Every finding on record at Bella Vista Hospice Care, Inc.

Based on observation, interview, record review and policy review, the hospice failed to promote and protect the patient’s rights in accordance with the hospice policy and procedures and nationally recognized guidelines. (Refer to L-502, L-512 and L-518) --- The CONDITION OF PARTICIPATION was not met when:1. the hospice agency (HA) failed to provide patient 1 a written or verbal notice patient rights. Patient 1 was not aware of his rights and responsibilities before the hospice begins to provide care.  (Refer to L-502)2. the hospice failed to ensure that two (patients 1 and 3) of the 14 patients in the sample received effective symptom control for conditions related to terminal illness. (Refer to L-512)3. the hospice agency (HA) failed to ensure patient 1 was fully informed of all hospice benefits. Patient 1 lacked three of the nine prescribed medications. (Refer to L-518) The cumulative effects of these systemic problems resulted in the hospice’s inability to ensure the provision of quality health care and inability to comply with the Conditions of Participation 42 CFR 418.52 Patients’ Rights.

Based on observation, record review, and interview, the hospice agency (HA) failed to provide a written or verbal notice of patient rights for one of three patients (Patient 1) who was selected for home visits. Patient 1 was not aware of his rights and responsibilities before the hospice begins to provide care.  This failure violated patient 1's autonomy and legal rights. --- During a review of the HA’s policy and procedure (P&P) titled “Patient Bill of Rights/Responsibilities” dated 4/2020, the P&P indicated, “Each patient will be an active, informed participant in his/her plan of care…” During a home visit observation on 3/19/25 at 5 :00PM at patient 1's house (independent living), Patient 1 was observed verbal/vocal, not physically or mentally incapacitated, can walk with the use of a walker and acting for himself. Patient 1 was questioned whether the hospice staff had informed him of his rights as a hospice patient, and if he has a copy of the hospice's legal documents or hospice binder. Patient 1 verbalized “I don't know what you're asking about. I don’t know what hospice means. No one explained to me what hospice is. I don’t have hospice binder. A guy with a beard came to visit me twice in three months and took my blood pressure, he asked what I was taking. And a little girl visited me a month and a half ago. They don't explain what hospice is. I thought they work for the hospital.”  During a concurrent record review and interview with the office assistant (OA) on 3/21/25 at 3:00 PM, patient 1's clinical record (CR) was discussed, the CR indicated that the consent for patient 1's hospice care and treatment was signed by his brother. OA explained that patient 1's brother does not have power of attorney (POA). The OA acknowledged that patient 1 has the capacity of making his own decisions, but the brother signed the consent for hospice on his behalf.

Based on observations, interviews and record reviews, the hospice failed to ensure that two (patients 1 and 3) of the 14 patients in the sample received effective symptom control for conditions related to terminal illness when: 1. Patient 1 had right foot pain documented, but no pain medication was ordered. This failure put the patient at risk for unmonitored discomfort, which could impair his ability to walk.2.The hospice staff failed to ensure that patient 3's oxygen (colorless gas essential for life) was administered in line with the care plan in place and as ordered by the physician. This failure had the potential to be harmful, resulting in oxygen toxicity and poisoning if too much oxygen was administered. --- Findings:2. During Patient 3’s visit at the facility (Senior Living) on 3/19/25, at 11:00 a.m. an oxygen concentrator machine (a type of medical device that delivers supplemental oxygen) with used oxygen tubing was observed on the floor next to Patient 3’s bed.During interview on 3/19/25, at 11:30 a.m. with the hospice Certified Home Health Aid (CHHA6), the CHHA6 verbalized that according to the facility staff, Patient 3 used the oxygen during the night.During a review of Patient 3’s Face Sheet, dated 11/21/24, Patient 3’s Start of Care was 11/21/24.During a review of Patient 3’s Comprehensive Nursing Assessment (a detailed assessment done by a Registered Nurse - RN), dated 11/21/24, Patient 3’s respiratory (breathing) assessment indicated, Patient 3 had shortness of breath (difficulty breathing) upon moderate exertion (physical activity). RN recommended the use of the use of an oxygen concentrator and an E tank (a portable medical device in tank that delivers oxygen).During a concurrent interview and record review on 3/21/25, at 4:00 p.m. with LN 1, Patient 3’s POC, and physician’s order were reviewed. LN 1 verbalized that Patient 3 has an order for oxygen due to risk for SOB. LN 1 further verbalized, the POC for respiratory must be initiated and was not.During a review of the facility’s policy and procedure (P&P) titled, “P&P titled, “Comprehensive Assessment,” dated 2018, the P&P indicated, “1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record including…P. Equipment presently in home and potentially needed by patient…”During a review of the facility’s P&P titled, “The Plan of Care,” dated 2018, the P&P indicated, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to hospice program…2. The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient’s needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered.” Findings : During a review of the medical record ) for Patient 1 on 3/14/25, the MR indicated the hospice  primary diagnosis is Chronic Obstructive Pulmonary Disease (COPD- air passages in the lungs and chest are obstructed - no airflow circulating in the body). The other diagnosis included pulmonary disease (PD-condition affecting the lung area), Chronic Kidney Disease (CKD- inability of the kidneys to function secondary to being diseased) among others. The MR further indicated, Patient 1's mode of mobility is via cane or walker, and the patient requires assistance on walking, toileting,transfer, dressing, and bathing .          Review of the nurses visit notes indicated entries dated 2/14/25,2/26/25,3/12/25 of the patient having right foot pain.           Review of Patient 1's current treatment, medication DME list dated 1/11/25 did not reflect any orders for  pain medication or intervention to address the patient's  right foot pain.           During an interview on 3/19/25 at 4:45 pm , the Assistant Director of Nursing (ADON) indicated, the hospice staff uses non pharmacological interventions (NPI)  to address Patient 1's right foot pain. The ADON was not able to show documentation or verbalize what are these NPIs implemented on Patient 1.

Based on observation, record review and interview, the hospice agency (HA) failed to ensure that one (patient 1) of the 14 patients in the sample was fully informed of all hospice benefits. Patient 1 lacked three of the nine prescribed medications. This failure had the potential to lead to a worsening of patient 1’s condition. --- During a home visit observation on 3/19/25 at 5 PM at patient 1's house (independent living), Patient 1 was queried about his medication supplies at home. Patient 1 showed the medications that were available, but when compared to the medication list, three out of the nine prescribed medications, including insulin injection, anti-cholesterol tablet, and anti-psychotic medication, were not at home. Patient 1 verbalized “I don't know the agency's phone number and medication supplies they provide. A girl (female) nurse came to see me a month and a half ago. They don't tell me when they will be returning."  During a concurrent record review and interview with the licensed nurse (LN1) on 3/21/25 at 3:15 PM, patient 1's clinical record (CR) was discussed, the CR indicated that patient 1 has medical conditions including but not limited to Type 2 diabetes (High blood sugar), Hyperlipidemia (high cholesterol) and psychotic disorder (mental disorder). Patient 1’s prescribed medications included insulin, anti-cholesterol and anti-psychotics. During the home visit on 3/19/25, these medications were not at home. Patient 1 does not know the phone number of the hospice. LN1 confirmed this finding.

Based on observation, interviews, and record reviews, the facility failed to ensure that nursing services were properly conducted in the following instances:No medication reconciliation for one patient (Patient 10) during a home visitMissed visits for 3 sampled patients (Patient 8, 9 and 12) out of 14 sampled patients.No visit notes for one patient (Patient 9) This facility failure had the potential to prevent patients from receiving the necessary care and services. --- 1. During a home visit with the licensed nurse (LN2)  on 3/19/25 at 2 pm, the licensed nurse was observed talking to the patient 10's wife asking if there were any medication needed to be refilled. The LN2 did not check the home medication list with the hospice facility medication list and did not check all the patient’s on hand home medication with the hospice medication list.During an interview with the LN2 on 3/19/25 at 2:38 pm, LN2 indicated she does not check all the patient’s medication every visit.During an interview with the assistant director of nursing assistant (ADON) on 3/21/25 at 4:33 pm, the ADON indicated medication reconciliation should be done every visit.The facility policy and procedure titled “Medication Monitoring” dated April 2020 indicates, “Evaluate the continued use of a medication in the current regimen” .2. Review of  Patient 12’s health record on 3/20/25 at 11:29 am, the health records indicates Patient 12 had an order for skilled nursing visit for one per week plus 3 visits as necessary for certification period 12/29/24 to 2/26/25. On the week of 2/9/25 to 2/15/25 no skilled nursing visit were recorded. No missed visit notes in the health record.Review of Patient 8’s health record on 3/20/25 at 2:49 pm, the health record indicates Patient 8 had an order for skilled nursing visit for one per week plus 3 visits as necessary for certification period 12/20/24 to 2/17/25. On he week of 2/2/25 to 2/8/25 there were no skilled nursing visit were recorded. No missed visit notes in the health record.During an interview with ADON on 3/20/25 at 3 pm, the ADON acknowledged the missed visits  and no missed visit note.Review of Patient 9’s health records on 3/20/25 at 3:44 pm, the health record indicates Patient 9 had an order for one skilled nursing visit per week plus 3 visits as necessary for the certification period 2/13/25 to 4/13/25. From 2/23/25 to 3/15/25 (3 weeks) there was no recorded skilled nursing visits.  During an interview with the ADON on 3/20/25 at 4 pm, the ADON acknowledged the missed visits  and no missed visit note.The facility policy and procedure titled “ Missed Visits” dated April 2020 indicates “Missed visits will be communicated to the interdisciplinary group at the IDG meeting. A missed visits will be rescheduled at the same week if possible. Missed visits will be documented in the clinical record.3. Review of Patient ’s 9 health record on3/20/25 at 3:44 pm, the health records indicates patient had an order for 1 skilled nursing visit per week wIth 3 visits as necessary. From 2/23/25 at 3/15/25 there was no recorded visit notes or assessments. During an interview with the ADON on 3/20/25 at 4 pm, the ADON assistant indicated she thinks visits were made but the licensed nurse (LN3) is “horrible” documenting patient visits.The facility policy and procedure titled “Assembly Of Clinical Record” dated April 2020 indicates in part “All clinical record will be assembled and maintained according to hospice policy and applicable state and federal law…. The contents of the record will be assembled as follows:… Section V: Nurses Clinical Notes; A – Initial, comprehensive and ongoing comprehensive assessments. B – Clinical notes.”

Based on record review and interview, the hospice agency failed to demonstrate, through documentation, that the medications and medication list for patient 10 were reconciled as frequently as needed. This failure had the potential to result in medication discrepancies, which could lead to dosing errors, omissions, and duplications. --- During a home visit with the licensed nurse (LN2) on 3/19/25 at 2 pm, the LN2 was observed speaking with patient 10’s wife and inquiring if she needed any medication refilled. The LN2 did not compare the home medication list to the hospice agency medication list, nor did she compare all the patient 10’s home medications with the list the hospice medication list. During an interview with the LN2 on 3/19/25 at 2:38 pm, LN2 stated, “I do not check all of the patient’s medications every visit.” During an interview with the director of nursing assistant (LN1) on 3/21/25 at 4:33 pm, the LN1 stated that “medication reconciliation should be done every visit.” During a review of the hospice agency’s policy and procedure (P&P) titled “Medication Monitoring” dated April 2020, the P&P indicated, “Evaluate the continued use of a medication in the current regimen.”

Based on observation, record review, and interview, the hospice failed to ensure nursing evaluations for one of 14 patients (Patient 3), when patient 3 was detected as having a wound (left breast lesion) and no wound measurement was documented and the plan of care not updated.  This failure had the potential to result in the wound not being effectively managed, causing discomfort and emotional distress for patient 3. --- Findings:During a review of the Patient 3’s Skin Assessment signed by the Registered Nurse (RN), dated 2/19/25, the skin documentation indicated, a right breast wound with the open date of 2/19/25, color of red, drainage serosanguinous (clear liquid part of blood), no odor, and no information on what the size of the wound was. The skin documentation further indicated in part, “…right breast wound was assessed for size, depth..”During a concurrent interview and record review on 3/21/25, at 4:08 p.m. with the LN 1, Patient 3’s Skin Assessment was reviewed. LN 1 verbalized that a comprehensive assessment must be done for skin assessment. LN 1 further verbalized that Patient 3's right breast wound was not comprehensively assessed and had an incomplete skin assessment information.During a review of the facility’s policy and procedure (P&P) titled, “Comprehensive Assessment,” dated 2018, the P&P indicated, “During comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including…E. Current treatment and patient’s response to that treatment…G. A physical assessment, including…skin and other relevant data related to the pertinent physical findings…”Further review of the P&P tiled, “Ongoing Assessment,“ dated 2018, the P&P indicated in part,  “1. During each home visit, the Case Manager will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse will assess each patient on each visit, for: … G. Skin integrity…”

Based on record review and interview, the hospice agency failed to ensure the update of the comprehensive assessment was accomplished by all members of the IDG team when IDG meetings were not signed for eight of 14 patients in the sample. (Patient 3, 11, 6, 4, 8, 9,10, and 12).This failure had the potential to cause each of these patients' care team members to fail to provide an update on the patient's current condition and or to identify any concerns. --- Findings:2. During a review of Patient 3’s IDG notes reveals only signed by the RN and MSW on 2/19/25, 2/26/25 and 3/12/25. During a review of Patient 4’s IDG notes reveals only signed by the MSW on 12/19/24, 1/2/25 2/12/25, 2/16/25 and 3/12/25. Further review of Patient 4’s IDG notes reveals that on 1/16/25 and 1/29/25, the notes was signed by the MSW, the RN and the physician.During a review of Patient 6’s IDG notes reveals only signed by the RN on 12/5/24, 12/19/24 1/2/25, 1/16/25, 1/29/25, 2/12/25 and 2/26/25. Further review of the IDG, dated 12/4/24, no signature of the IDG member was found.During a review of Patient 11’s IDG notes reveals only signed by the RN and SC (Spiritual Counsellor) on 9/26/24, Further review of Patient 11’s IDG notes reveals that on 10/10/24, 10/24/24 and 11/7/24, the notes was signed only by the SC.During an interview on 3/21/25, at 11:30 a.m. with the administrator (ADM), the ADM verbalized that the IDG meeting is attended by Administrator, Director of Nursing, Case Manager, Medical Director, MSW, Chaplain, visiting RN and Licensed Vocational Nurse and Home Health Aid. The ADM further verbalized that the IDG is done every other Wednesday in the office and the IDG meeting notes is signed by attendees.During a concurrent interview and record review on 3/21/25, at 11:35 a.m. with the Licensed Vocational Nurse (LN 1), the IDT notes for Patient 3,4, 6 and 11 were reviewed. LN 1 verbalized that the IDG is done via zoom (video call) meeting and no longer done in the office. LN 1 acknowledged the missing signatures on the IDG meeting notes for Patient 3, 4, 6 and 11.During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Group Meeting,” dated 2018, the P&P indicated, “The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, death and changes in patient and family/caregiver circumstances referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. The meeting will be facilitated by the hospice Clinical Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available…1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.   Review of the interdisciplinary group (IDG) notes on 3/21/25 at 10:30 indicates for: Patient 8, IDG review dated 2/26/25 reveals only the social worker (MSW) had signed the IDG review meeting.Patient 9, IDG review dated 2/26/25 reveals only the had signed the IDG review meeting.Patient 10, IDG review dated 2/26/25 reveals only the registered nurse only signed the IDG review meeting.Patient 12, IDG review dated 1/2/25 reveals only the registered nurse only signed the IDG review meeting. Interview with the administrator (ADM) on 3/21/25 at 11:30 am, the the ADM indicated IDG meetings are done every other Wednesday. The ADM acknowledged most members are not signing the IDG review. ADM indicated all members should sign the IDG review. The facility policy and procedure titled “ Contents Of Medical Record” dated April 2020 indicates in part “Documentation will include:…D. Plan of care developed/revised by the interdisciplinary group based on comprehensive assessments and desired outcomes with time frames… M. Signed and dated clinical notes.

Based on record review and interview, the hospice agency failed to provide services according to the plan of care for one of 14 patients in the sample when the hospice aide (HA) failed to follow the HA assignment of taking patient 3's vital signs at each visit. This failure has the potential to have an impact on and undermine the objectives of patient 3's care plan. --- Findings:During a review of the facility’s policy and procedure (P&P) titled, “Comprehensive Assessment,” dated 2018, the P&P indicated, “1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including…G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings…”During a review of Certified Hospice Aide Job Description, dated 2018, the job description indicated, “Responsibilities of the hospice aide include, but are not limited to the following:.. 8. Taking and recording oral, rectal and auxiliary temperatures, pulse, respiration and blood pressure when ordered with appropriate completed/demonstrated skills competency."During a concurrent interview and record review on 3/25/25, at 11:31 a.m. with the Licensed Vocational Nurse (LN 1). LN 1 verbalized that the RN will provide instructions to CHHA (Certified Home Health Aide) if vital signs are needed on form titled, (HA - Health Aide) “HA Assignment”. The HA Assignment and paper and electronic HA visit note were reviewed. The HA Assignment indicated, to check patient’s vital signs every visit. LN 1 acknowledged the missing vital signs.

Based on record review and interview, the hospice agency (HA) failed to ensure that all members of the interdisciplinary group (IDG) participated in the review and updates of the plan of care (POC) for one of 14 sampled patients. (Patient 7)This failure had the potential to prevent ongoing assessments conducted by IDG members from being evaluated and collaborated on by all members as well as the physician. --- During a review of the HA's policy and procedure (P&P) titled "Interdisciplinary Group Plan of Care" dated 4/2020, the P&P indicated, "...Care will be provided by an interdisciplinary group made up of physicians, nurses, social workers, certified hospice aides, homemakers, clergy, counselors, volunteers, and therapists...The interdisciplinary group...will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days..." During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/25/25 at 4:00 PM, patient 7’s clinical records (CR) for the election date 11/14/24 until the end day of the survey were reviewed. The CR included a plan of care/interdisciplinary group (POC/IDG) review conducted by the social worker on 11/21/24, 12/5/24, 12/19/24, 1/2/25, 1/16/25, 1/30/25, 2/10/25, and 2/26/25. There was no participation from the remaining IDG members. There was no subsequent POC/IDG review following the last one on 2/26/25. Patient 7 had a fall incident on 1/11/25, but there was no documented evidence that it was discussed in the IDG meeting or reported to the physician. These findings were validated by the licensed nurse (LN1).

Based on observation, record review, and interview, the hospice agency (HA) failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program had performance improvement initiatives in place, as well as a discussion of outcomes and ongoing plans. --- The CONDITION OF PARTICIPATION was not met when the hospice agency failed to: 1)Implement a quality assessment performance improvement (QAPI) program that regularly analyzes quality data, including patient care and other areas, to assess the effectiveness of its services and identify areas for improvement. (Refer to L-563) 2)Ensure performance improvement are being conducted, developed, documented, and progress tracked to measure improvement. (Refer to L571)  The cumulative effects of these systemic problems rendered the hospice unable to comply with Condition of Participation 42 CFR 418.58 Quality Assessment and Performance Improvement.

Based on record review and interview, the hospice agency (HA) failed to implement a quality assessment performance improvement (QAPI) program that regularly analyzes quality data, including patient care and other areas, to assess the effectiveness of its services and identify areas for improvement. This failure has the potential to not ensure that the services are adequate and had a potential to compromise the HA’s capacity to safeguard its patients. --- During a review of the HA's policy and procedure (P&P) revised 2015, the P&P indicated, "...Data collection will be ongoing...Data collected will be used to monitor the effectiveness and safety of services and the quality care..." During a record review and concurrent interview with the licensed nurse (LN1) on 3/25/25 at 3:00 PM, the QAPI was discussed, there was no documentation that the agency had evaluated its QAPI program annually for its hospice-wide effectiveness on the quality of care provided and activities that impact patient health and safety in 2024 and 2025. There was no documentation indicating that the QAPI committee met regularly to maintain an effective, ongoing, hospice-wide data driven QAPI plan for 2024 and 2025. The LN1 confirmed this finding.During an interview with the administrator (ADM) on 3/25/25 at 5:10 PM, the QAPI was discussed, the ADM was unable to comment. The ADM was unable to provide verification of QAPI documentation for 2024 and 2025.

Based on record review and interview, the hospice agency (HA) failed to ensure performance improvement are being conducted, developed, documented, and progress tracked to measure improvement. This failure had the potential to result in reduced or poor quality of care, potentially falling behind regulatory standards. --- The facility policy and procedure (P&P) titled "Quality Assessment and Performance Improvement (QAPI) Plan" revised 2015, indicated in part, "...The hospice must document what performance improvement projects (PIP) are being conducted...Hospice will document what performance improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on them…" During a review of the HA’s performance improvement project (PIP) binder and concurrent interview with the licensed nurse (LN1) on 3/25/25 at 3:00 PM, the PIP documents discovered were dated 2023. There are no PIP(s) for 2024 and 2025. The LN1 confirmed this finding. During an interview with the administrator (ADM) on 3/25/25 at 5:10 PM, the PIP was discussed, no documents were available for review and LN1 could not find it either. The ADM was unable to speak to it. The administrator was unable to produce documentation of any monitoring of the PIP, their effectiveness, or any changes made to address the need to adjust the plans.

Based on clinical record review, interview, and policy review, the hospice failed to ensure all Core Services were provided in a manner consistent with acceptable standards of practice. (Refer to L-590, L-591, L-594, and L-595) --- The Condition of Participation was not met when: 1.)the hospice licensed nurse failed to notify the physician of changes in condition and treatment on one (patient 3) of the 14 sampled records reviewed. (Refer to L-590) 2.)the hospice agency (HA) failed to ensure nursing care and services were provided for six of 14 patients in the sample (Patients 5, 2, 7, 3, 6, and 4). (Refer to L591) 3.)the hospice agency (HA) failed to ensure that one of the 14 sampled patients (patient 6) was assessed and evaluated by the medical social worker (MSW) within five days of admission. (Refer to L-594) 4.)the hospice agency (HA) failed to ensure counseling services were available to patient and family when no bereavement services were provided within 5 days of admission and after the death for patient 14 and no spiritual counseling services were provided for patients 2 and 14. (Refer to L-595) The cumulative effects of these systemic problems resulted in the hospice’s inability to comply with the Conditions of Participation 42 CFR 418.64 Core Services.

Based on observation, record review, and interview, the hospice licensed nurse failed to notify the physician of changes in condition and treatment on one (patient 3) of the 14 sampled records reviewed. This failure had the potential to adversely affect Patient 3's quality of life during their final months --- Findings:During a review of the facility’s policy and procedure (P&P) titled, “Verification of Physician’s Orders,” dated 2028, The P&P indicated, “Orders will be obtained from a licensed physician (or authorized independent practitioner) for care and services to be provided to hospice patients.”During a review of Patient 3’s Treatment Administration Record (TAR), dated 3/2025, the TAR indicated, Patient 3 left breast rash was treated daily with Nystatin (type of anti-fungal medication) powder and the left heel wound with triple antibiotic ointment daily and as needed.During a review of the Registered Nurse (RN) visit note, dated 3/11/25, the RN documentation indicated, Patient 3 had an existing right breast and left heel wound but no mention of the left breast skin condition.During a review of the hospice current physician’s order, no treatment order was found addressing Patient 3’s left breast rash and left heel wound.During a concurrent interview and record review on 3/21/25, at 3:55 p.m. with the LN 1, the hospice physician’s order and the facility TAR were reviewed. LN 1 verbalized, that the visiting nurse must check the patient’s binder and update the medication and treatment order, updates must be communicated with the facility staff. LN 1 further verbalized that there was no treatment order for the left breast and left foot treatment order.

Based on observation, record review and interview, the hospice agency (HA) failed to ensure nursing care and services were provided for six of 14 sampled patients. (Patients 5, 2, 7, 3, 6, and 4) when: 1)Patient 5 missed one skilled nurse (SN) visit for week 2/2/25 and 3/16/25. No certified hospice aide (CHA) visit for three weeks. The planned number (2X/WK) of CHA visit was reduced to 1X/WK without doctor's approval. Two SN visit notes without signatures.2)For patient 2, multiple clinicians/disciplines (RN, LVN, and CHA) charted incomplete information; CHA’s intended visit frequency of twice per week was not reflected in the plan of care; one out of two CHA visits did not occur on week 3/16/25; and no SN visit in week 3/16/25.3)For patient 7, there were NO skilled nurse (SN) visit on week 3/2-3/8; No supervisory evaluations for certified hospice aide (CHA) and licensed vocational nurse (LVN) during the week of 3/2/25; NO CHA visit on week 3/2-3/8 and 2 subsequent weeks (week 3/9 and 3/16); fall incident on 1/11/25 was not discussed in the interdisciplinary group (IDG) meeting, and not reported to the physician (MD).4)Patient 3 was not properly assessed and recognized as having a wound, resulting in an improperly managed wound; Patient 3 missed SN visits; Patient 3 missed CHA visit; plan of care (POC) was not updated for patient 3; and the CHA task of obtaining vital signs at each visit was not implemented. 5)Patient 6 missed CHA visit. 6)Patient 4 missed CHA visit.  These failures had the potential to prevent the hospice from meeting and achieving the requirements and goals necessary for patient care. --- Findings:4. A. During a review of Patient 3’s facility’s Treatment Administration Record (TAR), dated 9/24/24, the TAR indicated, Patient 3 had a rash under the left breast treated daily with Nystatin (medication that treat fungus) powder.During a review of the hospice POC, dated 3/21/25, there was no POC initiated for the left breast rash.During a concurrent interview and record review on 3/21/25, 3:45 p.m. with the LN 1, the hospice POC and treatment order were reviewed. LN 1 acknowledged the missing POC and hospice treatment order was not updated.During a review of the facility’s P&P titled, “The Plan of Care,” dated 2018, the P&P indicated, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to hospice program…2. The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient’s needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered.”Further review of the P&P titled, “Interdisciplinary Group Meeting,” the P&P indicated, “The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, death and changes in patient and family/caregiver circumstances referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires…6. An interdisciplinary group meeting plan of care update form will be used for update of the patient ad family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include: …B. An increase or decrease of symptoms acuity…3. Condition of skin/presence/status of pressure ulcers…11. For patient residing I a skilled nursing facility, any changes in the plan of care or patient education that has occurred during visit will be communicated to the nursing staff of the skilled nursing facility.”B.  During a review of the facility’s policy and procedure (P&P) titled, “Missed Visit,” dated 20218, the P&P indicated in part, “…1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit. B Document in the patient’s clinical record the…3. Reason for the missed visit.”During a review of Patient 3’s hospice benefit recertification period, dated 2/19/25 to 5/19/25. Patient 3’s Plan of Care (POC) Skilled Nursing (SN) visit order indicated one time per week.Further review of the Patient 3’s clinical record indicated, Patient 3 had missed SN visit the week of 3/2/25 – 3/8/25, 3/16/25 -3/22/25.During a concurrent interview and record review on 3/25/25, at 4:05 p.m. with the Licensed   Vocational Nurse (LN 1), LN 1 acknowledged the missed visits and patient’s POC was not followed. LN 1 was unable to provide additional proof of documentation the reason for the missed visits or if the IDG had been notified.C.  During a review of the facility’s policy and procedure (P&P) titled, “Missed Visit,” dated 20218, the P&P indicated in part, “…1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit. B Document in the patient’s clinical record the…3. Reason for the missed visit.”During a review of Patient 3’s hospice benefit recertification period, dated 2/19/25 to 5/19/25. Patient 3’s Plan of Care (POC) indicated, CHHA (Certified Home Health Aid) visit order indicated, Patient 3 is to be visited two times a week.Further review of the Patient 3’s clinical record indicated, Patient 3 had missed CHHA missed visit the week of 3/2/25 - 3/8/25, 3/9/25 -3/15/25.During a concurrent interview and record review on 3/25/25, at 4:05 p.m. with the Licensed   Vocational Nurse (LN 1), LN 1 acknowledged the missed visits and patient’s POC was not followed. LN 1 was unable to provide additional proof of documentation the reason for the missed visits or if the IDG had been notified.D. During Patient 3’s visit at the Senior Living on 3/19/25, at 11:00 a.m. an oxygen concentrator machine (a type of medical device that delivers supplemental oxygen) with used oxygen tubing was observed on the floor next to Patient 3’s bed.During interview on 3/19/25, at 11:30 a.m. with the hospice Certified Home Health Aid (CHHA6), the CHHA6 verbalized that according to the facility staff, Patient 3 used the oxygen during the night.During a review of Patient 3’s Face Sheet, dated 11/21/24, Patient 3’s Start of Care was 11/21/24.During a review of Patient 3’s Comprehensive Nursing Assessment (a detailed assessment done by a Registered Nurse - RN), dated 11/21/24, Patient 3’s respiratory (breathing) assessment indicated, Patient 3 had shortness of breath (difficulty breathing) upon moderate exertion (physical activity). RN recommended the use of the use of an oxygen concentrator and an E tank (a portable medical device in tank that delivers oxygen).During a concurrent interview and record review on 3/21/25, at 4:00 p.m. with LN 1, Patient 3’s POC, and physician’s order were reviewed. LN 1 verbalized that Patient 3 has an order for oxygen due to risk for SOB. LN 1 further verbalized, the POC for respiratory must be initiated and was not.During a review of the facility’s policy and procedure (P&P) titled, “P&P titled, “Comprehensive Assessment,” dated 2018, the P&P indicated, “1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record including…P. Equipment presently in home and potentially needed by patient…”During a review of the facility’s P&P titled, “The Plan of Care,” dated 2018, the P&P indicated, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to hospice program…2. The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient’s needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered.”E.  During a review of the facility’s policy and procedure (P&P) titled, “Comprehensive Assessment,” dated 2018, the P&P indicated, “1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including…G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings…”During a review of Certified Hospice Aide Job Description, dated 2018, the job description indicated, “Responsibilities of the hospice aide include, but are not limited to the following:.. 8. Taking and recording oral, rectal and auxiliary temperatures, pulse, respiration and blood pressure when ordered with appropriate completed/demonstrated skills competency.During a concurrent interview and record review on 3/25/25, at 11:31 a.m. with the Licensed Vocational Nurse (LN 1). LN 1 verbalized that the RN will provide instructions to CHHA (Certified Home Health Aide) if vital signs are needed on form titled, (HA - Health Aide) “HA Assignment”. The HA Assignment and paper and electronic HA visit note were reviewed. The HA Assignment indicated, to check patient’s vital signs every visit. LN 1 acknowledged that Patient 3's vital signs was not obtained.5. During a review of Patient 6’s hospice benefit recertification period, dated 12/4/24 to 3/3/25. The POC indicated, Patient 6 is to be visited by CHHA one time a week. Further review of the Patient 6’s clinical record indicated, Patient 6 had missed CHHA missed visit the week of 12/22/24 - 12/28/24, and 12/29/24 -1/4/25.During a concurrent interview and record review on 3/25/25, at 4:05 p.m. with the Licensed   Vocational Nurse (LN 1), LN 1 acknowledged the missed visits and patient’s POC was not followed. LN 1 was unable to provide additional proof of documentation the reason for the missed visits or if the IDG had been notified.6. During a review of Patient 4’s hospice benefit recertification period, dated 12/11/24 to 3/10/25. Patient 4’s POC CHHA visit order indicated two times per week.  Further review of the Patient 4’s clinical record indicated, Patient 4 was visited by the CHHA one time instead of two the week of 12/8/24 -12/14/24, 12/15/24 - 12/21/24, 12/22/24 - 12/28/24, 12/29/24 - 1/4/25, 1/5/25 - 1/11/25, 1/12/25 - 1/18/25, 1/19/25 - 1/25/25, 1/26/25 - 2/1/25, 2/2/25 - 2/8/25, 2/9/25 - 2/14/25.During a concurrent interview and record review on 3/25/25, at 4:05 p.m. with the Licensed   Vocational Nurse (LN 1), LN 1 acknowledged the missed visits and patient’s POC was not followed. LN 1 was unable to provide additional proof of documentation the reason for the missed visits or if the IDG had been notified. 1)During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/21/24, at 4:00 PM, for the certification period from 11/23/24 to 02/20/25 and beyond, the plan of care (POC) and clinical record (CR) for patient 5 were reviewed. The POC included the frequency of the skilled nurse (SN) visit: one per week (1X/WK) and certified hospice aide (CHA) visit: twice per week (2X/WK). A review of patient 5's visit calendar indicated that no SN visit occurred for the week 2/2/25 and 3/16/25; no CHA visits occurred for the weeks 12/1/24, 12/29/24 and 2/16/25. There was no evidence in patient 5’s CR that the provider/prescriber was notified of the missed SN and CHA visits, or that the appointments were rescheduled. The missed SN and CHA visits were not discussed at the interdisciplinary group (IDG) meeting. Further record review revealed that the IDG meeting on 12/5/24, which included a medical social worker (MSW) and a registered nurse (RN), altered the CHA visit frequency from two to one per week without the prescriber’s approval. In addition, the SN visit notes dated 3/7/25 and 3/13/25 were not signed by the writer. The LN1 acknowledged the findings. During a review of the hospice's policy and procedure (P&P) titled "Missed Visits" revised 4/2020, the P&P indicated, “Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.  2) During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/25/25, at 10:45 AM, patient 2’s plan of care (POC) and clinical record (CR) for the certification period from 02/25/25 to 05/25/25 were reviewed. The doctor’s order included the frequency of the CHA visits: twice per week which was not recorded in the patient 2’s POC. A review of patient 2's visit calendar revealed no CHA visit occurred on week 2/25/25 and 3/2/25. One of two proposed CHA visits did not occur in week 3/16/25. A review of CHA visit notes dated 3/11/25, 3/14/25, and 3/21/25 indicated that the tasks were not marked completed and not signed by the CHA. Further record review revealed that the comprehensive assessment dated 2/25/25, initiated by a registered nurse (RN), and the visit note dated 3/6/25, initiated by licensed vocational nurse (LVN), were incomplete, with no vital signs recorded and without discipline signatures. There was no further evidence that the SN visit occurred during week 3/16/25. The electronic record “care overview” indicated that the clinicians documentations were incomplete.  3)During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/25/25, at 4:00 PM, Patient 7's clinical records (CR) were reviewed for the two certification period of 11/14/24 and 2/12/25. The CR revealed the following: there were no skilled nurse (SN) visit and no certified hospice aide (CHA) visit for the week of 3/2/25 to 3/8/25; no CHA visit for the weeks of 3/9/25 and 3/16/25. There was no RN supervisory visit There was no RN supervisory visit to evaluate LVN and CHA performance during the week of 3/2/25. Patient 7 fell on 1/11/25, but it was not documented whether it was discussed in the IDG meeting or reported to the physician. These findings were validated by the licensed nurse (LN1).

Based on record review and interview, the hospice agency (HA) failed to ensure that one of the 14 sampled patients (patient 6) was assessed and evaluated by the medical social worker (MSW) within five days of admission.This failure had the potential to result in patient 6’s psychosocial needs being unmet. --- Findings:During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 2018, the P&P indicated, “Orders for the start of care will be received by the case manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care/physician order form.”During a review of Patient 6’s Face Sheet, dated 12/4/24, Patient 6’s Start of Care was 12/4/24.During a review of Patient 6’s Comprehensive Nursing Assessment (CNA), dated 12/4/24, the Registered Nurse (RN) documentation indicated, Patient 6 had a referral to be evaluated by the Social Worker.During a review of the Physician’s order (PO), dated 12/4/254,  the PO indicated, Patient 6’s and family needs is to be evaluated and assessed by the MSW for initial evaluation within 5 days for psychosocial counselling and support.During a concurrent interview and record review on 3/25/25, at 4:05 p.m. with the Licensed   Vocational Nurse (LN 1), Patient 6’s clinical record was reviewed. LN 1 was unable to provide proof of documentation done by the MSW within 5 days of Patient 6’s admission and acknowledged that Patient 6’s was not seen by the MSW.

Based on record review and interview, the hospice agency (HA) failed to ensure counseling services were available to patient and family when: 1)No bereavement services were provided within 5 days of admission and after the death for patient 14. (Refer to L-596) 2)No spiritual counseling services were provided for patients 2 and 14. (Refer to L-598)  This failure demonstrated the HA's ineffective bereavement and spiritual service, which had the potential to affect all HA patients. --- 1)During a review of the sample hard copy handbook given to hospice patients upon admission, under bereavement counseling, it indicated, "Family needs do not end with the death of a patient. The time of bereavement that follows can be very difficult. We want to offer support as you adjust to a new life without the presence of the person you cared for and loved..."  During a review of patient 14's clinical record (CR) and concurrent interview with the hospice licensed nurse (LN1) on 3/25/25 at 12:59 PM, the CR indicated that patient 14's hospice care started on 7/10/24 and end of care was on 2/2/25 due to death. Further CR review indicated that there was no bereavement services upon admission and no information was documented as to whether these services were continued after patient 14's death. The LN1 acknowledged that bereavement services were not provided to patient 14 and her family during admission and after her death.  2a)During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/25/25 at 10:45 AM, patient 2’s clinical records (CR) for the certification period beginning from 2/25/25 were reviewed. The POC included the spiritual counseling (SC) assessment within 5 days of admission. A review of patient 2's visit calendar indicated that the SC was not provided within 5 days of admission per doctor’s order. The CR for patient 2 has no visit notes from a SC. This is confirmed by LN1. 2b)During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/25/25 at 12:59 PM, patient 14’s clinical record (CR) for the certification period from 07/10/24 to 10/07/24 was reviewed. The physician’s order dated 7/10/24 indicated that spiritual assessment be performed within 5 days of admission to identify spiritual needs or support for the patient, family and primary caregivers. The comprehensive assessment done by a licensed nurse dated 7/10/24 indicated that on page 6, the box “decline to discuss spiritual matters” was checked, and on page 7, a referral to spiritual counselor was noted. A review of patient 14's visit calendar indicated that the spiritual counselor visit did not occur within 5 days of admission. There is no visit note in patient 14’s CR indicating that spiritual counseling was provided upon admission and after the patient passed away. The LN1 concurred with the findings, there were no visit notes from the spiritual counselor between 7/10/24 to 2/2/25, and she stated that “spiritual counseling should have followed up."

Based on record review and interview, the hospice agency (HA) failed to ensure bereavement services were provided within 5 days of admission and that these services were available to the family following the patient's death for one of two sampled patients (Patient 14).This failure had the potential to deprive the patient and their family of crucial assistance with end-of-life decisions, funeral arrangements, and access to resources that could mitigate risks and help them cope with emotional challenges. --- During a review of the sample hard copy handbook given to hospice patients upon admission, under bereavement counseling, it indicated, "Family needs do not end with the death of a patient. The time of bereavement that follows can be very difficult. We want to offer support as you adjust to a new life without the presence of the person you cared for and loved..."  During a review of patient 14's clinical record (CR) and concurrent interview with the hospice licensed nurse (LN1) on 3/25/25 at 12:59 PM, the CR indicated that patient 14's hospice care started on 7/10/24 and end of care was on 2/2/25 due to death. Further CR review indicated that there was no bereavement services upon admission and no information was documented as to whether these services were continued after patient 14's death. The LN1 acknowledged that bereavement services were not provided to patient 14 and her family during admission and after her death.

Based on record review and interview, the hospice agency (HA) failed to ensure spiritual counseling services or referrals were provided for two of 14 sampled patients. (Patients 2 and 14). This failure had the potential to deprive patients (facing end of life) and their families of a critical component of high-quality patient-centered hospice care. --- The facility policy and procedure (P&P) titled “Hospice Chaplain” dated 4/2020, the P&P indicated, “…The hospice chaplain is responsible for the provision of spiritual services to patients and families/caregivers…assures spiritual assessment of patients and families/caregivers …are rendered in a timely manner…”   1. During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/25/25 at 10:45 AM, patient 2’s clinical records (CR) for the certification period beginning from 2/25/25 were reviewed. The plan of care (POC) included the spiritual counseling (SC) assessment within 5 days of admission. A review of patient 2's visit calendar indicated that the SC was not provided within 5 days of admission per POC. The CR for patient 2 has no visit notes from a SC. This is confirmed by LN1.  2. During a concurrent record review and interview with the hospice agency’s (HA’s) licensed nurse (LN1) on 3/25/25 at 12:59 PM, patient 14’s clinical record (CR) for the certification period from 07/10/24 to 10/07/24 was reviewed. The physician’s order dated 7/10/24 indicated that spiritual assessment be performed within 5 days of admission to identify spiritual needs or support for the patient, family and primary caregivers. The comprehensive assessment done by a licensed nurse dated 7/10/24 indicated that on page 6, the box “decline to discuss spiritual matters” was checked, and on page 7, a referral to spiritual counselor was noted. A review of patient 14's visit calendar indicated that the spiritual counselor visit did not occur within 5 days of admission. There is no visit note in patient 14’s CR indicating that spiritual counseling was provided upon admission and after the patient passed away. The LN1 concurred with the findings, there were no visit notes from the spiritual counselor between 7/10/24 to 2/2/25, and she stated that “spiritual counseling should have followed up.”

Based on personnel records review, policy review and interview, the hospice agency failed to ensure that five certified hospice aides (CHA(s) 1, 2, 3, 4, and 5) accepted and agreed to their job description by signing the agreement. This failure has the potential to cause the five CHA(s) to fail to adhere and be accountable to the assigned duties in a manner that promotes the quality, continuity, and safety of a patient's care. --- During a review of employee staff records on 3/21/25 at 2:50 pm to 3:19 pm, employee records indicated CHHA1, CHHA2, CHHA3, CHHA4 and CHHA5 does not have a signed job description and skills competency checks on file.During an interview with the administrator office assistant (AOA) on 3/21/25 at 3:27 pm, the AOA acknowledged signed job description and skills competency checks are not in the employee file. The AOA indicated “that’s all I have”.The facility policy and procedure titled “Governing Body” dated April 2020 indicates “The governing body will assume full legal authority, responsibility, decision making and accountability for overall management and operations, the provision of services, fiscal operations, human resource management and performance improvement program.”

Based on a review of personnel records, policy review, and interview, the hospice agency failed to ensure that five employees [certified hospice aide-CHA(s)] successfully completed the required skills competencies. This failure has the potential to result in CHA(s) providing inadequate care. --- During a review of employee files on 3/21/25 at 2:50 pm to 3:15 pm, the employee files indicates CHHA1 has a hire date of 11/1/23, CHHA2 has a hire date of 10/1/24, CHHA3 has a hire date of 1/21/25, CHHA4  has a hire date of 9/9/24 and CHHA5 has a hire date of 3/18/24. All 5 CHHA’s does not have a competency checks and a signed job description in the employee file.During an interview with the administrator office assistant (AOA) on 3/21/25 at 3:27 pm, the AOA acknowledged signed job description and skills competency checks are not in the employee file. The AOA indicated “that’s all I have”.The facility policy and procedure titiled “Governing Body” dated April 2020 indicates “The governing body will assume full legal authority, responsibility, decision making and accountability for overall management and operations, the provision of services, fiscal operations, human resource management and performance improvement program.”

Based on document review, policy review, and interview, the hospice failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers, and families necessary for the palliation and management of terminal illness and related conditions in clinical records reviewed. --- The Condition of Participation was not met when:  1)the hospice agency’s (HA) governing body (GB) failed to establish a continuous quality program that specifies the detail of data collected and shows verifiable improvement. (Refer to L-651)  2)the hospice agency (HA) failed to ensure hospice care and services were available and provided in accordance with accepted standards of practice. These affected patients 6, 3, 5, 2, 7, 14, and 4. The cumulative effects of these systemic problems resulted in the hospice's inability to comply with the Conditions of Participation 42 CFR 418:100 Organization and Administration of Services.

Based on record review and interview, the hospice agency’s (HA) governing body (GB) failed to establish a continuous quality program that specified the detail of data collected and shows verifiable improvement.  This failure had the potential to leave adverse patterns in care quality undetected and unmeasured, resulting in poor quality care. --- The HA’s policy and procedure (P&P) titled “Quality Outcomes/Performance Improvement Plan” revised 2015, the P&P indicated, “…The QAPI committee will be responsible for coordinating all QAPI activities, reviewing collection of data, assisting staff in developing design or improvement activities, planning actions, collecting data, analyzing the effectiveness of actions and implementing effective actions. The GB is ultimately responsible for QAPI and implementation of the QAPI plan...” During a review of the QAPI binder with the licensed nurse (LN1) on 3/25/25 at 3:00 PM, the binder was empty; there was no QAPI for the year 2024, no QAPI for 2025, and no QAPI for the last quarter of 2023. The LN1 was asked to produce the meeting minutes of the GB for the years 2024, 2025 and the last quarter of 2023 and the LN1 verbalized she could not locate them. Furthermore, no evidence of GB meeting minutes for 2024 and 2025 was provided. The last GB meeting minutes were recorded in May 2023. The LN1 confirmed this finding. During an interview with the administrator (ADM) on 3/25/25 at 5:00 PM, the QAPI was discussed, the ADM was unable to enunciate the specifics of data collection and monitoring for service efficacy and safety. The ADM acknowledged the findings.

Based on observation, record review, and interview, the hospice agency (HA) failed to ensure hospice care and services were available and provided in accordance with accepted standards of practice when: 1) The hospice agency (HA) failed to ensure Patient 6 was assessed and evaluated by the medical social worker (MSW) within five days of admission. (Refer to L-594)2) The hospice licensed nurse failed to notify the physician of changes in condition and treatment for one of 14 sampled patients (Patient 3). (Refer to L590)3) The HA failed to ensure nursing care and services were provided for 6 of 14 patients sampled patients (Patients 5, 2, 7, 3, 6, and 4) (Refer to L-591)4) The HA failed to ensure spiritual counseling services or referrals were provided for 2 of the 14 sampled patients (Patients 2 and 14). (Refer to L-598) 5) The HA failed to ensure bereavement services were provided within five days of admission and were available to the family following the death for one of two sampled patients (Patient 14). (Refer to L-596)6) The HA failed to ensure Patient 1 was fully informed of all hospice benefits. Patient 1 lacked three of the nine prescribed medications. (Refer to L-518)These failures had the potential to result to inadequate care and unsafe conditions for patients. --- 1) During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 2018, the P&P indicated, “Orders for the start of care will be received by the case manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care/physician order form.”During a review of Patient 6’s "Face Sheet," dated 12/4/24,  the "Face Sheet" indicated, Patient 6’s Start of Care was 12/4/24.During a review of Patient 6’s "Comprehensive Nursing Assessment (CNA)," dated 12/4/24, the Registered Nurse (RN) documentation indicated, Patient 6 had a referral to be evaluated by the Social Worker.During a review of Patient 6's "Physician’s order (PO)," dated 12/4/24,  the "PO" indicated, Patient 6 and family needs is to be evaluated and assessed by the MSW for initial evaluation within 5 days for psychosocial counselling and support.During a concurrent interview and record review on 3/25/25 at 4:05 p.m. with Licensed Vocational Nurse (LN 1), Patient 6’s clinical record was reviewed. LN 1 was unable to provide proof of documentation done by the MSW within 5 days of Patient 6’s admission and acknowledged that Patient 6 was not seen by the MSW.2) During a review of the facility’s P&P titled, “Verification of Physician’s Orders,” dated 2028, The P&P indicated, “Orders will be obtained from a licensed physician (or authorized independent practitioner) for care and services to be provided to hospice patients.”During a review of Patient 3’s "Treatment Administration Record (TAR)," dated 3/2025, the TAR indicated, Patient 3's left breast rash was treated daily with Nystatin (type of anti-fungal medication) powder and the left heel wound with triple antibiotic ointment daily and as needed.During a review of Patient 3's "Registered Nurse (RN) Visit Note," dated 3/11/25, the "Visit Note indicated, Patient 3 had an existing right breast and left heel wound but no mention of the left breast skin condition.During a review of Patient 3's current "Physician’s Orders," the "Orders indicated, no treatment order was found addressing Patient 3’s left breast rash and left heel wound.During a concurrent interview and record review on 3/21/25 at 3:55 p.m. with LN 1, Patient 3's physician’s order and the facility TAR were reviewed. LN 1 verbalized the visiting nurse must check the patient’s binder and update the medication and treatment order, updates must be communicated with the facility staff. LN 1 further verbalized there was no treatment order for the left breast and left foot treatment order.3.1) Patient 5 missed one skilled nurse (SN) visit for week 2/2/25 and 3/16/25. No certified hospice aide (CHA) visit for three weeks. The planned number (2X/WK) of CHA visits was reduced to 1X/WK without doctor's approval. Two SN visit notes without signatures.3.2) For Patient 2, multiple clinicians/disciplines (RN, LVN, and CHA) charted incomplete information; CHA’s intended visit frequency of twice per week was not reflected in the plan of care; one out of two CHA visits did not occur on week 3/16/25; and no SN visit in week 3/16/25.3.3) For Patient 7, there were no skilled nurse (SN) visits for the week of 3/2-3/8/25; No supervisory evaluations for CHA and licensed vocational nurse (LVN) during the week of 3/2/25; No CHA visit the week of 3/2-3/8/25 and two subsequent weeks (week 3/9 and 3/16); fall incident on 1/11/25 was not discussed in the interdisciplinary group (IDG) meeting, and not reported to the physician (MD).3.4) Patient 3 was not properly assessed and recognized as having a wound, resulting in an improperly managed wound; Patient 3 missed SN visits; Patient 3 missed CHA visit; plan of care (POC) was not updated for Patient 3; and the CHA task of obtaining vital signs at each visit was not implemented. 3.5) Patient 6 missed CHA visit. 3.6) Patient 4 missed CHA visit. 4) During a review of the facility's P&P titled, “Hospice Chaplain,” dated 4/2020, the P&P indicated, “…The hospice chaplain is responsible for the provision of spiritual services to patients and families/caregivers…assures spiritual assessment of patients and families/caregivers…are rendered in a timely manner…” 4.1) During a concurrent record review and interview on 3/25/25 at 10:45 AM with licensed nurse (LN 1), Patient 2’s clinical records (CR) for the certification period beginning from 2/25/25 were reviewed. The plan of care (POC) included the spiritual counseling (SC) assessment within 5 days of admission. A review of Patient 2's visit calendar indicated, the SC was not provided within 5 days of admission per POC. The CR for Patient 2 had no visit notes from a SC. This is confirmed by LN1. 4.2) During a concurrent record review and interview on 3/25/25 at 12:59 PM with LN1, Patient 14’s CR for the certification period from 07/10/24 to 10/07/24 was reviewed. The physician’s order dated 7/10/24 indicated, spiritual assessment be performed within 5 days of admission to identify spiritual needs or support for the patient, family and primary caregivers. The comprehensive assessment done by a licensed nurse dated 7/10/24 indicated, on page 6, the box “decline to discuss spiritual matters” was checked, and on page 7, a referral to spiritual counselor was noted. A review of Patient 14's visit calendar indicated, the spiritual counselor visit did not occur within 5 days of admission. There was no visit note in Patient 14’s CR indicating, spiritual counseling was provided upon admission and after the patient passed away. LN1 concurred with the findings, there were no visit notes from the spiritual counselor between 7/10/24 to 2/2/25, and stated, “Spiritual counseling should have followed up.”5) During a review of the sample hard copy handbook given to hospice patients upon admission, under bereavement counseling, it indicated, "Family needs do not end with the death of a patient. The time of bereavement that follows can be very difficult. We want to offer support as you adjust to a new life without the presence of the person you cared for and loved..." During a review of Patient 14's CR and concurrent interview on 3/25/25 at 12:59 PM with LN1, the CR indicated Patient 14's hospice care started on 7/10/24 and end of care was on 2/2/25 due to death. Further CR review indicated, there was no bereavement services upon admission and no information was documented as to whether these services were continued after Patient 14's death. LN1 acknowledged that bereavement services were not provided to Patient 14 and her family during admission and after her death. 6) During a home visit observation on 3/19/25 at 5 PM at Patient 1's house (independent living), Patient 1 was asked about his medication supplies at home. Patient 1 showed the medications that were available, but when compared to the medication list, three out of the nine prescribed medications, including insulin injection, anti-cholesterol tablet, and anti-psychotic medication, were not at home. Patient 1 stated, “I don't know the agency's phone number and medication supplies they provide. A girl (female) nurse came to see me a month and a half ago. They don't tell me when they will be returning." During a concurrent record review and interview on 3/21/25 at 3:15 PM, with LN1, Patient 1's CR was reviewed, the CR indicated, Patient 1 had medical conditions including but not limited to, Type 2 diabetes (High blood sugar), Hyperlipidemia (high cholesterol) and psychotic disorder (mental disorder). Patient 1’s prescribed medications included, insulin, anti-cholesterol and anti-psychotics. During the home visit on 3/19/25, these medications were not at home. Patient 1 does not know the phone number of the hospice. LN1 confirmed this finding.

Upon patient record review, 2 of 14 (Patient 7 & 14) 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 7 medication profile includes "Benadryl Allergy 25 mg tab 1 tab po every 6 hours and as needed for allergies" with unclear frequency. Patient 14 medication profile included "Spironolactone 25 mg tab 1 tab po every shift" with frequency unclear.

Upon patient record review, 6 of 14 (Patient 1,6,7,8,10 &12) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1, 10 & 12 plan of care noted "MSW prn visit" and "SN prn visit" with no specific number of prn visits indicated. Patient 6 plan of care noted "MSW prn visit" with no specific number of prn visits indicated. Patient 7 plan of care notes "MSW prn visit" with no specific number of prn visits indicated. Patient 8 plan of care notes "SN prn visit" with no specific number of prn visits indicated.

Upon patient record review, 3 of 14 (Patient 3,7&14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3 plan of care noted "Left and right inferomedial lower leg wounds cleanse with wound cleanser, pat dry, apply hydrocortisone, then cover with kerlix and secure with tape" with no frequency indicated. Patient 7 plan of care includes "Benadryl Allergy 25 mg tab 1 tab po every 6 hours and as needed for allergies" with unclear frequency. Patient 14 plan of care included "Spironolactone 25 mg tab 1 tab po every shift" with frequency unclear. Plan of care also noted "Coccyx area pressure ulcer, cleanse with wound cleanser, pat dry, apply antibiotic ointment, cover with adhesive bordered dressing" with no frequency.

Upon patient record review 1 of 14 (Patient 7) did not have evidence of 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 7 plan of care notes aide 2 X Weekly. No evidence of aide visits week of 7/30/23-8/5/23. No evidence of second aide visit week of 8/6/23-8/12/23.