Every finding on record at Angel Care Hospice of Arcadia, Inc,

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not provided initial education and training in emergency management to volunteers. It was confirmed with the Volunteer Coordinator that the Volunteer (HR5) did not receive initial training in the emergency plan. This was discussed with the Administrator.

Observed in Record Review. In 4 of 16 patient records reviewed, the registered nurse did not reassess patients every 15 days. In the chart for RRDC#1, 30 days lapsed between RN visits. In the chart for RRHV#2, 18 days lapsed between RN visits in the current year. In the chart for RRNHV#7, 19 days lapsed between RN visits. In the chart for RRNHV#12, more than 18 days lapsed since the most recent RN visit as of the day of the survey. This was discussed with the administrator.

Observed in Record Review. In 2 of 16 patient records reviewed, the clinical record was not accurately documented. In the chart for RRDC#1, the IDT SN notes included information that the patient was a non-verbal female patient with pain management needs. This information did not match the patient who was actually a male patient with verbal communication abilities. In the chart for RRDC#2, the communication notes indicated that the patient had a planned procedure ordered and the hospice was unable to determine if it was related to the terminal illness. The discussion stated that the hospice would need to discharge the patient prior to the procedure. The patient's reason for discharge indicated they discharged due to extended prognosis, even though in the IDT note just prior to the discharge, the discussion was that the patient would be recertified due to continued decline. This was discussed with the Administrator. Observed in Record Review. In 4 of 16 patient records reviewed, the record was incomplete. In the charts for RRHV#1 and RRHV#2, the aide was providing care twice per week. There were no documented aide visit notes for more than 17 days at the time of the survey. In the chart for RRNHV#9, the patient has no documented nursing visit notes for more than 20 days as of the day of record review during the survey. In the chart for RRNHV#5, the aide is seeing the patient 3 times per week. There are no documented visits notes for more than 18 days at the time of the survey. Organizational policy required documentation to be completed within 7 days. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 1 of 16 patient records reviewed, the plan of care (POC) was not updated with a patient specific goal. In the chart for RRNHV#9, Silver Nitrate was added as a treatment per the SN notes, however the POC was not updated with a goal related to this need. This was discussed with the DPCS.

Observed in Record Review. In 4 of 16 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRDC#1, the initial POC had no visit frequencies for any discipline. The first POC update occurred 9 days post admission which included an LVN visit every other week and no RN frequency. There was no frequency for aide until 10 days after the aide began to provide care. In the chart for RRDC#2, the initial POC included no frequency of visits. In the chart for RRNHV#7, there were no frequency orders for SN visits until the 2nd POC review by the IDG; then the order was back-dated to 5 days after the admission. In the chart for RRNHV#11, there was no frequency for any discipline until the first POC update 10 days post-admission. There was no RN frequency written until 13 days post-admission. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 4 of 16 patient records reviewed, the plan of care did not include complete medication or treatment orders. During HV#4, it was discovered that the Insulin order read 30 units daily, however the instructions read to inject 40 units. It was clarified at the visit that this is actually 30 units. In the chart for RRNHV#6, the LVN documented wound care on the second visit. There were no orders found on the POC for wound care until three days later. In the record for RRNHV#9, the RN noted that the facility had been using Silver Nitrate to control bleeding in the wound, yet the POC was not updated with this treatment. In the chart for RRNHV#11, the RN provided wound care to a skin tear, yet the POC ws not updated with orders for wound care. This was discussed with the DPCS and Administrator. Observed in Record Review. In 16 of 16 patient records reviewed, the plan of care (POC) was not individualized to the patient. In all of the charts reviewed during the survey, the patient's had POLST forms that were individually signed by the physician BEFORE the admission to the hospice. Upon admission, when this documentation was requested by the patient and/or caregiver the RN would enter the date of admission next to the pre-signed physician signature line. This was discussed with the DPCS.

Observed in Record Review. In 4 of 16 patient records reviewed, the organization had not provided care according to the patient's individualized plan of care (POC). In the chart for RRHV#2, there were no documented social work visits in the previous benefit period. The POC included one visit per benefit period. In the chart for RRHV#1, the nursing staff was washing the patient's wound with soap and water. The POC included wound wash as the cleansing agent. This was also observed during the home visit. In the chart for RRNHV#9, the POC stated the wound care was to be completed by the hospice nurse and the facility treatment nurse. There was no wound care provided by the hospice nurses in the documented notes in the chart. In the chart for RRNHV#13, the LVN noted the patient's oxygen was at 6lpm; order was 5lpm. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 1 of 16 patient records reviewed, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and coordinated their efforts to support the goals outlined in the plan of care. In the chart for RRNHV#11, the patient had a fall with a skin tear. The RN made a visit and provided wound care, yet there was no indication the physician was informed. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the RN had not prepared written patient care instructions. In the chart for RRDC#1, the written aide plan of care was not created until more than 30 days after the aide made the first visit. This was discussed with the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, in which aide services were ordered, the RN had not supervised the aide at least every 14 days. In the chart for RRDC#1, more than 30 days lapsed between RN visits; no supervisory visits were documented in that 30 days. In the chart for RRHV#2, the last documented aide supervisory visit occurred more than 30 days prior to the date of the survey. This was discussed with the Administrator. Observed in Record Review. In 1 of 14 patient records reviewed, staff were not supervised effectively. In the chart for RRDC#2, the RN continued to document supervision of the hospice aide after the aide was no longer seeing the patient. This was discussed with the Administrator.

Observed in Record Review. In 1 of 16 patient records reviewed, the patient medication list was incomplete. In the chart for RRNHV#13, the LVN noted the patient was taking Melatonin and Diphenhydramine however these medications were not on the patient's medication list. This was discussed with the Administrator and DPCS. Observed in Record Review. In 1 of 16 patient records reviewed, the patient record did not include specific notes on care, treatment or services. In the chart for RRHV#1, the LVN note stated tx was provided to the scalp per MD orders. rather than documenting what care was provided. This was discussed with the Administrator and DPCS.

Based on observation, interview and record review, the hospice agency (HA agency providing care to terminally ill patients who have six months or less to live) failed to ensure all medications on the medication profile were coordinated for one of ten sampled patients (Patient 21) in an assisted living facility. The deficient practice had the potential to result in medications errors. --- Findings: During a review of Patient 21s Personal Information Sheet, the personal information sheet indicated Patient 21's start of care (SOC) date was 01/12/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) chronic systolic heart failure (a long term condition when the heart muscle doesnt work properly and does not effectively pump blood throughout the body). During a concurrent observation and interview on 02/12/2025 at 11:30 am with Registered Nurse 1 (RN 1) at Patient 21s assisted living residence, Acetaminophen 650 mg ER (extended release pain medication) 1 tablet once daily as needed for Arthritis ( swelling and tenderness in one or more joints, causing joint pain) observed. RN 1 stated, ";This medication was prescribed to her prior to Patient 21 being on hospice." When asked why this medication is not listed on the HAs medication profile, RN 1 stated, ";not sure why its not on out agency medication profile. This was missed. We are supposed to check the medication on every visit." During a review of Patient 21s Current Treatment and Medication, dated 1/12/2025, did not reflect Acetaminophen 650 mg ER 1 tablet once daily as needed for Arthritis. During an interview on 02/12/2025 at 11:37 am with assisted living medication tech 1 (Med Tech 1), Med Tech 1 stated, "this medication has been on Patient 21's profile for a long time." During an interview on 02/12/2025 at 11:45 am with Director of Patient Care Services, (DPCS), DPCS stated, ";the skilled nurses are supposed to do medication reconciliation on every visit." During a record review of HAs policy and procedure titled, ";Medication Profile" revised November 2023, the policy and procedure indicated, ";3. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment." The policy further indicated, ";during subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family caregiver, as well as other clinicians, understand the medication regimen." During your record review of HAs Policy and Procedure titled, ";Interdisciplinary Group Coordination of Care", revised April 2017, the Policy and Procedure indicated, ";The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients."

Based on observation, interview and record review, the Hospice agency (HA) failed to ensure skilled nurses conducted an ongoing medication reconciliation (process that compares a patient current medication to their medication orders to identify and resolve discrepancies) every visit for one of nineteen sampled patients (Patient 11). The deficient practice had the potential to result in medication errors and adverse drug reaction that could impact the patient's health status and wellbeing. --- A. During a record review of Patient 11s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 05/10/2023, with a terminal diagnosis Alzheimers disease unspecified, (a progressive disease that destroys memory and other important mental functions). During a record review of Patient 11s Current Treatment and Medication, undated, indicated a list of following medications including; Advair Diskus 250mcg/50mcg/actuation powder for inhalation one puff twice daily for COPD (Chronic obstructive pulmonary disease an inhaler to help dilate the bronchioles), the following medications are a part of the comfort pack; albuterol sulfate 0.083% solution for inhaler 1 vial every six hours as needed for shortness of breath and wheezing, Bisacodyl laxative Suppository 1 Suppository rectally once daily as needed for Constipation, Hyoscyamine Sulfate 0.125 mg oral one tab every six hours as needed for excessive secretions, lorazepam 2 milligram in one ML concentrate solution 0.25 ML's every six hours as needed for anxiety agitation, morphine sulfate 20 milligrams in one ML concentrated solution 0.25 ML orally sublingual every two hours as needed for pain breathlessness the wheezing, ondansetron tablet 4 milligram one tab orally every six hours as needed for nausea and vomiting. During a concurrent observation and interview on 12/11/2024 at 10:30 am with DPCS at Patient 11s residence, the following medications were observed with the expirations dates of: Advair Diskus 250mcg/50mcg/actuation expired 4/16/2024 Albuterol sulfate 0.083% solution for inhaler 1 vial expired 8/29/2024 Bisacodyl laxative Suppository expired 8/29/2024 Hyoscyamine Sulfate 0.125 mg oral expired 8/29/2024 Lorazepam 2 milligram in one ML expired 2/26/2024 Morphine sulfate 20 milligrams in one ML expired 2/26/2024 Ondansetron tablet 4 milligram expired 8/29/2024 During a concurrent interview with DPCS stated, ";the comfort pack isnt used until necessary, but still the visiting nurse is responsible to check them every visit. And the Advair, the patient doesnt use it but the family member doesnt want us to discontinue it, but again, she should have a current one in the house not an expired one. This was missed by the visiting nurse." During an interview on 12/23/2024 at 11:45 am with Director of Patient Care Services, (DPCS), DPCS stated, ";the skilled nurses are supposed to do medication reconciliation on every visit." During a record review of HAs policy and procedure titled, ";Medication Profile" revised November 2023, the policy and procedure indicated, ";3. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment." The policy further indicated, ";during subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family caregiver, as well as other clinicians, understand the medication regimen." During your record review of HAs Policy and Procedure titled, ";Ongoing Comprehensive Assessments", revised November 2021, the Policy and Procedure indicated, ";The nurse will assess each patient on each visit for: Q. compliance with treatment and medication regimen."

Based on record review and staff interview the hospice agency's interdisciplinary group (IDG-that include individuals who are qualified and competent to practice the professional roles such as physician, registered nurse, social worker, mental counselor, pastor) failed to meet and develop the hospice patient's plan of care for one of 19 sample patients (Patient 6). Patient 19 was provided registered nurse (RN), medical social work services (MSW), and chaplain services. These IDG members failed to participate and develop the plan of care (POC) for Patient 6. This deficient practice has the potential to result in not meeting the palliative (providing relief from pain and other symptoms of serious illness) needs and comfort measures to the hospice patient including family member involved in the care during the terminal stage of the illness. --- During a review of Patient 6s admission record indicated a start of care (SOC) date of 8/17/2022 with an end of care of 7/19/2024. The terminal diagnosis included basal cell carcinoma of (a type of skin cancer that develops in the basal cells- (A small round cell found in the lower part /base of the epidermis, the outer layer of the skin). During a review of Patient 6's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/17/2022, indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:50 p.m., the DPCS reviewed Patient 6s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) dated 2/3/2023, 5/4/2023, 6/1/2023, 8/10/2023, 3/26/2024, and 5/9/2024. The DPCS verified the POC/IDG Review were missing signatures from the RN, MSW, and Chaplain to indicate these professionals participated and coordinated in the development of the patient's plan of care. The DPCS failed to provide the documented evidence.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure coordination of the members of the IDG meeting does occur and were signed by the physician and registered nurse for four of nineteen sampled patients (Patient 1, Patient 3, Patient 5, and Patient 7). The deficient practice has the potential for the hospice patient's identified needs will not be assessed, reviewed, and updated in the POC. --- a.During a review of Patient 1 s admission record indicated a start of care (SOC) date of 8/20/2024, with a terminal diagnosis of hereditary ataxias (a group of disorders that affect the nervous system, leading to progressive loss of coordination /balance, slurred speech, eye problems, muscle weakness, difficulty swallowing, tremors, cognitive problems and other symptoms, it usually starts at childhood). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/20/2024, indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 10:10 a.m., the DPCS reviewed Patient 1s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), indicated the following POC/IDG Review notes 8/20/2024,8/29/2024, 9/26/2024,10/10/2024,11/7/2024,11/22/2024, 12/5/2024, and 7/11/2024. The DPCS verified the POC/IDG Reviews were missing the POC/IDG Review notes between 8/20/2024 to 9/26/2024 and that all documented notes listed above were missing the Medical Director (MD) and Registered Nurse (RN) signatures. The DPCS stated that the HA messed up the dates. The HA was unable to provide the missing documentations requested. There was no documented evidence of coordination of care between the IDG members. b. During a review of Patient 3 s admission record indicated a start of care (SOC) date of 8/29/2024, with a terminal diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a disorder of the central nervous system where the patient does not exhibit involuntary movement called dyskinesia and the symptoms do not significantly worsen or improve throughout the day). During a review of Patient 3's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/29/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 11:30 a.m., the DPCS reviewed Patient 3s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), the DPCS verified the following dates were not signed by the MD: 8/29/2024,9/12/2024,9/26/2024, and that the POC/IDG Review forms dated 9/26/2024,10/10/2024/10/24/2024,11/7/2024,11/21/2024, and 12/5/2024. IDG Review were missing the MD and RN, signatures. There was no documented evidence of coordination of care between the IDG members. c. During a review of Patient 5 s admission record indicated a start of care (SOC) date of 4/10/2024, with a terminal diagnosis of senile degeneration of brain, (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age. During a review of Patient 5's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 4/10/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:10 p.m., the DPCS reviewed Patient 5s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/23/2024 , 6/6/2024, and 6/20/2024 the DPCS verified they were missing the MD signatures. Continued concurrent review of Patient 5s POC/IDG review dated 7/4/2024,7/18/2024, 8/1/2024,8/15/2024 and 12/5/2024. The DPCS verified the POC/IDG Review were missing the RN, MDs signatures. There was no documented evidence of coordination of care between the IDG members. d. During a review of Patient 7's admission record indicated a start of care (SOC) date of 8/17/2022 with a terminal diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a disorder of the central nervous system where the patient does not exhibit involuntary movement called dyskinesia and the symptoms do not significantly worsen or improve throughout the day). During a review of Patient 7's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 7/24/2023, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:50 p.m., the DPCS reviewed Patient 7s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 4/25/2024,5/23/2024 and 6/20/2024 . The DPCS verified the POC/IDG Review were missing the MD and RNs, signatures. Review of the POC/IDG review dated 5/9/2024, the DPCS verified it was missing the RNs signature. There was no documented evidence of coordination of care between the IDG members. During a telephone interview with the MD in the HA on 12/13/2024, at 2:30 pm., regarding his missing signatures on the POC/IDG review forms, he stated," I may have fallen behind and have not gotten to it. The MD stated the importance of all disciplines signing thee POC/IDG forms was to ensure everyone is involved in the POC. Review of the HAs policy and procedure titled, ";INTERDISCIPLINARY GROUP COORDINATION OF CARE, Provision of Care, Treatment and Services, revised April 2017 indicated the following: (6). Written evidence of care coordination will be found in the plan of care and slash or interdisciplinary group meeting forms in the patients clinical record and will involve the Hospice patients attending physician. (7). Care will be provided by an interdisciplinary group made-up of physicians, nurses, social workers, certified Hospice aides, homemakers, clergy, counselors, volunteers, and therapist. These services will be provided in both residential and inpatient settings. (8). The interdisciplinary group (in collaboration with the attending physician comma if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two(2) weeks. The attending position will receive a copy of the care plan updates.

Based on interview and record review, the Hospice Agency (HA- agency providing care to terminally ill patients who have six months or less to live) ) failed to ensure the Condition of Participation (Conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) on Clinical Records was met as follows: --- The Hospice failed to ensure the clinical record contained documented evidence the IDG meetings held were signed by the physician, registered nurse, social worker (MSW), and Chaplain for five of 19 patients (Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7).This deficient practice has the potential to result in the lack of documented evidence for continuous assessment and care planning, patient's change of condition, progress or decline that will not be identified by the IDG for prompt intervention, treatment, and for palliation (relieving symptoms) and comfort during the terminal stage of the illness. Refer to L 672. The Hospice failed to ensure entries in the clinical records contained the medical director's and registered nurse's signatures in electronic IDG meetings for seven of nineteen sampled patients (Patient1, Patient 3, Patient 5, Patient 7, Patient 13, Patient 14, and Patient 15). The deficient practice has the potential to result in the misuse or abuse with alternate signature methods, non-authenticity of the information, and unauthorized use of confidential information. Refer to L679. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients clinical records are complete, accurate containing past and current information for continuity of care and safeguarded from unauthorized access by any individuals or hospice staff.

Based on record review and interview the HA failed to ensure the clinical record contained documented evidence the IDG meetings held were signed by the physician, registered nurse, social worker (MSW), and Chaplain for five of 19 patients (Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7). This deficient practice has the potential to result in the lack of documented evidence for continuous assessment and care planning, patient's change of condition, progress or decline that will not be identified by the IDG for prompt intervention, treatment, and for palliation (relieving symptoms) and comfort during the terminal stage of the illness. --- a. During a review of Patient 1 s admission record indicated a start of care (SOC) date of 8/20/2024, with a terminal diagnosis of hereditary ataxias (a group of disorders that affect the nervous system, leading to progressive loss of coordination /balance, slurred speech, eye problems, muscle weakness, difficulty swallowing, tremors, cognitive problems and other symptoms, it usually starts at childhood). During a review of Patient 1's Plan of Care (POC- the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/20/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 10:10 a.m., the DPCS reviewed Patient 1s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), indicated the POC/IDG Review notes dated 8/20/2024,8/29/2024, 9/26/2024,10/10/2024,11/7/2024,11/22/2024, 2/5/2024, and 7/11/2024 were missing signatures. The DPCS verified the POC/IDG Review were missing the POC/IDG Review notes between 8/20/2024 to 9/26/2024 from the Medical Director (MD) and Registered Nurse (RN) signatures. The DPCS stated that the HA messed up the dates. b. During a review of Patient 3 s admission record indicated a start of care (SOC) date of 8/29/2024, with a terminal diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a disorder of the central nervous system where the patient does not exhibit involuntary movement called dyskinesia and the symptoms do not significantly worsen or improve throughout the day). During a review of Patient 3's Plan of Care (POC- the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/29/2024, indicated an order for the skilled nurse (SN) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 11:30 a.m., the DPCS reviewed Patient 3s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), the DPCS verified the IDG review notes were not signed by the MD on 8/29/2024,9/12/2024,9/26/2024. The POC/IDG Review forms dated 9/26/2024,10/10/2024/10/24/2024,11/7/2024,11/21/2024, and 12/5/2024 were verified by the DPCS the POC/IDG Review were missing the MD and RN signatures. c. During a review of Patient 5 s admission record indicated a start of care (SOC) date of 4/10/2024, with a terminal diagnosis of senile degeneration of brain (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age. During a review of Patient 5's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 4/10/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:10 p.m., the DPCS reviewed Patient 5s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/23/2024, 6/6/2024, and 6/20/2024 the DPCS verified they were missing the MD signatures. Continued concurrent review of Patient 5s POC/IDG review dated 7/4/2024,7/18/2024, 8/1/2024,8/15/2024 and 12/5/2024. DPCS verified the POC/IDG Review were missing the RN and MDs signatures. d. During a review of Patient 6's admission record indicated a start of care (SOC) date of 8/17/2022, with a terminal diagnosis of Basal Cell Carcinoma of (a type of skin cancer that develops in the basal cells- (A small round cell found in the lower part /base of the epidermis the outer layer of the skin). During a review of Patient 6's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/17/2022, indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:50 p.m., the DPCS reviewed Patient 6s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) dated 2/3/2023,5/4/2023,6/1/2023,8/10/2023,3/26/2024, and 5/9/2024. DPCS verified the POC/IDG Review were missing the RN, MSW, and Chaplain signatures. Continued review of Patient 6's POC/ interdisciplinary group record with DPCS dated 2/3/2023, 5/42023, 6/1/2023, 8/10/2023, 3/26/2024, 5/9/2024, disclosed no IDG notes in patient's electronic clinical record. e. During a review of Patient 7's admission record indicated a start of care (SOC) date of 8/17/2022, with a terminal diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a disorder of the central nervous system where the patient does not exhibit involuntary movement called dyskinesia and the symptoms do not significantly worsen or improve throughout the day). During a review of Patient 7's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 7/24/2023, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:50 p .m., the DPCS reviewed Patient 7s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 4/25/2024, 5/23/2024 and 6/20/2024 . The DPCS verified the POC/IDG Review were missing the MD and RNs, signatures. Review of the POC/IDG review dated 5/9/2024, the DPCS verified it was missing the RNs signature. During a telephone interview with the MD in the HA on 12/13/2024, at 2:30 pm., regarding his missing signatures on the POC/IDG review forms, he stated," I may have fallen behind and have not gotten to it. The MD stated the importance of all disciplines signing thee POC/IDG forms is to ensure everyone is involved in the POC. Review of the HAs policy and procedure titled, ";INTERDISCIPLINARY GROUP COORDINATION OF CARE, Provision of Care, Treatment and Services, revised April 2017 under Procedure indicates the following: (6). Written evidence of care coordination will be found in the plan of care and slash or interdisciplinary group meeting forms in the patients clinical record and will involve the Hospice patients attending physician. (7). Care will be provided by an interdisciplinary group made-up of physicians, nurses, social workers, certified Hospice aides, homemakers, clergy, counselors, volunteers, and therapist. These services will be provided in both residential and inpatient settings.. (8). The interdisciplinary group (in collaboration with the attending physician comma if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two (2) weeks. The attending position will receive a copy of the care plan updates.

Based on interview and record review the Hospice Agency (HA) failed to ensure entries in the clinical record contained the medical director's and registered nurse's signatures in electronic IDG meetings for seven of nineteen sampled patients (Patient 1, Patient 3, Patient 5, Patient 7, Patient 13, Patient 14, and Patient 15). The deficient practice has the potential for misuse or abuse with alternate signature methods, non-authenticity of the information, and unauthorized use of confidential information. --- a. During a review of Patient 1 s admission record indicated a start of care (SOC) date of 8/20/2024, with a terminal diagnosis of hereditary ataxias (a group of disorders that affect the nervous system, leading to progressive loss of coordination /balance, slurred speech, eye problems, muscle weakness, difficulty swallowing, tremors, cognitive problems and other symptoms, it usually starts at childhood). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/20/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 10:10 a.m., the DPCS reviewed Patient 1s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), indicated the POC/IDG Review notes dated 8/20/2024,8/29/2024, 9/26/2024,10/10/2024,11/7/2024,11/22/2024, 2/5/2024, and 7/11/2024 were missing signatures. The DPCS verified the POC/IDG Review were missing the POC/IDG Review notes between 8/20/2024 to 9/26/2024 from the Medical Director (MD) and Registered Nurse (RN) signatures. The DPCS stated that the HA messed up the dates. The HA was unable to provide the missing documentations requested. b. During a review of Patient 3 s admission record indicated a start of care (SOC) date of 8/29/2024, with a terminal diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a disorder of the central nervous system where the patient does not exhibit involuntary movement called dyskinesia and the symptoms do not significantly worsen or improve throughout the day). During a review of Patient 3's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/29/2024, indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 11:30 a.m., the DPCS reviewed Patient 3s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), the DPCS verified the IDG review notes were not signed by the MD on 8/29/2024,9/12/2024,9/26/2024. The POC/IDG Review forms dated 9/26/2024,10/10/2024/10/24/2024,11/7/2024,11/21/2024, and 12/5/2024 were verified by the DPCS the POC/IDG Review were missing the MD and RN signatures. c. During a review of Patient 5 s admission record indicated a start of care (SOC) date of 4/10/2024, with a terminal diagnosis of senile degeneration of brain (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age. During a review of Patient 5's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 4/10/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:10 p.m., the DPCS reviewed Patient 5s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/23/2024, 6/6/2024, and 6/20/2024 the DPCS verified they were missing the MD signatures. Continued concurrent review of Patient 5s POC/IDG review dated 7/4/2024,7/18/2024, 8/1/2024,8/15/2024 and 12/5/2024. DPCS verified the POC/IDG Review were missing the RN and MDs signatures. d. During a review of Patient 6's admission record indicated a start of care (SOC) date of 8/17/2022 with an end of care of 7/19/2024, with a terminal diagnosis of Basal Cell Carcinoma of (a type of skin cancer that develops in the basal cells- (A small round cell found in the lower part /base of the epidermis the outer layer of the skin). During a review of Patient 6's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 8/17/2022, indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:50 p.m., the DPCS reviewed Patient 6s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) dated 2/3/2023,5/4/2023,6/1/2023,8/10/2023,3/26/2024, and 5/9/2024. DPCS verified the POC/IDG Review were missing the RN, MSW, and Chaplain signatures. There was no documented evidence of coordination of care between the IDG members. Continued review of Patient 6's POC/ interdisciplinary group record with DPCS dated 2/3/2023,5/42023,6/1/2023,8/10/2023,3/26/2024, 5/9/2024, disclosed no IDG notes in patient's electronic clinical record. e. During a review of Patient 7's admission record indicated a start of care (SOC) date of 8/17/2022, with a terminal diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a disorder of the central nervous system where the patient does not exhibit involuntary movement called dyskinesia and the symptoms do not significantly worsen or improve throughout the day). During a review of Patient 7's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 7/24/2023, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 12/13/2024 at 12:50 p .m., the DPCS reviewed Patient 7s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 4/25/2024,5/23/2024 and 6/20/2024 . The DPCS verified the POC/IDG Review was missing the MD and RNs, signatures. Review of the POC/IDG review dated 5/9/2024, the DPCS verified it was missing the RNs signature. There was no documented evidence of coordination of care between the IDG members. During a telephone interview with the MD in the HA on 12/13/2024, at 2:30 pm., regarding his missing signatures on the POC/IDG review forms, he stated," I may have fallen behind and have not gotten to it. The MD stated the importance of all disciplines signing thee POC/IDG forms is to ensure everyone is involved in the POC. f. During a record review of Patient 13s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 11/25/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airway and make it difficult to breathe). During a concurrent record review and interview on 12/13/2024 at 11:20 am., with Director of Patient Care Services (DPCS) of Patient 13s electronic medical record, the Interdisciplinary Group Meetings (IDG, a biweekly meetings held by hospice registered nurse, medical director, social worker, Chaplain, DCPS to discuss the plan of care and updates for all patients) dated from 11/31/2024 to 12/5/2024 did not have an electronic signature for Registered Nurse (RN) or Medical Director (MD). DPCS stated, ";This was missed. All disciplines who attend the meeting need to sign in." g. During a record review of Patient 14s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 08/08/2024, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (medical condition that occurs when a brain or parts of the brain shrink). During a concurrent record review and interview on 12/13/2024 at 11:25 am with DPCS of Patient 14s electronic medical record, the Interdisciplinary Group Meetings dated from 8/15/2024 to 12/5/2024 did not have an electronic signature for RN or MD. DPCS stated, ";This was missed. All disciplines who attend the meeting need to sign in." During a record review of Patient 15s Personal Information Sheet, the personal information sheet indicated a SOC date of 08/06/2024, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified. During a concurrent record review and interview on 12/13/2024 at 11:30 am with DPCS of Patient 15s electronic medical record, the Interdisciplinary Group Meetings dated from 8/15/2024 to 12/5/2024 did not have an electronic signature for RN or MD. DPCS stated, ";This was missed. All disciplines who attend the meeting need to sign in." During a review of HAs Policy and Procedure titled, ";Entries Into The Clinical Record", revised April 2017, the Policy and Procedure indicated, ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided." The policy and procedure further indicated, "; 6. The clinical note will include: E. Signature of clinician and his/her credentials."

Observed in Record Review. In 3 of 13 patient records reviewed, During review of HV#1 record review, the IDG did not update the comprehensive assessment the middle of November 2022. The RN summary lacked documentation of the description of a new coccygeal pressure ulcer. During review HV#3 record review it was noted on an SN note in January 2023 the documentation that the patient was having difficulty swallowing thin liquids and documented the MD was aware and ordered Thick it. The IDG RN summary at the next IDG after the SN visit did not include documentation of the thick-it added to the POC. During RR#3 it was noted an order for Cipro x 5 days the middle of January 2023 for a UTI without an update to the comprehensive assessment.

Observed in Record Review. In 1 of 13 patient records reviewed, During RR#1 it was noted a Physical Therapy (PT) order the end of January 2023 for PT 2x1 week, 1x 1week. The treatment orders and goals were not added to the POC. This was reviewed with the organization leadership. Observed in Record Review. In 1 of 13 patient records reviewed, During RR#8 it was noted the social worker visits were 1x/month. The POC lacked interventions and goals established by the social worker in conjunction with the IDG. Observed in Record Review. In 1 of 13 patient records reviewed, During HV#3 record review it was noted in an SN note the beginning of January 2023 documentation that the patient was having difficulty swallowing thin liquids, MD aware and ordered thick it. The POC was not updated to add instruction on the use of thick it. This was reviewed with the organization leadership.

Observed in Record Review. In 13 of 13 patient records reviewed, During HV#1-#3 record review and RR#1, #2, #4, #5, #6, #7, #8, #9 and #10, it was noted the frequency for the social worker and chaplain was once a month plus 1 PRN. The orders lacked the reason for PRN visits to be performed. During RR#3 it was noted the chaplain frequency of once a month plus 1 PRN lacked the reason for the PRN visit. The social work assessment was refused but the frequency of visits was written once a month plus 1 PRN visit. This was reviewed with the organization leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization did not implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. During HV#2 it was noted the SN disinfected the equipment used during the visit and placed the equipment on the same barrier after the vital signs were taken to dry the prescribed time. The equipment used was BP cuff, stethoscope, pulse oximeter, plastic coated measuring tape and digital thermometer. This was discussed with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 2 it was noted the organization did not implement its infection prevention and control activities. It was noted the SN did not remove her gloves after cleaning the equipment used during the visit before replacing the items back into her bag. This was discussed with the DPCS.

Observed in Record Review. In 1 of 13 patient records reviewed, During RR#1 it was noted the hospice aide assignment did not include the POC order for oxygen therapy 2L/min for shortness of breath. This was reviewed with the organization leadership.

Observed in Record Review. In 1 of 13 patient records reviewed, The supervision of the hospice aide by the RN was not performed at least every 14 days. During HV#2 record review it was noted the hospice aide frequency of visits was once a week starting the beginning of December 2022. The first RN supervisory visit was documented 24 days later. This was reviewed with the organization leadership.

Observed in Record Review. In 1 of 13 patient records reviewed, During HV#1 record review it was noted an order for respite care the end of December 2022. The documentation included the physician/IDG respite order and the name of the respite facility. The patient record lacked documentation of patient's care during the respite stay that included the communication and coordination with the facility on the implementation of the hospice POC, transportation to and from the facility and response of the patient to the respite stay. In discussion with the organization leadership, the DPCS stated that the coordination and communication was done but not documented in the patient record.

Observed in Document Review. During review of the organization contract with a skilled nursing facility it was noted lack of a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was reviewed with the organization leadership.

Observed in Document Review. During review of the organization's skilled nursing facility contract it was noted lack of a delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff. This was reviewed with the organization leadership.