Every finding on record at Care Alternatives of Pennsylvania, LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 1: The hospice plan of care dated 11/01/2023 did not include interventions and goals for hospice aide services provided to the patient. Clinical Record 2: The hospice plan of care dated 10/31/2023 did not include interventions and goals for hospice aide services provided to the patient. Clinical Record 4: The hospice plan of care dated 11/08/2023 did not include interventions and goals for hospice aide services provided to the patient. Clinical Record 5: The hospice plan of care dated 10/25/2023 did not include interventions and goals for hospice aide services provided to the patient. During an interview on 12/08/2023, the Executive Director of Clinical Operations reviewed the associated records and stated that the aide interventions and goals had been inadvertently omitted and had since been added to the hospice plans of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the individualized written plan of care included documentation of treatments necessary to meet the needs of the patient. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 5: The skilled nurse documented on the updated comprehensive assessment dated 12/03/2023 wound care was provided to a stage II left buttock wound three times a week by cleansing with normal saline, application of hydrogel to the wound bed and securing with optifoam. The updated hospice plan of care dated 12/06/2023 did not include wound care orders, as of the date of record review on 12/08/2023. During an interview on 12/08/2023, the Executive Director of Clinical Operations reviewed the associated record and stated that the wound care order had been inadvertently omitted and had since been obtained and added to the hospice plan of care.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the RN prepared written patient care instructions for the hospice aide that included clear and specific instructions to the aide. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 1: The patient elected the hospice benefit on 07/27/2023 with a terminal diagnosis of unspecified protein calorie malnutrition. The RN documented on the 12/03/2023 updated assessment and the 12/06/2023 interdisciplinary team meeting notes that the patient was receiving wound care to a left buttock stage II decubitus ulcer. The 07/27/2023 initial hospice aide plan of care did not include instructions/precautions related to the wound or wound care and there was no updated hospice aide plan of care since the original was created on 07/27/2023. Clinical Record 5: This patient elected the hospice benefit on 11/01/2023 with a terminal diagnosis of Alzheimer's disease. The RN documented on the initial comprehensive assessment dated 11/01/2023, the patient was using oxygen. The 11/01/2023 initial hospice aide plan of care did not include instructions/precautions related to the patient’s use of oxygen and there was no updated hospice aide plan of care since the original was created on 11/01/2023. During an interview on 12/08/2023, the Executive Director of Clinical Operations reviewed the associated records and stated that the instructions for the aide had been inadvertently omitted and had since been corrected.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. 12 of 19 (63%) records reviewed revealed the agency did not ensure the drug profiles were current and updated in accordance with agency policy. Document 1: Medication Profile Policy No. H:2-055.1 read '1. Upon admission to hospice the admitting nurse will initiate a medication profile to document the current medication regimen, 2. A drug regimen review will be performed at the initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication. Clinical Record 1: The 02/23/2023 hospice start of care assessment revealed the patient was utilizing Oxygen at 2LPM via nasal cannula as needed. The medication profile did not include oxygen. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 3: During the home visit observation, the spouse of the patient administered CBD drops orally and stated patient used to help control dry cough as needed. CBD oral drops were not included on the medication profile at the time of the visit or the clinical record review. Clinical Record 4: The 07/01/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2.5 LPM via nasal cannula. Oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 7: The 06/23/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 6LPM via nasal cannula however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 10: The 05/09/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2-4LPM via nasal cannula as needed however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 12: The 03/21/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2LPM via nasal cannula continuous however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 13: The 07/15/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2LPM via nasal cannula continuous however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 15: The 06/16/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2-4LPM via nasal cannula however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 16: The 03/02/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2-4LPM via nasal cannula as needed however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 17: The 07/18/2023 hospice start of care assessment indicated the patient was utilizing Oxygen however, oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 18: The 04/21/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2-4LPM via nasal cannula as needed however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 19: The 05/12/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 3LPM via nasal cannula however, oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. During interview 07/27/2023, Administrator reviewed the associated clinical records and stated that drug profiles were not complete and had since been corrected and staff had been educated as well.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 18 of 19 (95%) records reviewed revealed the agency did not ensure that the plans of care addressed the interventions and goals based on problems identified in the comprehensive assessments. Clinical Record 1: The 02/23/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 2: The 01/01/2022 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 4: The 07/01/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 5: The 06/15/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 6: The 06/01/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 7: The 06/23/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 8: The 06/23/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 9: The 05/17/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 10: The 05/09/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 11: The 04/03/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 12: The 03/21/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 13: The 07/15/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 14: The 06/13/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 15: The 06/16/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 16: The 03/02/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 17: The 07/18/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 18: The 04/21/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. Clinical Record 19: The 05/12/2023 hospice plan of care did not include any aide interventions and goals for associated service provision. There were no documented intervention and goals in the plan of care to address the hospice aide services. During interview 07/27/2023, the Administrator reviewed the associated clinical records and stated that care plan revisions had since been made where appropriate and staff had been educated as well. The Administrator explained that the new EMR learning curve resulted in the interventions and goals not functioning properly.

It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 10 of 19 (53%) records reviewed revealed that the agency did not ensure that written plans of care for each patient included documentation of specified care and services to meet the specific needs of the patients. Clinical Record 1: The 02/23/2023 hospice start of care assessment documented that the patient was utilizing Oxygen at 2LPM via nasal cannula as needed. However, there was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 4: The 07/01/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2.5 LPM via nasal cannula. There was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 5: The 06/15/2023 hospice start of care assessment indicated the patient was utilizing Oxygen. There was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. The plan of care included an active diagnosis of Diabetes and interventions included monitor blood sugars. There was no evidence of blood sugars results in the clinical record. Clinical Record 7: The 06/23/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 6LPM via nasal cannula however oxygen was not included on the plan of care at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 12: The 03/21/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2LPM via nasal cannula continuous however oxygen was not included on the medication profile at the time of review. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. The 03/21/2023 and all updated plans of care until time of review read "wound left breast, cleanse with soap and water, pat dry with gauze, may apply skin prep to peri wound, apply _____ to wound bed and secure with Opti foam every 3 days and as needed if soiled or dislodged." The blank does not specify what was to be applied to the wound bed. Clinical Record 13: The 07/15/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2LPM via nasal cannula continuously. There was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. The comprehensive assessment also indicated left foot wounds and a skin tear the right elbow requiring care however, there were no wound care orders on the plan of care at the time of the review. Clinical Record 15: The 06/16/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2-4LPM via nasal cannula. There was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 16: The 03/02/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2-4LPM via nasal cannula as needed. There was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 17: The 07/18/2023 hospice start of care assessment indicated the patient was utilizing Oxygen. There was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. Clinical Record 18: The 04/21/2023 hospice start of care assessment indicated the patient was utilizing Oxygen at 2-4LPM via nasal cannula as needed. There was no documented evidence that oxygen was included on the plan of care at the time of review on 7/27/2023. The medication review documentation was completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record. The hospice plan of care read 'incision care as follows; cleanse daily and cover with dry sterile dressing' with no specification to wound location or cleanser to be used. During interview 07/27/2023, Administrator reviewed the associated clinical records, confirmed the care plans did not document the care and services needed, and stated that care plan revisions had since been made where appropriate and staff had been educated as well.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was unmet, as evidenced by clinical record reviews and interviews. 5 of 15 (33%) applicable records with hospice aide services revealed a lack of clear and specific written instructions for the assignments, thus leaving the aide to make decisions outside the aide's scope of practice. Clinical Record 11: This patient elected the hospice benefit on 4/3/2023 with a diagnosis of cerebrovascular disease. The patient resided in an assisted living facility with limited mobility and impaired mental status. The 04/07/2023 hospice aide plan of care read shower as directed. The aide care plan remained active for the certification beginning on 7/2/2023. The aide documented that a bed bath was provided on 07/03/2023, 07/04/2023, 07/05/2023, 07/06/2023, and 07/07/2023, and both shower and bed bath was provided on 07/10/2023, 07/11/2023, and 07/12/2023. No documented evidence described criteria to be used by the aide to determine the type of bath the patient was to receive. Clinical Record 14: This patient elected the hospice benefit on 6/13/2023 with a diagnosis of senile degeneration of the brain. The patient resided in an SNF. The 05/29/2023 hospice aide plan of care specified a bed, bath, and shower every visit. The 06/29/2023 aide visit documentation indicated a sponge bath was provided. There was no documented evidence that described criteria to be used by the aide to determine the type of bath the patient was to receive. Clinical Record 17: This patient elected the hospice benefit on 7/18/2023 with a diagnosis of breast CA. The physician ordered an insertion of a 16Fr 10 cc foley catheter on 07/20/2023. The registered nurse completed and documented the visit on 7/20/2023. The hospice aide plan of care did not include instructions on providing foley catheter care. There was no documented evidence of an updated aide plan of care to reflect patient status and the change in care. Clinical Record 18: This patient elected the hospice benefit on 4/21/2023 with a diagnosis of Alzheimer's. This patient resided in an ICF. The registered nurse (RN) completed the comprehensive assessment on 4/21/2023 and documented that the patient was status post fall and left hip fracture with 28 staples still intact and wound care to be provided. The 04/21/2023 initial hospice aide plan of care did not include instructions/ precautions related to left hip care. 07/20/2023. Clinical Record 19: This patient elected the hospice benefit on 5/12/2023 with a diagnosis of Heart Failure. The RN completed the comprehensive assessment on 5/12/2023. and documented the patient was utilizing an 18 Fr 10 cc coude catheter and receiving wound care for a left inner malleolus stasis ulcer. The 05/12/2023 initial hospice aide plan of care did not include instructions/ precautions related to wound or foley catheter care. During an interview on 07/27/2023, the Administrator reviewed the associated clinical records and stated that care plan revisions had since been made where appropriate, and staff had been educated as well.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 4 of 15 (27%) applicable records with hospice aide services revealed the agency did not ensure that the hospice aide services provided were consistent with the plan of care. Clinical Record 1: This patient elected the hospice benefit on 2/23/2023 with a diagnosis of Alzheimer's, and resided in a SNF. The 02/23/2023 hospice aide plan of care assigned the hospice aide to apply barrier cream, apply deodorant, apply lotion to all extremities, bathroom assist, dressing assist, feeding assist, bath, change linens, clean fingernails, comb hair, document last BM, make bed, perineal care and shower on every visit. For the certification period beginning on 5/24/2023, the aide assignment remained the same. The aide visit notes dated 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023 and 07/14/2023 documented completion of oral hygiene and denture care, transfer assist and tidy patient area as well as companionship all of which were not included on the hospice aide plan of care. There was no documented evidence that the aide notified the RN of the tasks provided that were not included on the care plan or that the RN had acknowledged the changes. Clinical Record 2: This patient elected the hospice benefit on 1/1/2022, with a diagnosis of COPD, and resided in a SNF. The 01/01/2023 hospice aide plan of care assigned the hospice aide to apply barrier cream, apply deodorant, apply lotion to all extremities, dressing assist, feeding assist, bed bath, change linens, clean fingernails, comb hair, denture care, document last BM, file nails, foot care, perineal care and wash hair on every visit. For the certification period beginning on 6/25/2023, the aide assignment remained the same. The aide visit notes dated 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023 and 07/14/2023 indicated bed rest, turn and reposition assist and tidy patient area all of which were not included on the hospice aide plan of care. There was no documentation of denture care on these dates which was included in the plan of care for every visit. There was no documented evidence that the aide notified the RN of the tasks provided that were not included on the care plan or that the RN had acknowledged the changes in care. Clinical Record 4: This patient elected the hospice benefit on 7/1/2023 with a diagnosis of Alzheimer's and resided in a SNF. The hospice aide plan of care dated 07/21/2023 read clean fingernails and wash hair at each visit. The hospice aide visit note dated 07/24/2023 documented "no need". There was no documented evidence that the aide notified the RN that the assigned were not or that the RN had acknowledged this change. Clinical Record 12: This patient elected the hospice benefit on 3/21/2023 with a diagnosis of breast cancer, and resided in a SNF. The 03/21/2023 hospice aide plan of care assigned the hospice aide did not include companionship however the aide documented only companion care provided on 06/30/2023, 07/12/2023, 07/17/2023, 07/19/2023, 07/20/2023 and 07/24/2023. There was no documented evidence that the aide notified the RN that the assigned were not provided or that the RN had acknowledged this change. During interview 07/27/2023, Administrator reviewed the associated clinical records and stated that care plan had not been followed particularly with paper visit not submissions and staff had since been re-educated. She explained that the EMR system was down for a week which resulted in the submission of paper documentation.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by clinical record review, document review and interview. 19 of 19 (100%) records reviewed revealed the agency did not ensure that the hospice's written policies and procedures for the management and disposal of controlled medications were provided to the patient, family, or legal representatives. Document 2: PC.M70 Medications -Use and Disposal of Controlled Substances read 1. At the time when controlled substances are first ordered, the hospice, must: a. provide a copy of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or the patient representative and family. Clinical Record 1: The hospice election of benefits was dated 02/23/2023. The registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, During the home observation visit, the admission folder did not include the agency's current policies and procedures related to management and disposal of controlled medications. Clinical Record 2: The hospice election of benefits was dated 01/01/2022 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, During the home observation visit, the admission folder did not include the agency's current policies and procedures related to management and disposal of controlled medications. Clinical Record 3: The hospice election of benefits was dated 07/11/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, During the home observation visit, the admission folder did not include the agency's current policies and procedures related to management and disposal of controlled medications. Clinical Record 4: The hospice election of benefits was dated 07/01/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, During the home observation visit, the admission folder did not include the agency's current policies and procedures related to management and disposal of controlled medications. Clinical Record 5: The hospice election of benefits was dated 06/15/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 6: The hospice election of benefits was dated 06/01/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 7: The hospice election of benefits was dated 06/23/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 8: The hospice election of benefits was dated 06/23/2022 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 9: The hospice election of benefits was dated 05/17/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 10: The hospice election of benefits was dated 05/09/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 11: The hospice election of benefits was dated 04/03/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 12: The hospice election of benefits was dated 03/21/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 13: The hospice election of benefits was dated 07/15/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 14: The hospice election of benefits was dated 06/13/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 15: The hospice election of benefits was dated 06/16/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 16: The hospice election of benefits was dated 03/02/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 17: The hospice election of benefits was dated 07/18/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 18: The hospice election of benefits was dated 04/21/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, Clinical Record 19: The hospice election of benefits was dated 05/12/2023 and the registered nurse documented education on patient handbook and on provision of policy and procedure as required however the policy and procedure provided was Policy No H:2-059.1 per the handbook and that policy (policy vendor) was changed in August of 2020 to PC.M70 and the handbook did not include the current policy, During interview 07/27/2023, Administrator reviewed the associated patient handbook and stated that the new agency policy had not been included in last revision and had since been noted as an edit change with the next revision. The Administrator acknowledged that the admission packet included the agency's written policies and procedures about medication management and disposal. However, the admission booklets were not updated and did not include the updated policy and procedures.

The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 9 of 9 (100%) applicable records of patients residing in a skilled nursing facility revealed the hospice did not ensure the identification of which provider is responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 1: The 02/23/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 02/23/2023 hospice plan of care and all associated updated plans of care did not delineate the care provided by the hospice and facility staff. The initial and all ongoing plans of care lacked the identification of which provider was responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 2: The 01/01/2022 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 01/01/2022 hospice plan of care and all associated updated plans of care did not delineate the care provided by the hospice and facility staff. The initial and all ongoing plans of care lacked the identification of which provider was responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 4: The 07/01/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 07/01/2023 hospice plan of care and all associated updated plans of care did not delineate the care provided by the hospice and facility staff. The initial and all ongoing plans of care lacked the identification of which provider was responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 12: The 03/21/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 03/21/2023 hospice plan of care and all associated updated plans of care did not delineate the care provided by the hospice and facility staff. The initial and all ongoing plans of care lacked the identification of which provider was responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 13: The 07/15/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 07/15/2023 hospice plan of care and all associated updated plans of care did not delineate the care provided by the hospice and facility staff. The initial and all ongoing plans of care lacked the identification of which provider was responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 14: The 06/13/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 06/13/2023 hospice plan of care and all associated updated plans of care did not delineate the care provided by the hospice and facility staff. The initial and all ongoing plans of care lacked the identification of which provider was responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 15: The 06/16/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 06/16/2023 hospice plan of care and all associated updated plans of care did not delineate the care provided by the hospice and facility staff. The initial and all ongoing plans of care lacked the identification of which provider was responsible for performing respective functions agreed upon and included in the plan of care. The initial and all ongoing plans of care throughout discharge on 6/18/2023 lacked the identification of which provider is responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 16: The 03/02/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a skilled nursing facility. The 03/02/2023 hospice plan of care and all associated updated plans of care do not show evidence of delineation of care provided by the hospice and facility staff. The initial and all ongoing plans of care throughout discharge o 5/27/2023 lacked the identification of which provider is responsible for performing respective functions agreed upon and included in the plan of care. Clinical Record 17: The 07/18/2023 comprehensive assessment completed by the registered nurse indicated patient residence was a intermediate care facility. The 07/18/2023 hospice plan of care and all associated updated plans of care do not show evidence of delineation of care provided by the hospice and facility staff. The initial and all ongoing plans of care throughout discharge on 7/22/2023 lacked the identification of which provider is responsible for performing respective functions agreed upon and included in the plan of care. During interview 07/27/2023, Administrator reviewed the associated clinical records and stated that care plan revisions had since been made where appropriate and staff had been educated as well.