Every finding on record at Aultman Hospital

Observed in Record Review. In 2 of 16 patient records reviewed, for active patients with oxygen, it was noted by the nurse surveyor that orders were not clear or complete. For HOSRRHV#2, the oxygen order read “Oxygen O2 device inhale 2-5 liters per minute via nasal canula continuous as needed for SOB (shortness of breath)”. The patient was using the oxygen at night only with no liter flow noted in the electronic medical record (EMR). For HOSRRNHV#9, the oxygen order read “Oxygen O2 device, inhale 2-5 liters per minute intermittent as needed for SOB.” The documentation in the EMR indicated that he was using oxygen continuously but did not note a liter flow. Findings were verified with the Director, Hospice & Palliative Care and the Assistant Nurse Manger, Hospice & Palliative Care.

Observed in Patient Home. In 2 of 6 home visits conducted, it was noted by the nurse surveyor that the staff failed to follow acceptable practice and agency policy when performing patient care. During HOSRRHV#5, the hospice aide went to wash her hands in the communal resident bathroom in the Memory Care Unit. She set her baggies with soap, paper towels and gloves on the vanity without a barrier and proceeded to wash her hands. She then picked up the baggies and put them back in her bag. She then hand sanitized, with hand sanitizer by putting some in her palms and rubbing her palms together, then before it was dry, reached into her bag for her gloves and put them on. Throughout the visit when changing gloves she did not properly hand sanitize. During HOSRRHV#6, the registered nurse did not hand sanitize when donning or doffing gloves throughout the visit. She performed wound care without changing gloves between taking off the old dressing and cleaning the wound. She did change gloves before putting on the clean dressing, but she did not hand sanitize before putting the clean gloves on. Findings were discussed with the Assistant Nurse Manager, Hospice and Palliative Care who was present during the visits.

Observed in Record Review. In 4 of 14 patient records reviewed, with the hospice aide, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For HOSRRHV#2, and HOSRRNHV#7, the patient was on PRN oxygen, yet the care plan did not address what the aide should do regarding the oxygen should the patient be on it during the bath. Additionally, for HOSRRHV#3, HOSRRNHV#7, and HOSRRNHV#11, there were no instructions as to when the hospice aide should notify the nurse such as for change in condition or skin breakdown. Findings were verified with the Director, Hospice & Palliative Care and the Assistant Nurse Manger, Hospice & Palliative Care.

Observed in Building Tour. It was observed in the cross corridor there was an exit, however the exit sign did not have the proper chevron leading to the emergency egress door. This was verified by the Facilities Team. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. It was observed in the mezzanine level with multiple natural gas HVAC units, there was excessive combustible storage throughout the entire area, and a workstation set up. This was verified by the Facilities Team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. It was observed in the main IT closet that was smoke detector protected had multiple gaps in the drop ceiling greater than 1/8. This was verified by the Facility Team. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. It was observed at the main separation the 3 hour rated fire doors did not close and latch properly when tested. This was verified by the Facilities Team. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. It was observed in the main hallway outside the IT room this was a rated 1 hour fire barrier per the life safety drawings and had a penetration that was not sealed properly, also in the clean linen room in the cross corridor there were multiple unsealed pipes in the rated fire barrier.. This was verified by the Facilities Team. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. It was observed per the life safety drawings the 1 hour rated fire barrier for the fire riser room was missing the fire rating label on the frame. This was verified by the Facilities Team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Building Tour. It was observed in the family laundry room the ceiling exhaust vent was 100% clogged by lint and dust. This was verified by the Facilities Team. Observed in Document Review. It was observed in EP 19 for proper shut down testing of the RTU's the NFPA reference and code year were inaccurate. This was verified by the Facilities Team.

Observed in Record Review. In 1 of 10 patient records reviewed, The hospice nurse surveyor noted (RR#3) that the comprehensive assessment did not include an assessment of the severity of the patient's diabetes. The surveyor noted that the patient was ordered both Lantus Insulin daily and sliding scale Novolog insulin twice a day; however the assessment did not include an assessment of the patient's blood glucose levels or use of insulin. The surveyor noted that in subsequent notes the nurse indicated that the patient's blood glucose ran between 256-624; however there was no indication that it was assessed on admission. This was confirmed with the director.

Observed in Record Review. In 1 of 10 patient records reviewed, The hospice nurse surveyor noted (RR#3) that the plan of care did not include goals or interventions to manage the patient's diabetes or anasarca. The surveyor noted that the patient was on two types of insulin; however the assessment did not include an assessment of the diabetes status. The assessment did indicate that the patient had anasarca all extremities; however it was not addressed on the plan of care. This was confirmed with the director.

Observed in Individual Tracer. In 6 of 10 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the plan of care order was not followed to assess blood sugar monitoring and results. The surveyor noted that there was no evidence in the comprehensive assessment or subsequent visit notes to confirm that the anyone had monitored the patient's blood sugar. Also, in (RR#4) the record indicated that the physician wanted the blood sugar monitored daily in the morning and as needed for symptoms; however there was no evidence in the record that the blood sugar was monitored by anyone. This was confirmed with the director.

Observed in Record Review. The hospice nurse surveyor noted (RR#4) that the plan of care orders did not include BiPAP as indicated in the assessment, Foley catheter orders including the size and when to change the catheter. Also, in (RR#6), the plan of care did not include diet orders and there were no CPAP or oxygen orders for (RR#7), until a month after the patient was admitted with the treatments. This was confirmed with the director. Observed in Record Review. The hospice nurse surveyor noted (RR#3) that the communication notes indicated that the facility staff called to report the patient's blood glucose was 523 and the physician ordered an additional one time dose of Lantus insulin. In a prep note, the nurse documented that the patient's blood sugars were ranging from 256-624; however the care plan did not address and was not updated to include goals or interventions to manage the patient's diabetes or blood glucose levels. Also, in (RR#8), the patient was transferred to General Inpatient level of care for restlessness; however the care plan was not updated to include goals and interventions to manage the symptoms. This was confirmed with the director.

Observed in Tracer Activities. In 7 of 10 patient records reviewed, The hospice nurse surveyor noted that leadership and the governing body should have reasonably known about repeat finding with the requirements of the COP's (418.56 and 418.100).

Observed in Record Review. In 3 of 16 patient records reviewed, the organization did not perform a patient specific comprehensive assessment. In HSP RR #1, the hospice surveyor noted the patient's terminal diagnosis was cerebral infarction and the patient was on GIP care for seizures; however, the admission assessment did not include an assessment of the seizures to include type or last seizure. In addition, the patient was receiving IV phenobarbitol; however, there was no assessment of the IV site at the time of admission or the following visit. This was confirmed with the hospice director. In HSP HV #2, the hospice surveyor noted the wound measurements were only obtained twice since admission two months ago; however, the organization policy Wound Care and Management required weekly wound measurements. This was confirmed with the hospice director. In HSP RR #7, the hospice surveyor noted the organization did note measure the wound at admission or since the start of care. In addition, there was no wound assessment performed on the weekly skilled nursing visit, per documentation the father was performing wound care. This was confirmed with the hospice director.

Observed in Record Review. In 2 of 16 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings, and services required to meet those goals. In HSP RR #6, the hospice surveyor noted the plan of care teach fall prevention goal time frame was the end of the certification period. In addition, the following goal was non-measurable: anxiety reduced and within manageable level. This was confirmed with the hospice director. In HSP RR #8, the hospice surveyor noted the plan of care included the following non-measurable goal: patient will maintain optimum bowel functioning consistent with food intake and stage of disease. This was confirmed with the hospice director.

Observed in Record Review. In 14 of 16 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HSP HV #1, the hospice surveyor noted the patient was identified as requiring fall precautions; however, the plan of care did not include interventions to reduce the risk of falls. In addition, the patient developed constipation the second week of service in the first certification period and edema in the current certification period; however, the plan of care was not updated to include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #1 GIP, the hospice surveyor noted the patient was identified as having dysphagia, edema, and fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP HV #2, the hospice surveyor noted the patient was identified as having high nutritional risk and at risk for falls; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice director. In HSP HV #4, the hospice surveyor noted the patient identified as having pain, fatigue, nausea, depression, anxiety, fall risk and skin breakdown risk; however, the plan of care did not include interventions to address these identified needs except to assess the patient. This was confirmed with the hospice director. In HSP RR #2, the hospice surveyor noted the patient was identified as having pain, drowsiness, and at fall risk; however, the plan of care did not include interventions to address these identified needs except to assess the patient. This was confirmed with the hospice director. In HSP RR #3, the hospice surveyor noted the patient was identified as having depression, fatigue, poor appetite, depression, dysphagia, pain, fall risk and skin breakdown risk; however, the plan of care did not include interventions to address this identified risk,. This was confirmed with the hospice director. In HSP RR #5, the hospice surveyor noted the patient was identified as having fatigue, anxiety, dysphagia skin break down risk, and fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #6, the hospice surveyor noted the patient was identified as having pain, shortness of breath, edema, diarrhea, and dizziness; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #7, the hospice surveyor noted the patient was identified as having pain and anxiety; however, the plan of care did not include interventions to address identified needs. This was confirmed with the hospice director. In HSP RR #8, the hospice surveyor noted the patient was identified as having pain, anxiety, shortness of breath, edema and skin breakdown risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #9, the hospice surveyor noted the patient was identified as having diarrhea, skin breakdown, fall risk, and dysphagia; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #10, the hospice surveyor noted the patient was identified as having edema and at risk for falls ;however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #11, the hospice surveyor noted the patient was identified as having depression, skin breakdown; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #12, the hospice surveyor noted the patient was identified as having pain, anxiety, fall risk, skin breakdown risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director.

Observed in Record Review. In 6 of 16 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In HSP HV #2, the hospice surveyor noted the plan of care included the following visit frequencies: SN 10 PRN visits for symptom management, Chaplain 7 PRN as needed during cert period, MSW 8 PRN as appropriate for additional support; however, the indication for chaplain and MSW were not appropriate and the number of PRN visits were too high and therefore the visit frequency may not have met the patient identified needs. This was confirmed with the hospice director. In HSP HV #4, the hospice surveyor noted the plan of care visit frequency indicated: Chaplain 2 prn visits for support as needed, medical social worker 4 prn for assess caregiving needs and skilled nursing included 7 PRN visits. This was confirmed with the hospice director. In HSP RR #4, the hospice surveyor noted the plan of care included a skilled nursing visit frequency of 7 PRN visits to assess comfort; however, this was not a specific indication. This was confirmed with the hospice director. In HSP RR #6 and HSP RR #8, the hospice surveyor noted the plan of care included a medical social worker visit frequency of 4 PRN to assess caregiving needs. This was confirmed with the hospice director. In HSP RR #7, the hospice surveyor noted the plan of care included two different visit frequencies on plan of care for skilled nursing, one visit frequency indicated 2 - 3 week 12 starting second week of service and the second visit frequency for skilled nursing indicated 1 week 12 starting second week of service. In addition, the plan of care visit frequency for MSW indicated 1 -2 month 1 and then 1 - 4 month 3; however, this range is too great. This was confirmed with the hospice director. In HSP RR #10, the hospice surveyor noted the plan of care included 10 prn visits for skilled nursing and the chaplain visit frequency included 7 prn visits; however, the indication for the chaplain was as needed for cert period. This was confirmed with the hospice director.

Observed in Record Review. In 15 of 16 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In HSP HV #1, the hospice surveyor noted the plan of care included the following wound care treatment order: foam dressing for treatment of topical abrasions and/or stage 1 -2 pressure ulcers; however, the patient was not identified as having a skin abrasion on admission. In addition, the plan of care included the following prn medications: Guaifenesin with dextromethorphan syrup prn cough; however, the patient did not have a cough and this medication was not in the home at the time of the visit. Loperamide prn diarrhea; however, the patient did not have this symptom and the medication was not in the home at the time of the visit. Benadryl prn pruritis; however, the patient did not have this symptoms and this medication was not in the home at the time of the visit. The plan of care indicated foley catheter #16 fr to straight drain for urinary retention or incontinence or may use 18 fr if larger size indicated. May irrigate foley catheter with 30 - 60 ml NS prn occlusion; however, the patient did not have urinary issues identified on the admission assessment and the plan of care order was incomplete for the size of the catheter and balloon and frequency of change. In addition, the plan of care included an oxygen order for 2 - 5 liters per nasal cannula prn; however, the patient was on 5 liters continuous oxygen on admission. Also, the patient was identified as having a wound to left ankle; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice director. In HSP RR #1 GIP, the hospice surveyor noted the plan of care diet order indicated pleasure; however, the diet type was not specified and the patient was identified as having dysphagia. In addition, the plan of care indicated O2 2 - 6 liters continuous as needed; however, this order was not clear as to whether it was to be given as needed or continuous. Also, the plan of care indicated change foley catheter as ordered; however, did not specify the size of the catheter or balloon. This was confirmed with the hospice director. In HSP HV #2, the hospice surveyor noted the plan of care indicated change foley catheter prn if leaking or unable to irrigate; however, patient did not have foley catheter. Ice or heat to affected area for 20 minutes 4 x's per day prn comfort; however, no location was specified. Oxygen 2 -5 liters prn via nasal cannula prn comfort; however, the patient did not have oxygen in the home. This was confirmed with the hospice director. In HSP HV #3, HSP HV #4, HSP RR #3, HSP RR #4, HSP RR #5, HSP RR #6, HSP RR #7, HSP RR #8, HSP RR #9 and HSP RR #10, the hospice surveyor noted the plan of care indicated the plan of care included the following wound care treatment order: foam dressing for treatment of topical abrasions and/or stage 1 -2 pressure ulcers; however, the patient was not identified as having a skin abrasion or pressure ulcer on admission. In addition, the plan of care included the following prn medications: Guaifenesin with dextromethorphan syrup prn cough; however, the patient did not have a cough and this medication was not in the home at the time of the visit. Loperamide prn diarrhea; however, the patient did not have this symptom and the medication was not in the home at the time of the visit. Benadryl prn pruritis; however, the patient did not have this symptoms and this medication was not in the home at the time of the visit. The plan of care indicated foley catheter #16 fr to straight drain for urinary retention or incontinence or may use 18 fr if larger size indicated. May irrigate foley catheter with 30 - 60 ml NS prn occlusion; however, the patient did not have urinary issues identified on the admission assessment and the plan of care order was incomplete for the size of the catheter and balloon and frequency of change. In addition, the plan of care included an oxygen order for 2 - 5 liters per nasal cannula prn; however, the patient was on 5 liters continuous oxygen on admission. This was confirmed with the hospice director. In HSP HV #4, the hospice surveyor noted the plan of care included chest physiotherapy; however, the intervention did not specify the frequency or duration of treatment. This was confirmed with the hospice director. In HSP RR #2, the hospice surveyor noted the patient was identified as having a stage 1 pressure ulcer and a surgical incision; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director. In HSP RR #4, the hospice surveyor noted the nurse identified on admission the patient was to be on a 1.5 liter fluid restriction; however, this was not included on the plan of care. This was confirmed with the hospice director. In HSP RR #5, the hospice surveyor noted the plan of care diet indicated diet as tolerated; however, the plan did not specify a specific diet type and the patient had dysphagia. This was confirmed with the hospice director. In HSP RR #6, the hospice surveyor noted the plan of care included duplicate Ativan orders of 0.05 mg take 0.5 tabs every 6 hours as needed one entry for restlessness and the second entry was for anxiety; however, the organization did not clarify if the order to determine if the patient could take up to 1 mg every 6 hours. This was confirmed with the hospice director. In HSP RR #7 and HSP RR #9, the hospice surveyor noted the plan of care wound care order included prn dressing; however, the plan of care did not specify the indication. This was confirmed with the hospice director. In HSP RR #11, the hospice surveyor noted the patient was identified as having a wound and a foley catheter; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the director of hospice. In HSP RR #12, the hospice surveyor noted the patient had a pleurx catheter on admission; however, the plan of care did not include interventions to address the care of the pleurx catheter. This was confirmed with the hospice director.

Observed in Record Review. In 5 of 16 patient records reviewed, the organization did not ensure the care and services were provided in accordance with the plan of care. In HSP HV #2, the hospice surveyor noted the plan of care visit frequency for the aide was three times per week; however, the aide visited the patient four times the sixth week of service. The chaplain performed a telehealth visit; however, the plan of care did not include telehealth visits. In addition, the plan of care visit frequency for skilled nursing was three times per week; however, only two visits were made the fifth week of service. Also, the plan of care diet was full liquid; however, the nurse documented the patient had a sandwich placed by husband in front of her; there was no documentation of reinforcement of the plan of care. This was confirmed with the hospice director. In HSP HV #4, the hospice surveyor noted the plan of care aide visit frequency was two times per week; however, there was one documented missed visit and no second visit made. This was confirmed with the hospice director. In HSP RR #3, the hospice surveyor noted the plan of care indicated a skilled nursing visit frequency of two times per week; however, only one visit was made the fifth week of service. This was confirmed with the hospice director. In HSP RR #4, the hospice surveyor noted the chaplain performed a telehealth visit on the initial assessment; however, the plan of care did not include telehealth visits. In addition, the plan of care included an order to assess orthostatic BP each visit; however, this was not done on the second nursing visit performed. This was confirmed with the hospice director. In HSP RR #5, the hospice surveyor noted the plan of care skilled nursing visit frequency was two times per week; however, on the fifth week of service only one visit was made with no documentation of a missed visit. In addition, the skilled nurse performed two telehealth visits; however, the plan of care did not include telehealth visits. This was confirmed with the hospice director.

Observed in Record Review. In 3 of 16 patient records reviewed, all disciplines that provide care, treatment or services to the patient collaborate and coordinate their efforts to support the goals outlined in the plan of care. In HSP HV #1, the hospice surveyor noted the nurse documented the patient developed jerky body movements; however, the physician was not notified until 10 days later per the IDG documentation. This was confirmed with the hospice director. In HSP RR #4, the hospice surveyor noted the patient was identified as having an elevated diastolic BP of 94 on admission; however, the physician was not notified of the elevated blood pressure until 7 days later at IDG. This was confirmed with the hospice director. In HSP RR #9. the hospice surveyor noted the patient's blood pressure was 80/52; however, there was no documentation of physician notification. This was confirmed with the hospice director.

Observed in Individual Tracer. In 1 of 4 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HSP HV #2, the hospice surveyor noted the skilled nurse went into three pockets of the nursing bag without performing hand hygiene upon arrival to obtain equipment and hand hygiene supplies. In addition, the skilled nurse doffed their gloves and donned new gloves without performing hand hygiene as required by the hand hygiene policy. This was confirmed with the director of hospice.

Observed in Record Review. In 1 of 2 bereavement records reviewed, the hospice did not develop a bereavement plan of care that specified the type of services and the frequency of the services to be delivered. In BRV #1, the hospice surveyor noted the bereavement plan of care did not specify the frequency of the hospice mailings or the frequency of the phone contact. In addition, the bereavement plan of care was not developed until 2 months after the post-death bereavement risk assessment was performed. This was confirmed with the Bereavement Counselor.

Observed in Record Review. In 2 of 5 patient records reviewed where the patient received aide services, the registered nurse did not prepare written patient care instructions for the hospice aide. In HSP HV #1, the hospice surveyor noted the aide plan of care indicated shower; however, the plan did not specify shower chair. This was confirmed with the hospice director. In HSP HV #2, the hospice surveyor noted the aide plan of care included seizure precautions; however, the patient did not have seizures identified as a symptom on the admission assessment. This was confirmed with the hospice director.

Observed in Record Review. In 1 of 5 patient records reviewed where the patient received aide services, the hospice aide did not provide services as ordered in the plan of care. In HSP RR #5, the hospice surveyor noted the first aide visit note only indicated the aide assisted in dressing the patient. There was no documentation the other tasks assigned were performed which included a bed bath; however, there was no documentation the patient refused or the RN was notified. This was confirmed with the hospice director.

Observed in Record Review. In 2 of 5 patient records reviewed where the patient received aide services., the registered nurse did not supervise the hospice aide on-site every 14 days. In HSP HV #4, the hospice surveyor noted the aide supervisory visits were performed 15 days apart and 17 days apart. This was confirmed with the hospice director. In HSP RR #5, the hospice surveyor noted the first aide supervisory visit was performed 18 days after the first aide visit. This was confirmed with the hospice director.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.56.

Observed in Record Review. In 1 of 16 patient records reviewed, the patient record did not contain all clinical information. In HSP RR #5, the hospice surveyor noted in the PRN visit the second month of service, the skilled nurse inserted a foley catheter; however, the documentation did not specify the size of the catheter or the balloon. The documentation only indicated per facility protocol. This was confirmed with the hospice director.

Observed in Record Review. In 1 of 1 patient records reviewed where the patient was discharged from hospice services, the organization did not create a written discharge summary. In HSP RR #11, the hospice surveyor noted the organization did not prepare a written discharge summary when the patient revoked hospice services. This was confirmed with the hospice director.

Observed in Individual Tracer. In 3 of 4 home visits conducted, the hospice did not provide education on an individualized emergency plan based on the patient's identified needs. In HSP HV #1, HSP HV #2, and HSP HV #3 the surveyor noted the organization had not provided the patient with an individualized emergency plan based on the patient's assessed needs. There was no evidence the patient had been educated on an individualized emergency management plan to address clinical, functional, and communication needs; reliance upon equipment or assistive devices; and available caregiver support. In discussion with agency leadership, the organization did not have a process in place to provide the patient with this individualized information. This was confirmed with the hospice director.

Observed in Individual Tracer. In 1 of 4 home visits conducted, the organization did not take action to minimize identified safety and security risks. In HSP HV#1, the hospice surveyor noted there was a freestanding oxygen cylinder in the patient's home that the medical social worker identified; however, did not correct by lying the cylinder flat at the time of the visit. This was confirmed with the hospice director.

Observed in Building Tour. The hospice surveyor noted there was a bench located in the pathway of egress in the hallway of rooms 1 - 6 and rooms 1 - 7 that was not secured to the wall. This was confirmed with the director of safety/security/emergency management. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Record Review. In 2 of 3 patient records reviewed where the patient resided in a nursing facility, the hospice plan of care did not identify which provider was responsible for performing respective functions on the plan of care. In HSP RR #2, the hospice surveyor noted the patient resided in a skilled nursing facility; however, the plan of care did not specify which provider was responsible for the wound care or foley catheter care. This was confirmed with the hospice director. In HSP RR #3, the hospice surveyor noted the patient resided in a skilled nursing facility; however, the plan of care did not specify who was responsible for the wound care to the toes. This was confirmed with the hospice director.