Every finding on record at Calvary Hospital, Inc.

Based on clinical record reviews and staff interview, the agency failed to ensure the designated registered nurse provided care coordination to ensure that patient/family needs are adequately assessed and changes reported to the interdisciplinary team and physician.  This was evident for one (1) of three (3) clinical records reviewed (Patients #1).  Failure to ensure the designated registered nurse provide care coordination to ensure that patient/family needs are adequately assessed and changes reported to the interdisciplinary team and physician has the potential for negative patient outcome. The findings are: --- The “Plan of Care” Policy (Revision Date 01/08/2025) documents: “A registered nurse member of the IDG (Interdisciplinary Group) is designated as the RN (Registered Nurse) Case Manager for each patient/family.” “The RN (Registered Nurse) Case Manager is responsible for coordinating the care and services provided by the IDG (Interdisciplinary Group) ensuring continuous assessment of patient/family needs and implementing the interdisciplinary plan of care.” 1. Patient #1 has a start of care date of 07/04/2025, discharge date of 08/20/2025, with a terminal diagnosis of Malignant Neoplasm of Pancreas documented in the Hospice Plan of Care for the Certification Period 07/04/2025 to 10/01/2025.   The Hospice Plan of Care for the Certification Period 07/04/2025 to 10/01/2025 documents the following Skilled Nurse orders: “SN (Skilled Nurse) 1 Week 1 (one visit for one week); 1-2 Week 13 (one to two visits a week for 13 weeks); 6 (visits) as needed;” “Additional visits as needed for (or) relating to anticipated changes/decline in patient health status, and/or medication/treatment changes;”  “Assess/instruct: pain/symptom management;” Assess/instruct “dying process: what to expect, signs and symptoms to report, protocol at time of death.” The SN (Skilled Nurse) Hospice Visit note completed and dated 08/15/2025 by the Registered Nurse Case Manager documents: patient “seen for a prn (as needed) hospice visit;” “an episode of tremors/jerking movements happened an hour prior.  We had d/c (discontinued) morphine the day prior.  (Spouse) expressed unresolved pain relief with Tramadol and thinks the morphine was better.  I discussed this with Dr. (name).  We will continue with morphine.  Patient seems to have entered the dying phase, (patient) being less responsive, increasingly weak and no intake as of 2 days ago.  Emotional support provided to the family.” The SN (Skilled Nurse) Hospice Visit note dated 8/15/2025 lacks documented evidence of the nurse assessing the patient’s pain, assessing signs and symptoms of dying phase, and instructing the spouse on what to expect, sign and symptoms to report, protocol at time of death, as ordered in the Hospice Plan of Care. There is no documented evidence of the Registered Nurse Case Manager reported to the physician that the patient has entered the “dying phase.” The “SN (Skilled Nurse) On Call Communication” notes document the following about the patient changes/decline in health status: 8/18/2025 5:20 PM On Call Registered Nurse Regional Manager: “as per report (spouse) called earlier today and spoke to someone re: (spouse) interest on transferring the pt (patient) in IPU (inpatient Unit) and (spouse’s) waiting for a call back re: the status.  Call was transferred to the writer and (spouse) reported the same; as per (spouse)  pt (patient) is declining; (patient’s) not eating, drinking fluids minimally, sleeping most of the time, a couple of times have some blood when (patient) coughed and had a seizure about 2x but currently sleeping;” “writer explained to (spouse) that everything (spouse) said is part of the disease process and progression and expected to happen in pt with end stage terminal condition.  Spouse expressed that (spouse) is having a hard time seeing (patient) like this.;” “explained to (spouse) re: hospice respite program and (spouse) is interested.  Informed (spouse) that (spouse) intentions will be communicated with the team.”  “Writer reached out to hospice regional manager (Patient Care Coordinator) verbalized re: (spouse’s) interest on respite program; as per (regional manager) spoke to (spouse) late this afternoon and explained to (spouse) the same and to call back the office tomorrow as there are processes needs to be done and pt (patient) is not in an active crisis however (spouse) seems overwhelmed.” 08/20/2025 17:26 (5:26 PM)Triage RN (Registered Nurse): End of Live/Active Dying - Spouse “stated that the pt (patient) was taking (patient’s) last breaths.  The (spouse) sounded stressed.”  “The (spouse) wanted to know what (spouse) should do;” call transferred to on call regional manager. 08/20/2025 5:29 PM: On Call Regional Manager: Spouse “report pt (patient) is actively dying and breathing is very slow; (spouse) said (patient) looked comfortable and know that (patient) time is not gonna be long; (spouse) said (spouse) called as (spouse) just wanted to know what to do when pt (patient) away.  Writer gave (spouse) a lot of emotional support and instructed (spouse) to call hospice as soon as pt (patient) pass away.  Supervisor on call (name) informed writer pt (patient) passed away and TOD (time of death) 6:10 PM on 8/20/25.” The hospice Regional Manager/Patient Care Coordinator documents the following late entry case IDG (Interdisciplinary  Group) conference notes dated 08/22/2025: Late Enry: “Contacted pt’s spouse on 8/18 in the afternoon re: update in (patient’s) condition.” “Discussed transfer of patient to Calvary Hospital and spouse stated that (spouse) wants to leave (patient) home today and (spouse) might reconsider a transfer tomorrow.” Late Entry: “On 8/19/2025, contacted pt’s (patient’s) spouse re: update in (patient) condition.  Discussed with spouse re: transferring (patient) to Calvary and (spouse) reported that (spouse) ‘would think of it tomorrow, and not want (patient) transferred today. Late Entry: “In the a.m. of 8/20/2025 contacted spouse re: transfer to Calvary.” “Discussed the transfer of (patient) to Calvary and spouse reported that (spouse) ‘would consider it, but not today. The Case Communication note dated 08/26/2025 documents: Patient’s spouse and siblings stopped at the office. “Sibling reported that patient (spouse) was promised to have (patient) be transferred to Calvary Hospital for respite care; (spouse) reported that they waited but no ambulance came to pick patient up.” The clinical record documents the last nursing visit was on 08/15/2025, five days prior to the patient death. There is no documented evidence of the Registered Nurse Case Manager conducting an additional visit to ensure continuous assessment of the patient/family needs and to provide support during the patient’s end of life. There is no documented evidence of the Registered Nurse Case Manager coordinating the care and services provided by the IDG (Interdisciplinary Group) and implementing the interdisciplinary plan of care at the patient’s end of life. On 11/06/2025 at 4:50 PM, the Hospice Administrator/Senior Vice President and the Director of Patient Services/Senior Director of Clinical Services were interviewed.   The Senior Director of Clinical Service stated patient should have had another visit when entering in the dying phase; and “no” the nurse did not complete the assessment for the visit on 08/15/2025.   There was no further documentation provided for the findings.

Based on clinical care record reviews and staff interviews, the Hospice failed to include the patient's family in the on-going development of the patient's plan of care.  This was evident for three (3) of three (3) clinical records reviewed (Patients #1, #2 and #3).Failure to include the family in the planning of the patient's hospice care plan has the potential for negative patient outcomes including failing to respect the patient's rights.The findings are: --- 1. Patient #1 has a Start of Care date of 07/10/2025 with diagnoses of Moderate Protein-Calorie Malnutrition, Unspecified Dementia, and Essential (Primary) Hypertension documented on the Hospice Plan of Care with a Certification Period from 07/10/2025 to 10/07/2025.  The Hospice conducted an employee in-service on 07/31/2025 with the agency's nursing staff. The in-service record documents, "Caregiver Care Coordination Requirements . . . . Effective Monday, August 11 (2025), two new Care Coordination Notes, will be activated and required for the documentation of care coordination with the patient's caregiver and/or Attending Physician. The notes must include: The patient's current alert and orientation status, whether the patient has requested that their caregiver provide direction to the hospice team on their behalf, details of the communication, and caregiver's response to the communication." The clinical record documents nursing visits after the in-service on 08/12/2025, 08/20/2025, and 08/27/2025.  There is no documented evidence of care coordination notes with the patient's caregiver after 08/11/2025.  On 08/28/2025 at 3:45 PM, the Patient Care Coordinator was interviewed and stated, "I am not quite sure why it is not there." 2. Patient #2 has a Start of Care date of 02/18/2025 with diagnoses of Neurocognitive Disorder with Lewy Bodies, Essential (Primary) Hypertension, and Osteomyelitis of Right Orbit documented on the Hospice Plan of Care with a Certification Period from 08/17/2025 to 10/15/2025.  The Hospice medical orders with a begin date of 02/18/2025 and discontinue date of 05/18/2025 documents, "For Order: SN 1-2 Week 13, 5 As Needed (For Order: Skilled Nurse, 1 to 2 times a week for 13 weeks, and 5 as needed). The nursing visits changed from 1 to 2 times a week to 1 times a week starting from 05/19/2025 to 08/16/2025.  The Hospice Plan of Care (medical orders) with a Certification Period from 05/19/2025 to 08/16/2025 documents, "05/19/2025 - 08/16/2025 - SN 1 Week 13; 5 as needed (Skilled Nurse 1 times a week for 13 weeks, and 5 as needed). The patient's daughter is the Health Care Proxy. There is no documented evidence of the patient's daughter being informed of the change in the frequency of nursing visits from 1 to 2 times a week to 1 times a week.  On 08/27/2025 at 3:00 PM, the Administrator and Director of Clinical Services were interviewed. The Administrator stated if the family are not present at the visit they should be contacted after the visit.  The Skilled Nurse Hospice Visit note dated 04/19/2025 documents the patient's weight was "98.2# (98.2 pounds). The Skilled Nurse Hospice Visit note dated 06/04/2025 documents, "96.6# weight for June."The Skilled Nurse Hospice Visit note dated 07/16/2025 documents, "Staff nurse reported that the patient's July weight was 96.9 lbs (pounds)." There is no documented evidence of the patient's daughter being informed of the changes in the patient's weight that could affect the patient's plan of care.  On 08/28/2025 at 12:00 PM, the Administrator and Director of Clinical Services were interviewed and did not provide an explanation.  The Hospice conducted an employee in-service on 07/31/2025 with the agency's nursing staff. The in-service record documents, "Caregiver Care Coordination Requirements . . . . Effective Monday, August 11 (2025), two new Care Coordination Notes, will be activated and required for the documentation of care coordination with the patient's caregiver and /or Attending Physician. The notes must include: The patient's current alert and orientation status, whether the patient has requested that their caregiver provide direction to the hospice team on their behalf, details of the communication, and caregiver's response to the communication." The clinical record documents nursing visits after the in-service on 08/15/2025, 08/23/2025, and 08/26/2025.  There is no documented evidence of care coordination notes with the patient's caregiver after 08/11/2025.  On 08/28/2025 at 3:45 PM, the Patient Care Coordinator was interviewed and stated, "I am not quite sure why it is not there." 3. Patient #3 has a Start of Care date of 07/11/2025 with diagnoses of Alzheimer's Disease, Moderate Protein-Calorie Malnutrition, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, and Essential (Primary) Hypertension documented on the Hospice Plan of Care with a Certification Period from 07/11/2025 to 10/08/2025.  The Hospice conducted an employee in-service on 07/31/2025 with the agency's nursing staff. The in-service record documents, "Caregiver Care Coordination Requirements . . . . Effective Monday, August 11 (2025), two new Care Coordination Notes, will be activated and required for the documentation of care coordination with the patient's caregiver and /or Attending Physician. The notes must include: The patient's current alert and orientation status, whether the patient has requested that their caregiver provide direction to the hospice team on their behalf, details of the communication, and caregiver's response to the communication." The clinical record documents nursing visits after the in-service on 08/12/2025, 08/19/2025, and 08/20/2025.  There is no documented evidence of care coordination notes with the patient's caregiver after 08/11/2025.  On 08/28/2025 at 3:45 PM, the Patient Care Coordinator was interviewed and stated, "I am not quite sure why it is not there."

Based on clinical record reviews and staff interviews, the Hospice failed to provide and follow the patient’s individualized written plan of care. This was evident for (2) of three clinical records reviewed (Patients #2 and #3).Failure to follow the patient’s individualized plan of care has the potential for negative patient outcomes.The findings are: --- 1. Patient #2 has a Start of Care date of 02/18/2025 with diagnoses of Neurocognitive Disorder with Lewy Bodies, Essential (Primary) Hypertension, and Osteomyelitis of Right Orbit documented on the Hospice Plan of Care with a Certification Period from 08/17/2025 to 10/15/2025.  The Hospice medical orders with a begin date of 02/18/2025 and discontinue date of 05/18/2025 documents, "For Order: SN 1-2 Week 13, 5 As Needed (For Order: Skilled Nurse, 1 to 2 times a week for 13 weeks, and 5 as needed). The Hospice's work week is Sunday to Saturday. The clinical record lacks documented evidence of Skilled Nursing Services for the week of 04/27/2025 to 05/03/2025. There is no documented evidence of the patient receiving Skilled Nurse Services as ordered for the week of 04/27/2025 to 05/03/2025The Hospice Plan of Care (medical orders) with a Certification Period from 05/19/2025 to 08/16/2025 documents, "05/19/2025 - 08/16/2025 - SN 1 Week 13; 5 as needed (Skilled Nurse 1 times a week for 13 weeks, and 5 as needed). The clinical record lacks documented evidence of Skilled Nursing Services for the week of 07/06/2025 to 07/12/2025.  There is no documented evidence of the patient receiving Skilled Nursing Services as ordered in the plan of care for the week of 07/06/2025 to 07/12/2025. 2. Patient #3 has a Start of Care date of 07/11/2025 with diagnoses of Alzheimer's Disease, Moderate Protein-Calorie Malnutrition, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, and Essential (Primary) Hypertension documented on the Hospice Plan of Care with a Certification Period from 07/11/2025 to 10/08/2025.  The Hospice Plan of Care (medical orders) with a Certification Period from 07/11/2025 to 10/08/2025 documents, "07/13/2025 - 10/07/2025, SN 1-2 week 13, 5 As Needed (Skilled Nurse 1 to 2 times a week for 13 weeks, and 5 As Needed).  The clinical record lacks documented evidence of the patient receiving Skilled Nursing Services as ordered in the plan of care for the week of 08/03/2025 to 08/09/2025. On 08/28/2025 at 3:45 PM, the Administrator, Patient Care Coordinator, and Director of Clinical Services were interviewed. The Director of Clinical Services stated there were no visit notes for Patients #2 and Patient #3.

Based on clinical record reviews and staff interviews, the Hospice failed to ensure the Interdisciplinary Group (IDG) reviews and revises the individualized plan of care as the patient's condition requires, no less frequently than every fifteen (15) days.This was evident for three (3) of three (3) clinical records reviewed (Patients #1, #2, and #3).Failure to ensure the Interdisciplinary Group reviews and revises the plan of care has the potential for negative patient outcomes. The findings are: --- 1. Patient #1 has a Start of Care date of 07/10/2025 with diagnoses of Moderate Protein-Calorie Malnutrition, Unspecified Dementia, and Essential (Primary) Hypertension documented on the Hospice Plan of Care with a Certification Period from 07/10/2025 to 10/07/2025. The Skilled Nurse Hospice visit note dated 07/17/2025 documents, "July's weight was 74.8 lbs."There is no documented evidence of the Hospice Plan of Care being reviewed and revised to monitor the patient's weight. On 08/28/20/25 at 12:00 PM, the Administrator and Director of Clinical Services were interviewed. The Administrator stated it is to determine hospice eligibility and there would not be an intervention.2. Patient #2 has a Start of Care date of 02/18/2025 with diagnoses of Neurocognitive Disorder with Lewy Bodies, Essential (Primary) Hypertension, and Osteomyelitis of Right Orbit documented on the Hospice Plan of Care with a Certification Period from 08/17/2025 to 10/15/2025. The initial nursing assessment dated 02/18/2025 documents, “ . . . . Patient has difficulty swallowing and has progressive weight lost, with diagnosis currently of severe protein calorie malnutrition and weight loss of 23.7 lbs over 6 month period . . .” For the certification period from 02/18/2025 to 05/18/2025, the Interdisciplinary Team Case Conference Summary dated 02/19/2025 documents, “Interventions: . . . . Monitor monthly weights . . . .”For the certification period from 02/18/2025 to 05/18/2025, the “non-clinical note” documents, the following monthly weights, “03/5/25 – 95.2 # (pounds), 04/19/25 - 98.2 lbs (pounds), and 05/09/25 – 97 lbs.”There is no documented evidence of the Hospice Plan of Care being reviewed and revised to include monitoring monthly weights for the certification period from 02/18/2025 to 05/18/2025.  For the certification period from 05/19/2025 to 08/16/2025, the Skilled Nurse Hospice visit dated 06/04/2025 documents, “96.6 # (pounds) for June.”The LPN (Licensed Practical Nurse) visit dated 07/16/2025 documents, “Staff nurse reported that the patient’s July weight was 96.9 lbs (pounds).”For the certification period from 08/17/2025 to 10/15/2025, the LPN (Licensed Practical Nurse) visit dated 08/26/2025 documents, “August weight was 95.4 lbs (pounds).”There is no documented evidence of the Hospice Plan of Care being reviewed and revised to include monitoring monthly weights for the certification period from 05/19/2025 to 08/16/2025 and for the certification period from 08/17/2025 to 10/15/2025.On 08/28/20/25 at 12:00 PM, the Administrator and Director of Clinical Services were interviewed. The Administrator stated, it is to determine hospice eligibility and there would not be an intervention.3. Patient #3 has a Start of Care date of 07/11/2025 with diagnoses of Alzheimer's Disease, Moderate Protein-Calorie Malnutrition, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, and Essential (Primary) Hypertension documented on the Hospice Plan of Care with a Certification Period from 07/11/2025 to 10/08/2025. The initial nursing assessment visit dated 07/11/2025 documents, "Weight in Pounds - 133."The Skilled Nurse Hospice visit noted dated 07/30/2025 documents, "Last weight was 136.1 lbs on 07/24/2025."There is no documented evidence of the Hospice Plan of Care being reviewed and revised to monitor the patient's weight. On 08/28/20/25 at 12:00 PM, the Administrator and Director of Clinical Services were interviewed. The Administrator stated, it is to determine hospice eligibility and there would not be an intervention.

Based on clinical care record review and staff interviews, the governing authority failed to include the patient's family in the on-going development of the patient's plan of care.  This was evident for one (1) of three (3) patient care records reviewed (Patient #1).Failure to include the family in the planning of the patient's hospice care plan has the potential for negative patient outcome including failing to respect the patient's rights.The findings are: --- 1.  Patient #1 has a Start of Care date of 08/21/2024 and a discharge date of 08/26/2024 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Unspecified Female Breast, Pleural Effusion, Dyspnea" documented in the Hospice Plan of Care for the Certification Period 08/21/2024 to 11/18/2024.The Hospice Benefit Election/Consent for Care dated 08/21/2024 documents: I designate (name of son [SH]) as my primary care person.  This means he/she will be the person mainly responsible for overseeing my care at home.The Orders (interim/supplemental) documents:08/21/2024 New Order for Ativan 0.5 mg (milligram) tablet take 1 tab (tablet) by oral route bedtime as needed.08/24/2024 New Order for Morphine take 2.5 mg (milligram) by sublingual route every 4 hours as needed.08/25/2024 Take 0.25 ml (milliliters) by buccal route every 4 hours as needed.The SN (skilled nurse) on Call Communication dated 08/24/2024 documents: T/C (telephone call) from caregiver to report patient in pain: Caregiver states acetaminophen not providing relief.  NP (nurse practitioner name) informed.  Pt (patient) to start Morphine 2.5mg (milligram) q4hrs prn (every four hours as needed).The SN (skilled nurse) Hospice Visit dated 08/25/2024 documents: Mental status – Agitated; Emotional Status – Patient Helpless, Restless.  “Pt (patient) in bed, doing poorly, entering dying phase, feet being to mottle not able to make needs known.” “(Morphine) dose increased to 5 mg (milligram) every 4 h (four hours) as needed.  Restlessness managed with Lorazepam.” "nothing by mouth" “Writer unable to leave message with Pri CG (primary caregiver), (name of son).” Caregiver during assessment was the private hired aide.The clinical record lacks documented evidence of the hospice to include the patient's family in the on-going development of the patient's plan of care and during the changes in the plan of care including new medications: Ativan on 08/21/2024 and Morphine on 08/24/2024, increased on 08/25/2024 and nothing by mouth.On 05/27/2025 at 03:17PM, the Administrator, the Clinical Resource, the Quality Educator, and the Hospice Registered Nurse were interviewed and did not provide an explanation for the findings.

Based on clinical care record review and staff interviews, the governing authority failed to establish a written plan of care by the hospice interdisciplinary group in collaboration with the patient or representative, and the primary caregiver in accordance with the patient's needs.  This was evident for one (1) of three (3) patient care records reviewed (Patient #1).Failure to establish a written plan of care by the hospice interdisciplinary group in collaboration with the patient or representative, and the primary caregiver in accordance with the patient's needs has the potential for negative patient outcomes.The findings are: --- 1.  Patient #1 has a Start of Care date of 08/21/2024 and a discharge date of 08/26/2024 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Unspecified Female Breast, Pleural Effusion, Dyspnea" documented in the Hospice Plan of Care for the Certification Period 08/21/2024 to 11/18/2024.The Patient Information Facesheet documents: (Name [JH]), Roles / Relationships: Natural child – no financial responsibility.The Hospice Benefit Election/Consent for Care dated 08/21/2024 documents: I designate (name of son [SH]) as my primary care person.  This means he/she will be the person mainly responsible for overseeing my care at home.The clinical record lacks documented evidence of the collaboration with the primary caregiver (son [SH]) or the family member, (only present during the initial assessment was the privately hired aide) in accordance with the patient’s needs.On 05/27/2025 at 03:17PM, the Administrator, the Clinical Resource, the Quality Educator, and the Hospice Registered Nurse were interviewed and did not provide an explanation for the findings.

Based on clinical care record review and staff interviews, the governing authority failed to ensure plan of care must reflect patient and family goals and interventions   to manage pain.  This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #3).Failure to ensure plan of care must reflect patient and family goals and interventions   to manage pain has the potential for negative patient outcomes.The findings are: --- 1.  Patient #1 has a Start of Care date of 08/21/2024 and a discharge date of 08/26/2024 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Unspecified Female Breast, Pleural Effusion, Dyspnea" documented in the Hospice Plan of Care for the Certification Period 08/21/2024 to 11/18/2024.The SN (skilled nurse) On Call Communication dated 08/24/2024 documents: “T/C (telephone call) from caregiver to report patient in pain; Caregiver states acetaminophen not providing relief.  NP (nurse practitioner) informed.  Pt (patient) to start Morphine 2.5 mg (milligram) q4hrs prn (every four hours as needed).”The SN (skilled nurse) Hospice Visit dated 08/25/2024 documents: Pain Location: Abdomen; Pain Intensity: 3; pt (patient) in bed, doing poorly, entering dying phase; Morphine dose given by writer given during rv (routine visit) 4 p (four in the afternoon). Dose increased to 5 mg (milligram) every 4 h (four hours) as needed.The clinical record lacks documented evidence of the plan of care being updated to include goals and interventions to manage pain.On 05/27/2025 at 03:17PM, the Administrator, the Clinical Resource, the Quality Educator, and the Hospice Registered Nurse were interviewed and did not provide an explanation for the findings.2.  Patient #3 has a Start of Care date of 08/16/2024 and a discharge date of 10/04/2024 with the following diagnoses "Alzheimer’s Disease, Nutritional Deficiency" documented in the Hospice Plan of Care for the Certification Period 08/16/2024 to 10/14/2024.The SN (skilled nurse) Hospice Visit dated 08/27/2024, 09/05/2024, 09/13/2024, 09/18/2024, and 09/24/2024 documents: “Pain Location generalized; Pain Duration – Daily, but not constant, controlled with intervention; Generalized pain on T&P (turning and positioning)/personal care is controlled with PRN (as needed) Tylenol (less than daily).The clinical record lacks documented evidence of the plan of care to include goals and interventions to manage pain.On 05/27/2025 at 03:17PM, the Administrator, the Clinical Resource, the Quality Educator, and the Hospice Registered Nurse were interviewed and did not provide an explanation for the findings.

Based on clinical care record review and staff interviews, the governing authority failed to ensure that the interdisciplinary group reviews the plan of care to determine the ability of the patient and/or family to safely self-administer drugs.  This was evident for one (1) of three (3) patient care records reviewed (Patient #1).Failure to review the plan of care to determine the ability of the patient and/or family to safely self-administer drugs has the potential for negative patient outcomes.The findings are: --- 1.  Patient #1 has a Start of Care date of 08/21/2024 and a discharge date of 08/26/2024 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Unspecified Female Breast, Pleural Effusion, Dyspnea" documented in the Hospice Plan of Care for the Certification Period 08/21/2024 to 11/18/2024.The SN (skilled nurse) Hospice Care Plan dated 08/22/2024 documents: Comfort pack delivered. Reviewed with CGR (caregiver - is the privately hired aide).The clinical record lacks documented evidence of the hospice determination of the ability of the patient and /or family to safely self-administer drugs.On 05/27/2025 at 03:17PM, the Administrator, the Clinical Resource, the Quality Educator, and the Hospice Registered Nurse were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview the agency failed to ensure and protect the rights of the patient to receive timely and effective pain management. This was evident for one (1) of twenty -nine (29) clinical records reviewed (Patient #6). Failure to ensure patients receive timely and effective pain management has the potential risk for negative patient outcomes. The findings are: --- 1.Patient #6 has a Start of Care date of 09/16/2024 with diagnoses Malignant Neoplasm of Prostate, Essential (Primary) Hypertension documented in the ";Hospice Plan of Care" for Benefit Period 09/16/2024 to 12/14/2024. The ";Hospice Plan of Care" for Benefit Period 09/16/2024 to 12/14/2024 documents Skilled Nurse orders to assess/instruct pain/symptom management and medication management, and medications: Acetaminophen 325mg capsule, take 2 capsules by mouth 3 times per day as needed for Arthritic pain and Celebrex 200mg capsule, take 1 capsule by mouth 2 times per day every day for Osteoarthritis. The SN (Skilled Nurse) Hospice Visit note dated 10/15/2024 documents: ";Current pain control measures are not effective:" ";Pt(Patient) stated lower back pain can be a level 5 on pain scale 0-10, which is no longer fully alleviated w(with)/Tylenol 325mg 3x/Day PRN (as needed) and Celebrex 200mg, 1 tab in AM and 1 tab at bedtime." ";Pt (Patient) and PCG (Primary Caregiver) requesting pain medications other than Tylenol PRN (as needed). Update provided to PCC (Patient Care Coordinator)." The Physicians Order dated 10/17/2024 (two days later) documents: New order for Tramadol 50mg tablet, take 1/2tablet by mouth every 6 hours as needed for pain. The SN (Skilled Nurse) On Call Communication note dated 10/18/2024 documents: ";Pt was started on Tramadol 25mg yesterday, 10/17." There is no documented evidence of the Hospice providing a timely response to the management of the patient ' s pain symptoms. On 11/22/2024 at 1:00PM, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and staff interview the agency failed to ensure the patients comprehensive assessment is updated as frequently as the condition of the patient requires, but no less frequently than every 15 days. This was evident for four (4) of twenty -nine (29) clinical records reviewed. (Patient # 4, #7, #8, and#11). Failure to ensure all patients have an updated comprehensive assessment as frequently as the patients condition requires but no less frequently than every 15 days has the potential risk for negative patient outcomes. The findings are: --- 4. Patient #11 has a Start of Care date of 06/24/2024 with the following diagnosis "Myelodysplastic Syndrome, Alzheimers Disease" documented on the Hospice Certification and Plan of Care for the Certification Period 09/22/2024 to 12/20/2024. The order dated 10/06/2024 documents: ";Wound Care(R(right) Shin: Cleanse with wound cleanser, apply layer of xeroform, cover with border gauze. If no borderline gauze available may construct one out of nonwoven gauze and hypafix tape. To be done every other day but may be done additionally PRN (as needed) for soilage or displacement." The LPN (License Practical Nurse) Hospice Routine Visit dated 10/10/2024 documents: ";Skin Integrity: ";Patient does not have integrity issues at this time." There is no documented evidence that Skilled Nurse documentation reflect changes in the patient's skin integrity. On 11/21/2024 at 02:30PM, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. The ";Calvary Hospice Skin Tear Protocol ";Policy (Revised 10/21/2024) documents: ";The Admission RN (Registered Nurse), RN Case Manager, or On-call RN obtains MD (Medical Doctor/NP (Nurse Practitioner) order to initiate the Calvary Hospice Skin Tear Protocol." 3. Patient #8 has a Start of Care date of 09/19/2024 with diagnosis of Moderate Protein Calorie Malnutrition documented in the "Hospice Plan of Care" for Certification Period 09/12/2024 to 12/10/2024. The ";Order" with order taken date 09/19/2024 for the begin date 09/19/2024 and the end date 12/17/2024 documents: ";SN (Skilled Nurse) orders: Treatment: Measures to promote comfort, skin care and prevention, mobility/safety." The ";SN (Skilled Nurse) Hospice Care Plan (Visit 09/19/2024)" documents Hospice SN (Skilled Nurse) Routine Assessment: ";Skin Integumentary: No Signs/Symptoms." The ";SN (Skilled Nurse) Hospice Visit (Visit 09/23/2024)" documents Hospice SN (Skilled Nurse) Routine Assessment: ";Skin integrity 7 – Other (specify), Skin integrity Other skin tears. Wound Management Facility" The ";SN (Skilled Nurse) Hospice Visit (Visit 09/27/2024)" documents Hospice SN (Skilled Nurse) Routine Assessment: ";Skin integrity. Patient does not have integrity issues at this time." The ";SN (Skilled Nurse) ";Hospice Visit (Visit 10/01/2024)" documents Hospice SN (Skilled Nurse) Routine Assessment: ";Skin integrity Wound/Decubitus (go to wound addendum)." Wound addendum to the Skilled Nurse ";Hospice Visit (Visit 10/01/2024)" documents: ";Wound #1, Wound Location right forearm, Wound Length 2cm (centimeters) Wound Width 2cm (centimeters) Type Wound skin tear." The ";SN (Skilled Nurse) ";Hospice Visit (Visit 10/07/2024)" documents Hospice SN (Skilled Nurse) Routine Assessment: ";Skin Integrity: Patient does not have integrity issues at this time." The Hospice IDT (Interdisciplinary Team) Case Conference Note Report for meeting Date 09/24/2024 lacks documented evidence of the patient developing a skin tears. The Registered Nurse Routine Assessment ";Visit Note Report" dated 09/23/2024 lacks documented evidence of the Skin Tear Protocol Policy being initiated. The Registered Nurse Routine Assessment ";Visit Note Report" dated 09/27/2024 and 10/07/2024 lacks documented evidence of a comprehensive wound assessment, including measurement, in accordance with the agencys policies. On 11/21/2024 at 02:30PM, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 2.Patient #7 has a Start of Care date of 08/29/2024 with the following diagnoses "Moderate Protein – Calorie Malnutrition, Unspecified Fracture of Sacrum" documented in the Hospice Plan of Care for the Certification Period 08/29/2024 to 11/26/2024. The Order dated 08/29/2024 documents: ";SN (skilled nurse) 1 week 1 (once a week for one week), 1-2 week 12 (one to two times a week for twelve weeks), 1 week 1, 6 as needed." The SN On Call Communication dated 09/08/2024 documents: ";also reported that pt (patient) have no BM (bowel movement) x 5 days." The SN (Skilled Nurse) Hospice Visit dated 10/18/2024 documents: ";Last Bowel Movement Date: 10/12/2024; GI/GU/Reproductive (Gastrointestinal/ Genitourinary): Distention/Retention." The clinical record lacks documented evidence of the assessment of no bowel movement for five days documented on 09/08/2024 and for 6 days (from 10/12/2024 to 10/18/2024); and no follow up regarding bowel movement. The Case Communication Report documents: 09/16/2024 1:31pm ";pt (patient) is very agitated and restless. PRN (as needed) dose of Lorazepam administered during visit earlier today. Private aide called back to report medication was ineffective. Medical doctor advised patient to take an additional 0.5mg (milligram) of Lorazepam." 09/16/2024 3:27pm ";Received call from patient ts (patients) daughter (name), reporting pt (patient) is very agitated." 09/17/2024" Patients daughter (name) called. Pt (patient) was agitated and up all night, received 1 mg of Lorazepam at 4pm, rested for about an hour, woke up agitated and was up until 2 am. New order for Haldol 1 mg tablet one tab BID (twice a day) and Lorazepam 1.5mg tablet one-tab q6h (every six hours) PRN (as needed) anxiety/agitation. The SN (Skilled Nurse) Hospice Visit dated 09/18/2024 documents: ";Private aides do not seem to be administering Haldol as ordered or Lorazepam. Aide present today, (name), reports Lorazepam made pt (patient) very agitated, so she is not giving it to the patient at all." There is no documentation of agitation in the Call Communication on 09/20/2024 and 09/21/2024. The SN (Skilled Nurse) On Call Communication dated 09/23/2024 documents: ";(Name of daughter) wanted to know if medication for agitation could be changed. Patient had a reaction to Lorazepam when it was given previously." The clinical record lacks documented evidence of the follow-up regarding effectiveness, side effects, and compliance of medication, and agitation. The SN (Skilled Nurse) Hospice Routine Visit dated 09/30/2024 documents: ";Denies pain - however guarded to both lower exts (extremities) – ouches with sheet covering feet. Edema noted to both feet – elevated on pillow." The clinical record lacks documented evidence of the follow-up regarding edema on both feet. There is no documented evidence of the updated assessment documenting the evaluation of patients response to the care, medication, symptom management, and progress toward the desired outcome. On 11/21/2024 at 02:30PM, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. The Clinical Record Policy (Effective 09/26/2024) documents: ";Each patients clinical record includes, at a minimum the following: initial comprehensive assessment and routine, ongoing assessments." The ";Comprehensive Assessment of the Patient" Policy (Effective 11/07/2024) documents: ";Discipline-specific assessment tools obtain accurate and timely information that guide decisions for the development of the patients plan of care;" and ";Calvary Hospices assessment and reassessment tools contain data elements that allow for the measurement of outcomes." 1.Patient #4 a Start of Care date of 08/25/2024 with diagnoses Malignant Carcinoid Tumors of Other Sites, Chronic Kidney Disease, Atherosclerotic Heart Pancreas of Native Coronary Artery Without Angina Pectoris documented in the ";Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024. The ";Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024 documents orders for the SN (Skilled Nurse) visits 1-2 visits a week for 12 weeks to ";assess /instruct pain/symptom management, medication management, bowel and bladder management, nutrition and hydration needs during terminal illness. Treatment measures to promote comfort, skin care and prevention, mobility/safety/." The Registered Nurse/SN (Skilled Nurse) Routine Assessment visit note dated 08/31/2024 documents the note ";Contains: Hospice SN (Skilled Nurse) Routine Assessment." The ";Hospice SN Routine Assessment" section documents the nurse assessed the patients vital signs with no other assessment noted. The Registered Nurse documents: ";Clinical note" – skin intact healing wound to right big toe red, inflamed been putting antibiotic cream; pain 7/10 back refusing pain medications, appetite poor, reports nausea, denies vomiting, status post fall last week-unknown which day. The Registered Nurse/SN (Skilled Nurse) Routine Assessment visit notes lack documented evidence Registered Nurse completing the ";Hospice SN (Skilled Nurse) Routine Assessment" section for the routine ongoing assessment of the patient. The Registered Nurse/SN (Skilled Nurse) Routine Assessment visit note dated 11/05/2024 ";Patient c/o (complained of) mild pain in (patients) right hand. Presented with reddish puffy bruise on back of right hand. Baseline range of motion in wrist and fingers;" "Patient stated, I dont know how I got this bruise. I fall a lot and I forget a lot too. SN (Skilled Nurse) t/c (telephone call) with Dr. (name), no new orders. Dr. (name) advised patient to elevate the hand and apply cold pack for 15 minutes at a time. SN (Skilled Nurse) relayed Dr. (name) instructions. Patient able to tell back." The Registered Nurse/SN (Skilled Nurse) Routine Assessment visit note dated 11/07/2024: ";SN (Skilled Nurse) t/c (telephone call) with Dr. (name) to apprise (doctor) that patients right hand is still puffy, and the middle finger discolored." "Has active ROM (range of motion) in the wrist and all fingers except middle finger;" "patient claims that (patient) cant move the middle finger independently. Dr. (name) ordered an X-ray of the right hand." The subsequent Registered Nurse/SN (Skilled Nurse) Routine Assessment note dated 11/12/2024 lacks documented evidence of an assessment and status of the patients right hand. The clinical record lacks documented evidence of the Registered Nurse completing an ongoing assessment of the patient in accordance with the Hospice policies. On 11/21/2024 at 2:25PM, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and staff interview the hospice failed to provide and follow the patients individualized written plan of care. This was evident for five (5) of twenty-nine clinical records reviewed. (Patient #3, #9, #11, #12, and #20). Failure to follow the patients individualized plan of care has the potential for negative patient outcome. The findings are: --- 5. Patient #20 has a Start of Care date of 09/27/2024 with the following diagnoses "Alzheimers Disease, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Essential (Primary) Hypertension" documented on the Hospice Plan of Care for the Certification Period 09/27/2024 to 12/25/2024. The Supplemental order dated 10/04/2024 documents: ";HA (Hospice Home Health Aide) 5 week 11 (five times a week for eleven weeks), 3-week 1 (three times a week for one week) x 4 hours duration" The clinical record lacks documented evidence of an aide providing care for the week of: 10/13/2024 to 10/18/2024 - one missed visit, 10/20/2024 to 10/25/2024 - one missed visit; 10/27/2024 to 11/01/2024 - three missed visits, 11/03/2024 to 11/08/2024 - one missed visit. There is no documented evidence of the patient receiving aide services as ordered on the plan of care. On 11/21/2024 at 02:30 pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 2. Patient #9 has a Start of Care date of 05/10/2024 with the following diagnosis " Unspecified Bladder Disorder" documented on the Hospice Certification and Plan of Care for the Certification Period 08/08/2024 to 11/05/2024. The Hospice Certification and Plan of Care for the Certification 08/08/2024 to 11/05/2024 documents: ";SN (Skilled Nurse) 1 week 13 (once a week for thirteen weeks); 6 as Needed" The clinical record lacks documented evidence of Skilled Nurse Services for the week of 08/11/2024 to 08/17/2024: missed one visits, and for the week of 09/01/2024 to 09/07/2024: missed one visits. There is no documented evidence of the patient receiving Skilled Nurse Services as ordered in the plan of care. On 11/21/2024 at 02:30pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 3.Patient #11 has a Start of Care date of 06/24/2024 with the following diagnosis "Myelodysplastic Syndrome, Alzheimers Disease" documented on the Hospice Certification and Plan of Care for the Certification Period 09/22/2024 to 12/20/2024. The Hospice Certification and Plan of Care for the Certification Period 09/22/2024 to 12/20/2024 documents: ";MSS (Medical Social Services) 1 Month 1(one times a month for one month); 2 Month 3 (two times a month for three month); 3 as Needed" The clinical record lacks documented evidence of Medical Social Services for the month of October: missed one visits. There is no documented evidence of the patient receiving Medical Social Services as ordered in the plan of care. On 11/21/2024 at 02:30pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 4.Patient #12 has a Start of Care date of 06/20/2024 with the following diagnosis "Malignant Neoplasm of Prostate" documented on the Hospice Certification and Plan of Care for the Certification Period 09/18/2024 to 12/16/2024. The Hospice Certification and Plan of Care for the Certification Period 09/18/2024 to 12/16/2024 documents: ";MSS (Medical Social Services) 1 Month 1(one times a month for one month); 2 Month 2 (two times a month for second month); 1 Month 1 (one times a month for one month); 3 as Needed" The clinical record lacks documented evidence of Medical Social Services for the month of October: missed two visits. There is no documented evidence of the patient receiving Medical Social Services as ordered in the plan of care. On 11/21/2024 at 02:30pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 1.Patient #3 has a Start of Care date of 07/11/2024, Discharge Date of 08/15/2024, with diagnoses Malignant Neoplasm of Pancreas, Unspecified, Liver Cell Carcinoma documented in the ";Hospice Plan of Care" for Certification Period 07/11/2024 to 10/08/2024. The Physicians Order dated 08/07/2024 documents the following orders for Hospice Aide/Home Health Aide services: Begin Date 08/09/2024; 1 Week 1 (one visit a week for one week); 3 Week 8 (three visits a week for eight weeks) and 1 Week 1. The clinical record lacks documented evidence that aide services began on 08/09/2024 to provide one visit a week for week one. The Home Health Aide ";Electronic Duty Sheet" dated 08/12/2024 documents the first day of aide services on 08/12/2024. There is no documented evidence of the collaboration and notification regarding the missed visit to the Physician and patient/family. There is no documented evidence of home health aide services being furnished as ordered in the hospice plan of care/Physicians Order. On 11/21/2024 at 2:25pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and staff interview, the hospice failed to ensure that the patient and/or patient's family/caregiver receive education and training identified in the plan of care. This was evident in two (2) of twenty-nine (29) clinical records reviewed. (Patient #4 and #6). Failure to ensure that each patient or the primary care giver (s) receive education and training, identified in the plan of care has the potential for negative patient outcome. The findings are: --- 1.Patient #4 has a Start of Care date of 08/25/2024 with diagnoses Malignant Carcinoid Tumors of Other Sites, Chronic Kidney Disease, Atherosclerotic Heart Pancreas of Native Coronary Artery Without Angina Pectoris documented in the ";Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024. The ";Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024 documents orders for the patient to use ";Oxygen 4 Liters by inhalation rout every day as needed" for ";breathing," and for the Skilled Nurse to ";Instruct CG (caregiver)/Pt (Patient) in the use of meds (medications) to relieve dyspnea (shortness of breath) – opioids, anti-anxiety meds, nebulized medications, Oxygen." The ";SN (Skilled Nurse) Hospice Visit" note dated 09/03/2024 documents the following: Patient uses Oxygen 2LPM (Liters Per Minute) via N/C (Nasal Cannula) PRN (as needed) daily; stated that nebulized medications relieve dyspnea." The Skilled Nurse visit note lacks documented evidence of the nurse educating the patient to use Oxygen 4 LPM as ordered in the Hospice plan of care. On 11/21/2024 at 2:25pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings. 2.Patient #6 has a Start of Care date of 09/16/2024 with diagnoses Malignant Neoplasm of Prostate, Essential (Primary) Hypertension documented in the ";Hospice Plan of Care" for Benefit Period 09/16/2024 to 12/14/2024. The ";Hospice Plan of Care" for Benefit Period 09/16/2024 to 12/14/2024 documents Skilled Nurse orders to assess/instruct pain/symptom management and medication management, and list the following pain medications: Acetaminophen 325mg capsule, take 2 capsules by mouth 3 times per day as needed for Arthritic pain and Celebrex 200mg capsule, take 1 capsule by mouth 2 times per day every day for Osteoarthritis. The SN (Skilled Nurse) Hospice Visit note dated 10/15/2024 documents: ";Current pain control measures are not effective:" ";P t(Patient) stated lower back pain can be a level 5 on pain scale 0-10, which is no longer fully alleviated w(with)/Tylenol 325mg 3xDay PRN (as needed) and Celebrex 200mg, 1 tab in AM and 1 tab at bedtime." ";Pt (Patient) and PCG (Primary Caregiver) requesting pain medications other than Tylenol PRN (as needed). Update provided to PCC (Patient Care Coordinator)." The Physicians Order dated 10/17/2024 (two days later) documents: New order for Tramadol 50mg tablet, take 1/2tablet by mouth every 6 hours as needed for pain. The SN (Skilled Nurse) On Call Communication note dated 10/18/2024 documents: ";Pt (Patient) was started on Tramadol 25mg yesterday, 10/17 every 6 hours as needed for pain. (Primary Caregiver) inquired re: continuation of Celebrex that (Patient) has been taking for low abdominal/pelvic pain and how (Primary Caregiver) should manage the Tramadol along with the Celebrex. Spoke with Dr. (name) who ordered the Celebrex to continue and to the as needed Tramadol between the routine Celebrex." ";Explained to (Primary Caregiver) that the Celebrex and Tramadol would be the regimen that would be used for management of pts (patients) pain," The Skilled Nurse visit note lacks documented evidence of the nurse educating the patient on the use of the new pain medication prior to 10/18/2024. On 11/22/2024 at 1:00pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and staff interview the hospice failed to ensure the patient's plan of care is individualized with patient specific interventions based on the problems/ findings identified in the initial and updated assessments. This was evident for one (1) of twenty-nine (29) clinical records reviewed. (Patient #21). Failure to ensure the patients plan of care is individualized and reflect interventions identified in the assessments has the potential for negative patient outcome. The findings are: --- 1. Patient #21 has a Start of Care date of 07/05/2024 with the following diagnoses "Parkinsons Disease, Moderate Protein – Calorie Malnutrition " documented in the Hospice Plan of Care for the Certification Period 09/03/2024 to 11/01/2024. The Hospice Plan of Care for the Certification Period 09/03/2024 to 11/01/2024 and Certification period 11/02/20024 to 12/31/2024 documents: ";DME (durable medical equipment) and Supplies: DME (durable medical equipment) and Supplies as needed." ";A & D Ointment 10/05/2024 take 1 app by topical route 2 times per day." The SN (Skilled Nurse) Hospice Visit documents:09/16/2024 Patient was received neatly dressed sitting on her wheelchair.10/13/2024 Maximum assist OOB (out of bed) to her recliner wheelchair.11/07/2024 seated in her high-back recliner wheelchair.11/14/2024 DME (durable medical equipment) ordered. The plan of care lacks documented evidence of the durable medical equipment and the site of A&D ointment application and the indication. On 11/21/2024 at 02:30pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) review and revise the individualized plan of care as the patient's care needs change, but no less frequently than every fifteen (15) days. This was evident for one (1) of twenty-nine (29) clinical records reviewed (Patient #1). Failure to ensure the Interdisciplinary Group develop, review, and revise the plan of care has the potential for negative outcome. The findings are. --- 1.Patient #1 has a Start of Care date of 06/24/2024 with diagnoses Other Specified Diseases of Intestine, Atherosclerotic Heart Disease, of Native Coronary Artery Without Angina Pectoris documented in the ";Hospice Plan of Care" for Certification Period 09/22/2024 to 12/20/2024. The ";Case Conference Summary" documents the Hospice Interdisciplinary Group (IDG) reviewed the patient's individualized team care plan on 10/09/2021 and then on 11/06/2024 (28 days later). The Hospice failed to ensure the Interdisciplinary Group reviewed the patient's team care plan at a minimum of every 15 calendar days. On 11/21/2024 at 2:25pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and staff interview, the hospice agency failed to ensure the Interdisciplinary Group maintain, coordinate, communicate and supervise all care and services being provided. This was evident for five (5) of twenty-nine (29) clinical records reviewed. (Patient #1, #4, #6, #7, and #17). Failure to ensure the Interdisciplinary Group coordinate, communicate, and supervise all care and services being provided, has the potential for negative patient outcomes. The findings are: --- 5.Patient #17 has a Start of Care date of 11/05/2024 with the following diagnoses "Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Esophageal Obstruction" documented on the Hospice Plan of Care for the Certification Period 11/05/2024 to 02/02/2025. The Hospice Plan of Care for the Certification Period 11/05/2024 to 02/02/2025 documents: "SN (Skilled Nurse) 1 week 1; 1-2 week 12, 6 As Needed" The Agencys ";Levels of Care – General Inpatient Care" policy (Revision date: 09/26/2024) documents: ";The RN (Registered Nurse) Case Manager or designee communicate patient status, changes in condition or medications, or changes in plan of care to the attending on a daily basis and documents the communication in the medical record." The SN (Skilled Nurse) PRN (as needed) visit dated 11/13/2024 documents: ";Writer provided care, pulled patient up in bed and educated him on positioning to alleviate pressure to his sacrum where there is a PI (pressure injury). Allevyn dressing was applied." The SN (Skilled Nurse) PRN (as needed) visit dated 11/13/2024 lacks documented evidence of the skin/wound assessment and communication with the Physician. The Supplemental order dated 11/14/2024 documents:" For Order SN (Skilled Nurse) Transfer patient to Calvary Hospice for respite care 11/14/2024 – 11/18/2024." The Agencys ";Hospice Care for Nursing Facility Residents Coordination of Services (Revision Date: 04/2024) policy documents: ";The designate Interdisciplinary group member is responsible for: a. Providing overall coordination of the hospice care of the resident with facility representatives. b. Communicating with facility representative and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. The SN (Skilled Nurse) PRN (as needed) visit dated 11/15/2024 (reason for Inpatient Level of Care: Respite care) lacks documented evidence of the skin/wound assessment, communication and coordination with facility representatives and health care provider regarding patients skin/wound status and treatment. The SN Hospice Inpatient visit dated 11/17/2024 documents: "Contains: IPU (In-patient unit) Wound Present." The SN (Skilled Nurse) PRN (as needed) visit dated 11/17/2024 lacks documented evidence of the skin/wound assessment, communication and coordination with facility representatives and health care provider regarding patients skin/wound status and treatment. On 11/19/2024 a home visit was conducted. The patient stated that he has on and off pain/discomfort in sacral area. The Hospice RN (Registered Nurse) was interviewed and stated that the patient has Sacral wound (pressure ulcer) stage 3, wound care done daily by nursing staff. The clinical record lacks documented evidence of the initial/supplemental wound care order(s) for the sacral area. On 11/21/2024 at 02:30 pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 4.Patient #7 has a Start of Care date of 08/29/2024 with the following diagnoses "Moderate Protein – Calorie Malnutrition, Unspecified Fracture of Sacrum" documented in the Hospice Plan of Care for the Certification Period 08/29/2024 to 11/26/2024. The Order dated 08/29/2024 documents: ";SN (skilled nurse) 1 week 1 (once a week for one week), 1-2 week 12 (one to two times a week for twelve weeks), 1 week 1, 6 as needed." The SN On Call Communication dated 09/08/2024 documents: ";also reported that pt (patient) have no BM (bowel movement) x 5 days." The Interdisciplinary Team (meeting) dated 09/11/2024 lacks documented evidence of the coordination / discussion regarding no bowel movement for 5 days. The clinical record dated 09/16/2024, 09/17/2024 documents communication with nurse and aide regarding patient agitation and restlessness; ineffective medication; and changes with medication was made; and on 09/18/2024 non-compliance with medication administration and side effects of medications. The SN (skilled nurse) on Call Communication dated 09/23/2024 documents: ";(Name of daughter) wanted to know if medication for agitation could be changed. She reported patient had a reaction to Lorazepam when it was given previously." The Interdisciplinary Team (meeting) dated 09/25/2024 lacks documented evidence of the coordination / discussion regarding agitation, side effect of Lorazepam, and medication compliance. The SN (Skilled Nurse) Hospice Visit dated 10/18/2024 documents: ";Last Bowel Movement Date: 10/12/2024; GI/GU/Reproductive (Gastrointestinal/ Genitourinary): Distention/Retention." The Interdisciplinary Team (meeting) dated 10/23/2024 lacks documented evidence of the coordination / discussion regarding no bowel movement for 6 days, from 10/12/2024 to 10/18/2024. There is no documented evidence of the coordination of care with the Interdisciplinary group with patients care and needs. On 11/21/2024 at 02:30pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. The ";IDG (Interdisciplinary Group) Coordination of Services" Policy (Effective 09/28/2024) documents: the ";IDG (Interdisciplinary Group) ensures that there is a coordinated and effective ongoing sharing of information amongst and between disciplines, will all contracted service providers and in all settings." 1.Patient #1 has a Start of Care date of 06/24/2024 with diagnoses Other Specified Diseases of Intestine, Atherosclerotic Heart Disease, of Native Coronary Artery Without Angina Pectoris documented in the ";Hospice Plan of Care" for Certification Period 09/22/2024 to 12/20/2024. The ";Hospice Plan of Care" for Certification Period 09/22/2024 to 12/20/2024 documents orders for the Skilled Nurse to conduct ";6 as needed" additional visits ";relating to anticipated changes/decline in patients health status, and/or medication/treatment changes." The ";SN (Skilled Nurse) PRN (as needed) Visit" note dated 10/04/2024 documents the Skilled Nurse conducted an as needed visit. The Skilled Nurse visit note lacks documentation of the purpose for the additional visit. The clinical record lacks documented evidence of communication regarding the changes in the patients health status that necessitate an additional skilled nurse visit. There is no documented evidence of Interdisciplinary Group ensuring that all communication and sharing of information regarding additional visits are recorded in the clinical record. On 11/21/2024 at 2:25pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings. 2. Patient #4 has a Start of Care date of 08/25/2024 with diagnoses Malignant Carcinoid Tumors of Other Sites, Chronic Kidney Disease, Atherosclerotic Heart Pancreas of Native Coronary Artery Without Angina Pectoris documented in the ";Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024. The ";Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024 documents following orders for the Skilled Nurse to assess/instruct on medication management, mobility safety, and includes the following Skilled Nurse Care Plan interventions for Fall Risk: ";Instruct CG(Caregiver)/Pt(Patient) in general home safety and fall prevention program (Education tool in Admission Folder) – Document specific instructions, i.e. foot wear, rugs, assistive devices," ";Instruct family to call Hospice (if) patient should sustain a fall," and ";instruct CG(Caregiver)/Pt(Patient) in any mediations that are highly associated with fall risk, i.e. opioids, cardiac medication, etc." The Registered Nurse Start of Care comprehensive assessment dated 08/25/2024 documents the patient is at risk for falling and the nurse performed the fall interventions as ordered in the Hospice Plan of Care. The nurse documents: ";Fall risk due to unsteady gait;" ";SN (Skilled Nurse) instructed patient and caregiver (Health Care Proxy) that patient is at high risk for falls and needs assistance for all transfer and ambulation to prevent falls;" and ";Caregiver do not understand that patient is not safe to be left alone." The Registered Nurse/Skilled Nurse visit notes dated 09/06/2024, 09/23/2024, 09/30/2024, 10/10/2024, 10//11/2024, 10/26/2024, 11/02/2024, 11/05/2024, 11/07/2024, and 11/12/2024 document the following regarding multiples falls, changes in health status, and medication management: Falls 09/06/2024 Skilled Nurse: ";Patient stated that (patient) fell this morning, landed on (patients) right knee, did not hit head. ";No obvious injuries." ";SN (Skilled Nurse) t/c (telephone call) with Dr. (name) to apprise (doctor) of clinical findings as above and requested that patient be monitored for the next 24 hours;" 09/23/2024 Skilled Nurse: ";Patient fell earlier this morning." ";SN (Skilled Nurse) t/c (telephone call) with Dr. (name) to apprise (doctor) of clinical findings as above. Gave V/O (Verbal Order) to continue to monitor patient." 09/30/2024 Skilled Nurse: ";Patient fell last night." ";No obvious injuries." ";SN (Skilled Nurse) t/c (telephone call) with Dr. (name) to apprise (doctor) of clinical findings as above. Gave V/O (Verbal Order) to continue to monitor." 10/26/2024 Skilled Nurse: ";Pt (Patient) s/p (status post) fall last night. Pt (Patient) states (patient) was walking in living room and fainted. Pt (Patient) c/o (complained of) headache worsening pain to side, back pain, no injuries noted, tenderness to left side," ";Pt (Patient) refusing hospital." Changes in Health Status 09/23/2024 Skilled Nurse: ";Patient fell earlier this morning." ";Patient c/o (complained of) pain both arms and in right hip and leg where (patient) fell." ";Scabbed-over scratch on left forearm from where patient fell earlier this morning." 10/10/2024 Skilled Nurse: ";Patient stated that (patient) has been having headaches;" Patient ";has been having breakthrough seizures." ";PCC (Patient Care Coordinator) called a meeting with Dr. (name), VP of Nursing (name), PCG (Primary Caregiver), Patient, and SN (Skilled Nurse). Dr. (name) recommended that patient come to Calvary Bronx for Respite Care, as current regimen is not providing relief or controlling symptoms." 10/11/2024 Skilled Nurse Hospice Inpatient note: ";Describe the symptoms: weakness, dizziness, syncopal episodes with frequent falls at home, increased pain to right side of head and upper back extending to axilla and chest. Patient also reports increased confusion and memory loss." Medication Management 10/10/2024 Skilled Nurse: Patient is ";using an insulin syringe to give (self) 3 units of Morphine concentrate; 8 ml of Morphine left from a 15 ml bottle. SN (Skilled Nurse) apprised patient that (patient) does not have a doctors order for Morphine;" ";Patient stated that (patient) has been licking the Lorazepam liquid because (patient) has been having breakthrough seizures and I spilled most of the liquid in that bottle. Lorazepam Intensol bottle empty. SN (Skilled Nurse) informed patient that (patients) Lorazepam Intensol is for 2mg daily as needed for seizures and patient stated, I would never take that much Lorazepam – it is too much.' SN (Skilled Nurse) called PCC (Patient Care Coordinator) to inform (Patient Care Coordinator) that patient has been using Morphine without doctors orders" and ";that patient has been using Lorazepam Intensol but not using it as ordered." 10/26/2024 Skilled Nurse: ";Pt (Patient) c/o (complained of) headache worsening pain to side, back pain, no injuries noted, tenderness to left side, pain 6.5/10 – Pt (Patient) refusing pain medications." 11/02/2024 Skilled Nurse: "Patient had a seizure this morning. Gave (self) 'a little bit of Lorazepam.' SN (Skilled Nurse) instructed patient in how to draw up 2mg of Lorazepam Intensol into syringe." Patient stated, ";Oh, I would never take that much." ";Patientstated that (patient) took Hyoscyamine (in Comfort Pack) the other day by mistake. Thought it was Ambien as has (patient) kept both bottles in the end table near (patients) recliner chair." ";Patient is out of Ambien and stated (patient) would call the pharmacy and arrange for refill." 11/05/2024 Skilled Nurse: ";SN (Skilled Nurse) counted Midodrine pills (for Symptomatic Orthostatic Hypotension) as Dr. (name) had requested. There were 77 pills left in a 90-tablet bottle. Patient became angry that SN (Skilled Nurse) was counting the pills and asked SN (Skilled Nurse) to leave, stating that SN (Skilled Nurse) visits are intrusive." 11/07//2024 Skilled Nurse: ";Patient is out of Lorazepam Intensol. Stated, I might have spilled some. I only take a little bit. I stick my tongue in the bottle. SN (Skilled Nurse) reinforced the correct dose of Lorazepam Intensiol and how to draw it up in the syringe. Patient stated, Oh, I wound never take that much." 11/12/2024 Skilled Nurse: ";Patient had 77 Midodrine pills on 11/5. Patient is ordered the med (medication) 3x/Day. Patient should have 56 pills in the bottle but (patient) has 68. Patient declined to have SN (Skilled Nurse) set up pill box for (patient) to be able to keep track of medication. Stated, I take the medication 3xDay the way Im supposed to. Patient angry that SN counted (patients) pills. Stated, it is intrusive. I dont need you to keep track of my medication. I can do it." The MSW (Masters Social Worker) PRN (as needed) visit notes dated 10/17/2024 and 11/08/2024 the following regarding patients safety, fall risk, and medications: 10/17/2024: Patient stated, ";(I) was cognizant of the (fall) risks. (Patient) stated (I) would not change this (to walk) regardless of suggestions, admonitions, worries of Calvary Staff." ";SW (Social Worker) shared the concerns (social worker) and nurse and PCC (Patient Care Coordinator) and doctor have about patient falling and hurting (self)." ";Pt(Patient) understood this but was clear (patient) will continue to live (patients) life (patients) way and stated (patient) is mentally competent to make own choices." ";Pt(Patient) reported my (Primary Caregiver) gave me my medications." ";(Primary Caregiver) stated (I) could manage Pts (Patients) medications and felt Pt (Patient) was safe." ";(Primary Caregiver) reported (I) could possibly be available to meet Nurse and SW (Social Worker) on Wednesday or Thursday." 11/08/2024: ";Both (Primary Caregiver) and Pt (Patient) reported they felt Pt (Patient) could care for (self) safely when alone." ";(Patient) emphasized (patient) plans to stay in (patients) home, living on his own term, for as long as possible. (Patient) said (I) accepts the risks of falling down and that if (I) wind up at the nearby (Hospital) for this reason or any other, (patient) is okay with that." ";Pt (Patient) stated to SW (Social Worker) that I do not want someone here 24/7 and (I) would not accept night time aide, if that were available to (patient). Pt (Patient) stated, and (Primary Caregiver) agreed that (patient) does not need one and is safe in the apartment. The clinical record lacks documented evidence of communication between the nurse and the social worker to discuss a joint visit as mentioned in the Social Worker visit on 10/17/2024. The Interdisciplinary Group ";Case Conference Summary" dated 10/09/2024, 10/23/2024, and 11/06/2024 lacks documented evidence of addressing/supervising the care and ongoing concerns of the patients medication management and fall risk. On 11/21/2024 at 2:25pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings. 3.Patient #6 has a Start of Care date of 09/16/2024 with diagnoses Malignant Neoplasm of Prostate, Essential (Primary) Hypertension documented in the ";Hospice Plan of Care" for Benefit Period 09/16/2024 to 12/14/2024. The ";Hospice Plan of Care" for Benefit Period 09/16/2024 to 12/14/2024 documents Skilled Nurse orders to assess/instruct pain/symptom management and medication management, and list the following pain medications: Acetaminophen 325mg capsule, take 2 capsules by mouth 3 times per day as needed for Arthritic pain and Celebrex 200mg capsule, take 1 capsule by mouth 2 times per day every day for Osteoarthritis. The SN (Skilled Nurse) Hospice Visit note dated 10/15/2024 documents: ";Current pain control measures are not effective:" ";P t(Patient) stated lower back pain can be a level 5 on pain scale 0-10, which is no longer fully alleviated w/Tylenol 325mg 3xDay PRN (as needed) and Celebrex 200mg, 1 tab in AM and 1 tab at bedtime." ";Pt and PCG requesting pain medications other than Tylenol PRN (as needed). Update provided to PCC (Patient Care Coordinator)." The clinical record lacks documented evidence of the Patient Care Coordinator documenting the communication from the Skilled Nurse requesting a change in the pain medication. The ";Hospice Plan of Care" for Benefit Period 09/16/2024 to 12/14/2024 documents Skilled Nurse orders to assess/instruct CG(Caregiver) re: supra-pubic catheter care, to observe appearance and amount of urine output, patency, and s/s of infection, to instruct CGs (Caregivers) to notify Calvary if any changes in appearance of urine, hematuria, urine output, or leakage/dislodgement catheter." The Skilled Nurse/Licensed Practical visit note dated 09/30/2024 documents: ";Concern per (caregiver) leakage around urostomy insertion site last night. Dsng (Dressing) changed. Writer observed dsng (dressing) to be clean, dry cath (catheter) exit sit presents no s/s (signs/symptoms) of inflammation. No drainage at this time. Pt is scheduled for urologist f/u (follow up) within a week per (caregiver). Report they will cont (continue) to monitor and contact urologist as needed." ";RN (Registered Nurse) PCC (Patient Care Coordinator) updated." The clinical record lacks documented evidence of the Patient Care Coordinator documenting the communication from the Skilled Nurse regarding the leakage around the urostomy insertion site. On 11/22/2024 at 1:00pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on review of the Hospice Quality Assessment and Performance Improvement (QAPI) minutes and staff interviews the hospice failed measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance. Failure to measure, analyze, and track quality indicators to include adverse patient events has the potential for negative patient outcome. The findings are: --- 1.The agency's Quality Assessment and Performance Improvement (QAPI) meeting minutes for the previous twelve months: 1st Quarter 2024, 2nd Quarter 2024, 3rd Quarter 2023, and 4th Quarter 2023 were reviewed. The meeting minutes lack documented evidence of measuring, tracking and analyzing of patient adverse events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations for each quarter. On 11/21/2024 at 11AM the Administrator, Interim Director of Patient Services, Registered Nurse Quality and the Director of Regulatory and Compliance were interviewed and did not provide an explanation for the findings. The agency's Quality Assessment and Performance Improvement (QAPI) meeting minutes for the previous twelve months: 1st Quarter 2024, 2nd Quarter 2024, 3rd Quarter 2023, and 4th Quarter 2023 were reviewed. The meeting minutes lack documented evidence of consistent measuring, tracking and analyzing of patient adverse events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations for each quarter. On 11/21/2024 at 11AM the Administrator, Interim Director of Patient Services, Registered Nurse Quality and the Director of Regulatory and Compliance were interviewed and did not provide an explanation for the findings.

Based on review of the Hospice's Board of Directors Meeting Minutes, and staff interview the Hospice failed to ensure the Hospice Board of Directors Meeting Minutes frequency and data collection were documented and approved. Failure to have documented approved Board of Directors Meeting Minutes with frequency and details of the data collected has the potential to result in the development of a QAPI program that is of insufficient scope to improve quality of care and meet the needs of the patient population and hospice operations. The findings are: --- 1.The Board of Directors Meeting Minutes for the period 11/15/2023 through 11/12/2024 were reviewed, the Meeting Minutes documents Calvary Hospital Board of Director Meeting. There is no documented evidence of Board of Director Meeting Minutes for the Hospice. On 11/22/2024 at 11:00AM the Administrator was interviewed and did not provide an explanation for the finding

Based on review of the Quality Assurance and Performance Improvement Meeting Minutes and staff interview the Hospice failed to ensure the development and documentation of Performance Improvement activities that includes focus on high risk, high volume, problem-prone areas for the prevalence, incidence, and severity of the problems. Failure to develop, implement, and document active ongoing Performance Improvement activities has the potential for negative outcomes. The findings are: --- 1.The Hospice Quality Assurance Performance Improvement Meeting Minutes for the1st Quarter 2024, 2nd Quarter 2024, 3rd Quarter 2023, and 4th Quarter 2023 were reviewed. There is no documented evidence of active ongoing Performance Improvement Activities that identify and focus on high risk, high volume, or problem prone areas. On 11/21/24 at 11:30 Am the Administrator Interim Director of Patient Services, Registered Nurse Quality and the Director of Regulatory and Compliance were interviewed and did not provide an explanation for the findings.

Based on review of the hospice's Quality Assurance and Performance Improvement (QAPI) Program and activities for the period November 2023 through November 2024, the hospice failed to document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved. Failure to ensure Performance Improvement Projects are being conducted, reason for conducting the projects, and progress achieved has the potential for negative outcome. The findings are: --- 1.The Hospice Quality Assurance Performance Improvement Meeting Minutes for the1st Quarter 2024, 2nd Quarter 2024, 3rd Quarter 2023, and 4th Quarter 2023 were reviewed. The Quality Assurance Performance Improvement Meeting Minutes lacks documented evidence of an active ongoing Performance Improvement Project. On 11/21/24 at 11:30AM the Administrator Interim Director of Patient Services, Registered Nurse Quality and the Director of Regulatory and Compliance were interviewed. The Registered Nurse Quality stated we have a performance Improvement project (Wound and Assessments) that are being reviewed and will be implemented.

Based on review of the agency's Board of Directors Meeting Minutes for the period 11/15/2023 through 11/12/2024 and staff interview the Hospice failed to ensure an ongoing Quality Assurance and Performance Improvement (QAPI) program is defined and evaluated annually. Failure to ensure an ongoing Quality Assurance and Performance Improvement program is defined and evaluated annually has the potential to result in negative patient outcomes and adversely affect organizational operations. The findings are: --- The Board of Directors Meeting Minutes for the period 11/15/2023 through 11/12/2024 lack documented evidence of a Quality Assurance and Performance Improvement plan that is defined and evaluated annually. On 11/22/24 at 11:30AM the Administrator Interim Director of Patient Services, Registered Nurse Quality and the Director of Regulatory and Compliance were interviewed and did not provide an explanation for the finding.

Based on review of the hospice's Quality Assurance and Performance Improvement (QAPI) activities for 2023, and the hospice's infection control program the hospice failed to ensure the development of a comprehensive infection control program. Failure to ensure the development of a comprehensive infection control program and ensure it is an integral part of the hospice's QAPI program has the potential for negative patient outcomes. The findings are: --- The Hospice presented policies for review on 11/22/24 titled:" Calvary Hospital Infection Control Risk Assessment- 2024, and Calvary Hospital Influenza Vaccination Policy and Management Plan" The Hospice lacks a comprehensive infection Control Policy to include protocols for the prevention from Infusion therapy, Urinary tract infection, Wound care, Multidrug resistant organism, Blood borne pathogens, evidence of staff monitoring for compliance with policies and procedures, protocol for educating (contract and volunteer), patient, family, and other caregiver education, evidence of a specific program for protecting patients, and families for bi-directional spread of blood borne pathogens, transmission of infectious agents in all settings where patients reside (home, inpatient, Skilled Nursing Facilities, Assisted Living Facilities). There is no documented comprehensive infection control policy that is specific for Calvary Home Health Agency and Hospice Care. On 11/22/24 at 11:30AM the Administrator Interim Director of Patient Services, Registered Nurse Quality and the Director of Regulatory and Compliance were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview, the hospice failed to ensure the nursing needs and interventions for the patient are met/ provided as identified in the assessments. This was evident for two (2) of twenty-nine (29) clinical records reviewed. (Patients #7 and #21). Failure to ensure the nursing needs of the patients identified in the assessments are met/ provided has the potential for negative patient outcome. The findings are: --- 1.Patient #7 has a Start of Care date of 08/29/2024 with the following diagnoses "Moderate Protein – Calorie Malnutrition, Unspecified Fracture of Sacrum" documented in the Hospice Plan of Care for the Certification Period 08/29/2024 to 11/26/2024. The Orders dated 08/29/2024 documents: ";SN (skilled nurse) 1 week1, 1-2 week 12 (one to two times a week for twelve weeks), 1 week 1, 6 as needed." The SN (Skilled Nurse) Hospice Visit dated 09/23/2024, 09/30/2024, and 10/08/2024 documents: all care plan intervention as Not Performed. The clinical record lacks documented evidence of the nursing care being provided on 09/23/2024, 09/30/2024, and 10/08/2024. On 11/21/2024 at 02:30pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 2. Patient #21 has a Start of Care date of 07/05/2024 with the following diagnoses "Parkinsons Disease, Moderate Protein – Calorie Malnutrition " documented in the Hospice Plan of Care for the Certification Period 09/03/2024 to 11/01/2024. The Hospice Plan of Care for the Certification Period 09/03/2024 to 11/01/2024 documents: ";SN (skilled nurse) 1 week 8 (once a week for eight weeks), 6 as needed." The SN (Skilled Nurse) Hospice Visit dated 09/05/2024, 09/16/2024, 10/01/2024, and 10/30/2024 documents: all care plan intervention as Not Performed. The clinical record lacks documented evidence of the nursing care being provided on 09/05/2024, 09/16/2024, 10/01/2024, and 10/30/2024. On 11/21/2024 at 02:30pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure the Hospice Aide receive complete written patient care instructions prepared by a Registered Nurse. This is evident for one (1) of twenty-nine (29) clinical records reviewed (Patient # 3). Failure to ensure all Hospice Aides receive complete written patient specific care instructions prepared by a Registered Nurse has the potential for negative patient outcome. The findings are: --- 1.Patient #3 has a Start of Care date of 07/11/2024, Discharge Date of 08/15/2024, with diagnoses Malignant Neoplasm of Pancreas, Unspecified, Liver Cell Carcinoma documented in the ";Hospice Plan of Care" for Certification Period 07/11/2024 to 10/08/2024. The Physicians Order dated 08/07/2024 documents the following orders for Hospice Aide/Home Health Aide services: Begin Date 08/09/2024; 1 Week 1 (one visit a week for one week); 3 Week 8 (three visits a week for eight weeks) and 1 Week 1 to assist patient with personal care, ADLs (Activities of Daily Living)/IADLs (Instrumental Activities of Daily Living). The Electronic Duty Sheet for 8/12/2024 – 8/18/2024 documents the Home Health Aide provided services on 08/12/2024. The clinical record lacks documented evidence of the registered nurse preparing written patient care instructions for the Home Health Aide (Hospice Aide). On 11/21/2024 at 2:25pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and staff interview the hospice failed to provide aide services as identified in the aide care plan (POC). This was evident for two (2) of twenty-nine (29) clinical records reviewed (Patient: #15 and #16). Failure to ensure to provide aide services as identified in the aide care plan has the potential for negative patient outcomes. The findings are: --- 2.Patient #16 has a Start of Care date of 10/03/2024 with the following diagnoses "Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Bening Prostatic Hyperplasia without Lower Urinary Trac Symptoms" documented on the Hospice Plan of Care for the Certification Period 10/03/2024 to 12/31/2025. The Duty Sheet documents: task 480 "Turning and Positioning" services being performed by the aides on 10/24/2024, 10/30/2024, 10/31/2024 and 11/04/2024. The Duty Sheet documents: task 862 "Bleeding Precaution" services being performed by the aides from 10/08/2024 to 10/25/2024, 10/28/2024, 10/29/2024, 11/05/2024 to 11/2024 and from 11/13/2024 to 11/15/2024. The Hospice Aide Care Plan dated 10/08/2024 does not include documented evidence of the need for the aides to perform a task: 480: "Turning and Positioning" and 862 "Bleeding Precaution". There is no documented evidence of the aides providing patient care services in accordance with the Hospice Aide Plan of Care. On 11/21/2024 at 02:30 pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings. 1.Patient #15 has a Start of Care date of 07/05/2024 with the following diagnosis " Malignant Neoplasm Of Unspecified Site Of Unspecified Female Breast" documented on the Hospice Certification and Plan of Care for the Certification Period 09/03/2024 to 11/01/2024. The order dated 09/03/2024 documents: ";HA (Hospice Aide) 4 week 1 (four times a week for a week, 5 week 8 (five times a week for eight weeks); 5 days x 4hours." The Duty Sheet documents the following task being provided: Passive ROM (Range Of Motion) on 09/3/2024 to 09/06/24, 09/10/24 to 9/13/24, 09/16/24-09/18/24. These tasks are not on the Hospice Aide Care Plan dated 07/05/24. The SN (Skilled Nurse) Hospice Visit dated 09/09/2024 documents: ";Ambulation: unable" The Duty Sheet documents the following task being provided: Ambulation on 09/3/2024 to 09/06/24, 09/10/24, 09/12/24, and 9/13/24, 09/16/24-09/18/24. These tasks are not on the Hospice Aide Care Plan. The clinical care record lacks documented evidence of the aide providing services as specified in the Hospice Aide Care Plan dated 07/05/24. On 11/21/2024 at 02:30pm, the Administrator, the Interim Director of Patient Services, the Director of Regulatory Compliance, and other staff were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure the patient/ family/ caregiver are capable of safely administering the drugs and biologicals in the home. This was evident for one (1) of twenty-nine (29) clinical records reviewed. (Patient #4). Failure to ensure the safe administration of drugs/ biologicals has the potential for negative patient outcome. The findings are: --- 1.Patient #4 has a Start of Care date of 08/25/2024 with diagnoses Malignant Carcinoid Tumors of Other Sites, Chronic Kidney Disease, Atherosclerotic Heart Pancreas of Native Coronary Artery Without Angina Pectoris documented in the ";Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024. The "Hospice Plan of Care" for Certification Period 08/25/2024 to 11/22/2024 documents orders for the Skilled Nurse to assess/instruct on medication management. The Skilled Nurse and Social Worker visit notes document the following regarding the patients medication management and the ability to self-administer medications: 10/10/2024 Skilled Nurse: Patient is ";using an insulin syringe to give (self) 3 units of Morphine concentrate; 8 ml of Morphine left from a 15 ml bottle. SN (Skilled Nurse) apprised patient that (patient) does not have a doctors order for Morphine;" ";Patient stated that (patient) has been licking the Lorazepam liquid because (patient) has been having breakthrough seizures and I spilled most of the liquid in that bottle. Lorazepam Intensol bottle empty. SN (Skilled Nurse) informed patient that (patients) Lorazepam Intensol is for 2mg daily as needed for seizures and patient stated, I would never take that much Lorazepam – it is too much.' SN (Skilled Nurse) called PCC (Patient Care Coordinator) to inform (Patient Care Coordinator) that patient has been using Morphine without doctors orders" and ";that patient has been using Lorazepam Intensol but not using it as ordered." 10/26/2024 Skilled Nurse: ";Pt (Patient) c/o (complained of) headache worsening pain to side, back pain, no injuries noted, tenderness to left side, pain 6.5/10 – Pt (Patient) refusing pain medications." 11/02/2024 Skilled Nurse: "Patient had a seizure this morning. Gave (self) 'a little bit of Lorazepam.' SN (Skilled Nurse) instructed patient in how to draw up 2mg of Lorazepam Intensol into syringe." Patient stated, ";Oh, I would never take that much." ";Patient stated that (patient) took Hyoscyamine (in Comfort Pack) the other day by mistake. Thought it was Ambien as has (patient) kept both bottles in the end table near (patients) recliner chair." ";Patient is out of Ambien and stated (patient) would call the pharmacy and arrange for refill." 11/05/2024 Skilled Nurse: ";SN (Skilled Nurse) counted Midodrine pills (for Symptomatic Orthostatic Hypotension) as Dr. (name) had requested. There were 77 pills left in a 90-tablet bottle. Patient became angry that SN (Skilled Nurse) was counting the pills and asked SN (Skilled Nurse) to leave, stating that SN (Skilled Nurse) visits are intrusive." 11/07//2024 Skilled Nurse: ";Patient is out of Lorazepam Intensol. Stated, I might have spilled some. I only take a little bit. I stick my tongue in the bottle. SN (Skilled Nurse) reinforced the correct dose of Lorazepam Intensiol and how to draw it up in the syringe. Patient stated, Oh, I wound never take that much." 11/12/2024 Skilled Nurse: ";Patient had 77 Midodrine pills on 11/5. Patient is ordered the med (medication) 3x/Day. Patient should have 56 pills in the bottle but (patient) has 68. Patient declined to have SN (Skilled Nurse) set up pill box for (patient) to be able to keep track of medication. Stated, I take the medication 3xDay the way Im supposed to. Patient angry that SN counted (patients) pills. Stated, it is intrusive. I dont need you to keep track of my medication. I can do it." The MSW (Masters Social Worker) PRN (as needed) visit notes dated 10/17/2024 and 11/08/2024 the following regarding patients medication management: 10/17/2024: Patient stated, ";Pt (Patient) reported my (Primary Caregiver) gave me my medications." ";(Primary Caregiver) stated (I) could manage Pts (Patients) medications and felt Pt (Patient) was safe." ";(Primary Caregiver) reported (I) could possibly be available to meet Nurse and SW (Social Worker) on Wednesday or Thursday." 11/08/2024: ";Both (Primary Caregiver) and Pt (Patient) reported they felt Pt (Patient) could care for (self) safely when alone." ";pt (Patient) reported that (patients) medications can leave (patient) feeling disoriented and confused. (Patient) gave example of going out to sit on the stoop, not realizing (patient) had not dressed (self) and was only in (patients) boxer shorts." ";Pt (Patient) stated to SW (Social Worker) that I do not want someone here 24/7 and (I) would not accept night time aide, if that were available to (patient). Pt (Patient) stated, and (Primary Caregiver) agreed that (patient) does not need one and is safe in the apartment. The clinical record lacks documented evidence of a joint skilled nurse and social worker visit with the patients primary caregiver, as discussed by the Social Worker on 10/17/2024. The Hospice Plan of Care lacks documented evidence of addressing the patients ability to safely self-administer drugs in the home. On 11/22/2024 at 1:00pm, the Senior Vice President/Hospice Administrator, the Interim Director of Patient Services, Director of Regulatory and Compliance, and other staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record, review of complaint log, and staff interview the Hospice failed to ensure that all patient/caregiver complaints are documented, investigated and resolved as per the hospice's policy and procedures. This was evident for three (3) of three (3) clinical records reviewed (Patients #1, #2, and 3). Failure to ensure all patient/caregivers complaints are investigated and resolved has the potential for negative patient outcomes. The findings are: --- 3.Patient #3 has a Start of Care (SOC) date of 01/25/24 with diagnoses including Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Bone documented in the Hospice Plan of Care for Certification Period 01/25/24 to 03/24/24. The E-Mail (Electronic Mail) from Patient #3 s spouse to Social Worker dated 02/13/24; Titled: "Patient #3 s name" documents: ";If no one will explore a long-lasting anti-anxiety med, which Ive asked to be considered, Ive asked that Ativan be given every 4 hours as the doctor instructed. I dont know that he is getting it rather than having to ask for it. I am not sure why he should have to ask for something that keeps him calm, unagitated and helps him accept what is happening to him. If he is not in stable frame of mind, he wont remember to ask. Ive asked that this behavior be evaluated as it is most definitely related to cancer and his denial of death. ... I am not sure why his extreme anxiety is being left untreated when I am sure there must be a long lasting medication beside Ativan that would keep him calm and untraumatized by what is happening to him." There is no documented evidence that the hospice investigated the 2/13/24 complaint. The clinical record lacked documented evidence of all complaints being investigated with a resolution and response within fifteen (15) days. On 6/14/24 the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings. The agency's "Complaint Resolution Policy # AD.C15 documents: ";Agency name has a complaint resolution process that is implemented whenever a complaint is received. Appropriate personnel conduct a documented investigation of all written or verbal complaints received by the hospice within 5 days. The person filing the complaint will be provided information as to the status of the complaint investigation process within 10 days." The agencys Patients Rights and responsibilities: Patient /Family Bill of Rights documents: ";Each patient and family has the right to complain without fear of reprisal about the care and service. Hospice will respond in writing per your request or in response to a written complaint or grievance within 15 days of receipt. 1.Patient #1 has a Start of Care date of 5/15/24, discharge -death 5/23/24 with diagnosis ";Alzheimers Disease, Unspecified, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Unspecified Site, Unspecified Stage" documented on the Hospice Plan of Care for Certification Period 5/15/24 -08/12/24. The fax encounter dated 05/23/24 documents: Orders only date of service: 05/23/24:05:05 Note Type: Home Care Agencys Name: Facility: Attending Physicians Name: Practice: You have utterly failed to provide good care. You have provided thoughtless care and failed to communicate. You are giving an 85-year-old with Alzheimers disease and noncancer pain 180mg of morphine per day and thats insane." There is no documented evidence of Patient #1 receiving 180 mg of Morphine per day. There is no documented evidence of this complaint in the log and there is no documented evidence of a complaint investigation with resolution for Patient #1. On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings. 2.Patient # 2 has a Start of Care date of 2/24/24 discharge -death 2/24/24 with diagnoses ";Malignant Neoplasm of Unspecified part of Unspecified Bronchus or Lung, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Secondary Malignant Neoplasm of Brain, Essential (Primary) Hypertension" documented on the Hospice Plan of Care for Certification Period 02/24/24 -05/23/24. The email 2/25/24 12:52PM documents: ";Subject: Patient#1. The wife called several times today 2/25/24. She is infuriated with the service provided by our hospice organization." The agencys Case Communication Report documents: "Type: Case Communication General: Entered: 02/26/2024 4:53PM DPS (Director of Patient Services) spoke with spouse regarding her concerns about medication delivery and O2 face mask. DPS (Director of Patient Services) following up regarding her concerns and will review with quality Director for evaluation. Spouse request a call back shortly. DPS (Director of Patient Services) made several attempts to return call with no answer. Will follow up again tomorrow." There is not documented evidence of the 2/25/24 complaint in the complaint log. On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure all patients choice of attending physicians are included in providing and managing the patients care. This was evident for one (1) of three (3) clinical records reviewed. Patient #1. Failure to ensure that all chosen non-hospice attending physicians are involved in the collaboration of the patients medical care has the potential for negative patient outcome. The findings are: --- 1.Patient #1 has a Start of Care date of 5/15/24, discharge -death 5/23/24 with diagnoses ";Alzheimers Disease, Unspecified, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Unspecified Site, Unspecified Stage" documented on the Hospice Plan of Care for Certification Period 5/15/24 -08/12/24. The Attending Physicians Policy# PC. A45 documents: ";Hospice patients have the right to choose an attending physician to provide initial and ongoing management of the medical component of the patients care. The patients attending physician is responsible for management of the patients medical care: Signing the initial Certificate of Terminal Illness: consulting with the IDG (Interdisciplinary Group): participating in the development and review of the plan of care: providing verbal and signed orders: The hospice nurse notifies the attending physician of all changes in the patients condition. Consultation with the attending physician is documented in the clinical record." The Skilled Nurse Hospice Visit dated 5/17/24 documents: ";Effectiveness of current pain control measures: Current Pain Control Measures are not effective: Current Pain Meds: increased Morphine 10mg every 2 hours as needed: Patient is declining, daughters' reports increase pain, not relieved with current dose of morphine NP (Nurse Practitioner) called Morphine increased to 10 mg every 2 hours as needed." The Case communication Report documents: ";Instruct on dietary measures: 5/17/24: Not performed: Family reports patient unable to swallow any longer." 5/22/24: "Not performed: Patient is now NPO (Nothing by mouth), family understands patient is unable to swallow and does not need anything by mouth. Patient has had nothing by mouth since last Friday 5/17." The clinical record documents two fax from the attending physician dated 5/23/24: ";Orders Only: Case Review: Send plan of care for MD (Medical Doctor) review and approval. The clinical record lacks documented evidence of the interdisciplinary team involving the patients chosen attending physician in the collaboration and management of the patients medical care. On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings.

Based on clinical record reviews and staff interview, the hospice failed to ensure the patients individualized plan of care is established by the hospice interdisciplinary group in collaboration with the attending physician. This was evident for two (2) of three (3) clinical records reviewed (Patient#1 and #3). Failure to ensure the plan of care is established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative and the primary caregiver, has the potential for negative patient outcome. The findings are: --- 2.Patient #3 has a Start of Care date of 01/25/24 with diagnoses of ";Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Bone" documented in the Hospice Plan of Care for Certification Periods 01/25/24 – 03/24/24 and 03/25/24 to 05/23/24. The Hospice Plan of Care dated 01/25/24 to 03/24/24 documents: ";01/25/24 to 03/24/24 – MD (Medical Doctor) 3 as needed (three visits as needed). Hospice Physician to visit as needed to assess and manage potential exacerbation of symptoms relating to anticipated changes/decline in patients health connected to terminal illness. The SN (Skilled Nurse) Hospice Inpatient Visit note dated 02/14/24 documents: ";Nurse Name" reports patient tried to elope yesterday. He packed his bags and walked down the hall. Was agitated and upset when stopped from leaving. Patient was crying, restless and agitated yesterday as per ";Nurse Name". Patient asked for IV (intravenous) push of Lorazepam because he prefers how it feels." The E-Mail (Electronic Mail) from Social Worker to Patient #3 s spouse dated 02/20/24 documents:" I forwarded your questions on, and I am hopeful that there will be a cogent response soon. If you are in the hospital during the day, you can certainly ask for clarification ... for the results of the psychiatric consult." The IDT (Interdisciplinary Team) meeting minutes dated 2/14/24 and 2/28/24 lacks documented evidence of the interdisciplinary team discussing and including interventions specific for the management of the patients needs. The clinical lacks documented evidence of the interdisciplinary team collaborating with the physician regarding the changes in the patients behavior and for a review of the patients medication (Lorazepam) The clinical record lacks documented evidence of the social worker including and informing the interdisciplinary team regarding the family needs for clarification of the psychiatric consult. The Orders dated 4/05/24 documents: ";For Order: HA (Home Aide) 4-week 1 (four visits a week for one week), 5 week 5 (five visits a week for five weeks), 4 week 1(four visits a week for one week) Home Health Aide to assist with Personal Care, ADLs (Activities of Daily Living)/ IADLs (Instrumental Activities of Daily Living). Goal: Personal care needs met with assistance of Home Health Aide 5 days 4 hours. Begin Date: 4/09/24, Discontinue: 5/08/24." The Duty Sheets documents Home Health Aide services being provided on 4/9 - 4/12, 4/15- 4/19, 4/22 - 4/26, and 5/6-5/8/24. The clinical record lacks documented evidence of a written individualized plan of care established by the interdisciplinary team with task, frequency and instructions for the patient. On 06/14/24 at 10:34 am, the Administrator/Director of Patient Services was interviewed and stated, "there is no Paraprofessional Care Plan available." No additional information was provided. 1.Patient #1 has a Start of Care date of 5/15/24, discharge- death date 5/23/24 with diagnosis ";Alzheimers Disease, Unspecified, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Unspecified Site, Unspecified Stage" documented on the Hospice Plan of Care for Certification Period 5/15/24 -08/12/24. The fax dated 5/13/2024 documents: ";New referral": Electronically signed by Name MD (Medical Doctor) at 05/13/2024 04:04:22PM: Orders Only: Home Care: Agency Name: End Stage Alzheimers Disease: Pressure Ulcer: Constipation: Multiple Contractures: Do not deliver a ";comfort Pack": Medications: Miralax 17gm orally: Senna syrup 10 ml orally daily: Tylenol adult liquid 30 ml orally twice daily: Morphine concentrate 20mg/ml 0.25 ml SL every 4 hours as needed for pain. Do not provide pink tubes of saline for nebulization, Wound care: Please provide spray wound wash: Use wound wash, (not saline) if wound wash not available, then bar Ivory soap and water to irrigate ulcer every 3 days. Pat dry. Double layer Alginate lay over ulcer. Cover with Allevyn. Low air mattress Group 2 mattress. Please send me a photo of the ulcer at first visit. "; The Hospice Plan of Care for Certification Period: 05/15/2024 to 08/12/2024 documents: Medications: Senna 8.6 mg tablet take 22 tabs by oral route bedtime: Comfort Pack as directed by Hospice 1 comfort Pack: Medications Present In Comfort Pack To Be Used As Directed By Hospice Staff. Morphine 20 mg/ml take .25 ml by oral route every 4 hours as needed reason: pain/SOB (shortness of breath) Administer 0.25ml = 5mg by mouth every 4 hours as needed for pain: Morphine 20/ml take 0.5 ml by buccal route every 2 hours as needed reason: pain/SOB (shortness of breath). DME (Durable Medical Equipment) and Supplies: hospital bed. There is no documented evidence of the physicians wound care orders in the Hospice Plan of Care. There is no documented evidence of the medication: "Tylenol adult liquid 30 ml orally twice daily." The SN (Skilled Hospice Visit 5/20/2024 documents: The following medications is documented as being administered to the patient from the Comfort Pack documented in the Hospice Plan of Care: ";Pt (Patient is currently getting Lorazepam 0.5mg orally Q 6 hrs PRN (every six hours as needed). Hyoscyamine tab Q4 hrs PRN (every four hours as needed) moist congestion noted." Two faxes from the attending physician dated 5/23/24 documents: ";Order Only: Case Review: Send plan of care for MD (Medical Doctor) review and approval. I have not received hospice orders or a certificate of terminal illness. I have not received a second pressure ulcer photo promised by the nurse. Where is the plan of care. She can not stay on an egg crate overlay. I requested a group 2 mattress on my referral 5/13." The clinical record lacks documented evidence of an individualized written plan of care established by the interdisciplinary team in collaboration with the attending physician in accordance with the patients needs and signature of the Certificate of Terminal illness prior to 5/23/24. The clinical record lacks documented evidence of the interdisciplinary team collaborating with the attending physician regarding the ordering and administering of medications from the comfort pack. On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure that the content of each patient's Plan of Care includes the scope and frequency of services to be provided to meet each patient's individualized needs. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure that each patient's Plan of Care includes the frequency and scope of services necessary to meet their specific needs has the potential for negative outcomes. The findings are: --- 1.Patient #1 has a Start of Care date of 5/16/24 and discharge-death of 5/23/24 with diagnoses ";Alzheimers Disease, Unspecified, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Unspecified Site, Unspecified Stage" documented on the Hospice Plan of Care for Certification Period 5/15/24 -08/12/24. The fax from patients attending (Name) documents: ";Orders Only: To: Agency (Name): Home Care: Subject: New Referral: Date: 05/13/2024: 04:22PM: Pressure Ulcer Sacrum unstageable 4cm 2cm x 1cm. Wound care: Please; provide spray wound wash (not saline) and if wound wash not available, then use bar ivory soap and water to irrigate ulcer every 3 days. Pat dry. The agencys Hospice Plan of Care for Certification Period 5/15/24 -08/12/24 documents: ";Problem: Alteration in skin integrity: CG (Care giver) will demonstrate correct procedure for wound care. The 5/22/24 Case Conference Summary (Interdisciplinary Team) documents: Care Plan Items: Alteration in skin integrity: Perform Wound Care/ Assess Wound: Intervention: Dates: 5/20, 5/20, (two visits on 5/20 one Registered Nurse, and one License Practical Nurse visit) Not performed, 5/21 not performed. The Hospice Plan of Care lacks documented evidence of the frequency and treatment for wound care (pressure ulcer). On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure the Plan of Care included the necessary equipment to meet the management of the patients needs. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure the Plan of Care includes all necessary equipment to manage the patient's terminal illness and related condition has the potential for negative patient outcome. The findings are: --- 1.Patient #1 has a Start of Care date of 5/15/24 and discharge- death 5/23/24 with diagnoses ";Alzheimers Disease, Unspecified, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Unspecified Site, Unspecified Stage" documented on the Hospice Plan of Care for Certification Period 5/15/24 -08/12/24. The fax from patients attending (Name) documents: ";Orders Only: To: Agency (Name): Home Care: Subject: New Referral: Date: 05/13/2024: 04:22PM: Pressure Ulcer Sacrum unstageable 4cm 2cm x 1cm." "Low air loss mattress Group 2 mattress." The Hospice Plan of Care for Certification Period 5/15/24 -08/12/24 documents: DME and Supplies: hospital bed." The fax dated 5/23/24 documents: Attending Physicians name: To: Name Hospice: Subject: Patient#1: She can not stay on an egg crate overlay. I requested a group 2 mattress on my referral 5/13. The clinical record lacks documented evidence of the Low air loss mattress Group 2 mattress being included in the plan of care. On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings.

Based on clinical record review and staff interview, the hospice failed to ensure that the IDG (Interdisciplinary Group) review and revise the plan of care in collaboration with the attending physician as frequently as the patients condition requires. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure that IDG (Interdisciplinary Group) review, revise, and document changes in the plan of care as frequently as the patients condition requires has the potential for negative patient outcome. The findings are: --- 1.Patient #1 has a Start of Care date of 5/16/24 and discharge-death of 5/23/24 with diagnoses ";Alzheimers Disease, Unspecified, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Unspecified Site, Unspecified Stage" documented on the Hospice Plan of Care for Certification Period 5/15/24 -08/12/24. The Case communication Report dated 5/16/24 documents: ";Patient caregiver reports pain when moving in bed, asked to start Morphine. Morphine 0.25 ml administered to patient." The Skilled Nurse Hospice Visit dated 5/17/24 documents: ";Effectiveness of current pain control measures: Current Pain Control Measures are not effective: Current Pain Meds: increased Morphine 10mg every 2 hours as needed: Patient is declining, daughter reports increase pain, not relieved with current dose of morphine NP (Nurse Practitioner) called Morphine increased to 10 mg every 2 hours as needed." The Case communication Report documents: ";Instruct on dietary measures: 5/17/24: "Not performed: Family reports patient unable to swallow any longer." 5/22/24: "Not performed: Patient is now NPO (Nothing by mouth), family understands patient is unable to swallow and does not need anything by mouth. Patient has had nothing by mouth since last Friday 5/17." The clinical record documents two faxes from the attending physician dated 5/23/24 documents: ";Orders Only: Case Review: Send plan of care for MD (Medical Doctor) review and approval. I have not received hospice orders or a certificate of terminal illness. I have not received a second pressure ulcer photo promised by the nurse. Where is the plan of care. She (patient) can not stay on an egg crate overlay. I requested a group 2 mattress on my referral 5/13." The clinical record lacks documented evidence of the interdisciplinary team collaborating with the attending physician, revising, reviewing, and documenting the patient's changing conditions as frequently as needed in the plan of care. On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure that there is coordinated and effective sharing of information amongst and between all disciplines in all settings. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure a system of communication and an ongoing sharing of information between all disciplines and in all settings has the potential for negative patient outcome. The findings are: --- 1.Patient #1 has a Start of Care date of 5/15/24 and discharge-death 5/23/24 with diagnoses ";Alzheimers Disease, Unspecified, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Unspecified Site, Unspecified Stage" documented on the Hospice Plan of Care for Certification Period 5/15/24 -08/12/24. The agencys Coordination of Services Policy # PC.C45 documents: ";The IDG (Interdisciplinary Group) ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers and in all settings." The clinical record documents the following from two faxes dated 5/23/24 sent by the attending physician: ";Orders Only: Case Review: Send plan of care for MD (Medical Doctor) review and approval. I have not received hospice orders or a certificate of terminal illness. I have not received a second pressure ulcer photo promised by the nurse. Where is the plan of care. The clinical record lacks documented evidence of the hospices interdisciplinary team ensuring a system of communication, effective and ongoing coordination of services for all patients. On 6/13/24 at 3:45PM the Administrator/Director of Patient Services and Director of Regulatory and Compliance were interviewed and did not provide and explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure that all Hospice Aides received complete written patient care instructions prepared by a Registered Nurse (RN). This is evident for one (1) of three (3) clinical records reviewed. (Patient #3). Failure to ensure all Hospice Aides receive complete written patient care instructions prepared by a Registered Nurse (RN) has the potential for negative outcomes. The findings are: --- 1.Patient #3 has a Start of Care (SOC) date of 01/25/24 with diagnoses "Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Bone" documented in the Hospice Plan of Care for Certification Period 03/25/24 to 05/23/24. The Orders dated 4/05/24 documents "Home Health Aide: For Order: HA (Home Aide) 4 week 1 (four visits a week for one week), 5 week 5 (five visits a week for five weeks), 4 week 1(four visits a week for one week) Home Health Aide to assist with Personal Care, ADLs (Activities of Daily Living)/ IADLs (Instrumental Activities of Daily Living). Goal: Personal care needs met with assistance of Home Health Aide 5 days 4 hours. Begin Date: 4/09/24, Discontinue: 5/08/24." The Duty Sheets documents Home Health Aide services being provided on 4/9 - 4/12, 4/15- 4/19, 4/22 – 4/26, and 5/6-5/8/24. The Duty Sheets documents: Pre-pour Medication, Assess Vital Signs on 04/10/2024, Evaluation of Patient on 04/12/2024, Infant Care on 05/06/24. The clinical record lacks documented evidence of an individualized home health aide plan of care with clear, concise, and accurate instructions for task that are specific to the care of the patient. On 06/14/24 at 10:34 am, the Administrator/Director of Patient Services was interviewed and stated, "there is no Paraprofessional Care Plan available."

Based on clinical record review and staff interview the hospice failed to ensure that the hospice aide is adequately supervised by the Registered Nurse and services ordered by the interdisciplinary team is adequately furnished by the hospice aide to meet the specific needs of the patient. This was evident for one (1) of three (3) clinical records reviewed (Patient #3). Failure to ensure the Registered Nurse supervise the hospice aide to ensure services ordered by the interdisciplinary team are adequately furnished by the hospice aide to meet the specific needs of the patient has the potential for negative patient outcome. The findings are: --- 1.Patient #3 has a Start of Care (SOC) date of 01/25/24 with diagnoses" Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Bone documented in the Hospice Plan of Care for Certification Period 03/25/24 to 05/23/24. The Orders dated 4/05/24 documents: ";For Order: HA (Home Aide) 4 week 1 (four visits a week for one week), 5-week 5 (five visits a week for five weeks), 4 week 1(four visits a week for one week) Home Health Aide to assist with Personal Care, ADLs (Activities of Daily Living)/ IADLs (Instrumental Activities of Daily Living). Goal: Personal care needs met with assistance of Home Health Aide 5 days 4 hours. Begin Date: 4/09/24, Discontinue: 5/08/24." The clinical record documents the Registered Nurse supervisory visits on the following dates: 4/9, 4/17, 4/23, 4/26, 5/6. The Duty Sheets documents: Pre-pour Medication, Assess Vital Signs on 04/10/2024, Evaluation of Patient on 04/12/2024, Infant Care on 05/06/24. The clinical record lacks documented evidence of the Registered Nurse adequately supervising the tasks being provided and documented on the hospice aides duty sheet. The clinical record lacks documented evidence of the Registered Nurse ensuring that the hospice aide provided services that are specific to the patient. On 06/14/24 at 10:34 am, the Administrator/Director of Patient Services was interviewed and stated, ";there is no Paraprofessional Care Plan available."

Based on clinical record review, and staff interviews, the hospice failed to ensure that all comprehensive assessments are updated. This was evident for one (1) of twenty (20) clinical care records reviewed (Patient #5). Failure to ensure that all comprehensive assessments are updated, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #5 has a Start of Care date of 10/18/2022 with the diagnoses ";Heart Disease Unspecified" and ";Chronic Obstructive Pulmonary Disease Unspecified" documented in the Hospice Plan of Care dated 10/18/2022 to 12/16/2022. The initial RN comprehensive assessment visit note dated 10/18/2022 documents: ";Skin integrity: intact; thin, frail dry." The LPN SN Hospice Visit note dated 10/26/2022 documents: ";Skin clean, intact with exception of small escoriated (excoriated) area to buttock;" and ";IDT communication" with ";RN." The RN SN Hospice Visit noted dated 10/27/2022 documents: Skin integrity ";wound decubitus (go to wound addendum);" ";CG (Caregiver) reports she changed drsg (dressing) to resolving stage 2 pressure ulcer to sacrum this AM. Declined writer to assess; reports area now mildly red." The SN visit note lacks documentation of the ";wound addendum." The RN Hospice Visit noted dated 11/4/2022 documents: Skin integrity, ";Patient does not have integrity issues at this time;" ";(Caregiver) reports stage 2 pressure ulcer to lower sacral has resolved." The clinical records lack documented evidence of the RN updating the comprehensive assessment a complete a skin and wound assessment of the sacral stage 2 pressure ulcer, including wound measurement and characteristics. On 11/17/2022 at 3:30 PM, the Administrator, the Vice President of Community Patient Services, and the Director of Patient Services were interviewed and did not provide an explanation for the findings. .

Based on clinical record review and staff interview, the Hospice failed to ensure that all Plan of Care specify the care necessary to meet the patient and family-specific needs identified in the comprehensive assessment. This was evident for three (3) of twenty (20) clinical records reviewed (Patient #4, #6, and #7). Failure to ensure that patients have a complete Plan of Care, has potential for negative patient outcomes. The Findings Are: --- 1. Patient #4 has a Start of Care date of 10/24/2022 with the diagnosis ";Malignant Neoplasm of Unspecified Main Bronchus" documented in the Hospice Plan of Care dated 10/24/2022 to 1/21/2023. The RN initial comprehensive assessment visit note dated 10/24/2022 documents: Respiratory, ";shortness of breath;" ";Type of treatment of Dyspnea: Oxygen;" Oxygen Use, ";Continuous Oxygen 02 Flow Rate (LPM (liters per minute)) 4;" ";O2 via Nasal Cannula; notes: pt refuses O2 at night." The Hospice Plan of Care dated 10/24/2022 to 1/21/2023 documents: ";Problem: Dyspnea; Goal: Relief of breathing discomfort using O2." The Hospice Plan of Care lacks documented evidence the patients Oxygen use as specified in the comprehensive assessment, continuous O2 4 liters per minute and refuses O2 at night. On 11/16/2022 at 3:00 PM, the Administrator and the Vice President of Community Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 10/20/2022 with the diagnosis ";Nutritional Deficiency, Unspecified" documented in the Hospice Plan of Care dated 10/20/2022 to 1/17/2023. The RN initial comprehensive assessment visit note dated 10/20/2022 documents: ";LCW (Left Chest Wall) with open skin lesion – pt (patient) refused to biopsy and lesion coverage." The SN Hospice Visit note dated 10/24/2022 documents: ";Left CW has a lesion that DIL (daughter in-law) said is probably cancerous, but that patient chose to ignore. Small amount of serosanguinous fluid from lesion. DSD (Dry sterile dressing) placed. The SN note documents: ";wound care provided - wound cleansed (with) warm water; wound dressing applied – gauze." The Hospice Plan of Care dated 10/20/2022 to 1/17/2023 lacks documented evidence of wound care order for the LCW wound. On 11/17/2022 at 3:30 PM, the Administrator, the Vice President of Community Patient Services, and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #7 has a Start of Care date of 10/19/2022 with the diagnoses ";Chronic Obstructive Pulmonary Disease" and ";Respiratory Failure, Unspecified" documented in the Hospice Plan of Care dated 10/19/2022 to 1/16/2023. The RN initial comprehensive assessment visit note dated 10/19/2022 documents the patients uses the following oxygen treatment for shortness of breath/dyspnea: Continuous Oxygen 4.5 LPM via nasal cannula. The Hospice Plan of Care dated 10/19/2022 to 1/16/2023 documents: ";Mgmt (Management) of resp (respiratory) status use of O2." The Hospice Plan of Care lacks documented evidence the patients oxygen use as specified in the comprehensive assessment, continuous O2 4.5 liters per minute via nasal cannula. On 11/17/2022 at 3:30 PM, the Administrator, the Vice President of Community Patient Services, and the Director of Patient Services were interviewed and did not provide an explanation for the findings. .

Based on clinical record reviews and interviews, the hospice failed to ensure each individualized Plan of Care is followed. This was evident for one (1) of twenty (20) clinical records reviewed. (Patients #6). Failure to ensure that each individualized Plan of Care is followed, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #6 has a Start of Care date of 10/20/2022 with the diagnosis ";Nutritional Deficiency, Unspecified" documented in the Hospice Plan of Care dated 10/20/2022 to 1/17/2023. The physicians order dated 10/24/2022 documents: ";For bilateral skin tears below shin: gently clean area with NS (Normal Saline), apply small amount of TAO (antibiotic), cover with Xeroform dressing and abdominal pad." The ";SN Hospice Visit" note dated 11/2/2022 documents the SN provided the following wound care to the right and left shin skin tears: ";Wound cleansed (specify solution) soap and water." The ";SN Hospice Visit" note dated 11/4/2022 documents the SN provided the following wound care to the bilateral skin tears to lower shin: ";Wound cleansed (specify solution) water." The clinical record lacks documented evidence of the SN cleaning the wounds with Normal Saline as specified in the wound care order. There is no documented evidence the SN followed the plan of care. On 11/17/2022 at 3:30 PM, the Administrator, the Vice President of Community Patient Services, and the Director of Patient Services were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview, the hospice failed to ensure that IDG (Interdisciplinary Group) is reviewing and revising the Plan of Care. This was evident for two (2) of twenty (20) clinical records reviewed (Patient #3, and #5). Failure to ensure that IDG is reviewing and revising the Plan of Care, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #3 has a Start of Care date of 10/14/2022 with the diagnoses ";Unspecified Lump in the Left Breast, Unspecified Quadrant" and ";Pleural Effusion in Other Conditions Classified Elsewhere" documented in the Hospice Plan of Care dated 10/14/2022 to 1/11/2023. The initial ";Hospice Plan of Care" dated 10/14/2022 to 1/11/2023 documents: Oxygen ";(patient) take 2 L/Min (Liters/Minute) by inhalation route intermittent as needed." Th ";SN (Skilled Nurse) Hospice Visit" note dated 11/2/2022 documents: ";Patient is experiencing shortness of breath;" ";Intervention: Oxygen increased to 4 Liters continuously." The subsequent ";SN Hospice Visit" notes dated 11/4/2022 and 11/8/2022 continue to document the patient using ";Oxygen continuously at 4 Liters." The IDG ";Case Conference Summary" dated 10/26/022 to 11/9/2022 lacks documented evidence of the Hospice Plan of Care being reviewed and revised to reflect the patients increased Oxygen use. On 11/16/2022 at 3:00 PM, the Administrator and the Vice President of Community Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #5 has a Start of Care date of 10/18/2022 with the diagnoses ";Heart Disease Unspecified" and ";Chronic Obstructive Pulmonary Disease Unspecified" documented in the Hospice Plan of Care dated 10/18/2022 to 12/16/2022. The initial ";Hospice Plan of Care" dated 10/18/2022 to 12/16/2022 documents: Oxygen ";3 L/M (Liters/Minute) take 3Lby inhalation route continuous." The SN Hospice Visit notes document the patient uses varying liters per minute (LPM) of oxygen on the following dates: 10/20/2022 – ";O2 @3L NC (nasal cannula), ups to 4L at night as pt (patient) is a mouth breather per CG (caregiver);" 10/27/2022 – ";Oxygen Use: PRN (as needed); Oxygen 02 Flow Rate (LPM) 2-4;" ";pt appears comfortable, breathing O2 @ 2L NC (nasal cannula);" 11/1/2022 – ";Oxygen 3L via nasal cannula, CG stated pt gets 4L oxygen at bedtime as per MD order for SOB (shortness of breath);" 11/4/2022 – ";breathing O2 via NC @2-4L;" 11/7/2022 – ";breathing O2 via NC @2-4L." The IDG ";Case Conference Summary" dated 10/27/022 to 11/8/2022 lacks documented evidence of the Hospice Plan of Care being reviewed and revised to reflect the patients oxygen use and needs. There is no documented evidence of an order for the range in Oxygen the patient uses. The LPN "SN Hospice Visit" note dated 10/26/2022 documents: ";Skin clean, intact with exception of small escoriated (excoriated) area to buttock;" and ";IDT communication" with ";RN." The RN "SN Hospice Visit" note dated 10/27/2022 documents: Skin integrity ";wound decubitus (go to wound addendum);" ";CG (caregiver) reports she changed drsg (dressing) to resolving stage 2 pressure ulcer to sacrum this AM. Declined writer to assess; reports area now 'mildly red;' covering with ABD for added protection. (Instructed) to offload as tolerated." The RN Hospice Visit note dated 11/4/2022 documents: Skin integrity: ";Patient does not have integrity issues at this time;" ";(Caregiver) reports stage 2 pressure ulcer to lower sacral has resolved, covering with ABD for added protection; (instructed) to importance of compliance with wound care, offloading pt as tolerated." The IDG ";Case Conference Summary" dated 10/27/022 to 11/8/2022 lacks documented evidence of the Hospice Plan of Care being reviewed and revised to reflect the patients change skin care needs. There is no documented evidence of wound care orders for the stage 2 pressure ulcer. On 11/17/2022 at 3:30 PM, the Administrator, the Vice President of Community Patient Services, and the Director of Patient Services were interviewed and did not provide an explanation for the findings.