Every finding on record at Angenida Hospice LLC

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan based on the risk assessment and communication plan was reviewed and updated at least every two years.  This failure had the potential for not providing the necessary care and services to the patients during an emergency.Findings: --- Review of the hospice’s Emergency Plan was initiated on 4/8/25.  The Emergency Plan showed the hospice coordinated efforts with the area emergency management agencies to mitigate, prepare, respond and recover from high priority emergencies that impact the community, e.g. the local health department, law enforcement and office of the emergency management. Review of the Governing Body minutes on 1/2/24 and 1/2/25, showed the Emergency Plan was reviewed and updated.  However, there was no documented evidence on when the P&P and communication plan were reviewed and updated in the years of 2022, 2023, 2024, or 2025. On 4/9/25 at 1125 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the hospice's emergency preparedness P&P addressed a system of medical documentation that will secure and maintain the availability of the records during the emergency.   This failure had the potential for patient’s confidential information to not be protected.Findings: --- Review of the hospice’s P&P on emergency preparedness was initiated on 4/8/25.  The Emergency Plan did not address the system of medical documentation that will secure and maintain the availability of the records.On 4/9/25 at 1125 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&P addressed the use of other emergency staffing strategies to address the surge needs during an emergency.  This failure had the potential of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation.Findings: --- Review of the hospice’s P&P on emergency preparedness was initiated on 4/8/25.  The hospice's Emergency Plan showed the Director and/or Manager of Patient Services will immediately implement the emergency operations plan and will be responsible for triaging patients based on their needs, severity, and the availability of the staff.  The Director and/or Manager of Patient Services is responsible for contacting the staff when the emergency measures are  implemented.  In addition, following the initiation of the phone communication plan, all available and qualified personnel will be mobilized to perform the identified services.  However, the hospice's emergency preparedness P&P and plan did not include the use of other emergency staffing strategies to address the surge needs, including which external staffing agencies to be used, or the role for the integration of the State and Federal designated health care professionals to address the surge needs during an emergency. On 4/9/25 at 1125 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan maintained a communication plan that was reviewed and updated at least every two years.  This failure had the potential for the patients to not receive the adequate and timely assistance during an emergency crisis.Findings: --- Review of the hospice’s P&P on emergency preparedness was initiated on 4/8/25.  Review of the Governing Body minutes on 1/2/24 and 1/2/25, showed the Emergency Plan was reviewed and updated.  However, there was no documented evidence showing when the communication plan was reviewed and updated in the years of 2022, 2023, 2024, or 2025. On 4/9/25 at 1125 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness communication plan included the names and contact information of the patients’ physicians.  This failure had the potential for the physician to not be notified and staff to not be aware of the necessary care and services to provide to the patients. Findings: --- Review of the hospice’s Emergency Plan was initiated on 4/8/25.  The Emergency Plan showed the contact information for the local and regional agencies.  However, it did not include the names and contact information of the patients’ physicians, and the Medical Director Designee’s contact information was missing. On 4/9/25 at 1125 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency communication plan included the primary and alternate means of communication with the Federal, State, regional, and local emergencies management agencies.  This failure had the potential to not be able to contact and/or request for assistance in the emergency events.Findings: --- Review of the hospice’s P&P on emergency preparedness was initiated on 4/8/25.  The communication plan failed to include the primary and alternate means of communication with the Federal, State, regional, and local emergency management agencies. On 4/9/25 at 1125 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan maintained an emergency preparedness training and testing program that was reviewed and updated at least every two years.  This failure had the potential of not providing the necessary care and services to the patients.Findings: --- Review of the hospice’s P&P on emergency preparedness was initiated on 4/8/25.  The Emergency Plan and employee files review showed the hospice provided the new staff orientation and training of the emergency operations plan; and the ongoing staff education and training will occur annually as part of an exercise or in response to an actual emergency. Review of the hospice documents dated 7/17/23 and 10/7/24, showed the hospice conducted an earthquake and fire drills.  However, there was no documented evidence the emergency preparedness training and testing program were reviewed and updated at least every two years. On 4/9/25 at 1125 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on clinical record review and interview, the hospice failed to ensure the initial comprehensive assessment was completed within 48 hours after the election of hospice care for two of 14 sampled patients (Patients 2 and 12).  This failure had the potential for not addressing the care needs for these patients.Findings: --- 1.  Closed clinical record review for Patient 2 was initiated on 4/3/25.  The clinical record showed the SOC was on 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.Review of the Election of Medicare Hospice Benefit showed the patient had consented and signed the form to receive the hospice benefits on 12/30/23.Review of the patient’s closed clinical record showed the hospice’s RN had completed an initial comprehensive assessment on 1/4/24, more than 48 hours after the election of hospice care for the patient.On 4/4/25 at 0904 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.  2.  Closed clinical record review for Patient 12 was initiated on 4/8/25.  The clinical record showed the SOC was on 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.  Review of the initial Comprehensive Nursing Assessment dated 9/27/23, showed the bereavement screening section was not completed nor assessed within the 48 hours after the election of the hospice care for the patientOn 4/9/25 at 1213 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for nine of 14 sampled patients (Patients 1, 3, 6, 7, 9, 10, 12, 13, and 14).  This failure had the potential for not addressing the care needs for these patients. Findings: --- #. Review of Patient 1’s closed clinical record was initiated on 4/3/25. The closed clinical record showed the SOC was 7/25/24. The patient was certified for hospice services during the certification periods from 7/25/24 to 9/22/24, 9/23/24 to 11/21/24, and 11/22/24 to 1/20/25.The initial comprehensive nursing and spiritual assessment were conducted on 7/25/24 and 7/26/24, respectively.The Psychosocial Assessment dated 7/27/24, showed the POA requested for telehealth and can provide needed information. However, the MSW was not able to complete the assessment for the following:-Instrumental Activities of Daily Living;-Family-Psychosocial Distress/Concern;-PCG Family Anxiety Rating; and-Mortuary Info.Further review of the closed clinical record showed no documented evidence the hospice had completed the comprehensive psychosocial assessment for the patient.#. Review of Patient 14’s closed clinical record was initiated on 4/8/25. The closed clinical record showed the SOC was 5/9/24. The patient was certified for hospice services during the certification periods from 5/9/24 to 8/6/24, 8/7/24 to 11/4/24 and 11/5/24 to 1/3/25.The initial comprehensive nursing assessment was conducted on 5/9/24.The Psychosocial Assessment dated 5/11/24, showed the family member was out of the house and requested to do telehealth. However, review of the clinical record showed no documented evidence the hospice had completed the comprehensive psychosocial assessment timely for the patient. The Spiritual Assessment dated 5/13/24, showed the SC 1 reached out to the family/caregiver for spiritual assessment and support. Documentation showed the PCG nor the patient did not respond nor returned the call for any need of spiritual support. Documentation showed the SC would make a follow-up call and would be available whenever needed in person or would be available on the phone for telehealth support.There was no documented evidence the SC 1 attempted to make follow-up calls to the family/PCG. Further review of the closed clinical record showed no documented evidence the hospice had completed the comprehensive spiritual assessment for the patient.On 4/9/25 at 1042 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #. Review of Patient 3's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 3/12/25.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.  The patient was residing in a Board and Care Facility.The initial comprehensive psychosocial assessment dated 3/15/25, showed the MSW had performed a telephone assessment. However, the MSW failed to perform a completed comprehensive assessment within five calendar days from the election of benefits as the section for the patient’s psychosocial circumstances, psychosocial distress/ concern; patient response to illness; possible patient crisis; instrumental for activities of daily living; family - psychosocial distress/ concern; family crisis; planning/advance directive; mortuary and referral to the community program was left blank.On 4/9/25 at 1109 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.   The Patient Care Coordinator was informed and acknowledged the finding.#.  Review of Patient 13's closed clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 8/11/24.  The patient was certified for hospice services during the certification periods from 11/1/24 to 1/29/24 and 1/30/25 to 3/30/25.  The patient was discharged on 2/7/25.The initial comprehensive psychosocial assessment dated 8/13/24, showed the MSW had performed a telephone assessment. However, the MSW failed to perform a completed comprehensive assessment within five calendar days from the election of benefits as the section for the patient’s psychosocial circumstances, psychosocial distress/ concern; patient response to illness; possible patient crisis, instrumental for activities of daily living; family - psychosocial distress/ concern; family crisis, planning/advance directive, mortuary, and referral to the community program was left blank.On 4/9/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.   The Patient Care Coordinator was informed and acknowledged the finding.   #.  Review of Patient 12’s closed clinical record review was initiated on 4/8/25.  The clinical record showed the SOC 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.The initial comprehensive psychosocial assessment dated 9/30/23, showed no documented evidence the MSW assessed the patient’s instrumental for activities of daily living; family’s psychosocial distress/ concern; and information on family crisis, advance directive, mortuary, and referral to the community program.The initial comprehensive spiritual assessment dated 10/1/23, showed no documented evidence SC 1 assessed the patient for spiritual circumstances, patient/PCG’s faith community information, spiritual and cultural influences, spiritual support, patient-spiritual distress/concern, and source of distress/concern.*  However, there was no documented evidence the comprehensive psychosocial and spiritual assessments were completed no later than 5 calendar days after the election of hospice care.On 4/9/25 at 1216 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.  #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The initial comprehensive nursing assessment dated 10/27/24, showed no documented evidence the SN completed the assessment for the patient’s oral cavity. The initial comprehensive psychosocial assessment dated 10/30/24, showed no documented evidence the MSW assessed the patient’s instrumental for activities of daily living; family’s psychosocial distress/ concern; and information on family crisis, advance directive, mortuary, and referral to the community program. *  However, there was no documented evidence the comprehensive physical and psychosocial assessments were completed no later than 5 calendar days after the election of hospice care. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The initial comprehensive psychosocial assessment dated 3/7/25, showed MSW called the patient’s wife and declined physical visit but can provide information “when introduced self”.  There was no documented evidence the MSW assessed the patient’s psychosocial circumstances such as family/PCG name, number of children living in patient’s home, and the living arrangement; instrumental for activities of daily living; family’s psychosocial distress/concern; and information on family crisis and mortuary *  However, there was no documented evidence the comprehensive psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   The initial comprehensive psychosocial assessment dated 9/7/24, showed the living arrangement was unhealthy.  There was no documented evidence of an explanation why the living arrangement was unhealthy.    *  However, there was no documented evidence the comprehensive psychosocial assessment was completed no later than 5 calendar days after the election of hospice care On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The initial comprehensive nursing assessment dated 6/26/24, showed no documented evidence the SN completed the assessment for the patient’s oral cavity. *  However, there was no documented evidence the comprehensive physical assessment was completed no later than 5 calendar days after the election of hospice care. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments identified the physical, emotional, psychosocial, and spiritual needs for seven of 14 sampled patients (Patients 1, 6, 7, 9, 10, 12, and 14).  This failure had the potential of not providing care and services to meet the care needs for these patients. Findings: --- #. Review of Patient 1’s closed clinical record was initiated on 4/3/25. The closed clinical record showed the SOC was 7/25/24. The patient was certified for hospice services during the certification periods from 7/25/24 to 9/22/24, 9/23/24 to 11/21/24, and 11/22/24 to 1/20/25.Further review of the closed clinical record showed no documented evidence the hospice had completed the initial psychosocial assessment for the patient.#. Review of Patient 14’s closed clinical record was initiated on 4/8/25. The closed clinical record showed the SOC was 5/9/24. The patient was certified for hospice services during the certification periods from 5/9/24 to 8/6/24, 8/7/24 to 11/4/24 and 11/5/24 to 1/3/25.Further review of the closed clinical record showed no documented evidence the hospice had completed the initial psychosocial and spiritual assessments for the patient.On 4/9/25 at 1042 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #.  Review of Patient 12’s closed clinical record review was initiated on 4/8/25.  The clinical record showed the SOC 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.The initial comprehensive psychosocial assessment dated 9/30/23, showed the MSW assessment for the patient’s instrumental for activities of daily living; family’s psychosocial distress/ concern; information on family crisis, advance directive, mortuary, and referral to the community program was incomplete.The initial comprehensive spiritual assessment dated 10/1/23, showed SC 1 assessment for the patient's spiritual circumstances, patient/PCG’s faith community information, spiritual and cultural influences, spiritual support, patient-spiritual distress/concern, and source of distress/concern was incomplete.On 4/9/25 at 1216 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.    #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The initial comprehensive nursing assessment dated 10/27/24, showed the assessment for patient’s oral cavity was incomplete. The initial comprehensive psychosocial assessment dated 10/30/24, showed the MSW assessment for the patient’s instrumental for activities of daily living; family’s psychosocial distress/ concern; information on family crisis, advance directive, mortuary, and referral to the community program was incomplete. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. *  The initial comprehensive psychosocial assessment dated 3/7/25, showed the MSW assessment for patient’s psychosocial circumstances such as family/PCG name, number of children living in patient’s home, and living arrangement; instrumental for activities of daily living; family’s psychosocial distress/ concern; and information on family crisis and mortuary was incomplete. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   The initial comprehensive psychosocial assessment dated 9/7/24, showed the living arrangement was unhealthy.   *  There was no documented evidence of an explanation/information why the living arrangement was unhealthy.    On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. *  The initial comprehensive nursing assessment dated 6/26/24, showed the SN assessment on the patient’s oral cavity was incomplete. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.

Based on observation, interview, and record review, the hospice failed to include all current medications' side effects and actual or potential drug interaction in the comprehensive assessments and ensure the medication profile was reviewed and updated to reflect the current medications and include specific indications and parameters for its use for six of 14 sampled patients (Patients  2, 3, 6, 7, 9, and 10 ).  These failures had the potential for the patients to not receive the appropriate care and necessary services and negatively affect the patients' well-being. --- #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The POC/Review dated 2/24/25 showed the patient’s medication included lorazepam (antianxiety) 0.5 mg one tablet PO Q four hours PRN for anxiety/agitation and morphine sulfate (opioid analgesic) 20 mg 0.25 ml SL Q eight hours routinely and Q two hours PRN for severe pain/SOB. According to lorazepam’s prescribing information, the concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death *  Further review of the POC Summary showed no documented evidence the orders/medication profile have been reviewed for contraindication, side effects, interactions, duplications and lab therapy drugs. *   In addition, there was no documented evidence the IDG identified the potential drug interactions between the lorazepam and morphine sulfate medications. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.   The Administrator/LVN was informed and acknowledged the findings. #.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The POC/Review dated 3/3/25, showed the patient’s medication included Percocet (opioid analgesic) 5 mg-325 mg one tablet PO Q eight hours PRN for severe pain and tramadol hydrochloride (opioid analgesic) 50 mg one tablet PO TID for pain. According to Percocet’s prescribing information, the drug interactions of Percocet with benzodiazepines and other CNS depressants included  the concomitant use of benzodiazepines and other CNS depressants such as benzodiazepines and other sedative hypnotics, anxiolytics, and tranquilizers, muscle relaxants, general anesthetics, antipsychotics, and other opioids, including alcohol, can increase the risk of hypotension, respiratory depression, profound sedation, coma, and death. *  The POC Summary dated 3/3/25, showed no documented evidence the orders/medication profile have been reviewed for contraindication, side effects, interactions, duplications and lab therapy drugs. *   In addition, there was no documented evidence the IDG identified the potential drug interactions between Percocet and tramadol. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   The POC Summary dated 1/13/25, showed the patient’s medication included aspirin (non-steroidal anti-inflammatory drug) 81 mg one tablet PO daily and clopidogrel (antiplatelet) 75 mg one tablet PO QD. According to clopidogrel’s prescribing information, the coadministration of clopidogrel tablets and NSAIDs increases the risk of gastrointestinal bleeding. *  Further review of the POC Summary showed no documented evidence the orders/medication profile have been reviewed for contraindication, side effects, interactions, duplications and lab therapy drugs. *   In addition, there was no documented evidence the IDG identified the potential drug interactions between clopidogrel and aspirin. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The POC Summary dated 3/10/25, showed the patient’s medication included lorazepam (antianxiety) 0.5 mg one tablet PO Q four hours PRN for anxiety/agitation and morphine sulfate (opioid analgesic) 20 mg/ml 0.25 ml SL Q two hours PRN for severe pain/SOB. According to lorazepam’s prescribing information, the concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. *  Further review of the POC Summary showed no documented evidence the orders/medication profile have been reviewed for contraindication, side effects, interactions, duplications and lab therapy drugs. *   In addition, there was no documented evidence the IDG identified the potential drug interactions between lorazepam and morphine sulfate. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.   #.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.The POC/IDG Review dated 11/4, 11/18, 11/25, 12/2, 12/16, 12/30/24, 1/7, 1/13, and 1/27/25, showed patient’s medication included the following:-lidocaine 4% topical cream (used to prevent pain by blocking signals at the nerve ending of the skin) apply to affected area as needed.-DuoNeb (used to treat or prevent symptoms of wheezing and shortness of breath) 3 mg inhalation one vial every 4 to 6 hours as needed.-aspirin (used to treat mild pain or as a blood thinner) 81 mg by mouth in the morning daily-atenolol (used to treat high blood pressure) 50 mg one-half tablet by mouth daily-carbidopa/levodopa (used to treat some symptoms of Parkinson’s disease such as shaking, muscle stiffness, and slow/unsteady gait) 25 mg- 100 mg one tablet by mouth in the morning and noon.-docusate sodium (stool softener) 100 mg one capsule in the morning daily*However, the section for the medication profile was reviewed for contraindications, side effects interactions, duplication and lab therapy drugs had a box that was left blank. On 4/9/25 at 1208 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding. The Administrator Designee stated the nurse should mark the box with a check mark to indicate they reviewed all of the patient’s medication for any contraindications, side effects interactions, duplication and lab therapy drugs.   #.  The agency P&P titled Medication Profile revised 10/2019, showed patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record.  Medication profiles will be updated for each change to reflect current medications and new and or discontinued medications.  Deviations in taking medications as ordered will be documented in the clinical notes, and the physician will be notified. Review of Patient 3's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 3/12/25.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.  The patient was residing in a Board and Care Facility.The POC Summary  dated 4/3/25 showed the patient was on Morphine Sulfate (opiate) 20 mg/ml 0.25 mg SL every eight hours routinely and every two hours as needed for severe pain and shortness of breath, Ondansetron hydrochloride (nausea/vomiting) 4 mg one tablet SL every four hours as needed and Atrovent HFA 17 mcg/actuation inhalation aerosol, inhale 2 puffs four times a day as needed for shortness of breath/wheezes. A joint home visit with RN 1 to the B&C  where the patient resided was conducted on 4/4/25 at 1000 hours.  Review of the patients' medications included the following instructions:-Morphine sulfate 100 mg/5 ml,  take 0.25 ml SL (under the tongue) every two hours as needed for severe pain and shortness of breath.  However, the instructions failed to include to give every eight hours routinely as ordered.  -Ondansetron ODT 4mg tablet, place one tablet on top of tongue and allow to dissolve every four hours as needed for  nausea / vomiting.  However, the order for the route of administration was sublingual. -Atrovent HFA 17 mcg/actuation inhalation aerosol, inhale 2 puffs four times a day as needed for shortness of breath/wheezes.  However, the instructions on the B&C medication administration record was to give one puff two times a day which was inconsistent with the order. In addition, the patient was on fluticasone propionate and salmeterol inhalation powder (Wixela) 250/50 oral inhalation, inhale one puff two times daily.  However, the medication was not listed on the medication profile.On 4/4/25 at 1125 hours an interview and concurrent clinical record review was conducted with the RN 1.  The RN 1 was informed and acknowledged the findings.Moreover, review of the POC Summary as of 4/3/25, showed the patients was on lorazepam  (anti anxiety)  0.5 mg one tablet PO every four hours as needed and Morphine Sulfate 20 mg/ml 0.25 mg SL every eight hours routinely and every two hours as needed for severe pain and shortness of breath.However, the section for the medication profile was reviewed for contraindications, side effects interactions, duplication and lab therapy drugs was left blank. On 4/9/25 at 1128 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator. The Patient Care Coordinator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patients' progress, and reassessment of the patients' responses for five of 14 sampled patients (Patients 3, 4, 6, 9, and 10).  This failure had the potential of not addressing the care needs for these patients. Findings: --- #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The Communication Log dated 2/27/25, showed the SN reported the patient had wounds on the right lateral ankle and left knee.  Documentation showed the physician was informed and ordered a wound evaluation and treatment.  Documentation showed IDG was informed. The Communication Log dated 2/28/25, showed “Wound care” start visiting the patient. The physician’s order dated 2/28/25, showed the wound order included to cleanse with NSS, pat dry, apply collagen particles (wound dressing), cover with bordered foam dressing, change dressing three times per week and PRN soiled or loss of integrity. The Progress Note from Wound Care Provider 1 dated 2/28/25,  showed the NP conducted a wound care visit and treatment. The POC/IDG Review dated 2/24 and 3/10/25, showed the same information which included the patient’s condition was reviewed and discussed, changes in medication and treatment were reviewed and discussed. Documentation showed treatment and management remains the same. *  However, the IDG failed to discuss the specific changes on the patient’s wound on 3/10/25 as wounds were identified on 2/27/25. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The Communication Log dated 3/25/25, showed SN reported the patient had “fungal” on his toe.  Documentation showed the physician was informed and ordered clotimazole 1% (antifungal) fungal cream.  Documentation showed SN to report any changes and IDT was informed with the new medication. The POC/IDG Review dated 3/24 and 4/7/25, showed no documented evidence the IDG discussed on what the status/assessment of the patient’s toe was. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The POC/IDG Review dated 2/24/25, showed the IDG conducted a meeting.  Documentation included the patient’s condition was reviewed and discussed.  Documentation showed the patient’s condition continued to decline and the patient continued to manifest signs and symptoms of terminal illness and other underlying comorbidities.  Documentation showed treatment and management remains the same.  Documentation showed the plan of care was updated and reviewed. The Communication Log dated 2/27/25, showed the SN reported the patient had a wound on the right external ear and left ear lobe.  Documentation showed the physician was informed and ordered wound evaluation and treatment. The Communication Log dated 2/28/25, showed wound care provider started visiting the patient one time a week. The Progress Notes of Wound Care Provider 1 dated 2/28/25, showed the NP assessed and provided treatment on the patient’s left ear lobe and right external ear pressure injury. The POC/IDG Review dated 3/10/25, showed the IDG discussed the same information documented on the POC/IDG Review dated 2/24/25.   *  However, there was no documented evidence the IDG discussed the status of the patient’s left ear lobe and right external ear pressure injury. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.    #. Review of Patient 4’s clinical record was initiated on 4/4/25. The clinical record showed the SOC was 9/6/24. The patient was certified for hospice services during the certification period 3/5/25 to 5/3/25.Review of the RN Re-Cert Assessment dated 3/5/25, showed patient was on O2 therapy at two to three liters per minute via nasal cannula as needed. Furthermore, the documentation showed patient has DMEs consisting of O2 concentrator and E-tank.The POC/IDG Review dated 3/10/25, showed a care plan problem was developed for the patient’s respiratory system. However, it was not updated to include the patient’s use of oxygen. There was also no documented evidence showing the IDG had discussed the problem.On 4/9/25 at 1052 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for nine of 14 sampled patients (Patients 1, 2, 6, 8, 9, 10, 12, 13, and 14).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients.  Findings: --- #. Review of Patient 1’s closed clinical record was initiated on 4/3/25. The closed clinical record showed the SOC was 7/25/24. The patient was certified for hospice services during the certification periods from 7/25/24 to 9/22/24, 9/23/24 to 11/21/24, and 11/22/24 to 1/20/25.The initial Comprehensive Nursing Assessment dated 7/25/24 showed patient’s current oxygen treatment was given continuously at three liters per minute via nasal cannula.Further review of the closed clinical record, showed a physician’s order dated 7/25/24, may administer oxygen at two liters per minute via nasal cannula as needed for shortness of breath/discomfort. May titrate up to five liters to maintain saturation level to 90% and above.On 4/9/25 at 1042 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings.#. Review of Patient 14’s closed clinical record was initiated on 4/8/25. The closed clinical record showed the SOC was 5/9/24. The patient was certified for hospice services during the certification periods from 5/9/24 to 8/6/24, 8/7/24 to 11/4/24 and 11/5/24 to 1/3/25.The POC/IDG review dated 10/7/24 and 10/21/24 showed SN visit one per week plus three PRN visits.*However, the SN had no documented visits for the week starting 10/20/24 to 10/26/24. On 4/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #.  Review of Patient 13's closed clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 8/11/24.  The patient was certified for hospice services during the certification periods from 11/1/24 to 1/29/24 and 1/30/25 to 3/30/25.  The patient was discharged on 2/7/25.The POC/IDG dated 11/4, 11/18, 12/16, 12/30/24, 1/13, 1/27 and 2/10/25, showed a care plan issue related to complains of occasional constipation with bowel frequency of three times per week.  The intervention includes to check on the usual pattern of elimination, including frequency and consistency of stool.However, review of the SN visit notes dated 11/6, 11/14, 12/23/24, 1/8/25 failed to show documented evidenced of the patients last bowel movement was check as ordered in the POC. On 4/9/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.    The Patient Coordinator replied, will go back on that.   The Patient Coordinator was informed and acknowledged the findings. #.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.The POC/IDG Review dated 11/4, 11/18, 11/25, 12/2, 12/16, 12/30/24, 1/7, 1/13, and 1/27/25, cited for HA visit one time per week.*However, the HA visited the patient two times per week each week during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.On 4/9/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.#.  Review of Patient’s 8 clinical records was initiated on 4/4/25.  The clinical record showed the SOC was 8/12/24.  The patient was certified for hospice services during the certification periods from 2/8/25 to 4/8/25.The POC/IDG Review dated 2/10, 2/24, 3/10, and 3/24/25, showed a care plan issue related to genitourinary with an intervention to assess the patient’s bladder status every visit and determine the episodes of incontinence.However, review of the SN visit notes dated 2/12, 2/19, 2/26, 3/5, 3/12, 3/19, and 3/26/25  failed to show documented evidenced of the patients number of episodes of incontinence  was check as ordered in the POC. On 4/9/25 at 1212 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.#.  Review of Patient 12’s closed clinical record review was initiated on 4/8/25.  The clinical record showed the SOC 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.Review of the Physician’s Orders showed an order dated 9/27/23, the patient was offered CHHA visits but declined.The POC/IDG Review dated 11/18, 12/2, 12/16, and 12/30/24, cited for HA visit one time per week.*However, further review of Patient 2’s closed clinical records failed to showed documented evidence there was a HA visit for the patient.On 4/9/25 at 1223 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.  #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The Communication Log dated 2/27/25, showed the SN reported the patient had wounds on the right lateral ankle and left knee.  Documentation showed the physician was informed and ordered wound evaluation and treatment.  Documentation showed IDG was informed. The physician’s order dated 2/28/25, showed the wound order included to cleanse with NSS, pat dry, apply collagen particles (wound dressing), cover with bordered foam dressing, change dressing three times per week and PRN soiled or loss of integrity. The Progress Note from Wound Care Provider 1 dated 2/28/25, showed the NP conducted a wound care visit and treatment on the patient’s right lateral malleolus ankle and left knee wounds. The Progress Note from Wound Care Provider 1 dated 3/7/25, showed the NP conducted a wound care visit and treatment on the patient’s right lateral malleolus ankle wound.  Documentation showed the patient’s left knee wound was closed. *  However, the SN note dated 3/10/25, showed no documented evidence the SN performed wound care on the patient’s right lateral malleolus ankle wound. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The POC/IDG Review dated 3/24 and 4/7/25, showed RN visit 1W and 3 PRN, SN visit 1W and 3 PRN, and SC visit 1W and 3 PRN. *  The SN notes showed no documented evidence the RN conducted a visit on Week 8 (3/23/24 to 3/29/24), instead of one visit a week as per the POC. *  In addition, there was no documented evidence SC 2 conducted a visit on Week 8 (3/23/24 to 3/29/24), instead of one visit a week as per the POC. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The POC/IDG Review dated 3/10/25, showed the following: An order dated 2/28/25, showed the treatment for the left ear pressure ulcer and right external pressure ulcer included “Wound Cleanser Gauze Collagen Particles Bordered Foam Dressing change 2x a week.” An order dated 2/28/25, showed to cleanse with NSS left ear lobe and right external wound with NSS, pat dry, apply collagen particles (wound dressing), cover with bordered gauze, and change dressing “3x.” a.  The SN note dated 3/21/25, showed wound care done as ordered on the left ear lobe and right external ear by cleansing with NSS, patting dry, applying triple antibiotic ointment, and covering with bordered gauze. *  However, there was no documented evidence of the POC included wound care on the patient’s left ear lobe and right external ear by the application of triple antibiotic ointment. b. The POC/IDG Review dated 2/10, 2/24, 3/10, and 3/24/25, showed SN visits 2W. *  The SN notes showed on Week 2 (2/23/25 to 3/1/25), Week 3 (3/2/25 to 3/8/25), Week 4 (3/9/25 to 3/15/25), Week 5 (3/16/25 to 3/22/25), and Week 6 (3/23/25 to 3/29/25), showed one SN visit instead of two visits as per the POC. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for nine of 14 sampled patients (Patients 1, 3, 4, 5, 6, 7, 9, 10,  and 13).  This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health conditions.  Findings: --- #. Review of Patient 1’s closed clinical record was initiated on 4/3/25. The closed clinical record showed the SOC was 7/25/24. The patient was certified for hospice services during the certification periods from 9/23/24 to 11/21/24 and 11/22/24 to 1/20/25.a.Review of the RN Visit Note dated 10/15/24, showed the caregiver reported patient had dark orange and a foul-smelling urine.The POC/IDG Review dated 10/21/24, showed care plan problems were developed for infection/immunological. *However, there was no documented evidence showing an individualized POC was developed to address the patient’s episode of dark orange and foul-smelling urine.b.Review of the Communication Log dated 11/18/24, showed the SN called and reported patient had swollen gums due to tooth abscess.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s swollen gums.c.Review of the Communication Log dated 12/10/24, showed the SN called and reported patient had redness, itchy dry skin on the right arm and torso.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s skin problem.On 4/9/25 at 1042 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #. Review of Patient 4’s clinical record was initiated on 4/4/25. The clinical record showed the SOC was 9/6/24. The patient was certified for hospice services during the certification period 12/5/24 to 3/4/25.a.Review of the RN Visit Note dated 12/14/24, showed patient had episode of painful urination and foul-smelling urine. Patient has history of recurring UTIs.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s episode of painful urination, foul-smelling urine and recurring UTIs.b.Review of the Communication Log dated 3/1/25, showed the visiting RN reported patient’s current medication trazodone 50 mg was not working. MD was informed and ordered an increased dose to 100 mg.*However, there was no documented evidence the IDG had developed an individualized POC to address the patient’s difficulty of sleeping.On 4/9/25 at 1052 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #. Review of Patient 3's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 3/12/25.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.  The patient was residing in a Board and Care Facility.Review of the SN notes dated 3/18/25, showed the SN had performed integumentary assessment.  The assessment showed the patient had mild bruising on the periorbital area due to fall.However, there was no documented evidenced the IDG had developed an individualized POC related to the integumentary system to address the patients periorbital bruising due to fall. On 4/9/25 at 1109 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.   The Patient Care Coordinator was informed and acknowledged the finding. #.   Review of Patient 5's clinical record was initiated on 4/4/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification period from 12/24/24 to 3/23/25 and 3/24/25 to 5/22/25.  Review of the Recertification Assessment dated 12/18/24 and 3/18/25, showed the patient was assessed to have oxygen therapy at 2 to 3 liters via NC PRN. The assessment also showed the DME includes an oxygen concentrator. The POC IDG dated 12/30/24,1/13, 1/17, 2/10, 2/24, 3/10 and 3/24/25 showed a care plan problem for the potential for altered respiratory status.  The interventions includes to check the oxygen saturation PRN during SN visits.However, there were no documented evidence of the specific rate of oxygen to be given as needed. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was informed and acknowledged the findings.  #.   Review of Patient 13's closed clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 8/11/24.  The patient was certified for hospice services during the certification periods from 11/1/24 to 1/29/24 and 1/30/25 to 3/30/25.  The patient was discharged on 2/7/25.Review of the POC/IDG dated 11/18/24 showed a care plan for pain was developed.  The goal includes pain level will remain in less than three and maintain comfort/satisfaction from pain after nursing intervention/medication throughout the rest of benefit period. In addition, review of the POC/IDG dated 11/18/24 on the section of medications showed the patient was on tramadol (pain medication) 50 mg one tablet oral every 6 hours as needed for pain and acetaminophen (analgesic), 500 mg tablet one tablet oral every four to six hours as needed for mild pain. However, the instructions for the frequency and the pain scale when to give the pain medications was not specific.  On 4/9/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was informed and acknowledged the findings.  #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The Communication Log dated 2/27/25, showed the SN reported the patient had wounds on the right lateral ankle and left knee.  Documentation showed the physician was informed and ordered a wound evaluation and treatment.  Documentation showed IDG was informed. The physician’s order dated 2/28/25, showed the wound order included to cleanse with NSS, pat dry, apply collagen particles (wound dressing), cover with bordered foam dressing, change dressing three times per week and PRN soiled or loss of integrity. The POC/IDG Review dated 2/24, 3/10, and 3/24/25, showed SN visits 1W. *  However, there was no documented evidence the IDG had developed an individualized POC to address Patient 6’s wound. *  In addition, there was no documented evidence on who will be responsible for wound care during non-SN visit days and the wound location on the POC/physician’s order. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The POC/IDG Review dated 4/7/25, showed it was discussed in the IDG the patient showed signs of depression such as feeling down/sad and lonely; and feeling not worthy due to illness.  The patient’s medications included an order dated 4/7/25, for Lexapro (antidepressant) 10 mg one tablet PO once daily. *  However, there was no documented evidence the IDG developed an individualized POC to address Patient 10’s depression and the use of Lexapro. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   The initial comprehensive psychosocial assessment dated 9/7/24, showed the living arrangement was unhealthy.  The mortuary information showed it was pending. The MSW note dated 1/3 and 3/1/25, showed the living arrangement was unsafe.  Documentation showed the mortuary information was pending. *  However, there was no documented evidence the IDG developed an individualized POC to address the patient’s living arrangement and the pending information of the patient’s mortuary. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. a.  The Communication Log dated 2/27/25, showed the SN reported the patient had a wound on the right external ear and left ear lobe.  Documentation showed the physician was informed and ordered wound evaluation and treatment. The Communication Log dated 2/28/25, showed the wound care provider started visiting the patient one time a week. The Progress Notes of Wound Care Provider 1 dated 2/28/25, showed the NP assessed and provided treatment on the patient’s left ear lobe and right external ear pressure injury. *  However, there was no documented evidence the IDG developed an individualized POC to address the patient’s left ear lobe and right external ear pressure injury. b.  The initial psychosocial assessment dated 6/29/24 and the MSW note dated 2/20/25, showed the mortuary information was pending. *  However, there was no documented evidence the IDG developed an individualized POC to address the patient’s pending information of the mortuary. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits for 11 of 14 sampled patients (Patients 1, 2, 4, 6, 8, 7, 9, 10, 11, 12, and 14).  This failure had the potential of not providing necessary services for these patients. Findings: --- #.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.The POC/IDG Review dated 11/4/24, showed BC visit one per week and three prn visits, HA visit one per week, MSW visit one per week and three prn visits, SC visit one per week and three prn visits, and SN visit one per week and three prn visits.* However, there was no documented evidence showing the indication for the PRN discipline visits.On 4/9/25 at 1157 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding. Review of the clinical records for Patients 1, 2, 4, 6, 8, 7, 9, 10, 11, 12 and 14 failed to show documented evidence of the indication for the PRN discipline visits on the POCs.  For example: 1.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The POC/IDG Review dated 2/24/25, showed SN one per week, SC one time then PRN, MSW one time then PRN, HA three times per week, and volunteer declined. * However, there was no documented evidence showing the the indication for the PRN discipline visits. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. 2.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   The POC/IDG Review dated 1/13/25 , showed BC one time visit then PRN, HA visits 2W, MSW visit one time then PRN, and SN visit 1W and 3 PRN * However, there was no documented evidence showing the indication for the PRN discipline visits. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 14 of 14 sampled patients (Patients 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, 14).  This failure had the potential of not evaluating the POC and providing appropriate care and services to these patients.   Findings: --- Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 showed no documented evidence the POCs included measurable outcomes.  For example: 1.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The POC/IDG Review dated 2/24/25, showed the patient's identified problems with the established goal and interventions.  However, the POC failed to include measurable outcomes for the patient's identified problems.  For example, one of the goals for altered cardiac status related to stroke, heart attack, and other heart problems was to maintain optimum peripheral circulation.  There was no documented evidence as to what optimum peripheral circulation was. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. 2.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The POC/IDG Review dated 3/3/25, showed the patient's identified problems with the established goal and interventions.  However, the POC failed to include measurable outcomes for the patient's identified problems.  For example, the goal for risk for Covid-19 infection due to age and immunocompromised condition included “Risk for Covid-19 infection due to age and immunocompromised condition,” wherein there was no measurable goal established for this care plan problem. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days for four of 14 sampled patients (Patients 3, 4, 5, and 7).  This failure had the potential for not providing appropriate, consistent, and quality care to these patients. --- #.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   The POC/IDG Review dated 12/30/24, 1/13, 1/27, 2/10, 2/24, 3/10, and 3/24/25, showed MSW visit one time then PRN. The MSW notes dated 1/3/25 and 3/1/25, showed the MSW conducted visits. *  However, the IDG failed to update the POC regarding the visit frequency of the MSW. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 4/4/25. The clinical record showed the SOC was 9/6/24. The patient was certified for hospice services during the certification periods from 9/6/24 to 12/4/24, 12/5/24 to 3/4/25 and 3/5/25 to 5/3/25.On 2/10/25, the IDG had reviewed/revised the POCs, however, there was no documented POC/IDG review was completed 15 days after 2/10/25.On 4/9/25 at 1052 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #.  The agency's P&P titled Interdisciplinary Group Meeting revised 10/2019, showed the procedure includes a plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. Review of Patient 5's clinical record was initiated on 4/4/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification period from 12/24/24 to 3/23/25 and 3/24/25 to 5/22/25.  Review of the clinical record showed the POC/ IDG was conducted on 12/30/24, 1/13 and 1/17/25.However, the following POC/IDG was conducted on 2/10/25 which was more than 15 calendar days as per P&P. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was informed and acknowledged the findings. #.  Review of the hospice’s P&P titled Discharge Summary revised 10/2019, showed the procedure includes a copy of discharge summary will be sent to the patients attending physician. Review of Patient 3's closed clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 8/11/24.  The patient was certified for hospice services during the certification periods from 11/1/24 to 1/29/24 and 1/30/25 to 3/30/25.  The patient was discharged on 2/7/25.Review of the closed clinical record showed the POC/ IDG was conducted on 11/4 and 11/18/24.However, the following POC/IDG was conducted on 12/16/24 which was more than 15 calendar days as per P&P. On 4/9/25 at 1151 hours, an interview and concurrent closed clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patients' progress toward goals specified in the POCs for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14).   This failure had the potential for not addressing the care needs for these patients. Findings: --- Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14, showed no documented evidence the revised POCs included the patients’ progress towards goals.  For example: 1.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The POC/IDG Review dated 2/24/25, showed the hospice identified patient care problems included self-care deficit; bereavement assessment risk assessed as low,  altered with cardiac status, risk for Covid-19 infection, unstable blood glucose, impaired thyroid,  potential for harm related to oxygen use, risk for fall, potential for altered gastrointestinal status, altered bowel elimination, knowledge deficit, generalized body weakness, reduced food portion consumption, alteration in comfort, potential for altered respiratory status, and need for spiritual support.  The goals were established for these identified problems.  Documentation showed the status for these care plan problems were controlled. *  However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. 2.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The POC/IDG Review dated 3/3/25, showed the hospice identified patient care problems included self-care deficit, altered with cardiac status, risk for Covid-19 infection, unstable blood glucose, impaired thyroid,  potential for harm related to oxygen use, risk for fall, potential for harm and increased risk related to oxygen use, abdominal discomfort, bowel and bladder incontinence, risk for impaired skin integrity, potential for injury related to impaired balance, generalized body weakness, reduced food portion consumption, alteration in comfort, potential for altered respiratory status, and altered sleep patterns.  The goals were established for these identified problems.  Documentation showed the status for these care plan problems were controlled. *  However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to maintain a system of communication and integration in accordance with their P&P to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided for six of 14 sampled patients (Patients 1, 2, 6, 9, 12, and 14).  This failure had the potential of not addressing the care needs for these patients. Findings: --- #. Review of Patient 1’s closed clinical record was initiated on 4/3/25. The closed clinical record showed the SOC was 7/25/24. The patient was certified for hospice services during the certification periods from 7/25/24 to 9/22/24, 9/23/24 to 11/21/24, and 11/22/24 to 1/20/25.The initial Psychosocial Assessment dated 7/27/24, Psychosocial Assessments dated 9/18/24 and 11/16.24, showed the POA/family requested telehealth visit for this patient. However, there was no documented evidence for the reason why the POA requested for a telehealth visit. The IDG failed to supervise the use of telehealth with the MSW.On 4/9/25 at 1042 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings.#. Review of Patient 14’s closed clinical record was initiated on 4/8/25. The closed clinical record showed the SOC was 5/9/24. The patient was certified for hospice services during the certification periods from 5/9/24 to 8/6/24, 8/7/24 to 11/4/24 and 11/5/24 to 1/3/25.The initial Psychosocial Assessment dated 5/11/24, showed the family member was out of the house and requested to do telehealth. However, there was no documented evidence the MSW requested to reschedule the visit.The initial Spiritual Assessment dated 5/13/24, showed the SC 1 reached out to the family/caregiver for spiritual assessment and support. Documentation showed the PCG nor the patient did not respond nor returned the call for any need of spiritual support. Documentation showed the SC 1 would make a follow-up call and would be available whenever needed in person or would be available on the phone for telehealth support.There was no documented evidence the SC 1 attempted to make follow-up calls to the family/PCG. The IDG failed to supervise, coordinate, and ensure the MSW and SC 1 conducted the initial assessment at the patient’s home. On 4/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.The initial Spiritual Assessment dated 1/8/24, showed the SC 1 was completing a telehealth visit with the patient.  The patient’s family returned the SC 1’s phone call and responded positively.  *However, there was no documented evidence for the reason why the initial assessment was conducted through telehealth or if the patient or the patient’s family requested for a telehealth visit for the initial Spiritual Assessment.On 4/9/25 at 1146 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.  The Administrator Designee stated the SC 1 should conduct the Spiritual Assessment in person and not via telehealth because the physician’s order showed a visit.#.  Review of Patient 12’s closed clinical record review was initiated on 4/8/25.  The clinical record showed the SOC 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.The initial Spiritual Assessment dated 10/1/23, showed the SC 1 reached out to family/caregiver for a Spiritual Assessment and support.  The PCG nor the patient did not respond nor returned SC 1 call for any need of spiritual support.  *However, there was no documented evidence SC 1 attempted to make follow-up calls to the patient/PCG.* The IDG failed to supervise, coordinate, and ensure SC 1 conducted the initial assessment at the patient’s home. On 4/9/25 at 1216 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.    The agency’s P&P titled Interdisciplinary Group Coordination of Care dated 10/19, showed the hospice will utilize a case management system to guide an interdisciplinary group to provide comprehensive coordinated hospice care to patients and family/caregivers.  It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a RN.  The Case Manager will be responsible for the coordination of services with the IDG from referral to discharge.  The IDG will maintain the responsibility for the provision of care  regardless of the setting where care is provided to its patients.  The hospice's P&P titled IDG Membership and Responsibilities titled 10/19, showed the IDG will provide and/or supervise, and coordinate hospice care and services. #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The Communication Log dated 2/27/25, showed SN reported the patient had wounds on the right lateral ankle and left knee.  Documentation showed the physician was informed and ordered wound evaluation and treatment.  Documentation showed IDG was informed. The physician’s order dated 2/28/25, showed the wound order included to cleanse with NSS, pat dry, apply collagen particles (wound dressing), cover with bordered foam dressing, change dressing three times per week and PRN soiled or loss of integrity. *  However, there was no documented evidence the IDG had developed an individualized POC to address Patient 6’s wound.  In addition, there was no documented evidence on who will be responsible for wound care during non-SN visit days and the wound location on the POC/physician’s order.  Cross Reference L 545 example # a  The Progress Note from Wound Care Provider 1 dated 3/7/25, showed the NP conducted a wound care visit and treatment on the patient’s right lateral malleolus ankle wound.  Documentation showed the patient’s left knee was closed.  Documentation showed the treatment plan for the closed left knee wound was to apply vitamin A&D (emollient) PRN and leave open to air. *  However, there was no documented evidence the RN coordinated with the IDG regarding the Wound Care Provider 1’s treatment plan on the closed left knee wound. b. The Progress Note from Wound Care Provider 1 dated 3/14/25, showed the NP conducted a wound care visit on the patient’s right lateral malleolus ankle wound.  Documentation showed there was significant improvement on the patient’s right lateral malleolus ankle wound.  Documentation showed the treatment plan for the right lateral malleolus ankle wound was to apply vitamin A&D (emollient) PRN and leave open to air. *  However, there was no documented evidence the RN coordinated with the IDG regarding the Wound Care Provider 1’s treatment plan on the right lateral malleolus ankle wound. *The IDG failed to maintain the responsibility to supervise and coordinate the care regarding Patient 6's wound. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The Communication Log dated 2/27/25, showed the SN reported the patient had a wound on the right external ear and left ear lobe.  Documentation showed the physician was informed and ordered wound evaluation and treatment. The Communication Log dated 2/28/25, showed wound care provider started visiting the patient one time a week. The Progress Notes of Wound Care Provider 1 dated 3/14/25, showed bilateral ears were unchanged.  Documentation showed will recommend triple antibiotic ointment to keep sites clean, dry, and to prevent infection.  Documentation showed the treatment plan included to cleanse with NSS, pat dry, apply triple antibiotic ointment, cover with bordered gauze dressing, change three times per week and PRN for soiled or loss of integrity.  Documentation showed B&C staff may change dressing on days when hospice do not visit. The Communication Log dated 3/14/25, showed the wound care provider is signing off as debridement was not recommended with suspicion of malignancy.  Documentation showed recommended triple antibiotic ointment to keep site clean and prevent further break down.  Documentation showed the physician and IDT was informed. Review of the POC/IDG Review dated 3/24/25, showed no documented evidence the RN coordinated and followed up with the IDG the recommended treatment plan of Wound Care Provider 1. *  The IDG failed to maintain the responsibility to supervise and coordinate the care regarding Patient 9's wound. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for nine of 14 sampled patients (Patients 1, 2, 6, 8, 9, 10, 12, 13, and 14).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients.  Findings: --- 1.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The Communication Log dated 2/27/25, showed the SN reported the patient had wounds on the right lateral ankle and left knee.  Documentation showed the physician was informed and ordered wound evaluation and treatment, and the IDG was informed. The physician’s order dated 2/28/25, showed the wound order included to cleanse with NSS, pat dry, apply collagen particles (wound dressing), cover with a bordered foam dressing, change dressing three times per week and PRN soiled or loss of integrity. The Progress Note from Wound Care Provider 1 dated 2/28/25, showed the NP conducted a wound care visit and treatment for the patient’s right lateral malleolus ankle and left knee wounds. The Progress Note from Wound Care Provider 1 dated 3/7/25, showed the NP conducted a wound care visit and treatment for the patient’s right lateral malleolus ankle wound.  Documentation showed the patient’s left knee wound was closed. *  However, the SN note dated 3/10/25, showed no documented evidence the SN performed wound care on the patient’s right lateral malleolus ankle wound. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. 2.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The POC/IDG Review dated 3/24 and 4/7/25, showed RN visit 1W (one time a week) and 3 PRN visits, SN visit 1W and 3 PRN visits, and SC visit 1W and 3 PRN visits. *  The SN notes showed no documented evidence the RN conducted a visit on Week 8 (3/23/24 to 3/29/24), instead of one visit a week as per the POC. *  In addition, there was no documented evidence SC 2 conducted a visit on Week 8 (3/23/24 to 3/29/24), instead of one visit a week as per the POC. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. 3.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The POC/IDG Review dated 3/10/25, showed the following: -An order dated 2/28/25, for the treatment for the left ear pressure ulcer and right external pressure ulcer included “Wound Cleanser Gauze Collagen Particles Bordered Foam Dressing change 2x a week.” -An order dated 2/28/25, to cleanse with NSS left ear lobe and right external wound with NSS, pat dry, apply collagen particles (wound dressing), cover with bordered gauze, and change dressing “3x.” a.  The SN note dated 3/21/25, showed wound care done as ordered on the left ear lobe and right external ear by cleansing with NSS, patting dry, applying triple antibiotic ointment, and covering with bordered gauze. *  However, there was no documented evidence of the POC included wound care on the patient’s left ear lobe and right external ear by the application of triple antibiotic ointment. b. The POC/IDG Review dated 2/10, 2/24, 3/10, and 3/24/25, showed SN visits 2W. *  The SN notes for Week 2 (2/23/25 to 3/1/25), Week 3 (3/2/25 to 3/8/25), Week 4 (3/9/25 to 3/15/25), Week 5 (3/16/25 to 3/22/25), and Week 6 (3/23/25 to 3/29/25), showed one SN visit instead of two visits as per the POC. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. 4.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.The POC/IDG Review dated 11/4, 11/18, 11/25, 12/2, 12/16, 12/30/24, 1/7, 1/13, and 1/27/25, cited for HA visit one time per week.*However, the HA visited the patient two times per week each week during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.On 4/9/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding. 5.  Review of Patient’s 8 clinical records was initiated on 4/4/25.  The clinical record showed the SOC was 8/12/24.  The patient was certified for hospice services during the certification periods from 2/8/25 to 4/8/25.The POC/IDG Review dated 2/10, 2/24, 3/10, and 3/24/25, showed a care plan issue related to genitourinary with an intervention to assess the patient’s bladder status every visit and determine the episodes of incontinence.However, review of the SN visit notes dated 2/12, 2/19, 2/26, 3/5, 3/12, 3/19, and 3/26/25, failed to show documented evidence of the patient's number of episodes of incontinence as ordered in the POC. On 4/9/25 at 1212 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding. 6.  Review of Patient 12’s closed clinical record review was initiated on 4/8/25.  The clinical record showed the SOC 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.Review of the Physician’s Orders showed an order dated 9/27/23, the patient was offered HA visits but declined.The POC/IDG Review dated 11/18, 12/2, 12/16, and 12/30/24, cited for HA visit one time per week.*However, further review of Patient 2’s closed clinical records failed to showed documented evidence there was a HA visit for the patient.On 4/9/25 at 1223 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding. 7.  Review of Patient 13's closed clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 8/11/24.  The patient was certified for hospice services during the certification periods from 11/1/24 to 1/29/24 and 1/30/25 to 3/30/25.  The patient was discharged on 2/7/25.The POC/IDG dated 11/4, 11/18, 12/16, 12/30/24, 1/13, 1/27 and 2/10/25, showed a care plan issue related to complains of occasional constipation with bowel frequency of three times per week.  The intervention includes to check on the usual pattern of elimination, including frequency and consistency of stool.However, review of the SN visit notes dated 11/6, 11/14, 12/23/24, 1/8/25, failed to show documented evidenced of the patients last bowel movement was check as ordered in the POC. On 4/9/25 at 1151 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.    The Patient Coordinator replied, will go back on that.   The Patient Coordinator was informed and acknowledged the findings. 8. Review of Patient 1’s closed clinical record was initiated on 4/3/25. The closed clinical record showed the SOC was 7/25/24. The patient was certified for hospice services during the certification periods from 7/25/24 to 9/22/24, 9/23/24 to 11/21/24, and 11/22/24 to 1/20/25.The initial Comprehensive Nursing Assessment dated 7/25/24, showed patient’s current oxygen treatment was given continuously at three liters per minute via nasal cannula.Further review of the closed clinical record, showed a physician’s order dated 7/25/24, may administer oxygen at two liters per minute via nasal cannula as needed for shortness of breath/discomfort. May titrate up to five liters to maintain saturation level to 90% and above.On 4/9/25 at 1042 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. 9. Review of Patient 14’s closed clinical record was initiated on 4/8/25. The closed clinical record showed the SOC was 5/9/24. The patient was certified for hospice services during the certification periods from 5/9/24 to 8/6/24, 8/7/24 to 11/4/24 and 11/5/24 to 1/3/25.The POC/IDG review dated 10/7/24 and 10/21/24 showed SN visit one per week plus three PRN visits.*However, the SN had no documented visits for the week starting 10/20/24 to 10/26/24. On 4/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings.

Based on interview and record review, the hospice governing body failed to ensure the ongoing program plan for the quality improvement was accurate for the agency.  This failure had the potential for not identifying the areas for performance improvement to help improve the care and services provided to the patients. --- 1.  Review of the QAPI program documents for the year of 2023 showed the QAPI meeting was conducted on 1/6/23 at 1600 to 1800 hours.  The meeting was facilitated by the hospice's Chairperson/QAPI Coordinator. The meeting minutes included the assignment of the responsibility of the governing body, QAPI Coordinator, QAPI committee, evaluation of the QAPI plan and QAPI plan discussion. However, the name of the hospice documented on the QAPI plan discussion was for Hospice A, which was inaccurate.2.  Review of the QAPI program documents for the year of 2024 showed the QAPI meeting was conducted on 1/3/24 at 1600 to 1800 hours.  The meeting was facilitated by the hospice's Chairperson/QAPI Coordinator.  The meeting minutes included the assignment of the responsibility of the governing body, QAPI Coordinator, QAPI committee, evaluation of the QAPI plan and QAPI plan discussion. However, the name of the hospice documented on the QAPI plan discussion was for Hospice B, which was inaccurate.On 4/9/25 at 1040 hours, an interview and document review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the infection control education was provided for four of nine employees (SC 2, LVN 1, and RNs 1 and 2) whose files were reviewed.  This failure had the potential for the employees to not have the adequate knowledge of the infection control practices to meet the patients' needs. Findings: --- Review of the hospice's P&P titled Hospice Infection Training (undated), showed all new staff shall receive the infection control training as part of their orientation, before starting the direct patient care. The training will cover at a minimum standard precaution, transmission-based precautions, infection control protocols of specific conditions, proper cleaning and disinfection of the equipment and patient areas, safe disposal of the medical waste, proper handling of the contaminated laundry, vaccination requirements, and role of the infection control in patient's safety. Review of the employee files was initiated on 4/8/25.   The following was identified:-SC 2 was hired on 6/25/24,  -RN 1 was hired on 5/24/24,-LVN 2 was hired on 6/19/24, and-RN 2 was hired on 3/3/25. *  However, there was no documented evidence the infection control training for SC 2, RN 1, RN 2, and LVN 2 were conducted as part of their orientation. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to implement the bereavement program as per the hospice’s P&P to address the needs of the bereaved family members for one of 14 sampled patients (Patient 2) who was deceased.  This failure has the potential to not address the bereavement needs of the bereaved family members of the patients. Findings: --- Review of the hospice's P&P titled Bereavement Services revised 10/2019 showed the hospice will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient.  The program will provide bereavement services to the family/caregiver of hospice patients before and after the patient’s death, in accordance with the plan of care.  Within two weeks after the death of a patient, a sympathy card will be sent to the bereaved.  After three weeks, a bereavement letter will be sent to the bereaved; offering support and outlining the hospice bereavement services.  Within three to five weeks after the patient’s death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver.  This assessment will identify grief issues.  The bereavement counselor will render a professional judgment as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief.  If a person is noted as experiencing normal grief, the bereavement counselor will contact the bereaved person for an ongoing assessment and support for three, six, and nine months after the patient’s death and at the anniversary of the patient’s death.Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was on 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24, and 12/29/24 to 2/26/25. The patient had expired on 2/3/25.Review of the bereavement binder showed a photocopy of a sympathy card sent to the patient’s family/caregiver dated February 2025.  However, there was no documented evidence of the exact date when the sympathy card was mailed and if it was within two weeks after the death of the patient as per the hospice’s P&P.On 4/9/25 at 1140 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure HAs 1, 2, and 3 had received at least the 12 hours of in-service training during each 12 month period.  This failure had the potential of not updating with the current practices for these HAs. Findings: --- Review of the hospice’s P&P titled Hospice Aide Training revised 10/2019 showed the hospice will provide the performance review (at least annually) and in-service education (12 hours per year) to ensure the competency of hospice aides.  The performance review will address each of the areas of the competency evaluation.  The in-service will be provided by a qualified instructor and may occur while an aide is providing the care to patients.  The documentation will be made in the personnel files. Review of the personnel files was conducted on 4/8/25.  The HA’s personnel files did not include a documentation of the HA’s in-service education completed hours as per the hospice’s P&P. Review of the HA’s in-service binder was conducted on 4/8/25.  The binder showed the monthly sign-in sheet forms of HAs in-services conducted on 1/15, 2/6, 3/19, 4/10, 5/21, 6/13, 7/17, 8/23, 9/11, 10/1, 11/1, 12/11/24, 1/7, 2/13, and 3/3/25, with the different topics such as the medical procedures, patient care, and administration’s agendas.  The monthly in-service documentation showed a time for the in-service for 1000 hours to 1500 hours. *However, there was no documented evidence of the specific total number of hours the HAs spent or completed in the in-services for each month.  On 4/9/25 at 1055 hours, an interview and concurrent facility document review was conducted with the Administrator Designee.  The Administrator Designee stated the staff would come in the hospice’s office to attend the monthly in-service conducted by the RN.  The Administrator Designee further stated the RN allotted the five hours from 1000 hours to 1500 hours, for the HA to come in the office to complete the in-service when they were available to attend between the allotted hours.  The Administrator Designee stated the HAs would complete between one to two hours of the in-service trainings during the allotted hours, but not the complete five hours.  The Administrator Designee stated the RN should have documented the total number of hours that the HAs completed for the in-services in the form.  The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the HAs in-service training was supervised by a registered nurse in the classroom and the supervised practical training was performed by an RN.  This failure had the potential for the HA staff to be incorrectly trained. Findings: --- Review of the hospice’s P&P titled Hospice Aide Training revised 10/2019 showed the hospice will provide the performance review (at least annually) and in-service education (12 hours per year) to ensure competency of the hospice aides.  The performance review will address each of the areas of the competency evaluation.  The in-service will be provided by a qualified instructor and may occur while an aide is providing the care to patients.  The documentation will be made in the personnel files.Review of the HA’s in-service binder was conducted on 4/8/25.  The binder showed the monthly sign-in sheet forms of the HAs in-services conducted on 1/15, 2/6, 3/19, 4/10, 5/21, 6/13, 7/17, 8/23, 9/11, 10/1, 11/1, 12/11/24, 1/7, 2/13, and 3/3/25, with different topics such as medical procedures, patient care, and administration’s agendas.   * However, the documentation failed to show who had supervised and conducted the in-service education/training for the HA staff. On 4/8/25 at 1546 hours, an interview and concurrent facility document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the findings.

Based on interview, and record review, the hospice failed to ensure the written patient care instructions for the HAs were developed by the RN who was responsible for the supervision of the HA for two of 14 sampled patients (Patients 2 and 3).  This failure had the potential of not addressing the care needs for these patients.Findings: --- 2.  Review of Patient 3's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 3/12/25.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.  The patient was residing in a Board and Care Facility.Review of the HA assignment dated 3/12/25 showed the HA assignment included continence/toileting.  The task showed the assessment for urinary and bowel assessment had a marked on continent and incontinent. However, the assessment were inaccurate.In addition, review of the HA visit notes dated 3/14, 3/17, 3/20, 3/24 and 3/27/25 showed the HA had completed and marked the section for urinary and bowel assessment had a marked on continent and incontinent. However, the assessment were inaccurate.On 4/9/25 at 1109 hours, an interview and clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was informed and acknowledged the findings.    #.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.Review of the HA Assignment dated12/6/24, showed a check mark in a box for bed bound under the non-ambulatory section.  However, there was a check mark in a box for shower chair every visit under the bath section.  In addition, transfer section information was left blank.  The oxygen section showed a check mark for oxygen at 2 L/min.  However, there was no check mark in the boxes option if oxygen was administered continuously, prn, via nasal prongs, or mask.  *The HA Assignment was inaccurate and incomplete.On 4/9/25 at 1155 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the HAs were provided the HA services in accordance with the POC for four of 14 sampled patients (Patients 6, 7, 9, and 10).  This failure had the potential for not providing the appropriate, consistent, and quality care to the patients. Findings: --- Review of the hospice’s P&P titled Hospice Aide Services dated 2009 showed the hospice aides will document the care provided in accordance with the hospice aide assignments. 1.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was on 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The POC/IDG Review dated 2/24, 3/10, and 3/24/25, showed HA visits three times per week. The HA Assignment dated 2/21/25, showed the HA tasks included a bed bath. The HA Visit Notes dated 3/3, 3/7, 3/10, 3/12, 3/17, 3/21, 3/24, 3/26, 3/29, and 3/31/25, and 4/4/25, showed the HA had completed the bed bath task.   *However, the narrative section of the form showed a shower was provided to the patient, which was not consistent with the POC. On 4/9/25 at 1130 hours, an interview was conducted with the Administrator Designee. He stated the documentation on the narrative section was what the HA performed wherein the shower was provided to Patient 6, instead of the bed bath. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the findings. 2.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was on 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. The POC/IDG Review dated 3/3, 3/10, 3/24, and 4/7/25, showed HA visits 2W. The HA Assignment dated 3/3/25, showed the RN delegated HA tasks. *  However, there was no documented evidence the HA visit was conducted during Week 5 (3/3/25 to 3/8/25) to provide the two visit per week. *  Review of the HA Visit Notes showed the HA conducted one visit per week to the patient during Week 6 (3/9/25 to 3/15/25), Week 7 (3/16/25 to 3/22/25), Week 8 (3/23/25 to 3/29/25) instead of the two visits per week as per the POC. On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the findings. 3.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was on 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25, and 3/4/25 to 5/2/25.   The POC/IDG Review dated 12/30/24, and 1/13, 1/27, 2/10, 2/24, 3/10, and 3/24/25, showed HA visits 2W. The HA Assignment dated 9/5/24, showed to provide a bath with a shower chair Q visit. The HA Visit Notes dated 1/3, 1/7, 1/9, 1/14, 1/17, 1/21, 1/28, 1/31, 2/4, 2/6, 2/11, 2/18, 2/21, 2/25, 3/4, 3/7, 3/11, 3/14, 3/18, 3/21, 3/27, 3/31, and 4/3/25, showed the HA provided a bath with shower chair.   However, the narrative section of the form showed a bed bath was provided to the patient which was not consistent with the HA Assignment. On 4/9/25 at 1130 hours, an interview was conducted with the Administrator Designee.  He stated the documentation on the narrative section was what the HA performed which was a bed bath instead of bath with the shower chair. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings . 4.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was on 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The POC/IDG Review dated 2/24, 3/10, and 3/24/25, showed HA visits 3W. The HA Assignment dated 6/26/24, showed to record the bowel movements. The HA Visit Note dated 3/10 and 3/26/25, showed no documented evidence the patient’s bowel movement was recorded. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the RN provided timely supervision to the HAs to assess the quality of care and services provided for four of 14 sampled patients (Patients 6, 7, 9, and 10).  This failure had the potential of not providing the appropriate, consistent, and quality care to the patients. Findings: --- 1.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was on 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. Further review of the clinical record showed the HA did not provide the HA services in accordance with the POC for this patient.  Cross reference to L626, example #1. The Visit Note RN dated 3/7/25, showed the RN conducted a supervisory visit.  The documentation showed the HA demonstrated competence with the assigned tasks and HA services met the patient’s needs. *  However, the RN failed to identify the HA did not provide the HA services in accordance with the POC by providing a shower instead of a bed bath. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.   The Administrator/LVN was informed and acknowledged the findings. 2.  Review of Patient 10's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was on 3/3/25.  The patient was certified for hospice services during the certification period from 2/6/25 to 5/5/25.  The patient was transferred from another hospice. Further review of the clinical record showed the HA did not provide the HA services in accordance with the POC for this patient.  Cross reference to L626, example #2. The Visit Note RN dated 4/4/25, showed the RN conducted a supervisory visit.  The documentation showed the HA demonstrated competency with assigned tasks and HA services met the patient’s needs. *  However, the RN did not perform the timely supervision to the HA staff every 14 days.  In addition, the RN failed to identify the HA staff did not provide the HA services in accordance with the POC by not providing the required HA visits per week.  On 4/9/25 at 1145 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the findings. 3.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was on 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25, and 3/4/25 to 5/2/25.   Further review of the clinical record showed the HA staff did not provide the HA services in accordance with the POC.  Cross reference to L626, example #3. The Visit Note RN dated 1/5, 1/12, 1/19, and 1/26/25;  2/2, 2/9, 2/16, and 2/23/25; and 3/9, 3/16, 3/23, and 3/30/25, showed the RN conducted a supervisory visit.  The documentation showed the HA  demonstrated competency with the assigned tasks and HA services met the patient’s needs. *  However, the RN failed to identify the HA staff did not provide the HA services in accordance with the POC by providing a bed bath instead of a bath using a shower chair. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings. 4.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was on 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. Further review of the clinical record showed the HA staff did not provide the HA services in accordance with the POC for this patient.  Cross reference to L626, example #4. The Visit Note RN dated 3/21/25, showed the RN conducted a supervisory visit.  The documentation showed the HA staff demonstrated competence with the assigned tasks and HA services met the patient’s needs. *  However, the RN failed to identify the HA did not provide the HA services in accordance with the POC by not documenting the patient's bowel movements. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to maintain, document, and provide the orientation and  training to the volunteers.  This failure had the potential for the volunteers to not have the adequate knowledge of the hospice program to meet the patients' needs. Findings: --- Review of the hospice’s P&P titled Volunteer Services dated 1/1/24, showed there shall be a personnel file for each volunteer that includes but is not limited to the following:-Application,-Documentation of orientation and ongoing volunteer training,-Health record to confirm TB screening, and-Evidence the Hepatitis B vaccinations were offered to all volunteers whose job involve the risk of directly contacting blood or other potentially infectious materials. Review of Volunteer 1's personnel file showed the volunteer's start date was 9/1/22.  There was no documented evidence an orientation was provided to Volunteer 1. Further review of the personnel file showed no documented evidence of the volunteer training from the start date.  The documentation showed Volunteer 1 had completed the training and orientation on 8/7/21, with another hospice. On 4/9/25 at 1108 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the volunteer provided at a minimum, equals to 5% of the total patient care hours of all paid hospice employees and contract staff.  This failure had the potential of not providing the adequate volunteer services. Findings: --- Review of the hospice’s P&P titled Volunteer Cost Savings & Activity level dated 1/1/24, showed the volunteers will provide an administrative or direct services to the patients of the hospice in an amount that is at least equal to or greater than 5% of the total care hours of all paid hospice employees and contract staff. Review of the hospice's volunteer programs for the years of 2023, 2024, and 2025 was conducted on 4/8/25.  The following was identified: -The Volunteer Savings Report for November 2024 showed 271.36 hours of the total direct patient care hours and 10.42 volunteer hours.  The documentation showed the volunteer hours provided was 3.84% of the total patient care hours of all paid hospice employees and contract staff, which was less than 5%. -The Volunteer Savings Report for March 2025 showed 237.73 hours of the total direct patient care hours and 11.5 volunteer hours.  The documentation showed the volunteer hours provided was 4.84% of the total patient care hours of all paid hospice employees and contract staff, which was less than 5%. On 4/9/25 at 1108 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings.

Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all care provided as follows:-The Administrator failed to ensure wound care policy was implemented for one of 14 sampled patients (Patient 9).-The Administrator failed to ensure performance evaluation was completed for one of nine employee files reviewed (HA 1).- The Administrator failed to ensure the physical examination and tuberculosis screening were completed for three of nine employee files reviewed (DPCS Designee/RN, SC 2, and MSW).-The Administrator failed to ensure qualified personnel was employed as per employee job description for one of nine employee files reviewed (RN 1)-The Administrator failed to ensure the P&P for Responsibilities/Supervision of Clinical Services was complete to include the frequency of supervision.-The Administrator failed to ensure the written agreements for three of four (Contractors 1, 3, and 4) included the required elements related to term and conditions for its renewal, agreements shall be reviewed and revised as necessary, the required elements related to bereavement follow-up, patient admission process, patient care conference, discharge planning, and incomplete agreement. These failures had the potential to negatively impact the hospice’s operational performance. Findings: --- Review of the written agreement between the hospice and Contractor 1 for the MD Designee was initiated on 4/9/25. The written agreement showed the agreement will begin on 11/1/24, however, the agreement was made on 2/1/25. The agreement did not include the statement regarding agreements shall be reviewed and revised as necessary. Furthermore, the agreement was signed by the MD Designee, however, it was undated.On 4/9/25 at 1040 hours, an interview and concurrent record review was conducted with the Administrator/LVN. The Administrator/LVN verified the above findings. According to Standards of Quality Hospice Care, 2005 Section (B) Contractual Services, when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided.  The agreement shall address, but not be limited to: roles and responsibilities of the program and the contracted individual or organization in the following: patient/family admission process, interdisciplinary team conferences, discharge planning, bereavement follow-up, and term of the agreement and the conditions for its renewal or termination.  #.  Review of the written agreement between the hospice and Contractor 3 for the Medical Director was initiated on 4/9/25.  The written agreement showed the agreement was effective 9/1/22.  *However, the written agreement with Contractor 3 did not show documented evidence of a statement to include the roles and responsibilities of the contractor regarding the patient’s admission process, discharge planning, and bereavement follow-up.On 4/9/25 at 1052 hours, an interview and concurrent facility document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.#. Review of the written agreement between the hospice and Contractor 4 providing PT, OT, and ST services was initiated on 4/9/25.  The written agreement showed the agreement was effective on 1/1/22.  *However, the written agreement with Contractor 4 did not show documented evidence of a statement to include the roles and responsibilities of the contractor regarding the patient’s care conferences and bereavement follow-up.On 4/9/25 at 1054 hours, an interview and concurrent facility document review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding. The P&P titled Executive Director/Administrator dated 10/2019, showed the Executive Director/Administrator is responsible for the overall direction of the day-to-day operations of the hospice services.  He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision pf hospice services, directly and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. 1.The hospice’s P&P titled Wound Care undated showed at each visit the patient’s skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition.  Include a full set of vital signs including temperature.  At least every week, the wound assessment and documentation will include measurement of length, width, and depth, and undermining and tunneling if present. 1.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The Communication Log dated 2/27/25, showed the SN reported the patient had a wound on the right external ear and left ear lobe.  Documentation showed the physician was informed and ordered wound evaluation and treatment. a.  The SN note dated 3/7/25, showed complete skin assessment was done. Documentation showed the patient had a Stage IV left ear lobe pressure injury with a size of 0.9 cm (length) x 1.8 cm (width) x 0.1 cm (depth).  Documentation showed the patient had a right external ear wound with a size of 0.5 cm x 0.5 cm x 0.1 cm.  Documentation showed wound care was performed. The SN note dated 3/21/25, showed wound care was done as ordered on the left ear lobe and right external ear.  Documentation showed the left ear lobe pressure injury and right external ear wound’s measurement/size. *  However, there was no documented evidence the SN assessed the Stage IV left ear lobe pressure injury and right external ear wound for the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition on 3/7 and 3/21/25 as per the P&P. b.  The SN note for Week 4 (3/9/25 to 3/15/25) and Week 6 (3/23/25 to 3/29/25), showed the SN conducted a visit one time a week as per the POC.  Documentation showed wound care was provided to the left and right ear on Week 4 and Week 6. *  However, there was no documented evidence the SN assessed the left and right ear wound for the size, wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition as per the P&P. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. 2.  The P&P titled Competency Assessment dated 10/2019, showed competency assessments will be completed at least one time per year.  Additional competencies may be required for performance problems, new technology, or other appropriate indications. a. Review of the employee file for HA 1 was initiated on 4/8/25.   HA 1 was hired on 2/27/23.  Documentation showed competency assessments were conducted on 2/27/23 and 2/27/24. *  However, there was no documented evidence a competency assessment was conducted for 2025 at this time. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. 3. The P&P titled Performance Evaluations dated 10/2019, showed all hospice staff will be evaluated at periodic intervals based on their job description: during the probationary period, at the end of the first there months of employment, annually based on personnel’s annual evaluation date, after a promotion or transfer, and other occasions as performance warrants. a. Review of the employee file for HA 1 was initiated on 4/8/25.   HA 1 was hired on 2/27/23.  Documentation showed performance evaluation was conducted on 2/27/24. *  However, there was no documented evidence HA 1's  performance evaluation was conducted for 2025 at this time. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. 4.  According to Standards of Quality Hospice Care 2005 Section 6.3 (a) (1) (2):-  All persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment. Each examination shall include confirmation by the person performing the examination that the employee is physically and medically qualified to perform the duties to be assigned, and that employee has no health condition that would create a hazard to patients.-  The initial health examination shall include a tuberculosis screening. Tuberculosis screening shall occur annually thereafter. The hospice’s P&P titled Personnel Administration dated 10/2019, showed the health requirement for the clinical hospice staff included all new staff providing patient care and rehires who have not been employed by hospice for over six months, must undergo a physical screening before they are employed or reemployed, in accordance with other organization policies and federal, state, and local requirements. a.  Review of the employee file for SC 2 was initiated on 4/8/25.   SC 2 was hired on 6/25/24.  Documentation showed SC’s TB screening was completed on 7/31/24, which was more than 14 days of the date of employment. b.  Review of the employee file for the DPCS Designee/RN was initiated on 4/8/25.   The DPCS Designee/RN was hired on 8/1/21.  Documentation showed TB screening was completed on 8/9/23.  However, there was no documented evidence of what the result of the TB screening was. c. Review of the employee file for MSW was initiated on 4/8/25. The MSW was hired on 9/1/22.  Documentation showed TB screening and health examination was completed on 10/9 and 10/12/22, respectively.  However, the TB screening and health examination were completed more than 14 days of the date of employment. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. 5.  The hospice’s RN Job Description revised date 04/21, showed the position qualification included a graduate of an accredited school of nursing. One to two years of recent acute care experience in an institutional setting and one to two years of recent experience in home care. Review of the personnel file was conducted on 4/8/25.  RN 1's personal file showed the hire date was 5/24/24. RN 1’s resume showed the employment record included patient care coordinator from 2/24/23 to “present.”; assistant to the NP from September 2022 to February 2023; and as Senior Occupational Health Nurse in another country from  May 2007 to April 2022. *  However, there was no documented evidence RN 1 had one to two years of recent acute care experience in an institutional setting as per the RN’s job description. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. 6.  The P&P titled Responsibilities/Supervision of Clinical Services dated 10/2019, was reviewed on 4/9/25.  The P&P showed LVN will be supervised by a RN at least every “____” days or as directed by the State Practice Act, whichever is more frequent. *  However, the time frame on how often RN supervision will be conducted to LVN did not have the information. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the competency assessment was completed for one of nine employee files (HA1) reviewed. This failure had the potential for not having a qualified employee to meet the needs of the patients. Findings: --- Review of hospice's P&P titled Competency Assessment dated 10/2019 showed the competency assessments will be completed at least one time per year.  Additional competencies may be required for the performance problems, new technology, or other appropriate indications. Review of the employee file for HA 1 was initiated on 4/8/25.   HA 1 was hired on 2/27/23.  The documentation showed the competency assessments were conducted on 2/27/23 and 2/27/24. However, as of 4/9/25, there was no documented evidence a competency assessment was conducted for 2025. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the patients' clinical records were complete and accurate for nine of 14 sampled patients (Patients  2, 3, 4, 6, 7, 9, 11, 12, and 14 ).  This failure had the potential for the patients to receive a substandard care and disrupt the continuity of care due to the clinical records were incomplete and inaccurate. Findings: --- #. Review of Patient 4’s clinical record was initiated on 4/4/25. The clinical record showed the SOC was 9/6/24. The patient was certified for hospice services during the certification period 12/5/24 to 3/4/25.Review of the POC/IDG Review dated 3/4/25 showed that it was electronically signed by the MD, SC and MSW on 3/4/25. * However, the DPCS Designee’s electronic signature was dated 2/24/25.#. Review of Patient 14’s closed clinical record was initiated on 4/8/25. The closed clinical record showed the SOC was 5/9/24. The patient was certified for hospice services during the certification period from 11/5/24 to 1/3/25.Review of the RN Visit Note dated 11/21/24 showed an LVN supervisory visit was done by the DPCS Designee/RN for LVN 1. The LVN 1 visited the patient on 11/16/24.Review of the RN visit Note dated 12/19/24 showed an LVN supervisory visit was done by the DPCS Designee/RN for LVN 1. *However, there were no documented evidence LVN 1 had visited the patient.On 4/9/25 at 1052 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings.  #.a.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25Review of the Informed Consent and Treatment form dated 1/4/23, showed a documentation of Patient 2’s date of birth as 12/30/23.  However, Patient 2’s date of birth 7/20/50.  In addition, the form showed a staff signature dated 1/4/24.  However, the signature should be dated in the year of 2023.On 4/9/25 at 1149 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.b.  Review of the CTI for the certification period 10/30/24 to 12/28/24, showed a certifying physician narrative note to admit Patient 2 under routing level of care for fourth benefit period from 8/31/24 to 10/29/24.On 4/9/25 at 1203 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee stated the certifying physician should had documented in the narrative note section the current certification period of 10/30/24 to 12/28/24 and not 8/3124 to 10/29/24.  The Administrator Designee was informed and acknowledged the finding.c.  The SN note dated 1/10/25, showed patient had an oxygen saturation of 91% in room air.  In the narrative section of the SN note, showed “noted desaturation, patient was hooked on nasal cannula as needed.  However, there was no documented evidence to include a note of Patient 2’s oxygen saturation level for desaturation, what was hooked via nasal cannula, or an evaluation if an intervention was effective.On 4/9/25 at 1152 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding. #.a.  Review of Patient 12’s closed clinical record review was initiated on 4/8/25.  The clinical record showed the SOC 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.Review of the Spiritual Assessment dated 10/1/23, showed a question under Delivery of Care if spiritual care was decline by the patient or family and a coded “yes.”  However, the SC documented he had reached out to the family/caregiver for spiritual assessment and support, but the patient did not respond nor returned his call for any need of spiritual support.On 4/9/25 at 1215 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee stated the SC might had miscoded the question to a “yes.”  The Administrator Designee was informed and acknowledged the finding.b.  Review of the POC/IDG 9/27/23, 11/18,12/2, 12/16, and 12/30/24, showed a cardiovascular goal of patient/caregiver will verbalize/express understanding of medication/treatment orders and side-effects for simvastatin (used to lower cholesterol levels in the blood) 20 mg daily at bedtime.  However, simvastatin is not included in Patient 12’s medication list.On 4/9/25 at 1221 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.   #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. The SN Note dated 2/24, 3/7, 3/10, and 3/25, showed the patient was on mechanical soft diet. *  However, further review of the POC showed no documented evidence the POC included the patient’s diet was mechanical soft. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   a.  The SN note dated 3/2/25, showed the patient was not on oxygen therapy.  Documentation also showed the patient’s current oxygen rate was 2 liter per minute via nasal cannula PRN, which was not consistent. b. The Visit Note RN dated 3/9/25, showed the RN conducted a LVN supervisory visit *  However, review of the SN visit notes from certification period 1/3/25 to 3/3/25 and 3/4/25 to 3/30/25, showed no documented there was a LVN visit conducted. c. The SN Note dated 1/5, 1/12, 1/19, 1/26, 2/2, 2/9, 2/16, 2/23, 3/9, 3/16, 3/23, and 3/30/25, showed the patient was on mechanical soft diet. *  However, further review of the POC showed no documented evidence the POC included the patient’s diet was mechanical soft. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding. #.  Review of Patient 9's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 6/26/24.  The patient was certified for hospice services during the certification period from 2/21/25 to 4/21/25. The physician’s order dated 6/26/24, showed mechanical soft diet. The SN note dated 3/7 and 3/21/25, showed on the nutrition section of the form the patient was on mechanical soft diet.  Documentation showed on the narrative section of the form the patient was on regular diet, which was not consistent. On 4/9/25 at 1200 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  The agency's P&P titled Entries into the Clinical Record revised 10/2019, showed the policy includes a documentation in the clinical record will be accurate and reflect the care and services provided. Review of Patient 11's clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 1/2/24.  The patient was certified for hospice services during the certification period from 2/25/25 to 4/25/25.Review of the POC/IDG dated 2/24/25 showed the HA visit frequency was declined. However, review of the CTI (Certification of Terminal Illness ) dated 2/25/25, showed an order for HA visit one time per week for personal care and to assists with ADL's which was inconsistent. On 4/9/25 at 1048 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was informed and acknowledged the finding. #. Review of Patient 3's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 3/12/25.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.  The patient was residing in a Board and Care Facility.Review of the Physicians Order dated 3/12/24, showed an order for CHHA visit one time per week for personal care and to assists with ADL's. However, the CHHA visited the patient two times per week on Week 2 (3/16 to 3/22/25).In addition, review of the POC/IDG dated 3/24/25, showed an order for CHHA visit one time per week for personal care and to assists with ADL's.However, the CHHA visited the patient two times per week on Week 3 (3/23 to 3/29/25) instead of one per week as ordered by the physician.On 4/9/25 at 1048 hours, an interview and concurrent clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was asked at to the frequency of the CHHA visit.  The Patient Care Coordinator replied there was a change in the order for two times a week instead of one time per week.  There was a typographical error by the physician for the CHHA visit frequency order.  The Patient Care Coordinator was informed and acknowledged the finding.

Based on record review and interview, the hospice failed to authenticate the entries made into the clinical record for five of 14 sampled patients (Patients 2, 3, 6, 7, and 12).   This failure had the potential not to have verified patient information. Findings: --- #.  Review of Patient 3's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 3/12/25.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.  The patient was residing in a Board and Care Facility.Review of the HA assignment dated 3/12/25, showed the HA task every visit.However, the section for the signature of who completed the HA assignment was left blank. On 4/3/25 at 1547 hours, an audit trail was requested to the Administrator Designee. The Administrator Designee reported the electronic signature was was completed late. The Administrator Designee was informed and acknowledged the finding.On 4/9/25 at 1109 hours, the findings were shared with the Patient Care Coordinator.  #.  Review of Patient 2’s closed clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 1/4/24.  The patient was certified for hospice services during the certification periods from 10/30/24 to12/28/24 and 12/29/24 to 2/26/25.Review of the Bereavement Assessment dated 1/4/24, showed a signature of the Administrator/LVN with a note of “to close note on behalf of staff assigned” and dated 3/23/24.  *However, there was no documented evidence of the SC’s electronic signature.On 4/9/25 at 1138 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.  The Administrator Designee stated the staff who completed the assessment should electronically sign and close the assessment on the same day it was completed. #.  Review of Patient 12’s closed clinical record review was initiated on 4/8/25.  The clinical record showed the SOC 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.The POC/IDG Review dated 11/18, 12/2, 12/16, and 12/30/24, showed no documented evidence of the SC’s electronic signature.On 4/9/25 at 1222 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the finding.  The hospice's P&P titled Entries into The Clinical Record dated 10/19, showed the following in part:-  Documentation in the clinical record will be timely, detailed, accurate, and reflect the care of services provided.  -  Entries into the clinical record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization.  -  The clinical note will include: care that was provided; treatment or invasive procedures performed; patient response to treatment and/or procedures; date the service was provided (month, day, year); and signature of the clinician and his/her credential-  Signature authorization of clinical documentation will include the staff member’s name and credentials (as specified on the professional licenses and/or certification documents).-  All entries into the clinical record will reflect the date the care was provided, including the month, day, and year.  -  Late entries and amendments will be documented, stating “late entry or amendment for visit of (date and time of visit)” and include:A.  The date the entry is made (month, day, year).B. The date and documentation that was originally omitted or amended.C. The signature and title of the staff member making the late entry or amendment #.  Review of Patient 6's clinical record was initiated on 4/3/25.  The clinical record showed the SOC was 10/27/24.  The patient was certified for hospice services during the certification period from 2/24/25 to 4/24/25. *  The POC/IDG Review dated 2/24 and 3/24/25, showed no documented evidence of the SC’s electronic signature *  The POC/IDG dated 3/10 and 3/24/25, showed no documented evidence of the MSW’s electronic signature. On 4/9/25 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN.  The Administrator/LVN was informed and acknowledged the finding. #.  Review of Patient 7's clinical record was initiated on 4/7/25.  The clinical record showed the SOC was 9/5/24.  The patient was certified for hospice services during the certification periods from 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25.   Review of the electronic clinical record of the POC/IDG Review dated 3/10/25 and 3/24/25, showed no documented evidence of an electronic signature by SC 2 at the time of morning review on 4/7/25.   Further review again of the printed version of above POC/IDG showed an electronic signature by SC 2. Review of the Activity History showed on 4/7/25 at 1250 hours, showed there was an update in the “poc/idg” by  SC 2. On 4/7/25 at 1600 hours, an interview with the Administrator Designee.  He stated there were late electronic signatures entered on the POC/IDG Review dated 3/10 and 3/24/25. On 4/9/25 at 1131 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the copy of the discharge summary was forwarded to the physician for two of 14 sampled patients (Patients 3, and 14). This failure had a potential for not identifying the patients’ needs to ensure the continuity of the care after being discharged from the hospice services. Findings: --- #. Review of Patient 14’s closed clinical record was initiated on 4/8/25. The closed clinical record showed the SOC was 5/9/24. The patient was certified for hospice services during the certification periods from 5/9/24 to 8/6/24, 8/7/24 to 11/4/24 and 11/5/24 to 1/3/25. The patient was discharged on 1/3/25.Review of the closed clinical record showed a discharge summary was completed on 1/3/25.*However, there was no documentation of the discharge summary was sent to the physician.On 4/9/25 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings. #.  Review of the hospice’s P&P titled Discharge Summary revised 10/2019, showed the procedure includes a copy of discharge summary will be sent to the patients attending physician. Review of Patient 3's closed clinical record was initiated on 4/8/25.  The clinical record showed the SOC was 8/11/24.  The patient was certified for hospice services during the certification periods from 11/1/24 to 1/29/24 and 1/30/25 to 3/30/25.  The patient was discharged on 2/7/25. Review of the closed clinical record showed a discharge summary was completed on 2/7/25.  However, there was no documentation of the discharge summary was sent to the physician as per the hospice’s P&P. On 4/9/25 at 1151 hours, an interview and concurrent closed clinical record review was conducted with the Patient Care Coordinator.  The Patient Care Coordinator was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure a copy of the discharge summary was forwarded to the physician for one of 14 sampled patients (Patient 12) who revoked the election of hospice. This failure had the potential of not communicating the post-discharge care needs of the patient to the physician. Findings: --- Review of the hospice’s P&P titled Revocation of Hospice Benefit Election revised 10/2019 showed the Case Manager will facilitate the patient’s revocation and assist with a smooth transition to another setting or independent care.  A discharge summary will be sent to the attending physician.  A revocation of election of hospice care statement will be signed by the patient and will document the date, time, and reason for revocation.  A copy will be sent to billing and will be retained in the clinical record.  The organization will submit the revocation of hospice care statement (NOTR) to the Medicare contractor (MAC) within five calendar days of the date on the notice.Review of Patient 12’s closed clinical record was initiated on 4/8/25.  The clinical record showed the SOC was on 9/27/23.  The patient was certified for hospice services during the certification period from 11/20/24 to 1/18/25.  The patient was discharged and revoked hospice services on 12/31/24.Review of the closed clinical record showed a discharge summary was completed on 12/31/24.  However, there was no documented evidence the discharge summary was sent to the physician as per the hospice’s P&P.In addition, further review of the closed clinical record failed to show the completed and signed revocation of election of hospice care statement which included the date, time, and reason for the revocation by the patient as per the hospice’s P&P.On 4/9/25 at 1224 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee.  The Administrator Designee was informed and acknowledged the findings.

Based on interview and closed record review, the hospice failed to ensure the safe disposal of the controlled drugs in the patient’s home for one of 14 sampled patients (Patient 1). This failure had the potential for the controlled drugs to not be safely and appropriately disposed of  and posed a potential for the controlled drugs diversion. Findings: --- Review of the hospice's P&P titled Home Use and Disposal of Controlled Substances (undated) showed to ensure the appropriate use and disposal of controlled substances in accordance with the applicable state and federal regulations. The hospice nurse, social worker, or chaplain attending the death of a hospice patient will inform the family/caregiver of their responsibility to dispose of all the patient’s prescribed medications and will document the instruction in a clinical note. If the family/caregiver requests assistance with the disposal, the hospice employee will observe and provide verbal assistance as the family/caregiver properly disposed of the prescribed medications. The disposal will be documented in a clinical note.Review of Patient 1’s closed clinical record was initiated on 4/3/25.  The closed clinical record showed the SOC was 7/25/24. The patient was certified for hospice services during the certification periods from 7/25/24 to 9/22/24, 9/23/24 to 11/21/24, and 11/22/24 to 1/20/25.  The patient had  expired on 12/17/24.Review of the closed clinical record failed to show the report of death and disposal of controlled drugs were completed.On 4/9/25 at 1042 hours, an interview and concurrent clinical record review was conducted with the Administrator/LVN. The Administrator/LVN was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure one of one written agreement with the SNF included an agreement that it was the hospice's responsibility to provide the services at the same level and to the same extent as those services would be provided if the SNF resident were in his or her own home.  This failure had the potential to not address the patient care needs. Findings: --- Review of the written agreement between the SNF and the hospice was conducted on 4/8/25.   The written agreement with the SNF did not include an agreement that it was the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF resident were in his or her own home. On 4/9/25 at 1049 hours, an interview and concurrent record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure one of one written agreement with the SNF included a provision stating the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF administrator within 24 hours of the hospice becoming aware of the alleged violation.  This failure had the potential for abuse to not be detected.  Findings: --- Review of the written agreement between the SNF and hospice was conducted on 4/8/25.   The written agreement with the SNF did not include a provision stating he hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF administrator within 24 hours of the hospice becoming aware of the alleged violation. On 4/9/25 at 1049 hours, an interview and concurrent clinical record review was conducted with the HR Staff.  The HR Staff was informed and acknowledged the findings.