Every finding on record at Buena Vista Hospice

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who have six months or less to live) failed to ensure compliance with the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) related to the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial [relating social conditions to mental health], emotional, and spiritual needs associated with the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) as evidenced by the following: 1.The HA failed to ensure the Interdisciplinary Group (IDG – composed of a Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians {MD} who meet regularly to discuss patients’ plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for one of 19 sampled patients (Patient 3).This failure resulted in not meeting the hospice patients identified nursing needs related to their terminal illness and related conditions that could affect the patients and/or family members their inability to cope with the terminal illness and wellbeing (Refer to L523). 2. The HA failed to ensure that the content of the Physician’s Certification for Hospice Benefit reflects the current condition of the patient during the comprehensive assessment for five of 19 sampled patients (Patient  1, 3, 4,10 and Patient 11).This deficient practice had a potential to cause miscommunication between healthcare staff regarding patient’s eligibility for hospice. (Refer to L 524). 3. The HA failed to maintain an accurate and current medication profile for two of 19 sampled patients (Patient 1 and Patient 2).This deficient practice had the potential to place the patients at risk for medication errors and adverse drug reactions. (Refer to L530). --- The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the Federal regulations for Initial and Comprehensive Assessment of the patient to ensure hospice benefits and services were furnished in accordance with accepted standards of practice.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Interdisciplinary Group (IDG – composed of a Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians {MD} who meet regularly to discuss patients’ plan of care to be able to provide the best individualized care and support to patients and families) completed the comprehensive assessments no later than 5 calendar days after election of hospice care for one of 19 sampled patients (Patient 3).For Patient 3, the RN failed to conduct an initial comprehensive assessment during recertification within 5 days after the patient's start of care (SOC) date.This failure resulted in not meeting the hospice patients identified nursing needs related to their terminal illness and related conditions that could affect the patients and/or family members their inability to cope with the terminal illness and wellbeing. --- During a review of Patient 3’s face sheet, the face sheet indicated a SOC date of 12/30/2025 and recertified on 3/29/2026 with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (A condition causing hardening of the arteries from plaque buildup inside them without chest pain). During a review of Patient 3’ Electronic Health Record (EMR), Patient 3’s EMR indicated there was no documented evidence a comprehensive nursing assessment was conducted within 5 days from the recertification SOC date.During a concurrent interview and record review, on 4/28/2025 at 12:35 p.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s EMR. The ADM/DPCS stated and confirmed the registered nurse (RN) did not conduct an initial comprehensive assessment within 5 days from the recertification SOC for Patient 3. The ADM/DPCS stated, this is important to make sure the patient still qualifies for hospice services. During a record review of the HA’s policy and procedure, titled, “Initial Assessment/Comprehensive Assessment”, undated, the policy and procedure indicated “The Hospice RN must complete an initial assessment within 48 hours after the election of Hospice care.  The initial assessment will be conducted in the location where services will be provided… the policy and procedure further indicated the Hospice IG, in consultation with the patients attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after patient's election of Hospice care.”

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure the content of the Physician’s Certification for Hospice Benefit reflects the current condition of the patient identified during the comprehensive assessment for five of 19 sampled patients (Patient 1, Patient 3, Patient 4, Patient 10 and Patient 11).This deficient practice had a potential to result in miscommunication between healthcare staff regarding patient’s eligibility for hospice. --- a. During a review of Patient 10's face sheet indicated a start of care date (SOC) of 1/7/2026, with diagnosis of cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it).During a joint home visit, on 4/24/2026 at 10:33 a.m. with the Registered Nurse (RN 1) at Patient 10’s room, Patient 10 was observed lying down on the bed. Patient 10 was alert and oriented to name and date of birth (DOB). Observed oxygen equipment in the room unused and not set-up. Observed RN 1 take Patient 10’s vital signs - blood pressure at 100/62, pulse at 57, respiration at 16 and oxygen saturation at 97% on room air.During a review of Patient 10’s Physician’s Certification for Hospice Benefit Certification number two, dated 4/7/2026, indicated that patient continues to exhibit significant cardiovascular instability with persistent hypertension documented at 170/90 despite prescribed therapy, with only partial response to 150/80and an irregular pulse suggesting ongoing cardiac compromise. The Physician’s Certification for Hospice Benefit further indicated that Patient 10’s respiratory status shows further decline with continued requirement for continuous oxygen at 2 LPM (liters per minute).During a review of Patient 10’s Nursing Updated Assessment dated 3/19/2026, indicated that during the visit patient’s pulse was 57, respiration was 18, blood pressure was 134/72 and oxygen saturation was 97% on room air.During a review of Patient 10’s Nursing Updated Assessment dated 4/2/2026, indicated that during the visit patient’s pulse was 59, respiration was 20, blood pressure was 119/77 and oxygen saturation was 97% on room air.During a review of Patient 10’s Visit Note LVN dated 3/10/2026, indicated that during the visit patient’s pulse was 85, respiration was 19, blood pressure was 129/70 and oxygen saturation was 96% on room air.During a review of Patient 10’s Visit Note LVN dated 3/12/2026, indicated that during the visit patient’s pulse was 82, respiration was 20, blood pressure was 129/75 and oxygen saturation was 97% on room air.During a review of Patient 10’s Visit Note LVN dated 3/17/2026, indicated that during the visit patient’s pulse was 82, respiration was 20, blood pressure was 129/86 and oxygen saturation was 97% on room air.During a review of Patient 10’s Visit Note LVN dated 3/19/2026, indicated that during the visit patient’s pulse was 82, respiration was 20, blood pressure was 129/82 and oxygen saturation was 96% on room air.During an interview with the Medication Technician Supervisor (MTS 1) on 4/24/2026 at 12:01 p.m., MTS 1 stated that Patient 10 does not use oxygen and only has the oxygen in the room as needed.During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/27/2026, at 12:27 p.m., ADM/DPCS stated that there was no documentation found regarding Patient 10’s high blood pressure or continues oxygen at 2 LPM that was mentioned on the CTI (Certification of Terminal Illness) dated 4/7/2026. ADM/DPCS stated that it is important that the CTI is accurate and reflects the currents status of the patient and the charting of the nurses because it is important for continuation of care and certification of terminal illness.b. During a review of Patient 11's face sheet indicated a start of care date (SOC) of 10/22/2025, with diagnosis of chronic systolic heart failure (a long-term condition where the heart's main pumping chamber becomes weak, enlarged, or stiff, preventing it from squeezing strongly enough to pump sufficient oxygen-rich blood to the body).During a joint home visit, on 4/24/2026 at 11:12 a.m. with the Registered Nurse (RN 1) at Patient 11’s room, Patient 11 was observed lying down on the bed no shortness of breath. Patient 11 was alert and oriented x3 (patient is conscious and aware of three key areas: name, place and date/time). Observed oxygen concentrator at bedside not in use. Patient 11 stated that she has never used the oxygen that is at bedside. Observed RN 1 take Patient 11’s vital signs - blood pressure at 127/86, pulse at 63, respiration at 20 and oxygen saturation at 97% on room air. Full body assessment performed by RN 1 and no open wounds and skin intact. Observed RN 1 perform lung auscultation (the process of using a stethoscope to listen to the sounds of a patient's lungs through the chest wall to evaluate breathing) on Patient 11. RN 1 stated that Patient 11’s lungs were clear.During a review of Patient 11's Physician’s Certification for Hospice Benefit Certification number three, dated 4/20/2026, indicated that the oxygen dependence has progressed with documented hypoxia (low levels of oxygen in your body tissues) in the high 80% range on room air, requiring a 2 liters nasal cannula with partial improvement only to the mid 90 percent range.During a review of Patient 11’s Nursing Updated Assessment dated 4/16/2026, indicated that during the visit patient’s pulse was 71, respiration was 18, blood pressure was 110/69 and oxygen saturation was 97% on room air.During a review of Patient 11’s Visit Note LVN dated 4/8/2026, indicated that during the visit patient’s pulse was 82, respiration was 20, blood pressure was 129/69 and oxygen saturation was 97% on room air. The Visit Note LVN on the section Integumentary-Skin further indicated that skin was assessed and no issues reported.During a review of Patient 11’s Visit Note LVN dated 4/13/2026, indicated that during the visit patient’s pulse was 72, respiration was 20, blood pressure was 102/86 and oxygen saturation was 96% on room air.During a review of Patient 11’s Visit Note LVN dated 4/20/2026, indicated that during the visit patient’s pulse was 79, respiration was 19, blood pressure was 118/65 and oxygen saturation was 97% on room air. The Visit Note LVN on the section Integumentary-Skin further indicated that skin was assessed and no issues reported.During an interview with the Medication Technician Supervisor (MTS 1) on 4/24/2026 at 12:01 p.m., MTS 1 stated that Patient 11 has oxygen at bedside as needed.During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/27/2026, at 12:27 p.m. and 1:05 p.m., ADM/DPCS stated that there was no recent documentation found regarding Patient 11 requiring a 2 liters nasal cannula. ADM/DPCS stated that it is important that the CTI is accurate and reflects the currents status of the patient and the charting of the nurses because it is important for continuation of care and certification of terminal illness.During a review of the agency’s policy and procedure titled “Reassessment/Update to the Comprehensive Assessment” undated, indicated that each patient will have appropriate reassessment and updates to the comprehensive assessment performed and documented. The policy and procedure indicated that the update of the comprehensive assessment must be accomplished by the Hospice IDG and must consider changes that have taken place since initial assessment. The policy and procedure further indicated that staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided.During a review of the agency’s policy and procedure titled “Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face evaluation” undated, indicated that before recertification period for each patient, the medical Director, physician member of the IDG or physician designee must review the patient’s clinical information and develop a brief narrative statement. a. During a review of Patient 1’s face sheet, the face sheet indicated a SOC date of 9/27/2025 and recertified on 3/26/2026 with a terminal diagnosis of Alzheimer’s disease (Is a brain condition that slowly damages your memory, thinking, learning and organizing skills). During a record review of Patient 1’s the discharge summary from hospital 1, dated 9/27/2025, the discharge summary indicated Patient 1 is alert and oriented times 2 to 3. The discharge summary didn’t indicate a diagnosis of Alzheimer’s disease. During a record review of Patient 1’s updated assessment, dated 4/22/2026, indicated Patient 1 is disoriented. During an observation and interview on 4/24/2026 at 10:00 a.m. with RN 2, Patient 1 was observed laying awake and alert in a hospital bed. Patient 1 was able to state his full name, the year, the month, and the current president’s name. Patient 1 was aware of his location and able to have conversation regarding family and his visitors. Patient 1 was able to recall fall incident from a week ago and describe how it happened. During a record review of Patient 1’s Current treatment/Medication/DME List dated 9/27/2025 to 4/22/2026, there were no Alzheimer’s disease medications listed.During a concurrent interview and record review, on 4/27/2025 at 12:15 p.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 1’s EMR. The ADM/DPCS stated the incorrect diagnosis was missed during initial certification for Patient 1 and on the recertifications. Patient 1 is on recertification period 3 and this should have been captured. The patient has failure to thrive but does not have an Alzheimer’s or Dementia diagnosis. DPCS stated he is in charge of reviewing all admissions to ensure all documents written during admission are accurate, and this was missed on three certifications. Its important to do accurate RN assessment because that’s what guides the care and might determine if the patient requires hospice care.  b. During a review of Patient 3’s face sheet, the face sheet indicated a SOC date of 12/30/2025 and recertified on 3/29/2026 with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris. During a record review of Patient 3’s Comprehensive nursing assessment, dated 12/30/2025, indicated Patient 3 Is optimally treated for heart disease with diuretics (A type of drug that causes the kidneys to make more urine in order to help the body get rid of extra fluid) and vasodilators (a type of drug to help lower the blood pressure by dilating the blood vessels). The document further indicated patient 3 has had history of unexplained syncope/fainting. During a record review of Patient 3’s the discharge summary from hospital 1, dated 12/23/2025, the discharge summary did not indicate any diuretics, vasodilators or history of fainting. During a record review of Patient 3’s Current treatment/Medication/DME List dated 12/30/2025 to 4/08/2026, there were no diuretic medications listed, and one vasodilator medication listed; Lisinopril 40 mg 1 tablet daily for high blood pressure. During a concurrent interview and record review, on 4/27/2025 at 12:25 p.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s EMR. The ADM/DPCS stated the hospice criteria in the comprehensive nursing assessment is not accurate, and doesn’t accurately reflect Patient 3’s discharge summary from the hospital, Patient 3 has other heart issues but the eligibility criteria was not filled out correctly. DPCS stated he is in charge of reviewing all admissions documents. Its important to do accurate RN assessment because that’s what guides the care and might determine if the patient requires hospice care.  c. During a review of Patient 4’s face sheet, the face sheet indicated a SOC date of 12/01/2025 and recertified on 3/01/2026 with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris. During a record review of Patient 4’s Comprehensive nursing assessment, dated 12/01/2025, indicated Patient 4 Is optimally treated for heart disease with diuretics (A type of drug that causes the kidneys to make more urine in order to help the body get rid of extra fluid) and vasodilators (a type of drug to help lower the blood pressure by dilating the blood vessels). The document further indicated patient 4 has had history of unexplained syncope/fainting. During a record review of Patient 4’s the discharge summary from hospital 2, dated 11/02/2025, the discharge summary did not indicate any diuretics, or history of fainting. During a record review of Patient 4’s Current treatment/Medication/DME List dated 12/01/2025 to 4/21/2026, there were no diuretic medications listed, and one vasodilator medication listed; Losartan potassium  50 mg 1 tablet daily for high blood pressure. During a concurrent interview and record review, on 4/27/2025 at 12:27 p.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 4’s EMR. The ADM/DPCS stated the hospice criteria in the comprehensive nursing assessment is not accurate, and doesn’t accurately reflect Patient 4’s discharge summary from the hospital, Patient 4 has other heart issues but the eligibility criteria was not filled out correctly. DPCS stated he is in charge of reviewing all admissions documents. Its important to do accurate RN assessment because that’s what guides the care and might determine if the patient requires hospice care.

Based on observation, interview, and record review, the HA failed to maintain an accurate and current medication profiles for two of 19 sampled patients (Patient 1 and Patient 2).This deficient practice had the potential to place the patients at risk for medication errors and adverse drug reactions. --- a. During a review of Patient 1’s face sheet indicated a SOC date of 9/27/2025 and recertified on 3/26/2026 with a terminal diagnosis of Alzheimer’s disease.During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 1/27/2026, indicated the frequency of visit of the skilled nurse (SN) to visit once per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (PCG) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines).During an observation and interview on 4/24/2026 at 10 a.m., with RN 2, Patient 1 was observed lying awake and alert in a hospital bed. Patient 1 was able to state his full name, the year, the month, and the current president’s name. Patient 1 was aware of his location and able to have conversation regarding family and his visitors. Patient 1 was able to recall fall incident from a week ago and describe how it happened. During a concurrent record review and interview on 4/24/2026 at 10:30 a.m., of Patient 1’s Current treatment/Medication/DME List dated 9/27/2025 to 4/22/2026, with RN 2 and MT 3 in Patient 1’s residence the following medications were listed on the HA medication list but not available in Patient 1’s residence:-Medi honey topical (an ointment used to treat wounds) apply ample amount to affected area daily and as needed.-Ipratropium Bromide and Albuterol Sulfate (a medication used to treat bronchospasm from asthma or shortness of breath) 0.5/3mg/3ml 1 vial in the nebulizer (device used to give breathing treatments) every 6 hours as needed for shortness of breath.-Omeprazole and Sodium Bicarbonate 20mg/1680pm powder suspension 1 packet by mouth daily as needed for acid reflux.-Lorazepam 2mg/ml 0.25ml by mouth every 6 hours as needed for anxiety/agitation.RN 2 stated these medications need to be either discontinued from Patient 1’s medication list or refilled. RN 2 stated nurses are supposed to do medication reconciliation on every visit. b. During a review of Patient 2’s face sheet, the face sheet indicated a SOC date of 8/07/2025 with a terminal diagnosis of Alzheimer’s disease.During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 1/27/2026, indicated the frequency of visit of the skilled nurse (SN- LVN) visit twice per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (PCG) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines).During a joint home visit, on 4/24/2026 at 11:30 a.m., with the registered nurse (RN 2) at Patient 2’s residence, Patient 2 was observed lying in a hospital bed, awake, alert, disoriented and confused. During a concurrent record review and interview on 4/24/2026 at 11:46 a.m., of Patient 2’s current medication, with RN 2 and Med tech 2 (MT2), the following medications were listed in the HA’s, Current treatment/Medication/DME List, dated 8/07/2025 to 4/06/2026, but not available in Patient 2’s residence. -Albuterol 90 mcg/ actuation inhalation (News to treat or prevent bronchospasm in patients with asthma, bronchitis and other lung diseases) aerosol 1 puff by mouth every 6 hours as needed for shortness of breath and wheezing.-Phenergan DM (cough medication) 6.25 mg take 5mls by mouth every 4 hours as needed for cough.MT 2 stated we ran out of these two medications last week; we are waiting for the refills. During further review the following two medications had dosage and frequency discrepancies:-Fluticasone Propionate/Salmeterol 250mcg/50mcg powder (Used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma) dose 1 puff twice daily for asthma listed on the HA med list, but dosage available at Patient 2’s residence was 500mcg/50mcg.-Ipratropium Bromide and Albuterol Sulfate 0.5/3mg/3ml (1 vial in the nebulizer (device used to give breathing treatments) every 6 hours as needed for shortness of breath listed on the HA med list but frequency listed on the actual medication in Patient 2’s residence was every 4 hours as needed for shortness of breath. RN 2 stated, this was missed and needs to be corrected in our system. Nurses are supposed to do medication reconciliation on every visit. During a concurrent interview and record review, on 4/27/2025 at 11:15 a.m., with the ADM/DPCS stated all nurses need to do medication reconciliation every visit because that’s how they can keep track of what they have, what refills they need, and to make sure the patient doesn’t get harmed. During a record review of HA’s policy and procedure, titled “Medication Profile”, undated, the policy and procedure indicated, “The nurse will Add all new changed medications to the medication profile. This continued medications will be documented and dated. The medication profile will be reviewed every home visit, updated as changes occur and reviewed by the IDG.”

Based on interview and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure compliance with the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) related to the Interdisciplinary Group, Care Planning, and Coordination of Services as evidenced by the following:  1. The HA failed to ensure that all members of the Interdisciplinary Group (IDG) were in attendance for 15 of 19 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16 and Patient 17) IDG meeting.This deficient practice resulted in the Chaplain not contributing to Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16 and Patient 17’s ongoing assessments and care planning process. (Refer to L541). 2. The HA failed to ensure the Plan of Care (POC) was completed, accurate, implemented and reflected the current status of the patients, for eight of 19 sampled patients (Patient 1, Patient 2, Patient 5, Patient 10, Patient 11, Patient 12, Patient 13 and Patient 15).The deficient practice had the potential to result in an inconsistent assessment of the patient's status which could lead to inaccurate care. (Refer to L545). 3. The HA failed to ensure timely coordination of care for one of 19 sampled patients (Patient 12) when a recommendation for social worker was documented but not follow-up.This deficient practice resulted in a delay in the provision of care and services for Patient 12. (Refer to L554). --- The cumulative effect of this systemic practices resulted in the Hospice Agency's inability to deliver statutorily (written rules or laws) mandated compliance with the Federal regulations for Interdisciplinary Group, Care planning, Coordination of services to ensure the highest quality of care was being provided to certified hospice patients.

Based on interview and record review, the Hospice Agency (HA) failed to ensure members of the Interdisciplinary Group (IDG) including Chaplin services were in attendance for eight of 19 sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16 and Patient 17) IDG meetings. This deficient practice resulted in the Chaplain's no documented evidence spiritual care, emotional support, and crises intervention to patients, and families facing terminal illness or grief was provided and this provision had been coordinated with the other members of the IDG. --- a. During a review of Patient 10's face sheet indicated a start of care date (SOC) of 1/7/2026, with diagnosis of cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it).During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.b. During a review of Patient 11's face sheet indicated a start of care date (SOC) of 10/22/2025, with diagnosis of chronic systolic heart failure (a long-term condition where the heart's main pumping chamber becomes weak, enlarged, or stiff, preventing it from squeezing strongly enough to pump sufficient oxygen-rich blood to the body).During a review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.c. During a review of Patient 12's face sheet indicated a start of care date (SOC) of 9/13/2024, with diagnosis of heart failure (permanent, severe kidney failure where kidneys can no longer function on their own to support life).During a review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.d. During a review of Patient 13's face sheet indicated a start of care date (SOC) of 3/21/2026, with diagnosis of end stage renal disease (occurs when the heart muscle does not pump blood as well as it should).During a review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.e. During a review of Patient 14's face sheet indicated a start of care date (SOC) of 4/6/2026, with diagnosis of Alzheimer’s disease (a progressive brain disease that causes a slow decline in memory, thinking, and reasoning skills).During a review of Patient 14's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.f. During a review of Patient 15's face sheet indicated a start of care date (SOC) of 3/21/2026, with diagnosis of Alzheimer’s disease (a progressive brain disease that causes a slow decline in memory, thinking, and reasoning skills).During a review of Patient 15's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.g. During a review of Patient 16's face sheet indicated a start of care date (SOC) of 3/31/2026, with diagnosis of chronic respiratory failure (long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen).During a review of Patient 16's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.h. During a review of Patient 17's face sheet indicated a start of care date (SOC) of 3/31/2026 and end of care date EOC of 1/1/2026, with diagnosis of atherosclerosis heart disease (disease where fat, cholesterol, and other substances build up in the artery walls, forming "plaque" that narrows the arteries and restricts blood flow).During a review of Patient 17's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 1/2/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.During an interview with the Administrator/Director of Patient Care Services (ADM/DPCS) on 04/27/2026, at 12:22 p.m., ADM/DPCS stated that the IDG meetings are attended by the Medical Director (MD), Registered Nurse (RN), Master of Social Worker (MSW) and Chaplain and they electronically sign after the meeting to confirm attendance. ADM/DPCS stated that it is important that the core members attend the IDG meetings so that plan of care can be updated and they are aware of any updates to the patients.During a review of the agency’s policy and procedure titled “IDG Care Planning Process” undated, indicated that the IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of the Hospice patients and families facing terminal illness and bereavement. The policy and procedure further indicated that the IDG reviews, revises and documents the individualized plan of care as frequently as the patient’s condition requires, but no less frequently than every 14 calendar days. a. During a review of Patient 1’s face sheet, the face sheet indicated a SOC date of 9/27/2025 and recertified on 3/26/2026 with a terminal diagnosis of Alzheimer’s disease.During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.b. During a review of Patient 2’s face sheet, the face sheet indicated a SOC date of 8/07/2025  with a terminal diagnosis of Alzheimer’s disease.During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.c. During a review of Patient 3’s face sheet, the face sheet indicated a SOC date of 12/30/2025 and recertified on 3/29/2026 with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.d. During a review of Patient 4’s face sheet, the face sheet indicated a SOC date of 12/01/2025 and recertified on 3/01/2026 with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.e. During a review of Patient 5’s face sheet, the face sheet indicated a SOC date of 10/01/2025 with a terminal diagnosis of Chronic obstructive pulmonary disease with exacerbation (associated with increased airway and systemic inflammation and physiological changes of the lungs with episodes of worsening of symptoms leading to substantial morbidity and mortality). During a review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.f. During a review of Patient 6’s face sheet, the face sheet indicated a SOC date of 9/26/2025 with a terminal diagnosis of Malignant neoplasm (Colon cancer typically effects older adults which usually begins with small clumps of cells called polyps that form on the inside of the colon).During a review of Patient 6's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.g. During a review of Patient 9’s face sheet, the face sheet indicated a SOC date of 9/29/2025 and recertified and end of care on 12/04/2025 with a terminal diagnosis of heart failure (Occurs when the heart muscle doesn't pump as well as it should). During a review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 12/04/2025, the POC/IDG Review form indicated that the Chaplain’s signatures was blank.

Based on observation, interview, and record review, the hospice agency failed to ensure the Plan of Care (POC) was completed, accurate, implemented and reflected the current status of the patients for eight of 19 sampled patients (Patient1, Patient 2, Patient 5, Patient 10, Patient 11, Patient 12, Patient 13 and Patient 15).The deficient practice had the potential to result in an inconsistent assessment of the patients' health status, and not receiving the identified services for the palliation and management of the terminal illness and related conditions. --- a. During a review of Patient 10's face sheet indicated a start of care date (SOC) of 1/7/2026, with diagnosis of cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it).During a joint home visit, on 4/24/2026 at 10:33 a.m. with the Registered Nurse (RN 1) at Patient 10’s room, Patient 10 was observed lying down on the bed. Patient 10 was alert and oriented to name and date of birth (DOB). Observed oxygen equipment in the room unused and not set-up. Observed RN 1 take Patient 10’s vital signs - blood pressure at 100/62, pulse at 57, respiration at 16 and oxygen saturation at 97% on room air.During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/7/2026, the POC/IDG Review form under the nursing IDG update indicated that the cardiovascular status remained compromised with persistent hypertension (high blood pressure) recorded at 182/105 with partial improvement to 158/77 despite medication, along with irregular pulse. The POC/IDG Review form under the nursing IDG update further indicated that Patient 10’s respiratory status showed further decline with continued need for oxygen at 2 LPM (liters per minute) and presence of dyspnea at rest.During a review of Patient 10’s Nursing Updated Assessment dated 4/2/2026, indicated that during the visit patient’s pulse was 59, respiration was 18, blood pressure was 134/72 and oxygen saturation was 97% on room air.During a review of Patient 10’s Visit Note LVN dated 4/7/2026, indicated that during the visit patient’s pulse was 82, respiration was 20, blood pressure was 128/65 and oxygen saturation was 94% on room air.During an interview with the Medication Technician Supervisor (MTS 1) on 4/24/2026 at 12:01 p.m., MTS 1 stated that Patient 10 does not use oxygen and only has the oxygen in the room as needed.During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/27/2026, at 12:27 p.m., ADM/DPCS stated that there was no documentation found regarding Patient 10’s high blood pressure or continues oxygen at 2 LPM that was mentioned on the IDG on 4/7/2026. ADM/DPCS stated that it is important that the IDG is accurate and reflects the currents status of the patient and the charting of the nurses because it is important for continuation of care.b. During a review of Patient 11's face sheet indicated a start of care date (SOC) of 10/22/2025, with diagnosis of chronic systolic heart failure (a long-term condition where the heart's main pumping chamber becomes weak, enlarged, or stiff, preventing it from squeezing strongly enough to pump sufficient oxygen-rich blood to the body).During a joint home visit, on 4/24/2026 at 11:12 a.m. with the Registered Nurse (RN 1) at Patient 11’s room, Patient 11 was observed lying down on the bed no shortness of breath. Patient 11 was alert and oriented x3 (patient is conscious and aware of three key areas: name, place and date/time). Observed oxygen concentrator at bedside not in use. Patient 11 stated that she has never used the oxygen that is at bedside. Observed RN 1 take Patient 11’s vital signs - blood pressure at 127/86, pulse at 63, respiration at 20 and oxygen saturation at 97% on room air. Full body assessment performed by RN 1 and no open wounds and skin intact. Observed RN 1 perform lung auscultation (the process of using a stethoscope to listen to the sounds of a patient's lungs through the chest wall to evaluate breathing) on Patient 11. RN 1 stated that Patient 11’s lungs were clear.During a review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form under the nursing IDG update indicated that the respiratory status demonstrates a decline with diminished lung sounds and shortness of breath on exertion along with continued CPAP use at night and oxygen saturation at 94% on room air indicating pulmonary reserve. The POC/IDG Review form under the Integumentary/Skin section further indicated that Patient 11 had an open skin to the left buttocks.During a review of Patient 11’s Nursing Updated Assessment dated 4/16/2026, indicated that during the visit patient’s pulse was 71, respiration was 18, blood pressure was 110/69 and oxygen saturation was 97% on room air.During a review of Patient 11’s Skin Impairment Assessment dated 4/16/2026, indicated blanchable redness to bilateral heels.During a review of Patient 11’s Visit Note LVN dated 4/8/2026, indicated that during the visit patient’s pulse was 82, respiration was 20, blood pressure was 129/69 and oxygen saturation was 97% on room air. The Visit Note LVN on the section Integumentary-Skin further indicated that skin was assessed and no issues reported.During a review of Patient 11’s Visit Note LVN dated 4/20/2026, indicated that during the visit patient’s pulse was 79, respiration was 19, blood pressure was 118/65 and oxygen saturation was 97% on room air. The Visit Note LVN on the section Integumentary-Skin further indicated that skin was assessed and no issues reported.During an interview with the Medication Technician Supervisor (MTS 1) on 4/24/2026 at 12:01 p.m., MTS 1 stated that Patient 11 has oxygen at bedside as needed.During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/27/2026, at 12:27 p.m. and 1:05 p.m., ADM/DPCS stated that Patient 11’s skin care plan on the IDG was not accurate because patient’s open wound to the left buttocks already healed. ADM/DPCS stated that there was no recent documentation found regarding Patient 11 continued oxygen saturation at 94% on room air. ADM/DPCS stated that it is important that the IDG is accurate and reflects the currents status of the patient and the charting of the nurses because it is important for continuation of care.c. During a review of Patient 12's face sheet indicated a start of care date (SOC) of 9/13/2024, with diagnosis of heart failure (permanent, severe kidney failure where kidneys can no longer function on their own to support life).During a review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 3/22/2026, 3/24/2026, 4/7/2026 and 4/21/2026, the POC/IDG Review form indicated that there was no plan of care created for the patient.During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/28/2026, at 11:58 a.m., ADM/DPCS stated that Patient 12 did not have a plan of care for the dates 3/22/2026, 3/24/2026, 4/7/2026 and 4/21/2026. ADM/DPCS stated that it is important to have a plan of care so that healthcare staff know plan and direction on what to do for the patient. d. During a review of Patient 13's face sheet indicated a start of care date (SOC) of 3/21/2026, with diagnosis of end stage renal disease (occurs when the heart muscle does not pump blood as well as it should).During a review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form under the Integumentary/Skin section indicated that Patient 13 had an altered skin integrity related to fungal infection. POC/IDG Review further indicated that there was no plan of care created for Patient 13’s pressure ulcer (damage to the skin and underlying tissue caused by constant, prolonged pressure on a specific area of the body).During a review of Patient 13’s Updated Assessment dated 4/09/2026, the section Integumentary-Skin indicated that there was no mention regarding Patient 13 having a fungal infection.During a review of Patient 13’s Visit Note LVN dated 4/20/2026, the section Integumentary-Skin indicated that skin had no rash, wounds or other symptomsDuring a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/28/2026, at 1:17 p.m., ADM/DPCS stated that Patient 13’s plan of care for 4/21/2026 was not updated to reflect patient’s current skin condition. ADM/DPCS stated that there was no current documentation regarding Patient 13’s fungal infection. ADM/DPCS further stated that it is important to update the patients plan of care to reflect their current condition for continuity of care and to make sure that staff are aware of the patients current condition.e. During a review of Patient 15's face sheet indicated a start of care date (SOC) of 3/21/2026, with diagnosis of Alzheimer’s disease (a progressive brain disease that causes a slow decline in memory, thinking, and reasoning skills).During a review of Patient 15's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/21/2026, the POC/IDG Review form indicated that there was no plan of care created for the patient.During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/29/2026, at 10:55 a.m., ADM/DPCS stated that Patient 15 did not have a plan of care for 4/21/2026. ADM/DPCS stated that it is important to have a plan of care so that healthcare staff know the plan and everyone are on the same page regarding patient’s care.During a review of the agency’s policy and procedure titled “IDG Care Planning Process” undated, indicated that in order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, Hospice will utilize data/information gathered during comprehensive assessment, updates to the comprehensive assessment and reassessment, in the care planning process to provide care that is consistent with the patient and family need, with patient’s needs and goals as a priority. The policy and procedure stated that the care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. The policy and procedure further stated that an individualized written plan of care is developed for each patient and the plan of care reflects the patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessment. a. During a review of Patient 1’s face sheet, the face sheet indicated a SOC date of 9/27/2025 and recertified on 3/26/2026 with a terminal diagnosis of Alzheimer’s disease.During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 1/27/2026, indicated the frequency of visit of the skilled nurse (SN) to visit once per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (PCG) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines). Under Integumentary it indicated Patient is at increased risk for infection related to recent fall resulting in a wound required in a wound requiring in a wound requiring nine sutures, impaired skin integrity, and overall frailty, The plan of care further stated to perform wound care as ordered using clean aseptic technique. Administer antibiotic as prescribed. The plan of care did not indicate wound location. No other treatments were listed for this wound. During a concurrent observation and interview on 4/24/2026 at 10:20 a.m. with RN 2 at Patient 1’s residence, RN 2 was observed cleansing Patient 1’s forehead wound containing sutures with wound wash and patting it dry with gauze. No other treatment was done to the wound. RN 2 stated, this wound is healing and doesn’t need an antibiotic ointment, Patient 1 already finished oral antibiotics for the wound. During a concurrent interview and record review, on 4/27/2025 at 12:10 p.m., of Patient 1’s EMR Plan of Care with the ADM/DPCS, ADM/DPCS stated the Wound treatment order for Patient 1’s forehead does not identify all treatments and location of wound. POC /IDG does not list the complete wound treatment. ADM/DPCS stated this was missed, the wound care order should clearly list the wound care order the location of wound and the steps to the wound care. This is important so the nurses know how to do the wound care.   b. During a review of Patient 2’s face sheet, the face sheet indicated a SOC date of 8/07/2025 with a terminal diagnosis of Alzheimer’s disease.During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 1/27/2026, indicated the frequency of visit of the skilled nurse (SN- LVN) visit twice per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (PCG) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines).During a concurrent interview and record review, on 4/28/2025 at 11:41 a.m., of Patient 2’s EMR history of nurse visits with the ADM/DPCS, Patient 2 was being visited once a week by skilled nurses instead of twice a week. The ADM/DPCS stated, nurses are doing once a week visits instead of twice a week for Patient 2, as ordered by the doctor. ADM/DPCS stated the nurses are not following the plan of care and may miss a change of condition for the patient. There were no missed visit notes documented in the medical record.  c. During a review of Patient 5’s face sheet, the face sheet indicated a SOC date of 10/01/2025 with a terminal diagnosis of Chronic obstructive pulmonary disease with exacerbation (associated with increased airway and systemic inflammation and physiological changes of the lungs with episodes of worsening of symptoms leading to substantial morbidity and mortality). During a review of Patient 5's Plan of Care(POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 4/07/2026, indicated the frequency of visit of the skilled nurse (SN- LVN) visit once per week to monitor and assess effectiveness of current and new medication/treatment, and instruct patient caregiver (PCG) regarding new medication/treatment order and side effects (unwanted, usually unpleasant, effects caused by medicines).During a concurrent interview and record review, on 4/28/2025 at 11:45 a.m., of Patient 5’s EMR history of nurse visits with the ADM/DPCS, Patient 5 was being visited once a week by skilled nurses until 4/9/2026, after 4/9/2026 there are no documented nurse visits for Patient 5. ADM/DPCS  stated there is a new nurse assigned to this case and she has been visiting the patient but has not turned in her notes. Our note submission policy is 48 to 72 hours after the visit. This was not done. If its not documented its not done, there is a communication note that states there was report from a SN on 4/16/2026 post visit but there was no note. Nothing else in the communication section as far as missed visit.

Based on interview and record review the Hospice Agency (HA) failed to ensure timely coordination of care for one of 19 sampled patients (Patient 12) when a recommendation for social worker was documented but not followed up. This deficient practice resulted in a delay in the provision of care and services for Patient 12. --- During a review of Patient 12's face sheet indicated a start of care date (SOC) of 9/13/2024, with diagnosis of heart failure (permanent, severe kidney failure where kidneys can no longer function on their own to support life). During a review of Patient 12’s Nursing Updated Assessment dated 4/18/2026, indicated that patient reported not having a shower recently due to lack of access to warm water and recommendation made to social work consult to assist with obtaining appropriate resources.During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 4/28/2026, at 11:58 a.m., ADM/DPCS stated that there was no documentation the RN notified the hospice agency regarding a recommendation for a social worker for Patient 12. ADM/DPCS stated that since the RN did not notify the hospice agency regarding the social work recommendation the social worker has not reached out to Patient 12. ADM/DPCS stated that the RN should have notified the hospice agency regarding the need for a social worker. ADM/DPCS further stated that coordination of care is important to make sure that patient’s needs are taken care of and help prevent harm to the patient. During a review of the agency’s policy and procedure titled “Coordination of patient Care” undated, indicated that the purpose of the policy and procedure is to ensure that quality services are being provided to patients and to provide a mechanism for representatives from various discipline to discuss patient care in the IDG meeting. The policy and procedure further indicated that hospice staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the IDG plan of care.

Based on interview and record review, the hospice agency failed to ensure that at least 12 hours of in-service during a 12-month period was given to all Hospice Aides.This deficient practice has the potential to put the Hospice Aide at risk for not having the updated knowledge and skills to provide highest quality of patient care services. --- On 4/27/2026 at 1:36pm, in-service records for Hospice Aides were requested from the Administrator/Director of Patient Care Services (ADM/DPCS).During an interview with the Administrator/Director of Patient Care Services (ADM/DPCS) on 04/29/2026, at 12:01 p.m., ADM/DPCS stated that the hospice agency did not have in-service records for the Hospice Aides. ADM/DPCS stated that it is important to have in-services to make sure the staff are doing the right things and are educated on new things. During a review of the agency’s policy and procedure titled “Hospice Aide Services and Training Program” undated, indicated that the purpose of the policy and procedure is to define the scope of Hospice Aide services and to ensure the competence of Hospice Aides employed by Hospice. During a review of the agency’s policy and procedure titled “Inservice Education” undated, indicated that regular scheduled and appropriate in service programs will be made available for all employees. The policy and procedure further indicated that all in service and education programs will be documented and direct care personnel must have a minimum of 12 hours of ongoing education during each 12-month period.

Based on interview and record review, the Hospice Agency (HA) failed to provide in-services to all licensed staff. This deficient practice has the potential to put all licensed staff at risk for not having updated knowledge and skills to provide the highest quality of patient care services. --- On 4/27/2026 at 1:36 pm., in-service records were requested from the Administrator/Director of Patient Care Services (ADM/DPCS).During an interview with the Administrator/Director of Patient Care Services (ADM/DPCS) on 04/29/2026, at 12:01 p.m., ADM/DPCS stated that the hospice agency did not have in-service records for the licensed staff. ADM/DPCS stated that it is important to have in-services to make sure the staff are doing the rights things and are educated on new things.During a review of the agency’s policy and procedure titled “Inservice Education” undated, indicated that regular scheduled and appropriate in-service programs will be made available for all employees. The policy and procedure indicated that purpose of the policy and procedure is to ensure the continuing education of all hospice personnel. The policy and procedure further indicated that all in-service and education programs will be documented and direct care personnel must have a minimum of 12 hours of ongoing education during each 12-month period.

Upon patient record review, 5 of 14 records reviewed (Patient #1, #4, #6, #9, #10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The record indicated the patient needed a foley catheter based off the comprehensive assessment and assessment updates. There was no evidence of an individualized plan of care for this problem, there were no goals and or interventions. COS. Patient #4: The record indicated the patient had a colostomy based off the comprehensive assessment and assessment updates. There was no evidence of an individualized plan of care for this problem, there were no goals and or interventions. COS. Patient #6: The record indicated the patient was placed on continuous care on 07/20/24. There was no evidence of an individualized plan of care for this problem, there were no goals and or interventions. Patient #9: The record indicated the patient was placed on continuous care on 03/29/24. There was no evidence of an individualized plan of care for this problem, there were no goals and or interventions. Patient #10: The record indicated the patient was placed on continuous care on 12/01/23. There was no evidence of an individualized plan of care for this problem, there were no goals and or interventions.

Upon patient record review, 1 of 14 records reviewed (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated an MD order for a foley on 10/20/24, may change foley catheter 16F 10cc balloon as needed when clogged, soiled or pulled out/malfunction. May flush foley cath with 60cc of Normal Saline for clogged/sediments in the urine. There was no type of solution to put in the balloon. COS.

Upon patient record review, 2 of 14 record reviewed (Patient #1, #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The record indicated a bed with full rails, over bed table, low air loss mattress, nebulizer, suction machine, portable E-Tanks and walker was ordered on 10/20/24. There was no evidence of these items on the initial plan of care. COS. Patient #3: The record indicated a shower chair, bedside commode, bed with full rails, low air loss mattress, overbed table, nebulizer and E-Tanks were ordered on 09/24/24. There was no evidence of these items on the initial plan of care. COS

Upon patient record review, 1 of 14 records reviewed (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The record indicated on the Hospice Aide Care Plan for the Aide to reapply the condom catheter. There was no evidence of an MD order for the Condom Catheter and there was no evidence the RN assigned appropriate tasks to the Aide. COS. In addition: The Hospice Aide Care Plan had a mechanical lift on the care plan. There was no evidence of an order for a mechanical lift, the RN did not assign appropriate. COS.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #4: The record indicated the Election of Medicare Benefits was signed on 09/11/24. The election date was typed but was not legible as you could not read a number on the date.

Upon patient record review, 1 of 14 records reviewed (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: The record indicated an IDG was held on 10/29/24. The IDG plan of care was updated but the Chaplain Signature was missing for this IDG meeting. COS.