Every finding on record at Athena Inc.

Upon patient record review, 3 of 14 (Patient #2,5,6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2, Initial SC assessment on 9/7/25, only documents in narrative note visit was declined. No evidence of SC assessment was completed by SC or on the RN initial assessment. Patient #5, Initial SC assessment on 11/29/25, only documents in narrative note visit was declined. No evidence of SC assessment was completed by SC or on the RN initial assessment. Patient #6, Initial SC assessment on 10/4/25, only documents in narrative note visit was declined. No evidence of SC assessment was completed by SC or on the RN initial assessment.

Upon patient record review, 5 of 14 (Patient #1,2,3,6,8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1, Upon home visit and review of medication in the home, patient is taking carbidopa 500mg 3x/day. This medication was not listed on the medication profile. Patient #2, Upon home visit and review of medication in the home, patient is taking melatonin 5mg at bedtime. This medication was not listed on the medication profile. Patient #1,3,6,8, DME identified patient has oxygen concentrator and oxygen E tanks. No evidence of order for oxygen documented under medication profile.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1, Initial bereavement assessment narrative state both niece and son Gilbert as the bereaved with only the niece being identified for bereavement. Upon home visit met second son Tony, who shares in visiting and caring for their mother as Gilbert does. No evidence of Tony being identified as possible bereavement.

Upon observation and patient record review, 5 of 14 (Patient 2,3,6,7,8) there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #2, On 9/9/25, no nursing update documented and no RN signature noted on IDG form. Patient #3, On 6/20/25, no SC update documented on IDG form. Patient #6, On 10/7/25, no MSW update documented on IDG form. On 11/4/25, no RN or MSW signature on IDG form. Patient #7, On 9/23/25, no MSW update documented on IDG form. On 11/4/25, no RN or MSW signature on IDG form. Patient #8, On 11/4/25, no MSW or RN signature on IDG form.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, No evidence of goals and interventions for pain, patient rated pain at 4/10 on RN initial assessment. No goals and interventions for respiratory, admitting diagnosis COPD and no oxygen precautions. No goals and interventions for no funeral home identified on MSW initial assessment. Patient #2, No goals and interventions for no funeral home identified on MSW initial assessment. No evidence of goals and interventions for pain, patient rated pain at 2/10 on RN initial assessment. Patient #3,4,6,7,8,9,10, No goals and interventions for no funeral home identified on MSW initial assessment. Patient #5, No goals and interventions for no funeral home identified on MSW initial assessment. No goals and interventions for cardiac, admitting diagnosis is heart failure.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #3, Patient has imminently dying care plan initiated at start of care. Upon home visit patient was up in wheelchair talking. No evidence patient was still imminently dying.

Upon client record review, 6 of 14 (Patient #1,4,6,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, RN frequency every 2 weeks, LVN frequency 1x/week. RN made a visit on 7/21/25 and 7/23/25. No evidence RN frequency was followed. Patient #4, SC frequency 1x/month, visits completed on 12/1/25 and 12/9/25. No evidence SC frequency was followed. Patient #6, There was an order for SC evaluation. SC documented under initial assessment narrative, unable to reach patient by phone will consider patient declined. Patient #7, SC frequency documented as declined, visit made by SC on 9/17/25. Patient #8, SC frequency documented as declined, visits made by SC on 9/1/25 and 9/4/25. Patient #9, Wound care order states Iodosorb to wound bed on right heel. RN visit note on 10/13/25 and 12/8/25 document medihoney was applied to wound bed on right heel. No evidence that wound care was followed per MD orders.

Upon observation and home visits, 3 of 3 (Patients #1, 2, 3) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1,2, LVN entered in and out of nursing bag without hand sanitizing. Nursing bag was open with items exposed and both clean and dirty items in the same compartment of the bag as the nursing bag had only 1 compartment for clean and dirty. LVN used items, returned to clean area, used alcohol wipes to clean and immediately placed in plastic baggie and placed back into nursing bag. Per policy, all items were to be cleaned at the end of visit. Patient #3, LVN entered nursing bag prior to hand sanitizing to remove barrier for bag.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5, Aide competency form showed no evidence identifying if the aide was observed performing all tasks, there was only 1 page of the 4 page competency evaluation. The evaluation of each task competency was not identified.

Upon patient record review, 3 of 14 (Patient #5,6,8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #5, Aide care plan did not document precautions of fall, skin, bleeding, aspiration, universal and oxygen on aide care plan as evidenced by MD order for these precautions. Patient #6, Aide care plan did not document precautions of fall, skin, aspiration, universal and oxygen on aide care plan as evidenced by MD order for these precautions. Aide care plan documents under RN additional instructions as any changes on patient condition notify RN immediately. No evidence of documentation of specific issues to be reported. Patient #8, Aide care plan did not document precautions of fall, skin, aspiration, universal and oxygen on aide care plan as evidenced by MD order for these precautions

Upon patient record review 2 of 14 (Patient #5,8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5, Aide frequency 1x/week effective 12/3/25, Aide visits were made on 11/25/25. No evidence of order for this visit. Patient #8, Aide care plan directs the aide to provide companion care and encourage fluids. No evidence these tasks were completed or declined.

Upon patient client record review, 1 of 14 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2, RN initial assessment documents KPS 50 and PPS 50 then in narrative documentation states KPS 60 and PPS 70. No evidence of clear entries.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11,12, No evidence of discharge summary was sent to attending physician.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11,12, No evidence the discharge summary included treatments symptoms, pain management, current plan of care and latest physician orders.

Based on observation, interview and record review, the agency failed to provide the comprehensive assessment within 5 days from the start of care (SOC) when Master of Social Work (MSW) 1 did not make attempt to make home visit or contact family member within the five day time frame. This failure placed Patient 3 at risk for not receiving initial bereavement assessment necessary to receive the needed support upon admission to the hospice setting. --- During a concurrent observation and interview on 11/5/24 at 10:30 a.m., with Licensed Vocational Nurse (LVN) 1, in Patient 3s assisted living facility, LVN 1 stated it was her first-time seeing Patient 3. LVN 1 was observed providing the wound care on her coccyx. During wound care Patient 3 was observed cooperative and following directions. Patient 3 was very quiet and expressed minimal emotion. LVN 1 stated Registered Nurse (RN) 1 came to see Patient 3 few days ago after Patient 3 was discharged from a skilled nursing facility. During an interview on 11/5/24 at 4 p.m., with Registered Nurse (RN) 1, in the conference room, RN 1 stated when she admitted Patient 3, Patient 3s son was present, and he was the one who signed the consent to be admitted to the hospice agency to receive the hospice care. RN 1 stated it was her first time admitting a new patient as a case manager. RN 1 stated Patient 3 could let her needs be known. RN 1 stated she knew LVN 1, and Chaplain made visits to Patient 3. During a concurrent interview and record review on 11/6/24 at 11 a.m., with the Assistant Administrator (AADM), Patient 3s visit notes were reviewed. There was no visit note by MSW 1. The AADM called MSW 1 and confirmed she did not have any home visits scheduled the rest of 11/6/24. During a concurrent interview and record review, on 11/6/24 at 4 p.m., with the ADM, the ADM stated she could not locate any coordination note or visit note indicating MSW 1 tried to assess Patient 3 and Patient 3s sons psychosocial and emotional bereavement needs to develop individualized plan of care. During a phone interview on 11/6/24 at 4:05 p.m., MSW 1 stated she has not made a visit to Patient 3 or had not made a call to Patient 3s son. The ADM and MSW 1 both stated it was very important for interdisciplinary group (IDG-a group of professionals from several disciplines working independently in the same setting) members to complete each assessment within five days to generate individualized plan of care. During a review of the agencys policy and procedure (P&P) titled ";Comprehensive Assessment" dated, 4/20, the P&P indicated, ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician...A bereavement assessment of the needs of the patients family and other individuals focusing on: 1. The nature of the relationship to the patient 2. Circumstances surrounding the illness/prognosis 3. Behaviors prior to and after illness /prognosis 4. Survivor needs (social, spiritual and cultural) that may impact coping skills) 5. Potential for pathological grief reactions..."

Based on observation, interview and record review, the agency failed to develop bereavement plan of care after initial bereavement assessment for three of three sampled patients (Patient 1, 2 and 3). This failure resulted in the bereaved not receiving organized necessary bereavement counselling. --- During an observation on 11/5/24 at 2:30 p.m., the agencys Intradisciplinary Group Meeting (IDG), in the conference room, Master of Social Work (MSW) 1 joined the meeting virtually. The meeting was attended by the Medical Director (MD), NP (nurse practitioner) 1, the Administrator (ADM), the Director of Patient Care Services (DPCS) and Chaplain. The IDG meeting was not observed discussing any bereavement care plan. During a phone interview on 11/5/24 at 4 p.m., with MSW 1, MSW 1 stated she did not know she was the bereavement coordinator. MSW 1 stated upon her initial visit she identifies and evaluates psychosocial needs for the patients, family/caregiver and assists with immediate bereavement needs if identified. MSW 1 stated upon patients death she sends out letters to the bereaved as scheduled. MSW 1 stated she did not document a bereavement care plan or follow up. MSW 1 stated she did not have any documented evidence of bereavement counselling she offered. During a review of Patient 1. 2 and 3s clinical record, all three patients ";initial bereavement assessment" were completed with pre-populated information. Patient 1. 2 and 3s clinical record did not contain individualized bereavement plan of care, there were no notes to describe the kind of bereavement service offered and the frequency of service delivery. During an interview on 11/6/24 at 12:15 p.m., with Director of Patient Care Services (DPCS), the DPCS stated she realized the agencys current practice needed to be changed from conducting generalized initial bereavement risk assessment and after death follow up letters. The DPCS stated she reviewed current patients, and she identified five patients whose family member were at risk who would benefit from bereavement counselling. The DPCS stated she had already made documentation on narrative visit note and developed bereavement plan of care. The DPCS stated she would make the change to discuss the bereavement plan of care during IDG meetings to deliver the bereavement counseling service. During a review of the agencys policy and procedure (P&P) titled ";Bereavement Services" dated 4/20, the P&P indicated, ";After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed...bereavement counselors may need to contact and/or visit the patient and family/caregiver prior to death...The bereavement counselors may provide supportive counselling to the patient and family/caregiver prior to death..."

Based on interview and record review the agency failed to obtain physicians order with signature prior to start of care (SOC) for one of three sampled patients (Patient 3). This failure placed Patient 3 at risk for being admitted to the hospice agency without verification of admitting criteria from attending physician or the medical director per agencys policy and procedure (P&P). --- During a concurrent interview and record review on 11/6/24 at 10:30 a.m., with the Assistant Administrator (AADM), Patient 3s referral order was reviewed. The AADM stated she could not locate the referral with physicians signature. The AADM presented a note dated 10/29/24. The note indicated Patient 3 was in a skilled nursing facility (SNF) and Physician 1 called the agency from the SNF and referred Patient 3 to the [Agency] to evaluate. The note did not contain any medical terminal illness diagnosis. The AADM asked the ADM for help, the ADM presented the agencys form titled CTI (Certification of Terminal Illness) for Patient 3. Patient 3s CTI form did not contain Physician 1s signature. The ADM stated the CTI needed to have the actual handwritten signature or electronic signature for authentication. During a review of the agencys P&P titled ";Admission Criteria and Process" dated 4/20, the P&P indicated, ";[the agency] will admit a patient only on recommendation of the medical director in consultation with, or input from the patients attending physician, if any....The patients physician (or other authorized independent practitioner) must order and approve the provision of hospice care , be willing to sign or have a representative who is willing to sign the death certificate, and be willing to discuss the patients resuscitation status with the patient and family/caregiver."

Upon observation, there was not evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The last documented exercise was conducted on 4/12/19.

Upon patient record review, 4 of 11 records (Patient #2,#3,#8,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: The medication profile indicated Tylenol 650mg extended release gel tabs q6h prn for arthritic pain dated 9/9/22 and Acetaminophen 650mg rectal suppository, 1 q4h prn as needed for pain of fever, dated10/7/22. There was not evidence of a maximum allowable dose for 24h or a parameter for fever. Corrected on site. Patient #3: The medication profile indicated Tylenol 650mg extended release q8h prn as needed for pain and Tylenol 325mg, 2 tabs q4-6h prn pain. There was not evidence of a maximum allowable dose for 24h. Corrected on site. Patient #8: The medication profile indicated Acetaminophen 650mg rectal suppository, 1 q4h prn for pain of fever, and Tylenol with Codeine #3, 300mg 1 every 4-6h prn pain. There was not evidence of a maximum allowable dose per 24h period or a parameter for the fever. Corrected on site. Patient #9: The medication profile indicated Calmoseptine 20.6% topical ointment. Apply to affected area 2-4x/day. There was not evidence of a specific location for the application. Corrected on site.

Upon patient record review, 1 of 11 records (Patient #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: The record indicated that the bereavement assessment was conducted on the caregivers. The social work assessment conducted on 9/12/22 indicated that there was a grandson that was involved with care. (Consents were signed by the grandson). There was not evidence that a bereavement assessment was conducted on the grandson. Corrected on site.

Upon patient record review, 2 of 11 records (Patient #8,#9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #8: The patient was admitted with a diagnosis of COPD. She was on oxygen. Medications included but were not limited to Advair, Ventolin, and Robitussin. On 9/17/22, she developed paroxysmal coughing. She also required suctioning at times. There was not evidence of respiratory goals and interventions based on these problems and issues. Corrected on site. Patient #9: The patient was admitted with a diagnosis of dementia with behaviors. There was not evidence of neurological or mental goals and interventions related to these problems. Corrected on site.

Upon patient record review, 4 of 11 records (Patient #2,#3,#8,#9) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The plan of care indicated Tylenol 650mg extended release gel tabs q6h prn for arthritic pain dated 9/9/22 and Acetaminophen 650mg rectal suppository, 1 q4h prn as needed for pain of fever, dated10/7/22. There was not evidence of a maximum allowable dose for 24h or a parameter for fever. Corrected on site. Patient #3: The plan of care indicated Tylenol 650mg extended release q8h prn as needed for pain and Tylenol 325mg, 2 tabs q4-6h prn pain. There was not evidence of a maximum allowable dose for 24h. Corrected on site. Patient #8: The plan of care indicated Acetaminophen 650mg rectal suppository, 1 q4h prn for pain of fever, and Tylenol with Codeine #3, 300mg 1 every 4-6h prn pain. There was not evidence of a maximum allowable dose per 24h period or a parameter for the fever. Corrected on site. Patient #9: The plan of care indicated Calmoseptine 20.6% topical ointment. Apply to affected area 2-4x/day. There was not evidence of a specific location for the application. Corrected on site

Upon patient record review, 4 of 11 records (Patient #1,#4,#6,#9) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The nursing assessment on admission (10/8/22) indicated that the patient had or used an air mattress, bed, overbed table, eggcrate, wheelchair, shower chair and commode. There was not evidence that this equipment was included in the plan of care. Corrected on site. Patient #4: The initial nursing assessment indicated that the patient had or was using an air mattress, bed, eggcrate, overbed table, walker, wheelchair, shower chair and commode. There was not evidence that this equipment was included in the plan of care. Corrected on site Patient #6: The record indicated that the patient had or was using an air mattress, bed, eggcrate, cane, walker, overbed table, wheelchair, shower chair and commode. There was not evidence that this equipment was included in the plan of care. Corrected on site. Patient #9: The record indicated that the patient had or was using a bedside commode, an eggcrate, geri chair, shower chair and wheelchair. There was not evidence that this equipment was included in the plan of care. Corrected on site.

Upon client record review, 3 of 8 applicable records (Patient #3,#10,#11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The visit frequency for the social worker and the spiritual care counselor was for an evaluation. The record indicated that the social worker conducted visits monthly and spiritual care counselor conducted visits on 6/20/22, 7/14/22, 7/18/22, 8/2/22, 8/18/22, and 9/6/22. There was not evidence of continued orders for either of these disciplines after the initial evaluation. Patient #10: The visit frequency for the social worker was for an evaluation. The record indicated that the social worker conducted the evaluation and a subsequent routine visit on 9/12/22. Patient #11: The visit frequency for the social worker was for an evaluation. The record indicated that the social worker conducted the evaluation and subsequent routine visits on 9/11/22 and 10/1/22. In addition, the record indicated that the patient had a stage II wound on his coccyx and wound care was provided by cleansing with normal saline, patting dry , and applying medihoney, and covering with foam dressing. There was also a wound on the patients lower left leg which had wound care consisting of cleaning the wound, applying xeroform and covering with a sterile dressing. There was not evidence of wound care orders in the plan of care.

Upon observation, 2 of 3 home observation visits (Patient 2 and 3) did not have evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2, Aide & Patient #3, RN: The staff member was observed taking equipment out of the bag, using the equipment on the patient and going back in the bag for more equipment without washing or sanitizing hands prior to re-entry. Policy #6-013.1 Bullet 3 indicates 'After hand washing, the supplies and/or equipment needed for the visit will be removed from the bag.

Upon patient record review, 5 of 9 applicable records (Patient #2,#3,#8,#9,#11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions including alerts and precautions, for a hospice aide that are prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #2,#3: The aide tasks consisted of taking vital signs each visit. There was not evidence of reportable parameters. Corrected on site. Patient #8: The record indicated that the patient was on Eliquis 2.5mg po BID. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site. Patient #9: The record indicated that the patient was on Xarelto 10mg 1 tab daily. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site. Patient #11: The aide tasks consisted of taking vital signs each visit. There was not evidence of reportable parameters.

Upon patient record review 2 of 9 applicable records (Patient #2,#10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #2: The aide visit frequency was ordered on admission (9/9/22) at 2x/week. There was not evidence of a visit by the aide until 9/27/22. Patient #10: The aide visit frequency was 2x/week. The record indicated that the aide conducted visits 3x/week for the duration of the patient's time on hospice.

Upon patient record review 1 of 9 applicable records (Patient #5) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #5: The aide plan of care indicated to take vital signs every visit and the reportable parameters for the diastolic blood pressure indicated to notify if the diastolic was less than 60. From 10/24/22 to current, the record indicated that the diastolic was 26-44. There was not evidence that this was reported to the RN.

Upon patient client record review, 1 of 11 records (Patient #1) did not have evidence the patient record contains: • Signed election statement in accordance with 418.24 Patient #1: The Benefit Election Statement indicated that the patient/representative wished to receive care and the services were to begin on 10/7/22. The certification of terminal illness, initial orders, initial assessments, and date of the consent signature all indicated the date of 10/8/22.

Upon patient client record review, 1 of 11 records (Patient #5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #5: The record indicated a statement in the narrative section of the nursing assessment that included, 'hospice admission packet given which includes the Joint Commission hotline number....'

Upon observation, there was not evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.

Upon observation, there was not evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs.

Upon client record review, 11 of 11 records (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon client record review, 1 of 3 applicable records (Patient #7) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #7: The record indicated an order for wound care, dated 8/18/22, 'Cleanse left lateral knee wound with gauze moderately soaked with normal saline. repeat if necessary, maintain clean technique by changing gloves if contaminated. Pat dry and gently apply Calazime ointment sparingly. Cover with non-adhesive and secure with border foam dressing 2x/week by SN and prn by facility for dislodgement or soilage.' On 11/1/22 and 11/3/22, there was not documentation of wound care. On 11/4/22, the nurse documentation indicated the left lower leg treatment was provided with the help of the facility nurse. On 11/8/22 the documentation indicated , skin treatment to lower leg done, and on 11/10/22, there was no indication that the wound care being performed. The record did not indicate what wound care was provided nor did it indicate that it was conducted 2x/week as ordered in the plan of care.

Upon patient record review, 1 of 1 applicable record (Patient #1) did not have evidence that the hospice provided the following information to the SNF: • Hospice election form • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient