01/26/2023 and a signed date of 01/30/2023; - A SN with a service date of 01/30/2023 and a signed date of 02/04/2023; - A SN with a service date of 02/05/2023 and a signed date of 02/09/2023; - A SN with a service date of 02/07/2023 and a signed date of 02/16/2023; and - A SN with a service date of 02/14/2023 and a signed date of 02/19/2023. RECORD/PATIENT #3: Review of the clinical record showed the following: - A SN with a service date of 12/27/2022 and a signed date of 01/02/2023; - A SN with a service date of 12/29/2022 and a signed date of 01/03/2023; - A SN with a service date of 01/09/2023 and a signed date of 01/16/2023; - A SN with a service date of 01/18/2023 and a signed date of 01/25/2023; - A SN with a service date of 01/26/2023 and a signed date of 01/30/2023; - A SN with a service date of 01/30/2023 and a signed date of 02/03/2023; - A SN with a service date of 02/02/2023 and a signed date of 02/06/2023; - A SN with a service date of 02/13/2023 and a signed date of 02/17/2023; - A medical social worker note with a service date of 01/05/2023 and a signed date of 01/09/2023; - A chaplain note with a service date of 11/23/2022 and a signed date of 12/01/2023; and - A chaplain note with a service date of 12/15/2022 and a signed date of 12/22/2022. RECORD/PATIENT #5: Review of the clinical record showed the following: - An admission assessment by a registered nurse with a service date of 02/05/2023 and a signed date of 02/14/2023; - A SN with a service date of 02/06/2023 and a signed date of 02/15/2023; - A SN with a service date of 02/09/2023 and a signed date of 02/13/2022; - A SN with a service date of 02/13/2023 and a signed date of 02/19/2023; - A SN with a service date of 02/14/2023 and a signed date of 02/21/2023; - An aide note with a service date of 02/08/2023 and a signed date of 02/13/2023; - An aide note with a service date of 02/10/2023 and a signed date of 02/19/2023; - An aide note with a service date of 02/14/2023 and a signed date of 02/19/2023; - A chaplain admission assessment with a service date of 02/09/2023 and a signed date of 02/22/2023; and - A massage therapy assessment with a service date of 02/10/2023 and a signed date of 02/20/2023. During an interview on 02/23/2023 beginning at 12:30 PM, the administrator stated that he/she would expect documentation to completed in a timely manner.

Based on policy review, record review, and interview, the agency failed to ensure that the Skilled Nursing Facility (SNF) was provided the following: -The most recent plan of care (POC) specific to the patient, -Hospice election form, and -Physician certification of the terminal illness specific to the patient; in, but not limited to, one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Care to Residents of a Skilled Nursing Facility/Nursing Facility (SNF/NF)," dated 2017, showed, in part, the following: -[Named Hospice] will provide to the SNF/NF the following information: *The most recent [Named Hospice} plan of care (POC) specific to each patient; *[Named Hospice] election form and any advance directives specific to each patient; and *Physician certification and recertification of the terminal illness specific to each patient. RECORD/PATIENT #4: Review of the facility binder showed the agency failed to ensure the binder included the following: -The patient's most recent POC; -The patient's signed hospice election form; and -The physician certification of terminal illness for the patient. During an interview on 02/23/2023 at 11:30 AM, the administrator stated that he/she would expect these documents to be placed in the facility binder.

Based on agency policy, facility record review, and agency record review, the agency failed to assure that the comprehensive assessment contained the patient's progress toward desired outcomes and reassessment of the patient's response to care in, but not limited to, one (Record/Patient #2) of three records reviewed. This deficient practice has the potential to affect the comprehensive assessment of all of the agency's patients. Findings included: Review of the agency policy, revised 2017 and titled, "Reassessments/Update to the Comprehensive Assessment," showed that: - The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (IDG) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as, a reassessment of the patient's response to care. The assessment updates must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. The update to the comprehensive assessment will include changes in physical, psychosocial, emotional, and spiritual needs; and - Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided. Such reassessments will be documented on discipline-specific visit notes. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 09/27/2021 with a terminal diagnosis of colon and rectal cancer. The patient resided in a skilled nursing facility. Review of the facility documents dated 11/01/2021 to 11/30/2021 and titled, "eTAR," showed that a change in the plan of care occurred on: - 11/22/2021, and included treatment orders to check boot-style heel protector placement each shift; * The facility record showed documentation that the staff provided the treatment daily from 11/23/2021; and - 11/22/2021, and included treatment orders to monitor the left second toe for worsening bruise; * The facility record showed documentation that the facility staff monitored the area every shift until the order was discontinued on 01/13/2022, following surgical amputation of the digit. Review of the agency document dated 12/02/2021 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 11/22/2021 for the use of a foam dressing or waffle boot to left heel for prevention, and monitoring of the left second toe for worsening bruise. The IDT Plan of Care update documentation for problems with the skin showed, "Skin warm dry and intact without problems reported or assessed; will cont to assess." Review of the facility documents dated 12/01/2021 to 12/31/2021 and titled, "eTAR," showed that a change in the plan of care occurred on: - 12/21/2021, and included treatment orders to apply a foam dressing or waffle boot to the left heel for prevention; * The facility record showed documentation that the staff provided the treatment three times per day until the order was discontinued on 01/13/2022; and - 12/21/2021, and included treatment orders to cleanse the area on the left heel with wound cleanser, apply betadine (a topical antiseptic), and cover with Mepilex (a foam dressing) daily and as needed; * The facility record showed documentation that the facility staff provided the treatment daily until the order was discontinued on 01/06/2022. Review of the agency document dated 12/30/2021 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 12/21/2021 for the use of boot-style heel protectors and cleansing of the left heel with wound cleanser, application of betadine, and covering with Mepilex daily and as needed. The IDT Plan of Care Updated documentation for problems with the skin showed, "skin warm dry and intact without problems reported or assessed; will cont [continue] to assess." Review of the facility documents dated 01/01/2022 to 01/31/2022 and titled, "eTAR," showed that a change in the plan of care occurred on: - 01/06/2022, and included treatment orders to cleanse the area to the left heel with wound cleanser and cover with Mepilex daily and as needed; * The facility record showed documentation that the staff provided the treatment until the order was discontinued 01/11/2022; - 01/10/2022, and included treatment orders to cleanse the second digit of the left toe with wound cleanser, and apply dry gauze dressing every other day; * The facility record showed documentation that the facility staff provided the treatment until the order was discontinued 01/17/2022; and - 01/11/2022, and included treatment orders to cleanse the area to the left heel with wound cleanser and cover with Mepilex daily and as needed. Review of the agency document dated 01/13/2022 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 01/10/2022, cleansing of the second digit of let toe with wound cleanser, apply a dry gauze dressing, change every other day and as needed, 01/11/2022 application of a Mepilex bandage to the left heel daily and as needed. The IDT Plan of Care Updated documentation for problems with the skin showed, "skin warm dry and intact without problems reported or assessed; will cont to assess." Review of the facility documents dated 01/01/2022 to 01/31/2022 and titled, "eTAR," showed that a change in plan of care occurred on: - 01/14/2022, and included treatment orders to cleanse open area to coccyx with wound cleanser, and pat dry. Apply honey gel (a wound treatment that contains honey), Xeroform (a medicated gauze), 4x4, and island dressing once daily; * The facility record showed documentation that the facility staff provided the treatment beginning 01/14/2022; - 01/14/2022, and included treatment orders to paint the necrotic (area of dead tissue) area to left heel with betadine once daily; * The facility record showed documentation that the facility staff provided the treatment beginning 01/14/2022; - 01/14/2022, and included treatment orders to apply skin prep to shear wound (a wound caused by sliding against a surface) to left dorsal (top) foot once daily; * The facility record showed documentation that the facility staff provided the treatment daily until the order was discontinued 01/27/2022; - 01/21/2022, and included treatment orders to paint the left great toe with betadine once daily; * The facility record showed documentation that the facility staff provided the treatment daily until the order was discontinued on 01/27/2022; and - 01/27/2022, and included treatment orders to paint left foot including toes with betadine once daily; * The facility record showed documentation that the facility staff provided the treatment beginning 01/27/2022. Review of the agency document dated 01/27/2022 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 01/14/2022 for cleansing of open area to coccyx with wound cleanser, pat dry, apply honey gel, Xeroform, 4x4, and island dressing once daily and painting the necrotic area to left heel with betadine once daily. The IDT Plan of Care Updated documentation for problems with the skin showed, "skin warm dry and intact without problems reported or assessed; will cont to assess." The findings were reviewed with the administrator on 02/04/2022 at 04:00 PM and no further documentation was provided prior to the survey exit.

Based on agency policy and home visit observation, the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in one (Record/Patient #3) of one home visit observation performed. This deficient practice has the potential to affect infection control practices for all of the agency's patients. Findings included: Review of the agency policy revised in 2017 and titled, "Equipment Maintenance: Staff Equipment," showed that: - A sturdy canvas bag or a rolling duffel bag is often needed for housing and transporting patient care items such as stethoscope, blood pressure cuff, thermometer, etc.; - All items in the bag are considered clean and the principles of asepsis are followed in the delivery of care; and - A barrier such as a plastic bag or newspaper must be placed between the bag and the surface on which it is placed. RECORD/PATIENT #3: During a home visit observation on 02/04/2022 at 01:00 PM, the registered nurse: - Performed the patient assessment using the equipment (blood pressure cuff, stethoscope, thermometer, etc.); - Failed to clean the equipment before putting it into his/her uniform pocket; - Removed the equipment from his/her pocket; - Cleansed the equipment; and - Placed the equipment back into his/her soiled uniform pocket.

Based on policy review, clinical record review, and interview, the agency failed to ensure that coordination of care with the long term care facility (LTCF) was effective when the hospice failed to: - Ensure that the agency assumed responsibility for professional management of the resident's hospice services (L762); and - Ensure that changes in the plan of care were discussed with the patient or representative, and facility staff (776). The cumulative effect of these systemic practices resulted in the agency's inability to effectively provide care and services to hospice patients that reside in a LTCF.

Based on policy review, facility record review, agency record review, home visit observation, and interview the hospice provider failed to maintain professional management of hospice patient's plan of care in two (Records/Patients #2 and #3) of three records reviewed for patients residing in a skilled nursing facility (SNF). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy, revised March 2013, and titled, "Care to Residents of a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/MR (Intermediate Care Facility/Mental Retardation) showed, in part, that: - Hospice assumes responsibility for professional management of the resident's hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation; - The term professional management for a hospice patient who resides in a SNF/NF or ICR/MR has teh same meaning that it has if the hospice patient were living in his/her own home. Professional management involves assessing, planning, monitoring, directing, and evaluating the patient's hospice care across all settings; and - Hospice is responsible for providing all hospice services including ongoing assessment, care planning, monitoring, coordination, and provision of care by the hospice interdisciplinary group (IDG). Review of the agency's document dated 06/2009 and titled, "Hopice/LTC Coordinated Task Plan of Care" instructions, showed that: - The agency will coordiante services with each LTC [long-term care] provider. The agency and LTC provider will jointly ensure collaborative efforts between the LTC provider and the agency, by documenting which services will be provided, by whom, the frequency of services, updates when changes occur, dated signatures of both LTC provider and agency staff; - The Coordinated Task Plan will be initiated by the hospice provider upon start of care in the LTC and will be continuously updated with any chagnes as needed; At a minimum, the Coordinated Task Plan will be reviewed with recertification of the hospice resident; and - The procedure will include: * For the wound care schedule, circle the days of the week that hospice will provide the wound care. Update any on-going schedule changes on the next line. The LTC provider will be responsible for wound care on all other days * List each treatment planned and document frequency under each party responsible; and * Document a start date for each new or changed intervention and an end date for each discontinued intervention. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 09/27/2021 with a terminal diagnosis of colon and rectal cancer. The patient resided in a SNF. Example 1: Review of the facility record showed that: - The facility had received new orders for the patient to use a foam dressing or waffle boot to the left heel on 11/22/2021; - The facility had received new orders for the patient to use a boot-styled heel protector two times per day on 12/21/2021; - The facility had received new orders for facility staff to cleanse the ares of the left heel with wound cleanser, apply betadine, and cover with Mepilex (a wound dressing that provides a moist enviroment for wound healing) daily and as needed on 01/11/2022; - The facility had received new orders for the facility staff to paint the necrotic (area of dead tissue) area on left heel with betadine once daily on 01/14/2022; Review of the agency document signed by facility staff beginning 09/28/2021 and titled, "Hopice/LTC Coordinated Task Plan of Care" showed that: - The document failed to contain updates for the changes in the patient's plan of care related to the formation of a wound on the left heel and identified on the facility treatment administration record for the dates of 11/22/2021, 12/21/2021, 01/11/2022, and 01/14/2022. Example 2: Review of the facility record showed that: - The facility had received new orders for the patient to monitor the left second toe for worsening of a bruise; and - The facility had received new orders for facility staff to cleanse the left second toe with wound cleanser, apply a dry gauze dressing, changes every other day and as needed for soiling. Review of the agency document signed by facility staff beginning 09/28/2021 and titled, "Hopice/LTC Coordinated Task Plan of Care" showed that: - The document failed to contain updates for the changes in the patient's plan of care identified on the facility treatment administration record for the dates of 11/22/2021, 12/21/2021, 01/10/2022, 01/11/2022, 01/14/2022. Example 3: Review of the facility treatment administration record (TAR) and nurses notes showed: - The facility had received new orders for facility staff to cleanse the open area on the coccyx (tailbone) with wound cleanser and pat dry, apply honey gel, xeroform, gauze, and an island dressing one daily on 01/14/2022; Review of the agency document signed by facility staff beginning 09/28/2021 and titled, "Hopice/LTC Coordinated Task Plan of Care" showed that: - The document failed to contain updates for the changes in the patient's plan of care identified on the facility treatment administration record for the date of 01/14/2022. During an interview on 02/02/2022 at 2:58 PM, the patient's durable power of attorney (DPOA) stated that he/she had noticed that there was not much communication between the facility and hospice, and it seemed like they weren't communicating about the patient's needs. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of metastatic breast cancer (cancer of the breast that has spread to other parts of the body). He/she used a urinary catheter (a tube placed in the bladder to drain urine). The patient resided in a SNF. During a home visit observation on 02/04/2022 at 01:00 PM, the regisered nurse: - Cleansed the tubing on the patients urinary catheter; and - Applied Calmoseptine to the skin on the buttocks. During an interview on 02/04/2022 at 01:00 PM, the facility nurse stated that: - Either the agency or the facility staff can change the catheter; - When the facility changes the catheter they put a date on the drainage bag; - There was not a date on the drainage bag; - Review of the facility records showed a facility nurse had changed the catheter two weeks ago, and the facility clinical record failed to contain documentation of the procedure: and - When asked to see the Coordinated Task Plan, the facility nurse gave the surveyor a, "blank look." Review of the document last updated 12/20/2021 and titled, "Hospiice/LTC Coordinated Task Plan of Care," showed that the document failed to contain: - The responsible party for the change of the urinary catheter monthly; - Specific parameters for the change of the urinary catheter monthly to include the size of catheter and balloon volume; - Interventions for cleaning the urinary catheter tubing; and - Interventions and identification of who would apply, and, the frequency of application, of the Calmoseptine to the patient's buttocks.

Based on agency policy review, record review, and interview, the agency failed to assure that any changes in the hospice plan of care were discussed with the patient or representative, and facility staff in one (Record/Patient #2) of three facility records reviewed. This deficient practice has the potential to affect the care of all the agency's patients. Findings included: Review of the agency's policy revised 2017 and titled, "IDG Care Planning Process," showed that all care and services furnished to patients and their families follows an individualized written plan of care established by the IDG (interdisciplinary group) in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient's needs. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 09/27/2021 with a terminal diagnosis of colon and rectal cancer. The patient resided in a skilled nursing facility (SNF). Review of the hospice start of care forms dated 09/27/202 titled, "Informed Consent Electing Hospice Care, Medicare Hospice Benefit Election, Hospice Election Statement, and Admission Checklist, " were signed by the patient's durable power of attorney. Review of the agency's document dated 09/27/2021 and titled, "Informed Consent Electing Hospice Care," showed that an individualized plan of care would be developed with input from the patient and family. Review of licensed practical nurse's (LPN) documentation for the visit dated 10/04/2021, showed that the patient was having increased nausea and vomiting. A physician order was received on 10/04/2021 for Zofran (a medication used to treat nausea and vomiting) as needed. The record failed to contain documentation that the durable power of attorney (DPOA) was notified of the new medication order or the increased nausea and vomiting. Review of the LPN's documentation for visit dated 11/24/2021 showed that the patient had developed new pain on the lateral aspect of his/her left foot. The foot had no signs of trauma. The record failed to contain documentation that the DPOA was notified the patient reporting pain in a new area. Review of the facility nursing documentation showed that: - On 11/28/2021, the patient was able to transfer with minimal assist of one person and did not require repositioning in bed; and - On 12/02/2021 the patient needed one person to assist with transfers and was non-weight bearing on his/her left lower extremity. Review of the LPN's documentation for visit dated 12/06/2021 showed that the patient had increased weakness, continued episodes of nausea and vomiting, utilized as needed pain medication more frequently, and had constipation. The record failed to contain documentation that: - The hospice was aware that the patient had become non-weight bearing on the left lower extremity, and - The DPOA was notified of the new or worsening symptoms of increased weakness, continued episodes of nausea and vomiting, had increased use of pain medication, and constipation. Review of the LPN's documentation for visit dated 12/20/2021 showed that: - The patient stated that his/her left foot hurt and that the pain was getting worse; - The nurse removed the patient's sock and found the patient's second toe was black in color with a bandaid, "wrapped tightly," around it; - The bandaid was removed and the,"toenail came off as well;" - The director of nursing, facility administrator, and physician were notified and the patient was sent to the local emergency room; - The record failed to contain documentation that the DPOA was notified of the above information. Review of facility nursing documentation showed that on 12/21/2021 a new order was received to apply betadine and Mepilex (foam dressing that maintains a moist wound environment). Review of the LPN's documentation for visit dated 12/20/2021 showed that: - The wound on the left heel had eschar (brown/black colored dead tissue); - The LPN reapplied the heel protector and dressing; - The left second toe remained black in color, cool to touch, and hard; and - The record failed to contain documentation that the DPOA was notified of the above information. Review of the LPN's documentation for visit dated 12/27/2021 showed that: - The patient had a low level of oxygen in his/her blood; - The patient refused to wear oxygen; - The patient stated that he/she did not feel short of breath; - The above symptoms were discussed with the facility charge nurse (CN); - The patient continued to have: * Intermittent nausea and vomiting that was relieved with Zofran (a medicine used to treat nausea and vomiting); * A decreased appetite; and * Increased fatigue; - The record failed to contain documentation that the DPOA was notified of the above information. Review of LPN telephone progress note documentation dated 12/30/2021 showed that the: - LPN called the facility to check on the patient's condition, "d/t [due to] a recent COVID 19 outbreak;" - The patient continued to have: * A decreased appetite; * Increased fatigue; * He/she was spending the majority of the day in bed; and The record failed to contain documenation that the DPOA was notified of the above information. Review of the agency's document dated 01/07/2022, and titled, "After Visit Summary," showed that the patient underwent surgery on 01/07/2022 for amputation (surgical removal) of left second toe. During an interview on 02/02/2022 at 01:36 PM, the complainant stated that: - The communication between the nursing home, hospice, and family was not good; - The agency should have updated the family once a week with changes to the plan of care and what they were seeing; - The patient's care didn't stop just because he/she was terminal; and - The family could advocate for the patient if they were kept updated on the patient's condition. During an interview on 02/02/2022 at 2:58 PM the patient's child and DPOA stated that: - There was not much communication between the facility, hospice, and the family; - Communication was really lacking; and - The facility would say that the agency was responsible for care, and then the agency nurse would come in and look "stumped" when we asked questions. During an interview on 02/04/2022 at 04:09 PM, the administrator stated that, when the DPOA signs the consent forms, then the DPOA and patient should be notified of changes in the patient's condition and plan of care.