Every finding on record at Bristol Hospice - Pathways LLC

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 17 (6%) personnel records reviewed, the agency did not ensure that all personnel completed and documented annual training on the agency's Emergency Preparedness Plan. POLICY: The agency's "Natural Disasters/Emergencies" policy (Policy No. 2-047, Dated May 2020) stated in part, "1. The training includes: initial training and emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under agreement, and volunteers if applicable, 2. The training is provided annually and demonstrates staff knowledge of emergency procedures. 3. The organization will provide for orientation and annually thereafter of all personnel regarding participation in the Emergency Management Plan. Education to include: A. specifics of the Emergency management Plan, B. Specific assignment emergency response role, C. Information on developing their family's emergency response plan, D. information regarding accessing housing and transportation for staff if necessary. D-1. All training will be documented in the personnel record of staff, individuals under arrangement and volunteers, if applicable." PERSONNEL RECORD 15: A review of the volunteer personnel record (DOH 03/26/2024) revealed no documentation indicating that the volunteer had received annual training in 2025 on the Emergency Preparedness program, as required by the agency's policy. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, "The volunteers are assigned education to complete in the eLearning platform. She either didn't complete it, or it wasn't assigned in this case."

It is required that each patient’s individualized written plan of care includes all medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. In 3 of 24 (13%) clinical records reviewed, the agency did not ensure that the patient's individualized written plan of care included medical supplies and appliances necessary to meet the needs of the patient CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/25/2025. The Plan of Care (POC) dated 05/20/2026-07/18/2026 included an order for "Oxygen (O2) 1 - 4 liter/min Both Nostrils PRN Chest Pain, SOB", and Safety Measures "Fire, electric, & open flame safety". Oxygen and oxygen-related supplies were not documented in the DME and Supplies section of the POC. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/02/2025. The Plan of Care (POC) dated 05/02/2026-06/30/2026 included an order for "Oxygen (O2) 2 - 4 liter/min nasal continuous for Shortness of Breath". Oxygen and oxygen-related supplies were not documented in the DME and Supplies section of the POC. CLINICAL RECORD 18: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 01/28/2026. The Plan of Care (POC) dated 04/28/2026-07/26/2026 included "Oxygen (O2) 2 - 4 liter/min Both Nostrils continuous PRN Shortness of Breath" on the medication list. Oxygen and oxygen-related supplies were not documented in the DME and Supplies section of the POC. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and agreed the care plans did not include all of the oxygen and oxygen related supplies

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 10 of 20 (50%) clinical records reviewed where the patient received hospice aide services, the agency did not ensure that the hospice aide care plan included specific instructions for care. POLICY: The agency's "Hospice Aide Supervisory Visits" policy (Policy No. 1-037, Dated November 2021) stated in part, "3. The Case Manager will be responsible for: A. Providing written instructions to ensure compliance with the plan of care." CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 03/31/2022. The Plan of Care (POC) dated 05/09/2026-07/07/2026 included orders for Hospice Aide (HA) services. The HA care plan dated 05/09/2026 included, in part, the following orders: "Empty bedside commode, adult brief change, shampoo Hair, assist with dressing patient, assist with undressing patient, change bed linens, make bed." The HA care plan did not include specific instructions and frequencies for all personal care tasks. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 04/27/2026. The Plan of Care (POC) dated 04/27/2026-07/25/2026 included orders for Hospice Aide (HA) services. The HA care plan dated 04/28/2026 included, in part, the following orders: "Meet all personal care, safety and comfort needs, Complete Bed Bath, patient prefers morning, Empty catheter bag, Bed bath, Perineal Care, Assist with dressing patient, Assist with undressing patient, Assist brush teeth, Heel protectors." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/02/2026. The Plan of Care (POC) dated 05/02/2026-06/30/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 05/20/2026 included, in part, the following tasks: "Perform catheter care, turning and positioning, tidy patient's immediate area, adult brief change, assist with dressing patient, assist with undressing patient, fingernail care, foot care, mouth Care, routine hair and skin maintenance, apply moisture barrier cream to all extremities buttocks, change bed linens." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 01/02/2026. The Plan of Care (POC) dated 04/02/2026-06/30/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/02/2026 included, in part, the following tasks: "Transfer to chair, Assist with transfers Stand by Guard, Transfer on or off commode, Seated Shower, Perineal Care, Shampoo Hair, Assist with undressing patient, Comb or Brush Hair, Fingernail care, Brush teeth, Foot Care, Mouth Care, Routine hair and skin maintenance, Apply moisture barrier cream to Upper extremities." The HA care plan did not include specific instructions and frequencies for all personal care tasks. CLINICAL RECORD 15: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 02/13/2026. The Plan of Care (POC) dated 04/14/2026-06/12/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/14/2026 included, in part, the following tasks: "Complete bed bath, patient prefers afternoon, provide peri care, turning and positioning, adult brief change, perineal care, shampoo hair, comb or brush hair, brush teeth, routine hair and skin maintenance, change bed linens." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 16: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 02/14/2026. The Plan of Care (POC) dated 05/15/2026-08/12/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 05/11/2026 included, in part, the following tasks: "Empty catheter bag, turning and positioning, bed bath, perineal care, shampoo hair, apply lotion to back, comb or brush Hair, assist brush teeth, routine hair and skin maintenance, assist with shaving razor, apply moisture barrier cream to lower extremities, change bed linens." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 18: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 01/28/2026. The Plan of Care (POC) dated 04/28/2026-07/26/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/28/2026 included, in part, the following tasks: "Bed bath, perineal care, assist with dressing patient, fingernail care, brush teeth, foot care, make bed." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 21: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 08/19/2025. The Plan of Care (POC) dated 11/17/2025-02/14/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 11/17/2025 included, in part, the following tasks: "Document vital signs, patient can shower, with assist. patient prefers morning, shampoo hair, assist with dressing patient, assist with undressing patient, comb or brush hair." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 22: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 09/11/2025. The Plan of Care (POC) dated 03/10/2026-04/24/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/22/2026 included, in part, the following tasks: "Assist with ambulation using walker, assist with toileting, assist with bedside commode, empty bedside commode, provide peri care, adult brief change, bed bath." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 24: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 11/11/2025. The Plan of Care (POC) dated 11/11/2025-01/05/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 11/11/2025 included, in part, the following tasks: "Provide Peri Care, companionship, perform catheter care, empty colostomy bag, bed bath." The HA care plan did not include specific instructions that included frequencies for all personal care tasks. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, "The aide care plans should be specific and include the frequency of each task."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 20 (20%) clinical records reviewed where the patient received Hospice Aide services, the agency did not ensure that the aide provided services included in the plan of care. POLICY: The agency's "Hospice Aide Services" (Policy No. 0-020, Dated 09/2024) stated in part, "5. Hospice aides will document care provided in accordance with the Hospice Aide assignment. 6. Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities." POLICY: The agency's "Missed Visits" policy (Policy No. 1-027, Dated May 2020) stated in part, "3. If an aide visit is missed, the aide will contact the Hospice Case Manager or clinical management. The Direct of Patient Care Services/Clinical Supervisor will take the appropriate measures stated above." CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/25/2025. The Plan of Care (POC) dated 05/20/2026-07/18/2026 included orders for Hospice Aide (HA) services with a visit frequency of 3 visits per week for 1 week (05/20/2026-05/23/2026), 5 visits per week for 8 weeks (05/24/2026-07/18/2026), 4 visits per week for 1 week (05/26/2026-05/30/2026) and 5 visits per week for 7 weeks (05/31/2026-07/18/2026). 2 HA visits were performed and documented on both 05/20/26 and 05/21/2026, and 1 HA visit was documented on 05/22/2026 (totaling 5 HA visits from 05/20/2026 through 05/22/2026), exceeding the visit frequency of 3 visits as written in the POC. An interim order was documented on 05/25/2026, changing the HA visit frequency to 4 visits per week for 1 week (05/26/2026-05/30/2026), then 5 visits each week for 7 weeks (05/31/2026-07/18/2026). 2 HA visits were documented each day on 05/26/2026, 05/27/2026, 05/28/2026, and 05/29/2026, totaling 10 visits. The provided visits exceeded the weekly HA visit frequency for the week of 05/26/2026 through 05/30/2026 by 4 visits. The HA provided visits that were not included in the care plan. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 03/31/2022. The Plan of Care (POC) dated 05/09/2026-07/07/2026 included orders for Hospice Aide (HA) services at a frequency of 5 visits per week for 10 weeks. There were 4 documented HA visits during the week of 05/17/2026, and 3 documented visits and 1 missed visit during the week of 05/24/2026. There was no documentation of HA missed visits, nor of any communication between the HA and the RN Case Manager regarding the missed visits. CLINICAL RECORD 8: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 10/10/2025. The Plan of Care (POC) dated 04/08/2026-06/06/2026 included orders for Hospice Aide (HA) services at a frequency of 3 visits per week for 1 week, then 5 visits per week for 8 weeks. There were only 4 documented HA visits during the weeks of 05/11/2026 and 05/26/2026. There was no documentation of HA missed visits, nor of any communication between the HA and the RN Case Manager regarding the missed visits. CLINICAL RECORD 9: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 04/08/2026. The Plan of Care (POC) dated 04/08/2026-06/06/2026 included orders for Hospice Aide (HA) services at a frequency of 2 visits per week for the first week, then 5 visits per week for 13 weeks. There were only 4 documented HA visits during the weeks of 04/13/2026 and 05/04/2026. There was no documentation of HA missed visits, nor of any communication between the HA and the RN Case Manager regarding the missed visits. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, "The aide didn't visit the patient as ordered in the care plan."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 20 (10%) records reviewed where the patient received Hospice Aide services, the agency did not ensure that the hospice aide reported patient changes related to the plan of care. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 10/09/2025. The Plan of Care (POC) dated 04/07/2026-06/05/2026 included orders for Hospice Aide (HA) with a visit frequency of 4 visits for 1 week, then 5 visits each week for 8 weeks. The Aide care plan dated 04/07/2026 included instructions, in part, as follows: "Bed bath M, W, F, Shampoo Hair M W F, Change bed linens M W F." The HA note dated Tuesday, 06/02/2026 included documentation that the HA performed a bed bath, shampooed his hair, and changed the bed linens. These tasks were assigned by the Registered Nurse (RN) on the aide care plan for each Monday, Wednesday, and Friday. There was no additional documentation in the aide's note indicating that the RN was notified of changes in the patient's condition that required a deviation from the aide care plan. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/25/2025. The Plan of Care (POC) dated 05/20/2026-07/18/2026 included orders for Hospice Aide (HA) services. The HA care plan was updated on 05/20/2026 and included personal care tasks for the HA to perform at each visit. The HA noted dated 06/02/2026 included a note in the "Narrative" section that stated, "Sweet Dreams Visit (SDV)". There was no other documentation in the note indicating interventions that were performed or omitted during the visit. There was no documentation in the note indicating that the HA contacted the Registered Nurse to notify them of changes in the patient's condition that required a deviation from the aide's care plan. The Administrator (Personnel Record 1) was interviewed on 06/04/2026 and stated, "The aides are instructed to contact the nurse whenever there is a change in the patient's plan of care."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the agency's volunteer program and volunteer utilization statics provided by the Administrator (Personnel Record 1), revealed the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Volunteer Program: The Administrator (Personnel Record 1) provided data regarding volunteer utilization. In calendar year 2024, the percentage of volunteer utilization was 5.71%; in calendar year 2025, it was 1.35%; and year-to-date in 2026, it was 0.16%. The agency did not maintain volunteer use of at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, "We changed our volunteer program in 2025 and have seen a decrease in volunteer use. We have a PIP in place to work on increasing use." A review of the agency's Volunteer program and Volunteer utilization statics provided by the Administrator (Personnel Record 1), the agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 4 of 17 (24%) personnel records reviewed, the agency did not ensure that clinical competencies were performed and documented as required by the agency's policies. POLICY: The agency's "Competency Program" (Policy No. 3/001-HR, Dated May 2020) stated in part, "5. A preceptor will be assigned to each new staff member as part of the orientation process. The preceptor supervisor will observe and deem proficient the indicated skills and core competencies. If necessary, additional training, or in service education will be provided to the staff member. Hospice personnel will not provide the care or service independently until satisfactory completion of a required skilled competency 6. After the completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process. POLICY: The agency's "Annual Core Competence" policy (Policy No. 3-005-HR, Dated May 2020) stated in part, "1. Hospice personnel will demonstrate proficiency in the performance criteria/skills during the orientation, and at least annually thereafter as part of the annual performance evaluation process." PERSONNEL RECORD 7: A review of the Registered Nurse (RN) personnel record (DOH 09/17/2025) revealed no documentation of an initial skills competency. PERSONNEL RECORD 10: A review of the Hospice Aide (HA) personnel record (DOH 04/23/2025) revealed no documentation that an initial skills competency was completed. PERSONNEL RECORD 13: A review of the Bereavement Coordinator personnel record (DOH 11/29/2021) revealed documented competencies dated 03/29/2023 and 09/04/2024. There was no documented annual competency in 2025. PERSONNEL RECORD 15: A review of the Volunteer personnel record (DOH 03/26/2024) revealed a documented initial competency dated 04/09/2024. There was no documented annual competency for 2025. The Administrator (Personnel Record 1) was interviewed on 06/04/2026 and stated, "The competencies were done, we just can't locate them right now."

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by interview and personnel record review. In 1 of 17 (6%) personnel records reviewed, the agency did not ensure that criminal background checks were performed and documented as per state requirements on all employees who have direct patient contact or access to patient records. POLICY: The [state] Health and Human Services Handbook, Appendix VIII (Dated 06/2019, Accessed 06/05/2026) stated in part, "Chapter 250, Health and Safety Code, requires that persons convicted of certain crimes may not be employed in direct contact with an individual in specified facilities and agencies providing care to the aged and disabled. Therefore, criminal history checks on certain employees must be performed prior to an offer of permanent employment with the facility or agency except in emergency situations." and "Criminal history checks are required for providers listed below...Home and community support services agencies licensed by HHSC under Chapter 142, Health and Safety Code." PERSONNEL RECORD 7: A review of the Registered Nurse (RN) personnel record (DOH 09/17/2025) revealed no documentation indicating that a criminal background check had been completed and documented per state requirements. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, "We know it was done, but we can't find it."

Based on record review and interview, the agency failed to comply with the provisions of the Texas Human Resources Code, Chapter 102 on 1of 3 active patients (Patient#1), to which the Patient #1 refused to be bathed by the hospice HHA. This failure placed the agency's Patients at risk for ANE and inadequate care. --- Findings include: Record Review of the State of Texas regulation titled, “Texas Human Resource Code § 102.003 Section 102.003 - Rights of the Elderly,” revealed “(b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: (1) has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits, and services;” During record review and interview with the family member of Patient #1 on 3/28/2025 at 7:00 p.m., the family member of Patient #1 presented a video with low audio of the hospice HHA visit on 9/30/2024 with Patient #1 from a camera in Patient #1’s room. The camera revealed while HHA was touching Patient #1, Patient #1 began to scream and yell for a facility staff member. During the interview of the family member of Patient #1, the family member stated that she feels felt Patient #1 did not have her rights adhered to during the visit with the hospice HHA. During home visit to Patient #1’s home on 3/21/2025 at 11:30 a.m., Patient #1 expressed that she did not want a shower when the hospice HHA came to her room.   Patient #1 stated that she was trying to inform the hospice HHA during the visit that she only wanted her dress changed because she already washed herself up. Patient #1 stated that she felt that her rights were violated by the hospice HHA. During a record review of Patient #1’s clinical records revealed that Patient #1 was admitted to hospice on 5/16/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (long term damage to lungs).  Further record review revealed that Patient #1 lived in a skilled nursing facility since 5/15/2023.  Further record review of clinical records reveal Patient #1 received skilled nursing visits once weekly, hospice HHA twice weekly, chaplain visits once monthly, and social worker visits once monthly. During an interview with HHA A on 10/31/2024 at 4:35 p.m., HHA A stated that she went Patient #1’s room to give her a bath and Patient #1 agreed. HHA A also stated, ‘I could not really understand what she was saying. The other aide from the facility said to give her a bed bath. This was the first time I ever saw her. I wish I had known more about her.” During an interview with the Administrator on 3/31/2025 at 3:00 p.m., the Administrator was informed of the above findings. The Administrator stated she stated that HHA was educated on ANE and removed from the case.   During a review of the agency’s policy titled, “Bristol Hospice Companies,” dated 5/2022, revealed, “The Bill of Rights statement defines the right of the patient to…F.  Refuse care or treatment.”

Based on record review and interview, the agency, whose records were reviewed, failed to enforce written policies addressing a definitive line of authority in that: 1.       The hospice agency did not have a designated Alternate Administrator for the agency’s one parent agency and two branches (Branch #2 and Branch #3) between 1/29/2025 and 3/21/2025. 2.       The hospice agency did not report a designated Alternate Administrator to HHSC during the period of 1/29/2025 and 3/21/2025. This failure placed the agency's patients at risk for inadequate care. --- Findings included: During a presurvey record review on 3/20/2025 at 10:00 am in TULIP, revealed that the agency’s Alternate Administrator listed a previous employee. During an entrance interview with the Administrator on 3/20/2025 at 1:00 pm, when asked who the Alternate Administrator was, the Administrator stated that they don’t currently have an Alternate Administrator.  The Administrator further revealed that the previous Alternate Administrator that was based in Branch #2, no longer works for the agency as of 1/29/2025. During an interview on 3/31/2025 at 2:30 p.m. with RVPCO, the RVPCO stated that addressing the Alternate Administrator designation and reporting to HHSC failure was overlooked during the period of 1/29/2025 to 3/21/2025.   Record review of an agency email by the Administrator, no title, dated 3/28/2025, read in part, “Our process is for the RVPO to contact GB, Licenses and Credentialing to notify state of TX within 7 days (per their State regs.)  All 3 are to be notified for a vacancy and new Admin hire…”

Based on record review and interview, the agency failed to maintain a system of communication and integration, in accordance with the hospice's own policies and procedures to ensure that the care and services provided are based on all assessments of the patient and family needs for 1 of 2 discharged patients (Patient #5), in that: 1. The hospice nurse assessed Patient #5 four and a half hours after the agency received the call that Patient #5 was experiencing signs of a stroke. 2. Patient #5's family member was not notified by the agency at the time of the discovery of the onset of stroke symptoms. This deficient practice placed the agency's patients at risk for receiving inadequate and timely care. --- The findings included: Review of Patient #5's hospice Plan of Care, certification dates between 12/13/2023 to 2/10/2024, revealed a terminal diagnosis of Alzheimers disease (a progressive disease that destroys mental functions) with Patient #5 living in a skilled nursing facility. Further review of the plan of care revealed that Patient #5 received hospice nursing visits twice weekly for eight weeks with one visit as needed for a vital sign assessment. Review of Patient #5s clinical record revealed on 12/25/2023 at 7:30 a.m., nursing facility staff called the agencys on-call nurse (RN C) to inform RN C regarding symptoms of a possible stroke. Record review further revealed that RN C informed the caller that someone will be out to assess Patient #5. Further review revealed Patient #5 was assessed by RN A for stroke symptoms. When she arrived at the nursing facility at 12:00 pm. RN A spoke with the family member of Patient #5 regarding stroke symptoms after an assessment was made. Further review revealed that Patient #5 was sent to the emergency room after the assessment where it was confirmed that Patient #5 did experience a stroke. During an interview with the phone triage nurse RN C on 12/29/2023 at 3:40 p.m., RN C stated that she worked the phone triage the night of 12/24/2023 with her shift ending at 8 am on 12/25/2023. RN C stated that she received a phone call from the skilled nursing facility staff regarding Patient #5 having a blood pressure of 160 over 101 and an oxygen saturation of 94%. RN C stated she was also informed by the facility staff of the facial weakness and Patient #5 ";leaning to the left." RN C stated ";This was at 7:32 a.m. I then sent an email to all staff regarding the nursing facilitys phone call." When asked if the family member was called, RN C stated ";No, because it was shift change so I sent out a blast email so everyone can see it. It is not unusual for people to think that the patient is having a stroke with possible stroke symptoms. Besides, I didnt know who to call." During an interview on 12/29/2023 at 4:00 p.m., with Nursing Supervisor RN D, the Nursing Supervisor RN D was asked why the family member was not called at the time of discovery of Patient #5s stroke symptoms on 12/25/23 at 7:30 a.m. Nursing Supervisor RN D stated that the family member was not informed until (Patient #5) was assessed at 12 noon, however she now understands that a phone call should have been made to the family member as part of the plan of care and the decision making. Nursing Supervisor RN D had no explanation as to the cause of the time lapse in assessing Patient #5. During an interview with the Administrator on 12/29/2023 at 4:00 p.m., the Administrator was informed of the above findings. The Administrator acknowledged the above findings and stated there is really no excuse for the four and a half hour time span that Patient #5 was not assessed. The Administrator also stated that the agency takes full responsibility for the incident and takes patient care very seriously. Record review of an agency policy titled, "On-Call/Weekend Services," dated 5/2020, read in part, "Purpose: To establish the process by which patients have access to hospice services 24 hours per day...Procedure: 5. The on-call nurse will provide follow-up appropriate to the call a. Call the...family/caregiver b. Visit the patient...6. The on-call nurse will document each patient/family interaction in a clinical note...8. On-call staff will respond to a call within 15 minutes and must be able to reach a patient within one hour..."

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed where hospice aide services were accepted, a lack of clear and specific written instructions for the aide assignment, thus leaving the aide to make decisions outside the aides' scope of practice. THIS IS A CONTINUING PRIOR REQUIRED ACTION. Clinical Record 2: The patient’s date of election of hospice services occurred on 05/9/2023 with a primary diagnosis of Parkinson's disease. The patient resides and receives hospice care in a group home. The hospice aide plan of care dated 05/09/2023 assigned a seated shower to be performed Monday through Friday. The hospice aide order dated 07/26/2023 had seated showers Monday, Wednesday, and Friday. The aide's care plan did not get updated to reflect the change in the task frequency. On 07/28/2023, 07/26/2023, and 08/02/2023, the frequency for seated showers documented was Monday through Friday instead of Monday, Wednesday, and Friday. The Director of Clinical Services was interviewed on 08/14/2023 and confirmed that the RN did not update the aide plan of care. CONTINUIG PRIOR REQUIRED ACTION.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 4 (25%) observations during home visits where medication reconciliations were performed revealed discrepancies in the medication profile. Document 8: The agency policy number 2-004, dated May 2020 and titled Medication Profile, stated in part, "(7) A drug regimen review will be performed at the time of initial and comprehensive assessment when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. The interdisciplinary group will confer with an individual with education in drug management to ensure the drugs and biologicals meet the patient's needs." Home Visit 3: During the home visit at the skilled nursing facility with the Registered Nurse and the patient (Record 13) on 3/29/2023, a medication reconciliation was completed comparing the hospice medication profile to the facility medication review report. On the hospice medication profile, the medication with a start date of 2/16/2023, hydroxyzine hydrochloride 10mg, one (1) tablet orally three (3) times a day for itching, was scheduled for the patient; however, it was missing from the facility medication profile. In addition, the medication with the start date of 2/16/2023, methocarbamol 500mg, one (1) tablet orally every 6 hours as needed (PRN) for muscle spasms, was scheduled four times a day on the facility medication profile, but as needed on the hospice profile. Acetaminophen 650mg suppository rectally every 6 hours PRN for pain and fever was also missing from the facility medication profile but on the hospice profile.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. The agency policy number 9-017, dated November 2021, titled The Plan of Care, states in relevant parts, "A written individualized patient and family/caregiver plan of care 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 meet the documentation requirements of the physician-directed medical orders and the care planning process. 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 than every fifteen (15) days; (12) The written plan of care will contain, but will not be limited to, the following...(I) DME and medical supplies necessary to meet patient needs." 7 of 19 (37%) clinical records reviewed revealed the Durable Medical Equipment (DME) and/or medical supplies were not documented on the plans of care. Clinical Record 5: The patient with an election of the hospice benefits dated 2/17/2022 had a written plan of care dated 2/17/2022 documenting DME and Supplies as "not applicable". It was documented in the record that the patient had incontinence of the bowel and bladder. The Director of Patient Care Services confirmed during the joint record review on 3/31/2023 that the DME and supplies were missing from the plan of care, as the agency provided the patient with the following medical supplies and DME: XL briefs, wipes, 3-1 body wash shampoo, underpads. Geri-chair, a fall pad, 5L oxygen concentrator, E-cart and e-tanks, APP mattress, and an oxygen regulator. Clinical Record 6: The patient with an election of the hospice benefits dated 12/21/2022 had a plan of care for the benefit period of 3/21/2023 through 6/18/2023, where DME and Supplies was documented as "not applicable" (N/A), and an oxygen concentrator. The Admission Visit Summary dated 12/21/2022 documented, "DME not needed. Family has purchased a hospital bed with mattress, wheelchair, potty chair, shower chair, motorized wheelchair prior to admission." Clinical Record 7: The patient with an election of the hospice benefit dated 10/19/2022 had a plan of care for the benefit period of 10/19/2022 through 12/17/2022, documented gloves-unsterile; DME and Supplies as needed. The Director of Patient Care Services confirmed during the joint record review on 3/31/2023 that the DME and supplies were missing from the plan of care. The agency provided the patient with the following medical supplies and DME: a full electric bed with foam mattress, shampoo, wipes, underpads, periwash, barrier cream, and medium briefs. Clinical Record 3: The patient with an election of the hospice benefit dated 7/1/2022 had a written plan of care dated 7/1/2022 documenting DME and Supplies as not applicable. The Director of Patient Care Services confirmed during the joint record review on 3/31/2023 that the DME and supplies were missing from the plan of care. She stated the facility where the patient resided provided the DME. However, the agency provided the patient with medical supplies, including a bath basin, shampoo/bath wash, lotion, mouth swabs, and wipes. Clinical Record 14: The patient with an election of the hospice benefit dated 5/26/2022, had a plan of care for the benefit period of 3/22/2023 through 5/22/2023, which documented DME and Supplies to include unsterile gloves, 5L concentrator, and DME and supplies as needed. The Director of Patient Care Services confirmed during the joint record review on 3/31/2023 that the DME and supplies were missing from the plan of care, as the agency provided the patient with incontinent pads, wipes, and a wheelchair. Clinical Record 16: The patient with an election of the hospice benefit dated 1/20/2023 had a plan of care dated 1/20/2023 that documented DME and Supplies as not applicable (N/A). The Nursing Admission evaluation dated 1/20/2023 documented the patient was oxygen-dependent, and DME in the home was purchased by the family, and they do not want to replace it. The Director of Patient Care Services confirmed during the joint record review on 3/31/2023 that the DME and supplies were missing from the plan of care, as the agency provided the patient XL briefs, underpads, and shampoo 3-1 wash. The patient-owned DME was a portable oxygen concentrator and wheelchair. NOTE: The plan of care was updated on 3/31/2023 to include all supplies and DME used by the patient. Clinical Record 17: The patient with an election of the hospice benefit dated 11/3/2022 had a plan of care for the benefit period of 2/15/2023 through 4/15/2023, documented only DME, and no medical supplies: wheelchair, overbed table (OBT), and a full electric bed. The Director of Patient Care Services confirmed during the joint record review on 3/31/2023 that the supplies were missing from the plan of care, as the agency provided the patient gloves, XL briefs, underpads, and shampoo. NOTE: The plan of care was updated with the provided supplies.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. The agency's policy number 9-023, dated July 2021, titled Bereavement Services, states in relevant parts, "(8) Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. (9) After three (3) weeks, a bereavement letter will be sent to the bereaved, giving support and outlining the hospice bereavement services. (10) Within thirty (30) days of the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver; (13) A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: (A) All bereavement assessments made; (B) A bereavement plan of care; (C) All bereavement clinical notes that have been written and/or letters sent to the bereaved; (D) Record of mailings. (14) Ongoing bereavement contact will be concluded at the end of up to one (1) year if the bereaved is no longer in need of hospice bereavement services. (A) A letter will be sent indicating the completion of bereavement services. (B) A copy of the letter will be placed in the bereavement file and the file retained." 4 of 4 (100%) bereavement records reviewed revealed the agency did not adhere to its bereavement services policy. Clinical Record 4: The patient, with a date of death of 2/15/2023, had a family member's bereavement risk assessed as low risk. However, the bereavement care plan dated 2/15/2023 was not individualized, and the deliveries of services were not specified and with no frequencies when to be completed. "The Bereavement Needs: Initiate bereavement mailings. Assess bereavement needs. Allow for expression of feeling by client/family." Clinical Record 5: The patient, with a date of death of 4/13/2022, had a family member's bereavement risk assessed as low risk; however, no bereavement care plan was documented. A chaplain bereavement call was documented on 4/14/2022, and a bereavement mailing was on 5/3/2022. No other contact was documented thereafter. Clinical Record 2: The patient, with a date of death of 4/18/2022, had a family member's bereavement risk assessed as low risk; however, no bereavement care plan was documented. In addition, a chaplain bereavement call was documented on 4/20/2022 but no other contact or mailings by bereavement after that. Clinical Record 10: The patient, with a date of death of 1/15/2023, had a family member's bereavement risk assessed as low risk. However, the bereavement care plan dated 1/14/2023 was not individualized, and the deliveries of services were not specified and with no frequencies when to be completed. "The Bereavement Needs: Initiate bereavement mailings. Assess bereavement needs. Allow for expression of feeling by client/family." In addition, a chaplain bereavement call was documented on 1/16/2023 but no other contact or mailings by bereavement after that.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview and observation. 10 of 18 (56%) clinical records reviewed for which a hospice aide was accepted revealed a lack of clear and specific written instructions for the aide assignments, thus leaving the aides to make decisions outside the aides' scope of practice. Home Visit 2: On 3/29/2023, a home visit was observed with the hospice aide for the patient (Record 11), who resided in a skilled nursing facility. The aide verbally reviewed all the care provided to the patient and discussed historical issues with the patient's very dry, flaky, itchy skin. The hospice aide visit frequency was five times per week (5xweek). The aide care plan documented a bed bath three times per week (3xweekly); however, the other interventions did not have any frequencies. The hospice aide stated she performed perineal care on the days the bed bath was not completed. The patient had antifungal powder at the bedside, and the aide stated it was used for the perineal area due to excoriation of the site. She also said to use barrier cream. The antifungal powder and the barrier cream were not located on the medication profile for either the hospice or facility, and the instructions were not on the hospice aide care plan. The hospice aide also stated that the patient had a very dry, itchy scalp and scratches, creating sores on his head. The patient had noticeable red abrasions on his scalp from the scratching. The hospice aide stated that using a generic T-gel shampoo for dandruff and itching helped the patient; however, the instructions and frequency for the hair care were not on the care plan. The hospice aide did provide the patient with a washcloth to clean his face, and she shaved the patient. The assigned task of "assist with shaving razor" did not have a frequency. The hospice aide stated she usually performed shaving three times per week and only used body wash instead of shaving cream because the patient had sensitive skin, and the shaving cream irritated his skin. The hospice aide also stated that the patient had suffered two falls without injury in the last few weeks; however, fall precautions were not in the precautions section of the aide care plan. The hospice aide stated she changed linens typically three times per week; however, the assigned task was not documented on the aide care plan. The aide noted the patient does not like deodorant for his underarms and requested lotion instead. Due to the extreme dryness, the hospice aide applied moisturizing cream to the patient's face, scalp, and all extremities and body. Oral care was not on the care plan to assist the patient with the setup of the toothbrush with toothpaste and basin for rinsing. The patient could brush his teeth with minimal assistance but depended on the setup of the toothbrush and rinsing due to his bedbound status. After the visit, the findings of the visit were reviewed with the Director of Patient Care Services, who confirmed the aide care plan lacked clear, specific instructions for the assigned aide. NOTE:The aide care plan was updated on 3/30/2023 to include frequencies and specific instructions for the patient's care. Clinical Record 1: The patient with an election of the hospice benefit dated 3/3/2022 had a primary diagnosis of multiple myeloma and received hospice services three times per week (3x/wk). The hospice aide care plan dated 3/3/2022 assigned two bath types which included a bed bath and a complete bath. The complete bath option did not provide specific instructions to the hospice aide, and it could be unsafe to assume it is a shower or another type of bath beside the bed bath due to the functional status of wheelchair-bound of the patient. The Skilled Nursing Admission Visit Summary dated 3/3/2022 documented that he ambulated independently before the patient suffered a heart attack on 8/2021. However, the admission nurse noted the patient had an electric wheelchair and that he could maneuver well alone but was dependent on ADL 5/6. Additionally, none of the assigned tasks had frequencies or instructions for the hospice aide to follow as to when to complete. Clinical Record 2: The patient with an election of the hospice benefit dated 10/27/2021 had a primary diagnosis of hypertensive heart disease and received hospice services twice weekly (2x/wk) at an assisted living facility. The aide care plan dated 10/27/2021 had assigned tasks without frequencies as to when to complete them. Clinical Record 3: The patient with an election of the hospice benefit dated 7/1/2022 received hospice services twice weekly. The hospice aide care plan dated 7/3/2022 had assigned interventions without frequencies or details of instructions for the assigned aide. Clinical Record 5: The patient with an election of the hospice benefit dated 2/17/2022 received hospice aide services three times per week (3x/wk) at a skilled nursing facility. The aide care plan dated 2/20/2022 did not have an assigned bath type. An interview with the Certified Nurse's Aide on 3/31/2023 stated a bed bath was provided every visit despite it not being assigned. NOTE: The aide care plan was updated on 3/30/2022 with the bed bath assignment. The other assigned tasks on the care plan did not have frequencies for when to complete them. Clinical Record 6: The patient with an election of the hospice benefit dated 12/21/2022 received aide services three times per week (3x/wk). The aide care plan dated 3/12/2023 did not have frequencies for the assigned tasks to direct the aide for when to complete. Clinical Record 7: The patient with an election of the hospice benefit dated 10/19/2022 received hospice services three times weekly at a skilled nursing facility. The aide care plan did not assign frequencies for when to complete the assigned task for the aide. Home Visit 4: On 3/30/2023, a home visit with a registered nurse was observed with the patient (Record 19), who resided in a private residence with her husband and son. During the visit, the son was interviewed, and he stated that the patient's hair was shampooed once a week on Fridays. However, the current aide care plan did not include a frequency for the shampoo hair or the other assigned tasks. Clinical Record 9: The patient with an election of the hospice benefit dated 2/24/2023 received hospice services three times per week (3xwk) at an assisted living facility. The assigned tasks on the aide care plan dated 2/24/2023 did not have frequencies for the assigned tasks to direct the aide for when to complete them. Clinical Record 11: The patient with an election of the hospice benefit dated 11/4/2022 had a primary diagnosis of senile degeneration of the brain and received hospice services. The hospice aide care plan dated 3/3/2023 included assigned tasks without frequencies or specific instructions that included adult brief change, bed bath 3xweekly, perineal care, assist with dressing patient, personal care, assist with the undressing patient, routine hair and skin maintenance, assist with shaving razor, and observe standard universal precautions. NOTE: After the observed home visit, the aide care plan was updated on 3/30/2023 with frequencies and instruction details; however, the EMR does not allow frequencies to be entered on all assigned tasks per the Director of Patient Care Services. Clinical Record 12: The patient with an election of the hospice benefit dated 3/26/2023 received hospice aide services three times per week (3xwk) at a home setting. The aide care plan dated 3/26/203 did not have frequencies for the assigned tasks to direct the aide for when to complete them. An interview with the Director of Patient Care Services on 3/30/2023 confirmed the aide care plans lacked frequencies during the joint record reviews.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 4 of 18 (22%) clinical records in which care tasks for the hospice aide were assigned and not completed revealed the aide did not document notification of the nurse. Clinical Record 2: The patient with an election of the hospice benefit dated 10/27/2021 received hospice aide services twice weekly at an assisted living facility. The hospice aide visit dated 11/4/2021 documented the patient refused the following assigned tasks without reporting to the Registered Nurse: assist brush teeth, assist toileting, comb or brush hair, shower, pericare, and shampoo hair. The hospice aide visit dated 11/11/2021 documented all the assigned tasks as not performed due to the patient's refusal and no documentation of the nurse being notified. The hospice aide visit dated 1/20/2022 documented the patient refused to shower, shampoo hair, and assist with toileting, with no documentation of the nurse being notified. The aide documented, "patient stated she needed a laxative, maybe constipated," however there was no documentation of it being reported to the nurse. Clinical Record 6: The patient with an election of the hospice benefit dated 12/21/2022 received hospice services three times weekly. The hospice aide visit dated 1/4/2023 documented not performing the following assigned tasks because "patient refused: did not occur:" seated shower, shampoo hair, shower bath, and transfer to or from tub or shower. The hospice aide documented that it was not applicable to the "RN notified of any changes." The hospice aide visit dated 1/11/2023 documented not performing a seated shower and shower bath because a "partial sponge bath" was completed. The Registered Nurse was not notified of any changes because it was "not applicable." The hospice aide visit dated 1/13/2023 documented not performing a seated shower bath or shampooing hair because the patient refused. The aide documented the "RN notified of any changes" task as not applicable. The hospice aide visit dated 1/16/2023 documented the "wash up method" under comments for seated shower bath and not performing hair shampooing due to patient refusal. The aide documented the notification of the RN of any changes as not applicable. Clinical Record 8: The patient with an election of the hospice benefit dated 12/21/2022 received hospice services twice weekly. The hospice aide visit dated 1/27/2023 documented the patient refused assigned tasks, but there was no documentation of the notification to the nurse: apply barrier cream, assist brush teeth, assist with ambulation using walker, assist with bedside commode, assist with dressing and undressing patient, comb or brush hair, empty bedside commode, fingernail care, assist with shower, routine hair and skin maintenance, and shampoo hair. The hospice aide visit dated 1/30/2023 documented not performing the following assigned tasks because the patient refused, and no documentation of the nurse being notified: assisting brushing teeth, assist with ambulation using a walker, assisting with bedside commode, assisting with dressing and undressing patient, assisting with showering, shampooing of hair, and routine hair and skin maintenance. The hospice aide visits dated 2/3/2023 and 2/6/2023 documented not performing the assigned task of assisting the patient with a shower because the patient refused and no documentation of the nurse being notified. Clinical Record 9: The patient with an election of the hospice benefit dated 2/24/2023 received hospice aide services at an assisted living facility three times weekly. The hospice aide visit dated 3/1/2023 documented the assigned tasks of brushing teeth and fingernail care as "not applicable" without further comment or notification of the nurse documented.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed revealed physician orders were missing or written inaccurately. Clinical Record 5: The patient with an election of hospice benefits dated 2/17/2022 had a percutaneous endoscopic gastrostomy (PEG) tube. The Skilled Nursing (SN) Routine Visit dated 3/17/2022 documented patient was bedbound and NPO (nothing by mouth) and received tube feedings for nutrition. The SN Routine Visit on 4/11/2022 documented an assessment of tube feedings via peg "TF 50cc/her 22/24 hours, 160cc flushes TID via the pump, due to dysphagia and oral care only." The plan of treatment order for nutritional requirements dated 2/17/2022 stated NG feeding through a PEG tube; however, there were no specific physician orders for the type of tube feedings, rate, PEG tube maintenance, including residual checks and flushing, and skin integrity assessment PEG tube care. Additionally, there were physician orders for medications written for the route orally for the following medications: morphine 20mg/mL, give 1mL orally every 4 hours; lorazepam tablet 0.5mg orally every 6 hours as needed for anxiety, Senna 8.8mg/5mL give 10mL orally daily as needed for constipation, prochlorperazine maleate tablet 10mg orally every 6 hours as needed for nausea/vomiting. The following medications were written with a sublingual route: haloperidol 2mg/mL, give 0.5mL sublingually every 6 hours as needed for agitation; hyoscyamine 0.125mg sublingually every 4 hours as needed for excessive secretions. The Director of Patient Care Services confirmed on 3/31/2023 during the joint record review that the PEG tube orders were missing and the medication orders were written incorrectly. Clinical Record 9: The patient, with an election of hospice benefit dated 2/24/2023, had a documented skin tear to the right lower arm. The plan of care dated 2/24/2023 had a wound care order treatment without a frequency: "wound #1 skin tear, posterior right lower arm. 1. Irrigate the wound gently with normal saline or wound cleanser. 2. Pat dry gently. 3. Cover with no adhesive dressing, IV sleeve, or rolled gauze, Koban." The Director of Patient Care Services confirmed on 3/31/2023 during the joint record review that the frequency was missing from the wound care order. Clinical Record 10: The patient with an election of hospice benefits dated 1/11/2023 received general inpatient (GIP) level of care services at a local contracted hospital for symptom management of pain and shortness of breath. The nursing assessment documented the assessment and management of a Foley catheter, chest tube, and morphine IV infusion. The patient had the chest tube clamped on 1/12/2023, but no physician order was documented or updated on the written plan of care. The hospice nurse documented the patient was receiving the morphine IV 1mg/hr, and on 1/13/2023, the peripheral IV site was leaking, and the patient became symptomatic with restlessness and pain. The Registered Nurse documented the morphine IV infusion was increased from 1mg/hr to 4mg/hr; however, there were no physician orders documented. In addition, there were no physician orders for the Foley catheter, the increase of morphine infusion, or the chest tube clamped on the hospice plan of care. The Director of Patient Care Services stated that the contracted hospital record should have the physician's orders; however, the documents were not uploaded or included in the hospice records for review.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. This standard was not met as evidenced by clinical record review, document review, and interview. 2 of 6 (33%) clinical records reviewed where the patient received hospice services at skilled nursing facilities revealed the agency did not follow their procedure of completing the agency form that delineated the responsibilities and duties between the nursing facility and hospice agency. The agency policy number 1-030 dated May 2020 and title Provision of Care to Residents of SNF/NF or ICF/IID states in part, "(4) A written plan of care must be established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided must be in accordance with this plan of care. The plan of care must: (A) Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions. (B) Reflect the participation of the hospice, the SNF/NF or ICF/IID, and the patient and family to the extent possible." Clinical Record 3: The patient with an election of the hospice benefit dated 7/1/2022 received hospice services at a skilled nursing facility. The agency form titled Nursing Facility and Hospice Delineation of Duties was missing from the record. Clinical Record 17: The patient with an election of the hospice benefit dated 11/3/2022 received hospice services at a skilled nursing facility. The agency form titled Nursing Facility and Hospice Delineation of Duties was missing from the record.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care, hospice election form and any advance directives, Physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, instructions on how to access the hospice’s 24-hour on-call system, hospice medication information, and Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by document review, interview, and observation. The agency policy number 1-030, titled Provision of Care to Residents of SNF/NF or ICF/IID, dated May 2020, with no review or revision dates, states in part, "(7) The hospice will provide the SNF/NF or ICF/IID the following information specific to each patient: (A) The most recent plan of care; (B) Hospice election form and Advance Directives; (C) Physician certification and recertification of the terminal illness; (D) Names and contact information for hospice personnel involved in hospice care.; (E) Instructions on how to access the hospice's 24-hour on-call system; (F) Hospice medication information; (G) Hospice physician and attending physician (if any) orders." 1 of 2 (50%) hospice facility binders reviewed during observed home visits conducted in skilled nursing facilities revealed that required documents were missing. Home Visit 2: During the observed home visit with the hospice aide on 3/29/2023 for the patient (Record 11) who resided in a skilled nursing facility, the hospice facility binder was reviewed for required information. The hospice election form and consent were missing from the hospice facility binder. However, State-specific advance directives were present. In addition, the physician recertification of the terminal illness for the benefit period 1/3/2023 through 3/3/2023, signed by the physician on 12/28/2022, was located in the hospice facility binder, however, the current physician recertification of the terminal illness was missing for the benefit period that began 3/4/2023. The physician did not sign the current plan of care. The last IDT meeting, dated 3/15/2023, and the current medication profile were in the binder. An interview on 3/31/2023 with the Director of Patient Care Services confirmed the required documents were updated on the facility's binder after the findings were reviewed on 3/30/2023.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. 3 of 5 (60%) facility contracts reviewed revealed the missing criminal background check clause that ensured all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Contract 3: The agency contract, titled Residential Hospice Agreement and Nursing Home Facility Contract, with an effective date of 4/19/2019, was missing the criminal background check clause. The agency had several patients currently receiving hospice services at this facility. Contract 4: The agency contract, titled Hospice and Inpatient Facility Services Agreement, with an effective date of 7/3/2019, was the agency's active contract for providing the level of care of general inpatients for symptom management. The contract was missing the criminal background check clause. Contract 5: The agency contract, titled Hospice Service Agreement, with an effective date of 2/4/2020, was missing the criminal background clause. The contract was with a skilled nursing facility where the agency was currently providing hospice services to patients. An interview with the Executive Director on 3/31/2023 confirmed the criminal background check clauses were missing on Contract 3, Contract 4, and Contract 5.