Every finding on record at Artemis Healthcare Services LLC

Observed in Emergency Management Session. During the EM/EOC session, the surveyor noted that the organization did not conduct an exercise every year to test emergency operations and procedures, with a drill or an actual event critique.. The last drill was an actual snowstorm that occurred on 2/12/21. This was validated in a discussion with and observation by the Director of Compliance.

Observed in Tracer Visit. In 2 of 2 home visits conducted, During HV 1 and HV 3, the surveyor noted that the nurses did not do medication reconciliation during their visit. Organization policy GH49.1 sttes that medication reconciliation is performed weekly and both patients had a frequency of one visit per week. This was validated in a discussion with and observation by the Director of Clinical Services.

Observed in Document Review. In 2 of 2 patients with foleys, During RR 1, the surveyor noted that the plan of care did not include the size of the foley catheter In RR 3 there was no order for the frequency of the catheter to be changed. This was validated in a discussion with and observation by the Director of Clinical Operations.

Observed in Individual Tracer. In 3 of 5 home visits conducted, During the HV 2, the surveyor noted that the aide did not change her gloves after cleaning the peri area during the shower. In HV 4, the aide cleaned the peri area and then finished the legs and right arm with the same washcloth. The RN who did a revisit with patient 4 assessed the feet and then took her equipment to take vital signs without changing her gloves. This was validated in a discussion with and observation by the Director of Clinical Services.

Observed in Data Session. During the Data session, the surveyor noted that the organization did not have a process to collect surveillance of hand hygiene data to prove improvement. This was validated in a discussion with and observation by the Director of Clinical Services and the Director of Compliance.

Observed in Infection Control Tracer. During the IC session, the surveyor noted that the organization had not provided education to staff regarding flu vaccinations. This was validated in a discussion with and observation by the Director of Clinical Services and the Director of Compliance.

Observed in Document Review. :During the document review and IC and data sessions, the surveyor noted that there was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.60 as there were issues with infection control activities and education. This was discussed with Leadership at the exit.

Observed in HR File Review. In 2 of 2 medical doctor's, During HR file review, session the surveyor noted that initial clinical competencies had not been conducted by another MD on the Medical Director or the Alternate. This was validated in a discussion with and observation by the Director of Compliance. Observed in HR File Review. In 9 of 9 HR files reviewed, During HR file review, session the surveyor noted that initial clinical competencies had not been conducted and documented. This was validated in a discussion with and observation by the Director of Compliance.

Observed in Record Review. In 2 of 2 live dischrges, During the review of live discharges, the surveyor noted that there were no completed discharge summaries that was sent to the next level of care. This was validated in a discussion with and observation by the Director of Clinical Operations.

Observed in Individual Tracer. In 4 of 4 home visits conducted, During the home visits and document review,, the surveyor noted that the organization did not have a process in place to provide an individualized plan of care in emergencies that would include the equipment needed by the patient and the level of ADLs. This was validated in a discussion with and observation by the Director of Compliance and the Director of Clinical Operations.

Based on interview and record review, the hospice failed to include measurable outcomes anticipated from implementing and coordinating the plan of care. Specifically, the agency failed to ensure patient's plans of care had goals and interventions for all disciplines caring for the patient for 5 of 8 patients receiving care (Patients #2, #4, #5, #7 and #8). --- Findings include: HOSPICE POLICY According to a hospice policy revised on 3/10/21, titled, Plan of Care, (read in pertinent parts): "Based on the assessment, the IDT [interdisciplinary team] must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments." 1. The clinical record for Patient #7 was reviewed on 6/12/23. The patient was admitted for hospice care and services on 11/17/22 with a terminal diagnosis of malignant neoplasm of right main bronchus at another agency and transferred to Agape Hospice on 12/21/22. Patient #7 revoked his hospice benefit and was transferred to an acute care hospital on 4/8/23. The plan of care for the certification periods dated 12/21/22 to 2/19/23 and 2/20/23 through 4/8/23 included orders for: skilled nurse (SN) services one time a week for one week effective 12/22/22, three as needed (PRN) visits effective 12/21/22; two times per week effective 1/9/23 with three PRN visits effective 1/14/23, five PRN visits effective 3/16/23 and four PRN visits effective 4/5/23 and 4/8/23; spiritual counseling visits one visit every four weeks with 3 PRN visits effective 1/6/23 and seven PRN visits effective 3/13/23; social worker (SW) visits one time every four weeks with three PRN visits effective 12/29/22, one time a week every two weeks with three PRN visits effective 2/23/23, and one time a week every four weeks effective 3/20/23; and hospice aide visits one time a week for one week effective 12/22/22, three times a week effective 12/24/22, and five times a week effective 4/3/23. a) The hospice failed to ensure the plan of care for Patient #7 included goals and interventions for the spiritual counselor. Review of spiritual counselor notes for Patient #7 from 12/26/22 to 3/30/23 showed Patient #7 received six spiritual counselor visits, five completed by Spiritual Counselor #16 and one by Spiritual Counselor #17. During Spiritual Counselor #16's visits she identified the following problems for Patient #7 - on 12/26/22, Patient #7 was identified to be anxious, restless, agitated, frustrated with his lack of independence, and lonely; -on 1/10/23 Patient #7 was identified to not be coping effectively and lonely; -on 1/24/23 Patient #7 was identified to be agitated and anxious and a meditative practice was completed; -on 2/23/23 Patient #7 was identified to be oriented to place and requested to cancel his spiritual counselor visit which Spiritual Counselor #16 honored; and -on 3/30/23 Patient #7 was identified to be anxious, confused, and paranoid. Spiritual Counselor #17 on 3/6/23 identified by Patient #7 to be depressed, peaceful, angry, and agitated. Review of Patient #7's combined discipline plans of care dated 12/29/22, 1/12/23, 1/25/23, 2/8/23, 2/22/23, 3/2/23, 3/9/23, and 4/6/23 failed to show any spiritual goals or interventions were documented. On 6/14/23 at 10:29 a.m., Spiritual Counselor #17 confirmed he had provided Patient #7 one on-call visit. Spiritual Counselor #17 reviewed Patient #7's plans of care and confirmed Patient #7's plans of care failed to have documented goals and interventions for problems identified by the spiritual counselors. Spiritual Counselor #17 stated he had worked for the hospice for approximately four months and found the hospice's electronic medical record (EMR) system a challenge to use at times. b) The hospice failed ensure the plan of care for Patient #7 included goals and interventions for the hospice aide. Review of the clinical record revealed on 12/22/22, SN #14 created a hospice aide care plan which stated Patient #7 required assistance with ambulation and showering. Hospice aides were directed to assist Patient #7 with the following tasks: pericare, toileting, oral care, hair care, skin care, tidy patient area, tidy bathroom and provide companionship every visit and showering, shaving, and shampooing two times a week. Review of hospice aide notes for Patient #7 from 12/26/22 to 4/7/23 revealed Patient #7 received 44 visits and Patient #7 received assistance with care planned tasks as well as linen changes and dish washing. Review of Patient #7's combined discipline plans of care dated 12/29/22, 1/12/23, 1/25/23, 2/8/23, 2/22/23, 3/2/23, 3/9/23, and 4/6/23 failed to show any hospice aide goals or interventions were documented. During an interview on 6/14/23 at 12:20 p.m., SN #14 confirmed she was Patient #7's RN case manager (RNCM) and responsible for creating the hospice aide care plan and supervising the hospice aides who provided care to Patient #7. SN #14 stated she was responsible for documenting the hospice aide was providing care to the patient and for communicating with the IDT that a patient was receiving hospice aide services, but she was not sure how goals and interventions were added to the combined disciplinary plan of care. 2. The clinical record for Patient #2 was reviewed on 6/12/23. Patient #2 was admitted for hospice care and services on 3/6/23 with a terminal diagnosis of cerebral atherosclerosis and passed away on 4/15/23. The plan of care for the certification period dated 3/6/23 through 6/3/23 included orders for: SN services two times a week effective 3/7/23, seven visits a week effective 4/8/23, two visits a week effective 4/11/23, five visits a week effective 4/16/23 and 10 PRN visits effective 3/6/23; spiritual counseling one visit every four weeks and seven PRN visits effective 3/10/23; SW services one visit a week every four weeks effective 3/13/23 and three PRN visits effective 3/6/23; and hospice aide services one visit per week effective 3/7/23 and two visits per week effective 3/11/23. a) The hospice failed to ensure the plan of care for Patient #2 included goals and interventions for the spiritual counselor. Review of the spiritual counselor notes for Patient #2 from 3/9/23 to 4/15/23 revealed Patient #2 received seven spiritual care service visits. Spiritual Counselor #16 completed five of those visits and documented she identified the following issues: -on 3/9/23, Patient #2 was identified to be calm and peaceful and unable to communicate, but identified Catholicism as her religion and Spiritual Counselor #16 would reach out to Patient #2's family to gather and understanding of Patient #2's "relationship with her religion and to the world"; -on 4/4/23, Patient #2 was identified to be peaceful, still attempting to contact Patient #2's family, and provided patient with compassionate presence; -on 4/11/23, Patient #2 was identified to be peaceful and her son was identified to be calm and sad; -on 4/13/23, Patient #2 was identified to be sleeping and visited due to an end of life visit; and -on 4/15/23, Patient #2 was identified to be unconscious, actively dying, calm and peaceful. On 4/9/23, Spiritual Counselor #9 identified Patient #2 to be oriented to person and Spiritual Counselor #9 arranged for a Catholic priest to come and give Patient #2 the Sacrament of the Sick. On 4/15/23, Spiritual Counselor #18 identified Patient #2 to be sleeping and Patient #2's condition had not changed in the past few days. Spiritual Counselor #18 documented Patient #2's Roman Catholic priest had provided Patient #2 with the Sacrament of the Sick and Last Rights and Spiritual Counselor #18 had discussed Patient #2 and her funeral arrangements with Patient #2's son. Review of Patient #2's combined discipline plans of care dated 3/9/23, 3/16/23, 3/30/23, 4/13/23 failed to show any Spiritual goals or interventions were documented. During an interview on 6/14/23 at 9:54 a.m., Spiritual Counselor #9 stated she began working for the hospice on 12/27/22. She stated she was still learning the hospice EMR system and she was not sure how goals and interventions were generated on a patient's combined discipline plan of care. b) The hospice failed to ensure the plan of care for Patient #2 included goals and interventions for the hospice aide. Review of the clinical record revealed on 3/7/23, SN #5 created a hospice aide care plan which stated Patient #2's functional limitations were decreased, ambulation/wheelchair bound, incontinent, required assist of one person and mechanical soft diet. Hospice aides were directed to assist Patient #2 with the following tasks: pericare, toileting, oral care, hair care, skin care, tidy patient area, tidy bathroom and provide companionship every visit and showering and shampooing two times a week. Review of hospice aide notes for Patient #2 from 3/9/23 to 4/14/23 revealed Patient #2 received 11 visits and Patient #2 received assistance with care planned tasks as well as linen changes and feeding assistance. Review of Patient #2's combined discipline plans of care dated 3/9/23, 3/16/23, 3/30/23, 4/13/23 failed to show any hospice aide goals or interventions were documented. 3. The clinical record for Patient #5 was reviewed on 6/13/23. Patient #5 was admitted for hospice care and services on 3/29/23 for the terminal diagnosis of chronic obstructive pulmonary disease. The plan of care for the certification period of 3/9/23 to 6/26/23 included orders for the following services: SN visits two times a week effective 4/2/23 and one visits a week effective 5/16/23 with 10 PRN visits effective 3/30/23; spiritual counselor visits one every four weeks with five PRN visits effective 4/6/23; SW visits one every four weeks effective 4/3/23 with five PRN visits effective 6/12/23; and hospice aide services four visits per week effective 4/3/23. a) The hospice failed to ensure the plan of care for Patient #5 included goals and interventions for the spiritual counselor. Review of the spiritual counselor notes for Patient #5 from 3/29/23 to 5/31/23 revealed Patient #5 received seven spiritual care service visits completed by Spiritual Counselor #16. Spiritual Counselor #16 documented she identified the following regarding Patient #5: -on 3/29/23, Patient #5 was identified to be coping effectively and unable to articulate his belief system so Spiritual Counselor #16 documented she would reach out to Patient #5's family for context on Patient #5's spiritual and religious background; -on 4/13/23, Patient #5 was identified to have a flat affect and be emotionally distant; -on 4/25/23, Patient #5 was identified to need spiritual counseling and life review; -on 5/9/23, Patient #5 was identified to be peaceful, appropriate and required an empathetic presence; -on 5/17/23, Patient #5 was identified to be asleep and Spiritual Counselor #16 checked in with a SN who worked in the facility where Patient #5 resided and cared for Patient #5, who indicated Patient #5 had no concerns at this time; -on 5/24/23, Patient #5 was identified to be calm, in good spirits and denied pain; and -on 5/31/23, Patient #5 was identified to be sleeping. Review of Patient #5's combined discipline plans of care dated 4/6/23, 4/13/23, 4/27/23, 5/11/23,and 5/25/23 failed to show any spiritual goals or interventions were documented. b) The hospice failed to ensure the plan of care for Patient #5 included goals and interventions for the hospice aide. Review of the clinical record revealed on 3/30/23, SN #5 created a hospice aide care plan which stated Patient #5's functional limitations were Patient #5 was ambulatory, had a Foley catheter and had a skin tear to his left upper extremity. Hospice aides were directed to assist Patient #5 with the following tasks: pericare, toileting including catheter care, oral care, hair care, skin care, and provide companionship every visit and showering and shampooing two times a week. Review of hospice aide notes for Patient #5 from 3/31/23 to 6/9/23 revealed Patient #5 received 29 visits and Patient #5 received assistance with care planned tasks as well as linen changes, feeding assistance, tidying his area, tidying his bathroom, laundry and backrubs. Review of Patient #5's combined discipline plans of care dated 4/6/23, 4/13/23, 4/27/23, 5/11/23,and 5/25/23 failed to show any hospice aide goals or interventions were documented. 4. Similar findings of the hospice failing to ensure all disciplines providing care to a patient had goals and interventions on the plan of care occurred for Patients #4 and #8. 5. On 6/14/23 at 9:52 a.m. an interview was attempted with Spiritual Counselor #16. At approximately 10:45 a.m., Spiritual Counselor #17 stated Spiritual Counselor #16was ill and at approximately 12:00 p.m. the DCS confirmed this, thus unable to complete the interview. During an interview on 6/14/23 at 12:46 p.m., Clinical Manager #3 acknowledged Patients #2, #4, #5, #7 and #8 were missing goals and interventions for all disciplines providing care to those patients. Clinical Manager #3 stated in order for a goal and intervention to appear on a patient's combined discipline care plan the clinician completing the assessment of the patient needed to document goals and interventions in their individual assessment as the hospice's EMR then pulled the goals and interventions from the last clinician's assessment for each discipline providing care to a patient to create the combined discipline plan of care. The director of clinical services stated the hospice was looking into getting a new EMR system for the hospice.

Based on interview and record review, the hospice failed to ensure each patient's plan of care included all information necessary to meet the needs of the patient for 1 of 1 patients reviewed who had a pleura chest drain (drains blood, fluid or air from around a patient's lungs) (Patient #7). --- Findings include: HOSPICE POLICY According to the agency policy revised on 3/10/21, titled, Plan of Care, (read in pertinent parts): "A written, individualized plan of care (POC) is established for each patient/family by the IDT [interdisciplinary team] in collaboration with the attending physician, the hospice Medical Director or physician designee and the patient or representative and the primary caregiver. The care plan provided to an individual must be in accordance with the POC." "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions and will include: -Interventions for the management of discomfort and symptom relief." 1. The clinical record for Patient #7 was reviewed on 6/12/23. The patient was admitted for hospice care and services on 11/17/22 with a terminal diagnosis of malignant neoplasm of right main bronchus at another agency and transferred to Agape Hospice on 12/21/22. Patient #7 revoked his hospice benefit and was transferred to an acute care hospital on 4/8/23. The plan of care for the certification periods dated 12/21/22 to 2/19/23 and 2/20/23 through 4/8/23 included orders for: skilled nurse (SN) services one time a week for one week effective 12/22/22, three as needed (PRN) visits effective 12/21/22; two times per week effective 1/9/23 with three PRN visits effective 1/14/23, five PRN visits effective 3/16/23 and four PRN visits effective 4/5/23 and 4/8/23; spiritual counseling visits one visit every four weeks with 3 PRN visits effective 1/6/23 and seven PRN visits effective 3/13/23; social worker (SW) visits one time every four weeks with 3 PRN visits effective 12/29/22, one time a week every two weeks with three PRN visits effective 2/23/23, and one time a week every four weeks effective 3/20/23; and hospice aide visits one time a week for one week effective 12/22/22, three times a week effective 12/24/22, and five times a week effective 4/3/23. Review of Patient #7's combined discipline plans of care dated 12/29/22, 1/12/23, 1/25/23, 2/8/23, 2/22/23, 3/2/23, 3/9/23, and 4/6/23 showed SN services were for symptom management and to maintain Patient #5's pleura chest tube and drain for comfort as needed when Patient #7 became short of breath or fluid could be heard on his lungs. a) The hospice failed to ensure all necessary information pertaining to dressing for Patient #7's pleura chest tube was included in the patient's plan of care. Review of the initial comprehensive assessment, completed on 12/21/22 by SN #14, revealed SN #14 documented Patient #7 had his pleura chest drain placed in November of 2022 to manage his pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). SN #14 documented Patient #7's pleura chest drain was to be maintained and drained for comfort as needed when Patient #7 became short of breath or the SN could hear fluid on his lungs. The initial assessment failed to reveal documentation of what type of dressing covered Patient #7's pleura tube drain. Further review of the combined discipline plans of care dated 12/29/22, 1/12/23, 1/25/23, 2/8/23, 2/22/23, 3/2/23, 3/9/23, and 4/6/23 and supplemental physician orders for Patient #7 failed to show orders for what type dressing Patient #7 pleura chest drain should have or how often the dressing should be changed. Review of SN notes for Patient #7 from 12/21/22 to 4/8/23 show SN #14 drained Patient #7's pleura chest drain seven times (12/29/22, 1/6/23, 1/16/23, 1/26/23, 2/2/23, 2/15/23, and 2/24/23) and changed Patient #7's pleura chest tube drain dressing without draining six times (1/3/23, 1/4/23, 1/10/23, 2/6/23, 3/20/23 and 3/29/23). Patient #7 had the dressing around his pleura chest tube drain changed three additional times by the following SNs: by SN # 6 on 1/15/23, by SN #15 on 2/5/23 and by SN #10 on 3/18/23. During an interview on 6/13/23 at 5:08 p.m., SN #10 acknowledged on 3/18/23 she was sent to see Patient #7 as the hospice had received a phone call from Patient #7 requesting a new chest drain dressing be applied. SN #10 stated she applied a new dressing for Patient #7 and failed to ensure she had physician orders to complete this task. SN #10 stated the process she typically used when she was sent out to complete a triage visit was she reviewed the patient's clinical record to see if she had orders for the tasks she was sent to complete. If she failed to find orders, she would call the patient's physician to receive orders before proceeding. SN #10 could not recall why she did not follow this process for the visit she completed with Patient #7 when she changed his pleura chest drain dressing, but stated she would ensure to follow regulatory procedures of ensuring she had physician orders prior to completing a treatment with all future visits. During an interview on 6/14/23 at 12:03 p.m., SN #14 confirmed she was Patient #7's RN case manager and had completed his initial SN comprehensive assessment. SN #14 acknowledged Patient #7's clinical record lacked physician orders on what type of dressing Patient #7's chest tube drain should have and how often it should be changed. SN #14 stated she failed to seek orders from Patient #7's physician for his pleura chest drain dressing as when she drained his chest using the chest drain the equipment used was all packaged as a kit and included the dressing for the chest tube drain which was a split foam dressing, covered with a split 4x4 gauze, then covered with Tegaderm (a transparent film dressing). SN #14 acknowledged Patient #7's chest tube drain dressing was changed several times without draining his chest, and thus, physician orders should have been obtained and his plan of care should have reflected the dressing to be used and how often the dressing should be changed.

Based on interview and record review, the hospice failed to ensure care and services were provided in accordance with the plan of care for 5 of 8 patient records reviewed (Patients #1, #2, #4, #5, and #7). --- Findings include: HOSPICE POLICY According to the agency policy revised on 8/22/11, titled, Patient Services Coordination, (read in pertinent parts): "The Interdisciplinary Team (IDT) maintains responsibility for directing, coordinating, and supervising care and services provided to hospice patients." "The IDT will ensure care and services are provided based on assessments and in accordance with the Plan of Care. The IDT will provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Changes in condition and other pertinent information will be communicated to the attending physician within 24 hours. Voice mail messages are acceptable." According to the agency policy revised on 3/10/21, titled, Plan of Care, (read in pertinent parts): "A written, individualized plan of care (POC) is established for each patient/family by the IDT in collaboration with the attending physician, the hospice Medical Director or physician designee and the patient or representative and the primary caregiver. The care plan provided to an individual must be in accordance with the POC." "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions and will include: -Identification of assigned team members and in detail, the scope and frequency of the services needed to meet the patient's and family's needs." 1. The clinical record for Patient #2 was reviewed on 6/12/23. Patient #2 was admitted for hospice care and services on 3/6/23 with a terminal diagnosis of cerebral atherosclerosis and passed away on 4/15/23. The plan of care for the certification period dated 3/6/23 through 6/3/23 included orders for skilled nurse (SN), spiritual care, social worker (SW) and hospice aide services. a) The hospice failed to provide SN services to meet the patient's needs in accordance with the plan of care orders. Review of the combined disciplinary plans of care dated 3/9/23, 3/16/23, 3/30/23, 4/13/23 revealed orders for SN services for management of the following: pain, neuro/mental/emotional status, nutritional/hydration status, skin integrity, and safety. Review of a physician order dated 3/7/23 revealed orders for SN services two times a week. Review of a physician order dated 4/7/23 revealed orders to increase SN services to seven times a week. Review of an internal hospice communication message titled, "EOL [end of life] SPOT," revealed on 4/7/23 at 10:36 a.m., SN #5 documented the following: Patient #2 "is no longer eating, taking sips of fluids. Slightly hypoxic, lethargic and unable to respond in a meaningful way. Still able to take po [by mouth] oxycodone [pain medication] and lorazepam [anti anxiety medication] in juice, sending concentrates to have in the facility when she no longer can swallow. Begin daily RN [registered nurse] visits 4/7/23." Review of completed SN visit notes for Patient #2, from 3/6/23 to 4/14/23, failed to show SN services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #2 failed to reveal SN visits were conducted on 4/8/23, 4/9/23 and 4/10/23. Additionally, the record failed to show documentation the visits were missed, the physician was aware the visits were not completed and how the patient's SN needs were met. During an interview on 6/12/23 at 1:50 p.m., the director of compliance, quality, and administrative services (DCQAS), the director of clinical services (DCS), and Clinical Manager #3 all acknowledged the hospice failed to provide Patient #2 three EOL visits on 4/8/23, 4/9/23, and 4/10/23; failed to have missed visit documentation for these three missed visits, and failed to notify Patient #2's physician of the missed visits. Clinical Manager #3 stated the hospice on-call SN for Saturday, 4/8/23, SN #6, and Sunday, 4/9/23, SN #7, were each scheduled to go provide Patient #2 with her EOL SN visit, but were rerouted to care for other patients and were unable to complete the visit. The DCQAS stated Patient #2 received a visit from SW #8 on Saturday, 4/8/23, and from Spiritual Counselor #9 on Sunday, 4/9/23, but acknowledged Patient #2 did not receive SN visits on either of those two days. The DCS stated SN #5 called in sick on Monday, 4/10/23, and the hospice should have covered the EOL visit for the day. The DCS stated the hospice had procedures in place to cover visits when a SN called in sick which included: using a float SN, sending either Clinical Manager #3 or #4, or the DCS to cover the visit. The DCS stated Clinical Manager #4 was responsible for finding coverage for SN visits when a SN was off for vacation or called in sick. The DCS stated Clinical Manager #4 was on maternity leave when Patient #2 had her three missed EOL visits occur and the hospice procedures for covering these visits failed. 2. The clinical record for Patient #4 was reviewed on 6/13/23. Patient #4 was admitted for hospice care and services on 9/9/22 with a terminal diagnosis of cerebral atherosclerosis and passed away on 5/23/23. The plan of care for the certification periods 12/7/22 to 3/7/22 and 3/8/23 through 5/6/23 included orders for SN, spiritual counselor, SW and hospice aide services. The plan of care for the certification period 5/7/23 through 7/5/23 included orders for SN and hospice aide services. a) The hospice failed to provide SN services to meet the patient's needs in accordance with the plan of care orders. Review of the combined disciplinary plans of care dated 3/2/23, 3/9/23, 3/23/23, 4/6/23, 4/20/23, 5/4/23 and 5/18/23 revealed orders for SN services for management of the following: pain, neuro/mental/emotional status, nutritional/hydration status, gastrointestinal status, skin integrity, and safety. Review of a physician order dated 9/10/22 effective 9/9/22 revealed orders for SN services three times a week. Review of a physician order dated 3/22/23 revealed orders to decrease SN services to one time a week and five PRN (as needed) visits. Review of completed SN visit notes for Patient #4, from 3/1/23 to 5/22/23 failed to show SN services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #4 failed to reveal SN visits were conducted three times as ordered the week of 3/5/23 to 3/11/23 (one SN visit provided on 3/8/23) and 3/12/23 to 3/18/23 (one SN visit provided on 3/15/23) Additionally, the record failed to show documentation of why Patient #4's four SN visits were missed, if Patient #4's physician was aware the visits were not completed and how the Patient #4's SN needs were met. During an interview on 6/14/23 at 1:52 p.m., the DCS stated Patient #4's SN visits were once a week on Wednesdays for several months. The DCS, the director of business services, Clinical Managers #3 and #4 all reviewed Patient #4's SN orders and confirmed from 9/10/22 to 3/21/23, Patient #4's SN orders were three visits a week and her SN frequency was decreased to one time a week on 3/22/23. The director of business services stated SN #5 was a new RN case manager (RNCM) to the agency in March of 2023 and must have failed to request a decrease in SN frequency from Patient #4's physician in a timely manner. 3. The clinical record for Patient #5 was reviewed on 6/13/23. Patient #5 was admitted for hospice care and services on 3/29/23 for the terminal diagnosis of chronic obstructive pulmonary disease. The plan of care for the certification period of 3/9/23 to 6/26/23 included orders for SN, spiritual counselor, SW and hospice aide services. a) The hospice failed to provide hospice aide services to meet the patient's needs in accordance with the plan of care orders. Review of the hospice aide care plan date 3/30/23 revealed the hospice aide was to assist Patient #5 with the following: peri care, toileting/catheter care, oral care, hair care, skin care and companionship every visit and showering two times per week. Review of a physician order dated 4/3/23 revealed orders for hospice aide services four times a week. Review of completed hospice aide notes for Patient #5, from 4/4/23 to 6/9/23, failed to show hospice aide services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #5 failed to reveal hospice aide visits were provided four times a week as ordered for the following weeks: 4/16/23 to 4/22/23, 4/23/23 to 4/29/23, 4/30/23 to 5/6/23 and 5/7/23 to 5/13/23 three hospice aide visits were provided; and 5/14/23 to 5/20/23, 5/21/23 to 5/27/23, 5/28/23 to 6/3/23, and 6/4/23 to 6/10/23 two hospice visits were provided. Review of missed visit documentation showed licensed practical nurse (LPN) #10 documented on 4/21/23, 4/25/23, and 5/2/23 the scheduled hospice aide visit for those days was missed due to "unable to perform the visit." The missed visit documentation failed to show how Patient #5's hospice aide needs were met and failed to show if Patient #5's physician was notified of the missed visits. Further review of Patient #5's clinical record failed to show documentation for the nine missed hospice aide visits, from 5/7/23 through 6/10/23, if the physician was aware the visits were not completed and how the patient's hospice aide needs were met. During an interview on 6/14/23 at 8:38 a.m., Hospice Aide #11 confirmed she was the primary hospice aide assigned to Patient #5 when he started services and she was scheduled to see Patient #5 Tuesdays through Fridays. Hospice Aide #11 stated her last visit with Patient #5 was in late May 2023 (5/25/23) and she was not aware of a change in frequency for hospice aide visits for Patient #5 prior to his care being transferred to another hospice aide. Hospice Aide #11 stated she was aware Patient #5's RNCM, SN #5, had discussed decreasing Patient #5's hospice aide frequency to two or three times a week, but stated she was not aware if the change ever occurred. During an interview on 6/14/23 at 9:03 a.m., Hospice Aide #12 confirmed she had provided Patient #5 with hospice aide services as a fill-in hospice aide. Hospice Aide #12 stated she thought Patient #5 was scheduled to receive hospice aide visits two times a week. During an interview on 6/13/23 at 4:21 p.m., Clinical Manager #3 confirmed Patient #5's hospice aide orders were four times a week and the hospice only had incomplete missed visit documentation for 4/21/23, 4/25/23 and 5/2/23. During an interview on 6/13/23 at 4:30 p.m., the DCS stated SN #5 resigned on 5/12/23 and she had limited communication with the management team two to three weeks prior to her resignation. The DCS stated SN #5 might have forgotten to seek physician orders to reduce Patient #5's hospice aide frequency to two times a week. The DCS stated, Clinical Manager #3 and the DCS were responsible for auditing patient charts to ensure they received services as ordered but they had failed to audit as well as they should have. The DCS indicated she would review with Clinical Manager #3, the process she used to audit to ensure patients received care as ordered. 4. Similar findings of the hospice failing to ensure patients received care as ordered on the plan of care were found for Patients #1 and #7.

Observed in Record Review. It was found on review of HV#1 record that the Chaplain had 10 prn visits however there was no frequencies noted. This was confirmed with the Clinical Manager.

Observed in Individual Tracer. It was found on HV#1 that further education was needed to be given to the patient's private care givers regarding oxygen safety and storage. There were multiple M tanks standing up and leaning out of a flimsy cardboard box. The oxygen concentration was pushed up against the wall in the living room and the filter was extremely dirty with dust.