Every finding on record at Bjc Home Care Service

Based on policy review, record review, and interview, the hospice provider failed to ensure the patient received effective pain management and symptom control for conditions related to the terminal illness, causing the patient to revoke his/her hospice benefits and go to the hospital (L512).The cumulative effect of this deficient practice has the potential to affect all the patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to ensure that pain and symptoms were managed in one of two revoked records reviewed (Record/Patient #8).  This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy titled, “[Named Hospice] Hospice Patient Bill of Rights,” showed in part, the patient has the right to receive effective pain management including pain assessment, reassessment, treatment and or referral for treatment and symptom control for conditions related to terminal illness.RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 04/16/2025 with a terminal diagnosis of malignant neoplasm of the head of the pancreas with metastasis to the liver (a type of cancer in the pancreas which has spread to the liver). The patient resided at home with his/her spouse as a caregiver.  The patient’s caregiver revoked hospice services on 05/11/2025.Review of the initial comprehensive assessment dated 04/16/2025, showed the following:- The patient described his/her pain as generalized, on bilateral sides of the body, of a mixed type, aching, intermittent, lasting for “a while,” exacerbated (made worse) by fevers, rigidity, and fatigue, and relieved by medications and rest.  The patient’s highest level of pain was 2 out of 10 on the pain scale (a tool used to assess the intensity of pain using a numerical scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable) and his/her pain goal was 0 out of 10.  The pain was also associated with nausea and the patient reported treating his/her pain with acetaminophen (a medication used for mild to moderate pain) four times per day for fever and pain;- The cardiovascular assessment showed the patient had hypotension (low blood pressure) and edema (swelling of the tissues) described as located in the bilateral lower extremities to the ankles and feet and pitting at 1+ (edema is classified according to the grade of swelling);- The gastrointestinal assessment showed the patient had flatus (gas), indigestion, nausea, and diarrhea.  The abdomen was soft, non-tender, with bowel sounds noted in all four quadrants; and- The genitourinary assessment showed the patient had clear yellow urine and no issues with urination.Review of the initial plan of care dated 04/16/2025 to 07/14/2025, showed in part, the following medications:- Haldol (a medication used for agitation) 2 milligrams (mg) per milliliter (mL) take 0.5 mg by mouth every 4 hours as needed for agitation or nausea;- Zofran (a medication used for nausea) 8 mg take one tablet by mouth every 8 hours as needed for nausea and vomiting (first line of defense for nausea);- Compazine (a medication used for nausea) 10 mg take one tablet every 6 hours as needed for nausea and vomiting (second line of defense for nausea); - Acetaminophen 500 mg take one tablet every 6 hours as needed for fever or pain; and- Morphine (a narcotic medication used for severe pain) 100mg per 5 mL take 0.25 mL by mouth every hour as needed for mild pain or 0.5 mL by mouth every hour for moderate to severe pain.Review of the initial plan of care dated 04/16/2025 to 07/14/2025, showed in part, the following:- All disciplines should assess for nausea/vomiting and instruct on management of symptoms each visit;- All disciplines should assess for level of comfort and symptom control and uncontrolled pain should be resolved within two hours of exacerbation throughout hospice care;- All disciplines should assess for effectiveness of pain management at each visit; and- Skilled nursing should assess the patient for difficulty with elimination (excretion of urine or bowel from the body) each visit.Review of a skilled nurse (SN) visit dated 04/22/2025, showed the patient had edema in the bilateral lower extremities described as 3+, complaints of nausea, and the assessment failed to include if the patient was having any issues with elimination or if the physician was notified of the change in edema.Review of a SN visit dated 04/24/2025, showed in part, the following:- The patient described his/her pain as located in the right side of the chest, somatic in type (pain that originates from the tissues and structures of the body), with an ache and pull, intermittent in nature and lasting for 15 to 30 minutes, exacerbated by movement and relieved by rest and pain medication.  The patient’s highest level of pain was 5 out of 10 and was described as waxing and waning (increasing and decreasing over time rather than constant), was associated with nausea, and the patient reported treating the pain with acetaminophen;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+;- The gastrointestinal assessment showed the patient had flatus, indigestion, nausea, and diarrhea.  The abdomen was soft, non-tender, with bowel sounds noted in all four quadrants;- The genitourinary assessment showed the patient had clear yellow urine and no issues with urination; and- The narrative note showed “BLE (bilateral lower extremities) edema worsening.  Edema 1+ on previous visit.  Today 3-4+ pitting.  Pt reports feet and toes feel tight and unable to more toes easily.  [Named provider] notified of edema and order received for Lasix (a medication used to treat edema) 20 mg daily.”Review of a SN visit dated 04/28/2025, showed in part, the following:- The patient described his/her pain as located in the right side of the chest, somatic in type, with an ache, infrequent in nature and varied, exacerbated by movement and relieved by rest.  The patient’s highest level of pain was 3 out of 10, was associated with nausea, and the patient reported treating the pain with acetaminophen;- The cardiovascular assessment failed to be included;- The gastrointestinal assessment showed the patient had flatus, indigestion, nausea, and diarrhea.  The abdomen was soft, non-tender, with bowel sounds noted in all four quadrants;- The genitourinary assessment showed the patient had clear yellow urine, no issues with urination and the “patient denied an increase in urine output after starting Lasix;” and- The narrative note showed “BLE remain very edematous 3-4+pitting, R>L (right greater than left).  H/o (history of) DVT (deep vein thrombosis) to right leg.  [Named provider] notified and order received to increase Lasix to 40 mg daily.”Review of a SN visit dated 04/30/2025, showed in part, the following:- The patient described his/her pain as located in the right side of the chest, somatic in type, with a muscle ache, intermittent in nature and varied, exacerbated by movement and relieved by rest and medication.  The patient’s highest level of pain was 5 out of 10, was associated with nausea, and the patient reported treating the pain with acetaminophen;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+.  The additional comments stated “BLE slightly improved with Lasix 40 mg daily.  Spouse reports saw PCP (primary care provider) yesterday who recommended increasing protein and adding compression.  PCP ordered compression boots.  Explained to pt and spouse those are not hospice covered.  Spouse to look into obtaining on own;”- The gastrointestinal assessment showed the patient had flatus, indigestion, nausea, and diarrhea.  The abdomen was soft, non-tender, with bowel sounds noted in all four quadrants; and- The genitourinary assessment showed the patient had clear yellow urine, no issues with urination and the patient reported “decreased urine output and weak flow this AM.  Stated he/she was only able to go a little bit.  Encouraged pt to increase fluid intake as tolerated and contact hospice if no output by this afternoon.  V/u (voiced understanding).”Review of a triage encounter note dated 05/04/2025 at 2:34 PM, showed the patient’s spouse called with a concern that the patient had been nauseated for the last 48 hours and that he/she was concerned that the patient may have a blockage in a stent.  Antiemetics (a class of medications used for nausea and vomiting) were reviewed and the spouse reported the patient had been using Zofran and Compazine as ordered.  The patient’s spouse was instructed to try Ativan (a medication used for anxiety) and to call back if no improvement.  [Named provider] notified and requested the patient and spouse be contacted to offer an evaluation in an emergency room for labs.  The patient and spouse were contacted and declined the emergency room visit and stated they preferred to try the Ativan.  The physician was notified of patient’s choice and ordered lab work to be drawn on the next SN visit which was 05/05/2025.  An as needed SN visit was declined.  At 7:04 PM the spouse called back and stated that the nausea was no better and the patient had decided to go to the emergency room for labs and an evaluation of persistent nausea.Review of a SN missed visit note dated 05/05/2025, showed that the patient’s spouse declined a nurse visit due to returning home at 3:00 AM and the patient being very tired.Review of a SN visit note dated 05/07/2025, showed in part, the following:- The patient denied pain and nausea;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+.  The additional comments stated “patient is orthostatic (a form of low blood pressure that happens when standing up from sitting or lying down);- The gastrointestinal and genitourinary assessments failed to be included;- The narrative note showed “Patient reports while he/she was sitting outside and went to stand up he/she felt very weak, legs felt wobbly and that he/she might pass out.  Patient reports that yesterday he/she had four liters of fluids removed during paracentesis (a medical procedure that involves removing excess fluid from the abdominal cavity); and- The SN visit note failed to indicate if labs were drawn as ordered.Review of a SN visit note dated 05/08/2025, showed in part, the following:- The patient denied pain but had the associated symptom of nausea;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+;- The gastrointestinal assessment showed the patient had flatus, indigestion, nausea, and diarrhea.  The abdomen was soft, non-tender, with bowel sounds noted in all four quadrants;- The genitourinary assessment showed the patient had clear yellow urine, no issues with urination; and- The SN visit note failed to indicate if labs were drawn as ordered.Review of a SN visit note dated 05/09/2025, showed in part, the following:- The patient denied pain;- The patient reported having daily nausea and Haldol was discussed with the patient and spouse;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+. The additional comments show that the “pt is doing compression therapy to BLE for edema;”- The gastrointestinal assessment showed the patient had flatus, indigestion, nausea, and diarrhea.  The abdomen was soft, non-tender, with bowel sounds noted in all four quadrants;- The genitourinary assessment failed to be included; and- The SN visit note failed to indicate if labs were drawn as ordered.Review of a triage encounter note dated 05/10/2025 at 8:49 AM, showed the patient’s spouse reported that in the previous 48 hours several of the patient’s medications had been changed and that prior to three days ago the patient had no issues with weakness.  During the night the patient’s legs became weak, his/her lower back was weak, and his/her mobility decreased, and he/she had no strength, and this was all of a sudden.  Reported that last week patient was on 20 mg of Lasix and it was increased due to swelling in his/her lower legs to 40 mg and then the patient became dehydrated.  The patient went to the hospital and then on Tuesday had a paracentesis and had four liters of fluids drained from the abdomen.  An as needed nurse visit was arranged.Review of a triage encounter note, dated 05/10/2025 at 10:02 AM, showed the patient’s spouse reported the patient was having a “little stomachache” below the belly button and reported that 20 minutes later he/she had a large bowel movement that was tarry black (an indication that blood is present in the bowel movement).  The spouse reported that after the bowel movement the patient’s pain had decreased.  The spouse reported administering one dose of Olanzapine (an antipsychotic medication) prior to the phone call.Review of a SN visit note dated 05/10/2025 at 10:30 AM, showed in part, the following:- The patient described his/her pain as located in the abdomen on both sides, somatic in type, with a severity of 4 out of 10.  The patient’s highest level of pain was 4 out of 10, was associated with nausea and guarding (a protective involuntary contraction of muscles in response to pain or discomfort) and was described as waxing and waning, and the patient’s pain level at the end of the visit was noted to be 3 out of 10;- The cardiovascular and genitourinary assessments failed to be included;- The gastrointestinal assessment showed the patient had flatus, indigestion, nausea, and diarrhea.  The abdomen was non-tender with distension (an abnormal enlargement or swelling of an organ or body part often caused by a build-up of gas or fluid) with bowel sounds noted in all four quadrants; and- The narrative note showed the patient’s abdomen was rounded and firm, bowel sounds absent, complaining of nausea unresponsive to medications, abdominal pain 4 out of 10 and had black tarry stools twice this date.  [Named provider] notified and the patient was to be transferred to general inpatient hospice (GIP) via car transport with his/her spouse.Review of a SN visit note dated 05/10/2025 at 4:00 PM, showed in part, the following:- The patient was admitted to GIP level of care for symptom management of uncontrolled pain, uncontrolled anxiety or psychosocial distress, and uncontrolled nausea and vomiting;- The patient was admitted to GIP from the emergency department with lower abdominal pain, nausea, and reports of tarry stools with symptoms ongoing for several days;- The patient reported to have taken Zyprexa (an antipsychotic medication), Haldol, Compazine, and Zofran without relief for nausea;- The patient had a bladder scan completed at the bedside in the emergency department which revealed >1100 mLs in the bladder prompting foley catheter (a sterile tube placed in the bladder to drain urine) placement with an improvement in symptoms; and- The patient’s spouse stated that the patient had never had adequate symptom control while at home.Review of a SN visit note dated 05/11/2025, showed the patient and spouse revoked hospice care due to their “overall experience with hospice at home.”During an interview on 09/11/2025 beginning at 1:20 PM, the administrator and the registered nurse coordinator stated that they would expect a patient’s symptoms to always be managed and that a head-to-toe assessment should be completed on each skilled nurse’s visit.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure:- The patients received a complete physical assessment (L0524);- Staff maintained an accurate and updated medication profile (L0530); and- An initial bereavement assessment of the needs of the patient’s family and other individuals was completed within five days after the election of hospice (L0531). The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the patients received a complete physical assessment in one of seven full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s undated policy titled, “Initial Assessment,” showed, in part:- The purpose: To provide guidelines for the initial assessment to evaluate the patient’s physical, psychosocial, and emotional needs and determine immediate care and support needs;- Admitting registered nurse (RN) will determine the patient’s and caregiver’s primary concern, goals, and immediate care needs; - Admitting RN will document interventions and teaching performed; and -Based on the initial assessment, the plan of care will be initiated on the day of admission RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the initial comprehensive assessment, dated 07/18/2025, showed, in part:-Integumentary (skin) section:*Issues- scars and fragile skin; and -Summary: The patient was alert and oriented to person and place only. The spouse and children were the patient’s primary caregivers. Review of the skilled nurse (SN) visit note, dated 07/19/2025, showed the patient had a large growth tumor behind his/her left ear related to cancer. The patient had confusion and reported that the growth sometimes “bites me”. Observation and interview on 09/09/2025 starting at 11:00 AM, showed the patient with a large reddish-purple growth coming out from behind his/her left ear. The patient’s spouse stated that the patient had the growth since before he/she went on hospice and that was the main reason for going on hospice. The initial comprehensive assessment failed to be complete and include the description or location of the tumor (this was due to the patient's terminal diagnosis). During an interview on 09/11/2025 beginning at 1:20 PM, the registered nurse coordinator stated that the tumor should have been on the initial comprehensive assessment.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in two of seven full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s undated policy titled, “Home Medication Management,” showed, in part:- Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record;- Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications;- Medications will be reconciled by the nurse at each visit by checking the patient’s medication bottles against the medication list in the patient’s home and against the medication profile list in the hospice electronic medical record; and- A complete list of the patient’s medications will be communicated to the next provider of service when a patient is transferred or referred to another setting, service, practitioner, or level of care within or outside the organization.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025 with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she had a history of a liver transplant in 2014 and a myocardial infarction (heart attack) in 2022. The patient lived in a long-term care facility (LTCF) and had an adult child who visited regularly. Review of the provider’s current medication profile, dated 08/03/2025 to 10/31/2025, and the LTCF’s medication list, dated 08/09/2025 to 09/09/2025, showed the following discrepancies:- The provider’s profile showed bisacodyl suppository (for constipation) 10 milligrams (mg). Insert one suppository into the rectum daily as needed for constipation. The LTCF list failed to include the suppository;- The provider’s profile showed gabapentin (used for nerve pain) 100 mg take one by mouth three times a day. The LTCF list showed the gabapentin was discontinued on 09/03/2025; - The provider’s profile showed haloperidol (used to treat delirium/agitation) 2 mg/milliliter (ml), take 3 mg by mouth (PO) every four hours as needed for agitation. The LTCF list showed the haloperidol dosage was 4 mg every four hours and it was discontinued on 08/23/2025; -  The provider’s profile showed hydrocortisone rectal cream 2.5%, insert into the rectum (the order failed to clarify how much cream to insert) four times a day as needed for hemorrhoids. The LTCF list failed to include the rectal cream;- The provider’s profile showed lorazepam 2 mg/ml concentrated solution, take 1.5 mg PO every two hours as needed for anxiety. The LTCF list showed take 1.5 ml (the provider had 1.5 mg) every two hours as needed and it was discontinued on 08/23/2025;- The provider’s profile showed naloxegol (used to treat opioid-induced constipation) 25 mg, take one tablet PO daily after breakfast. The LTCF list failed to include the naloxegol;- The provider’s profile showed nitroglycerine 0.4 mg sublingual (SL, under the tongue) every five minutes as needed for chest pain. Give up to three doses, five minutes apart. The LTCF list failed to include the nitroglycerine; - The provider’s profile showed omeprazole (for acid reflux) 20 mg PO, daily. The LTCF list showed the omeprazole was discontinued on 08/23/2025; - The provider’s profile showed odansetron orally disintegrating tablet (ODT) 4 mg, take two tablets PO, every six hours as needed for nausea/vomiting. The LTCF list showed the odansetron was discontinued on 09/03/2025;                                                                                                                                                                                                                                 - The provider’s profile showed polyethylene glycol (a laxative) 17 gm packet, take one packet PO two times a day, The LTCF list showed the medication was discontinued on 09/03/2025; - The provider’s profile showed two separate entries for quetiapine (used for agitation), take 50 mg PO, one time daily as needed and quetiapine 50 mg PO two times a daily as needed. The effective date was 08/16/2025. The LTCF list showed quetiapine 50 mg every eight hours routinely at 10:00 PM, 6:00 AM, and 2:00 PM, (the provider showed the medication taken as needed) effective 08/16/2025 and was discontinued on 08/28/2025;- The provider’s profile showed senna-docusate (for constipation) 8.6 mg-50 mg, take one PO two times daily for constipation. The LTCF list failed to include the senna-docusate; and- The provider’s profile showed tacrolimus (used to prevent transplant rejection) 1 mg immediate-release capsule, take two capsules PO every morning and one capsule nightly. The LTCF list showed the tacrolimus was discontinued on 09/03/2025.  Review of the skilled nursing (SN) visit notes showed:-  Visits were made on 08/23/2025, 08/25/2025, 08/29/2025, 09/03/2025, 09/04/2025, 09/05/2025, and 09/06/2025 (LTCF discontinued medications on 08/23/2025, 08/28/2025, and 09/03/2025); - The SN note, dated 09/03/2025, showed the hospice registered nurse (RN) documented he/she met with the LTCF nurse practitioner at bedside and discussed the patient was a high aspiration risk (when food/fluid/medications are accidentally inhaled into the lungs), was pocketing food (holding food in the cheeks instead of swallowing it), and PO medications would be discontinued from the LTCF medication list; and- The RN failed to update the provider’s medication profile.  RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). Other hospice diagnoses included panlobular emphysema (a chronic disease characterized by destruction of the air sacs in the lungs), Type 2 (two) diabetes mellitus (a chronic disease that affects how the body uses sugar for energy), slow transit constipation, benign prostatic hyperplasia (enlarged prostate) with lower urinary symptoms.  The patient resided at home with family. Observation and interview on 09/09/2025 showed the following discrepancies between the provider’s current medication profile and the patient’s home medication bottles: - The provider’s medication profile showed hydrocodone/acetaminophen (opioid pain medication) 5/325 mg one PO every four hours PRN (pro re nata- as needed).  The patient’s medication bottle showed the frequency as every six hours PRN;- The provider’s medication profile showed metformin XR (extended-release anti-diabetic medication) 500 mg two tablets PO daily with breakfast.  The patient’s family stated that he/she took 500 mg, one tablet, every AM;- The provider’s medication profile showed bisacodyl (stimulant laxative)10 mg suppository daily as needed for constipation. The patient’s family stated that he/she was not taking the bisacodyl;- The provider’s medication profile showed cholecalciferol (Vitamin D-3) 4000-unit tablet PO daily.  The patient’s family stated that he/she was not taking this medication; - Cyanocobalamin (Vitamin B-12) 500 microgram (mcg) tablet PO daily. The patient’s family stated that he/she was not taking this medication;- Dutasteride (medication to treat enlarged prostate) 0.5 mg one capsule PO daily. The patient’s family stated that he/she was not taking this medication;  - Haloperidol 2 mg/ml (milliliter) solution every four hours PO as needed for agitation. The patient’s family stated that he/she was not taking this medication;- Promethazine-DM (dextromethorphan) (used to treat coughing) 1.25-3 mg/ml syrup, take 5 ml, four times a day as needed for cough. The patient’s family stated that he/she was not taking this medication;- Ventolin HFA 90 mcg/actuation inhaler (a device used to deliver medication into the lungs) inhale two puffs every six hours as needed for shortness of breath.  The patient stated that he/she was not taking this medication;- The patient was taking Prilosec (medication to decrease stomach acid) 20 mg take one PRN. The provider’s profile failed to include this medication; and - The patient was taking fluticasone pronate nasal spray (steroid nasal spray to relieve allergy symptoms) 50 mcg one spray each nostril as needed (the expiration date was 05/2022).  The provider’s profile failed to include this medication.  During an interview on 09/11/2025 beginning at 1:20 PM, the administrator stated that he/she expected the clinicians to update the medication profile and expected their medication profile to match the LTCF medication list and the patient’s home medications.

Based on policy review, record review, and interview, the hospice provider failed to ensure that an initial bereavement assessment of the needs of the patient’s family and other individuals was completed within five days after the election of hospice in two of seven full records reviewed (Records/Patients #3 and #7). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Bereavement Assessment and Follow-up Policy,” dated 04/2019, showed:- The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient’s death, in accordance with the plan of care; and- A bereavement risk assessment will be completed by the hospice social worker, chaplain, or registered nurse at the time of admission to hospice.RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the Master of Social Work (MSW) note, dated 06/16/2025, showed the patient’s support consisted of his/her two sons and some good friends. The eldest son was the primary contact as well as the bereavement contact.Review of the initial bereavement assessment, dated 06/24/2025 (11 days after admission), showed the assessment was completed on the patient’s friend.The provider failed to complete bereavement assessments on the patient’s two sons (who the patient lived with until going to inpatient).During an interview on 09/10/2025 at 3:45 PM, the bereavement coordinator stated that they only do the bereavement assessment on one primary individual unless they were asked to perform additional bereavement assessments by the patient/family. He/she stated that they were unsure why neither of the sons were not assigned to be the primary bereaved.During an interview on 09/10/2025 at 4:00 PM, the Registered Nurse Coordinator stated that they only choose one individual to do the initial bereavement assessment on until the patient’s death then they assess for other bereaved after the death. This then gets discussed at the next Interdisciplinary Group (IDG) meeting.During an interview on 09/11/2025 at 1:20 PM, the hospice administrator stated that he/she would expect the bereavement assessment to be done within five days of admission. He/she also stated that he/she did not know why neither of the sons were chosen as the primary bereaved. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the initial comprehensive assessment, dated 07/18/2025, showed the following:- Primary family contact and members: spouse, son, and daughter;-The daughter was a paid caregiver four hours per day for four days a week;- The son lived with the patient and spouse and had stage 4 prostate cancer and was going through treatment; and- The spouse and children were the patient’s primary caregivers.Review of the bereavement risk assessment, dated 07/22/2025, showed the assessment was only completed on the spouse.Review of the clinical record failed to show a bereavement risk assessment was completed on the son and daughter who was also listed as caregivers of the patient.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure:- The interdisciplinary group (IDG) met the needs of the patient and family (L0539);- All care and services furnished to patients and their families follow an individualized, written plan of care (POC) (L0543);- An individualized POC was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments (L0545);- Interventions were in place to manage pain and symptoms (L0546);- The POC included the scope and frequency of services necessary to meet the specific needs of the patient and family (L0547);- The patient’s POC contained measurable goals and outcomes (L0548);- The POC contained all of the necessary drugs and treatments necessary to meet the needs of the patient (L0549);- The patient’s POC contained all durable medical equipment (DME) and appliances necessary to meet the needs of the patient (L0550);- The POC was revised and updated based on the patient's updated comprehensive assessment and noted the patient's progress towards their outcomes and goals as specified in the POC (L0553); and- Coordination of care so that patient and family needs were met (L0556).The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, Job description, record review, observation, and interview, the hospice provider failed to ensure the interdisciplinary group (IDG) met the needs of the patient and family in six of seven full records reviewed (Records/Patients #1, #2, #3, #4, #6, and #7). This deficient practice has the potential to affect all the patients served by the provider.  Findings included:Review of the provider’s undated policy titled, “Coordination of Care with IDG,” showed, in part, the following:- The IDG (in collaboration with the attending physician, if any) will conduct assessments, develop, and update the plan of care, and review the effectiveness of care a minimum of every 15 days unless required more frequently by state statute;- Continuity of care will be maintained throughout the patient’s course with hospice; - Core hospice services will be available 24 hours a day, seven days a week, as will drugs, biologicals, and medical supplies.   Other services may be available as needed and will include hospice aide, homemaker, therapies, volunteer, and bereavement services;- The type and scope of services provided by the IDG will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions; and- The IDG will maintain responsibility for the provision and coordination of care, regardless of the setting where the care is provided to its patients.  Review of the provider’s undated policy titled, “(Named Provider) – The Plan of Care (POC) – Provision of Care Treatment and Service/Hospice,” showed, in part:- The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief; and- It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. Review of the provider’s undated policy titled, “Pressure Ulcer Assessment and Interventions,” showed, in part:- The purpose of this policy is to identify patients at risk for developing pressure ulcers (also known as pressure injuries) and to implement preventive interventions;- The Braden assessment (a tool used to determine a patient’s risk for the development of pressure injury) will be conducted at the following intervals: * At the start of care; * Upon resumption of care; * During recertification; and * At any additional time based on the clinician’s professional judgement e.g. reduced mobility, illness, hospitalization;- Clinicians will regularly monitor the effectiveness of interventions by reassessing the Braden score at prescribed intervals;- Clinicians will implement pressure prevention interventions for patients that score 18 or less on the Braden scale. All assessments and interventions will be documented in the patient’s electronic health record;- Report any new or worsening pressure ulcers immediately, with follow-up interventions documented in the patient’s care plan; and- Educational materials will be provided to patients and caregivers regarding pressure ulcer prevention. Review of the provider’s job description policy for the medical social worker (MSW), status date 03/03/2015, showed, in part, the following:- Under the direction of a physician, assists patients and their families in their residences to adapt and plan an interdisciplinary approach to treating the patient-family system;- Consults with patients, families and staff regarding goals of care, end of life issues and palliative needs; and- Plans and implements social work services on assigned clinical service or unit in collaboration with the healthcare team. --- RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the plan of care, dated 09/03/2025, showed the patient had a wound/pressure injury to the right anterior (front) shin/tibia discovered on 08/27/2025.Review of the default flowsheet data (a collection of data from nursing assessments) dated 08/27/2025 – 09/02/2025, showed the patient was getting nonadherent foam dressings applied to the wound every three days (without an order).The IDG failed to ensure there was an order in place for the wound dressing changes.During an observation on 09/09/2025 at 9:30 AM, during the inpatient IDG meeting, showed that the IDG group failed to discuss the patient’s wounds and wound dressing orders.During an interview on 09/11/2025 at 2:25 PM, the hospice administrator stated that he/she would expect wounds and orders to be discussed at IDG meetings. 539RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025. Review of the updated POC, for the dates of 08/21/2025 to 09/04/2025 and 09/03/2025 to 09/17/2025, showed in part, the notes failed to address the condition of the patient’s nephrostomy tube and the events leading up to the patient’s general inpatient stay for uncontrolled pain.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the initial comprehensive assessment, dated 07/18/2025, showed the following:- The patient was 90 years old;- The patient needed assistance with bathing, dressing, toileting, transfer, and continence;- Living arrangements: In own home with spouse. Additional comments: Patient and spouse have a son that was living with them, and they were all moving on 07/19/2025 to a new home;-Integumentary (skin) section:*Issues- scars and fragile skin;- Psychosocial of caregiver;*Behaviors- anxious*Stress factors- exhaustion, health changes, loss of control*Coping responses- acceptance, anxiety, sadness- Neurological;*Level of consciousness- alert*Orientation level- person and place*Memory loss- immediate, short term*Issues- depressed mood, fatigue, and forgetfulness- Urgent needs: The patient and spouse were moving into a new home in the same town and anticipated to be at the new address by 07/20/2025;- Disciplines requested: skilled nurse and medical social worker (MSW); and- Social issues: The patient and spouse were moving into a smaller home in the same town that weekend. The daughter was paid thru the Veteran’s administration to be a caregiver for the patient four (4) hours per day for 4 days a week and assisted them regularly. A son also lived with them, who was battling stage 4 cancer and was also moving with them to the new home;- Primary family contact and members: spouse, son, and daughter; and- The spouse and children were the patient’s primary caregivers.Review of the plan of care (POC), dated 07/18/2025, showed the MSW was to visit one to two times a month and as needed.The POC failed to show:- Problems, interventions, or goals for the terminal diagnosis;- Problems, interventions, or goals for the co-morbid diagnosis of dementia (yet assessment showed forgetfulness and only oriented times two, plus patient moving into a new home);- Problems, interventions, or goals for the patient and family moving; and - Problems, interventions, or goals for the potential grieving children. Review of the skilled nurse (SN) visit note, dated 07/19/2025, showed the patient had a large growth tumor behind his/her left ear related to cancer. The patient had confusion and reported that the growth sometimes “bites me”. Review of the bereavement risk assessment, dated 07/22/2025, showed the assessment was only completed on the spouse.Observation on 09/09/2025 starting at 11:00 AM, showed the patient with a large reddish-purple growth coming out from behind his/her left ear. Per interview conducted during observation, the patient’s spouse stated that:- The patient had the growth since before he/she went on hospice and that was the main reason for going on hospice;- Respite services had not been offered until “today” (09/09/2025); and- He/she also denied ever being offered volunteer services. The IDG failed to meet the physical, medical, psychosocial, and emotional needs of the patient and family when they failed to ensure a complete comprehensive assessment was completed, when they failed to ensure a bereavement assessment was completed on the patient’s children who were listed as caregivers, when they failed to ensure the plan of care was individualized, when they failed to ensure respite or volunteer services were offered when the patient and family were moving, and when they failed to ensure the plan of care was followed.  RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family. Review of the physician’s order sheet, dated 06/25/2025, showed an order for medical social work (MSW) for psychosocial support of patient and family for six visits as needed from 06/24/2025 to 09/20/2025. Review of the clinical record showed one MSW visit note from an initial visit on 06/24/2025.  At the conclusion of the note the MSW documented “MSW will continue to monitor.” Review of the Interdisciplinary Group (IDG) notes from the MSW, dated 06/26/2025, documented that the MSW continues to follow POC with one to two times per month and PRN (as needed) visits with availability for additional resource or support needs. Review of the IDG notes from the MSW, dated 07/10/2025, 07/24/2025, 08/07/2025, and 08/21/2025 showed the MSW documented the patient/family declined MSW visits.  Skilled Nurse (SN) visits notes, dated 06/25/2025, 06/30/2025, 07/04/2025, 07/07/2025, 07/10/2025, 07/16/2025, 07/23/2025, 07/30/2025, 08/06/2025, 08/13/2025, 08/20/2025, 08/27/2025, 09/04/2025, documented that the MSW was welcome.  Review of the plan of care (POC), dated 06/24/2025 to 09/20/2025, showed the following psychosocial problems:- MSW Emotional Support Needs – deficit related to emotional support.  The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process.  Interventions included assessing for emotional distress and providing emotional support at each visit;- MSW Resource Needs – understanding of available resources.  The goal showed the resource needs would be met as evidenced by patient/family/caregiver would verbalize understanding of available resources and ways to obtain these.  Interventions included assess and assist with financial resources and provide assistance with identifying community resources; and- The POC failed to identify the frequency of MSW services required to meet the patient’s/family’s/caregiver’s psychosocial needs. During an interview on 09/11/2025, governing body appointee-B stated that there were no additional social work visit notes for Patient #4. During an interview on 09/09/2025, at 12:35 PM, the patient stated he/she received visits from the chaplain and nurse, but the social worker had only been there one time (the MSW visited on 06/24/2025, 76 days prior to the survey entrance).  He did not indicate that he did not want visits from the social worker.    The IDG failed to:- Follow up to ensure visits to the patient and family were conducted to assess their psychosocial needs;- Follow up to meet the emotional support needs and resource needs of the patient and family; and- Address the inconsistencies in the information provided by the MSW and SN regarding if the patient/family welcomed MSW visits or not.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family. Review of the physician’s order sheet, dated 06/25/2025, showed an order for medical social work (MSW) for psychosocial support of patient and family for six visits as needed from 06/24/2025 to 09/20/2025. Review of the clinical record showed one MSW visit note from an initial visit on 06/24/2025.  At the conclusion of the note the MSW documented “MSW will continue to monitor.” Review of the Interdisciplinary Group (IDG) notes from the MSW, dated 06/26/2025, documented that the MSW continues to follow POC with one to two times per month and PRN (as needed) visits with availability for additional resource or support needs. Review of the IDG notes from the MSW, dated 07/10/2025, 07/24/2025, 08/07/2025, and 08/21/2025 showed the MSW documented the patient/family declined MSW visits.  Skilled Nurse (SN) visits notes, dated 06/25/2025, 06/30/2025, 07/04/2025, 07/07/2025, 07/10/2025, 07/16/2025, 07/23/2025, 07/30/2025, 08/06/2025, 08/13/2025, 08/20/2025, 08/27/2025, 09/04/2025, documented that the MSW was welcome.  Review of the plan of care (POC), dated 06/24/2025 to 09/20/2025, showed the following psychosocial problems:- MSW Emotional Support Needs – deficit related to emotional support.  The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process.  Interventions included assessing for emotional distress and providing emotional support at each visit;- MSW Resource Needs – understanding of available resources.  The goal showed the resource needs would be met as evidenced by patient/family/caregiver would verbalize understanding of available resources and ways to obtain these.  Interventions included assess and assist with financial resources and provide assistance with identifying community resources; and- The POC failed to identify the frequency of MSW services required to meet the patient’s/family’s/caregiver’s psychosocial needs. During an interview on 09/11/2025, governing body appointee-B stated that there were no additional social work visit notes for Patient #4. During an interview on 09/09/2025, at 12:35 PM, the patient stated he/she received visits from the chaplain and nurse, but the social worker had only been there one time (the MSW visited on 06/24/2025, 76 days prior to the survey entrance).  He did not indicate that he did not want visits from the social worker.    The IDG failed to:- Follow up to ensure visits to the patient and family were conducted to assess their psychosocial needs;- Follow up to meet the emotional support needs and resource needs of the patient and family; and- Address the inconsistencies in the information provided by the MSW and SN regarding if the patient/family welcomed MSW visits or not.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family. Review of the physician’s order sheet, dated 06/25/2025, showed an order for medical social work (MSW) for psychosocial support of patient and family for six visits as needed from 06/24/2025 to 09/20/2025. Review of the clinical record showed one MSW visit note from an initial visit on 06/24/2025.  At the conclusion of the note the MSW documented “MSW will continue to monitor.” Review of the Interdisciplinary Group (IDG) notes from the MSW, dated 06/26/2025, documented that the MSW continues to follow POC with one to two times per month and PRN (as needed) visits with availability for additional resource or support needs. Review of the IDG notes from the MSW, dated 07/10/2025, 07/24/2025, 08/07/2025, and 08/21/2025 showed the MSW documented the patient/family declined MSW visits.  Skilled Nurse (SN) visits notes, dated 06/25/2025, 06/30/2025, 07/04/2025, 07/07/2025, 07/10/2025, 07/16/2025, 07/23/2025, 07/30/2025, 08/06/2025, 08/13/2025, 08/20/2025, 08/27/2025, 09/04/2025, documented that the MSW was welcome.  Review of the plan of care (POC), dated 06/24/2025 to 09/20/2025, showed the following psychosocial problems:- MSW Emotional Support Needs – deficit related to emotional support.  The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process.  Interventions included assessing for emotional distress and providing emotional support at each visit;- MSW Resource Needs – understanding of available resources.  The goal showed the resource needs would be met as evidenced by patient/family/caregiver would verbalize understanding of available resources and ways to obtain these.  Interventions included assess and assist with financial resources and provide assistance with identifying community resources; and- The POC failed to identify the frequency of MSW services required to meet the patient’s/family’s/caregiver’s psychosocial needs. During an interview on 09/11/2025, governing body appointee-B stated that there were no additional social work visit notes for Patient #4. During an interview on 09/09/2025, at 12:35 PM, the patient stated he/she received visits from the chaplain and nurse, but the social worker had only been there one time (the MSW visited on 06/24/2025, 76 days prior to the survey entrance).  He did not indicate that he did not want visits from the social worker.    The IDG failed to:- Follow up to ensure visits to the patient and family were conducted to assess their psychosocial needs;- Follow up to meet the emotional support needs and resource needs of the patient and family; and- Address the inconsistencies in the information provided by the MSW and SN regarding if the patient/family welcomed MSW visits or not. RECORD/PATIENT #2:Review of clinical record showed the patient was admitted to hospice services on 07/09/2025 with a terminal diagnosis of hepatic cirrhosis, unspecified (permanent scarring of the liver that leads to progressive decrease in liver function), and a secondary diagnosis of acute renal failure (a sudden decline in kidney function where the kidneys no longer filter waste, excess fluid or electrolytes from the blood). The patient resided at home with family.  Review of the provider’s job description for the medical social worker (MSW), dated 09-08-2025, showed in part the following:Under the direction of a physician, assists patients and their families in their residences to adapt and plan an interdisciplinary approach to treating the patient-family system;Consults with patients, families and staff regarding goals of care, end of life issues and palliative needs; andPlans and implements social work services on assigned clinical service or unit in collaboration with the healthcare team. Review of the clinical record showed one MSW visit note from an initial visit on 07/10/2025.  At the conclusion of the note the MSW stated “MSW will continue to monitor.”Review of the plan of care (POC), dated 07/09/2025, showed the MSW was to visit six times a month as needed.The POC failed to show:Problems, interventions or goals to understand impact of illness as evidenced by verbalizing acceptance of disease process; andProblems, interventions or goals to understand the available resources; andProblems, interventions or goals to meet family income issues and ways to obtain the resources.  The IDG failed to ensure the patient and family needs were being met by the MSW with a scheduled follow up of current issues.

Based on policy review, record review, and interview, the hospice provider failed to ensure all care and services furnished to patients and their families follow an individualized, written plan of care in two of seven full records reviewed (Records/Patients #3 and #6). This deficient practice has the potential to affect the care of all the patients served by the provider. Findings included:Review of the provider’s undated policy titled, “The Plan of Care (POC) – Provision of Care, Treatment, and Service - Hospice,” showed, in part: - The plan of care will identify the patient’s needs, the services to meet those needs, including the management of pain and discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs; and- Care provided to the patient will be in accordance with the plan of care. --- RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025. Review of the updated plans of care, for the dates of 07/23/2025 to 08/06/2025, 08/06/2025 to 08/20/2025, and 08/21/2025 to 09/04/2025, showed in part that:- Effective 07/17/2025, the skilled nurse was to change the dressing to the patient’s nephrostomy insertion site daily and as needed if soiled or dislodged; and- A skilled nursing frequency of one to two times per week for eight weeks. During an interview on 09/11/2025 at 10:23 AM, the patient’s spouse stated that he/she: - Had changed the patient’s nephrostomy tube dressing daily for a very long time, and the nurses seldom asked him/her to remove the dressing; - Flushed the nephrostomy tube every other day with ten milliliters of normal saline;- Bought big bandages from the pharmacy for wound care;- Cleansed the insertion site with alcohol before reapplying the clean bandage; and- The patient received a nursing visit one to two times per week. During an interview on 09/10/2025 at 3:00 PM, governing body appointee-A stated that:- They were unable to locate documentation that the patient/caregiver had received education on performance of nephrostomy care in the absence of the nurse; and- They would expect the nurses to provide education on procedures performed in the absence of the nurse; and- They would expect the order to include the verbiage that the patient/caregiver would perform the procedure in the absence of the nurse after teaching of the procedure was completed.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the initial comprehensive assessment, dated 07/18/2025, showed the following:- Urgent needs: The patient and spouse were moving into a new home in the same town and anticipated to be at the new address by 07/20/2025;- Disciplines requested: skilled nurse and medical social worker (MSW); and- Social issues: The patient and spouse were moving into a smaller home in the same town that weekend. The daughter was paid thru the Veteran’s administration to be a caregiver for the patient four (4) hours per day for 4 days a week and assisted them regularly. A son also lived with them, who was battling stage 4 cancer and was also moving with them to the new home.Review of the plan of care (POC), dated 07/18/2025, showed the MSW was to visit one to two times a month and as needed.Review of MSW note, dated 08/05/2025, showed he/she arrived for visit and the patient was not present, as he/she had gone for a car ride and would not be back for an hour. The MSW would contact the spouse to reschedule visit. Review of the record showed the next MSW was on 09/09/2025.The MSW failed to follow the POC and see the patient the month of August 2025. During an interview on 09/10/2025 at 2:25 PM, Governing body appointee-A stated that the MSW should have called and rescheduled for the August visit.

Based on policy review, record review, and interview, the hospice provider failed to ensure an individualized plan of care (POC) was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, in six of seven full records reviewed (Records/Patients #1, #2, #3, #4, #6, and #7). This deficient practice has the potential to affect the provision of care to all the patients served by the provider. --- RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (an abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung and had chronic wounds. The patient was to have nothing by mouth (NPO- nil per os). The patient was living at home with his/her two sons but transferred to an inpatient facility on admission.Review of the Hospice Plan of Care (POC), dated 09/03/2025, showed the following interventions:-       -     Patient/caregiver/family will follow prescribed medication therapy and schedule;-        -    Instruct family on wound care;-         -   Instruct patient on maintaining adequate nutrition and weight; and-          -  Instruct patient/family/caregiver on infection control and safe disposal of dressing materials.The hospice failed to ensure that the interventions on the POC were individualized to the patient.During an interview on 09/11/2025 at 2:00 PM, the hospice administrator stated that he/she would expect the interventions on the POC to be individualized. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025.Review of the medical social work (MSW) documentation, for the visit dated 08/22/2025, showed in part the patient was preparing paperwork for a class action lawsuit. The MSW had prepared and arranged notarization of a letter related to the case. Review of the nursing reassessment visit documentation, dated 08/28/2025, showed in part that the patient had:-  Burning pain rated three (3) on a zero (0) to ten (10) high scale, movement increased the pain and rest relieved the pain.  The patient’s pain goal was 0. The patient was using Tramadol (a pain medication used to treat moderate pain) four times per day; - Financial difficulties; - Anxiety and tearfulness. He/she used lorazepam (an antianxiety medication) four to five times per day, and mirtazapine (an antidepressant) at bedtime to help with sleep; - Lower extremity edema (swelling); - Oxygen in the home and the patient smoked during the visit. The patient reported he/she only used oxygen at night. The home did not have a no smoking sign posted.  - Problems with constipation. The patient’s last bowel movement was nine days before the visit. The patient was advised to use the bisacodyl suppository (a stimulant laxative) and increase the senna (a laxative that counteracts the root cause of opioid-induced constipation) dose; - Dysuria (difficulty with urination) and hematuria (blood in the urine). He/she had a nephrostomy tube in the left kidney that was changed two times since the last reassessment visit. The patient was able to void (urinate) only a few drops of urine at a time; - Was on a regular diet, ate one meal, and one snack per day. He/she had ill-fitting dentures; and- A high risk for falls with age, diagnosis, fall history, impaired functional mobility, environmental hazards, poly pharmacy, and pain identified as fall risks. Review of the updated POC, with dates from 08/21/2025 to 09/04/2025, showed the document failed to contain:- The patient’s goal for pain control identified in the comprehensive assessment as 0 on 0-10 high scale; - Identification of the patient’s involvement in a class action lawsuit and the MSW’s involvement in the process; - Interventions to address the patient’s pitting edema including, but not limited to, assessment of the amount of edema and measures to reduce/manage it; - Interventions to address the patient smoking with oxygen in the home;- The patient’s constipation and specific interventions to manage it;- Information that the patient/caregiver performed nephrostomy tube care in the absence of the nurse;  - Interventions and teaching related to the patient’s frequent urinary tract infections;- The patient’s diet and supplement plan related to severe malnutrition, and ill-fitting dentures; - Interventions to address the patient’s potential for skin breakdown, itching, and use of Sarna lotion; and- Patient specific interventions to address the patient’s identified fall risk.During an interview on  09/10/2025 at 11:00 AM, the administrator stated that the care plan would only address active problems for the patient and should ebb and flow as the patient’s condition changes.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the initial comprehensive assessment, dated 07/18/2025, showed the following:- The patient was 90 years old;- The patient needed assistance with bathing, dressing, toileting, transfer, and continence;- Living arrangements: In own home with spouse. Additional comments: Patient and spouse have a son that was living with them, and they were all moving on 07/19/2025 to a new home;- Spiritual: *Religious affiliation- Jehovah’s witness*The clergy from Jehovah’s witness visits the patient regularly*Additional comments: denied chaplain, deeply connected to their church and well supported-Integumentary (skin) section:*Issues- scars and fragile skin;- Neurological;*Level of consciousness- alert*Orientation level- person and place*Memory loss- immediate, short term*Issues- depressed mood, fatigue, and forgetfulness- Med management:*Not taking meds as prescribed*Spouse admits patient did not take his/her medications routinely and with increasing difficulty administering medications- Hospice diagnosis: parotid gland squamous cell carcinoma;- Comorbidities: dementia; and- Adamantly refused chaplain.Review of the initial POC, dated 07/18/2025, showed:- The chaplain was to do several interventions at each visit (yet the patient and family refused chaplain visits);- Problem: Impaired elimination. The goal was the patient/caregiver/family would maintain usual pattern of bowel and urinary function as evidenced by verbalizing understanding of bowel regime, catheter care, and incontinence (yet the patient was not on a bowel regime and did not have a catheter); and- Problem: Management of medications. The goal was the patient/caregiver/family would follow prescribed medication therapy and schedule and verbalize understanding of purpose and side effects of medication. Interventions included: Assess for unsafe medication practices at each visit, assist with med management and set up as needed, instruct on high-risk medications as needed, and instruct on medications as needed (yet the spouse admitted the patient was not taking meds as prescribed and was having difficulty administering).The POC failed to be individualized and include goals and interventions for the terminal diagnosis, comorbidity diagnosis, new home, and it had goals and interventions that were not specific to the patient.   RECORD/PATIENT #2:Review of clinical record showed the patient's admittance to hospice on 07/09/2025 with a terminal diagnosis of hepatic cirrhosis, unspecified (permanent scarring of the liver that leads to progressive decrease in liver function), and a secondary diagnosis of acute renal failure (a sudden decline in kidney function where the kidneys no longer filter waste, excess fluid or electrolytes from the blood). The patient resided at home with family. Review of the clinical record showed one medical social work (MSW) visit note from an initial visit on 07/10/2025.  At the conclusion of the note the MSW stated “MSW will continue to monitor.”Review of the POC, dated 07/09/2025, showed the MSW was to visit six times a month as needed.The POC failed to show:Problems, interventions or goals to understand impact of illness as evidenced by verbalizing acceptance of disease process; andProblems, interventions or goals to understand the available resources; andProblems, interventions or goals to meet family income issues and ways to obtain the resources.  The POC failed to be individualized and include goals and interventions specific to the patient to follow up of current issues.  Review of the provider’s undated policy titled, “(Named Provider) The Plan of Care-Provision of Care Treatment and Service/Hospice,” showed, in part;- A written, individualized patient and family/caregiver POC will be established and maintained for each individual admitted to the hospice program;- The care provided to the patient must be in accordance with the POC;- The POC will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group (IDG); - The IDG will review the effectiveness and update, as needed, every 15 days unless required more frequently by state statute; - The POC will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief;- It (the POC) must state, in detail, the scope and frequency of services needed to meet the patient’s and family caregiver’s needs; - The individualized plan of care will be reviewed by the rest of the IDG within five days of start of care;- Any change in the patient’s condition must result in a change in the POC; - The written POC will contain, but will not be limited to: * Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, and counseling;* Safety measures to protect against abuse, injury, infection, or communicable disease;* DME (durable medical equipment) and medical supplies necessary to meet patient needs; * Frequency of services; and * Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers, and adjunctive services.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025, with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she had a history of a liver transplant in 2014 and myocardial infarction (heart attack) in 2022. The patient, initially, lived with his/her adult child in the home, was ambulatory, confused, suffered frequent hallucinations, and had aggressive behavior. He/she moved to a long-term care facility (LTCF), on 08/15/2025, and his/her adult child visited regularly.  Review of the initial, comprehensive assessment, dated 08/03/2025, showed:- The patient had intermittent pain in the abdomen and groin;- The patient’s highest level of pain in the last 24 hours was a 7/10 (using a numerical pain scale of zero to 10 where zero indicated no pain and 10 indicated the worst imaginable pain);- The lowest level of pain was a zero out of 10;- The patient’s pain goal was a zero; - The pain was triggered by eating;- The pain affected the patient’s mood, behavior, concentration, and physical activity;- Appetite was poor;- Dysphagia (difficulty swallowing) was noted in the variables for determination of life expectancy of six months or less; and- The patient was alert and oriented to person, followed commands, displayed inappropriate judgement, was impulsive, displayed short-term memory loss, had anxiety, agitation, was combative and restless.   Review of the plan of care (POC), dated 08/03/2025, showed the following narrative notes:- A skilled nurse (SN) note that showed the patient had a poor appetite but denied dysphagia (contradicting the selected variable from the comprehensive assessment), had a slow, unsteady gait, woke up in severe pain at a 7/10, and had weakness getting out of bed, the home had hardwood stairs that were steep, and the patient was encouraged to stay downstairs for safety; and- A medical social worker (MSW) note that showed the patient lived with his/her adult child and three-year-old grandchild who was very close to his/her grandparent. The patient identified pain as a constant problem, had visual hallucinations, had another adult child who was incarcerated in another state and was due to be released later that month, the incarcerated child was possible going to live with the patient after their release. Review of the POC, dated 08/03/2025, also showed:- Problem: Altered nutrition;  * Interventions included instruct on prevention of pulmonary aspiration; * Instruct patient/caregiver on prevention of pulmonary aspiration (when food/fluid/medications are accidentally inhaled into the lungs); * Keep head of bed elevated at 30-45 degrees at all times during administration of feedings; and * The provider failed to individualize the POC as evidenced by the SN narrative note that showed the patient denied difficulty swallowing, there was no indication that the patient ate meals in bed, and the patient was not receiving “administered” feedings; - Problem: Pain: * Interventions included instruct patient/family/caregiver on non-pharmacological pain management; * The comprehensive assessment did not identify non-pharmacological methods used by the patient; and  * The provider failed to individualize the POC when it failed to identify specific non-pharmacological methods the patient should use; - Problem: Medication management; * Interventions included instruct on high-risk medication;  * Instruct patient/caregiver on oral or injectable high-risk medications, including anticonvulsant, antiretroviral, anticoagulant, antibiotics, chemotherapeutic, hypoglycemic including insulin, immunosuppressant, antipsychotic, and opioids; and  * The provider failed to individualize the POC when it put interventions in place to instruct the patient/caregiver on high-risk medications the patient was not taking, which included, anticonvulsants, antiretrovirals, anticoagulants, antibiotics, and chemotherapeutics.  RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family.Review of the hospice plan of care update, effective 08/21/2025 to 09/03/2025, showed the following:- Instruct patient/caregiver on prevention of pulmonary aspiration (when food/fluid/medications are accidentally inhaled into the lungs);- Keep head of bed elevated at 30-45 degrees at all times during administration of feedings; the patient did not eat in his/her bed and was not receiving administered feedings;- Refer patient to outside service; (the POC failed to mention specific outside services); -Goal of the patient/caregiver/family:  will maintain usual pattern of bowel and urinary function as evidenced by verbalizing understanding of bowel regime, catheter care, and incontinence care. The patient did not have a catheter and was not incontinent;- Instruct patient/caregiver on oral or injectable high-risk medications, including:  anticonvulsant, antiretroviral, anticoagulant, antibiotics, chemotherapeutic, hypoglycemic including insulin, immunosuppressant, antipsychotic, and opioids.  The patient was not on anticonvulsant, antiretroviral, antibiotics, chemotherapeutic, or immunosuppressant medication; and- The provider failed to individualize the POC when it included:  * Interventions for catheter care when the patient did not have a catheter;  * Interventions for incontinence care when the patient was not incontinent; and  * Interventions for high-risk medications the patient was not taking.   During an interview on 09/11/2025 at 1:20 PM, the administrator, registered nurse coordinator, and governing body appointee-A, stated that the plans of care were not individualized.

Based on policy review, record review, and interview, the hospice provider failed to ensure that interventions were in place to manage pain and symptoms in one of two revocation records reviewed (Record/Patient #8).  This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy titled, “Ongoing Comprehensive Assessment,” showed, in part;- During each home visit, the case manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and, thereafter, the comprehensive assessment;- The nurse will assess the patient on each scheduled visit for:  * Secondary symptoms related to the terminal illness such as nausea, vomiting, and respiratory distress, and the patient’s response to medications and other interventions;  * Factors that alleviate or exacerbate physical symptoms;  * Current treatment related to identified symptoms and the patient’s response; and  * Bowel sounds, elimination (excretion of urine or bowel from the body).- Ongoing comprehensive assessment should focus on:  * Patient’s and family/caregiver’s response to care;  * Changes in patient condition, level of deterioration; and  * Change in patient’s and family/caregiver’s perceived needs.- The physician will be notified to verify any changes in medications and treatment/interventions that require physician approval.Review of the provider’s undated policy titled, “The Plan of Care-Provision of Care and Treatment and Service/Hospice,” showed in part:- A written individualized patient and family/caregiver plan of care (POC) will be established and maintained for each individual admitted to the hospice program;- The care provided to the patient must be in accordance with the plan of care;- The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessment performed by members of the interdisciplinary group (IDG) and will review effectiveness and update, as needed, a minimum of every 15 days unless required more frequently;- This plan will focus on identified problems, goals, and interventions;- The case manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the POC;- The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief;- Each patient will be monitored for his/her response to care and services provided against established patient goals and patient outcomes to evaluate progress toward goals;- Any change in the patient’s condition must result in a change in the plan of care; and- The written plan of care will contain, but will not be limited to, the following: pain and symptom management interventions. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 04/16/2025 with a terminal diagnosis of malignant neoplasm of the head of the pancreas with metastasis to the liver (a type of cancer in the pancreas which has spread to the liver) and a secondary diagnosis of chronic kidney disease (a disease of the kidneys that leads to renal failure). The patient resided at home with his/her spouse as a caregiver.  The patient’s caregiver revoked hospice services on 05/11/2025.Review of the initial comprehensive assessment dated 04/16/2025, showed the following:- The patient’s highest level of pain was two (2) out of 10 on the pain scale (a tool used to assess the intensity of pain using a numerical scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable) and his/her pain goal was zero (0) out of 10.  The pain was also associated with nausea and the patient reported treating his/her pain with acetaminophen (a medication used for mild to moderate pain) four times per day for fever and pain;- The cardiovascular assessment showed the patient had hypotension (low blood pressure) and edema (swelling of the tissues) described as located in the bilateral lower extremities to the ankles and feet and pitting at 1+ (edema is classified according to the grade of swelling); and- The POC dated 04/16/2025 to 07/14/2025 failed to include interventions for the management of the patient’s hypotension and edema and failed to indicate whether the patient’s current medication regimen for pain and nausea was effective.Review of a skilled nurse (SN) visit dated 04/22/2025, showed the patient had edema in the bilateral lower extremities described as 3+, complaints of nausea, the assessment failed to include if the physician was notified of the change in edema and the POC failed to include any interventions for the management of the patient’s edema or if the patient’s medication regimen for nausea was effective.Review of a SN visit dated 04/24/2025, showed in part, the following:- The patient’s highest level of pain was five (5) out of 10 and was described as waxing and waning (increasing and decreasing over time rather than constant), was associated with nausea, and the patient reported treating the pain with acetaminophen (an over-the-counter medication for mild-moderate pain);- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+;- The narrative note showed “BLE (bilteral lower extremity) edema worsening.  Edema 1+ on previous visit.  Today 3-4+ pitting.  Pt (patient) reports feet and toes feel tight and unable to more toes easily.  [Named provider] notified of edema and order received for Lasix (a medication used to treat edema) 20 mg daily;” and- The POC failed to include interventions for the management of the patient’s hypotension, the POC showed that the start date for the Lasix was 04/28/2025 (four days after the medication was ordered), no other interventions for edema were added to the POC, and the POC failed to show if the patient’s regimen for nausea and pain was effective.Review of a SN visit dated 04/28/2025, showed in part, the following:- The patient’s highest level of pain was three (3) out of 10, was associated with nausea, and the patient reported treating the pain with acetaminophen;- The genitourinary assessment showed the patient had clear yellow urine, no issues with urination and the “patient denied an increase in urine output after starting Lasix;” and- The narrative note showed “BLE remain very edematous 3-4+pitting, R>L (right greater than left).  H/o DVT (history of deep vein thrombosis , a blood clot) to right leg.  [Named provider] notified and order received to increase Lasix to 40 mg daily;” and- The POC failed to show the increase in Lasix, any other interventions related to edema, any interventions related to the patient’s urine output, and if the patient’s regimen for nausea and pain was effective.Review of a SN visit dated 04/30/2025, showed in part, the following:- The patient’s highest level of pain was 5 out of 10, was associated with nausea, and the patient reported treating the pain with acetaminophen;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+.  The additional comments stated “BLE slightly improved with Lasix 40 mg daily.  Spouse reports saw PCP (primary care physician) yesterday who recommended increasing protein and adding compression.  PCP ordered compression boots;”- The genitourinary assessment showed the patient had clear yellow urine, no issues with urination and the patient reported “decreased urine output and weak flow this AM.  Stated he/she was only able to go a little bit.  Encouraged pt to increase fluid intake as tolerated and contact hospice if no output by this afternoon.  V/u;” and- The POC failed to show any interventions related to increasing the patient’s protein, the use of compression for edema, any interventions related to the patient’s decreased urine output or the increase in fluid intake, and if the patient’s regimen for nausea and pain was effective.Review of a SN visit note dated 05/07/2025, showed in part, the following:- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+.  The additional comments stated “patient is orthostatic (a form of low blood pressure that happens when standing up from sitting or lying down);- The narrative note showed “Patient reports while he/she was sitting outside and went to stand up he/she felt very weak, legs felt wobbly and that he/she might pass out.  Patient reports that yesterday he/she had four liters of fluids removed during paracentesis (a medical procedure that involves removing excess fluid from the abdominal cavity); and- The POC failed to include if the physician was notified of changes in the patient’s condition, any interventions related to hypotension, orthostatic blood pressure changes, edema, or paracentesis.Review of a SN visit note dated 05/08/2025, showed in part, the following:- The patient denied pain but had the associated symptom of nausea;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+; and- The POC failed to include any interventions for hypotension, edema, and if the patient’s regimen for nausea was effective.Review of a SN visit note dated 05/09/2025, showed in part, the following:- The patient reported having daily nausea and Haldol (a medication used to treat delirium and agitation) was discussed with the patient and spouse;- The cardiovascular assessment showed the patient had hypotension and edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+. The additional comments show that the “pt is doing compression therapy to BLE for edema;” and- The POC failed to include any interventions related to hypotension or edema, including the use of compression therapy.During an interview on 09/11/2025 beginning at 1:20 PM, the administrator and registered nurse coordinator stated that they would expect the POC to be updated with changes and to include problems that are relevant to the patient’s assessment.

Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care included the scope and frequency of services necessary to meet the specific needs of the patient and family in two of seven full records reviewed (Records/Patients #2 and #4) This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy titled, “(Named Provider) – The Plan of Care – Provision of Care Treatment and Service/Hospice,” showed, in part:-  The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief; and - It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs.Review of the provider’s undated policy titled, “Coordination of Care with Interdisciplinary Group (IDG),” showed in part the following:        - The IDG (in collaboration with the attending physician, if any) will conduct assessments, develop, and update the plan of care, and review the effectiveness of care a minimum of every 15 days unless required more frequently by state statute;          - Continuity of care will be maintained throughout the patient’s course with hospice; and          - Core hospice services will be available 24 hours a day, seven days a week, as will drugs, biologicals, and medical supplies.   Other services may be available as needed and will include hospice aide, homemaker, therapies, volunteer, and bereavement services. RECORD/PATIENT #2:Review of clinical record showed the patient was admitted to hospice services on to hospice on 07/09/2025 with a terminal diagnosis of unspecified hepatic cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) and a secondary diagnosis of acute renal failure (a sudden decline in kidney function where the kidneys no longer filter waste, excess fluid or electrolytes from the blood). The patient resided at home with family. Review of the plan of care (POC), dated 07/09/2025, showed the following the following psychosocial problems:          - MSW Emotional Support Needs – deficit related to emotional support.  The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process; and         -  MSW Resource Needs – understanding of available resources.  The goal was that the resource needs were met as evidenced by patient/family/caregiver verbalize understanding of available resources and ways to obtain these.       Review of the clinical record showed one medical social work (MSW) visit note from an initial visit on 07/10/2025.  At the conclusion of the note the MSW documented “MSW will continue to monitor.”       The POC failed to identify the frequency of MSW services required to meet the patient’s/family’s/caregiver’s psychosocial needs. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family. Review of the physician’s order sheet, dated 06/25/2025, showed an order for MSW for psychosocial support of patient and family for six visits as needed from 06/24/2025 to 09/20/2025.Review of the clinical record showed one MSW visit note from an initial visit on 06/24/2025.  At the conclusion of the note, the MSW documented “MSW will continue to monitor.”Review of the POC, dated 06/24/2025 to 09/20/2025, showed the following psychosocial problems:- MSW Emotional Support Needs – deficit related to emotional support.  The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process.  Interventions included assessing for emotional distress and providing emotional support at each visit;- MSW Resource Needs – understanding of available resources.  The goal showed the resource needs would be met as evidenced by patient/family/caregiver would verbalize understanding of available resources and ways to obtain these.  Interventions included assess and assist with financial resources and provide assistance with identifying community resources; and- The POC failed to identify the frequency of MSW services required to meet the patient’s/family’s/caregiver’s psychosocial needs. During an interview on 09/11/2025, governing body appointee- B stated, there were no additional visit notes for Record/Patient #2 or #4.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the patient’s plan of care (POC) contained measurable goals and outcomes in six of seven full records reviewed (Records/Patients #1, #2, #3, #4, #6, and #7). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy titled, “(Named Provider) The Plan of Care – Provision of Care Treatment and Services/Hospice,” showed the written plan of care will contain measurable outcomes anticipated from implementing and coordinating the plan of care.RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the plan of care, dated 09/03/2025, showed:-         -   A problem of anxiety/agitation;-         -    The goal was anxiety management- the patient/caregiver/family will verbalize and demonstrate ability to manage patient’s anxiety throughout hospice care;-         -    The POC failed to contain data elements to measure a “reduction in anxiety”;-         -   A problem of pain;-         -   The goal was level of comfort and symptom control- patient/ caregiver/family will verbalize satisfaction with the patient’s level of comfort and symptom control.-         -   The POC failed to included a measurable pain goal (the comprehensive assessment showed the patient’s pain goal was zero);-         -   A problem of bowel incontinence;-         -   The goal was problems with incontinence being minimized - problems associated with bowel incontinence will be minimized;-         -   The POC failed to include measurable data elements to measure “minimizing bowel incontinence problems”-         -   A problem with alteration in mobility;-         -   The goal was independence- patient will remain as independent as possible;-         -   The POC failed to include measurable data elements to show how independent the patient was;-         -   A problem with end of life- complications related to disease process, condition or treatment will be avoided or minimized; and-         -   The POC failed to include measurable data elements to show what complications were.During an interview on 09/11/2025 at 1:20 PM, the hospice administrator stated that he/she would expect the goals and outcomes to be measurable and updated as the patient’s condition progressed. During an interview on 09/11/2025 at 1:20 PM, the hospice administrator stated that he/she would expect the goals and outcomes to be measurable and updated as the patient’s condition progressed. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025. Review of the updated POC, dated 09/03/2025 to 09/17/2025, showed:- An identified problem with anxiety/agitation:  * The goal stated, “The patient/caregiver/family will verbalize and demonstrate ability to manage the patient’s anxiety throughout hospice care”; and   * The POC failed to include measurable data elements to show what the patient’s anxiety was “managed;”  - And identified problem with bleeding risk;   * The goal stated, “Increased risk of bleeding;” and  * The POC failed to include measurable data elements to show what was expected as a result of the interventions;  - An identified problem associated with catheter (a sterile tube placed in the bladder to drain urine) care;   * The goal stated, “Alterations in urination due to retention and/or incontinence;”  * The POC failed to include measurable goals and outcomes;  - An identified problem with medication management;   * The goal stated, “Patient/caregiver/family will follow prescribed medication therapy and schedule, and verbalize understanding of purpose and side effects of medication;” and  * The POC failed to include measurable  goals and outcomes;  - An identified problem with oxygen;   * The goal stated, “Complications related to oxygen use will be avoided or minimized;” and  * The POC failed to include measurable data elements to show what complications were “avoided or minimized;”- An identified problem with pain;   * The goal stated, “Patient/caregiver/family will verbalize satisfaction with the patient’s level of comfort and symptom control;” and  * The POC failed to include a measurable pain goal (the general inpatient comprehensive assessment documentation, dated 09/05/2025, showed the patient’s pain goal was two); - An identified problem with the peripheral IV (intravenous access);  * The goal stated, “Complications related to PIV (peripheral intravenous access) will be avoided or minimized;” and  * The POC failed to include measurable data elements to show what complications were “avoided or minimized.”During an interview on 09/11/2025 at 11:00 AM, the administrator stated that they would expect the goals to be measurable. . RECORD/PATIENT #2:Review of clinical record showed the patient's admittance to hospice on 07/09/2025 with a terminal diagnosis of hepatic cirrhosis, unspecified (permanent scarring of the liver that leads to progressive decrease in liver function). The patient had a co-morbidity of acute renal failure (a sudden decline in kidney function where the kidneys no longer filter waste, excess fluid or electrolytes from the blood). The patient resided at home with family. Review of the comprehensive assessment showed one medical social work (MSW) visit note from an initial visit on 07/10/2025.  At the conclusion of the note the MSW stated “MSW will continue to monitor.”Review of the POC dated 07/09/2025 to 10/06/2026 showed: The goal was emotional support- the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process; The goal was resource needs- the patient/family/caregiver verbalize understanding of available resources and ways to obtain the resources; andThe POC failed to include measurable data elements to show they were following up with the patient and family.   RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the POC, dated 07/18/2025 to 10/15/2025, showed:- A problem of anxiety/agitation;- The goal was anxiety management – the patient/caregiver/family will verbalize a reduction or the absence of patient’s anxiety each visit;- The POC failed to contain data elements to measure a “reduction” in anxiety;- A problem of pain;- The goal was level of comfort and symptom control – the patient/caregiver/family will verbalize satisfaction with the patient’s level of comfort and symptom control;- The POC failed to include a measurable pain goal (the comprehensive assessment showed the patient’s pain goal was zero);- A problem of impaired elimination;- The goal was to demonstrate knowledge of elimination – the patient/caregiver/family will maintain usual pattern of bowel and urinary function as evidenced by verbalizing understanding of bowel regime (the patient did not have one), catheter care (the patient did not have a catheter at this time), and incontinence care;- The POC failed to include measurable date elements to show what the “usual bowel pattern and urinary function” were;- A problem of management of medications;- The goal was medication management – the patient/caregiver/family will follow prescribed medication therapy and schedule and verbalize understanding of purpose and side effects of medication (the patient did not take his/her medications regularly and the spouse was having increased difficulty administering medications according to the comprehensive assessment); and- The POC failed to include measurable data elements to show they were following prescribed medication therapy and schedule and “understanding of purpose and side effects”. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services, on 08/03/2025, with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she had a history of a liver transplant in 2014 and myocardial infarction (heart attack) in 2022. The patient, initially, lived with his/her adult child in the home, was ambulatory, confused, suffered frequent hallucinations, and had aggressive behavior. He/she moved to a long-term care facility (LTCF) on 08/15/2025 and his/her adult child visited regularly. Review of the initial comprehensive assessment, dated 08/03/2025, showed the patient's pain goal was zero. Review of the plan of care (POC), dated 08/03/2025 to 10/31/2025, showed: - A problem of anxiety/agitation; - The goal was anxiety management – the patient/caregiver/family will verbalize a reduction or the absence of patient’s anxiety each visit; - The POC failed to contain data elements to measure a “reduction” in anxiety;- A problem of pain;- The goal was level of comfort and symptom control - patient/caregiver/family will verbalize satisfaction with the patient’s level of comfort and symptom control; - The POC failed to include a measurable pain goal (the comprehensive assessment showed the patient’s pain goal was zero); - A problem of impaired elimination;- The goal was to demonstrate knowledge of elimination - the patient/caregiver/family will maintain usual pattern of bowel and urinary function as evidenced by verbalizing understanding of bowel regime, catheter care (the patient did not have a catheter at this time), and incontinence care; and- The POC failed to include measurable data elements to show what the “usual bowel pattern and urinary function” were.  Review of the hospice plan of care update, effective 08/07/2025 to 08/21/2025, showed: - A skilled nurse (SN) entry, dated 08/21/2025, that showed the patient’s last bowel movement (BM) was 08/17/2025. The POC update failed to indicate whether a BM four days prior was part of the patient’s “usual” (per the initial POC goal) bowel pattern and failed to indicate if outcomes were meeting the goals of care; and- The POC update failed to address whether pain management outcomes were meeting the goals of care.  RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family.Review of the comprehensive assessment, dated 06/24/2025, showed the patient’s pain goal was five and the patient usually had a bowel movement every day. Review of the plan of care update, effective 08/21/2025 to 09/03/2025, showed the following:- A problem of pain; the goal was level of comfort and symptom control – patient/caregiver/family will verbalize satisfaction with the patient’s level of comfort and symptom control;  - The POC failed to include a measurable pain goal (the comprehensive assessment showed the patient’s pain goal was a five);- A problem of impaired elimination;- The goal was to demonstrate knowledge of elimination - the patient/caregiver/family will maintain usual pattern of bowel and urinary function as evidenced by verbalizing understanding of bowel regime, catheter and incontinence care (the patient did not have a catheter and was not incontinent); and- The POC failed to include measurable data elements to show what the “usual bowel pattern and urinary function” were for the patient. (the comprehensive assessment showed the patient’s normal bowel routine was daily).During an interview on 09/11/2025 at 1:20 PM, the administrator stated that POC goals and outcomes should be updated.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained all of the necessary drugs and treatments necessary to meet the needs of the patient in three of seven full records reviewed (Records/Patients #1, #6, and #7. This deficient practice has the potential to affect all of the provider’s patients. Findings included: Review of the provider’s undated policy titled, “The Plan of Care – Provision of Care Treatment and Service/Hospice,” showed in part that the plan of care would identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. --- RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the plan of care, dated 09/03/2025, showed the patient had a wound/pressure injury to the right anterior (front) shin/tibia discovered on 08/27/2025.Review of the default flowsheet data (a collection of data from nursing assessments) dated 08/27/2025 – 09/02/2025, showed the patient was getting nonadherent foam dressings applied to the wound every three days.The hospice failed to ensure there was an order in place for the wound dressing changes.During an interview on 09/11/2025 at 1:00 PM, the Registered Nurse Coordinator stated that he/she would expect an order for the dressing before the dressing was applied. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient (GIP) care beginning 09/05/2025.Review of the GIP initial nursing documentation and orders dated 09/05/2025, showed in part that: - The patient arrived at the GIP facility at 10:20 AM. He/she ambulated to his/her room with a walker, was alert and oriented to person, place, time, and situation. The patient had increased difficulty breathing during ambulation and during conversation. His/her bowel sounds were active. The patient reported his/her bladder pain was rated four (4) on a zero (0) to ten (10) high scale as a baseline, and increased to nine (9) on a 0-10 high scale with urination; - Review of facility admission orders received 09/05/2025 showed, but not limited to, that:   * Maintain intravenous (IV) access continuous;   * If IV access is lost, may place subcutaneous line;   * Saline lock IV order; and  * Flush urinary catheter (a sterile tube placed in the bladder to drain urine) every shift as needed for sediment, poor flow. Place a three-way urinary catheter (a sterile tube with three connections used to administer fluids and medication into the urinary bladder). Review of the updated POC for the dates of 09/03/2025 to 09/17/2025, showed in part that the document failed to contain:- Interventions to manage the patient’s uncontrolled diabetes; - A complete order for urinary catheter including, but not limited to, the catheter size, bulb volume, and catheter care; - Orders for care of the nephrostomy tube insertion site; - Orders for the subcutaneous line placement including size and specific site care; - Peripheral IV size, specific site care including a reason for the as needed dressing change; - Care of the saline lock to include cap changes and frequency and volume of flushes; and- The frequency for the urinary catheter flush (the initial order was for each shift).   During an interview on 09/10/2025 at 10:35 AM, the administrator stated that the medical record did contain orders for the patient’s care:- The physician orders were a part of the updated POC; and- They did not have a written policy stating that the physician orders were to be included in the updated POC  RECORD/PATIENT #1:  Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025 with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she moved into a long-term care facility (LTCF) on 08/15/2025 and his/her adult child visited regularly.  Review of the hospice plan of care (POC) update, effective 08/21/2025 to 09/04/2025, showed:- A skilled nurse (SN) note, last edited on 09/04/2025, included the following narrative: patient bed bound, maximum assist to transfer. And “on right heel and great toe, purple discoloration present. BLE (bilateral lower extremities) elevated to prevent further pressure”;- The POC update failed to include an assessment or measurements of the wound;- The interdisciplinary group (IDG) notes showed the following categories, and the notes entered into the category by the IDG:  * IDG discussion: Continue with POC as discussed in IDG (The POC failed to include problems, interventions, and goals for pressure ulcers); * Physician medication and/or treatment recommendations/orders: “no changes at this time” (the IDG/POC failed to include orders for dressings for the pressure wound); and * Updated to hospice POC/plan for next two weeks: Continue interventions and assess for necessary updates (The POC failed to contain interventions for wound care prevention or treatment).  Review of the skilled nurse (SN) visit note, dated 09/04/2025, showed a narrative note “on right heel and great toe, purple discoloration present. BLE (bilateral lower extremities) elevated to prevent further pressure” and “ordered foam dressings per (named medical supply company)”. The nurse failed to perform an assessment or obtain measurements of the wound.  Review of the hospice POC update, effective 09/04/2025 to 09/18/2025, showed: - A problem of impaired skin integrity effective 09/04/2025; - Under the problem, was the direction to elevate BLE on pillows and to ensure heels were not resting against the bed after placing pillows underneath; - The POC update failed to contain dressing orders for the right heel;- The POC update failed to include orders to assess and measure the pressure injury on the right heel;- The heading of SN notes showed no note was created for the current plan; - The heading of plan of care note – other disciplines showed no POC notes were created for the plan; and- The heading of IDG notes showed no note was created for the current plan.  Review of the SN visit note, dated 09/05/2025, showed a narrative note, “Foam dressing placed over right heel purple discoloration” The nurse failed to perform an assessment or obtain measurements of the wound.  Review of the physician orders from 08/03/2025 to 09/08/2025, showed the SN failed to obtain orders for a protective dressing to the newly developed pressure wound.  Observation on 09/09/2025 at 9:15 AM, showed the patient was lying in bed, responsive to touch, the right heel was lying directly on the bed and had a foam dressing that was rolled up and was no longer covering the wound. The wound presented as a suspected deep tissue injury (SDTI), was the approximate size of a silver dollar, skin over the area was intact. The pressure area was purple in color and had black discoloration in the center (that was approximately 1 ½ centimeter (cm) long by ½ cm wide) The patient’s feet were not elevated to keep them off the bed and there were no extra pillows in the room to elevate them. The POC failed to include the treatments necessary to meet the needs of the patient.  During an interview on 09/10/2025 at 4:00 PM, governing body appointee – B stated that there were no wound assessment or measurements for the date the wound was discovered.  During an interview on 09/11/2025 at 1:45 PM, the administrator stated that he/she would expect the registered nurse to assess and measure the newly discovered pressure wound and obtain orders for any interventions performed on the wound. If the wound was discovered by the LTCF before their next visit and notified them, he/she would expect the nurse to do a visit to assess and measure.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the patient’s plan of care (POC) contained all durable medical equipment (DME) and appliances necessary to meet the needs of the patient in one of seven full records reviewed (Record/Patient and #7). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy, “(Named Provider) The Plan of Care – Provision of Care Treatment and Service/Hospice,” showed the written plan if care will contain durable medical equipment (DME) and medical supplies necessary to meet patients needs.RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the physician’s orders showed an order, dated 08/07/2025, to place a foley catheter (a sterile tube placed in the bladder to drain urine) for comfort or urinary retention.Review of the default flowsheet data (a collection of data from nursing assessments) showed the foley catheter was placed on 08/14/2025.Review of the plan of care, dated 08/26/2025 – 09/09/2025, failed to show the addition of the foley catheter to the DME list.During an interview on 09/11/2025 at 2:00PM, the administrator stated that he/she would have expected the foley catheter to get added to the DME list on either 08/14/2025 or 08/15/2025.

Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) was revised and updated based on the patient's updated comprehensive assessment and noted the patient's progress towards their outcomes and goals as specified in the POC in six of seven full records reviewed (Records/Patients #1, #2, #3, #4, #6, and #7).This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the skilled nurse (SN) note dated 08/27/2025 showed patient was readmitted to inpatient hospice for general inpatient care.Review of the plan of care dated 09/03/2025 showed the following interventions:-          -  The patient/caregiver/family will verbalize and demonstrate ability to manage the patient’s anxiety throughout hospice care;-         -   Patient/caregiver/family will follow prescribed medication therapy and schedule, and verbalize understanding of purpose and side effects of medication;-        -    Instruct patient/family/caregiver on infection control and safe disposal of dressing materials; and-       -     Instruct family on wound care.The hospice failed to update the interventions on the plan of care once the patient had admitted to general inpatient care.During an interview on 09/11/2025 at 2:00 PM, the hospice administrator stated that he/she would expect the plan of care to be updated as the patient’s condition changed. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025. Review of the clinical documentation, for the dates of 08/07/2025 to 08/20/2025, showed in part that: - The nursing visit documentation, dated 08/07/2025, showed the patient had:  * Intermittent pain that worsened with urination rated four (4) on a zero (0) to ten (10) high scale;  * A pain goal of 0 on a 0-10 high scale;- The social services visit documentation, dated 08/13/2025, showed that the patient’s spouse had gotten a change in antibiotics approved by the provider’s nurse practitioner; - The nursing visit documentation, dated 08/13/2025, showed that the patient:  * Rated his/her pain a three (3) on a 0-10 high scale;  * Had pain (dysuria) and bleeding (hematuria) during urination; and  * Had some pain relief with the use of Cipro (an antibiotic);- On 08/14/2025, the patient received a new medication order for Cipro with a start date of 08/14/2025;- The nursing triage encounter documentation, dated 08/19/2025, showed in part that the patient:   * Was having severe, burning pain before and during urination;   * Had blood in his/her urine and the urine was cloudy;   * Felt the Cipro was not working, had stopped taking it, and had resumed taking Augmentin (a combination of two types of antibiotics);   * He/she felt the current bowel regimen of Senna (a laxative) and MiraLAX (a laxative) was not working, and had been taking bisacodyl suppositories (a stimulant laxative) from the local pharmacy with results; and  * The nurse notified the nurse practitioner, and orders were received to use Tramadol (a pain medication used to treat moderate pain), discontinue Cipro, Senna, and MiraLAX; - Review of the updated plan of care, for the dates of 08/06/2025 to 08/20/2025, showed in part the document failed to contain, but not limited to, progress toward goals related to:   * The patient’s multiple changes in antibiotics to manage urinary pain;   * The changes in bowel regimen to manage the patient’s problem with constipation; and  * The patient having problems with the emotional/mental challenges related to pain. Review of the clinical documentation, for the dates of 08/21/2025 to 09/05/2025, showed in part that:- Review of the social worker visit documentation, dated 08/21/2025, showed in part that:   * The social worker had been working with the patient for the past week to gather paperwork for a class action lawsuit;   * The social worker had taken documents to be notarized for the patient; and  * The patent continued to grapple with urinary tract infections, pain, and frequent changes in medications:- The nursing visit documentation, dated 08/21/2025, showed in part that the patient had:  * Pain rated at a 9 (nine), on a 0-10 high scale, in the past 24 hours;   * The patient had used his/her spouse’s old prescription for Darvocet (a medication used for pain) in an attempt to control his/her pain, and Tramadol every six hours and acetaminophen (an over-the-counter pain medication) as needed;  * The patient was smoking during the visit with oxygen in use at night and as needed, oxygen safety education provided;   * The patient was experiencing dysuria and hematuria;   * The patient was taking Augmentin, had a left side nephrostomy tube draining yellow urine, and the patient would urinate a small amount, at time, drops or spoon full; - The comprehensive recertification nursing visit documentation, dated 08/28/2025, showed in part that the patient had:   * Pain rated at a 3 on a 0-10 high scale, with a goal of 0;   * Trouble with constipation, and the nurse advised the patient to use the bisacodyl suppository and increase the dose of senna;  * Dysuria and hematuria,   * An increase in dry, itchy, skin, and the nurse advised the patient to use lotion;   * An unchanged appetite, was eating one meal per day of a regular diet;  * His/her nephrostomy tube changed out two times due to clotting, and he/she was now flushing the tube daily. At times the tube was filled with bright red blood and clots:   * Itchy red skin with Sarna lotion ordered;- Review of the updated plan of care. For the dates of 08/21/2025 to 09/04/2025, showed in part that the document tailed to contain updates and progress toward goals for, but not limited to:    * Documentation from medical social services addressing the patient’s participation in a class action lawsuit;   * The nephrostomy tube changes and flushing orders;   * His/her red itchy skin, and use of Sarna lotion;   * A nutritional status update;    * Constipation and multiple changes in medications;   * Documentation of the patient’s progress toward outcomes and goals specified on the POC (the last updates to the problems and goals were dated 07/19/2023);   - Review of the case communication documentation, dated 09/05/2025 at 9:33 AM, showed in part the patient was transferred for general inpatient care (GIP) care. The patient had urinating one liter (approximately four cups) of blood via urinal and nephrostomy bag, unmanaged pain not relieved with Tramadol. The patient reported uncontrolled shaking this morning; and- Review of the updated plan of care, for the dates of 08/21/2025 to 09/05/2025, showed the document failed to contain documentation of the patient’s progress toward outcomes and goals specified on the plan of care (The last updates to goals were dated 07/19/2023).During an interview on 09/11/2025 at 10:45 AM, the administrator stated that they would expect the POC to contain updates as the patient’s condition changed; andThey were unable to locate documentation of progress toward the patient’s goals on this POC.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of SN visit, dated 07/19/2025, showed in part:- The patient had a large growth/tumor behind his/her left ear related to cancer;- The patient had confusion but reported that at times the tumor would “bite me”, instructed the patient to report the pain. The spouse was educated on non-verbal signs and symptoms of pain and using the prescribed medications for pain relief and he/she verbalized an understanding; and- The patient reported mild/moderate intermittent pain in left head with large tumor noted. Review of SN visit, dated 07/23/2025, showed in part:- The patient was alert with confusion and disorientation present; and- The spouse reported they had contacted the patient’s physician about removing the grapefruit sized tumor behind and around his/her left ear and the physician told them that he/she would not perform the surgery due to the risks involved. The spouse stated that he/she wanted the surgeon to tell the patient that as the patient thinks it could be removed;- The spouse was aware of the patient’s confusion and disorientation and reported being under much stress of moving, remodeling, and caregiver role for not only the patient, but also a son who lived with them and had stage 4 (four) cancer.Review of the initial POC, failed to show updates to include problems, goals, or interventions for the following:- The large growth/tumor that the patient complained of biting him/her;- The intermittent tumor pain (pain was a problem on the POC, but failed to be individualized to monitor the patient’s progress toward goal);- The patient’s confusion and disorientation; - The patient wanting the tumor removed; - The move; and- The spouse’s stress (coping and emotional distress was on the POC but failed to be individualized regarding the spouse’s stress related to moving, remodeling, and caregiver role).Review of SN visit, dated 07/28/2025, showed in part:- The patient was alert and pleasantly confused;- Incontinent with unawareness and the spouse cleaned and assisted the patient;- The spouse reported the patient usually slept alone in bed after he/she assisted the patient to bed; and- The spouse reported the patient stayed in bed “for the most part”.Review of SN visit, dated 08/01/2025, showed in part:- Prior to the visit, the spouse had requested a more absorbent brief as the ones they were using were not providing the patient the level of absorbency he/she required;- An overnight style brief was ordered off the non-formulary list; and- One of the patient’s caregivers reported that the patient had complained of the tumor itching.Review of SN visit, dated 08/04/2025, showed in part:- The patient asked randomly four different times during the visit, if he/she could get rid of the tumor on the left side of his/her face;- The patient’s spouse reported that he/she administers the patient’s medications but that the patient did not take any of them regularly;- The patient’s spouse reported the patient was incontinent with unawareness of a large loose bowel movement overnight; and- The patient with a new trace of edema to lower legs and feet with erythema (redness) of feet noted. The patient refused to wear socks/shoes at the time or elevate his/her legs/feet. Review of the POC update, effective from 07/24/2025 to 08/07/2025, showed in part:- IDG discussion: The patient was confused and disoriented with a large tumor on the left side of his/her head/face. He/she had minimal signs and symptoms of pain. He/she was incontinent of bowel and bladder with increasing episodes. He/she was unable to walk steps and took a few steps with assistance;- Physician med and/or treatment recommendations/orders: No changes at that time; and- Updates to hospice POC/plan for next two weeks: Continue interventions and assess for necessary updates. The POC update failed to:- Address the confusion and disorientation (failed to show problem, goals, or interventions for confusion and disorientation);- Address the patient getting up in the night (patient in a new home and had co-morbid diagnosis of dementia);- Address the large tumor and the patient wanting it removed and complaints of it itching (failed to show problem, goals, or interventions for tumor);- Address the need for different incontinent product;- Address the patient not taking his/her medications regularly; - Address the new onset of edema with erythema; and- Address progression towards outcomes and goals. Review of SN visit, dated 08/07/2025, showed in part:- The patient inquired a few times about the tumor protruding from the left side of face, asking if it would ever go away. Discussion had regarding quality of life and impact the treatment; and- The patient denied the tumor being painful, just bothersome, and occasionally itchy.Review of SN visit, dated 08/12/2025, showed in part:- The patient inquired about the tumor protruding from his/her left side of face, the spouse reported the patient asked about it all the time;- The patient denied pain, but did complain of it being tender to touch, itched, and was bothersome to him/her; and- Discussed adding hospice aide once bathroom remodel was completed.Review of SN visit, dated 08/14/2025, showed the patient wandered at night sometimes. Review of the POC update, effective from 08/07/2025 to 08/21/2025, showed in part:- IDG discussion: See SN note;- SN note: Wanders at night. Has protruding tumor to left side of face that was itchy and bothersome but denied pain;- Physician med and/or treatment recommendations/orders: No changes at that time; and- Update to hospice POC/plan for next two weeks: Continue interventions and assess for necessary updates. The POC update failed to:- Address the patient wandering at night (patient in a new home and had co-morbid diagnosis of dementia);- Address the patient’s continued questions of the tumor (failed to show problem, goals, or interventions for tumor); and- Address adding a hospice aide once bathroom remodel completed; and- Address progression towards outcomes and goals.  Review of SN visit, dated 08/21/2025, showed in part:- The patient was no longer taking any routine oral medications and had not needed any as needed (PRN) medications; and- Discussed changing SN visits to one to two times a week, instead of the current two to three times a week. Review of SN visit, dated 08/28/2025, showed in part:- The spouse reported the patient was sleeping poorly at night, was frequently wandering, mostly in the kitchen;- The spouse reported the patient slept frequently during the day and wondered if that was due to the poor sleeping at night; and- Inquired about medications for sleep. Discussed using lorazepam (used to treat anxiety, insomnia, severe agitation) for anxiety, which was available in the home. Demonstrated dosing recommendations. The spouse planned on initiating and would monitor the patient’s response and make medication adjustments as necessary.Review of SN visit, dated 09/03/2025, showed in part:- Caregiver/daughter was present and reported the feeling that the tumor had grown and was causing the patient some degree of pain or discomfort;- Caregiver/daughter reported the patient touched the tumor all the time and told her that it was hard to sleep with it on his/her neck; and- Discussed and reviewed PRN morphine (opioid used for pain) with caregiver/daughter and advised to try 0.25 milliliter (ml) or 5 milligram (mg) at night and monitor the patient’s response for relief.Review of the POC update, effective from 08/21/2025 to 09/04/2025, showed in part:- IDG discussion: The patient continues to wander at night, the family suspected the tumor was interfering with the ability to sleep. The patient denied pain, but the tumor area was growing. The family was to trial morphine at bedtime that week and monitor the response and see if the sleep improved and if pain was a factor (the week prior had the spouse use lorazepam and nothing was documented in update regarding that and if it was effective or not);- Physician med and/or treatment recommendations/orders: No changes at that time; and- Update to hospice POC/plan for next two weeks: Continue interventions and assess for necessary updates. The POC update failed to:- Address the patient’s tumor (failed to show problem, goals, or interventions for tumor);- Address the wandering as far as a problem, goals, or interventions; - Address the fact that on 08/28/2025 that lorazepam was to be given to aide in sleeping and no documentation or discussion on whether it worked or not; and - Address progression towards outcomes and goals.   RECORD/PATIENT #2:Review of clinical record showed the patient's admittance to hospice on 07/09/2025 with a terminal diagnosis of hepatic cirrhosis, unspecified (permanent scarring of the liver that leads to progressive decrease in liver function). A co-morbidity of acute renal failure (a sudden decline in kidney function where the kidneys no longer filter waste, excess fluid or electrolytes from the blood). The patient resided at home with family.Review of the POC, dated 07/09/2025, showed two problems addressed by the medical social work (MSW), which included the following:MSW emotional support needs - The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process; andMSW resource needs –   The goal was that the resource needs be met as evidenced by patient/family/caregiver verbalize understanding of available resources and ways to obtain these.  Review of the initial comprehensive assessment MSW notes, dated 07/10/2025, showed, in part:The family/spouse needed community resources to assist with financial needs;The spouse was concerned about being able to make the house payment;The spouse was unable to work full-time; and  The MSW concluded that the “MSW will continue to monitor.”Review of the clinical record for the MSW, on 08/11/2025, showed, in part, the following:The Spouse called the MSW regarding an additional social security payment the patient had received;The MSW suggested spouse call the social security office and the banking institution; andThe MSW did not schedule a visit, or a follow-up telephone call, with the spouse. Review of the IDG hospice plans of care, dated 07/24/2025, 08/07/2025, and 08/21/2025, in the section titled "medical social worker," all notes showed:Review: MSW continue to follow POC with PRN visits with availability for additional resource or support needs;Follow-up since admit or last IDG meeting: - Pt/family decline SW will follow through IDG and assist/support as needed; Plan for next 2 weeks: continue interventions and assess for necessary updates; andThe IDG failed to ensure the MSW plan was updated based on family needs.  RECORD/PATIENT #1:  Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025 with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she had a history of a liver transplant in 2014 and myocardial infarction (heart attack) in 2022. The patient, initially, lived with his/her adult child in the home, was ambulatory, confused, suffered frequent hallucinations, and had aggressive behavior. He/she moved to a long-term care facility (LTCF) on 08/15/2025 and his/her adult child visited regularly.   Review of the initial comprehensive assessment, dated 08/03/2025, showed:- The patient was ambulatory with supervision at the time of admission; - The patient had confusion and restlessness, would get up during assessment and wander off;- The skin assessment showed the patient’s skin had normal temperature, turgor (elasticity) and color; - The Braden scale assessment (a tool used to determine a patient’s risk for the development of pressure injury) showed the patient’s score was 19 (no risk = 19–23); and  - The patient did not have wounds/pressure ulcers.  Review of the initial plan of care (POC), dated 08/03/2021 to 10/31/2025, showed:-  A problem of home safety;- The goal for home safety was “patient/caregiver maintain safe home environment as evidenced by verbalizing understanding of oxygen safety and remaining free from falls;- Interventions included:  * Assess home environment for safety concerns; * Encourage family to stay with patient when appropriate; and * Instruct patient/caregiver on strategies to reduce injury in the home. Review of the medical social worker’s (MSW) phone call note, dated 08/17/2025, showed the patient’s child reported to the MSW that patient eloped from the LTCF on 08/16/2025 and was moved to a locked unit for safety reasons.   Review of the hospice POC update, effective from 08/07/2025 to 08/21/2025, showed: - Skilled nurse (SN) notes, last edited on 08/21/2025, failed to address the patient’s elopement and move to the locked unit in the LTCF;- The SN plan for the next two weeks was to continue interventions and assess for necessary updates;- The MSW’s note, last edited on 08/20/2025, failed to address the elopement and the move to a locked unit in the LTCF;- The POC update failed to include updates to the home safety problem/goals/interventions to reflect the patient’s move to the LTCF (on 08/15/2025), the patient’s elopement from the LTCF (on 08/16/2025), and the resulting move to the locked unit in the LTCF; and- The POC update failed to note the patient’s progress toward outcomes and goals.  Review of the SN visit note on 08/18/2025, showed the patient was confused, oriented to self, had increase in bilateral lower extremity (BLE) weakness with unsteady gait. He/she needed two person assist to walk back from the bathroom to the chair and to transfer from the chair to his/her bed. The patient received quetiapine for restlessness and had a fentanyl patch in place for pain. The patient also received as needed (PRN) doses of lorazepam (for anxiety), oxycodone (for pain) and quetiapine (for restlessness/ agitation) from the LTCF.  Review of the SN visit note on 08/21/2025, showed the patient was found on the floor on his/her knees that morning by the LTCF staff. The LTCF staff reported the patient was starting to refuse food. At the time of SN assessment, the patient was lethargic and was falling asleep leaning forward in the chair. He/she was assisted back to bed with the help of two staff. Review of the SN visit note on 08/23/2025, showed the patient’s adult child called the provider with concerns the patient was over sedated. When SN arrived, the patient was very lethargic and sedated. The LTCF nurse was unable to provide the SN with 24 hour totals of medication but the facility certified medication technician (CMT) informed the SN the patient had received haloperidol (for agitation), lorazepam (for anxiety) and oxycodone (for pain) between 2:50 PM and 3:30 PM that day. The patient also had a fentanyl patch (for pain) in place and, per the adult child’s report, had a second patch in place that he/she requested the facility CMT remove. The adult child reported to the SN he/she felt the patient was being purposefully sedated, so the facility didn’t “have to deal with” him/her. The adult child requested that the LTCF no longer give the patient haloperidol and to phone him/her prior to giving the lorazepam. Review of the SN visit note on 08/25/2025, showed the patient was “more alert”, cooperative, still required two person assist to stand and pivot to the wheelchair and toilet. The adult child and grandchild were in room visiting at the time of SN visit and reported he/she received no calls regarding the need to administer lorazepam. The patient received only scheduled medications that day.  Review of the SN visit note dated 09/03/2024 showed the patient was now bed bound and “max” (maximum) assistance to transfer. He/she was minimally responsive but could open his/her eyes at the SN request. The SN met with the LTCF nurse practitioner (NP) at bedside. Discussed the patient’s high aspiration risk (when food/fluid/medications are accidentally inhaled into the lungs), and pocketing food (holding food in the cheeks instead of swallowing it) and the NP would discontinue oral medication from the LTCF medication administration record (MAR). The patient status was changed to nothing by mouth (NPO) with oral care recommended every two hours. The SN ordered toothettes (sponge swabs on a stick used for oral care to provide moistening and cleansing) from (named supply company).  Review of the POC update, effective 08/21/2025 through 09/04/2025, showed: - The SN documented the patient had a “purple discoloration” on “right heel and great toe” and both lower extremities were elevated to “prevent further pressure”; - Physician medication and/or treatment recommendations showed “no changes at this time”;  - The interdisciplinary group (IDG) failed to update the POC to include a new Braden scale assessment (a tool used to determine a patient’s risk for the development of pressure injury); - The IDG failed to update the POC to include interventions and goals for the pressure area on the right heel;  - The IDG failed to update the POC to address the family’s initial concern about the patient being over sedated;- The IDG failed to update the POC to address the LTCF discontinued oral medications, the NPO status, and the need to perform oral care every two hours;- The IDG failed to update the patient’s medication list to reflect the discontinued medications; and- The IDG failed to update the patients POC problems/interventions/goals to reflect the patient’s decline in condition. RECORD/PATIENT #4:L553Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family.Review of the initial comprehensive assessment, dated 06/24/2025, showed the patient had pain in his/her back and legs. He/she rated the back pain at an eight out of 10 (on the numerical pain scale in which zero equals no pain and 10 equals worst pain imaginable) and the leg pain at a five. The skilled nurse (SN) documented a narrative note that showed the patient reported that his/her “muscle relaxant (tizanidine), gabapentin (for nerve pain), and short acting pain pill (patient took diclofenac – a non-steroidal anti-inflammatory medication for pain) two times a day keeps pain manageable”.  Review of initial plan of care (POC), dated 06/24/2025, and the updated plan of care, dated 08/21/2025 to 09/03/2025 showed pain as an identified problem with the following goals and interventions:- Goal: level of comfort and symptom control. The patient will verbalize satisfaction with the patient’s level of comfort and symptom control. Uncontrolled pain will be resolved within two hours of exacerbation throughout hospice care;- Intervention:* Assess effectiveness of pain management for each patient visit;*Assess patient for signs and symptoms of acute pain each visit;* Assess patient for signs and symptoms of chronic pain each visit;* Instruct patient/family/caregiver on non-pharmacological pain management;* Instruct patient/caregiver on pain scale; and*Instruct patient /caregiver on pharmacological pain management. Review of the SN note, dated 07/07/2025, showed the patient’s Norco (a combination narcotic pain reliever) changed to every four hours as needed for pain. The patient reported to the SN that his/her back pain was an eight. Stated that the pain was manageable but would like to get it lower. Review of the SN note dated 07/16/2025, showed the patient was started on MS Contin (a opioid pain reliever) 15 mg two times a day. The patient rated back pain at a 4 reported medication was working well. Review of the POC updates effective 07/10/2025 to 07/24/2025; 07/25/2025 to 08/06/2025; 08/07/2025 to 08/20/2025; and 08/21/2025 to 09/03/2025  showed the provider failed to ensure the interdisciplinary group (IDG) updated the POC to show the patient’s progress toward outcomes and goals.During an interview on 09/11/2025 at 1:45 PM, the administrator stated that he/she would changes in patient condition to be addressed in the POC updates with updated problems and goals.

Based on policy review, record review, and interview, the hospice provider failed to ensure coordination of care so that patient and family needs were met in one of seven full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy titled, “Coordination of Care with Interdisciplinary Group (IDG),” showed in part:- The purpose: To ensure the coordination of services for each patient; and- The type and scope of services provided by the IDG will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions.RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the initial comprehensive assessment, dated 07/18/2025, showed the following:- The patient was 90 years old;- The patient needed assistance with bathing, dressing, toileting, transfer, and continence;- Living arrangements: In own home with spouse. Additional comments: Patient and spouse have a son that was living with them, and they were all moving on 07/19/2025 to a new home;- Psychosocial of caregiver;*Behaviors- anxious*Stress factors- exhaustion, health changes, loss of control*Coping responses- acceptance, anxiety, sadness- Neurological;*Level of consciousness- alert*Orientation level- person and place*Memory loss- immediate, short term*Issues- depressed mood, fatigue, and forgetfulness- Urgent needs: The patient and spouse were moving into a new home in the same town and anticipated to be at the new address by 07/20/2025;- Disciplines requested: skilled nurse and medical social worker (MSW); and- Social issues: The patient and spouse were moving into a smaller home in the same town that weekend. The daughter was paid thru the Veteran’s administration to be a caregiver for the patient four (4) hours per day for 4 days a week and assisted them regularly. A son also lived with them, who was battling stage 4 cancer and was also moving with them to the new home.Review of the clinical record failed to show any coordination took place regarding the urgent needs with moving. Review of the clinical record failed to show the caregiver was offered respite services or volunteer services to assist during the move to lessen the burden of also caring for the patient and moving at the same time. Review of skilled nurse (SN) visit, dated 07/19/2025, showed the patient and caregivers were actively moving. The spouse reported they would be between both homes for the next one to two weeks and both addresses were in the chart. The record failed to show any coordination took place regarding helping the patient and caregivers move. Review of SN visit, dated 07/23/2025, showed the spouse with much stress with moving, remodeling, and his/her caregiver role for spouse and son who had stage 4 (four) cancer and also lived with them. The record failed to show any coordination took place regarding helping the caregiver with his/her stress. During an interview with the patient’s spouse on 09/09/2025 at 11:26 AM, he/she stated that respite services had not been offered until “today” (09/09/2025). He/she also denied ever being offered volunteer or homemaker services and stated that both of those would be helpful.During an interview on 09/11/2025 starting at 1:20 PM, the administrator stated that the caregiver should have been offered respite or volunteer services during the move.

Based on policy review, job description review, record review, and interview, the hospice provider failed to:- Ensure nursing care and services were provided to meet the nursing needs of the patient as identified in the patient’s initial assessment, comprehensive assessment, and updated assessment (L0591); and- Provide medical social services to meet the psychosocial needs (L0594). The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, job description review, record review, and interview, the hospice provider failed to ensure nursing care and services were provided to meet the nursing needs of the patient as identified in the patient’s initial assessment, comprehensive assessment, and updated assessment in three of seven full records reviewed (Records/Patients #1, #3, and #8). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 04/16/2025 with a terminal diagnosis of malignant neoplasm of the head of the pancreas with metastasis to the liver (a type of cancer in the pancreas which has spread to the liver) and a secondary diagnosis of chronic kidney disease (a disease of the kidneys that leads to renal failure). The patient resided at home with his/her spouse as a caregiver.  Review of the initial comprehensive assessment dated 04/16/2025, showed the cardiovascular assessment showed the patient had hypotension (low blood pressure) and edema (swelling of the tissues) described as located in the bilateral lower extremities to the ankles and feet and pitting at 1+ (edema is classified according to the grade of swelling).Review of the initial plan of care dated 04/16/2025 to 07/14/2025, showed the patient failed to have orders or interventions for the management of hypotension or edema.Review of a skilled nurse (SN) visit dated 04/22/2025, showed the patient had edema in the bilateral lower extremities described as 3+ and the assessment failed to include if the physician was notified of the change in edema.Review of a SN visit dated 04/30/2025, showed the patient had edema described as located in the bilateral lower extremities to the ankles and feet and pitting at 3+, the patient’s  spouse reported a visit with the patient’s primary care physician (PCP) yesterday and the PCP ordered compression boots, and the patient reported decreased urine output and a weak flow of urine and was only able to go “a little bit.  The assessment failed to include if the physician was notified of the new orders from the PCP or the change in urinary output.Review of a SN visit note dated 05/07/2025, showed the additional comments stated “patient is orthostatic” (a form of low blood pressure that happens when standing up from sitting or lying down), the narrative note showed “Patient reports while he/she was sitting outside and went to stand up he/she felt very weak, legs felt wobbly and that he/she might pass out.  Patient reports that yesterday he/she had four liters of fluids removed during paracentesis (a medical procedure that involves removing excess fluid from the abdominal cavity) and the assessment failed to include if the physician was notified of the patient’s orthostatic blood pressure or change in condition.During an interview on 09/11/2025 beginning at 1:20 PM, the administrator stated that he/she would expect the physician to be notified of changes in a patient’s condition. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of cancer of the bladder. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025. Review of the clinical documentation, for the dates of 08/07/2025 to 08/20/2025, showed in part that: - The nursing visit documentation, dated 08/07/2025, showed the patient had:  * Intermittent pain that worsened with urination rated four (4) on a zero (0) to ten (10) high scale;  * A pain goal of 0 on a 0-10 high scale;- The social services visit documentation, dated 08/13/2025, showed that the patient’s spouse had gotten a change in antibiotics approved by the provider’s nurse practitioner; - The nursing visit documentation, dated 08/13/2025, showed that the patient:  * Rated his/her pain a three (3) on a 0-10 high scale;  * Had pain (dysuria) and bleeding (hematuria) during urination;   * Had some pain relief with the use of Cipro (an antibiotic); and  * The visit note failed to contain documentation to address why the spouse had reached out to the provider’s nurse practitioner, instead of the patient’s case manager, regarding the patient’s pain;- A new medication order for Cipro with a start date of 08/14/2025; - The chaplain visit documentation, dated 08/19/2025, showed in part that the patient had:   * Discussed increased pain and the emotional/mental challenges due to pain; - The nursing triage encounter documentation, dated 08/19/2025, showed in part that the patient:   * Was having severe, burning pain before and during urination;   * Had blood in his/her cloudy urine;    * He/she felt the Cipro was not working, had stopped taking it, and had resumed taking Augmentin (an antibiotic);   * He/she felt the current bowel regimen of senna (a laxative) and MiraLAX (a laxative) was not working, and had been taking bisacodyl suppositories (a stimulant laxative) from the local pharmacy with results; and  * The nurse notified the nurse practitioner, and orders were received to use Tramadol (a pain medication used to treat moderate pain), discontinue Cipro, Senna, and MiraLAX; and  * The encounter note failed to contain documentation of discussion of increasing nursing visits to address the patient’s pain and the patient getting medications from the local pharmacy; - Review of the updated plan of care, for the dates of 08/06/2025 to 08/20/2025, showed in part the document:- Contained orders for nursing visit 1-2 times per week and as needed. The patient received nursing visits once per week; and- Failed to contain documentation of:   * The patient’s multiple changes in antibiotics to manage urinary pain;   * The changes in bowel regimen to manage the patient’s problem with constipation;   * The patient having problems with the emotional/mental challenges related to pain; and  * A discussion of the patient’s increased symptoms and the possible need to increase nursing visits/contact encounters. Review of the clinical documentation, for the dates of 08/21/2025 to 09/05/2025, showed in part that:- Review of the social worker visit documentation, dated 08/21/2025, showed in part that the patent continued to grapple with urinary tract infections, pain, and adjusting medications:- The nursing visit documentation, dated 08/21/2025, showed in part that:  * The patient’s highest pain in the past 24 hours had been 9 (nine) on a 0-10 high scale;   * The patient had used his/her spouse’s Darvocet (a pain medication) in attempt to get pain relief, Tramadol (an opioid pain medication) every six hours, and acetaminophen (an over-the-counter pain medication) as needed;  * The patient was experiencing dysuria and hematuria;   * The patient was taking Augmentin, had a left side nephrostomy draining yellow urine, and the patient would urinate a small amount, at time, drops or spoon full;- The comprehensive recertification nursing visit documentation, dated 08/28/2025, showed in part that the patient had:   * Pain rated at a 3 on a 0-10 high scale, with a goal of 0;   * The patient was having trouble with constipation, and the nurse advised the patient to use the suppository and increase the senna;  * The patient had dysuria and hematuria,   * The patient had an increase in dry skin, and the nurse advised the patient to use lotion;   * The patient’s appetite was unchanged, eating one meal per day of a regular diet;  * Nephrostomy tube was changed out two times due to clotting, and the patient/caregiver were flushing the tube daily, having times with bright red blood and clots in the tubing;   * Itchy red skin with Sarna lotion ordered;- Review of the updated plan of care, for the dates of 08/21/2025 to 09/04/2025, showed in part that the document tailed to contain updates and progress toward goals for, but not limited to:    * The nephrostomy tube changes and tube flushing orders;   * Red itchy skin and use of Sarna lotion not on care plan;   * The patient’s nutritional status; and  * The updated care plan failed to contain documentation of the patient’s worsening pain or a discussion of increasing patient visits/contacts to manage the pain;During an interview on 09/11/2025 at 10:23 AM, the patient’s spouse stated that he/she: - Felt the nurses had done a very good job in trying to manage the patient’s pain. That he/she had just tried his/her Darvocet to manage the patient’s pain because they were just trying anything to get him/her relief; - Had changed the patient’s nephrostomy tube dressing daily for a very long time, and the nurses seldom asked him/her to remove the dressing; - Flushed the nephrostomy tube every other day with ten milliliters of normal saline;- Bought big bandages from the pharmacy for wound care; and- Cleansed the insertion site with alcohol before reapplying the clean bandage.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of SN visit, dated 08/04/2025, showed in part, the patient asked randomly four different times during the visit, if he/she could get rid of the tumor on the left side of his/her face. The patient had a new trace of edema (swelling) to lower legs and feet with erythema (redness) of feet noted and the assessment failed to include if the physician was notified of the new onset of edema and erythema. Review of SN visit, dated 08/07/2025, showed in part:- The patient inquired a few times about the tumor protruding from the left side of face, asking if it would ever go away. Discussion had regarding quality of life and impact the treatment; and- The patient denied the tumor being painful, just bothersome, and occasionally itchy.Review of SN visit, dated 08/12/2025, showed in part:- The patient inquired about the tumor protruding from his/her left side of face, the spouse reported the patient asked about it all the time; and- The patient denied pain, but did complain of it being tender to touch, itched, and was bothersome to him/her.Review of the clinical record failed to show the physician was notified regarding the patient’s constant questions about getting tumor removed, being bothersome, and itching. Review of SN visit, dated 08/28/2025, showed in part:- The spouse reported the patient was sleeping poorly at night, was frequently wandering, mostly in the kitchen;- The spouse reported the patient slept frequently during the day and wondered if that was due to the poor sleeping at night; and- Inquired about medications for sleep. Discussed using lorazepam (used to treat anxiety, insomnia, severe agitation) for anxiety, which was available in the home. Demonstrated dosing recommendations. The spouse planned on initiating and would monitor the patient’s response and make medication adjustments as necessary.Review of the clinical record failed to show any follow-up on the lorazepam to see if it helped or not. Review of SN visit, dated 09/03/2025, showed in part:- Caregiver/daughter was present and reported the feeling that the tumor had grown and was causing the patient some degree of pain or discomfort;- Caregiver/daughter reported the patient touched the tumor all the time and told her that it was hard to sleep with it on his/her neck; and- Discussed and reviewed PRN morphine (opioid used for pain) with caregiver/daughter and advised to try 0.25 milliliter (ml) or 5 milligram (mg) at night and monitor the patient’s response for relief.Review of the clinical record failed to show any follow-up on the morphine to see if it helped or not. During an interview on 09/11/2025 beginning at 1:20 PM, the administrator stated that he/she would expect the physician to be notified of changes in a patient’s condition and would have expected the nurse to follow-up on the lorazepam and morphine and document if they helped or not.  Findings included:  Review of the provider’s job description titled, “Nurse, Clin (clinical) 1 (one) – Homecare (E),” status date 10/20/2023, showed, in part:- The registered nurse (RN) evaluates the client and furnishes services requiring substantial and specialized skill, appropriate preventive and rehabilitative nursing procedures;- When assigned as case manager, the staff nurse is responsible for coordinating all aspects of care related to that patient;- Responsibilities included: * Monitors patients’ response and modifies plan of care accordingly; * Provides accurate documentation as required;  * Delivers direct patient care by assessing and evaluating patient’s physical, psychosocial and emotional needs; and * Develops and implements individual plans of care in accordance with the established guidelines and standards of nursing care.  Review of the provider’s undated policy titled, “Ongoing Comprehensive Assessment,” showed, in part: - During each home visit, the case manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment;- The nurse will assess the patient on each scheduled visit for: * Secondary symptoms related to the terminal illness such as nausea, vomiting, and respiratory distress, and the patient’s response to medications and other interventions; * Factors that alleviate or exacerbate physical symptoms; * Current treatment related to the identified symptoms and the patient’s response; * Skin integrity; * Bowel sounds, elimination (urinary and bowel); - Ongoing comprehensive assessment should focus on: * The patient’s response to care; * Changes in patient condition, level of deterioration;  * Changes in patient’s care environment or support systems; * Change in patient’s and family/caregiver’s perceived needs; - Based upon the findings of the assessment, additional orders will be generated and forwarded to the physician (or other authorized licensed independent practitioner) for signatures; and- The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approval.  RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025 with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she moved into a long-term care facility (LTCF) on 08/15/2025 and his/her adult child visited regularly.  Review of the skilled nurse (SN) visit note, dated 09/04/2025, showed a narrative entry, “on right heel and great toe, purple discoloration present. BLE (bilateral lower extremities) elevated to prevent further pressure” and “ordered foam dressings per (named medical supply company)”. The nurse failed to perform an assessment or obtain measurements of the wound. Review of the SN visit note, dated 09/05/2025, showed a narrative entry, “Foam dressing placed over right heel purple discoloration” The nurse failed to perform an assessment or obtain measurements of the wound. Review of the physician orders from 08/03/2025 to 09/08/2025, showed the SN failed to obtain orders for a protective dressing to the newly developed pressure wound. During an interview on 09/10/2025 at 3:13 PM, the registered nurse (RN) coordinator stated that he/she could not find any wound measurements prior to 09/08/2025 and would expect the nurse to assess and measure the wound when it was discovered. He/she also could not find an order for the wound dressing applied by the nurse and he/she would expect the nurse to obtain a physician’s order for wound dressings. During an interview on 09/11/2025 at 1:45 PM, the administrator stated that he/she would expect the RN to assess and measure the newly discovered pressure wound and get physician orders for any intervention to the wound.

Based on policy review, record review, and interview, the hospice provider failed to provide medical social services to meet the psychosocial needs and financial resources in two of seven full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all the patients and families served by the provider. --- RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/24/2025 with a terminal diagnosis of primary squamous cell carcinoma of upper lobe of left lung (lung cancer). The patient resided at home with family.Review of the clinical record showed one medical social work (MSW) visit note from an initial visit on 06/24/2025.  At the conclusion of the note the MSW stated “MSW will continue to monitor.”Review of the plan of care, dated 06/24/2025, showed the following psychosocial problems: - MSW Emotional Support Needs – deficit related to emotional support.  The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process.  Interventions included assessing for emotional distress and providing emotional support at each visit; and- MSW Resource Needs – understanding of available resources.  The goal was that the resource needs be met as evidenced by patient/family/caregiver verbalize understanding of available resources and ways to obtain these.  Interventions included assessing and assisting with financial resources and providing assistance with identifying community resources.  Review of the clinical record showed the MSW failed to perform additional visits to further assess the psychosocial needs of the patient/family since their initial assessment (76 days prior). During an interview on 09/11/2025, governing body appointee-B stated there were no additional social work visit notes for Patient #4.  Findings included:Review of the provider’s Job Description for the Social Worker, dated 09-08-2025, showed, in part, the following:Under the direction of a physician, assists patients and their families in their residences to adapt and plan an interdisciplinary approach to treating the patient-family system;        Consults with patients, families and staff regarding goals of care, end of life issues and palliative needs; and       Plans and implements social work services on assigned clinical service or unit in collaboration with the healthcare team.Review of the provider’s undated policy titled, “Coordination of Care with Interdisciplinary Group (IDG),” showed, in part, the following:          The IDG (in collaboration with the attending physician, if any) will conduct assessments, develop, and update the plan of care, and review the effectiveness of care a minimum of every 15 days unless required more frequently by state statute; and         Continuity of care will be maintained throughout the patient’s course with hospice.RECORD/PATIENT #2:Review of clinical record showed the patient's admittance to hospice on 07/09/2025 with a terminal diagnosis of hepatic cirrhosis, unspecified (permanent scarring of the liver that leads to progressive decrease in liver function), and a secondary diagnosis of acute renal failure (a sudden decline in kidney function where the kidneys no longer filter waste, excess fluid or electrolytes from the blood). The patient resided at home with family. Review of the Plan of Care (POC) starting on 07/09/2025 showed two problems addressed by the medical social worker (MSW), which included the following:         MSW Emotional Support Needs – deficit related to emotional support.  The goal was for the patient/family/caregiver to understand impact of illness as evidenced by verbalizing acceptance of disease process; and          MSW Resource Needs – understanding of available resources.  The goal was that the resource needs be met as evidenced by patient/family/caregiver verbalize understanding of available resources and ways to obtain these.   Review of the clinical record for the MSW visit note for the initial visit, on 07/10/2025, showed, in part, the following:The family/spouse needed community resources to assist with financial needs;Spouse concerned with being able to keep up house payment;Spouse unable to work full-time; and  At the conclusion of the note the MSW stated “MSW will continue to monitor.”Review of the clinical record for the MSW, on 08/11/2025, showed, in part, the following: The Spouse called the MSW regarding an additional social security payment the patient had received;The MSW suggested spouse call the social security office and the banking institution; andThe MSW did not schedule a visit, or a follow-up telephone call, with the spouse. Review of the subsequent hospice plan of care, dated 07/24/2025, 08/07/2025, and 08/21/2025, in the section titled "medical social worker notes all stated, "Review: MSW continue to follow POC with PRN visits with availability for additional resource or support needs. Follow-up since admit or last IDG meeting: - Pt/family decline SW will follow through IDG and assist/support as needed. Plan for next 2 weeks: continue interventions and assess for necessary updates."During an interview on 09/11/2025, governing body appointee- B stated, there were no additional visit notes for Record/Patient #2.

Based on policy review, current survey findings, and interview, the hospice provider failed to:- Provide hospice care that optimized comfort and dignity and was consistent with patient and family needs and goals (L0650); - Ensure the administrator was responsible for the day-to-day operations of the organization (L0651); and- Continually monitor and manage all services provided at all of its locations to ensure that services are delivered in a safe and effective manner and to ensure that each patient and family receives the necessary care and services outlined in the plan of care (L0660).The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on current survey findings and interview, the hospice provider failed to provide hospice care that optimized comfort and dignity and was consistent with patient and family needs and goals. This deficient practice has the potential to affect all the patients on service with the provider. --- Findings included:The current survey findings showed the organization failed to effectively ensure the provision of hospice care and services that optimized patient comfort and dignity, and was consistent with patient and family needs and goals resulting in noncompliance with the following six Conditions of Participation: - §418.52 Condition of participation: Patient rights;- §418.54 Condition of participation: Initial and comprehensive assessment of the patient; - §418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services;- §418.64 Condition of participation: Core services;- §418.100 Condition of Participation: Organization and administration of services; and- §418.104 Condition of participation: Clinical records. During an interview on 09/11/2025 beginning at 1:20 PM, the registered nurse coordinator (RNC) stated that:- A head-to-toe assessment should be completed on the initial comprehensive assessment and patient’s symptoms to always be managed;-They only choose one individual to do the initial bereavement assessment on until the patient’s death then they assess for other bereaved after the death. This then gets discussed at the next interdisciplinary group (IDG) meeting;- The plan of care (POC) should be individualized;- The IDG met every week. The supervisor oversaw the IDG. First, they discussed deaths and bereavement. Admissions were the next topic discussed. The nurse started the discussion followed by the social worker then the chaplain. The meeting discussed patients whose last names began with letters A through L one week and letters M through Z the next week. If the pharmacist attended, they reviewed medications; and- He/she would expect the nurses to assess and measure wounds when they were discovered and he/she would expect the nurses to obtain physician’s order for wound dressing.During an interview on 09/11/2025 beginning at 1:20 PM, the administrator stated that:- He/she would expect a patient’s symptoms to always be managed and that a head-to-toe assessment should be completed on each skilled nurse’s visit;- He/she expected the clinicians to update the medication profiles and expected the patient’s medication profiles to match the long-term care facility (LTCF) medication lists and the patient’s home medications;- The plan of care POC should be individualized, including the interventions; - He/she would expect the POC to be updated with changes and to include problems that were relevant to the patient’s assessment;- He/she would expect the bereavement assessment to be done within five days of admission;- The supervisors cover “good to great” visits that ensure the patient needs were being met.  He/she would expect changes in condition to be addressed in the POC updates with updated problems and goals;- He/she would expect the registered nurses (RN) to assess and measure newly discovered pressure wounds and obtain physician orders for any interventions to the wound; and- He/she would expect physicians to be notified of changes in a patient’s condition and would expect the nurses to follow-up on any medication changes.  Review

Based on current survey findings, the hospice director (administrator) job description, and interview, the hospice provider failed to ensure the administrator was responsible for the day-to day operations of the organization. This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:The current survey findings showed the hospice administrator failed to effectively manage the overall day-to-day operations of the provider resulting in noncompliance with the following six Conditions of Participation: - §418.52 Condition of participation: Patient rights;- §418.54 Condition of participation: Initial and comprehensive assessment of the patient; - §418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services;- §418.64 Condition of participation: Core services;- §418.100 Condition of Participation: Organization and administration of services; and- §418.104 Condition of participation: Clinical records.Review of the hospice director job description, as of 09/10/2025, showed, in part:- Responsible for the strategic direction, oversight and overall operations of the hospice;- Entrusted to lead and manage an interdisciplinary team of hospice care providers, ensuring the highest level of care in an efficient and cost effective manner;- Expected to manage all aspects of the operation resulting in meeting or exceeding company goals related to quality, operations, finances and employee retention;- Ensures the highest quality of care is provided and is in compliance with federal, state, and local regulatory requirements and established departmental policies and procedures. Oversees the implementation of agency (provider) policies and procedures; and- Researches, identifies, and implements best practice models to support organization initiatives and strategic plans. Monitors the allocation and utilization of agency resources based on continual changes in patient population/needs and provides the best level of patient care while optimizing efficiencies and cost management.During an interview on 09/11/2025 beginning at 1:20 PM, the administrator stated that:- He/she would expect a patient’s symptoms to always be managed and that a head-to-toe assessment should be completed on each skilled nurse’s visit;- He/she expected the clinicians to update the medication profiles and expected the patient’s medication profiles to match the long-term care facility (LTCF) medication lists and the patient’s home medications;- The plan of care POC should be individualized, including the interventions; - The accrediting organization had informed him/her that if something was not an active problem (i.e., patient not experiencing pain) it did not have to be on the POC;- He/she would expect the POC to be updated with changes and to include problems that were relevant to the patient’s assessment;- He/she would expect the bereavement assessment to be done within five days of admission;- The supervisors cover “good to great” visits that ensure the patient needs were being met.  He/she would expect changes in condition to be addressed in the POC updates with updated problems and goals;- He/she would expect the registered nurses (RN) to assess and measure newly discovered pressure wounds and obtain physician orders for any interventions to the wound; and- He/she would expect physicians to be notified of changes in a patient’s condition and would expect the nurses to follow-up on any medication changes.  Review

Based on current survey findings and interview, the hospice provider failed to continually monitor and manage all services provided at all of its locations to ensure that services are delivered in a safe and effective manner and to ensure that each patient and family receives the necessary care and services outlined in the plan of care. This deficient practice has the potential to affect all the patients on service with the provider. --- The current survey findings showed the organization failed to continually monitor and manage all services provided at all of its locations to ensure that services were delivered in a safe and effective manner and failed to ensure that each patient and family received the necessary care and services as outlined in their plan of care, resulting in noncompliance with the following six Conditions of Participation: - §418.52 Condition of participation: Patient rights;- §418.54 Condition of participation: Initial and comprehensive assessment of the patient; - §418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services;- §418.64 Condition of participation: Core services;- §418.100 Condition of Participation: Organization and administration of services; and- §418.104 Condition of participation: Clinical records.During the entrance interview on 09/08/2025 at 11:27 AM, the administrator stated that:- The census was 303 current patients; and - He/she rotated between the multiple locations in order to continually monitor and manage.During an interview on 09/11/2025 beginning at 1:20 PM, the administrator stated that:- He/she had misinformed the state agent regarding current census, that he/she had forgotten to count the patients at the multiple locations in that number and the total census was 369 current patients; and - He/she was working on brining the multiple location’s staff into the parent location to have better oversight of them. Review

Based on policy review, review of patient/caregiver handbook, record review, observation, and interview, the hospice provider failed to ensure:- Follow-up to patient/family care provided by the medical social worker (MSW) was documented in the clinical record (L0672);- Each patient's record included an accurate advance directive (L0677);- That there was a complete physician’s order prior to treatment (L0678);- All entries were complete and dated in accordance with the hospice policy (L0679); and - The clinical record was safeguarded against unauthorized use (L0680).The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to ensure follow-up to patient/family care provided by the medical social worker (MSW) was documented in the clinical record in one of seven full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s undated policy titled, “(Named provider) – Entries into the Clinical Record- Management of Information/Home Care,” showed, in part:- Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided;- Entries into the clinical record will be made on the day care is provided to the patient;  - All documentation will be completed by the end of the work day; and- The clinical note should include care that was provided and response to treatment. RECORD/PATIENT #1:  Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025 with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she moved into a long-term care facility (LTCF) on 08/15/2025 and his/her adult child visited regularly.  Review of the hospice MSW phone call note dated 08/25/2025, showed a call was placed to the patient’s adult child family member in response to a triage call that the LTCF was over medicating the patient and the patient’s cell phone was stolen. The family member stated that he/she tracked the cell phone and it was “driving 5 (five) minutes away from the facility before it stopped." The family member expressed desire to have the patient transferred to another LTCF. The MSW informed the family member they would assist them.Review of the hospice MSW phone call note dated 08/26/2025, showed the MSW called the patient’s adult child family member and inquired whether he/she wanted to move the patient to (named facility). The family member confirmed they would like to pursue the transfer. Review of the MSW visit note dated 09/02/2025, failed to show follow up on the patient’s transfer. Review of the clinical record showed no further documentation regarding the status of the patient’s transfer to another LTCF.  During an interview on 09/10/2025 at 2:00 PM, the registered nurse (RN) coordinator stated that the MSW reached out and visited with the adult child on 09/02/2025 and discussed the patient’s declining condition. The MSW asked the patient’s adult child if he/she still wanted to transfer to a different LTCF and he/she decided not to pursue transferring to a different LTCF. The MSW failed to document this in the visit note. The RN coordinator stated that the MSW should have documented the follow up conversation in the clinical record.

Based on patient/caregiver handbook review, record review, and interview, the hospice provider failed to ensure each patient's record included an accurate advance directive in one of seven full records reviewed (Record/Patient #2). A patient that elected to be a full resuscitation, was incorrectly identified as a do not resuscitate (DNR) status. This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the undated patient and caregiver handbook (given to patients upon election of hospice), showed, in part, the following:- You may ask your health care professional about having a do not resuscitate (DNR)/ practitioner orders for life-sustaining treatment;- If you have not executed an advance directive, decisions regarding your health care will have to be made by someone else (who might not be the person you would have chosen) and may place additional burdens on your family and physician or other health care provider; and- Each of our patients will receive total life-sustaining treatments unless the physician, patient and/ or family decide otherwise. Sometimes a patient's vital organs fail. At that time, "total life-sustaining treatment" means every appropriate and available treatment will be used to sustain life. RECORD/PATIENT #2:Review of clinical record showed the patient was admitted to hospice services on 07/09/2025 with a terminal diagnosis of hepatic cirrhosis, unspecified (chronic liver damage from a variety of causes leading to scarring and liver failure) and a secondary diagnosis of acute renal failure (a sudden decline in kidney function where the kidneys no longer filter waste, excess fluid or electrolytes from the blood). The patient resided at home with family. Review of the initial comprehensive assessment, dated 07/09/2025, showed a “discussion occurred” between the patient, family and registered nurse regarding the patient’s cardiopulmonary resuscitation (CPR) preferences. The encounter note summary showed the code status was CPR only with comfort care. Review of the clinical record showed a document titled, “Outside the Hospital Do Not Resuscitate,”. The patient signature line showed “N/A” (not applicable) and the document was signed by the physician on 07/09/2025. Review of the plan of care, dated 07/09/2025, showed the patient’s resuscitation (code) status as: “not on file”.Review of the skilled nursing (SN) encounter note summaries, with dates ranging from 07/09/2025 to 09/09/2025, showed the following code status: “code status: not on file”.Review of the interdisciplinary group (IDG) notes, with dates ranging from 07/09/2025 to 09/04/2025, showed the patient had a decline in health and mental status but failed to show a code status. Per an interview on 09/09/2025 at 2:15 PM, the patient’s significant other stated that he/she did not know what an advance directive was. During an interview on 09/10/2025 at 10:15 AM, the registered nurse (RN) coordinator stated that the letters “NA” in the signature block below the patient’s name on the DNR authorization, meant the patient and/or the family, wanted CPR to be performed. This state agent informed the RN coordinator that the provider’s records showed the patient had not signed the DNR document, however, the physician had signed the document (the physician’s signature on the document indicated the patient did not want to be resuscitated). During an interview on 09/10/2025 at 10:36 AM, the medical director stated that the patient wanted to be a full resuscitation, and he should not have signed the DNR. During an interview on 09/10/2025 at 1:14 PM, governing body appointee - B stated that no further discussions had been documented regarding CPR or DNR, since the initial assessment on 07/09/2025, even though the patient’s condition had declined.

Based on policy review, record review, and interview, the hospice provider failed to ensure that there was a complete physician’s order prior to treatment in one of seven full records reviewed (Record/Patient #7). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy titled, “Provider Orders,” showed orders will be obtained from a licensed physician for care and services to be provided to hospice patients.RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to an inpatient facility on admission.Review of the physician’s order dated 08/07/2025, showed an order for a Foley catheter (a sterile tube placed in the bladder to drain urine) to gravity drainage. May be placed for comfort or urinary retention.The physician’s order failed to include a French size (the external diameter of the catheter tube) and balloon size (the volume of fluid used to inflate the balloon at the catheter's tip).During an interview on 09/11/2025 at 2:30 PM, the registered nurse (RN) coordinator stated that he/she would expect an order to contain the care to the catheter, when to change the catheter, when to notify a physician, a French size, and a balloon size.

Based on policy review, record review, and interview, the hospice provider failed to ensure all entries were complete and dated in accordance with the hospice policy in four of seven records reviewed (Records/Patients #1, #3, #6, and #7). This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025 with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she moved into a long-term care facility (LTCF) on 08/15/2025 and his/her adult child visited regularly.  Review of the clinical record showed the following late documentation:- A medical social worker (MSW) assessment, dated 08/04/2025, was signed on 08/10/2025 ( six days later); - A MSW case communication note, dated 08/08/2025, was signed on 08/17/2025 (nine days later);-  A skilled nursing (SN) note, dated 08/08/2025, was signed on 08/11/2025 (three days later); - A SN case communication note, dated 08/12/2025, was signed on 08/15/2025 (three days later); - A MSW case communication note, dated 08/13/2025, was signed on 08/17/2025 (four days later);- A MSW case communication note, dated 08/14/2025, was signed on 08/17/2025 (three days later);- A SN visit note, dated 08/15/2025, was signed on 08/17/2025 (two days later); and- A SN visit note, dated 09/06/2025, was signed on 09/08/2025 (two days later). During an interview on 09/11/2025 at 1:45 PM, the administrator and governing body appointee – A stated that the expectation was to complete and finalize documentation the same day.    Findings included:Review of the provider’s undated policy titled, “(Named Hospice) – Entries Into the Clinical Record – Management of Information/Home Care,” showed entries into the clinical record will be made on the day care is provided to the patient. All documentation will completed/synced by the end of the workday.RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the clinician visit notes showed the following:-           - A Master of Social Work (MSW) visit was made on 07/18/2025 and signed/completed by the clinician on 07/21/2025 (three days later);-           - A MSW visit was made on 07/21/2025 and signed/completed by the clinician 07/23/2025 (two days later);-           - A MSW visit was made on 08/05/2025 and signed/completed by the clinician on 08/25/2025 (20 days later); and-          -  A MSW visit was made on 08/12/2025 and signed/completed by the clinician on 08/25/2025 (13 days later).During an interview on 09/11/2025 at 2:30 PM, the hospice administrator stated that the visit notes need to be completed/closed and finalized same day unless the clinician is waiting for a physician call back. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of cancer of the bladder. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025.  Review of the clinical documentation, for the dates of 08/07/2025 to 08/20/2025, showed in part that: - The social services visit documentation, dated 08/13/2025, showed that the patient’s spouse had gotten a change in antibiotics approved by the provider’s nurse practitioner; - The nursing visit documentation, dated 08/13/2025, showed that the patient:  * Rated his/her pain a three (3) on a zero (0) to ten (10) high scale;  * Had pain dysuria (pain) and hematuria (bleeding) during urination;   * Had some pain relief with the use of Cipro (an antibiotic); and  * Failed to contain documentation that the nurse practitioner was contacted to verify the change in antibiotics, a verbal order to change the antibiotic from Augmentin (a combination antibiotic) to Cipro, and that the patient had used left over Cipro for treatment of a previous urinary tract infection (UTI) pain instead of getting a new prescription filled; - The chaplain visit documentation, dated 08/19/2025, showed in part that the patient had:   * Discussed increased pain and the emotional/mental challenges due to pain; and   * The pain assessment showed the patient had no pain; Review of the clinical documentation, for the dates of 08/21/2025 to 09/05/2025, showed in part that:- The nursing visit documentation, dated 08/21/2025, showed:  * The patient’s highest pain in the past 24 hours had been 9 (nine) on a 0 - 10 high scale;   * The patient had used Darvocet (an opioid pain medication), Tramadol (an opioid pain medication) every six hours and acetaminophen (an over-the-counter pain medication) as needed;  * The patient was experiencing dysuria and hematuria;   * The patient was taking Augmentin, had a left side nephrostomy draining yellow urine, and the patient would urinate a small amount, at time, drops or spoonful;   * The visit note failed to include documentation that the physician was notified of the patient’s pain being 9 and using Darvocet related to uncontrolled pain;- Review of the case communication documentation, dated 09/05/2025 at 9:33 AM, showed in part the patient was transferred for general inpatient (GIP) care. The patient was urinating one liter of blood via urinal and nephrostomy bag, unmanaged pain not relieved with Tramadol, Dilaudid (an opioid pain medication), and morphine (an opioid pain medication). The patient reported uncontrolled shaking this morning; and - The clinical record failed to contain documentation of the interdisciplinary group involvement in the patient’s transfer to inpatient care on 09/5/2025.Review of the patient’s clinical documentation showed that the updated plan of care for the dates of 07/23/2025 to 08/06/2025; the narrative notes for nursing visits performed on 08//07/2025 and 08/13/2025, and the updated plan of care for the dates of 08/06/2025 to 08/20/2025 contained an identical narrative notes. During an interview on 09/10/2025 at 3:00 PM, governing body appointee-A stated that: - The notes were identical in the identified areas of the clinical record; and- They would expect clinicians to document current and accurate clinical findings on the plan of care updates and clinical notes. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the clinical record showed one late document, an MSW initial assessment, dated 07/22/2025, was signed on 07/26/2025 (four days later).  Findings included:Review of the provider’s undated policy titled, “(Named Hospice) – Entries Into the Clinical Record – Management of Information/Home Care,” showed entries into the clinical record will be made on the day care is provided to the patient. All documentation will be completed/synced by the end of the workday.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/03/2025 with a terminal diagnosis of small cell carcinoma of the prostate (prostate cancer) with metastasis (spreading of cancer) to the rectum. Additional diagnoses included encephalopathy (a disturbance in brain function), hepatocellular carcinoma (liver cancer), and chronic heart failure (a decrease in the ability of the heart to pump blood). He/she moved into a long-term care facility (LTCF) on 08/15/2025 and his/her adult child visited regularly. Review of the clinical record showed the following late documentation:- A medical social worker (MSW) assessment dated 08/04/2025, was signed on 08/10/2025 (six days later);- An MSW case communication note dated 08/08/2025, was signed on 08/17/2025 (nine days later);-  A skilled nursing (SN) note dated 08/08/2025, was signed on 08/11/2025 (three days later);- A SN case communication note dated 08/12/2025, was signed on 08/15/2025 (three days later);- An MSW case communication note dated 08/13/2025, was signed on 08/17/2025 (four days later);- An MSW case communication note dated 08/14/2025, was signed on 08/17/2025 (three days later);- A SN visit note dated 08/15/2025, was signed on 08/17/2025 (two days later); and- A SN visit note dated 09/06/2025, was signed on 09/08/2025 (two days later). RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 07/18/2025 with a terminal diagnosis of malignant neoplasm of the parotid gland (cancer of salivary gland). The patient had a co-morbidity of dementia (decline in mental capacity). The patient resided at home with family. Review of the clinical record showed an MSW initial assessment dated 07/22/2025, was signed on 07/26/2025 (four days later).  RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 07/17/2023 with a terminal diagnosis of cancer of the bladder. The patient had secondary diagnoses of, but not limited to, severe malnutrition, poorly controlled diabetes (a chronic disease that affects how the body uses sugar for energy), a left kidney nephrostomy tube (a tube inserted into the kidney to drain urine), and a history of urinary tract infections. The patient resided in his/her private residence with the assistance of his/her spouse until unmanageable pain created a need for general inpatient care beginning 09/04/2025.  The chaplain visit documentation dated 08/19/2025, showed in part that the patient had:   * Discussed increased pain and the emotional/mental challenges due to pain; and   * The pain assessment showed the patient had no pain.Review of the case communication documentation dated 09/05/2025 at 9:33 AM, showed in part, the patient was transferred for general inpatient (GIP) care. The patient was urinating one liter of blood via urinal and nephrostomy bag, unmanaged pain not relieved with Tramadol, Dilaudid (an opioid pain medication), and morphine (an opioid pain medication). The patient reported uncontrolled shaking this morning; and the clinical record failed to contain documentation of the interdisciplinary group involvement in the patient’s transfer to inpatient care on 09/05/2025.Review of the patient’s clinical documentation showed that the updated plan of care for the dates of 07/23/2025 to 08/06/2025; the narrative notes for nursing visits performed on 08/07/2025 and 08/13/2025, and the updated plan of care for the dates of 08/06/2025 to 08/20/2025 contained identical narrative notes. During an interview on 09/10/2025 at 3:00 PM, governing body appointee-A stated that: - The notes were identical in the identified areas of the clinical record; and- They would expect clinicians to document current and accurate clinical findings on the plan of care updates and clinical notes. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2025 with a terminal diagnosis of malignant neoplasm (cancer- abnormal growth of cells that invade and spread to other parts of the body) of overlapping sites of the left lung. The patient was living at home with his/her two sons but transferred to inpatient facility on admission.Review of the clinician visit notes showed the following:-- - An MSW visit was made on 07/18/2025 and signed/completed by the clinician on 07/21/2025 (three days later);-      An MSW visit was made on 07/21/2025 and signed/completed by the clinician 07/23/2025 (two days later);-           - A MSW visit was made on 08/05/2025 and signed/completed by the clinician on 08/25/2025 (20 days later); and-          -  An MSW visit was made on 08/12/2025 and signed/completed by the clinician on 08/25/2025 (13 days later). During an interview on 09/11/2025 starting at 1:20 PM, the administrator and governing body appointee – A stated that the expectation was to complete and finalize documentation the same day unless the clinician was waiting for a physician call back.

Based on policy review, observation, and interview, the hospice provider failed to ensure the clinical record was safeguarded against unauthorized use. This deficient practice has the potential to affect patient record security for all the patients served by the provider. --- Findings included: Review of the provider’s policy titled, “Information Security Awareness and Training Standards,” revised 11/05/2024, showed in part, that staff members must log off or lock systems (computers) when leaving them unattended. Observation on 09/08/2025 at 12:30 PM, showed that:- Registered nurse-A (RN)-A failed to log off or lock his/her computer prior to leaving it unattended;  - Per interview conducted during the observation, the administrative assistant stated that it was okay that the workstation was unlocked because no programs were open and the SA (State Agent) could not see patient information;- This SA continued to monitor the unsecure workstation for a period of two minutes until the administrative assistant got out of his/her chair and stated, “I’ll lock this workstation because apparently it’s an issue, you keep staring at it;”- RN-B entered the nurses’ station, swiped his/her badge to unlock his/her computer, and opened the electronic medical record; and- Per interview conducted during observation, RN-B stated that once he/she unlocked the computer using his/her badge, no additional credentials were required to access the electronic medical record.  During an interview on 09/08/2025 at 10:04 AM, governing body appointee-A stated that they would expect clinicians to log off or lock their computers before leaving them unattended.

Based on policy review, record review, observation, and interview, the hospice provider failed to identify pressure wound care needed and specifically identify which provider was responsible for providing wound care in the hospice plan of care in one of one patient living in a long-term care facility (LTCF) (Record/Patient #1). This deficient practice has the potential to affect the provision of care to all the patients living in a LTCF. --- Findings included:  Review of the provider’s undated policy titled, “Coordination of Care with Nursing Facilities,” showed, in part:- The purpose was to ensure the coordination of care provided to residents of a SNF/NF (skilled nursing facility/nursing facility);- Hospice will assume responsibility for professional management of the SNF/NF resident’s hospice services provided; - It is hospice’s responsibility to provide services at the same level and to the same extent as those services would be provided if the resident were in his or her own home; - A written plan of care (POC) must be established and maintained in consultation with SNF/NF representatives;- The hospice POC must: * Identify the care and services that are needed and specifically which provider is responsible for performing the respective functions;  * Document any hospice approved changes in the plan of care and that changes were discussed with the patient or representative, and SNF/NF representatives; and- The hospice will designate a member of each interdisciplinary group that is responsible for communicating with the facility representatives and other health providers participating in the provision of care for the terminal illness and related conditions to ensure quality of care for the patient and family.  RECORD/PATIENT#1: Review of the skilled nurse (SN) visit note, dated 09/04/2025, showed a narrative entry, “on right heel and great toe, purple discoloration present. BLE (bilateral lower extremities) elevated to prevent further pressure” and “ordered foam dressings per (named medical supply company)”. The nurse failed to perform an assessment or obtain measurements of the wound.  Review of the SN visit note, dated 09/05/2025, showed a narrative entry, “Foam dressing placed over right heel purple discoloration” The nurse failed to perform an assessment or obtain measurements of the wound.  Observation on 09/09/2025 at 9:15 AM, showed the patient was lying in bed, responsive to touch, the right heel was lying directly on the bed and had a foam dressing that was rolled up and was no longer covering the wound. The wound presented as a suspected deep tissue injury (SDTI), was the approximate size of a silver dollar, skin over the area was intact. The pressure area was purple in color and had black discoloration in the center (that was approximately 1 ½ centimeter (cm) long by ½ cm wide) The patient’s feet were not elevated to keep them off the bed and there were no extra pillows in the room to elevate them.Per interview conducted immediately after observation, the LTCF registered nurse (RN) stated that he/she did not know the patient had a pressure wound on their right heel.  Review of the document titled, “(Named hospice) / LTC Facility Coordinated Task Plan of Care,” showed the hospice nurse failed to communicate the following to the LTCF staff:- The patient had a newly discovered pressure injury on the right heel;- The patient’s heels needed to be elevated off bed with pillows;- A dressing was applied to the right heel and who would perform the subsequent dressing changes; and- Assessment and measurements of the new pressure injury on the right heel and who would be performing ongoing measurements.  During an interview on 09/11/2025 at 1:45 PM, the administrator stated that he/she would have expected the hospice nurse to notify the LTCF of the new pressure wound when he/she discovered it, and would have expected the nurse to update the coordinated task plan of care.

Based on nationally-recognized standards, observation, and interview, the hospice provider failed to ensure that a safe physical environment was maintained.  This deficient practice has the potential to affect all the patients, staff, and visitors of the inpatient facility. --- Findings included:Review of the National Fire Protection Association (NFPA) 1 Fire Code, 2012 edition, showed 11.1.2 All electrical appliances, fixtures, equipment, or wiring shall be installed and maintained in accordance with NFPA 70, National Electrical Code.Observation on 09/08/2025 beginning at 12:15 PM of the inpatient facility, showed the following:- The front entrance lobby had a lamp plugged into an extension cord behind a couch;- The music room had a power strip dangling from the wall with two phone chargers plugged into it;- The volunteer office had a power strip with one item plugged into it; and- The use of extension cords and power strips can increase the potential for a fire.During an interview on 09/08/2025 at 12:15 PM, the inpatient facility supervisor stated that extension cords and power strips are allowed if they are medical grade and are used for the right application.  During an interview on 09/08/2025 at 2:00 PM, the inpatient facility supervisor stated that the extension cord and power strips found during observation were not medical grade and should not have been in use.

Based on nationally-recognized standards, observation, and interview, the hospice provider failed to ensure that the sprinkler system was maintained according to National Fire Protection Association (NFPA) standards and that a smoke barrier door closed upon testing of the fire alarm system at the provider's inpatient facility. This deficient practice has the potential to affect all the patients, staff, and visitors of the inpatient facility. --- Findings included:Review of the NFPA 25, 2011 edition, showed 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (a sprinkler head that has experienced degradation due to a chemical reaction with the environment) (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (a sprinkler head that has an accumulation of dust, debris, paint, or other foreign materials on its surface) (6) Painting unless painted by the sprinkler manufacturer.Review of the NFPA 105, 2010 edition, showed 5.1.2 Operability. Doors shall be operable at all times. 5.1.2.1 The doors shall be kept closed or arranged for automatic closing.Observation on 09/08/2025 beginning at 12:15 PM of the inpatient facility, showed the following:- Room number seven had one loaded sprinkler head by the bathroom;- Room number eight had one loaded sprinkler head by the door;- The back patio area outside of room number nine had two corroded sprinkler heads with rusted areas;- The back patio area outside of room number 10 had one corroded sprinkler head that was also loaded;- The back patio area outside of room number 11 had one corroded sprinkler head that was also loaded;- The back patio area outside of room number 12 had one corroded sprinkler head;- The back patio area outside of room number 13 had one corroded sprinkler head that was also loaded;- The back patio area outside of room number 14 had one corroded sprinkler head;- The back patio area outside of room number 15 had one corroded sprinkler head;- The back patio area outside of room number 16 had one corroded sprinkler head that was also rusted;- Room number 10 had one loaded sprinkler head by the bathroom;- The loading dock/transition vestibule area had one loaded sprinkler head;- The conference room had two loaded sprinkler heads;- The provider’s office area had one loaded sprinkler head;- The family gathering room had one loaded sprinkler head;- The staff bathroom (room 156) had one loaded sprinkler head and the hallway outside of the bathroom had one loaded sprinkler head; and- The staff lounge bathroom had one loaded sprinkler head.During an interview on 09/08/2025 at 2:00 PM, the inpatient facility supervisor and the inpatient facility manager agreed with the findings of the observations. Observation on 09/09/2025 beginning at 2:08 PM, showed that the fire alarm was activated for testing and that one of the smoke barrier doors in the north corridor failed to close completely.  This failure has the potential to allow smoke and fire to spread throughout the facility.During an interview on 09/09/2025 at 2:20 PM, the maintenance employee stated that the latch on the door needed to be reset and was not reset from the last time the system was tested.During an interview on 09/09/2025 at 2:40 PM, the inpatient facility manager stated that he/she would expect all of the components of the fire alarm system to work correctly when they are tested.

Based on policy review, record review, and interview, the agency failed to complete initial bereavement risk assessments in, but not limited to, three (Records/Patients #2, #4, and #5) of nine full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy, "Bereavement Services- Provision of Care Treatment and Service/Hospice," dated 05/03/2021: -A bereavement risk assessment will be completed by the hospice social worker, chaplain, or registered nurse at the time of admission to hospice. RECORD/PATIENT #2: Review of the clinical record showed: -Patient was admitted to hospice services on 06/10/2022; -Review of Skilled Nurse Hospice Assessment- Initial Nursing Assessment dated 06/10/2022 failed to show an initial bereavement risk score; and -Review of Chaplain Hospice Assessment dated 06/10/2022 failed to show an initial bereavement risk score. RECORD/PATIENT #4: Review of the clinical record showed: -Patient was admitted to hospice services on 07/22/2022; and -Review of the Skilled Nursing inital assessment dated 07/22/2022 showed that the patient had no initial bereavement assessment completed RECORD/PATIENT #5: Review of the clinical record showed: -Patient was admitted to hospice services on 05/19/2022; and -Review of the Skilled Nursing inital assessment dated 05/19/2022 showed that the patient had no initial bereavement assessment completed During an interview on 09/21/2022 at 4:20 PM, the manager of regulatory compliance stated that he/she would expect the policy to be followed.

Based on policy review, record review, and interview, the agency failed to ensure the plan of care (POC) was followed and hospice aide services were provided at the frequency ordered on the plan of care in three (Record/Patient #1, #2, & #15) of nine full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Missed Visits - Provision of Services, Treatment, and Care/Hospice," reviewed 11/2020 showed in part: - Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record; - 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: *Notify the IDG and clinical supervisor of the missed visit and reason for missed visit; *Document in the patient's clinical record the patient's name, date and type of visit that was missed, reason for the missed visit, description of any unmet needs and how the patient's needs were met, any other follow-up needed, other person (s) that were notified of the missed visit, and signature of staff member reporting the information; and - If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. Review of the agency's policy titled, "Named Hospice"-The plan of Care- Provision of Care Treatment and Service/Hospice" dated reviewed 11/09/2021, showed in part: - A written individualized patient and family/caregiver plan of care will be established for each individual admitted to the hospice program; - The care provided to the patient must be in accordance with the plan of care; - The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less that every fourteen (14) days; - The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief; - It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs; - The individualized plan of care will be reviewed by the rest of the interdisciplinary group within five (5) days of start of care; - The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 14 days, by the interdisciplinary group, with input from the attending physician, the patient, the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver; - Review of the plan of care will be documented in the clinical record; - Revision dates will be noted on the plan of care; - The written plan of care will contain, but will not be limited to frequency of services; and - Care provided to the patient will be in accordance with the plan of care. RECORD/PATIENT #1: Review of the plan of care (POC) dated 07/02/2022 showed an order for hospice aide visits two times a week for 13 weeks (07/03/2022 - 09/29/2022). Review of the aide visit notes showed: - No visits the week of 07/03/2022; - One visit the week of 07/10/2022; - One visit the week of 07/24/2022; and - One visit the week of 08/21/2022. The findings were reviewed with the hospice director and administrator on 09/20/2022 beginning at 2:55 PM. The hospice director stated that he/she would look for the missing visits. RECORD/PATIENT #2: Review of the clinical record, POC update, dated 08/24/2022 showed under "skilled wound assessment," -Full wound assessment including measurements weekly; and -Wound assessment each visit. Review of Skilled Nurse (SN) visit showed: -On 09/16/2022 a Licensed Practical Nurse (LPN) made visit; -LPN failed to measure wounds; and -LPN failed to assess or describe wounds. During an interview on 09/21/2022 at 4:20 PM, the manager of regulatory compliance stated that he/she would expect the plan of care to be followed. RECORD/PATIENT #15: Review of the clinical record showed the patient was admitted to hospice on 09/15/2022, with disseminated malignant neoplasm of ovary (ovarian cancer that has spread throughout the body). Review of the Hospice Initial POC dated effective from 09/15/2022 to 12/13/2022 showed, in part, aide personal care: - Assist with shower every other day; and - Assist with shampoo every other day. Review of the aide visit notes, done on the computer with the lead registered nurse (RN), showed bathing documented on 09/16/2022 and not again until 09/19/2022 (three days later). During an interview on 09/21/2022 at 4:15 PM, the Regional Hospice Director stated that he/she would expect documentation of bathing every other day as per the POC or documentation of refusal.

Based on policy review, record review, and interview, the agency failed to ensure that each patient received an individualized initial or revised care plan in, but not limited to, two (Records/Patients #3, #16) of nine full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "The plan of Care- Provision of Care Treatment and Service/Hospice" dated reviewed 11/09/2021, showed, in part: - A written individualized patient and family/caregiver plan of care will be established for each individual admitted to the hospice program; - The care provided to the patient must be in accordance with the plan of care; - The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group (IDG) and will be reviewed on a regular basis but no less that every fourteen (14) days; - The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief; - The individualized plan of care will be reviewed by the rest of the interdisciplinary group within five (5) days of start of care; - The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 14 days, by the interdisciplinary group, with input from the attending physician, the patient, the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver; - Review of the plan of care will be documented in the clinical record; - Revision dates will be noted on the plan of care; and - Care provided to the patient will be in accordance with the plan of care. -The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief; -Any change in the patient's condition must result in a change in the plan of care, prior to implementation of the new service; -The plan of care will contain, but will not be limited to, the following: -Individualized interventions to assist with end-of-life care; and -Drugs and treatments. RECORD/PATIENT #3: Review of the clinical record showed: -Hospice plan of care (POC) initial, dated 07/15/2022, showed that the patient had a diagnosis of Type 2 Diabetes Mellitus; -The patient received Metformin (an oral medication used to control blood sugar) 1000 milligrams (mg) twice per day and Amaryl (an oral medication used to control blood sugar) two mg daily before breakfast; -Skilled Nurse (SN) visit dated 07/21/2022 showed that the patient received blood glucose checks every morning by his caregiver and that medication Amaryl had been discontinued due to low blood sugar; -SN visit dated 07/26/2022 showed that morning fasting blood glucose was 80-104 and that medication Metformin had been discontinued due to low blood sugar; -Hospice POC update, dated 08/03/2022, failed to show care plan for checking blood glucose or any interventions for elevated or low blood sugar related to changes in medications; -SN visit dated 08/05/2022 showed that the caregiver was to complete daily blood glucose checks until the next registered nurse (RN) visit due to increased thirst and recent discontinuation of diabetic medications; -Hospice POC update, dated 08/17/2022, failed to show care plan for checking blood glucose or any interventions for elevated or low blood sugar related to changes in medications. During an interview on 09/21/2022 at 4:20 PM, the manager of regulatory complaince stated that he/she would expect the plan of care to be followed. RECORD/PATIENT #16: Review of the clinical record showed the patient was admitted to hospice on 09/15/2022, with small cell lung cancer (a fast-growing type of lung cancer commonly caused by smoking). Review of the Hospice Initial POC dated 09/15/2022 to 12/13/2022 showed: - Aide aware of precautions; and - Aide is aware of MRSA (methicillin-resistant staphylococcus aureus- a drug resistant bacteria. Review of the nursing orders in the active order set, printed 09/19/2022 at 5:22 PM, showed patient isolation status- none to display. Further review of the clinical record, including referral information failed to show any documentation of the patient ever having MRSA. During an interview on 09/21/2022 at 12:20 PM, the lead nurse stated that: - He/she was unable to find any information about the patient needing isolation precautions; - It (the discrepancy) would have been something he/she should have caught in IDG, when he/she asked the nurses if they agree with the aide POC; and - It should have been caught and the POC updated.

Based on hospice standards, policy review, observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections was followed, but not limited to, one (Record/Patient #18) of seven home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of official reference: [Centers for Disease Control and Prevention] CDC (2022). Guidelines for Hand Hygiene in Healthcare Settings; Clinical indications for hand hygiene include: - Immediately before touching a patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluid, or contaminated surfaces; and - Immediately after glove removal. Review of the agency's policy titled, "Hand Hygiene - Infection Prevention and Control/Home Care," dated 11/04/2021, showed: -Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC regulations and guidelines for hand hygiene in health care settings; -When hands are not visibly soiled, they should be decontaminated using an alcohol-based hand rub. An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water; -Apply alcohol-based hand rub product to palm of one hand and rub hands together, covering all surfaces of hands and fingers (including under nails) until hands are dry; -Hand hygiene using an alcohol-based hand rub should be performed: *Before having direct contact with patients; *After contact with a patient's intact skin (when taking a pulse, blood pressure, or lifting a patient); *After contact with body fluids or excretions, mucous membranes, non- intact skin, and wound dressings, if hands are not visibly contaminated; *When moving from a contaminated body site to a clean body site during patient care; and *After removing gloves. RECORD/PATIENT #18: Observation on 09/20/2022 beginning at approximately 12:13 PM, during administration of patient medication and repositioning him/her in bed (located in a hospice house), showed hospice nurse Registered Nurse (RN) B removed the dirty Allevyn (name brand) dressing off of the patient's buttocks and then he/she touched the cabinet handle inside the patient's room to get another dressing without removing his/her gloves and placed the new dressing on the buttocks, and he/she reached into his/her pocket to obtain a marker and dated the dressing 09/20/2022. During an interview on 09/20/2022 at 12:28 PM, RN B stated that he/she should have changed gloves and washed hands when going from dirty to clean prior to getting dressing from the closet and placing on the patient. Observation on 09/21/2022 beginning at approximately 11:25 AM, during catheter care: -Certified nurse aide (CNA) C took bath basin, filled it with warm water and sat it down on a stool in the patient's room without a barrier; -Lead nurse grabbed a wash cloth and stated put this down and placed the wash cloth under basin of water on the stool; -RN D, CNA C and lead nurse all assisted patient to his/her left side; -RN D assisted positioning the patient's bottom half, touching his/her legs with gloves; -CNA C wiped patient's bottom with the last washcloth; -RN D went to the cabinet to get more washcloths after touching the patient, without removing gloves and got two washcloths out of the cabinet; -CNA C took the bath basin to the bathroom without removing gloves and touched the faucet handles for more water; -CNA C finished cleaning patient's buttocks; -CNA C touched closet handle to get a new pad out for patient and then he/she removed gloves; -Patient repositioned to his/her right side to change pad and catheter tubing repositioned by lead nurse and RN D; and -Lead nurse instructed RN D to raise patient's head to place a pillow d/t his/her hands were clean and lead nurse then handed RN D the pillow. During an interview on 09/21/2022 at 11:48 AM, the lead nurse stated that he/she should have changed gloves after touching the catheter and prior to touching the patient's pillow. During an interview on 09/21/2022 at 11:51 AM, RN D stated that he/she should have changed gloves prior to going to the cabinet to get clean/more washcloths. During an interview on 09/21/2022 at 11:58 AM, CNA C stated that he/she should have changed gloves prior to getting more water. During an interview on 09/21/2022 at 4:50 PM, the Regional Hospice Director and Vice President stated that he/she would expect staff to remove gloves and wash hands when going from clean to dirty.

Based on employee record review and interview, the agency failed to ensure that appropraitely licensed employees provided services and practiced under the hospice's policies and procedures. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the employee files showed that RN #1 was licensed in the state of South Carolina with a single state license instead of a multistate license after the license renewal. During an interview on 09/21/2022 at 3:45 PM, the Human Resources personnel stated that the employee had been removed from the schedule immediately after the licensing issue was discovered and would not be returning to work until the licensing issue was resolved.

Based on policy review, clinical record review, and interview, the agency failed to ensure that the licensed professional services, delivered by their healthcare professionals, were practiced under the hospice's policies and procedures in two (Records/Patients #17 and #18) of nine full records reviewed. This deficient practice had the potential to adversely affect the quality of care provided to all the agency's patients. Findings included: Review of the agency's undated policy titled "Midline Catheter: Maintenance and Dressing Change" showed: - Catheter flushing and locking: Confirm patency of the VAD (venous access device) by aspirating for blood return and flushing the VAD using a 10-ml (milliliter) syringe filled with preservative-free 0.9% sodium chloride (normal saline) solution; - Open the clamp and gently aspirate until a blood return is visible in the tubing; - With each aspiration during a flush, apply gentle pressure against the syringe plunger to avoid catheter or vein damage; and - Slowly inject the flush solution into the port, noting any resistance or sluggishness of flow. Review of the agency's policy, "Wound Care- Provision of Care Treatment and Service/Home Care," dated 1/12/2021 showed: -Wound assessment should be performed with each visit/shift and documented thoroughly; -Wounds should be measured every 7-10 days by the primary nurse; and -Wound assessments include wound measurements. RECORD/PATIENT #17: Review of the clinical record showed the patient was admitted to hospice 09/13/2022, with Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (a life threatening complication of an infection). Review of the current PRN (as needed) medications on the active order set dated printed 09/19/2022 at 5:30 PM showed a start date of 09/15/2022 at 1054, Hydromorphone (a narcotic pain medication) injection 1.8mg (milligram) intravenous (administer into a vein), every 1 (one) hour prn moderate pain. (The order failed to show diluting with normal saline) Observation on 09/21/2022 at 11:05 AM showed RN A failed to aspirate and verify patency of the VAD. Per interview conducted during observation, RN A stated that he/she checked the VAD patency at the beginning of the shift. During an interview on 09/21/2022 at 4:30PM, when discussing if verifying patency of the VAD prior to administering IVP (intravenous push) medication was necessary, the VP of Hospice stated that it's in their policy to do so. RECORD/PATIENT #18: Review of the plan of care (POC) effective 09/07/2022 showed the following under "wound care": - Assess wound every shift; and - Refer to wound care policy as needed. Review of Skilled Nurse (SN) visit on 09/07/2022 at 2:04 PM showed: -A Registered Nurse (RN) shift note showed wound stage II (Partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.) coccyx; -SN failed to document measurements; -Problem: Wound care; and -Goal: Alterations in skin requiring wound care. Review of SN visit on 09/07/2022 at 7:00 PM showed: -At 4:30 AM a RN documented wound to buttocks was assessed, cleansed and left open to air; -SN failed to document measurements; -Problem: Wound care; and -Goal: Alterations in skin requiring wound care. Review of SN visit on 09/08/2022 at 7:00 AM showed: -At 11:00 AM a RN documented Bath completed. Tolerated well. Allevyn (absorbent foam dressing) dressing applied to stage II ulcer on coccyx. See wound picture in media; -SN failed to document measurements; -Problem: Wound care; and -Goal: Alterations in skin requiring wound care. Review of SN visit on 09/11/2022 at 7:00 PM showed: -At 3:00 AM a RN documented two small stage II pressure ulcers noted under Allevyn; -SN failed to document measurements; -Problem: Wound care; and -Goal: Alterations in skin requiring wound care. Review of SN visit on 09/12/2022 at 7:44 PM showed: -At 8:46 PM a RN documented Allevyn dressing intact to buttocks with no drainage noted; -SN failed to document measurements; -Problem: Wound care; and -Goal: Alterations in skin requiring wound care. Review of SN visit on 09/14/2022 at 9:02 AM showed: -At 5:47 PM a RN documented he/she changed Allevyn at this time; and -SN failed to document measurements. Review of SN visit on 09/17/2022 at 9:49 PM showed dressing intact to sacrum. Review of SN visit on 09/18/2022 at 9:11 PM showed: -At 2:40 AM a RN documented Allevyn to coccyx d/I, wound care accomplished on 9/18; -Problem: Wound care; and -Goal: Alterations in skin requiring wound care. Review of the clinical record, done on the computer with the lead RN, showed no wound measurements completed. During an interview on 09/21/2022 at 4:50 PM, the Regional Hospice Director and Vice President stated that he/she would expect documentation of wounds when identified and every 7-10 days.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure that physician's orders were in place and were being followed in, but not limited to, six (Record/Patient #1, #2, #4, #5, #16, #17) of nine full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Verification of Physician Orders- Provision of Care Treatment and Service/Hospice" dated 11/10/2021, showed, in part, the following: - Complete medication orders will include the medication name, indications for use, dose, frequency, route, rate of administration and when generic or brand names are acceptable or required; and - Additionally, an order or prescription will be verified when orders are incomplete, illegible, or unclear. Review of the agency's policy titled, "Ongoing Comprehensive Assessment - Provision of Care Treatment and Service/Hospice," reviewed 05/04/2021, showed in part that based upon the findings of the assessment, additional orders will be generated and forwarded to the physician (or other authorized licensed independent practitioner) for signature. The physician will be notified to verify any changes in treatment/interventions that require physician approval. Review of the agency's policy, "The Plan of Care-Provision of Care Treatment and Service/Hospice," dated 11/09/2021, showed: -The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief; -Any change in the patient's condition must result in a change in the plan of care, prior to implementation of the new service; -The plan of care will contain, but will not be limited to, the following: -Individualized interventions to assist with end-of-life care; and -Drugs and treatments. RECORD/PATIENT #1: Review of the initial nursing assessment dated 07/02/2022, showed: - Chief complaint - COPD (chronic obstructive pulmonary disease - a chronic disease of the airway); - Oxygen available but not in use; last used during hospitalization. Admits to being short of breath (SOB) walking down the hall to activities. The nurse suggested using oxygen for relief; - Interventions included to instruct on strategies to effectively manage dyspnea (difficulty breathing), instruct on oxygen use and safety precautions; and - Discussed use of oxygen, lorazepam and morphine for relief of SOB. Review of the plan of care (POC) dated 07/02/2022, showed oxygen and supplies listed under durable medical equipment. The POC failed to include orders for oxygen use. Observation on 09/20/2022 beginning at 12:10 PM, during the patient's home visit at skilled nursing facility, showed the patient sat in a wheelchair in his/her room. The patient did not have oxygen on. An oxygen concentrator sat beside the patient's bed. Review of the skilled nursing facility order summary report showed an order dated 09/20/2022, for oxygen 2-4 liters per minute via nasal cannula as needed for SOB. Two liters for mild SOB, 3 liters for moderate SOB, and 4 liters for severe SOB. During an interview on 09/20/2022 beginning at 2:55 PM, the hospice director stated that he/she would expect there to be an order for oxygen if the patient used oxygen. He/she would check on the order. RECORD/PATIENT #2: Review of the Skilled Nurse (SN) Hospice Assessment- Initial Nursing Assessment dated 06/10/2022 showed: -Patient is receiving hospice services for congestive heart failure (an overload of fluid in the body); -Patient has a co-morbidity of chronic obstructive pulmonary disease (a chronic disease of the airway); -Patient was experiencing lung sounds that were abnormal; -Patient was experiencing shortness of breath during assessment; and -Patient uses Bi-pap at night. Review of plan of care dated 06/10/2022 and medication list printed 09/19/2022 failed to show an order for the Bi-pap machine or any settings required to operate the machine. During a home visit conducted on 09/20/2022 beginning at approximately 2 PM the caregiver stated that patient uses the Bi-pap every night. During an interview on 09/21/2022 at 4:20 PM manager of regulatory compliance stated that he/she would not expect the Bipap to be on the POC because it is not related to the terminal diagnosis. RECORD/PATIENT #4: - Review of the Skilled Nurse initial assessment dated 07/22/2022 showed patient was on oxygen at 3 liters per minute (lpm) via nasal cannula; and - Review of the medication profile dated 09/19/2022 failed to contain an order for oxygen containing dose, route, and rate of administration. During an interview on 09/21/2022 at 4:00 PM, the manager of regulatory compliance stated that he/she would expect all orders to be on the medication profile. RECORD/PATIENT #5: - Review of the Skilled Nurse initial assessment dated 05/19/2022 showed patient was on oxygen at 2 lpm via nasal cannula: and - Review of the medication profile dated 09/19/2022 failed to contain an order for oxygen containing dose, route, and rate of administration. During an interview on 09/21/2022 at 4:00 PM, the manager of regulatory compliance stated that he/she would expect all orders to be on the medication profile. RECORD/PATIENT #16: Review of the clinical record showed the patient was admitted to hospice on 09/15/2022, with small cell lung cancer (a fast-growing type of lung cancer commonly caused by smoking). Review of the nursing orders in the active order set, printed 09/19/2022 at 5:22 PM, showed: - Cold Compress- Discomfort/fever as needed, ordered 09/15/2022 1318 (order failed to include application location, frequency or duration); and - Apply heat to affected area- discomfort as needed, ordered 09/15/2022 1318 (order failed to include frequency or duration of application). During an interview on 09/21/2022 at 10:15 AM, the lead nurse stated that he/she did not have specifications as to the cold compress application location, frequency or duration, or the heat application frequency or duration at this time. During an interview on 09/21/2022 at 4:15 PM, the VP (vice president) of Hospice stated that we (the agency) don't have a policy with order specificity. RECORD/PATIENT #17: Review of the clinical record showed the patient was admitted to hospice 09/13/2022, with sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (a life threatening complication of an infection). Review of the current PRN (as needed) medications on the active order set, date printed 09/19/2022 at 5:30 PM, showed 09/15/2022 1054 Hydromorphone (a narcotic pain medication) injection 1.8mg (milligram), intravenous (administer into a vein), every 1 (one) hour prn moderate pain. (The order failed to show diluting with normal saline) Observation on 09/21/2022 at 11:05 AM showed: - RN A withdrew 1.8mg of hydromorphone from the vial of hydromorphone; - RN A then withdrew normal saline from the normal saline vial in an amount unknown to this surveyor combining it with the hydromorphone; and - RN A then administered the mixture of hydromorphone and normal saline intravenously to the patient. Per interview conducted during observation, RN A stated that he/she diluted the medication with an equal amount of normal saline to the amount of medication.

Based on policy review, record review, and interview, the agency failed to: - Provide education and training for the caregiver as appropriate to their responsibilities (L544); - Develop an individualized plan of care with frequency of services necessary to meet the specific patient and family needs (L547); and - Provide medical supplies and appliances necessary to meet the needs of the patient (L550). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview the agency failed to provide/document education and training for the caregiver as appropriate to their responsibilities in one (Record/Patient #1) of six records reviewed. This deficient practice has the potential to affect all patients serve by the agency. Findings included: Review of the policy, last reviewed 05/02/2022, titled "Patient Education Process," showed in part, the following: - Purpose: To provide guidelines for giving specific instruction and information to patients and family/caregivers regarding hospice services; - Policy: Patients and family/caregivers will receive education in verbal, visual and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsibility of each interdisciplinary group member and will focus on, as appropriate: * Facilitating the patient's and family/caregiver's understanding of his/her health status, healthcare options, and consequences of options; * Maintaining the patient's and family/caregiver's health status; * Assisting the patient's and family/caregivers ability to cope with hospice care and the patient's impending death; * Pain and symptom management; -Procedure: As part of the comprehensive assessment, the following will be assessed and included in the plan of care (POC), as appropriate; * The atmosphere for conducive learning; * The pertinent information needed by the patient and family/caregiver in relation to the care being rendered; * The level of knowledge of the patient and family/caregiver in relation to the diagnosis, POC, required activities by patient and family/caregiver, lifestyle changes and etc.; * The ability and readiness of the patient and family/caregiver to learn; * Emotional barriers that might affect learning; * Physical and/or cognitive limitations, as well as communication and language barriers to learning; - The comprehensive assessment will be used as the basis for planning patient and family/caregiver education. In the event that any barriers to learning exists, these barriers, as appropriate, will be discussed with the patient and family/caregiver as well as the Clinical Supervisor. If they cannot be overcome, the patient's physician will be contacted; - Unless otherwise ordered by the physician (or other authorized licensed independent practitioner), the patient and family/caregiver will receive verbal, and as appropriate, written instructions on: * The patient's disease process and prognosis; * Medication management and administration; * Pain management; * Safe, effective use of equipment and supplies; - Documentation of patient and family/caregiver education will consist of: * Describing what was taught to the patient; * Describing the patient's response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught; * The patients and family/caregiver's knowledge, skills, and behaviors will be assessed during hospice visits. Re-education, when appropriate, will be provided; and * Individual needs and learning styles will be evaluated when identifying appropriate methods and resources for patient education. RECORD/PATIENT #1: Review of the plan of care dated 05/23/2022 to 05/27/2022 showed: - Instruct maintain tube patency: Instruct patient/caregiver on methods to maintain tube patency and prevent tube clogging. Instruct on flush feeding tube immediately before and after intermittent feedings, flush at standardized intervals for continuous feedings, flush before and after medication administration; - Instruct on enteral access care: Skilled nurse/patient/caregiver to perform care to enteral access daily and as needed (PRN). Enteral access type for venting. Frequency PRN. - Instruct on enteral feeding: Instruct patient/caregiver in administration of enteral tube feedings per med list; - Instruct on methods to open clogged feeding tube: Instruct on methods to open clogged feeding tube. Instruct on instilling warm water and applying gentle back and forth motion; - Instruct on prevention of pulmonary aspiration: Instruct patient/caregiver on prevention of pulmonary aspiration (keep head of bed elevated at 30 to 45 degrees at all times during administration of feedings); and - Ostomy care: Type of Ostomy two-piece. Change ostomy device daily and PRN for leaking or irritation. Cleanse with normal saline, apply skin prep. Family or caregiver may do in skilled nurse absence. Instruct family on care of ostomy, signs and symptoms of infection, and emptying of device. Review of the initial nursing visit dated 05/23/2022, showed: -Gastrointestinal: * Issues: Ascites (fluid collects in spaces within your abdomen); * Pattern: Ostomy (life-saving procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a prosthetic known as a pouch); * Ostomy type: Colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); and - No documentation of education , level of understanding, or ability to repeat or demonstrate what was taught regarding how to: maintain tube patency, perform care to enteral access daily, administration of enteral tube feedings, method to opening a clogged feeding tube, prevention of pulmonary aspiration, and how to provide ostomy care. Review of the Telephone Encounter with hospice Registered Nurse (RN) B, dated 05/25/2022 at 8:26 AM, showed: - Summary: Ostomy question; - Contact person: Patient's spouse; and - Communication details: Spoke with patient's spouse who reported a one piece ostomy bag (Plan of Care (POC)shows two piece ostomy device) was placed over puncture site on stomach and is filled up with fluid and they do not know how to empty it. Instructed spouse to release the clip at the bottom of the bag and empty into a container. Advised bag does not need to be rinsed out. Encouraged spouse to call hospice triage at any time. During an interview on 06/03/2022 at 9:09 AM, with the hospice admitting registered nurse (RN) A stated that: - The patient's caregivers included the patient's spouse and mother. They provided education to the patient's spouse but he/she was not certain they understood as he/she was crying, but did nod his/her head and verbalized understanding and comprehension; - When asked about the primary caregivers coping ability, he/she stated the spouse was crying. The patient's mother was interactive but wasn't crying and verbalized understanding of the education; - The RN felt like the patient's spouse was prepared and handled the visit and situation of the patient being admitted to the hospice well; - The patient's spouse/caregiver was crying the whole time during the teaching, so he/she pulled the patient's mom to the side and also educated her on the patient's medications; - The patient had a tube to drain infection, it started leaking stool and the hospital staff placed an ostomy bag over the whole thing. When the RN asked the family about it, they said it was the only place the patient had pain. The RN got a lidocaine patch out of the bag, but the patient was having so much pain that he/she didn't want the RN to touch the area. The hospital had sent home a couple ostomy bags with the family; - The spouse/caregiver was distraught the whole time but the patient's mom was there and he/she felt like the teaching/education went through. There was a lot of people there and it was a small home. The teaching/education was done with the spouse and mom of the patient. She taught about draining and burping the ostomy bag. She did not teach on changing the bag, just the maintenance. The hospital staff had taught the family how to change the ostomy bag; and - He/she documented the education to the caregivers in the interventions on the plan of care (POC). (However, upon review of the documentation there was no education on burping the ostomy bag and no evidence of return demonstration on providing care to the ostomy bag.) During interview on 06/07/2022 at 1:11 PM with the patient's caregiver (spouse), he/she stated that: - The patient had an ostomy bag that was put on four to five days prior to the patient being discharged from the hospital on 05/23/2022 (same day he was admitted to hospice.) There was no education from the hospital staff or the hospice staff regarding the ostomy bag care; - The ostomy bag was about to explode on Wednesday (05/25/2022) and the caregiver called hospice to see what to do. The triage nurse had to tell the caregiver what to do, and the caregiver/spouse and the patient's mom had to figure out, how to take care of the ostomy bag; - There was no education given to either of the caregivers on admission; - There was no education given on the ostomy; - There was also a tube that was put in the patient's neck to drain fluid (it was placed in his neck 2 to 3 days prior to discharge (05/23/2022) from the hospital) and the caregivers learned how to drain it in on their own into a Tupperware bowl. They were not educated, but they figured it out on their own, there was a big drain bag and a tab that said open or close so they just learned to drain it on their own.

Based on record review and interview, the agency failed to ensure the plan of care (POC) included the correct frequency of visits needed for the skilled nurse in one (Record/Patient #5) of six records reviewed to meet the specific patient and family needs. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the Inpatient Discharge Summary, dated 05/23/2022, showed the patient's platelets down to 11,000 (normal is 150,000 to 400,000 platelets per microliter) on the day of discharge and family made aware about possible spontaneous bleed. Review of the initial registered nurse visit note dated 05/23/2022, showed: - Urgent Needs: Rapid decline. - The patient was unable to get out of bed on his/her own; - He/she has been unable to keep any food down and has had multiple episodes of nausea and bilious vomiting; - Patient has a drain tube; - Endorses failure to thrive, shortness of breath, increasing abdominal distention, some leakages around the drain tube, etc.; and - He/she is using accessory muscles with 5 liters of oxygen. Review of the POC's dated 05/23/2022 through 05/27/2022 ordered skilled nursing to visit one to two visits every week for 13 weeks and six visits as needed. Review of the Telephone Encounter, dated 05/25/2022 at 8:26 AM, showed: - Summary: Ostomy question; - Contact person: Patient's spouse; - Communication details: Spoke with patient's spouse who reported a one piece ostomy bag placed over puncture site on stomach is filled up with fluid and they do not know how to empty it. Instructed spouse to release the clip at the bottom of the bag and empty into a container. Advised bag does not need to be rinsed out. Encouraged spouse to call hospice triage at any time. Review of the Telephone Encounter, dated 05/25/2022 at 12:52 PM, showed: - Summary: Symptom; - Contact person: Patient's spouse; - Communication details: Received phone call from patient's spouse wanting to know when a nurse will be coming to see patient since only a certified nurse aide (CNA) is assigned, and when will they receive supplies. Patient's spouse reports patient is changing, becoming minimally responsive and his/her breathing is more labored. Reports administering morphine. Instructed on use of morphine for breathing and pain and side effects of medication. Instructed the supplies come from a vendor and usually take 1 to 2 days for delivery by FedEx, but when the nurse comes today, she may have some stock in her car to assist. Instructed on end-of-life symptoms. Instructed to keep patient comfortable, keep lights low, conversations low and that hearing is the last sense. Answered all questions and emotional support given. Review of the Telephone Encounter, dated 05/25/2022 at 2:35 PM (third call in six hours), showed: - The patient's spouse called concerned with change in the patient. Reports his/her breathing is more labored, despite Oxygen at 5L, head of bed up and morphine. Reports patient is barely responsive and his/her lower extremities are very cold. Instructed on decreased circulation due to dying process. Instructed to give 0.5 mL (10 mg) Morphine now and repeat in one hour for the labored breathing and to assess in two hours patient's breathing if nurse has not arrived. Instructed may call this nurse for any changes, concerns or questions this afternoon. (no mention of whether or not a nurse is enroute to address caregiver's concerns in person) During an interview on 05/25/2022, at 2:36 PM, the family member calling the hotline stated that the physician had told the family the patient's platelet (pieces of very large cells that help form blood clots to slow or stop bleeding) count is 11,000 and normal is over 100,000 and when the patient gets to 5,000, he/she will probably bleed out and the patient and his/her spouse had a one year old residing in the home with them. During interview on 06/02/2022 2:54 PM and 3:23 PM, the hospice director stated he/she had no knowledge about the patient's platelet count and the patient possibly bleeding out. During an interview on 06/03/2022 at 9:09 AM with the hospice admitting registered nurse (RN) A, he/she stated: - When asked about the primary caregiver's coping ability, he/she stated the spouse was crying the whole time; - When the surveyor asked if the patient's family or caregiver mentioned that the patient's platelet count was low and that he/she will probably bleed out, the RN stated that they said the count was low and the hospital staff said he/she would only live approximately seven days; and - When the surveyor asked the RN if the family was OK with the nurse only coming two times a week, he/she told the family the schedule and they knew hospice was only coming twice a week, but if the patient declined and symptoms were not controlled they would visit daily. The admitting RN did not know the schedule the patient was to be seen. He/she just scheduled/ordered twice a week. During an interview on 06/03/2022 at 9:48 AM with the patient's family member, he/she stated the following: - The patient's caregiver/spouse called the hospice agency on Tuesday, (05/24/2022) a day after the patient was admitted and asked when a nurse was coming. He/she was told it would be Wednesday but when Wednesday came it was only a bath tech that came; - The ostomy bag was full and the caregiver called on 05/25/2022 at 8:26 AM asking if they would change the bag and was told no. The family was told there were no nurses on the schedule, and no one scheduled for him/her; and - There was no urgency or humanity at this point and no nurse scheduled to come until Thursday, until I called the hotline and a nurse was sent out Wednesday and stayed about 10-15 minutes. During an interview on 06/07/2022 at 1:11 PM with the patient's caregiver (spouse), he/she stated that: - "Hospice basically left us here to find it out on our own;" - No hospice staff was coming for two days and we had to call and talk to about 100 people before they sent someone out; - On Tuesday (05/24/2022) he/she called hospice to find out when the nurse was to come, and was told it would be tomorrow and come to find out, it was only a bath tech that showed up; and - On Wednesday (05/25/2022) the he/she called hospice in the morning to have a nurse come and he/she was told someone would be coming in the morning (Thursday - 05/26/2022) and then the patient's sister called and that's when they sent someone out to see the patient on Wednesday. During a telephone interview on 06/13/2022 at 11:00 AM, the Executive Director Home Care stated he/she could not answer if a nursing visit was scheduled to go out and see the patient on 05/25/2022 prior to the family calling.

Based on record review and interview, the hospice failed to ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient in, but not limited to, one of six records reviewed (Record/Patient #1). The deficient practice has the potential to affect all patients on service with the hospice Findings included: RECORD/PATIENT #1: Review of the skilled nurse (SN) hospice assessment dated 05/23/2022, showed in part, the following was completed by registered nurse (RN) A: - Patient was diagnosed with metastatic colon cancer in September 2021; - Gastrointestinal: * Issues: Ascites (fluid collects in spaces within your abdomen); * Pattern: Ostomy (life-saving procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a prosthetic known as a pouch); * Ostomy type: Colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Genitourinary: * Decreased urine volume; -Musculoskeletal: * Musculoskeletal assessment: Weakness; * Ambulation assist: Non-ambulatory; - Modified Activities of Daily Living (ADL): * Toileting: Total dependence; * Transfer: Total dependence; * Continence: Total dependence; - Problem: Impaired elimination: * Intervention: Ostomy care; *Type of ostomy two piece. Change ostomy device daily and PRN for leaking or irritation. Cleanse with normal saline (NS), apply skin prep. Family or caregiver may do in skilled nurse absence. Instruct family on care of ostomy, signs and symptoms of infection, and emptying of device; and - Currently unable to get out of his/her own bed and has some leakage around the drain tube etc. Review of the plan of care, dated 05/23/2022, showed no intervention or supplies listed for the use of urinal, chux, and graduate/container to drain fluids from the ostomies. Review of the skilled nurse hospice visit, dated 05/25/2022 at 4:10 PM showed: Patient has a colostomy in right lower quadrant (RLQ) (placed 09/13/2021). Noted right psoas malignant cecal perforation with abscess drain (placed 05/12/2022). It was noted the drain continued to have significant feculent discharge around it, and it is covered with colostomy bag. Patient indicates extreme pain when the area is touched/moved. Spouse and mother emptied bag earlier. Patient has a percutaneous Tran's esophageal gastrostomy (nonsurgical technique that creates an esophagostomy and allows enteral access in patients with hostile abdomen, altered gastric anatomy, massive ascites, and carcinomatosis) placed 05/20/2022 to decompress and ease pain. It is draining to gravity: dark green black noted. There is no documentation that the caregivers were given anything to empty it in (using a plastic bowl from the kitchen). During an interview on 06/03/2022 at 9:09 AM with the hospice admitting registered nurse, RN A, he/she stated that: - There were no supplies taken to the home, the patient had four bags of stuff sent from the hospital (there was no documentation of what was in the bags); and - When the surveyor asked why the chuxs/pads and incontinence supplies were purchased by the family, RN A responded that the patient was continent on admission (Admission assessment shows total dependence for toileting and initial RN visit note states "rapid decline"). During an interview on 06/03/2022 at 9:48 AM with the patient's family member, he/she stated the following: - The hospice agency left no supplies. Last week when the patient was in the hospital, he/she didn't have strength to get up out of bed and was told he/she would lose control of his/her bowel and bladder. The family had to go buy a urinal for him/her to urinate in and chux for the bed as he/she was bedbound; - The ostomy bag had to be emptied in a Tupperware container because they were not given anything to empty it into; and - It was really hard on the family not having the supplies they needed. During interview on 06/07/2022 at 1:11 PM with the patient's caregiver (spouse), he/she stated that: - There were no supplies left at the home. The family received supplies on the day of the patient's death of 05/27/2022 and the day after the patient's death. One of the shipments showed it had not been shipped until 05/26/2022 and the patient died on 05/27/2022; and - I (caregiver/spouse) was really upset due to no supplies and no pads/chux left for the patient and when he/she urinated it got on the bed and they had no way of rolling and caring for him very easy to change the sheets because there were no pads.

Based on policy review, Medicare benefit manual review, record review, and interview, the hospice failed to ensure that the hospice interdisciplinary group (IDG) documented consideration of level of care changes for uncontrolled symptoms in one (Record/Patient #1) of three sampled patient records. This deficient practice has the potential to affect all patients served by the hospice. Findings included: Review of the agency's policy titled, "Continuous Care Services," last revised in 2019 stated in part, the following: - Continuous care to achieve palliation to manage acute symptoms, and to maintain the patient in his/her residence; and - The hospice nurse confirms appropriateness of continuous care and will contact the physician and interdisciplinary group members to report the patient's condition, assessment, and relevant information. Review of the Medicare benefit manual section "40.2.1 - Continuous Home Care (CHC-Revision 188)" shows in part that continuous home care may be provided only during a period of crisis as necessary to maintain an individual at home. A period of crisis is a period in which a patient requires continuous care which is predominantly nursing care to achieve palliation or management of acute medical symptoms. RECORD/PATIENT #1: Review of medical record showed the 17 year old patient was admitted to hospice service on 12/03/2021 with a terminal diagnosis of Alveolar Rhabdomyosarcoma (cancer). The patient's guardian and caregiver was his/her parent. The patient had a patent (operational) central venous catheter from admission to his/her death on 01/23/2022. Review of the plan of care orders from 12/04/2022 showed the patient had immediate release Zofran tablets and scoplomine patches (anti-emetic agents) as needed (PRN) for control of nausea and vomiting. Review of a hospice nurse "telephone encounter" entry, dated 12/04/2022 at 1:42 AM showed the patient's guardian/primary caregiver called the nurse on-call and reported "pt symptoms of intractable nausea and vomiting since this morning following dose of oxycodone" given by (caregiver). The patient had 8 out of 10 pain (scale where 10 is the worst pain) with wrenching and dry heaving. The caregiver/guardian requested an intravenous (IV) antiemetic. The nurse educated the caregiver to give the dissolving Zofran as prescribed. Review of a nurse visit note dated 12/04/2021 at 11:30 AM through 1:40 PM by registered nurse (RN-A), showed the patient was in 8 out of 10 pain. The patient "vomited/wretch/dryheave" for the "next many hours" after oxycodone was provided. The nurse educated the primary caregiver to use the available scoplomine patch and "may take up to 24 hours to be effective". The scopolamine patch was applied by the hospice nurse at 12:30 PM. The caregiver informed the nurse that the patient was resistant to medications by mouth due to the patient's history of an ileus (lack of movement within the intestines). Review of a hospice nurse "telephone encounter" entry, dated 12/04/2021 at 2:03 PM by RN-A showed the patient's caregiver/guardian made multiple "calls and texts between 2:03 PM and 6:08 PM that the patient continued to vomit with shaking, that the patient threw up pain meds and ativan". The caregiver/guardian stated that the patient "was not getting what he/she needs". Review of the coordination notes showed no discussion with the IDG team regarding changing the patient's level of care or plan of care based on uncontrolled symptoms. Review of a hospice nurse "telephone encounter" entry, dated 12/04/2021 at 4:01 PM by RN-A showed the patient's caregiver/guardian reported "intractable vomiting/wrenching", and the Zofran tablets and current medication regimen were ineffective. The nurse called the hospice physician and a "plan" was made to start IV morphine (an opiate narcotic) by an infusion pump. Review of a nurse visit note dated 12/04/2021 at 6:23 PM through 8:01 PM by RN-A showed the patient was in nine out of 10 pain. The patient reported the constant need to vomit. IV morphine via an infusion pump was started by the hospice nurse. The IV morphine was delayed due to the pharmacy failure to supply a key to the infusion pump. The caregiver/guardian requested IV Zofran. Oral Haldol PRN was started for nausea and vomiting. Review of the coordination notes showed no discussion with the IDG team regarding changing the patient's level of care based on uncontrolled symptoms. Review of a hospice nurse "telephone encounter" entry, dated 12/04/2021 at 8:32 PM by RN-A showed the caregiver/guardian reported that the patient was now throwing up blood "suggested that this may be the result of so many hours of ongoing wretching/dry heaving and vomiting". The nurse instructed the caregiver to stop providing the patient ibuprofen. The nurse relayed the information to the hospice physician. The physician directed to continue treatments as ordered and "if not in alignment, to revoke hospice service and seek treatment in the emergency room". Review of the coordination notes showed no discussion with the IDG team regarding changing the patient's level of care based on uncontrolled symptoms. Review of the clinical record showed no follow-up on the patient's uncontrolled symptoms until 12/05/2021 at 3:33 PM. Review of a hospice nurse "telephone encounter" entry, dated 12/05/2021 at 3:33 PM by RN-A, showed the caregiver/guardian reported the patient vomited eight times since the last hospice nurse visit on 12/04/2021. The patient had the nausea and vomiting until 3:00 PM. During an interview with RN-A on 04/25/2022 at 1:35 PM, he/she stated the following: - The patient had uncontrolled nausea and vomiting the weekend of his/her on-call; - When asked why IV Zofran was not considered, he/she stated that it was a safety risk, and the dissolving Zofran tablets were not effective; -When asked if general inpatient (GIP) level of care was offered for the uncontrolled nausea and vomiting, he/she stated that hospitalization was offered but the patient's caregiver/guardian refused. (It should be noted that the 12/04/2021 at 8:32 PM entry stated that the hospital intervention would require revocation of the patient's hospice benefit). - When asked if continuous care was offered, he/she stated that the patient historically became anxious when hospice nurses were present so continuous care was not offered. Review of a written statement from the caregiver/guardian of the patient showed: - The patient had uncontrolled symptoms until the day he/she died; - To control the patient's uncontrolled nausea, he/she was told by hospice staff that the option was to revoke hospice and go to the emergency room; and - The patient and caregiver/guardian elected hospice because he/she did not want to the patient to go back into a hospital.