Every finding on record at Arias Health Care, Inc,

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan was reviewed and updated at least every two years. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed the strategies for addressing emergency events based on the hospices risk assessments. However, there was no documented evidence when the plan was reviewed and updated. In addition, the Emergency Management Plan was not revised to reflect the hospices current location and alternate locations in case of emergencies. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding. When asked when the emergency preparedness plan was last reviewed or updated, the DPCS stated it had not been updated since 2018.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included the process for cooperation and collaboration with the local, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed the contact information for local and regional officials. However, it did not include the process on how the hospice will cooperate and collaborate with the local, regional, State, and Federal emergency preparedness officials. On 8/28/23 at 1137 hours, an interview and concurrent Emergency Management Plan review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

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 created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed the hospice analyzed the type of emergencies most likely to occur in their geographical area. It also included the contact information of the local agencies and officials. However, there was no documented evidence the risk assessment and communication plan were reviewed and updated at least every two years. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included the procedures to follow-up with on duty staff and patients; and inform the State and local officials in the event the hospice was unable to contact them during an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed information on when to contact the staff and patients during an emergency. However, it did not include the procedures on informing the State and local officials of any on duty staff and patients they were unable to contact during an emergency. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included the procedures to inform State and local officials about patients in need of evacuation from their residences due to an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan included the contact information of the local officials the hospice may contact. However, there was no documented evidence on the procedures on informing the State and local emergency preparedness officials about patients in need of evacuation. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included a system of medical documentation that preserved patient information, protect confidentiality, and maintained the availability of patient records during an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed no documented evidence showing how the hospice will preserve patient information, protect confidentiality, and maintain the availability of patient records in the event of an emergency. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included other emergency staffing strategies including the process and role of integration of State and Federally designated healthcare professionals to address the surge needs during an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency in the event the hospice and local agencies resources were exhausted. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed no documented evidence on how the hospice will use other emergency staffing strategies including the process and role of integrating State and Federal healthcare professionals when there is a surge need during an emergency. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were 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 created the risk for the patients not receiving adequate and timely assistance during emergency crises. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed no documented evidence the communication plan was reviewed and updated at least every two years. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were 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 hospice staff, contractors, physicians, and other hospices and facilities. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed the contact information for the local and regional agencies. However, it did not include the names and contact information of the staff, contractors, physicians, and other hospices and facilities. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness communication plan included the primary and alternate means for communication of the hospices staff and the Federal, State, regional, and local emergency management agencies. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan showed the primary phone numbers of the local and regional emergency management agencies, but it did not include any alternate means of communication. In addition, the plan did not include the primary and alternate means for communication with the hospices staff and the Federal and State emergency management agencies. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan included a method for sharing information and medical documentation of the hospices patients with other health providers to maintain continuity of care. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan did include any documented evidence on how the hospice will share information and medical patient documents with other health providers to maintain continuity of care during an emergency. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were 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 created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. The Emergency Management Plan and review of employee files showed the hospice provided initial emergency preparedness trainings to the staff. Review of the hospice documents dated 5/3/23 and 5/10/22 showed the hospice conducted fire drills. However, there was no documented evidence the emergency preparedness training and testing program was reviewed and updated at least every two years. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to conduct an additional exercise that tested the hospices emergency preparedness plan. This failure created the risk of not identifying the gaps in the hospices emergency program including the staffs knowledge in responding to various types of emergencies. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan (undated) was initiated on 8/23/23. Review of the hospice documents dated 5/3/23 and 5/10/22, showed the hospice conducted fire drills as part of the emergency training and testing. However, there was no documented evidence the hospice conducted other types of emergency drills. In addition, there was no documented evidence the hospice conducted exercises from 2019 to 2021. On 8/28/23 at 1137 hours, an interview and concurrent hospice document review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the finding. The DPCS verified the hospice only conducted fire drills as part of their emergency preparedness testing.

This CONDITION is not met as evidenced by: Based on interview and record review, the hospice failed to ensure the initial and comprehensive assessments were completed, reviewed, and revised to address and meet the patients' care needs as evidenced by: --- Findings: 1. The hospice failed to ensure the comprehensive assessments were completed no later than five calendar days. Cross reference to L523. 2. The hospice failed to ensure the comprehensive assessments had identified the psychosocial, and spiritual needs. Cross reference to L524. 3. The hospice failed to ensure the comprehensive assessments had identified the imminence of death. Cross reference to L528. 4. The hospice failed to include all current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments and the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use. Cross reference to L530. 5. The hospice failed to ensure the initial bereavement assessment was completed. Cross reference to L531. 6. The hospice failed to ensure the updated comprehensive assessments were completed and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses. Cross reference to L533. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the initial and comprehensive assessments to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days for 16 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16), creating the risk of not identifying the care needs for these patients. --- XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. Review of the clinical record showed the hospice had completed the initial comprehensive nursing, psychosocial, and bereavement assessments. However, there was no documented evidence showing the hospice had completed the initial comprehensive spiritual assessment for the patient. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 16's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 1/26/23. The patient was certified for hospice services during the certification period from 1/26/23 to 4/25/23. Review of the clinical record showed the hospice had completed the initial comprehensive nursing assessment. However, there was no documented evidence showing the hospice had completed the initial comprehensive spiritual and psychosocial assessments for the patient. On 8/28/23 at 1053 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12, 13, 14, 15, and 16, showed no documented evidence the comprehensive assessments were completed for these patients. For example: 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. The comprehensive nursing and psychosocial assessments were conducted on 8/1/22. Further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual assessment for the patient. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. The comprehensive nursing and psychosocial assessments were conducted on 8/3/22. Further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual assessment for the patient. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the psychosocial and spiritual needs for 16 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, and 16). This failure created the risk of not identifying the care needs for these patients. --- XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. Further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual assessment for the patient. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification periods from 5/3/22 to 7/1/23 and 7/2/23 to 8/30/23. Further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual assessment for the patient. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, and 16, showed no documented evidence the patients' needs for psychosocial and spiritual needs were assessed during the initial comprehensive assessment for these patients. For example: 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. Further review of the clinical record showed no documented evidence the hospice had completed the initial comprehensive spiritual assessment for the patient. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. Further review of the clinical record showed no documented evidence the hospice had completed the initial comprehensive spiritual assessment for the patient. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 3. Review of Patient 6s clinical record was initiated on 8/16/23. The clinical record showed the SOC was 1/13/23. The patient was certified for hospice services during the certification periods from 4/13/23 to 7/11/23 and 7/12/23 to 9/9/23. The comprehensive nursing assessment was conducted on 1/13/23. The psychosocial assessment dated 1/18/23, showed a MSW visit. However, the section under the assessment of family crisis and referral to what community program was not completed. Further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual assessment for the patient. On 8/28/23 at 1035 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the imminence of death for 16 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 14, and 16), creating the risk of not appropriately addressing the patient's needs. --- XX. Review of Patient 12's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 2/3/22. The patient was certified for hospice services during the certification period from 10/1/22 to 11/29/22. Review of the initial comprehensive nursing and psychosocial assessments dated 2/3/22 and 5/4/22 showed no documented evidence the patients imminence of death was identified. On 8/28/23 at 1023 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 8's clinical record was initiated on 8/17/23. The clinical record showed the SOC was 7/13/23. The patient was certified for hospice services during the certification period from 7/13/12 to 10/10/23. Review of the initial comprehensive nursing and psychosocial assessments dated 7/13/23 and 7/17/23 showed no documented evidence the patients imminence of death was identified. On 8/28/23 at 0950 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 showed no documented evidence the patients' imminence of death were assessed during the initial comprehensive assessment for these patients. For example: 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. However, further review of the clinical record showed the initial comprehensive assessment did not identify the imminence of death for the patient. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on observation, interview, and record review, the hospice failed to include all current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments; and the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use for 15 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, and 16). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. --- XX. Review of Patient 15's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 2/9/23. The patient was certified for hospice services during the certification period from 2/9/23 to 5/9/23. The Current Treatment/Medication/DME List showed the patient was taking Ativan (antianxiety) 0.5 mg SL Q eight hours PRN for anxiety and morphine sulfate (opioid analgesic) 0.5 mg SL Q four hours PRN for pain. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the patients current medication list showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the potential drug interactions were identified. On 8/28/23 at 1041 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. On 8/16/23 at 1458 hours, a joint home visit was conducted with HA 1 to Patient 2s home. Review of the patient's medications with HA 1 and the PCG showed the patient was taking lisinopril (antihypertensive) 2.5 mg PO QD PRN if the SBP is greater than 140 or the DBP is greater than 90 mmhg instead of 5 mg as listed in the medication profile. The patient was also taking Protonix (acid reducer) 20 mg PO QD PRN for stomach pain which was not listed in the medication profile. Further review of the patients current medication list showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the potential drug interactions were identified. On 8/16/23 at 1535 hours, an interview and concurrent clinical record review was conducted with HA 1. HA 1 was informed and verified the finding. XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. On 8/16/23 at 1225 hours, a joint home visit was conducted with RN 1 to Patient 1s home. Review of the patient's medications with RN 1 and the PCG showed the patient was taking omeprazole (antacid) 20 mg via GT QD PRN for stomach pain instead of 40 mg. The patient was also taking Maalox (antacid) 30 ml via GT BID PRN for GERD or stomach discomfort instead of QID as listed in the medication profile. On 8/16/23 at 1248 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and verified the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 8, 9, 10, 12, 11, 13, 14, 15, and 16 showed no documented evidence the patients' medications were reviewed to include the following: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy currently associated with laboratory monitoring for these patients and updated to reflect the current medications and include specific indications and parameters for its use. For example: 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. The Current Treatment/Medication/DME List for the certification period from 7/27/23 to 9/24/23, showed the patients medications included atenolol (antihypertension) 50 mg one tablet PO BID, finasteride (urinary retention medication) 5 mg one tablet PO QD, Januvia (antidiabetic) 50 mg one tablet PO QD, Novolog (insulin) 100 u/ml 15 ";Sol" SC TID, Tylenol (analgesic) two tablet PO Q six hours PRN, and tamsulosin hydrochloride (urinary retention) 0.4 mg two capsule daily. According to Lexicomps pharmacology website, under Januvias drug interaction included antidiabetic agents may enhance the hypoglycemic effect of hypoglycemia-associated agents. However, there was no documented evidence the IDG had identified the potential drug interactions between Januvia and Novolog. A joint home visit with the DPCS and HA 2 to the patient's home was conducted on 8/21/23 at 1300 hours. Review of the patient's medications with the family member and the DPCS showed the patient's medication included valsartan hctz (antihypertension) 320/12.5 mg one half tablet PO QD, Norvasc (antihypertension) 5 mg PO QD, Lipitor (antilipemic) 40 mg PO QD, ";Xarel" 15 mg PO QD, amiodarone hcl (antiarrhythmic) 100 mg PO QD, levothyroxine (hormone) 0.1 mg PO QD, calcium and vitamin D (supplement) one tablet twice a day, folic acid (supplement) 1 mg PO QD, omeprazole DR (used for GERD) 20 mg PO QD, Lexapro (antidepressant) 20 mg PO QD, Basaglar (insulin) 24 u at bedtime, levocetirizine (antihistamine) 5 mg PO QD, and docusate sodium (laxative) 250 mg one tablet PO QD. The family member stated the patient had been taking the above medications for a long time. The hospice failed to update patients medication profile. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. The Current Treatment/Medication/DME List for the certification period from 6/29/23 to 8/27/23, showed the patient's medication included memantine hydrochloride (cognition enhancing medication) 10 mg one tablet PO QD, omeprazole (used to treat GERD) 40 mg delayed release PO BID, DSS (stool softener) 250 mg PO QD, vitamin D3 (supplement) 50000 u one capsule PO Q week, gabapentin (anticonvulsant) 100 mg one capsule PO TID, doxazosin (antihypertension) 4 mg PO QD, Maxitrol (antibiotic/corticosteroid) ophthalmic ointment 0.1% QD, Norco (opioid analgesic) 5-325 mg one tablet PO Q six hours PRN, Tussin-V (used for cough) 2mg-2.5 mg-30 mg/5 ml syrup 2mg 5 nl PO Q four hours PRN, and Celebrex (nonsteroidal anti-inflammatory drug) 200 mg one capsule PO QD. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Celebrex included NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at higher risk for serious GI events. However, there was no documented evidence the potential adverse reaction was identified and what preventative measure was implemented regarding the potential adverse reaction from the medication. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 3. Review of Patient 9's clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/8/23. The patient was certified for hospice service during the certification period from 8/8/23 to 11/15/23. The Current Treatment/Medication/DME List for the certification period from 8/8/23 to 11/15/23, showed the patients medication included acetaminophen (analgesic) 500 mg one to two tablets Q six hours for pain. However, there was no documented evidence on when to administer one or two tablets of acetaminophen. On 8/28/23 at 1002 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the initial bereavement assessment was completed for four of 16 sampled patients (Patients 7, 8, 14, and 15). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. --- XX. Review of Patient 7's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 6/23/23. The patient was certified for hospice services during the certification period from 6/23/23 to 9/20/23. Review of the clinical record showed the initial bereavement assessment was completed for the patient. However, the initial bereavement assessment was completed on 8/10/23, more than 30 days after the SOC. On 8/28/23 at 1000 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator acknowledged the finding and stated she may have documented the incorrect date. XX. Review of Patient 8's clinical record was initiated on 8/17/23. The clinical record showed the SOC was 7/13/23. The patient was certified for hospice services during the certification period from 7/13/12 to 10/10/23. Review of the clinical record showed the initial bereavement assessment was completed on 7/17/23. However, the assessment was incomplete and did not include the contact information of the bereaved. On 8/28/23 at 0950 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 15's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 2/9/23. The patient was certified for hospice services during the certification period from 2/9/23 to 5/9/23. Review of the clinical record showed no documented evidence the initial bereavement assessment was completed. On 8/28/23 at 1041 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 1. Review of Patient 14's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 6/3/22. The patient was certified for hospice services during the certification periods from 11/30/22 to 1/28/23 and 1/29/23 to 3/29/23. Review of the clinical record showed no documented evidence the initial bereavement assessment was completed. On 8/28/23 at 1017 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments were completed and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses for 15 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, and 16), creating the risk of not addressing the care needs for these patients. --- XX. Review of Patient 7's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 6/23/23. The patient was certified for hospice services during the certification period from 6/23/23 to 9/20/23. Review of the RN Visit Notes dated 7/22/23 showed the RN visited the patients home and documented the patient was exhibiting increased weakness, increased stiffness, and agitation. The POC/IDG Review dated 7/24/23 showed no documented evidence the IDG had updated the comprehensive assessment and discussed the patients musculoskeletal issues and agitation. On 8/28/23 at 1000 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 16's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 1/26/23. The patient was certified for hospice services during the certification period from 1/26/23 to 4/25/23. The POC/IDG Review dated 1/26, 2/1, 2/15, 3/1, 3/15, 3/29, and 4/12/23 cited HA visits once per week. However, review of the clinical record showed the HA only visited on 4/18/23, during the certification period. There was no documented evidence showing the IDG had updated the comprehensive assessments and discussed whether the patient needed HA services prior to 4/18/23. On 8/28/23 at 1053 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator acknowledged the finding and stated the family may have declined services, but it was not documented. Findings: 1. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, and 16, showed no documented evidence the need for volunteer was assessed during the ongoing assessment with the IDG. For example: a. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. Further review of the clinical record showed no documented evidence of an ongoing assessment for volunteer needs during the IDG meetings. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. b. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. Further review of the clinical record showed no documented evidence of an ongoing assessment for volunteer needs during the IDG meetings. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. c. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. Review of the clinical record showed the IDG met on 7/5, 7/19, and 8/2/23. However, there was no documented evidence showing the volunteer needs were assessed during the meetings. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. d. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification periods from 5/3/23 to 7/1/23 and 7/2/23 to 8/30/23. Review of the clinical record showed the IDG met every 14 days. However, there was no documented evidence showing the volunteer needs were assessed during the meetings. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 2. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, and 16 showed no documented evidence spiritual needs was assessed during the ongoing assessment with the IDG. For example: a. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. Further review of the clinical record showed no documented evidence of an ongoing assessment for spiritual needs during the IDG meetings. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. b. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. Further review of the clinical record showed no documented evidence of an ongoing assessment for spiritual needs during the IDG meetings. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. c. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. Review of the clinical record showed the IDG met on 7/5, 7/19, and 8/2/23. However, there was no documented evidence of an ongoing assessment for spiritual needs during the IDG meetings. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. d. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification periods from 5/3/22 to 7/1/23 and 7/2/23 to 8/30/23. Review of the clinical record showed the IDG met every 14 days. However, there was no documented evidence an ongoing assessment for spiritual needs during the IDG meetings. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 3. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. The SN note dated 6/22/23, showed the patients edema on both lower extremity was still present. Documentation showed any activity caused patient shortness of breath and discomfort. The POC/IDG dated 7/3/23, showed no documented evidence the IDG had updated the comprehensive assessment and discussed about any activity caused patient shortness of breath and discomfort. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 4. Review of Patient 5's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 10/7/22. The patient was certified for hospice service during the certification period from 6/24/23 to 8/22/23. The SN note dated 6/29/23, showed the patient was combative today (6/29/23), and hit the HA and the family member when personal care was being given. Documentation showed the physician was notified and an order was given. The POC/IDG Review dated 7/5/23, showed the family member stated the patient had been less combative. Documentation showed the family member realized it was part the of the patients disease process. Documentation showed the family member had not given risperidone (antipsychotic). The SN note dated 7/6/23, showed the same information on the above POC/IDG Review dated 7/5/23. However, the IDG failed to consistently update the patients episode of combativeness; and hitting the HA and the family member when personal care was being given on 6/29/23. In addition, the information discussed by the IDG on 7/5/23, was the same information documented on the SN visit (7/6/23), which was the day after the IDG meeting. On 8/28/23 at 1000 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

This CONDITION is not met as evidenced by: Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients' care needs as evidenced by: --- Findings: 1. The hospice failed to ensure the care and services were provided in accordance with the POCs. Cross reference to L543. 2. The hospice failed to develop an individualized written POCs that reflected goals and interventions based on the problems identified. Cross reference to L545. 4. The hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN discipline visits. Cross reference to L547. 5. The hospice failed to ensure the POCs included measurable outcomes. Cross reference to L548. 6. The hospice failed to ensure the IDG had reviewed/revised the POCs no less frequently than every 15 calendar days. Cross reference to L552. 7. The hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs. Cross reference to L553. 8. The hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided. Cross reference to L554. 9. The hospice IDG failed to ensure the care and services were provided in accordance with the POCs. Cross reference to L555. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for three of 16 sampled patients (Patients 2, 7, and 11). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. --- XX. Review of Patient 7's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 6/23/23. The patient was certified for hospice services during the certification period from 6/23/23 to 9/20/23. The POC/IDG Review dated 6/26/23, cited RN visit once per week plus one PRN visit. However, review of the clinical record showed no documented evidence the RN visited the patients home during Week 2 (6/26/23 to 7/1/23). On 8/28/23 at 1000 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/23. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. Review of the Skin Impairment Assessment dated 7/6/23 showed the patient had a Stage 2 PI on the left foot. The note showed the wound was measured and the status showed to treat the wound. However, there was no documented evidence showing the wound was treated. Further review of the clinical record showed no documented evidence of the wound treatment orders from the physician. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator acknowledged the finding and stated the RN may have forgotten to transcribe the verbal order. #. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. The POC/IDG dated 8/5/23, showed RN 2W and 1 PRN visit. The SN notes showed the RN conducted one visit on Week 1 (8/5/22 to 8/6/22), instated of two visits per week as per the POC. On 8/28/23 at 1030 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the written POCs were developed and updated to reflect the patient and family goals and interventions based on the problems identified for 15 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, and 16), creating the risk of not addressing the care needs for these patients. --- XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. Review of the RN Visit Note dated 7/18/23 showed the RN documented the patient had ear pain with foul drainage. The note also showed the patients GT site continued to have serosanguinous drainage with foul odor. The POC/IDG Review dated 7/19/23 showed the patients issues were discussed. However, there was no documented evidence showing the individualized POCs were developed to address the patients ear pain and GT site. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. Review of the Skin Impairment Assessment dated 7/6/23 showed the patient had a Stage 2 PI on the left foot. The note showed the wound was measured and the status showed to treat the wound. The POC/IDG Review dated 7/19/23 showed the care plan problems were developed for cardiovascular, environment, neurologic, and pain. However, there was no documented evidence showing the individualized POC was developed to address the patients Stage 2 PI. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 7's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 6/23/23. The patient was certified for hospice services during the certification period from 6/23/23 to 9/20/23. Review of the RN Visit Notes dated 7/22/23 showed the RN visited the patients home and documented the patient was exhibiting increased weakness, increased stiffness, and agitation. The POC/IDG Review dated 7/24/23 showed no documented evidence showing the individualized POC was developed to address the patients musculoskeletal issues and agitation. Further review of the clinical record showed no documented evidence the initial POC was developed. On 8/28/23 at 1000 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Xx. Review of Patient 8's clinical record was initiated on 8/17/23. The clinical record showed the SOC was 7/13/23. The patient was certified for hospice services during the certification period from 7/13/12 to 10/10/23. Review of the RN Visit Notes dated 7/27/23 showed the RN visited the patients home and documented the patient had been experiencing constipation. The POC/IDG Review dated 8/11/23 showed no documented evidence the individualized POC was developed to address the patients constipation. Further review of the clinical record showed no documented evidence the initial POC was developed. On 8/28/23 at 0950 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Xx. Review of Patient 12's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 2/3/22. The patient was certified for hospice services during the certification period from 10/1/22 to 11/29/22. Review of the RN Visit Notes dated 10/29/22 showed the RN documented the patient had a very cloudy urine and increased abdominal girth. The POC/IDG Review dated 11/2/22 showed no documented evidence showing the individualized POC was developed to address the patients cloudy urine and abdominal girth. On 8/28/23 at 1023 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 13's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 12/2/21. The patient was certified for hospice services during the certification period from 1/26/23 to 3/26/23. Review of the RN Visit Notes dated 2/2/23 showed the RN documented the patient was experiencing burning with urination and foul odor. The POC/IDG Review dated 2/15/23 showed the patients issues were discussed. However, there was no documented evidence showing the individualized POC was developed to address the patients UTI. On 8/28/23 at 1031 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 15's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 2/9/23. The patient was certified for hospice services during the certification period from 2/9/23 to 5/9/23. Review of the RN Visit Notes dated 2/12/23 showed the RN documented the patient was experiencing increased anxiety with slight shortness of breath, confusion, and restlessness. The documentation also showed the patient had a very cloudy urine and increased abdominal girth. The POC/IDG Review dated 2/23/23 showed the patients the care plan problems were developed for mobility and pain. However, there was no documented evidence showing the individualized POCs were developed to address the patients issues identified by the RN on 2/12/23. On 8/28/23 at 1041 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 16's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 1/26/23. The patient was certified for hospice services during the certification period from 1/26/23 to 4/25/23. Review of the RN Visit Notes dated 2/23/23 showed the RN documented the patient had not had a bowel movement since 2/19/23 and the physician was notified. The POC/IDG Review dated 3/1/23 showed the patients issue were discussed. However, there was no documented evidence showing an individualized POC was developed to address the patients constipation. Further review of the clinical record showed no documented evidence the initial POC was developed. On 8/28/23 at 1053 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: The hospices P&P titled Hospice Plan of Care dated 12/15/12, showed there will be as individualized plan of care established for every hospice patient accepted for care. The written plan of care will specify the care and services necessary to meet the patient and family specific needs related to terminal illness and related conditions. A written plan of care will be developed for each hospice patient. The plan of care will reflect the patient and family goals and intervention based on problems identified in the initial, comprehensive, and updated comprehensive assessments. 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. The SN note dated 5/28/23, showed the patient had currently been experiencing increased lower extremities pain. Documentation showed the patient complained of mild lower back discomfort. Documentation showed the patient had taken Tylenol 650mg Q eight hours PRN for discomfort. However, further review of the clinical record showed no documented evidence the IDG had developed an individualized POC to address patients pain/discomfort. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. The SN note dated 7/13/23, showed the patient had blisters on the right foot. Documentation showed the blisters were cleansed with soap and water, pat dry, and left open to air. Documentation showed the physician was notified. The SN note dated 7/15/23, showed the patient exhibited +4 edema in the extremities. Documentation showed the physician was notified. However, further review of the clinical record showed no documented evidence the IDG had developed an individualized POC to address patients the blisters on the right foot and edema on the extremities. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 10/7/22. The patient was certified for hospice service during the certification period from 6/24/23 to 8/22/23. The POC/IDG Review dated 7/19/23, showed the family member would like to find a PCG to assist. Documentation showed the patients combativeness may be an issue. Documentation showed the family member was giving the patient risperidone. The POC/IDG Review dated 7/26/23, showed he family member stated the patient had itchiness and rash on the nape. Documentation showed to give either Atarax (antihistamine) or Benadryl (antihistamine). However, there was no documented evidence the IDG had developed an individualized POC to address patients behavior and use of risperidone as per the POC/IDG Review dated 7/19/23; and the rash and itchiness on the nape as per the POC/IDG Review dated 7/26/23. 4. Review of Patient 9's clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/8/23. The patient was certified for hospice service during the certification period from 8/8/23 to 11/15/23. The Current Treatment/Medication/DME List for the certification period from 8/8/23 to 11/15/23, showed the patients medication included acetaminophen 500 mg one to two tablets Q six hours for pain. The SN note dated 8/11/23, showed the patient had 3/10 pain level (0=no pain and 10=worst pain). However, further review of the clinical record showed no documented evidence the IDG had developed an individualized POC to address patients pain/discomfort. On 8/28/23 at 1002 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 5. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. The POC/IDG Review dated 8/31/22, showed the IDG had discussed about the patients severe edema to all extremities, severe abdominal distention, nonproductive cough, the patient unable to cough and deep breathe, and the patient had coccyx pressure injury. However, further review of the clinical record showed no documented evidence the IDG had developed an individualized POC to address patients severe edema to all extremities, severe abdominal distention, nonproductive cough, the patient unable to cough and deep breathe. In addition the IDG failed to update the POC for skin related to Braden score less than 14 (assessment of the risk of pressure injury) to the patient had coccyx pressure injury. On 8/28/23 at 1030 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 6. Review of Patient 14's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 6/3/22. The patient was certified for hospice services during the certification periods from 11/30/22 to 1/28/23 and 1/29/23 to 3/29/23. The POC/IDG Review dated 11/23/22, showed the patient had 6/10 pain (0=no pain and 10=worst pain). Documentation showed the patient was taking Tramadol (opioid analgesic) but was reluctant to take the medication. Documentation showed the patient was on several medications but still exhibits elevated blood pressure at times. However, further review of the clinical record showed no documented evidence the IDG had developed an individualized POC to address patients pain and elevated blood pressure. On 8/28/23 at 1017 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 7. Review of Patient 6s clinical record was initiated on 8/16/23. The clinical record showed the SOC was 1/13/23. The patient was certified for hospice services during the certification periods from 4/13/23 to 7/11/23 and 7/12/23 to 9/9/23. a. The POC/IDG Review dated 4/12, 4/26, 5/10, 5/24, 6/7, 6/21, 7/19, and 8/2/23, showed treatment were conducted to the coccyx and left shoulder wound. Documentation showed bed pads were usually soaked with urine. Bed pads were changed. The POC/IDG Review dated 7/5/23, showed the patient does not like to wear diapers and urinates on the bed pads. * However, there was no documented evidence an individualized POC was developed to address bed pads were soaked with urine and the patient did not like to wear diapers. b. The POC/IDG Review dated 4/12/23, showed the patients right ear was painful and had a foul smelling discharge. Documentation showed Oflaxacin (antibiotic) 3% otic solution was ordered for ear infection for seven days. * However, there was no documented evidence an individualized POC was developed to address the patient's ear infection and the use of otic antibiotic. The POC/IDG Review dated 4/26/23, showed the patient had frequent productive cough with green sputum. Documentation showed the patient had congestion, increased SOB, and wheezing. Documentation showed the patient complained of URI and Levaquin (antibiotic) 500 mg was ordered for five days. * However, there was no documented evidence an individualized POC was developed to address URI and the use of Levaquin. The POC/IDG review dated 5/24/23, showed the patients left shoulder wound got redder, had an odor, and purulent drainage on 5/18/23. Documentation showed the physician ordered Bactrim DS (antibiotic) twice daily. * However, there was no documented evidence an individualized POC was developed to address the use of antibiotic on the patients left shoulder wound. The SN note dated 7/5/23, showed the patient recently had left should wound infection and was ordered Keflex (antibiotic) 500 mg Q eight hours for 10 days. The physicians orders dated 7/6/23, showed cephalexin (generic name for Keflex) 500 mg PO Q eight hours for 10 days for wound infection. * However, there was no documented evidence an individualized POC was developed to address the wound infection and the use of Keflex. c. The POC/IDG Review dated 4/12, 4/26, and 5/10/23, showed the patient continued to have a yeast like rash on the left arm and left under breast. Documentation showed Lotrimin (antifungal) 1% was ordered for the yeast rash under the breast area. The POC/IDG Review dated 4/12/23, showed Lotrimin (antifungal) 1% was ordered for the yeast rash under the breast area. * However, there was no documented evidence an individualized POC was developed to address yeast like rash on the left arm and under left under breast and the use of Lotrimin. d. The POC/IDG Review dated 4/12, 4/26, and 5/10/23, showed the patient cannot reposition self or help with repositioning, and was uncomfortable during wound care. The POC/IDG Review dated 4/12/23, showed the patient was instructed to stay off the left shoulder and left arm as much as possible. The POC/IDG Review dated 5/10/23, showed the importance of turning and repositioning Q two hours was discussed. The POC/IDG dated 6/7 and 6/21/23, showed the patient was unable to assist at all with repositioning or turning. Documentation showed the patient was allowing to reposition but not Q two hours; and turning and repositioning every two hours was reinforced. The POC/IDG dated 7/5/23, showed the patient required maximal assistance to turn and reposition in bed. Documentation showed the patient did not like to turn and reposition because it caused discomfort. * However, there was no documented evidence an individualized POC was developed to address the patients inability to reposition self or help with repositioning, patient not allowing to be repositioned Q two hours, and the patient did not like to turn and reposition because it caused discomfort. e. The POC/IDG Review dated 5/24/23, showed the physician ordered Seroquel for depression, Xanax (antianxiety) for anxiety, and MS Contin (opioid analgesic) was increased to three times daily due to increased pain. * However, there was no documented evidence an individualized POC was developed to address the use of Seroquel for depression, the use of MS Contin for increased pain, and Xanax for anxiety. f. The POC/IDG dated 7/5/23, showed the patient had episodes of poor appetite. Documentation showed the patient chokes on liquid at times. Documentation showed the patient can still administer own medications; however, sometimes pills were found on the patients bed due to poor hand grasp However, there was no documented evidence an individualized POC was developed to address patient choking on liquids and pills found on the bed due poor hand grasp. g. The SN note date 8/9/23, showed the patient had reddened open area on the right shoulder. * However, there was no documented evidence an individualized POC was developed to address the patients reddened open area on the right shoulder. On 8/28/23 at 1035 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN discipline visits for 16 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16). This failure created the risk of not providing necessary services for these patients. --- XX. Review of Patient 8's clinical record was initiated on 8/17/23. The clinical record showed the SOC was 7/13/23. The patient was certified for hospice services during the certification period from 7/13/23 to 10/10/23.The POC/IDG Review dated 7/13/23, cited one MD visit PRN and during recertification, one MSW visit PRN and during recertification, and one RN visit per week plus one PRN visit. However, there was no documented evidence showing the specific frequencies and the indications for the PRN discipline visits. On 8/28/23 at 0950 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23.The POC/IDG Review dated 7/5/23, cited one MSW visit then PRN, one MD visit then PRN, and one RN visit per week plus one PRN visit. However, there was no documented evidence showing the specific frequencies and the indications for the PRN discipline visits. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14,15, and 16 failed to show documented evidence of the discipline visit frequencies and/or the indication for the PRN discipline visits on the revised POCs. For example: #. 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. Review of the clinical record showed RN and HA visits during the certification period. Review of the POC/IDG Review dated 6/1, 6/15, 7/3, and 7/21/23, cited HA per week, physician 1 PRN and recertification, MSW 1 PRN and recertification, and RN 1W and 1 PRN visits. However, there was no documented evidence showing the specific frequencies and the indication for the PRN discipline visits. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. Review of the POC/IDG Review dated 7/17 and 7/31/23, cited HA 2 W, physician 1 PRN and recertification, MSW 1 PRN and recertification, and RN ";1 1 PRN" However, there was no documented evidence showing the specific frequencies and the indication for the PRN discipline visits. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 13 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 7, 8, 11, 12, 13, 14,15, and 16 ), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. --- XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. The POC/IDG Review dated 7/5/23 showed a care plan problem was developed for integumentary/skin. The goal listed was to minimize the risk of bedsores with no skin breakdown which was not measurable. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. The POC/IDG Review dated 7/5/23 showed a care plan problem was developed for cardiovascular issues. The goal listed was for the patient to maintain optimum peripheral circulation and to maintain the patients comfort which were not measurable. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 7, 8, 11, 12, 13, 14, 15, and 16, showed the initial and updated/revised POCs did not include the measurable outcomes anticipated to evaluate the effectiveness of the plan of care to meet the patients' needs. For example: 1. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. The POC/IDG Review dated 6/21, 7/17, and 7/31/23, showed the patient's identified problem with the established goal and interventions. However, the POC failed to include measurable outcome for the patient's identified problem. For example, the goal for gastrointestinal status was for the patient to have reduced discomfort and improved bowel elimination status for the certification period. There was no measurable outcome as to what reduced discomfort and improved bowel elimination for the patient was. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs no less frequently than every 15 calendar days for 16 of 16 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. The POC/IDG Review during the certification period showed there were multiple dates where not all the IDG members participated in the meetings as evidenced by the lack of notes and attendance signatures. For example, on 7/5/23, there was no documented evidence of the MD, MSW, and Chaplains notes and signatures during the meeting. Further review of the clinical record showed the IDG did not meet Q 15 days. The last IDG meeting during the certification period was conducted on 8/2/23. There was no documented evidence showing an IDG meeting was held after. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 8's clinical record was initiated on 8/17/23. The clinical record showed the SOC was 7/13/23. The patient was certified for hospice services during the certification period from 7/13/12 to 10/10/23. The POC/IDG Review during the certification period showed there were multiple dates where not all the IDG members participated in the meetings as evidenced by the lack of notes and attendance signatures. For example, on 7/13/23, there was no documented evidence of the MSW and Chaplains notes and signatures during the meeting. On 8/28/23 at 0950 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: The hospice's P&P titled Interdisciplinary Team Meeting dated 12/15/12, showed it is the policy of the HHA to conduct an interdisciplinary care plan development, review, and update for every hospice patient at least every two weeks. The IDT includes hospice RN, case manager, hospice physician, social worker, spiritual counselor, bereavement coordinator, volunteer coordinator, and/or volunteer, RD if indicated, other members of the IDG may attend as necessary, family and caregivers may attend as necessary. A record of attendance is kept on file in the Medical Records Department. On 8/15/22 at 1030 hours, an interview was conducted with the DPCS. She stated the IDG meeting attendance were documented in the patients electronic record during the IDG meeting. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, and 16, showed no documented evidence all IDG members had reviewed/revised the patient's POCs at least every 15 days. For example: 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. a. The POC/IDG dated 6/1, 6/15, 7/3, and 7/21/23, showed no documented evidence all IDG members participated in the IDG meeting as there were no signatures of the MSW, Spiritual Counselor, and Volunteer Coordinator in the clinical record. b. The POC/IDG dated 6/15/23, showed the IDG meeting was conducted. Further review of the clinical record showed the next IDG meeting was held on 7/3/23, which was more than 15 days. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. a. The POC/IDG dated 6/21 and 7/31/23, showed no documented evidence all IDG members participated in the IDG meeting as there were no signatures of the MSW, Spiritual Counselor, and Volunteer Coordinator in the clinical record. The POC/IDG dated 7/17/23, showed no documented evidence all IDG members participated in the IDG meeting as there were no signatures of the RN, MSW, Spiritual Counselor, and Volunteer Coordinator in the clinical record. b. The POC/IDG dated 6/21/23, showed the IDG meeting was conducted. Further review of the clinical record showed the next IDG meeting was held on 7/17/23, which was more than 15 days. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 5's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 10/7/22. The patient was certified for hospice service during the certification period from 6/24/23 to 8/22/23. The POC/IDG Review dated 6/21, 7/5, 7/19, and 7/26/23, showed HA visit 1W. Further review of the clinical record showed no documented evidence of a HA visit from Week 3 (7/2/23 to 7/8/23) to Week 7 (7/30 to 8/5/23). On 8/28/23 at 1000 hours, a concurrent interview and clinical record review was conducted with the DPCS. She stated the patient hit the HA and the family member. She stated the HA refuse to go and the family member stated to take away the HA for a while. She stated the HA visit frequency in the POC should have been updated. She was informed and acknowledged the finding. 3. Review of Patient 6s clinical record was initiated on 8/16/23. The clinical record showed the SOC was 1/13/23. The patient was certified for hospice services during the certification periods from 4/13/23 to 7/11/23 and 7/12/23 to 9/9/23. The POC/IDG Review for the certification period 4/13/23 to 7/11/23, and the POC/IDG Review dated 7/19, and 8/2/23 , showed no documented evidence all IDG members participated in the IDG meeting as there were no signatures of the MSW, Spiritual Counselor, and Volunteer Coordinator in the clinical record. On 8/28/23 at 1035 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 4. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. The physicians order dated 8/5/22, showed an order for Calmoseptine (moisture barrier). However, there was no documented evidence the IDG had updated the POC during the certification period on the specific information related to who and when the Calmoseptine will be applied. On 8/28/23 at 1030 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs for 12 of 16 sampled patients (Patients 1, 2, 4, 5, 7, 8, 11, 12, 13, 14, 15, and 16). This failure created the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. --- XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. The POC/IDG Review for the certification period showed the hospice identified patient care problems related to environment/safety, integumentary, and respiratory system. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. The POC/IDG Review for the certification period showed the hospice identified patient care problems related to cardiovascular, environment/safety, neurological, and pain. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: Review of the clinical records for 1, 2, 4, 5, 7, 8, 11, 12, 13, 14, 15, and 16 was conducted from 8/15/23 to 8/28/23. The clinical records did not include the patients' progress toward the goals as specified in the POCs. For example: #. Review of Patient 5's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 10/7/22. The patient was certified for hospice service during the certification period from 6/24/23 to 8/22/23. 1. Review of Patient 5's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 10/7/22. The patient was certified for hospice service during the certification period from 6/24/23 to 8/22/23. Review of the POC/IDG Review dated 7/26/23 and 8/2/23, showed the hospice identified patient care problems included fall risk, weakness relative to the progression of the disease process, and potential for altered neurological status. The goals were established for these identified problems. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 8/28/23 at 1000 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for one of 16 sampled patients (Patient 6), creating the risk of not addressing the care needs for these patients. --- Findings: The hospices P&P titled Interdisciplinary Team/Interdisciplinary Group dated 7/15/13, showed the responsibilities of the Interdisciplinary Group Team: - The Interdisciplinary Team/ Group establishes the patients plan of care. - Provide supervision and collaboration of care and services to patient and their families. Supervision accomplished by face-to-face conferences, evaluation, discussion, and general oversight, as well as direct supervision - The Interdisciplinary Group (in collaboration with the patients physician, if any) reviews, revises, and documents the individualized plan as frequently, as the patients condition requires, but no less frequently than every 15 calendar. - The Interdisciplinary Group report unusual change on the patients condition to the attending physician, primary caregiver, and other members of the interdisciplinary team/group. - The Interdisciplinary group implements hospices policies. Review of Patient 6s clinical record was initiated on 8/16/23. The clinical record showed the SOC was 1/13/23. The patient was certified for hospice services during the certification periods from 4/13/23 to 7/11/23 and 7/12/23 to 9/9/23. Further review of the clinical record showed the IDG failed to maintain the responsibility of directing and coordinating the care and services provided to Patient 6. For example: a. The IDG failed to develop an individualized POC for the patient. Cross reference to L545, example #7. b. The IDG failed to ensure the all the IDG had participated during the IDG meeting. Cross reference to L552, example #3. c. The IDG failed to ensure a thorough assessment was conducted related to the patients wound. Cross reference to L651, example #2.b. d. The IDG failed to ensure the POC included specific information related to wound treatment. The POC/IDG Review dated 5/24, 6/7, 7/19, 7/26, and 8/2/23, showed RN visits 2W and 1 PRN visit. The physicians order dated 5/25/23, showed using aseptic technique, cleanse coccyx wound with NS, pat dry, pack with iodoform (antiseptic), cover with an island dressing. Documentation showed to cleanse the left shoulder wound with Betadine (antiseptic) then NS, abdominal dressing, and apply Bactroban (topical antibiotic). The physicians order dated 6/20/23, showed using aseptic technique, cleanse coccyx wound with NS, pat dry, pack coccyx wound with gauze, cover with an island dressing. Documentation showed to cleanse the left should wound with Betadine then NS, abdominal dressing, and apply Bactroban (topical antibiotic). * However, there was no documented evidence the POC included the frequency of the wound treatment and who would be responsible during non-SN visit. The POC/IDG Review dated 5/10 and 5/24, and 6/21/23, showed apply Calprotect (moisture barrier) to reddened areas of skin. However, there was no documented evidence on the frequency when Calprotect would be administered. e. The SN note date 8/9/23, showed the patient had reddened open area on the right shoulder. Documentation showed treatment was performed on the left shoulder and coccyx wounds. The SN notes dated 8/11 and 8/15/23, showed the shoulder wounds were cleansed with Betadine (antiseptic) then NS, and applied gauze and abdominal dressing. * However, there was no documented evidence of a physicians order for the treatment of the right shoulder wound. On 8/28/23 at 1035 hours, an interview and concurrent clinical record review was conducted with the DPCS. She 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 three of 16 sampled patients (Patients 2, 7, and 11). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. --- Findings: 1. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. The POC/IDG dated 8/5/23, showed RN visits two visits per week and 1 PRN visit. The SN notes showed the RN conducted one visit on Week 1 (8/5/22 to 8/6/22), instead of two visits per week as per the POC. On 8/28/23 at 1030 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 2. Review of Patient 7's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 6/23/23. The patient was certified for hospice services during the certification period from 6/23/23 to 9/20/23. The POC/IDG Review dated 6/26/23, cited RN visits once per week plus one PRN visit. However, review of the clinical record showed no documented evidence the RN visited the patients home during Week 2 (6/26/23 to 7/1/23). On 8/28/23 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 3. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/23. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. Review of the Skin Impairment Assessment dated 7/6/23, showed the patient had a Stage 2 PI on the left foot. The note showed the wound was measured and the status showed to treat the wound. However, there was no documented evidence the wound was treated. Further review of the clinical record showed no documented evidence of wound treatment orders from the physician. On 8/28/23 at 0940 hours, an interview and concurrent clinical record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator acknowledged the finding and stated the RN might have forgotten to transcribe the verbal order.

This CONDITION is not met as evidenced by: Based on interview and record review, the hospice failed to develop an effective, on-going, hospice-wide date-driven QAPI program as evidenced by: --- Findings: 1. The hospice failed to measure, analyze, and track quality indicators including adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations. Cross reference to L562. 2. The hospice failed to use quality indicator data including adverse events, infection control, or other patient care in its design of the QAPI program. Cross reference to L563. 3. The hospice failed to ensure the QAPI had tracked the adverse patient events from the years of 2019 to 2022. Cross reference to L569. 4. The hospice failed to develop and implement the PI projects from the years of 2019 to 2023. Cross reference to L571. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the QAPI to ensure quality of care provided to the patients.

Based on interview and record review, the hospice failed to measure, analyze, and track quality indicators including adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations for their QAPI program for the years of 2019, 2020, 2021, and 2022. This created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. --- Findings: The hospices P&P QAPI dated 12/15/12, showed the following: - The hospice will measure, analyze, and tract quality indicators including patient adverse events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operation. - The hospice approach to improving its performance includes the following: * Designing processes - The design will be planned systemic and organization wide. Activities will be planned in interdisciplinary collaborative manner. * Monitoring performance through data collection - Data are collected to monitor existing processes. Identify opportunities for improvement. Sustain improvement. * Analyzing current performance - Data are aggregated and analyzed on an ongoing basis. Appropriate statistical techniques are used. Performance is compared over time and with external sources. Undesirable patterns or trends and sentinel events will be evaluated. Information is used to develop action plans to improve performance. * Improving and sustaining improved performance - Action plans will be tested and implemented and if successful. Performance measures will be used to determine if improvements are sustained. Developing performance improvement projects. Based on the needs of the hospice population and internal organizational needs. It will reflect the scope, complexity, and past performances, document the reason for conduction the projects. Achieve measurable outcomes. - The QAPI committee will meet quarterly and will compose of representatives from the following: DPCS, Administrator, Nursing Services, Social Services, Medical Director, and counselor (Spiritual, Bereavement and Registered Dietitian) - The QAPI team monitoring/evaluation activities shall include analysis and review of problems previously identified as well as documentation of progress or lack of progress toward problem resolution; identification of new problem areas and recommendation for problem resolutions; compilation of data from previous months for presentation at quarterly agency meetings; identification of improvements in patient care resulting from QAPI activities; and a written report shall include identifiable patterns or trends of care/services both positive and negative - The quarterly reporting activities showed perception of care and services surveys which may include but not limited to physician, nursing facilities, family, and referral source; infection control; medication errors; care or services provide to high risks patients; incident reports/grievances; and sentinel events. Review of the hospice's QAPI meeting minutes for 2019, 2020, 2021, 2022, and 2023 was conducted on 8/24/23. Review of the QAPI meeting dated 9/16/19, showed the meeting included review of medication process (needs to be stream lined), pharmacy contracts review (hospice looking for pharmacy who will be able to satisfy the need of hospice patients), the ";Hospice MD" system for medication ordering system was new (the pharmacy ordering portal was not in conjunction with the ";Hospice MD" yet, and meeting with the responsible persons who will assist hospice agency to be able to correct better medication ordering and dispensing. Documentation showed the attendees included the Medical Director, MSW, and DPCS. Review of the QAPI meeting dated 9/9/21, showed there was a lock down due to COVID-19 pandemic. Documentation showed PPE were issued to all visiting personnel; good hand washing was reviewed, ";donning of protective gowns if necessary", wearing of both mask and gloves mandatory; every patient and family were called initially to ask if they were tested and vaccinated for the virus; all personnel were mandated for testing and vaccinated for the virus; and most communication done telephonically. There was no documented evidence who attended the meeting. Review of the QAPI meeting dated 7/6/22, showed the hospice care P&P and different referrals from the hospitals and case managers for getting hospice patients were reviewed; ";issues of caregivers for family who are needing it to care for their loved ones"; ";hospice assisted thorough Asian-American Social Foundation as Seniors Caregiving groups;" hospice assisted in giving caregiver hours to aid families and patients for their personal needs; and MSW gave the families information for other government aids. Documentation showed the attendees included the Medical Director, MSW, and DPCS. However, there was no documented evidence of measuring, analyzing, and tracking of quality indicators including adverse events, infection control, and other services provided which would enable the hospice to assess processes of care, hospice services, and operation for the years of 2019, 2020, 2021, and 2022. In addition, there was no documented evidence the QAPI meetings were attended by all QAPI members and conducted quarterly to discuss the hospices QAPI program as per the hospices P&P. On 8/24/23 at 0945 hours, an interview and concurrent hospice document review was conducted with the DPCS. She stated the QAPI meetings were attended by the Medical Director, DPCS, and Administrator/MSW/Bereavement Coordinator. She stated the QAPI meetings were conducted yearly. She stated whatever discussed during the QAPI meetings were all located in the QAPI binder. She stated the hospices first quarter for the year would be from July to September, second quarter was from October to December, third quarter was from January to March, fourth quarter was from April to June. On 8/28/23 at 1115 hours, an interview and concurrent hospice document review was conducted with the DPCS. The DPCS was informed of the finding.

Based on interview and record review, the hospice failed to use quality indicator data including adverse events, infection control, or other patient care in the design the QAPI programs for 2019, 2020, 2021, 2022, and 2023. This created the risk of not including relevant data for performance improvement to improve care and services provided to the patients. --- Findings: Review of the hospice's QAPI meeting minutes for 2019, 2020, 2021, 2022, and 2023 was conducted on 8/24/23. However, there was no documented evidence of quality indicator data, including adverse events, infection control, or other patient care, being monitored for each quarter for 2019, 2020, 2021, and 2022. On 8/28/23 at 1115 hours, an interview and concurrent hospice document review was conducted with the DPCS. The DPCS was informed of the finding.

Based on interview and record review, the hospice failed to ensure the QAPI had tracked the adverse patient events from the years of 2019 to 2022, creating the increased risk of not identifying the area for performance improvement. --- Findings: Review of the hospice's QAPI meeting minutes for 2019, 2020, 2021, 2022, and 2023 was conducted on 8/24/23. However, there was no documented evidence the hospice had tracked the adverse events from the years of 2019 to 2022. On 8/28/23 at 1115 hours, an interview and concurrent hospice document review was conducted with the DPCS. The DPCS was informed of the findings.

Based on interview and record review, the hospice failed to develop and implement the PI projects from the years of 2019 to 2023, creating the risk of not improving the care and services provided to the patients. --- Findings: Review of the hospice's QAPI programs from the years of 2019 to 2023 showed no documented evidence of the PI projects for the years of 2019 to 2023. On 8/24/23 at 0945 hours, an interview and concurrent hospice document review was conducted with the DPCS. She stated there were no PI projects for right now. When asked if there were any PI projects from 2019. The DPCS replied none. On 8/28/23 at 1115 hours, an interview and hospice document review was conducted with the DPCS. The DPCS was informed of the findings.

Based on observation, interview, and record review, the hospice failed to implement infection control practices related to hand hygiene for two of 16 sampled patients (Patients 1 and 2). This failure had the potential to spread the risk of infection. --- Findings: According to CDC, the Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patients immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal 1. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. On 8/16/23 at 1225 hours, a joint home visit was conducted with RN 1 to Patient 1s home. RN 1 informed the patient and PCG that she will be changing the GT dressing. Prior to performing the procedure, RN 1 washed her hands and donned a clean pair of gloves. RN 1 removed the old GT dressing and placed it in the trash. RN 1 then removed her gloves, donned a new pair, and proceeded to clean the GT site. RN 1 did not wash or sanitize her hands after removing the old dressing and before donning a new pair of gloves. On 8/16/23 at 1248 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. On 8/16/23 at 1458 hours, a joint home visit was conducted with HA 1 to Patient 2s home. Upon arriving at the patients home, HA 1 stated she had already finished helping the patient in the shower to clean his body. However, HA 1 mentioned she still needed to shampoo and dry the patients hair. HA 1 was already wearing a pair of gloves as she prepared to wash the patients hair. After washing and rinsing the hair, HA 1 proceeded to comb and dry the patients hair using a hair dryer. HA 1 did not change her gloves and wash her hands after washing and before combing and drying the patients hair. On 8/16/23 at 1535 hours, an interview and concurrent clinical record review was conducted with HA 1. HA 1 was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections that was an integral part of the hospice's QAPI program. These created the risk of spread of infections and not improving the infection control program. --- Findings: Review of the hospice's infection control program showed the hospice had identified infection cases from 1/18/21 to 1/14/22. Cross reference to L581. However, there was no documented evidence the infection data from 1/18/21 to 1/14/22, were presented and integrated into the QAPI program. On 8/28/23 at 1110 hours, an interview and concurrent hospice document review was conducted with the DPCS. She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to maintain a coordinated agency-wide program for the surveillance identification, prevention, control, and investigation of infections that included a method of identifying the infections and a plan for implementing the appropriate actions that were expected to result in improvement and infection prevention. This created the risk of spread of infections. --- Findings: The hospice's P&P titled Infection Control Program dated 12/15/12, showed the following: - Infection control program includes the following elements: identification of infections risks based on the geographic location served by the hospice, community where hospice patient is located, and population served; identification of infection risks based on the care, treatment, or services provided (i.e. patient on urinary catheter, patient with wounds); surveillance activities which includes types of infection; monitoring of identified problems or trends; provision of equipment and supplies to support infection prevention and control activities; P&P on prevention activities; policies to prevent employee transmission of communicable diseases; investigation of infectious and communicable diseases; control mechanisms to follow in case of disease outbreak; reporting of outbreaks as required by law and regulation; reporting to QAPI for monitoring and evaluation; and education. - An Infection Control Surveillance form will be completed by the person that has identified an identification problem. On 8/24/23 at 1000 hours, the DPCS was asked for the infection control program from the years of 2019, 2020, 2021, 2022, and 2023. Review of the infection control data for the years of 2019, 2020, 2021, 2022, and 2023, showed the following information: - An attendance sheet date 8/17/22, showed information related to how to recognize and treat an infected wound was discussed. - An attendance sheet dated 12/16/22, showed information such as Hepatitis A, Infection Preventionists, health care associated infections, cleaning the home environment, how to be a good visitor during flu season, gonorrhea- a sexually transmitted disease with growing resistance, pertussis, Zika virus, Lyme disease, food borne botulism, hand hygiene ad antimicrobial stewardship, the truth about back yard poultry, mumps -vaccine preventable disease, preventing infection in adult day centers, preventing infection in early childhood centers, is it allergies or flu, how to be a good and healthy roommate, diabetes, hepatitis- clean your hands often, meningococcal disease, is strep causing the sore throat, fecal transplants, worlds AIDS day, sepsis, preventing food borne disease, preparing for natural disasters, genital herpes and other sexually transmitted disease, tuberculosis, APIC infection prevention updates were discussed. - An in-service document dated 4/20 showed, ";all employees work at home due to COVID." - An attendance sheet dated 4/25/23, showed information related to infection control and hand hygiene in health care settings. - An attendance sheet dated 6/15/23, showed infection control meeting with the Medical Director and Administrator/MSW/Bereavement Coordinator. Documentation showed allergy and infection-understanding their relations and exposure response in occupational allergy were discussed. - The infection control report showed five infection control cases from 1/18/21 to 1/14/22. On 8/24/23 at 0900 hours, an interview and concurrent hospice document review was conducted with the DPCS. The DPCS was asked about the infection control program. She stated there were only five cases of infection from the years 2019 to 2023. She stated the hospice reviewed the patients who had antibiotics as infection cases. She stated when there was an infection case, the DPCS would gather the information from the SN note or talk to the SN. She stated in three months from when the antibiotic was started, the DPCS would text or call the SN if the infection was resolved or not. She stated she would review the patients clinical record if the patients on the antibiotics had their infection resolved or not for the quarter from the computer. She stated she would discuss with the Medical Director about the infection control cases monthly or quarterly or when the problem arises. Further review of the documents showed no documented evidence the infection control programs included a method of identifying infections (signs and symptoms), summary and analysis of data, and a plan for implementing the appropriate actions that were expected to result in improvement and infection prevention. There was no documented evidence the hospice had investigated to identify the cause of each type of infection to develop appropriate plans to improve and prevent infections for the infection control cases from 1/18/21 to 1/14/22. The Infection Control Surveillance form was not utilized for infection cases identified from 1/18/21 to 1/14/22. In addition, review of Patient 6s clinical record was initiated on 8/16/23. The clinical record showed the SOC was 1/13/23. The physicians order showed the following information: - an order dated 2/16/23, included cephalexin (antibiotic) 400 mg one capsule PO every eight hours for 10 days for wound infection - an order dated 2/23/23, included levofloxacin (antibiotic) 500 mg one tablet daily for seven days for lung infection - an order dated 4/13/23, included Ofloxacin (antibiotic) 0.3% otic solution 10 drops right ear daily for seven days - an order dated 4/26/23, showed included Levaquin (antibiotic) 500 mg one tablet PO QD for five days for respiratory infection - an order dated 5/16/23, included Bactrim DS (antibiotic) 800 -160 mg one tablet PO BID for 10 days for wound infection - an order dated 7/6/23, included cephalexin (antibiotic) 500 mg one capsule PO every eight hours for 10 days for wound infection However, there was no documented evidence Patient 6 was included in the infection control report provided by the DPCS for the year of 2023. There was no documented evidence of the Infection Control Surveillance Report form was utilized. On 8/28/23 at 1110 hours, an interview and concurrent clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to implement the bereavement program as per the hospices P&P to address the needs of the bereaved family members for three of three sampled deceased patients (Patients 11, 12, and 15). This failure created the risk of not addressing the bereavement needs of the bereaved family members of these patients. --- XX. Review of Patient 12s closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 2/3/22. The patient was certified for hospice services during the certification period from 10/1/22 to 11/29/22. The RN Visit Note dated 11/12/22 showed the patient expired and the physician was informed. Review of the Bereavement POC dated 11/12/22 showed a condolence call was made to the bereaved family on 11/12/22. The note showed the hospice will mail the six letters according to the bereavement program. Review of the bereavement log showed the dates when the bereavement mail was to be sent out which included the following dates: 12/12/22, 2/12/23, 4/12/23, 6/12/23, 8/12/23, and 10/12/23. However, there was no documented evidence showing what letters were sent and the dates of when they were sent. In addition, there was no documented evidence showing a post-death bereavement assessment was completed. On 8/28/23 at 1023 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator acknowledged the finding and stated she did not keep a copy of the letters that were sent. XX. Review of Patient 15s closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 2/9/23. The patient was certified for hospice services during the certification period from 2/9/23 to 5/9/23. The RN Visit Note dated 3/7/23 showed the patient expired and the physician was informed. Review of the bereavement log showed the dates when the bereavement mail was to be sent out which included the following dates: 4/7/23, 6/7/23, 8/7/23, 10/723, 12/7/23, and 2/7/24. However, there was no documented evidence showing what letters were sent and the dates of when they were sent. In addition, there was no documented evidence showing the bereavement POC, post-death bereavement assessment, and IDG meeting were completed after the patient expired. On 8/28/23 at 1041 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. The hospices P&P titled Bereavement Program dated 12/15/12, showed the following : - The HHA offers a comprehensive bereavement program to families/significant others for up to one year after the patients death. - Services provided include a series of bereavement letters with accompanying grief literatures and resource information to help family members cope with their loss. The letters are sent to survivors at regular intervals. - The hospice has the primary responsibility to provide bereavement services in coordination with the Bereavement Coordinator. Bereavement assessment shall start prior to the passing of the patient. The patient and family/significant others will be evaluated by the social worker or designee. That assessment along with input from other disciplinary team members will be discussed during the IDT conference. - Upon the patient's death, a condolence call/visit will be made to the family/significant others by the social worker or designee. Bereavement assessment will be made at this time. Additionally, all patient death will be discussed by the hospice IDG and a ";Bereavement Assessment, Intervention, and Plan of Care" form will be completed. If the risk level is deemed moderate to high and an in-depth assessment has not been completed, one will be done as soon as possible. - A sympathy card signed by the hospice team members will be sent to family members within two weeks of patients death. - The bereavement POC shall include the frequency and type of contact, and for what period of time, which specific team members (including volunteers) will follow the bereaved and what, if any, referrals to the community are necessary. The POC will be revised and modified according to the needs of the identified bereaved and changes made accordingly. - An on-going bereavement record will be kept to track all patient deaths and bereavement activity. This record will include the date of death, start of care, medical record number, patient name, name of bereaved, counselor assignment, and date of condolence call/four week follow-up/ closing of case and reason for closure. All professional staff who has been assigned bereavement cases will maintain a tickler file for each deceased patient on order to o provide timely follow up. Assessment forms as well as other documentation regarding bereavement activity will be placed in the patients medical record chart. The P&P titled Bereavement Services dated 12/15/22, showed an initial bereavement assessment of the needs of the patients family and other individuals will be focused on the social, spiritual and cultural factors that may impact their ability to cope with the patients death. Information gathered from the initial assessment will be incorporate into the POC. The information will be considered on the bereavement POC. A bereavement POC is developed which identifies the services to be provided. The bereavement process will begin upon completion of the initial bereavement assessment. On 8/23/23 at 1135 hours, an interview was conducted with the Administrator/MSW/Bereavement Coordinator. She stated when she would see the patient for the first time, she would conduct a bereavement risk assessment. She stated upon patient's death, she will conduct a condolence telephone call to check if the bereaved needed any assistance. She stated the hospice would send bereavement mail one month after the patients death and then every two months for a total of six bereavement mails. She stated there is a log in the bereavement binder that includes the date when the mails were to be sent out. When asked for documentation on what and when the bereavement mails were sent out. She stated the hospice do not have documented evidence on what and when the bereavement mails were sent out. 1. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. The Visit Note Death Visit dated 9/5/22, showed the patient died. The POC/IDG Review dated 9/7/22, showed the family accepted the patients death well. However, there was no documented evidence all IDG participated as there were no signatures of the MSW, Chaplain, and Volunteer Coordinator. Review of the bereavement log showed the dates when the bereavement mails were to be sent out. Documentation showed the dates were 10/5 and 12/5/22, and 2/5/23, 4/5/23, 6/5/23, and 8/5/23. However, there was no documented evidence on what was sent or when the bereavement mails were sent out. In addition, there was no documented evidence of a sympathy card sent within two weeks of patients death as per the hospice's P&P. On 8/28/23 at 1030 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the agency 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 six of 16 sampled patients (Patients 1, 2, 3, 4, 12, and 13), creating the risk of not addressing the care needs for these patients. --- XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. The POC/IDG Review dated 7/5/23, cited HA visits twice per week. Review of the clinical record showed the most current HA Assignment was dated 1/3/22. There was no documented evidence showing the HA Assignment was developed every recertification period. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. The Administrator/MSW/Bereavement Coordinator stated the HA assignments should be developed by the RN every recertification period. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. The POC/IDG Review dated 7/5/23, cited HA visits twice per week. Review of the clinical record showed the most current HA Assignment was dated 3/9/22. There was no documented evidence showing the HA Assignment was developed every recertification period. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 12's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 2/3/22. The patient was certified for hospice services during the certification period from 10/1/22 to 11/29/22. The POC/IDG Review dated 10/5/22, cited HA visits three times per week. Review of the clinical record showed the most current HA Assignment was dated 2/3/22. There was no documented evidence showing the HA Assignment was developed every recertification period. On 8/28/23 at 1023 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 13's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 12/2/21. The patient was certified for hospice services during the certification period from 1/26/23 to 3/26/23. Review of the POC/IDG Review dated 2/1/23, cited HA visits twice per week. Review of the clinical record showed the most current HA Assignment was dated 1/10/22. There was no documented evidence showing the HA Assignment was developed every recertification period. On 8/28/23 at 1031 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 1. Review of Patient 3's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/1/22. The patient was certified for hospice service during the certification periods from 5/28/23 to 7/26/23 and 7/27/23 to 9/24/23. Review of the clinical record showed HA visits during the certification period from 5/28/23 to 7/26/23. Review of the POC/IDG Review dated 6/1, 6/15, 7/3, and 7/21/23, cited ";HA: per week". Review of the HA Assignments dated 12/29/22 and 7/21/23, showed the RN developed the HA written patient care instructions. However, there was no documented evidence of a written patient care instructions for the HA to follow at the beginning of the certification period from 5/28/23 to 7/26/23. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. She stated the written instructions for the HA should be done every certification period. 2. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. Review of the clinical record showed HA visits during the certification period from 6/29/23 to 8/27/23. Review of the POC/IDG Review dated 6/21, 7/17, and 7/31/23, cited HA visits 2W. Review of the HA Assignment dated 4/28/23 and 8/3/22, showed the RN developed the HA written patient care instructions. However, there was no documented evidence of a written patient care instructions for the HA to follow at the beginning of the certification period from the certification period from 6/29/23 to 8/27/23. On 8/28/23 at 0931 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. She stated the written instructions for the HA should be done every certification period.

Based on interview and record review, the hospice failed to ensure the HAs provided services in accordance with the POC for six of 16 sampled patients (Patients 1, 2, 10, 11, 13, and 15). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. --- XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. The POC/IDG Review dated 7/5/23, cited HA visits twice per week. Review of the HA Assignment dated 1/3/22, showed to record the patients last bowel movement. Review of the HA Visit Notes throughout the certification period showed the HA did not document the patients last bowel movement. For example, on 6/27/23 and 6/30/23, there were no documented evidence showing when the patient last had a bowel movement. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. The POC/IDG Review dated 7/5/23, cited HA visits twice per week. Review of the HA Assignment dated 3/9/22, showed to record the patients last bowel movement. Review of the HA Visit Notes during the certification period showed there were multiple dates where the HA did not document the patients last bowel movement. For example, on 7/8/23 and 7/10/23, there were no documented evidence showing when the patient last had a bowel movement. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 10's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 8/9/22. The patient was certified for hospice services during the certification period from 8/9/23 to 11/6/23. The POC/IDG Review dated 7/9/23, cited HA visits three times per week. Review of the HA Assignment dated 8/9/23, showed to record the patients last bowel movement and check the vital signs every visit. Review of the HA Visit Notes during the certification period showed there were multiple dates where the HA did not document the patients last bowel movement and check the vitals signs. For example, on 8/10/23 and 8/11/23, there were no documented evidence showing the patients last bowel movements and vital signs. In addition, there was no documented evidence showing the HA visited the patients home three times per week as cited in the POC for Week 1 (8/9/23 to 8/12/23) and Week 2 (8/13/23 to 8/19/23). The HA only visited on 8/10, 8/11, 8/14, and 8/15/23. On 8/28/23 at 1017 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 13's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 12/2/21. The patient was certified for hospice services during the certification period from 1/26/23 to 3/26/23. The POC/IDG Review dated 2/1/23, cited HA visits twice per week. Review of the HA Assignment dated 1/10/22, showed to record the patients last bowel movement and check the vital signs every visit. Review of the HA Visit Notes during the certification period showed there were multiple dates where the HA did not document the patients last bowel movement and check the patients complete vital signs. For example, on 2/6/23 and 2/8/23, there were no documented evidence showing the patients last bowel movements and temperatures. On 8/28/23 at 1031 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 15's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 2/9/23. The patient was certified for hospice services during the certification period from 2/9/23 to 5/9/23. The POC/IDG Review dated 2/9/23, cited HA visits once per week. Review of the HA Assignment dated 2/9/23, showed to record the patients last bowel movement and check the vital signs every visit. Review of the HA Visit Notes during the certification period showed there were multiple dates where the HA did not document the patients last bowel movement and check the patients vital signs. For example, on 2/21/23 and 2/28/23, there were no documented evidence showing the patients last bowel movements and vital signs. In addition, there was no documented evidence showing the HA visited the patients home once per week as cited in the POC for Week 1 (2/9/23 to 2/11/23) and Week 2 (2/12/23 to 2/18/23). On 8/28/23 at 1041 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. #. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. The POC/IDG dated 8/5/23, showed HA visits 2W. However, there was no documented evidence the HA conducted HA visit on Week 1 (8/5/23 to 8/6/23) and Week 2 (8/7/23 to 8/13/23), instead of two visits per week. On 8/28/23 at 1030 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the RNs provided supervision to assess the quality of care and services provided by the HAs for five of 16 sampled patients (Patients 1, 2, 11, 13, and 15). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- Review of the hospices P&P titled Hospice Aide Services dated 12/15/12 showed all Hospice Aide services will be given in accordance with the plan of treatment and will be supervised by a Registered Nurse. The RN Supervisor will make assignments based on the plan of care; provide hospice aide with written instructions; and will visit the home site/nursing facility at a minimum of every 14 days when Hospice Aide services are being provided in order to assess/supervise that the services are being given accordance with the plan of care. XX. Review of Patient 1's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 11/5/21. The patient was certified for hospice services during the certification period from 6/28/23 to 8/26/23. Review of the clinical record for Patient 1 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example X. The RN Visit Note dated 7/6/23, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 8/28/23 at 0916 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. Review of the clinical record for Patient 2 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example X. The RN Visit Note dated 7/12/23, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 8/28/23 at 0940 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 13's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 12/2/21. The patient was certified for hospice services during the certification period from 1/26/23 to 3/26/23. Review of the clinical record for Patient 13 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example X. The RN Visit Note dated 2/9/23, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 8/28/23 at 1031 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 15's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 2/9/23. The patient was certified for hospice services during the certification period from 2/9/23 to 5/9/23. Review of the clinical record for Patient 15 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example X. The RN Visit Note dated 3/1/23, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 8/28/23 at 1041 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 1. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. Review of the clinical record for Patient 11 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626. For example The SN note dated 8/15/22, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 8/28/23 at 1030 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

This CONDITION is not met as evidenced by: Based on record review and interview, the hospice failed to ensure the volunteer services were provided to meet the patients' care needs as evidenced by: --- Findings: 1. The hospice failed to maintain, document, and provide the training to the volunteer. Cross reference to L643. 2. The hospice failed to ensure the volunteers were utilized in the administrative and/or direct patient care roles. Cross reference to L644. 3. The hospice failed to document and demonstrate viable and ongoing efforts to recruit volunteers for the years 2019, 2020, 2021, 2022, and 2023. Cross reference to L645. 4. The hospice failed to document the estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. Cross reference to L646. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with volunteer services to ensure the provision of quality healthcare provided to meet the patients' needs.

Based on interview and record review, the hospice failed to maintain, document, and provide the training to the volunteers, creating the increased risk of having inadequate knowledge of hospice program to meet the patients' needs. --- Findings: The hospices P&P titled Volunteer Recruitment, Orientation, Training and Retention dated 12/15/12 showed the volunteer orientation and training program follows the National Hospice and Palliative Care Organization and includes but is not limited to the following areas: an introduction to hospice (history, philosophy, and structure of the hospice concept), the volunteer roles and responsibility in hospice care, volunteer program policies, communication skills, care and comfort measures, diseases and medical condition, psychosocial and spiritual issues related to death and dying, the concept of the hospice family, stress management, bereavement, infection control, safety, confidentiality, and patients rights. Additional training is provided for volunteers working in specialized programs. The skills and competence of all volunteers providing direct patient care, and as necessary, provide in-service training and education programs were required. A written description of the in-service training provided during the previous 12 months must be maintained. The hospices P&P titled Volunteer Services dated 12/15/12 showed the hospice will provide volunteer services according to the standards defined in the Medicare Conditions of Participation Section 418.78-Volunteers. The hospice must provide appropriate orientation and training that is consistent with acceptable standards of hospice practice. * Review of Volunteer 1's personnel file showed the volunteer's start date was 7/23/13. The file showed the volunteer had an orientation and training on 7/24/13. Further review of the volunteer file showed no documented evidence of the volunteer training since 2013. On 8/24/23 at 1000 hours, the DPCS stated the Volunteer Coordinator started as a volunteer in 2016 and became a Volunteer Coordinator in 2017. She stated the Volunteer Coordinator would perform as a volunteer too. She stated the Volunteer Coordinator would not get paid when doing volunteer work. * Review of the Volunteer Coordinators file showed a volunteer training was conducted in 2015. Further review of the personnel file of the Volunteer Coordinator showed no documented evidence of a volunteer training since 2015. On 8/28/23 at 1108 hours, the DPCS was informed and acknowledged the findings. The DPCS stated the hospice had only Volunteer 1 and the Volunteer Coordinator as volunteers since 2019.

Based on record review and interview, the hospice failed to ensure the volunteers were utilized in the administrative and/or direct patient care roles for 15 of 16 sampled patients, creating the risk of not addressing the care needs of the patients. --- Findings: Review of 15 sampled patients clinical records (Patient 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, and 16), showed no documented evidence the patients were assessed for ongoing volunteer needs. Cross reference L533. Review of the hospices documents for the year of 2019 showed no documented evidence the hospice had utilized the volunteer for administrative and/or direct patient care role. On 8/28/23 at 1108 hours, the DPCS was informed and acknowledged the findings. The DPCS stated the hospice had only Volunteer 1 and the Volunteer Coordinator as volunteers since 2019. The DPCS stated there was no volunteer activity for Volunteer 1 after the pandemic and Volunteer 1 was utilized before the pandemic one time to drive the DPCS.

Based on record review and interview, the hospice failed to document and demonstrate viable and ongoing efforts to recruit the volunteers for the years of 2019, 2020, 2021, 2022, and 2023, creating the increased risk of not having adequate number of the volunteers to meet the patients' needs. --- Findings: Review the hospice's Volunteer programs for 2019, 2020, 2021, 2022, and 2023 was conducted on 6/23/23. The hospice's documents for 2019, 2020, 2021, and 2022 showed no recruitment activity records for these years. On 8/22/23 at 1526 hours, the Volunteer Coordinator was asked for the documents related to volunteer recruitment activity. The Volunteer Coordinator was asked on how the hospice would recruit volunteers. He stated he would go to senior special event. He stated he would also conduct marketing and give fliers. When asked for documented evidence of the recruitment activities, he stated there was no documentation of recruitment activities. On 8/28/23 at 1108 hours, the DPCS was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to document the estimate of the dollar costs that the hospice would have incurred if the paid employees occupied the positions. This had the potential to not being able to evaluate the use of volunteers. --- Findings: Review of the hospices volunteer program for 2019, 2020, 2021, 2022, and 2023 was conducted on 8/23/23. Review of the Hospice Volunteer/Patient Related Progress Notes dated 2/2/22, showed a home visit was conducted by the Volunteer Coordinator. Documentation showed services rendered including active listening and helped the patient choose the ramp for the wheelchair at the patients house. On 8/24/23 at 1000 hours, the DPCS stated the Volunteer Coordinator was a volunteer in 2016 and became a volunteer Coordinator in 2017. She stated the Volunteer Coordinator would perform as a volunteer too. She stated the Volunteer Coordinator would not get paid when doing volunteer work. There was no documented evidence of the cost savings achieved using a volunteer. On 8/28/23 at 1108 hours, the DPCS was informed and acknowledged the findings.

This CONDITION is not met as evidenced by: Based on record review and interview, the hospice failed to ensure the COP regarding Organization and Administration of Services was met. --- Findings: The P&P titled Governing Body dated 12/15/23 showed the Governing Body assumes full legal responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous QAPI. The Governing Body is responsible for ensuring the following: that an ongoing program for quality improvement and patient safety is defines, implemented and maintained, and is evaluated annually; that the hospice wide QAPI efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; that one or more individual who are responsible for operating the QAPI are designated; and that resources required for performance improvement and change management including sufficient staff , access to information and training are provided. The GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with all COPs. Cross reference to L651. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Organization and Administration of Services.

Based on interview and record review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:58 (Quality Assessment & Performance Improvement); 418.78 (Volunteers); and 418.100 (Organization and Administration of Services). In addition, the hospice's Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all the care provided as follows: - The Administrator failed to ensure the written agreement for one of three contractors (Contractor 1) included the required elements related to supervision and evaluation of services in the contract as per Title 22. - The Administrator failed to ensure the performance evaluations were completed for seven of seven employee files reviewed (Administrator/MSW/Bereavement Coordinator, DPCS, Chaplain, Volunteer Coordinator, HA 1, LVN 1, and RN 1). - The Administrator failed to ensure the job descriptions were included as part of the employee files for three of seven employee files reviewed (Volunteer Coordinator, HA 1, and LVN 1). - The Administrator failed to ensure the hospice P&Ps were implemented related to wound care for two of 16 sampled patients (Patients 4 and 6). These failures had the potential to negatively impact the hospice's operational performance. --- Review of the hospices P&P titled Appointment and Designation of Administrator dated 10/1/2012 showed the Administrator has the overall responsibility for day-to-day operation of the hospice and complies with the overall rules and regulations of a hospice program. 1. According to the Hospice Standards Article 6, Section 6.2 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 the rights and responsibilities of the program or individual providing services and of the contracting organization in the implementation, coordination, supervision, and evaluation of the care of services. Review of the written agreement between the hospice and Contractor 1 providing laboratory services was initiated on 8/23/23. The written agreement with Contractor 1 did not include a statement showing the rights and responsibilities related to the supervision and evaluation of the care services. On 8/28/23 at 1102 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 2a. Review of the hospices P&P titled Performance Evaluations dated 12/14/2012 showed staff will receive a performance evaluation in 90 days and annually thereafter. Review of the employee file for the Administrator/MSW/Bereavement Coordinator was initiated on 8/23/23. The Administrator/MSW/Bereavement Coordinator was hired on 2/15/13. Review of the employee file showed no documented evidence the annual performance evaluations were completed from 2019 to 2023. b. Review of the employee file for the DPCS was initiated on 8/23/23. The DPCS was hired on 7/27/16. Review of the employee file showed no documented evidence the annual performance evaluations were completed from 2019 to 2023. c. Review of the employee file for RN 1 was initiated on 8/23/23. RN 1 was hired on 5/27/14. Review of the employee file showed no documented evidence the annual performance evaluations were completed from 2019 to 2023. d. Review of the employee file for LVN 1 was initiated on 8/23/23. LVN 1 was hired on 3/7/21. Review of the employee file showed no documented evidence the annual performance evaluations were completed from 2022 to 2023. e. Review of the employee file for HA 1 was initiated on 8/23/23. HA 1 was hired on 1/6/22. Review of the employee file showed no documented evidence the annual performance evaluation was completed for 2023. f. Review of the employee file for the Volunteer Coordinator was initiated on 8/23/23. The Volunteer Coordinator was hired on 3/1/17. Review of the employee file showed no documented evidence the annual performance evaluations were completed from 2019 to 2023. g. Review of the employee file for the Chaplain was initiated on 8/23/23. The Volunteer Coordinator was hired on 8/4/16. Review of the employee file showed no documented evidence the annual performance evaluations were completed from 2019 to 2023. 3a. Review of the hospices P&P titled Contents of Personnel Files dated 12/15/2012 showed each personnel file shall contain a job description signed by the employee. Review of the employee file for LVN 1 was initiated on 8/23/23. LVN 1 was hired on 3/7/21. Review of the employee file showed no documented evidence of the signed job description for LVN 1. b. Review of the employee file for HA 1 was initiated on 8/23/23. HA 1 was hired on 1/6/22. Review of the employee file showed no documented evidence of the signed job description for HA 1. c. Review of the employee file for the Volunteer Coordinator was initiated on 8/23/23. The Volunteer Coordinator was hired on 3/1/17. Review of the employee file showed no documented evidence of the signed job description for the Volunteer Coordinator. On 8/28/23 at 1120 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. Findings: The P&P titled Governing Body dated 1215/13, showed the Governing Body will select and appoint a qualified Administrator who has overall responsibility for day to day operations, complying with applicable rules and regulations, and reporting to the Governing Body. 1. The hospice failed to ensure the COPs under 418.54 (Initial & Comprehensive Assessment of Patient); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418.58 (Quality Assessment & Performance Improvement); 418.78 (Volunteers) and 418.100 (Organization and Administration of Services) were met. Cross references to L520, L530, L559, L641, and L648. #. The hospices P&P titled Wound Care dated 12/15/12, showed it is the policy of the hospice to provide pressure injury and wound care in a manner commensurate with standards of practice. When a wound is initially identified, the IDG will be consulted and physician orders for treatment obtained. Initial documentation will include location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue, and any discomfort to the patient. a. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. The SN note dated 7/13/23, showed the patient had blisters on the right foot. Documentation showed the blisters were cleansed with soap and water, pat dry, and left open to air. Documentation showed the physician was notified. However, there was no documented evidence of the measurement /size of the right foot blisters as per the hospice's P&P. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. b. Review of Patient 6s clinical record was initiated on 8/16/23. The clinical record showed the SOC was 1/13/23. The patient was certified for hospice services during the certification periods from 4/13/23 to 7/11/23 and 7/12/23 to 9/9/23. The SN note dated 5/3/23, showed the patient had several reddened areas on bony pressure points. Documentation showed Calprotect (moisture barrier) were applied to the reddened areas. Documentation showed treatment were performed to coccyx and left shoulder wound. The Skin Impairment Assessment dated 5/3/23, showed the coccyx trauma wound had a measurement of 2 cm (length) x 2 cm (width) x 0.5 cm (depth) and the left shoulder Stage 2 pressure injury had a wound measurement of 7 cm x 6 cm x 0.2 cm. * However, there was no documented evidence of the location of the several reddened areas on bony pressure points, the measurements, and if the reddened areas on bony pressure points were blanchable or not. The SN note dated 5/25/23, showed the patient had reddened areas of coccyx. Documentation showed Calprotect applied to reddened areas of the skin. Documentation also showed treatment were performed to coccyx and left shoulder wound. The Skin Impairment Assessment dated 5/25/23, showed the coccyx trauma wound had a measurement of 2 cm (length) x 2 cm (width) x 0.3 cm (depth) and the left shoulder Stage 2 pressure injury had a wound measurement of 6.5 cm x 6.5 cm x 0.2 cm. * However, there was no documented evidence of the measurement of the reddened areas of the coccyx and if the reddened areas were blanchable or not. The SN note date 8/9/23, showed the patient had reddened open area on the right shoulder. Documentation showed treatment was performed on the left shoulder and coccyx wound. The Skin Impairment Assessment dated 8/9/23, showed the right shoulder pressure injury had a measurement of 6 cm x 4 cm x 0.1 cm. * However, there was no documented evidence on what the stage of the pressure injury was. On 8/28/23 at 1035 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the employees skills competencies were completed annually for seven of seven employee files reviewed (Administrator/MSW/Bereavement Coordinator, DPCS, Chaplain, Volunteer Coordinator, HA 1, LVN 1, and RN 1). These failures had the potential to negatively impact the hospice's operational performance. --- Findings: 1.a. Review of the employee file for the Administrator/MSW/Bereavement Coordinator was initiated on 8/23/23. The Administrator/MSW/Bereavement Coordinator was hired on 2/15/13. Review of the employee file showed no documented evidence the annual skills competencies were completed from 2019 to 2023. b. Review of the employee file for the DPCS was initiated on 8/23/23. The DPCS was hired on 7/27/16. Review of the employee file showed no documented evidence the annual skills competencies were completed from 2019 to 2023. c. Review of the employee file for RN 1 was initiated on 8/23/23. RN 1 was hired on 5/27/14. Review of the employee file showed no documented evidence the annual skills competencies were completed from 2019 to 2023. d. Review of the employee file for LVN 1 was initiated on 8/23/23. LVN 1 was hired on 3/7/21. Review of the employee file showed no documented evidence the annual skills competencies were completed from 2022 to 2023. e. Review of the employee file for HA 1 was initiated on 8/23/23. HA 1 was hired on 1/6/22. Review of the employee file showed no documented evidence the annual skills competencies were completed from 2022 to 2023. f. Review of the employee file for the Volunteer Coordinator was initiated on 8/23/23. The Volunteer Coordinator was hired on 3/1/17. Review of the employee file showed no documented evidence the annual skills competencies were completed from 2019 to 2023. g. Review of the employee file for the Chaplain was initiated on 8/23/23. The Volunteer Coordinator was hired on 8/4/16. Review of the employee file showed no documented evidence the annual skills competencies were completed from 2019 to 2023. On 8/28/23 at 1120 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator acknowledged the findings and stated the skills competencies should be completed annually.

Based on interview and record review, the hospice failed to ensure the patients' clinical records were complete and accurate for seven of 16 sampled patients (Patients 2, 4, 6, 7, 11, 13, and 16). This failure created the risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete and inaccurate documentation. --- XX. Review of Patient 2's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 3/9/22. The patient was certified for hospice services during the certification period from 7/2/23 to 8/30/23. The POC/IDG Review dated 7/5/23, cited RN visits once per week plus one PRN visit. Review of the RN Visit Note dated 7/12/23, showed the RN visited the patients home. However, the form showed no documented evidence of the patients vital signs. On 8/28/23 at 0940 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 7's clinical record was initiated on 8/15/23. The clinical record showed the SOC was 6/23/23. The patient was certified for hospice services during the certification period from 6/23/23 to 9/20/23. The POC/IDG Review dated 6/26/23, cited RN visit once per week plus one PRN visit. Review of the RN Visit Notes showed there were multiple dates where the RN did not document the patients last bowel movements. For example, review of the RN Visit Note dated 7/8/23, showed the RN visited the patients home. However, the form showed no documented evidence of the patients last bowel movement. On 8/28/23 at 1000 hours, an interview and concurrent record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 13's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 12/2/21. The patient was certified for hospice services during the certification period from 1/26/23 to 3/26/23. The POC/IDG Review dated 2/15/23, cited RN visits twice per week plus one PRN visit. Review of the RN Visit Note dated 2/25/23, showed the RN visited the patients home. However, the form showed no documented evidence of the patients vital signs. On 8/28/23 at 1031 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 16's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 1/26/23. The patient was certified for hospice services during the certification period from 1/26/23 to 4/25/23. The POC/IDG Review dated 2/1/23, cited RN visits twice per week plus one PRN visit. Review of the RN Visit Notes showed there were multiple dates where the RN did not document the patients vital signs. For example, review of the RN Visit Note dated 2/3/23, showed the RN visited the patients home. However, the form showed no documented evidence of the patients vital signs. On 8/28/23 at 1053 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. 1. Review of Patient 4's clinical record was initiated on 8/16/23. The clinical record showed the SOC was 8/3/22. The patient was certified for hospice service during the certification period from 6/29/23 to 8/27/23. The SN note dated 7/13/23, showed the patients BP was 132/75 mm Hg. Documentation showed the vital signs were normal. The SN note dated 7/15/23, showed the patients BP was 128/75. On the narrative section of the note showed the BP was elevated today (7/15/23). Documentation showed the physician was notified. On 8/28/23 at 0935 hours, a concurrent interview and clinical record review was conducted with the DPCS. The DPCS was asked on what was the patients elevated BP on 7/15/23. She stated the BP documented on 7/15/23 was when the BP went down already and not when the BP was elevated. She was informed and acknowledged the finding. 2. Review of Patient 11's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 8/5/22. The patient was certified for hospice service during the certification period from 8/5/22 to 11/2/22. The Skin Impairment Assessment dated 8/18 and 8/24/22, showed the patient had Stage 2 coccyx pressure injury. Documentation showed the color was pink, no drainage and no odor. Documentation showed the wound size was 3 cm (length) x 2 cm (width) x 0.1 cm (depth.) The SN note dated 8/24/22, showed the patient had coccyx pressure wound. Documentation showed the wound had worsened. However, there was no documented evidence on the information/explanation of why the wound had worsened as the Skin Impairment Assessment dated 8/18 and 8/24/22, had the same information. On 8/28/23 at 1030 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. 3. Review of Patient 6s clinical record was initiated on 8/16/23. The clinical record showed the SOC was 1/13/23. The patient was certified for hospice services during the certification periods from 4/13/23 to 7/11/23 and 7/12/23 to 9/9/23. The SN notes dated 4/20, 4/25, 4/28, 5/2, 5/3, 5/10, 5/12, 5/15/5/16, 5/18, 5/30, and 6/1/23, showed no documented evidence the patients last BM was completed. On 8/28/23 at 1035 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the discharge summaries were complete for three of three sampled discharged patients (Patients 13, 14, and 16). This created the risk of not identifying the patients needs to ensure continuity of care after being discharged from the hospice services. --- #. Review of Patient 14's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 6/3/22. The patient was certified for hospice services during the certification periods from 11/30/22 to 1/28/23 and 1/29/23 to 3/29/23. The Discharge Summary dated 2/10/23, showed the reason for discharge was the due to declined of further services. Documentation showed the patients left hip and knee pain were better. However, the discharge summary was incomplete as there was no documented evidence of the summary of the patient's pain management. On 8/28/23 at 1017 hours, a concurrent interview and clinical record review was conducted with the DPCS. She was informed and acknowledged the finding. Review of the hospices P&P titled Discharge from Hospice dated 12/15/12 showed appropriate patient information will be provided when the patient is referred, transferred, or discharged. The information will include the patients physical and psychosocial status including specific medical, psychosocial, or other problems requiring intervention or follow-through; extent to which treatment goals were obtained; summary of care or services provided and progress towards goals; copy of the medication profile including discontinued medications, provided to both the next provider of care and to the patient; and continuing symptom management needs. XX. Review of Patient 13's closed clinical record was initiated on 8/21/23. The clinical record showed the SOC was 12/2/21. The patient was certified for hospice services during the certification period from 1/26/23 to 3/26/23. The patient was discharged on 3/31/23. Review of the clinical record showed a discharge summary was completed on 3/31/23. However, it was incomplete and did not include information on the patients summary of care and services including the patients status upon discharge, current plan of care, and treatment. On 8/28/23 at 1031 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding. XX. Review of Patient 16's closed clinical record was initiated on 8/22/23. The clinical record showed the SOC was 1/26/23. The patient was certified for hospice services during the certification period from 1/26/23 to 4/25/23. The patient was discharged on 4/23/23. Review of the clinical record showed a discharge summary was completed on 4/23/23. However, it was incomplete and did not include information on the patients summary of care and services including the patients status upon discharge, current plan of care, and treatment. On 8/28/23 at 1053 hours, an interview and concurrent closed record review was conducted with the Administrator/MSW/Bereavement Coordinator. The Administrator/MSW/Bereavement Coordinator was informed and acknowledged the finding.