Every finding on record at Care Hospice Services LLC

Upon patient record review 3 of 19 (Patient #3,#5,#10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient#1,#5,#10: There is no evidence of an initial spiritual assessment being completed within 5 days.

Upon patient record review, 8 of 19 (Patient #2,#6,#8,#9,#10,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#2: The medication profile contained acetaminophen PRN for fever. However, there was no evidence of parameters for the fever. The medication profile contained oxygen. However, there was no evidence of an indication or route for the oxygen. This was corrected on site by adding the missing information. Patient#3,#6,#9,#10,#14: The medication profile contained acetaminophen for fever. However, there was no evidence of parameters for the fever. This was corrected on site by adding parameters. Patient#8: The medication profile contained lidocaine 5% topical ointment per instructions. There is no evidence of a specified area of application. This was corrected on site as specific are for application was added. Patient#12: The medication profile contained polyethylene glycol 17 grams. However, there is no evidence of instructions for preparation with dilutant. This was corrected on site by adding dilutant instructions. Patient#13: The medication profile contained Sarna to be applied topically for itching. However, there was no evidence of a specified area of application. This was corrected on site by adding the area for application.

Upon patient record review, 2 of 19 (Patient #6,#7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient#6: The patient was admitted on 5/23/25. There is evidence that the initial bereavement assessment was not completed until 6/6/25. Patient#7: The patient was admitted on 5/2/25. There is evidence that the initial bereavement assessment was not completed until 6/17/25.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#5: There is no evidence of measurements or assessments of wound to left leg from 6/23/25 to present. The agency policy indicates this is to be performed weekly.

Upon patient record review, 4 of 19 (Patient #2,#3,#6,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#2: The record indicates the patient is a fall risk, and requires oxygen in home. There is no evidence of problems with goals and interventions related to fall precautions or oxygen safety. Corrected on site by updating plan of care to include education and precautions for fall and oxygen safety. Patient#3,#6: The record indicates the patient has fall precautions and aspiration precautions on aide plan of care. However, there are no problems with goals and interventions on the plan of care for these needs. The agency corrected the fall precaution by adding this to the plan of care. They state their EMR does not have any options for aspiration precautions and are unable to correct at this time. Patient#7:The record indicates the patient has fall precautions on aide plan of care. However, there are no problems with goals and interventions on the plan of care for these needs. The agency corrected the fall precaution by adding this to the plan of care. The record indicates patient admitted with terminal diagnosis of Alzheimer's. There is no evidence of neurological problems with goals and interventions on the plan of care related to this patient's needs. This was corrected on site by agency adding related neurological problems, goals and interventions.

Upon patient record review, 11 of 19 (Patient #1,#2,#3,#6,#8,#9,#10,#12,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: The record indicates patient has a foley catheter. There is no evidence of an order to change or replace the foley. This was corrected on site as an order obtained. Patient#2: The medical record contained an order for acetaminophen PRN for fever. However, there was no evidence of parameters for the fever. The medical record contained an order for oxygen. However, there was no evidence of an indication or route for the oxygen. This was corrected on site by obtaining order. Patient#3,#6,#9,#10,#14: The medical record contained an order for acetaminophen for fever. However, there was no evidence of parameters for the fever. This was corrected on site by obtaining order that included parameters. Patient#6:The record indicates patient required nectar thick liquids. There is no evidence of an order for this need. This was corrected on site by obtaining the order. Patient#8: The medical record contained an order for lidocaine 5% topical ointment per instructions. There is no evidence of a specified area of application. This was corrected on site as a correct order was obtained. Patient#12: The medical record contained an order for polyethylene glycol 17 grams. However, there is no evidence of instructions for preparation with dilutent. This was corrected on site by obtaining a correct order. Patient#13: The medical record contained an order for Sarna to be applied topically for itching. However, there was no evidence of a specified area of application. This was corrected on site by obtaining a correct order.

Upon patient record review, 2 of 19 (Patient #1,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient#1: The record indicates patient has a foley catheter. There is no evidence of catheter supplies on the plan of care. This was corrected on site and these supplies were added. Patient#5: The record indicates the patient requires and is using a Hoyer lift, hospital bed, mattress, oxygen equipment, and a walker. There is no evidence of these items on the plan of care. This was corrected on site as these items were added to the plan of care.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. The contracted agency was unable to provide OT and SLP due to these employees recently leaving and the hospice Administrator stated the contract agency is working on hiring new therapists.

Upon patient record review, 2 of 19 (Patient #1,#2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#1: The aide plan of care states all task to be completed every visit. The details of the assignment done by RN state "offer every visit". Aide POC did not note patient was cognitively able to make decisions. Patient#2: The record indicates the 7/14/25 aide plan of care assigns aide to assist to toilet per patient request. This was corrected on site by removing the "per patient request" and designating to be completed every visit.

Upon patient record review 2 of 19 (Patient #2,#3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient#2: There is no evidence of an aide supervisory visit being completed from 6/16/25 to present. Patient#3: There is no evidence of an aide supervisory visit being completed from 5/21/25 to present.

Upon patient client record review, 1 of 19 (Patient #13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient#13: The record indicates the patient/family requested to receive addendum on admit. There is no evidence the addendum was completed or given to patient/family.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 15 (Personnel #15) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel#15:The contract agency did not have SLP at this time.

Upon personnel record review, 1 of 15 (Personnel #14 ) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel#14:The contract agency did not have OT at this time.

Upon personnel record review, 2 of 15 (Personnel #14,15) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Based on record review and interview, the agency failed to notify the Indiana Department of Health of the neglect of a patient for 1 of 1 neglect incidents, with the potential to affect all patients. Findings include: --- 1. Review of the policy on Abuse, Neglect and Exploitation, last reviewed 10/01/2021, identified neglect as ";... failure to provide goods and/ or services necessary to avoid physical harm, mental anguish, or mental illness." The policy evidenced instruction for the hospice to report verified violations to ";... the State Survey and Certification Agency ... within five working days of becoming aware of the verified violation ...." 2. Review of the addendum to the Abuse, Neglect, and Exploitation policy, specific to Indiana, last reviewed 11/27/2023, defined neglect as ";... fails to provide adequate food, clothing, shelter or medical care." 3. Review of video clips of Former Employee 4 with Patient #3 on 1/9/2025, evidenced Former Employee (LPN) 4 assist Patient #3 out of the recliner, then sat in a chair while the patient used a rollator to ambulate to the bathroom, where Patient #3 fell. 4. Review of the occurrence report completed by Former Employee 4 on 1/13/2025, indicated ";Pt [patient] was standing halfway nud3 [sic] her bathroom after saying come in after writer knocked. Writer sat writer"s [sic] things and put on gloves. Pt asked writer to get [Patient #3s] baby wipes from shelf. Writer did so and whe [when] writer put down package sat down on floor on bath mat. Pt sat rather than sit down firml y [sic] against a flat surface. Pt denied dizziness or pain. No NV [nausea or vomiting]. Writer stood between Pt and wall to prevent Pt from hitting [Patient #3s] head. When staff nurse [nurse at Entity 1] arrived writer took Pts vitals which were WNL [within normal limits] for Pt..." 5. In an email exchange between Corporate Staff 6, the Human Resources Manager, and the Chief Compliance Officer, dated January 13 and 14, 2025, the Chief Compliance Officer indicated Patient #3 fell while alone in the bathroom. The email indicated the agency determined that neglect occurred by Former Employee 4. 6. The Administrator provided notes regarding the fall. The notes indicated Former Employee 4 said they escorted Patient #3 to the bathroom and remained with them. According to the notes, Former Employee 4 assisted the patient to the floor in a controlled fall. The notes indicated Former Employee 4 did not call the hospice RN, Clinical Manager, Administrator, or the Physician. The notes outlined a discussion with Person 3, from Entity 1. Person 3 indicated Former Employee 4 did not assess or provide post – fall care to Patient #3. The notes indicated the Administrator called Adult Protective Services to report neglect on 1/13/2025. During an interview beginning at 4:35 PM on 2/26/2025, the Administrator indicated they believed they reported the neglect to Adult Protective Services and the report would then go to all required agencies. The Administrator confirmed they did not report the neglect to the Indiana Department of Health.

Based on record review and interview, the hospice failed to ensure care and services were provided according to the physical needs of the patient and failed to ensure all members of the IDG were notified of a fall for 1 of 1 records reviewed of a patient who sustained a fall with a hospice staff member present (Patient #3). --- Findings include: The review of Patient #3s clinical record indicated a hospice benefit election date of 4/26/24, terminal diagnosis of heart disease, and secondary diagnoses including dementia. Patient resided at Entity 1, an assisted living facility. The record included a recertification POC for the benefit period 12/22/24 – 2/19/25, which indicated Patient was to receive SN visits once a week. The POC indicated the SN was to ";evaluate Patient and develop a nursing plan of care ... coordinate plan of care with facility staff." The POC also included an identified problem of ";Altered Home Safety" with a goal of ";Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention." Skilled nurse interventions for this problem included the nurse would assess ";Patients functional status in relationship to potential safety hazards in Patients living area" and would instruct ";on safety measures." The record included a NP Face-to-Face note, dated 12/10/24 by NP 1, which indicated Patient required a one-person physical assist to ambulate to the bathroom, along with a walker. NP 1 noted Patient had ";progressive weakness" to the lower extremities. At the time of the exam, Patient had 11 falls in 6 months, including two with injury. NP 1 noted Patient had a hand tremor in both hands with ";action," and Patient ";chronically laughs at no particular stimuli." The record included a SN visit note, dated 12/23/24 by Former Employee 4, an LPN. The nurse documented Patient was not having pain during the visit nor did Patient have any pain since the last visit. Patient was noted to be ";forgetful," have ";abnormal insight and judgement," and was ";impulsive." The note failed to evidence a musculoskeletal assessment was completed. The record included a SN visit note, dated 1/02/25 by Former Employee 7, an RN. The nurse documented Patient was not having pain during the visit nor did Patient have any pain since the last visit. The RN noted Patient had decreased strength to his/her lower extremities and Patient required assistance with toileting. The record included a SN visit note, dated 1/09/25 by Former Employee 4. The nurse noted she began the visit by conducting aide tasks. Former Employee 4 documented she walked with Patient to the bathroom while Patient used their walker. After toileting, Patient ambulated with their walker to the sink. While performing personal care tasks, the nurse documented Patient ";took a half step back as if [he/she] were going to sit." The nurse documented she ";stood behind [Patient] immediately as writer remains within arms reach of [Patient] at all times due to [history of] falls." The LPN reportedly assisted Patient down to the bathroom floor and called for assistance. Former Employee 4 documented Patient had pain to the ";mid and lower back," which was rated as a ";6" on a 0-10 verbal pain scale and was exacerbated with movement. Patient also had ";pain/stiffness" and decreased strength to all extremities and their back. The LPN documented interventions performed during the visit included instructing Patient on home safety measures, and Patients goal for verbalizing/demonstrating understanding of proper safety measures related to fall prevention was marked as ";met." The record failed to evidence the nurse notified Patients physician of the fall. The review of home camera footage from 1/09/25 evidenced Former Employee 4 assisted Patient up from a chair. Patient ambulated him/herself to the bathroom with a walker while the nurse sat down in the living room. Once in the bathroom, Patient stood at the sink with the walker between him/herself and the bathroom door. The LPN later stood outside of the bathroom door, with the walker between the nurse and Patient. Patient could then be seen taking a step back and beginning to lose their balance, before the video ended. Footage from later in the visit evidenced Patient and Former Employee 4 sitting on the bathroom floor. Person 5, an employee of Entity 1, entered and Former Employee 4 reported Patient was standing at the sink and ";just sat down on the floor ... just hit [his/her] butt." The review of an agency Client Occurrence Report, documented on 1/13/25 by Former Employee 4, indicated when the nurse arrived for her visit, Patient was ";standing halfway [nude]" in their bathroom. The nurse documented she entered the bathroom and was obtaining supplies for Patient, then Patient ";sat down on floor on bath mat. [Patient] sat rather than sit down firmly against a flat surface." The nurse documented Patient ";moved all extremities per baseline." The incident report failed to evidence the nurse notified Patients physician of the fall. The review of Entity 1s clinical record for Patient included a service plan, dated 11/21/24, which indicated Patient required standby assistance during bathroom use and bathing. A nurse note, documented on 1/09/25 at 1:07 PM by Person 5, indicated Patient was found ";sitting up on buttock in bathroom with hospice nurse." Former Employee 4 documented Patient was standing up at the sink, began to complain of feeling dizzy, then Patient ";sat on [his/her] buttock." Entity 1s documentation after the fall evidenced the following nurse notes- a. On 1/10/25 at 6:22 AM, Person 8 documented Patient was unable to stand and bear weight to walk to the bathroom. b. On 1/10/25 at 2:19 PM, Person 5 documented Patient complained of pain to the right buttock and was unable to bear weight to his/her lower extremities. c. On 1/10/25 at 7:08 PM, Person 9 documented Patient complained of pain to the right buttock and was unable to bear weight to his/her lower extremities. d. On 1/11/25 at 6:12 AM, Person 10 documented Patient complained of pain to the ";butt" and was unable to bear weight to his/her lower extremities. e. On 1/11/25 at 2:31 PM, Person 11 documented Patient complained of pain and was unable to bear weight to his/her lower extremities. Patient remained in bed during Person 9s shift. f. On 1/11/25 at 9:51 PM, Person 11 documented Patient complained of pain to the hip and was unable to bear weight to his/her lower extremities. g. On 1/12/25 at 3:52 AM, Person 10 documented Patient was unable to bear weight to his/her lower extremities. h. On 1/12/25 at 2:02 PM, Person 11 documented Patient complained of pain to the hip. The entitys records also indicated Patient received doses of Tramadol (a pain medication), ordered to be given as needed for pain, on the following days and times for the month of January 2025: a. 1/10/25 at 8:09 AM b. 1/10/25 at 3:15 PM c. 1/14/25 at 3:46 PM d. 1/16/25 at 3:07 PM e. 1/21/25 at 7:47 AM f. 1/22/25 at 3:18 PM g. 1/23/25 at 9:39 AM During an interview with Person 3 and Person 13, employees of Entity 1, on 2/25/25 beginning at 12:25 PM, the facility staff reported prior to the 1/09/25 fall, Patient was a known high fall risk due to their history of falls. Due to Patients history of dementia, Patient would ";laugh at everything," which would cause him/her to lose their balance. The facility staff reported Patient was to have someone walk with him/her at all times due to the risk of falls. The hospice record evidenced Patient was discharged on 1/13/25 to Entity 6, a hospice agency, per Patients caregiver request. The review of Entity 6s clinical record evidenced a hospice admission assessment completed on 1/13/25. The entitys hospice nurse noted Patient had acute, daily pain to the ";bottom/hip" which was worse with movement. The assessment noted ";prior to this admission Patient participated in activities. Patient sustained a fall 4 days ago and has been bedbound since. Patient is no longer able to stand and bear weight. Patient was able to ambulate short distances with a walker and used a wheelchair for long distances. Patient was able to assist with cares [sic] and now is a total care ...." During an interview with Administrator on 2/26/25 at 10:47 AM, she reported she was notified of Patients fall by Person 3 on 1/13/25. Administrator reported Patient was at risk for falls, however the POC failed to evidence interventions to address the fall risk. Administrator reported Former Employee 4 should have assisted Patient with ambulation due to his/her fall risk. Administrator also stated Former Employee 4 failed to communicate the fall to Patients RN case manager or physician.

Based on record review and interview, the hospice agency failed to develop and follow an individualized written plan of care in accordance with the patients needs for 6 of 8 records reviewed of a patient with a fall (Patients #3, 6, 7, 8, 9, 10). --- Findings include: 1. The agency policy ";The Individualized Plan of Care," last reviewed 11/06/24, indicated ";Hospice care and services provided to patients and their families need to stick to a personalized written Plan of Care. This plan should capture the goals of the patient and their family, along with the actions to take based on the issues found in the initial and ongoing reassessments." 2. The review of Patient #3s clinical record indicated a hospice benefit election date of 4/26/24, terminal diagnosis of heart disease, and secondary diagnoses including dementia. Patient resided at Entity 1, an assisted living facility. The record included a recertification POC for the benefit period 12/22/24 – 2/19/25, which indicated Patient was to receive SN visits once a week. The POC indicated the SN was to ";evaluate Patient and develop a nursing plan of care ... coordinate plan of care with facility staff." The POC also included an identified problem of ";Altered Home Safety" with a goal of ";Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention." The POC failed to evidence patient-specific interventions to address Patients fall risk. The record included a NP Face-to-Face note, dated 12/10/24 by NP 1, which indicated Patient required a one-person physical assist to ambulate to the bathroom, along with a walker. NP 1 noted Patient had ";progressive weakness" to the lower extremities. At the time of the exam, Patient had 11 falls in 6 months, including two with injury. NP 1 noted Patient had a hand tremor in both hands with ";action," and Patient ";chronically laughs at no particular stimuli." The record included a SN visit note, dated 1/09/25 by Former Employee 4. The nurse noted Patient needed a staff member to remain within arms-reach while ambulating due to a history of falls. Former Employee 4 documented Patient had an assisted fall while in the bathroom during the visit. The review of Entity 1s clinical record for Patient included a service plan, dated 11/21/24, which indicated Patient required standby assistance during bathroom use and bathing. During an interview with Person 3 and Person 13, employees of Entity 1, on 2/25/25 beginning at 12:25 PM, the facility staff reported prior to the 1/09/25 fall, Patient was a known high fall risk due to their history of falls. Due to Patients history of dementia, Patient would ";laugh at everything," which would cause him/her to lose their balance. The facility staff reported Patient was to have someone walk with him/her at all times due to the risk of falls. During an interview with Administrator on 2/26/25 beginning at 10:47 AM, she reported Patients POC should have included individualized interventions to address Patients fall risk. 3. The review of Patient #6s clinical record indicated a hospice benefit election date of 9/24/24 and terminal diagnosis of lung cancer. The record included a recertification POC for the benefit period of 12/23/24 – 3/22/25. The POC included an identified problem of ";Altered Home Safety" with a goal of ";Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention." The POC failed to evidence patient-specific interventions to address Patients fall risk. The review of an agency ";Client Occurrence Report" evidenced Patient sustained a fall on 2/16/25 with a skin tear above the right eye. During an interview on 2/26/25 beginning at 1:32 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 4. The review of Patient #7s clinical record indicated a hospice benefit election date of 10/16/23, a terminal diagnosis of heart disease, and secondary diagnoses including dementia. The record included a recertification POC for the benefit period of 2/01/25 – 4/01/25. The POC included an identified problem of ";Altered Home Safety" with a goal of ";Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention." The POC failed to evidence patient-specific interventions to address Patients fall risk. The review of two agency ";Client Occurrence Report" evidenced Patient sustained a fall on 2/05/25 and 2/21/25. During an interview on 2/26/25 beginning at 1:41 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 5. The review of Patient #8s clinical record indicated a hospice benefit election date of 1/03/23, a terminal diagnosis of Alzheimers disease, and secondary diagnoses including ";history of falling." The record included a recertification POC for the benefit period of 12/23/24 – 1/22/25. The POC included an identified problem of ";Altered Home Safety" with a goal of ";Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention." The POC failed to evidence patient-specific interventions to address Patients fall risk. The review of two agency ";Client Occurrence Report" evidenced Patient sustained a fall on 2/14/25. During an interview on 2/26/25 beginning at 1:48 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 6. The review of Patient #9s clinical record indicated a hospice benefit election date of 8/28/24, a terminal diagnosis of Parkinsons Disease, and secondary diagnoses including dementia and a history of falling. The record included a recertification POC for the benefit period of 12/26/24 – 2/23/25. The POC failed to evidence goals or patient-specific interventions which would be enacted to address Patients fall risk. The review of an agency ";Client Occurrence Report" evidenced Patient sustained a fall on 1/15/25. During an interview on 2/26/25 beginning at 1:55 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 7. The review of Patient #10s clinical record indicated a hospice benefit election date of 8/19/21, a terminal diagnosis of heart failure, and secondary diagnoses including dementia. The record included a recertification POC for the benefit period of 12/01/24 – 1/29/25. The POC failed to evidence goals or patient-specific interventions which would be enacted to address Patients fall risk. The review of two agency ";Client Occurrence Report" evidenced Patient sustained a fall on 1/02/25 and 1/06/25. During an interview on 2/26/25 beginning at 1:55 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk

Based on record review and interview, the licensed professional failed to document events of a skilled nurse visit according to professional standards for 1 of 1 record reviewed of a patient who sustained a fall with a hospice staff member present (Patient #3). --- Findings include: 1. The agency policy ";Medical Record Content," last reviewed 11/30/22, indicated an ";accurate" medical record would be maintained for all patients. Clinical notes were to include ";functional and activity limitations, all actions, interventions, and procedures provided by the hospice ...." 2. The review of Patient #3s clinical record indicated Patients medical history included dementia. Patient resided at Entity 1, an assisted living facility. The record included a SN visit note, dated 1/09/25 by Former Employee 4. The nurse noted she began the visit by conducting aide tasks. Former Employee 4 documented she walked with Patient to the bathroom while Patient used their walker. After toileting, Patient ambulated with their walker to the sink. While performing personal care tasks, the nurse documented Patient ";took a half step back as if [he/she] were going to sit." The nurse documented she ";stood behind [Patient] immediately as writer remains within arms reach of [Patient] at all times due to [history of] falls." The LPN reportedly assisted Patient down to the bathroom floor and the nurse then called for assistance. The review of home camera footage from the 1/09/25 visit evidenced Former Employee 4 assisted Patient up from a chair in the living room. Patient ambulated him/herself to the bathroom with a walker while the nurse sat down in the living room. Once in the bathroom, Patient stood at the sink with the walker between him/herself and the bathroom door. The nurse was observed looking at her tablet, vaping, then looking at her phone while Patient ambulated then stood at the bathroom sink. The nurse then walked and stood outside of the bathroom door, with the walker between the nurse and Patient. Patient could be seen taking a step back and beginning to lose their balance, before the video ended. Footage from later in the visit evidenced Patient and Former Employee 4 sitting on the bathroom floor. Person 5, an employee of Entity 1, entered and Former Employee 4 reported Patient was standing at the sink and ";just sat down on the floor ... just hit [his/her] butt." The review of an agency Client Occurrence Report, documented on 1/13/25 by Former Employee 4, indicated when the nurse arrived for her visit, Patient was ";standing halfway [nude]" in their bathroom. The nurse documented she entered the bathroom and was obtaining supplies for Patient, then Patient ";sat down on floor on bath mat. [Patient] sat rather than sit down firmly against a flat surface." The review of Entity 1s clinical record for Patient included a nurse note, documented on 1/09/25 at 1:07 PM by Person 5, indicated Patient was found ";sitting up on buttock in bathroom with hospice nurse." Former Employee 4 documented Patient was standing up at the sink, began to complain of feeling dizzy, then Patient ";sat on [his/her] buttock." The review of an internal email exchange sent by HR Manager 2 on 1/14/25 indicated after speaking with Administrator, Former Employee 4 reported she had stayed with Patient while Patient walked to and was in the bathroom, but the ";video footage says otherwise." During an interview with Administrator on 2/26/25 at 10:47 AM, she reported she discussed the 1/09/25 visit with Former Employee 4 after it was reported to the agency. The LPN was reportedly adamant she remained with Patient at all times during the visit. Administrator stated Entity 1s staff report of the events and review of the home camera footage conflicted with the nurses report and documentation. Administrator reported she had not reviewed the occurrence report the nurse documented regarding Patients fall.

Based on record review and interview the agency failed to ensure collaboration occurred with family and/or caregivers in the development of a patients care plan in 1 of 6 active records reviewed. (Patient #3) Findings include: --- 1. Review of an agency document dated 2022, titled, PC.P55 PLAN OF CARE – CONTENT indicated but was not limited to, ";Policy: The Plan of Care Specifies the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions ... Procedure: ... 2. Hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals ... 3. Hospice services interventions include: ... e. Assisting the patients family in understanding patients status related to the progression of end-stage disease; ... i. Evaluating patients/familys ability to understand information and caregiver routines ... " Review of the clinical record for Patient #3, contained a Plan of Care dated 7-25-2023 for the benefit period of 6-13-2023 through 8-11-2-23 with diagnoses which included but were not limited to: Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination, symptoms usually begin gradually and worsen over time, as the disease progresses may have difficulty walking and talking), and pressure ulcer of sacral region stage 4 (a wound caused by prolonged pressure over a bony area, located below the lumbar spine and above the tailbone, where the sore extends below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments, in more severe cases they can extend as far down as the cartilage or bone). The Plan of Care evidenced a Nursing frequency of one (1) time per week, Hospice Aide frequency of two (2) times per week, Chaplain frequency of two (2) times per month, and Medical Social Worker frequency of two (2) times per month. The Comments section of the Plan of Care stated, ";...What services will be given to ensure patient/family needs are met: SN x 1wk, HHA x 2wk, MSW x1 month, CH x1 month ...Patient/caregiver participated in this plan of care. Patient/Caregiver/POA was provided with a copy of written instructions/POC that includes: the visit schedule and frequency, ... , treatment plan with interventions and goals ..." 2. In a telephone interview on 8-9-2023 at 2:48 PM, Person A, legal guardian and family member of Patient #3, indicated the patient had been on service for more than a year and was ";surprised [Patient #3] was still alive". When queried as to who comes to see the patient from the hospice agency, Person A indicated being aware there were nurses who came regularly to provide care to the patient but could not indicate who, when, or how often, and believed the visits to be at least weekly. Indicated they believed there was also an aide provided but not when or how often and knew the hospice chaplain had made visits as well, but not when or how often. Indicated was unaware as to whether a social worker was involved. Was unable to offer names of the hospice staff that provided care or made visits to the patient. Indicated staff did reach out sporadically by phone with updates on the patient, but there would be extended periods of not hearing from them, and indicated would like to have contact more often to be updated on the patients status. When queried as to whether the agency had involved Person A in Patient #3s care planning indicated, ";Not really. You know, my [spouse] and I were just talking about calling the Administrator to sit down and discuss a care plan. Where do they want to go with this? What is the grand plan?" In an interview on 9-10-2023 at 1:53 PM, when queried as to the above response from Person A, the Administrator indicated the concern would be addressed by arranging a meeting with the family and with facility where patient resided, to ensure the care plan included all parties needs/concerns. Indicated further, clinicians should be asking at the time of assessment, when or how often the family wants to be called with updates, indicated some families/caregivers want to be contacted after every visit and some preferred be contacted only with changes in the patients condition, and planned to look further into this matter.

Based on record review and interview, the agency failed to ensure a system of communication was in place with other entities to ensure the agency was responsible for, and directed, coordinated, and/or supervised all care and services provided to all patients who received services from others in 1 of 7 records reviewed. (Patient #2) The findings include: --- A review of an agencys policy PC.90 COORDINATION OF SERVICES, dated 2022, revealed, ";Policy ... coordinated and effective ongoing sharing of information...with all contracted service providers and in all settings ... e. Provide for ongoing sharing of information with other non-hospice healthcare providers ... 2. The Director of Clinical Services assumes overall responsibility for ensuring there are effective methods of communication ..." A review of an agencys policy PC.P15 PATIENT/CAREGIVER EDUCATION dated 2022, revealed, ";...3. All teaching provided to patients/caregivers, whether verbal or in the form of written ... documented in the patients clinical record and includes the information provided ... " A review of an agencys policy PC.C30 CLINICAL RECORDS dated 2022, revealed, ";... v. Evidence of coordination of care/service provided by the hospice with others who may be providing care/service ... z. Complete documentation of all know services ... Documentation must show that effective interchange, and coordination of care occurs as required ...i. ... The record must include all services whether furnished directly or under arrangement ..." A review on 08/07/23 of the clinical record for Patient #2 revealed a Indiana Physician Orders for Scope of Treatment (Post) form dated 06/16/23 evidenced the patient was ";A. Cardiopulmonary Resuscitation (CPR) Patient has no pulse and is not breathing: Do Not Attempt Resuscitation /DNR..." signed by Person 4 and dated 06/16/23. A review on 08/07/23 of an RN Initial Assessment dated 06/18/23 and signed by RN 1, indicated the only caregiver was the patients family member, Person 4, and that Home Health Aide services were declined at admission, that other pertinent instructions related to the patient care needs were discussed but ";other pertinent instructions" were not identified or defined. A review on 08/07/23 of an MSW (Medical Social Worker) Assessment dated 06/21/23 evidenced the patient was receiving caregiver services through Entity 5. A review on 08/07/23 of Patient #2s clinical record of all communication notes from 06/16/23 to 08/10/23 failed to evidence Hospice training or education with Entity 5 or their staff. A review on 08/07/23 of Patient #2s clinical record of all skilled nursing notes from 06/1623 to 08/10/23 failed to evidence Hospice training or education with Entity 5 or their staff. On 08/10/23 at 10:50 AM, a phone interview with Person 7 with Entity 5, indicated they had heard Patient #2 was going to start with Hospice and hadnt realized a Hospice company had started their services. On 08/10/23 at 10:55 AM, during a 3-way phone call with Person 7 and Person 6, Person 6 indicated if Patient #2 would stop breathing, they would call 911, start chest compressions, and notify Entity 5. Person 6 indicated they are often alone with Patient #2 so Person 4 could run errands, go shopping, or go to appointments. On 08/10/23 at 11:54 AM, a phone interview with RN 1 indicated they had instructed Person 6 to call Hospice if a change of condition with Patient #2 occurred, but could not recall the dates the instruction/education occurred, but stated, ";I go over that all the time with Person 6". On 08/10/23 at 1:30 PM, Administrative Staff 2 indicated it was the responsibility of the agency to notify and educate other agencies and their caregivers on Hospice. On 08/10/23 at 2:50 PM, Administrative Staff 1 indicated they could not locate the ";education/instructions" from 06/16/23 to 08/10/23 that had been completed for Entity 5 or their staff.

Based on observation, record review, and interview, the hospice failed to ensure the hospice aide was compliant with the aide care plan by completing all assigned tasks for 1 of 3 patients where a home visit observation occurred, and the clinical record was reviewed. (Patient #6) Findings include: --- A review of an agency policy PCH25 HOSPICE AIDE ASSIGNMENTS AND DUTIES dated 2022 revealed, ";... 1. Hospice aides ... follow written patient care instruction in providing care ... 7. Hospice aides must report changes ... as the changes relate to the plan of care ... 8. Hospice aides must complete accurate ... documentation of services ... " A review of the clinical record of Patient #6 revealed a document titled, Aide Care Plan dated 08/03/2023, signed by RN 2, evidenced a complete bed bath was to be performed at every visit. A review of the clinical record of Patient #6 revealed a document titled, Aide Care Visit dated 08/08/23 from 8:05 AM to 9:30 AM, signed by HHA (Home Health Aide) 1, evidenced a complete bed bath was performed. During an observation on 08/08/23 at 8:30 AM, HHA 1 was to provide a bed bath for Patient #6. Upon arrival, Patient #6 was observed in the patients bathroom, standing at the sink, next to their wheelchair, with their pants down to their knees, and a pair of adult diapers on. Patient #6 asked HHA 1 for assistance. HHA 1 assisted Patient #6 to their wheelchair, then onto the toilet, where a bath took place from 8:30 to 9:30 AM. On 08/10/23 at 10:38 AM during a phone interview with HHA 1 indicated Patient #6 was terrified of showers, and since HHA 1 has been providing personal care, most days, a sponge bath was given instead of showers, and did not report to RN 2 changes to the care plan on 08/08/23. On 08/10/23 at 11:12 AM during a phone interview with RN 2 indicated on 08/03/23 they had a conversation with HHA 1, who indicated Patient #6 was sleeping more, doesnt hardly get out of bed, and when HHA 1 was able to get Patient #6 into the shower, Patient #6 panics, becomes afraid of the shower, and becomes aggressive toward HHA 1, and that is why the Aide Care Plan was changed on 08/03/23 from a shower to a complete bed bath. When this writer told RN 2 of the observed home visit, they stated they would have to readdress the Aide Care Plan, and they had not spoken with HHA 1 since 08/03/23.

Based on record review and interview, the hospice Interdisciplinary Group (IDG) failed to update the individualized plan of care with a change in patient condition and failed to ensure notification to and collaboration with the patients attending physician (when an attending physician was designated), for 4 of 7 records reviewed which indicated a change in patient condition (Patients #1, 3, 4, and 6). Findings include: --- 3. A review of Clinical Record #3 revealed an SN PRN visit by RN 4 for a reported fall on 3/27/23 that indicated that Patient #3 had a small abrasion above the right eyebrow and a complaint of neck pain. No measurements of the wound were documented. A review of physician orders for Patient #3 revealed an order for a SCOOP MATTRESS dated 3/29/23 A review of the Plan of Care for Patient #3, order dated 6/2/23 for the Benefit Period of 4/5/23 through 6/3/23 failed to identify the scoop mattress ordered on 3/29/23. 4. A review of Clinical Record #4 revealed a Plan of Care order dated 4/4/23 for the Benefit Period of 4/4/23 through 6/2/23 which evidenced but not limited to, ";3/6/23: Pt had a fall over the weekend resulting in a Fractured left hip, multiple bruising to the Left temple and Left upper extremity" and evidenced ";3/6/23 Patient buttocks are bright red in color". A review of Clinical Record #4 revealed an IDG meeting dated 3/7/23 evidenced on 3/6/23 Pts buttocks are bright red...the RN IDG Note which was submitted on 3/15/23, ";...Wound: N/A...Changes since last IDG: Pt had a fall with no injuries on 3/14/23...Not completely sure if Pts pain is under control from recent Hip Fx. Pt moans, but when asked if...pain...states no. Intergluteal cleft reddened. Pt had choked on food on 3/9/23 while eating dinner, Heimlich performed...Pain managed well with Tramadol 50 mg every 8 hrs. for pain, Tramadol PRN...". The Summary/Comments evidenced, ";Patient continues to be clinically appropriate at the time for hospice as per the report given by IDG team. Medications reviewed by the AN. All frequencies remain appropriate New Problem: No New problems at this time. Pt is well managed on current plan of care interventions: Change made/Discussed during this IDG meeting:" [Left blank]. A review of Clinical Record #4 revealed a IDG meeting note dated 5/16/23, that evidenced ";Impaired Skin Integrity Description: Patient has suspected Deep Tissue Injuries to left heel. Area is closed, black in color. Measures 4 cm x 3 cm x 0.1 cm Patient also has suspected deep tissue injuries to the right heel measuring 2.2 x 1.3 x0.1; closed, black in color. There are deep tissue injuries to the top of the patients right great toe measuring 1 cm x 1 cm x 0.1 cm. Finally patient has a deep tissue injury to the outer right great toe measuring 0.5 cm x 0.5 cm x 0.1 cm, closed and black in color. 4/20/23 deep tissue injuries to bilateral heels remain present. The color is a dark brown or black color. There are two additional pressure areas, black in color to the top of the patient right great toes and outer right great toe; new measurements: Great toe top 0.9 cm x 0.7 cm x 0.1 cm, outer great toe 0.4 cm x 0.4 cm x 0.1 cm, right heel 2 cm x 1.5 cm, x 0.1 cm, left heel 3.3 cm x 3.5 cm x 0.1 cm Writer ordered patient bunny boots...to wear while in bed" On 5/8/23, ";Right heel healed; left heel deep tissue injury remains. New order Apply hydrogel 2 x 2 to left heel. Cover with silicone dressing every other day until healed", evidenced the buttocks were resolved 5/15/23, 4/28/23 identified a new skin tear to the right lower extremity with steri strips applied, on 5/11/23, ";Patient started on Keflex 500 mg three times daily x 7 days for probable skin infection of LLE. New order for dressing: Cleanse skin tear with wound wash, pat dry. Apply collagen silver wafer to wound bed, cover with silicone dressing...Summary/Comments Patient continues to be clinically appropriate at this time for hospice as per the report given by the IDG team. Medications reviewed by the SN. All frequencies remain appropriate New Problem: No new problems noted at this time. Pt is currently well managed with current plan of care interventions: To continue with current interventions and plan of care at this time Change made/Discussed during this IDG meeting: None made during this IDG meeting". A review of the Plan of Care order for the Benefit Period of 4/4/23 through 6/2/23 evidenced Patient #4 was at risk for impaired skin integrity, noted, ";3/6/23: Pts buttocks are bright red in color". No other wounds were identified on the Plan of Care. 5. Record review for Patient #6 revealed of a Skilled Nursing Visit dated 5/15/23 which evidenced a wound to the left buttock, ";onset date 5/14/23, pressure Injury, stage 1, length 2 cm, width 3 cm, depth 0 cm". The record failed to evidence new orders. Record review of an IDG meeting on 5/16/23 evidenced RN 9 submitted a note, dated 5/16/23, ";Pt has stage 1 to coccyx. Barrier cream applied to the coccyx. Education also given to caregivers on repositioning patient in the bed every 2 hours". The record failed to evidence new orders. Record review of a Physician Order dated 6/2/23 for Patient #6 evidenced, ";Wash wound with normal saline or wound wash to left buttocks and pat dry. Apply collagen sheet to wound bed and cover with border dressing. Perform two times per week and prn for soilage or displacement. Caregiver may perform dressing change when hospice not present." This writer requested a current plan of care for Patient #6 for the home visit which was scheduled for 6/5/23 at 11:00 AM to observe wound care. A review of the Plan of Care order dated 6/2/23 of Patient #6 for Benefit Period dated 5/8/23 through 7/6/23 evidenced a wound to the patients knee that was resolved on 6/2/23, with no other wounds identified on the Plan of Care. 6. During an interview with RN 7 on 6/16/23 at 2:22 PM, RN 7 indicated there is no way to notify nurses that are on call of changes with the patients, not on the plan of care, ";no triggers", a nurse would need to read the last couple of visits to get an idea of wounds, and that a wound could get missed easily. 1. A review of an agency policy PC.P50 PLAN OF CARE dated 2022 revealed, ";Policy: The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions...The care and services provided...to patients...are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician, the patient and/or ...representative and the primary caregiver...4. The plan of care is reviewed and updated at specified intervals by the attending physician, the medical director or physician designee and the IDG: a. The written plan is reviewed every 15 days or more frequently as dictated by the patients condition; b. the plan of care is revised as needed, c. Review of the patient plan of care is documented...6. The Hospice written interdisciplinary plan of care is developed and individualized for each patient...reflect patient...goals based upon problems identified in the initial/updated assessments...h. Treatments...interventions to manage pain and symptoms...l. Detail of the scope and frequency of services needed...m. Safety measures to protect against...injury, infection...8. The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions. 9. The hospice interdisciplinary group (in collaboration with the individuals attending physician, if any) must review, revise, and document the individualized plan as frequently as the patients condition requires...10. A revised plan of care must include information from the patients updated comprehensive assessment and must note the patients progress..." A review of an agency policy PC.P55 PLAN OF CARE CONTENT dated 2022 revealed, ";Policy: The plan of care specifies the hospice care and services necessary to meet the patient and family-specific needs...in the comprehensive assessment...Procedure: 1. The patients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The hospice must develop and individualized written plan of care for each patient. The plan of care must reflect patient...goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness...including the following: a. An assessment...b. An identification of services...c. A statement detailing the scope and frequency of services...f. A detailed statement of the scope and frequency of services necessary to meet the specific patient...needs; g. Measurable outcomes anticipated from implementing and coordinating the plan of care..." An agency document dated 2022, titled, 'PC.A40 ATTENDING PHYSICIAN' stated, "POLICY: Hospice patients have a right to choose an attending physician to provide initial and ongoing management of the medical component of the patient's care... PROCEDURE: 1. At the time of admission to hospice the patient is encouraged to designate an attending physician who will have the most significant role in the determination and delivery of the patient's medical care... 5. The patient's attending physician is responsible for: a. Management of the patient's medical care, particularly those areas not related to the terminal illness with respect of the patient choices; 6. The hospice nurse notifies the attending physician of all changes in the patient's condition; ..." 2. In an interview 6-5-2023 at 10:20 AM, Person C indicated Entity V was a Medicare part B provider of wound care supplies. When queried as his/her role indicated title was Clinical Care Representative, and that they gave advice and recommendations for wound care supplies and also orders supplies. Indicated had a relationship with the hospice agency and used a secure chat server Tiger Text to communicate through a wound thread using photographs and texts. When the agency would get a patient they contacted Person C, but typically did not communicate by telephone calls. Person C will then recommend dressings, ";then the MD signs off on the order." When queried, ";In your recommendation do you create an order that would say: cleanse with this, apply this, secure with this, change every so many days?" Person C stated, ";Yes." Indicated further that the process involves the order being created, sent back through Tiger Text, then the hospice office processes this and ensures the MD signs. Indicated that Tiger Text deletes the texts and photographs after 30 days. On 6-2-2023 at 10:57 AM, the Administrator indicated Nurse Practitioner (NP) X with Entity W, refused to sign off on wound care orders for Patient #1 as NP (X) indicated was not aware of these wounds. In a telephone interview on 6-5-2023 at 1:56 PM, the attending provider, NP X, with Entity W, indicated became the Primary Care Provider (PCP) for Patient #1 in March of 2023, began treating the patients edema in April with wraps to legs and diuretics, in order to address patients pain and comfort. When queried if NP X had ever seen the wounds on Patient #1s legs indicated was told about them, and saw the patient on 5-4-2023 and there were ";no open areas" but had blistering. When queried if the agency had requested wound care orders from him/her, NP X indicated was not aware of the wounds, and indicated the agency presented orders to be signed after the patient had been hospitalized on 5-14-2023, and so NP X refused to sign them. NP X was queried as to the visit performed on 5-11-2023 by LPN 1 and whether NP X had actually declined to see the wounds, as documented. NP X indicated that was an inaccurate statement and indicated had made plans with LPN 1 to meet at the patients at 11:00 AM that day. LPN 1 was not there when NP X arrived. They spoke later and NP X indicated to LPN 1 if wound photographs had already been taken, to go ahead and send them. Indicated should have made LPN 1 'tear down' the dressings to visualize the wounds, it would have been the first time NP X had seen them. Indicated the photographs did not arrive timely and when they were finally received on 5-15-2023, indicated the wrappings ordered for the Patient #1s legs were not appropriate. Stated, ";I was sickened" and indicated had noted a significant wound to the right inferior calf, multiple areas of necrosis, slough covered the wound bed, would not have ordered to have wounds wrapped with necrosis present, and noted significant infection as the right medial anterior calf looked infected to NP X. Had not spoken with hospice agency since Patient #1 was hospitalized on 5-14-2023, was aware the patient had expired. When queried as to any concerns with the agency, was concerned there was ";always a lack of communication" and had requested to have a copy of the Plan of Care but only ever received the IDG meeting notes. Indicated having spoken to a hospice agency liaison about getting that information. States nursing communication has since improved, but Plans of Care were yet to be received. On 6-5-2023 at 2:39 PM, received a follow-up phone call from NP X, with Entity W. Indicated it was his/her expectation that the hospice agency would run all orders for Patient #1 through [NP X]. It was not NP Xs understanding that there would be a need to co-sign with the hospice physician. NP X also stated received most communications through LPN DD, with Entity W, and/or the LPNs cell phone. On 6-5-2023 at 2:50 PM, the Administrator confirmed wound care orders from Person C (with Entity V) for Patient #1, written 4-7-2023, titled Physician Order NORTH had been signed by Dr 3. Indicated NP X gets updated on such orders. When queried as to how she was certain NP X saw the orders, indicated ";We verbally will tell her stuff, but [NP Xs] doc [Dr CC] signs everything". Requested documents showing same, these were not submitted. In an interview 6-5-2023 at 3:40 PM, when discussing the 'Tiger Text' wound care thread shared with Person C (representative for DME company, Entity V), the Administrator indicated this is how the agency communicated with Person C. When queried as to how wound care orders would get to NP X with Entity W, the Administrator could not answer. Indicated all RN case managers and LPNs have access to this wound thread, NP X did not. Indicated all parties are alerted when someone makes an entry into the log. Indicated hospice Dr 3 receives faxes and then signs these orders, and hospice Dr 1 and Dr 2 sign orders in the agencys EMR.

Based on record review, observation, and interview, the agency failed to ensure a system of communication was in place with other entities to ensure the agency was responsible for, and directed, coordinated, and/or supervised all care and services provided to all patients who received services from others in 2 of 7 records reviewed. (Patients #1 and #6) Findings include: --- 3. On 6/5/23 at 10:45 AM, a home visit was conducted at Patient #6s to observe SN Left buttock wound care with RN 2. Upon assessment and wound care as ordered to the left buttock of Patient #6, 2 other dressings were identified one on the Right forearm, and one on the left lower back. RN 2 assessed both areas, taking a picture of the right forearm and measured the area, to send on the wound thread. The 2 small areas on the left lower was not measured, the skin was intact but red, with RN 2 applying A & D ointment to the area. Record review of Patient #6 for a Plan of Care order dated 6/2/23 for the Benefit Period dated 5/8/23 through 7/6/23 evidenced a wound to the patients knee that was resolved on 6/2/23, with no other wounds identified on the Plan of Care. 4. During an interview on 6/5/23 at 11:30 AM, RN 2 indicated they were unaware of the other 2 dressings, and they were not sure who was putting the dressings on Patient #6, and indicated some people will use protective coverings. RN 2 further indicated they would send the picture through the wound thread, and they will write orders for us". During an interview with Person Y, a family member of Patient #6, on 6/8/23 at 9:46 AM, indicated they had informed LPN 1 on 5/29/23 of the wound on Patient #6s left lower back, that the patient had been scratching the area. Person Y asked if there was a problem. This writer explained to Person Y, whenever there was a change with Patient #6, the hospice agency needs to be informed, Person Y indicated they hadnt realized the agency needed to be notified and verbalized understanding. On 6/8/23 at 5:19 Person Y phoned this writer and indicated they had private nurses coming in to care for Patient #6 at various times, and that one of those nurses had put the dressings on the back, and further indicated Entity AA was also providing services for Patient #6. Person Y indicated again; that they had informed LPN 1 of the wound on the left lower back. The area on the right forearm, Person Y felt had come from a privately hired caregiver (not affiliated with Care Hospice or Entity AA), whom they ";fired". Person Y indicated to this writer they had informed Entity AA and the other private nurses, any time there is a change with the patient that they are to call Care Hospice. During an interview on 6/8/23 at 11:32 AM, LPN 1 indicated they were not aware of the wounds on the right forearm and left lower back. During an interview on 6/12/23 at 4:07 RN 9 indicated there is a communication log in the home for people to use to communicate and that there is a high turnover rate of caregivers, that its difficult to educate all of them. During an interview on 6/8/23 at 4:45 PM, the Administrator indicated they would expect the nurses to assess, report, and document the wound(s), possibly send a picture of it on the wound thread and obtain wound orders, then indicated that wound pictures are not part of the clinical record but should be. 1. A review of an agencys policy PC.90 COORDINATION OF SERVICES dated 2022, revealed, ";Policy...coordinated and effective ongoing sharing of information...with all contracted service providers and in all settings...e. Provide for ongoing sharing of information with other non-hospice healthcare providers....2. The Director of Clinical Services assumes overall responsibility for ensuring there are effective methods of communication..." 2. In a telephone interview on 6-5-2023 at 1:56 PM, the attending provider, Nurse Practitioner (NP) X, with Entity W, indicated became the Primary Care Provider (PCP) for Patient #1 in March of 2023, began treating the patients edema in April with wraps to legs and diuretics, in order to address patients pain and comfort. When queried if NP X had ever seen the wounds on Patient #1s legs indicated was told about them, saw the patient on 5-4-2023 and there were ";no open areas" but had blistering. When queried if the agency had requested wound care orders from him/her, NP X indicated was not aware of the wounds, and indicated the agency presented orders to be signed after the patient had been hospitalized on 5-14-2023, and so NP X refused to sign them. NP X was queried as to the visit performed on 5-11-2023 by LPN 1 and whether NP X had actually declined to see the wounds, as documented. NP X indicated that was an inaccurate statement and indicated had made plans with LPN 1 to meet at the patients at 11:00 AM that day. LPN 1 was not there when NP X arrived. They spoke later and NP X indicated to LPN 1 if photographs had already been taken, to go ahead and send them. Indicated should have made LPN 1 'tear down' the dressings to visualize the wounds, as it would have been the first time NP X had seen them. Indicated the photographs did not arrive timely and when they were finally received on 5-15-2023, indicated the wrappings ordered for the Patient #1s legs were not appropriate. Stated, ";I was sickened" and indicated noted a significant wound to the right inferior calf, multiple areas of necrosis, slough covered the wound bed, would not have ordered to have wounds wrapped with necrosis present, and noted significant infection as the right medial anterior calf looked infected to NP X. Had not spoken with hospice agency since Patient #1 was hospitalized on 5-14-2023, was aware the patient had expired. When queried as to any concerns with the agency, was concerned there was ";always a lack of communication" and had requested to have a copy of the Plan of Care but only ever received the IDG meeting notes. Indicated having spoken to a hospice agency liaison about getting that information. States nursing communication had since improved but Plans of Care were yet to be received. On 6-5-2023 at 2:39 PM, received a follow-up phone call from NP X, who indicated it was his/her expectation that the hospice agency would run all orders for Patient #1 through [NP X]. It was not NP Xs understanding that there would be a need to co-sign with the hospice physician. NP X stated she received most communications through LPN DD with Entity W, and/or the LPNs cell phone. On 6-5-2023 at 2:50 PM, the Administrator confirmed wound care orders from Person C (with Entity V) for Patient #1, written 4-7-2023, titled Physician Order NORTH had been signed by Dr 3. Indicated Dr 3 helps with everything. Indicated NP X gets updated on such orders. When queried as to how she was certain NP X saw the orders, indicated ";We verbally will tell her stuff, but [NP Xs] doc [Dr CC] signs everything". Requested documents showing same, these were not submitted. On 6-5-2023 at 3:40 PM, when discussing the 'Tiger Text' wound care thread shared with Entity V, the Administrator indicated this is how the agency communicated with Person C, representative of the DME (Entity V). When queried as to how orders would get to attending provider, NP X (with Entity W), the Administrator could not answer. Indicated all RN case managers and LPNs have access to this wound thread, NP X did not. Indicated all parties are alerted when someone makes an entry into the thread. Indicated hospice Dr 3 receives faxes and then signs these orders, hospice Dr 1 and Dr 2 sign orders in the agencys EMR. On 6-8-2023 at 10:41 AM, when queried as to whether NP X got to see the wound care orders for Patient #1, the Administrator indicated that there wasnt a way to track faxes that are sent, and admittedly had no proof.

Based on record review, observation, and interview, the hospice failed to ensure hospice staff followed accepted standards of practice in relation to infection control in 1 of 3 patient care visits observed (Patient #7.) Findings include: --- 1. A review of an agencys policy PCI10 INFECTION CONTROL – HAND HYGIENE AND BAG TECHNIQUE, dated 2022 revealed, ";1. Use of alcohol-based hand sanitizer is preferred...a. Before and after caring for patients...b. Between tasks on the same patient...d. After touch objects that are potentially contaminated...:" A review of the Centers for Disease Control on 1/23/23, "WHEN TO PERFORM HAND HYGIENE," (https://www.cdc.gov/handhygiene/providers/), revealed that, "Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene:  Use an Alcohol-Based Hand Sanitizer or wash with soap and water immediately before touching a patient...before moving from work on a soiled body site to a clean body site on the same patient... after touching a patient or the patient's immediate environment...or contaminated surfaces, or immediately after glove removal...WHEN AND HOW TO WEAR GLOVES" revealed, "Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membrane...potentially contaminated skin or contaminated equipment could occur  ... Change gloves and perform hand hygiene during patient care, if...moving from work on a soiled body site to a clean body site on the same patient..." On 6/6/23, 11:00 am at Entity O, a skilled nursing facility (SNF), Licensed Practical Nurse (LPN) 1 was observed providing wound care to Patient #7. The visit was initiated by LPN 1, who washed their hands in the patients bathroom, then asked this writer if it was appropriate to get into their nursing bag to retrieve a barrier without using alcohol hand sanitizer, then created a barrier to place all items on the bedside table. LPN 1 obtained Patient #7s vital signs and listened to their anterior lung sounds and then bowel sounds. As LPN 1 cleaned their equipment, they placed the equipment immediately into their nursing bag. LPN 1 performed hand hygiene, donned a pair of gloves and removed Patient #7 dressing from the left lateral abdomen. LPN 1 threw the dressing and gloves into the trash, hand hygiene was performed, and doffed a pair of gloves. LPN 1 cleansed the wound with wound wash and gauze, then took a piece of silver alginate, tore it to the approximate size, placed it on the wound, and covered it with a border dressing. LPN 1 doffed their gloves and washed their hands in the patients bathroom. LPN 1 failed to change their gloves and perform hand hygiene after cleansing the wound and before dressing the wound and failed to allow dwell time of their equipment prior to placing the items into their nursing bag. During an interview with the administrator on 6/8/23 at 4:42 PM, the administrator indicated that a full head-to-toe assessment should have been completed, and hand hygiene with a glove change should have been performed after the wound was cleaned and indicated they would have to check into the dwell time. During an interview on 6/16/23 at 10:57 the alternate administrator indicated they do not have a clinical procedure manual regarding hand hygiene.

Based on record review and interview, the hospice agency failed to ensure complete integumentary assessments on patients and failed to complete accurate updates of the comprehensive assessments by the interdisciplinary group in 3 of 7 record reviews. (Patients #1, 3, and 7) The cumulative effect of these deficient practices resulted in the agency having an Immediate Jeopardy at 42 CFR 418.54, Initial and Comprehensive Assessment of the Patient, with the likelihood to affect all 118 current patients receiving hospice services from this provider. Findings include: --- 1. A review of an agencys policy PC.C70 COMPREHENSIVE ASSESSMENT – UPDATES dated 2022 revealed, ";...1. An update of the comprehensive assessment is conducted by the hospice interdisciplinary team in collaboration with the patients attending physician as frequently as the patients condition warrants...a. Identification of changes that have occurred since the initial assessment; 2. Information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patients plan of care as needed. 3. Documentation of the IDGs care planning meetings reflects the ongoing reassessment of the patient/caregivers status and needs." A review of an agencys policy PC.C30 CLINICAL RECORDS dated 2022, revealed ";Policy...The record is complete...accurately documented...z. Complete documentation of all known services and significant events. Documentation must show that effective interchange, reporting, and coordination of care occurs...i. Each entry to the patient record must be current, accurate..." 2. Record review of clinical record for Patient #1 evidenced an election date of 12/29/2022, with diagnoses which included but were not limited to: senile degeneration of the brain (mental deterioration that is associated with or the characteristics of old age), frequent urinary tract infections, and sinus node dysfunction (disorders that affect the heart's natural pacemaker, causing irregular heart rhythms that can be too slow) with pacemaker (an electronic device that is implanted in the body to monitor heart rate and rhythm and gives the heart electrical stimulation when it does not beat normally). Patient #1 resided at an assisted living facility (ALF), Entity A, in the Memory Care unit. The review indicated edema to the bilateral lower extremities was identified on 2/18/23 and the cause was determined to be related to the patients preference to remain in their recliner throughout the day and overnight, refusing to lay in bed or recline in the chair. Concerns for the possibility of dependent edema (gravity-related swelling in the lower body), and for unrelieved pressure on the buttocks were also identified. The attending provider, Nurse Practitioner X with Entity W, and ALF Memory Care staff were jointly consulted and conferenced as to how to further avoid any pressure ulcers and impairment of skin integrity. Record review evidenced a skilled nursing visit on 3/23/23 by RN 7, indicating the right buttock wound was redressed with a collagen pad and bordered dressing. A new intervention appears as a non-specific ";wound", the site of the wound is not named. The record failed to evidence current wound care orders related to this visit. Record review evidenced a skilled nursing visit on 3/29/23, RN 7 identified a new wound to the left shin. The intervention of non-specific ";wound" remained unchanged and new wounds or sites were not added. The record failed to evidence current wound care orders related to this visit. Record review evidenced a skilled nursing visit on 3/30/23 and 3/31/23, LPN 1 failed to document wound care to the left buttock. The intervention for non-specific ";wound" remained unchanged. The record failed to evidence current wound care orders related to this visit. Record review evidenced a skilled nursing visit on 4/1/23 and 4/2/23 RN 1 failed to document wound care to the left buttock. The intervention for non-specific ";wound" remained unchanged. The record failed to evidence current wound care orders related to this visit. Record review evidenced a skilled nursing visit on 5/9/23, RN 2 completed a PRN (as needed) visit related to a reported fall. A complete assessment was not documented. The right leg wound was observed and redressed, no other wounds were reported observed. Record review evidenced a PRN (as needed) skilled nursing visit on 5/12/23, RN 1 indicated the visit was related to a reported fall. A new skin tear was assessed and dressed. A complete assessment was not documented, and the patients other wounds were not addressed or assessed. 3. A review of Clinical Record #3 revealed an SN PRN visit by RN 4 for a reported fall on 3/27/23 that indicated that Patient #3 had a small abrasion above the right eyebrow and a complaint of neck pain. No measurements of the wound were documented. The record failed to evidence physician notification or new orders related to this visit. A review of Clinical Record #3 revealed an SN visit on 3/29/23 by RN 5 indicated, ";Patient noted with symptoms of neck pain" with a new order for diclofenac muscle rub prn for neck, bilateral shoulder, and knees. There was no mention of the fall and the small abrasion above the right eyebrow. 4. On 6/6/23 at 11:00, a home visit at Patient #7 was conducted to observe LPN (Licensed Practical Nurse) 1 perform wound care. The visit was initiated by LPN 1, who washed their hands in the patients bathroom, and created a barrier to place all items on the bedside table. LPN 1 obtained Patient #7s vital signs and listened to their anterior lung sounds and then bowel sounds. LPN 1 completed the wound care and proceeded to clean up the area. LPN 1 failed to listen to posterior lung sounds, assess the patients posterior side, assess the patients lower extremities, and measure arm circumference. 5. During an interview with the administrator on 6/8/23 at 4:42 PM, the administrator indicated that a full head-to-toe assessment should have been completed with each visit. During an interview on 6/12/23 at 4:12 PM, RN 9 indicated each visit is automatically filled in from the previous visit, that everyone is taught to delete the information and complete their visit, and that full head-to-toe assessments were expected with each visit.

The hospice agency failed to ensure its IDG team addressed all of the patient's care needs and services, to include the condition and number of wounds, failed to document their discussions/care plan updates, failed to ensure that the care and services provided were based on assessments, and failed to provide ongoing sharing of information with other non-hospice providers in 5 of 7 records reviewed. (Patients #1, 2, 3, 4 and 6) The cumulative effect of these deficient practices resulted in the agency having an Immediate Jeopardy at 42 CFR 418.56, Interdisciplinary Group, Care Planning, and Coordination of Services, and has the likelihood to affect all 118 current patients receiving hospice services from this provider. --- A review of an agencys policy PC.I45 INTERDISCIPLINARY GROUP, dated 2022, revealed, ";...IDG composed of qualified individuals who assess, plan, provide, and evaluate the care and services provided...ensures the ongoing sharing of information between all disciplines...2. ...meet the physical, medical...needs of the hospice patients...3. ...must supervise the care and services. 4. The hospice must designate a registered nurse that is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patients...needs and implementation of the interdisciplinary plan of care...including services of the IDG...5. A registered nurse coordinates the implementation of the plan of care for each patient...c. Communication of findings to the attending physician Medical Director and IDG members; d. Implementation of the plan of care...f. Care coordination and case management; g. Ongoing evaluation and assessment...h. Recommending to the IDG modifications to the plan of care based on ...response to hospice services; j. Utilization review; l. Communication between hospice and other health care providers ...8. The IDG is responsible for: c. Directing, coordinating and supervising hospice care and services ...A review of an agencys policy PC.I50 INTERDISCIPLINARY GROUP MEETING dated 2022, revealed, ";The IDG meets at least every 15 days and more often as necessary to plan and coordinate the care and services...1. ...reviews each patients plan of care every two weeks, or more frequently if needed...to continually monitor the care and services...2. During the interdisciplinary group meeting the patients plan of care is reviewed and updated and changes are communicated to the patients attending physician with requests for new orders when needed. 3. The Interdisciplinary Team /Group reviews and updates the plan of care...during IDG conferences which include: b. Identifying obstacles to and solutions for access of care issues; ...d. Reviewing updated comprehensive assessment; e. Determining level of services...f. Developing, reviewing, and modifying...plans of care, as appropriate, considering: i. Changes in patients clinical status...g. Oversight of plan of care by the Medical Director; h. Evidence of communication with the attending physician...and that approval is obtained if there is a revision to the plan of care...l. Evaluating and documenting patient/family progress toward achievement of expected outcomes, and revising goals...4. The interdisciplinary group meeting follows a consistent agenda to ensure that all patients are reviewed, and that appropriate care planning occurs...5. The clinical record or minutes of the IDG document that the plan of care was reviewed and updated and that effective interchange, reporting and coordination of patient/family care occurs...7. The focus of the IDG meeting is reviewing the patients plan of care and revising it as needed, based on updated comprehensive assessments." A review of an agencys policy PC.90 COORDINATION OF SERVICES, dated 2022, revealed, ";Policy The IDG ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines ... a. Ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided; b. Ensure that the care and services are provided in accordance with the plan of care; c. Ensure that the care and services provided are based on all assessments ... d. Provide for and ensure the ongoing sharing of information ... e. Provide for ongoing sharing of information with other non-hospice healthcare providers ... 2. The Director of Clinical Services assumes overall responsibility for ensuring there are effective methods of communication ... 4. Each patient/caregiver is discussed ... 5. All members of the IDG participate in care planning and document problems, interventions, goals observations ... based on the assessed and reassessed needs..." A review of an agencys policy PC.C70 COMPREHENSIVE ASSESSMENT – UPDATES, dated 2022 revealed, ";...1. An update of the comprehensive assessment is conducted by the hospice interdisciplinary team in collaboration with the patients attending physician as frequently as the patients condition warrants ... a. Identification of changes that have occurred since the initial assessment; 2. Information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patients plan of care as needed. 3. Documentation of the IDGs care planning meetings reflects the ongoing reassessment of the patient/caregivers status and needs." 2. A record review of the clinical record for Patient #1 evidenced an election date of 12/29/2022, with diagnoses that included, but were not limited to, senile degeneration of the brain (mental deterioration that is associated with or the characteristics of old age), frequent urinary tract infections, and sinus node dysfunction (disorders that affect the heart's natural pacemaker, causing irregular heart rhythms that can be too slow) with a pacemaker (an electronic device that is implanted in the body to monitor heart rate and rhythm and gives the heart electrical stimulation when it does not beat normally). Patient #1 resided at an assisted living facility (ALF) Entity A, in the Memory Care unit. The review indicated edema to the bilateral lower extremities was identified on 2/18/23 and the cause was determined to be related to the patients preference to remain in their recliner throughout the day and overnight, refusal to lay in bed or recline in the chair. Concerns for the possibility of dependent edema (gravity-related swelling in the lower body), and for unrelieved pressure on the buttocks were also identified. The attending provider, Nurse Practitioner X with Entity W, and ALF Memory Care staff were jointly consulted and conferenced as to how to avoid any pressure ulcers and impairment of skin integrity. The record review evidenced registered nurse (RN) 7 completed a recertification skilled nursing visit on 3-21-2023, and discovered a new wound to the right buttock, ";Onset Date: 3-20-2023" ... ";Treatment: AREA CLEANSED WITH SOAP AND WATER THEN PAT DRY. [sic]COLLOGEN PAD PLACED OVER WOUND BED THEN SECURED IN PLACE WITH BORDER DRESSING. MEASUREMENTS AND PICTURES SENT TO WOUND CARE AND NOW WAITING ON ORDERS...". The Summary/Comments section stated, ";Current Treatments: WOUND CARE TO RIGHT BUTTOCKS OVERSEEN BY HOSPICE WOUND CARE TEAM." Review of a skilled nursing care visit note on 3/23/23 by RN 7, indicating the right buttock wound was redressed with a collagen pad and bordered dressing. A new intervention appeared as a non-specific ";wound", the site of the wound was not named. The record failed to evidence wound care orders were obtained prior to the furnishing of wound care services on this visit. A skilled nursing visit note on 3/29/23, RN 7 identified a new wound to the left shin. The intervention of non-specific ";wound" remained unchanged and new wounds or sites were not added. The record failed to evidence current wound care orders related to this visit and the wound care services provided to the left shin. A record review evidenced a skilled nursing visit on 3/30/23 and 3/31/23, LPN 1 failed to document wound care to the left buttock. The intervention for non-specific ";wound" remained unchanged. The record failed to evidence current wound care orders related to wound care services furnished for the left buttock. Review of a nursing care visit note on 4/1/23 and 4/2/23 by RN 1 failed to evidence documentation of an assessment or wound care to the left buttock. The intervention for non-specific ";wound" remained unchanged. 3. Record review evidenced an IDG meeting note dated 4-4-23 contained a nursing narrative note dated 4-2-2023, RN 7 stated, ";WOUNDS: NONE ... NOW DAILY VISITS TO TRY TO CONTROL SWELLING TO BLE [Bilateral Lower Extremities] WITH WEEPING AND TRY AND HEAL WOUND TO BUTTOCK. PT IS HAVING BLE WRAPPED DAILY WITH 2 LAYER WRAP. EVERY TIME GOING IN THE WRAPS HAVE BEEN REMOVED ALONG WITH DRESSING ON BUTTOCK. PT REFUSES TO PROP FEET WHILE SITTING IN RECLINER AND DOES NOT GET IN THE BED AT NIGHT. CONSTANT COMMUNICATION WITH FACILITY STAFF FACILITY NP AND DTR HAVE BEEN DONE...[PROVIDER X] HAS MADE MEDICATION CHANGES AS NEEDED AND KEEPS A CLOSE EYE ON PT STATUS. THERE IS FRUSTRATION WITH ALL INVOLVED ON HOW TO MANAGE THIS PATIENT. A CARE PLAN MEETING WILL BE SET UP FOR THIS WEEK TO TRY AND COME UP WITH A SOLUTION..." IDG meeting Summary/Comments stated, ";Patient continues to be clinically appropriate at this time for hospice as per the report given by IDG team. Medications reviewed by the SN. All frequencies remain appropriate Change made/discussed during this IDG meeting: No changes made on this IDG. Pt remains hospice appropriate with current plan of care." The IDG notes failed to evidence discussion or collaboration among the IDG team members related to two (2) new wounds, or coordination of care concerns detailed by RN 7. An IDG meeting dated 4-12-2023 contained a nursing narrative note dated 4-11-2023, RN 5 stated, WOUNDS: RIGHT BUTTOCK ...Wound care is following ... CHANGE SINCE LAST IDG: Patient is being seen daily for dressing changes. Facility does not want to do the dressing changes. Patient [#1] having pain in hip and knees when her legs are elevated. Facility NP discontinued scheduled Tramadol. Patient daughter is agreeable to restart Tramadol will call the NP to discuss..." The IDG meeting Summary/Comments stated, ";Patient continues to be clinically appropriate at this time for hospice per the report given by IDG team. Medications reviewed by the SN. All frequencies remain appropriate." The IDG meeting failed to evidence discussion or collaboration among IDG team members related to the patients wounds, coordination of care, and concerns identified by RN 5 about the ALF. Review of a skilled nursing visit note on 4/13/23, RN 7 evidenced documentation of a wound on the left outer ankle. A review of a skilled nursing visit note on 4/24/23, evidenced RN 7 documented a new wound to the right lower leg and indicated the edematous leg had previously blistered and was now opened. ";pictures were taken for WOC [acronym for Wound and Ostomy Nurse, who possesses a baccalaureate degree, has received special training, and is certified in wound and ostomy care.]" Review of an IDG meeting note dated 4/26/23, evidenced a nursing narrative note dated 4-25-2023, RN 5 stated, "; ...WOUNDS: R buttock...Wound care is following...There is an area on patients left leg that measures 4cm x 3.5 cm x 0.3 cm. Waiting on wound care orders for that wound. Patient no longer on daily visits and is being seen 3 times a week. Some days legs are dry but recently they are draining a lot. There are large blisters that form and drain slowly...had a lot of pain...facility not wanted to give pain meds even though...scheduled...finally reached agreement with facility and NP to give Tramadol for pain...also increased Torsemide 20mg to two times a day for 7 days and added Keflex...for possible cellulitis...INFECTIONS: NONE..." The IDG Summary/Comments stated, ";Patient continues to be clinically appropriate at this time for hospice as per the report given by IDG team. Medications reviewed by the SN. All frequencies remain appropriate." The IDG meeting failed to evidence discussion or collaboration among IDG team members related to all of the patients wounds. A review evidenced a skilled nursing visit note on 5/1/23, RN 7 documented six (6) additional wounds, ";Wound 3 – Left lateral calf...Wound 4 - Left lower leg #1... Wound 5 - Left lower leg #2... Wound 6 - Left lower leg #3... Wound 7 - Right lower leg #1..." Of particular note, ";Wound 8 - Right lower leg #2, Status: Open, Onset date: 5/1/2023, Type: Venous Ulcer, Size: Length: 5cm, Width: 4cm, Depth: 0.2 cm, Wound bed: White..." A review of a 5/5/23, LPN 1, nurse care visit note evidenced the LPN documented wound care completed to legs and buttocks "There are no dressings on legs upon arrival... Legs were washed with soap and water and dried with a clean towel. Legs are slightly red. Wound to right leg 100% Epithelial tissue, pearly white in color. Wound to left leg is 100% Epithelial tissue, pearly white in color with some pale pink ... Patient has several areas that scabbed over on legs ..." A review of a skilled nursing care visit note on 5/8/23, evidenced LPN 1 documented wound care completed to legs and buttocks. Indicated, ";Patient having [sic]patient to knees and buttocks... Spoke with [Provider X, with Entity W] wounds were reported and observed." A review of a skilled nursing care visit note on 5/10/23, evidenced LPN 1 noted Patient #1 was, ";becoming weaker." ";Dressing intact to right leg no dressing on left leg. Wound care completed area to legs...Wound to right leg 100% Epithelial tissue, 50% pearly white 50% pink, Wound to left leg is 100% Epithelial tissue, 25% pearly white 75% pale pink." A review of a skilled nursing visit note on 5/11/23, LPN 1 indicated Nurse Practitioner X with Entity W arrived during the visit and discussed recent lab results and decreased diuretics which had recently been prescribed to aid in reducing the patients ongoing bilateral lower extremity edema. ";Offered to remove dressings for [Provider X] to assess the wound [Provider X] declined...Wound to right leg 100% Epithelial tissue, 25% pearly white 75% pink, Wound to left leg is 100% Epithelial tissue, 50% pearly white 50% pale pink...Updated [Person C] wound care nurse." Person C was employed by a contracted DMEPOS (Entity V) provider and was a physical therapy assistant, not a wound care nurse. A record review of a PRN (as needed) skilled nursing visit note on 5/12/23, evidenced RN 1 indicated the visit was related to a reported fall. A new skin tear was assessed and dressed. A complete integumentary assessment was not documented and there was no documentation of an assessment of Patient #1's other wounds. A review of an IDG Meeting dated 5/20/23, evidenced a nursing narrative note dated 5/5/23, RN 5 stated, "; ... WOUNDS: R buttock is healing well. Wound Care is following... Patient now has multiple open areas on [their] legs from blisters that have ruptured. Wound care has sent supplies and is following this closely... CHANGE SINCE LAST IDG: Patient has continued to have large amounts of weeping and drainage from [their] legs. Consulted with facility NP [Provider X] and we have increased Torsemide 40 mg BID and Metolazone 5mg on Mondays. When last seen on 5/3/23, her legs were dry and dressings were stuck to legs causing pain. New orders from wound care are when dry to apply collagen sheets to legs and cover with absorbent dressings and wrap with kerlix. Edema is down from +4 to +3. Patient is to get Tramadol before dressing changes..." The IDG Summary/Comments stated, ";Patient continues to be clinically appropriate at this time for hospice as per the report given by IDG team. Medications reviewed by the SN. All frequencies remain appropriate." There was no wound care consultant, a contracted DMEPOS (Entity V) provider with a physical therapy assistant (Person C), provided wound care orders based on photographs and a description texted by the hospice's nurses. The IDG meeting note failed to evidence discussion or collaboration among IDG team members related to the patients wounds and coordination of care. 4. A review of Clinical Record #2 revealed an SN (skilled nursing) visit note on 5/8/23, at 13:35 to 14:05 PM, that evidenced that Patient #2 had a new right back ankle abrasion, .7cm L, .5cm W, .1 cm depth. The wound was cleansed a band-aid was applied and heel protectors applied. Education was documented as completed with the facility staff regarding the abrasion of the right heel. A review of a Physician Order dated 5/8/23 at 3:48 PM, for Patient #2 evidenced wound orders ";Cleanse wound with wound wash, apply a foam dressing one time per week." The SN provided wound care without IDG input or physician orders. A review of a Physician Order date 5/10/23 at 14:20, for Patient #2 evidenced a change in service that HHA (home health aide) visits were to be increased to 3 times a week starting the week of 5/15/23. A review of an IDG meeting note on 5/10/23, evidenced by a note by RN 8 indicating ";Wound: None, Changes since last IDG: No Changes since the last IDG..." The IDG summary evidenced, ";Patient continues to be clinically appropriate at this time for hospice as per the report given by the IDG team. Medications reviewed by the SN. All frequencies remain appropriate." The IDG failed to address the right ankle abrasion. All IDG disciplines failed to discuss the wound, treatments, and interventions, why HHA visits were increased, and the risk of aspiration with any diet changes and/or recommendations. A review of an SN visit note dated 6/5/23 by RN 8, evidenced ";r ankle abrasion has completely healed...Will increase SN [skilled nursing] Visits to twice weekly to monitor patient." A review of a Physician Order on 6/5/23 at 12:56 PM signed by RN 8, evidenced SN visits were increased to 2 times a week. A review of an IDG meeting note on 6/7/23, revealed the RN IDG note indicated the right heel wound was healed, no changes since the last IDG meeting, and the frequency for SN was 2 times a week, the summary/comments evidenced, ";Patient continues to be clinically appropriate at this time for hospice as per the report given by the IDG team. Medications reviewed by the SN. All frequencies remain appropriate." The healing of the right heel wound was a change that failed to be addressed by the IDG. All disciplines of the IDG failed to evidence a discussion/comments on why SN visits were increased to 2 times a week. 5. A review of Clinical Record #3 revealed a care visit note on 2/12/23 by LPN 1 from 12:10 PM to 12:40 PM, which indicated the visit was a PRN (as needed) visit for a fall follow-up. Patient #3 was in the dining room and refused vital signs to be taken. LPN 1 indicated the facility nurse reported the fall occurred around 5 AM and Patient #3 had fallen out of the bed onto the floor, opposite the floor mat placed next to one side of the bed. LPN 1 indicated having inspected the bed, found it to be without wheel locks, and reported it to the DME company. The record failed to evidence the attending physician was notified of the fall and the defective DME. The IDG meeting note on 2/21/23 for Patient #3 IDG summary evidenced, ";Patient continues to be clinically appropriate at this time for hospice as per the report given by IDG team Medications reviewed by the SN All Frequencies remain appropriate at this time New Problem: No new problems, pt is well managed by current hospice plan of care Interventions: No New interventions at this time Change made/Discussed during this IDG meeting: None at this time. Pt remains appropriate with current plan of care." All disciplines of the Interdisciplinary Group failed to discuss the fall and that the DME company supplied a patient hospital bed without wheel locks. A review of an SN PRN care visit note by RN 1 on 3/5/23 from 10:30 AM to 11 AM, evidenced Patient #3 had a fall earlier in the morning without injury. The record failed to evidence the attending physician was notified to discuss possible changes to the care plan related to the 2 recent falls. A review of the IDG meeting note dated 3/7/23, for Patient #3, the IDG RN, evidenced, ";Pt continues to have wound to the heel that is painted with betadine. There is no drainage at this time. Pt is also becoming more weak and is being moved out of memory care. Pt is utilizing the wheelchair more. Pt continues to have aggressive behaviors with care." All IDG disciplines failed to evidence an IDG summary and failed to recognize or discuss the fall that occurred on 3/5/23. A review of a Skilled Nurse PRN care visit note by RN 4 for a reported fall on 3/27/23, indicated that Patient #3 had a "small" abrasion above the right eyebrow and a complaint of neck pain. A complete pain assessment was not documented and the visit failed to document the measurement of the new wound/abrasion. A review of physician orders for Patient #3 revealed an order for a SCOOP MATTRESS dated 3/29/23. A review of an SN care visit note on 3/29/23 by RN 5 indicated, ";Patient noted with symptoms of neck pain" with a new order for diclofenac muscle rub prn for neck, bilateral shoulder, and knees. There was no notation of the fall or an assessment of the small abrasion above the right eyebrow or a complete pain assessment. The visit note failed to document a complete pain assessment or the abrasion above the right eyebrow sustained on 3/27/23. A review of the IDG meeting note dated 4/4/23 for Patient #3, evidenced, ";Patient continues to be clinically appropriate at this time for hospice as per the report given by IDG team. Medications reviewed by the SN. All frequencies remain appropriate Change made/Discussed during this IDG meeting: No changes made on this IDG. Pt remains hospice appropriate with current plan of care." All disciplines of the IDG failed to recognize and discuss the fall that occurred on 3/27/23, the abrasion above the right eyebrow, the patient's neck pain, the order for diclofenac, and failed to identify the new order for a scoop mattress obtained on 3/29/23. 6. A review of Clinical Record #4 revealed a Plan of Care order dated 4/4/23 for the Benefit Period of 4/4/23 through 6/2/23 which evidenced but was not limited to, ";3/6/23: Pt had a fall over the weekend resulting in a Fractured left hip, multiple bruising to the Left temple and Left upper extremity ... 3/6/23 Patient buttocks are bright red in color." A review of Clinical Record #4 revealed an IDG meeting note dated 3/7/23, that evidenced on 3/6/23 Pts buttocks were bright red...the RN IDG Note which was submitted on 3/15/23, ";...Wound: N/A...Changes since last IDG: Pt had a fall with no injuries on 3/14/23...Not completely sure if Pts pain is under control from recent Hip Fracture. Pt moans, but when asked if...pain...states no. Intergluteal cleft reddened. Pt had choked on food on 3/9/23 while eating dinner, Heimlich performed. Psychosocial: Pt will be transferring to Skilled Nursing Facility of Power of Attorney's choice soon as Pt is out of finances to stay at Assisted Living Facility...Pain managed well with Tramadol 50 mg every 8 hrs. for pain, Tramadol PRN...". The Summary/Comments evidenced, ";Patient continues to be clinically appropriate at the time for hospice as per the report given by IDG team. Medications reviewed by the AN. All frequencies remain appropriate New Problem: No New problems at this time. Pt is well managed on current plan of care interventions: Change made/Discussed during this IDG meeting:" (Left blank)." All IDG disciplines failed to identify the 2 falls, one on the weekend of 3/4/23, where the patient had suffered a fractured hip and multiple bruising areas, and one on 3/14/23; there was no discussion on causes and interventions, the choking episode that was noted on 3/9/23, and no discussion on the need of possible diet changes. No discussion was documented as having occurred of the RN not being sure if the pain was under control, then stated the patients pain was under control and failed to discuss Patient #4 reddened buttocks. 5. Record review of a Plan of Care order dated 6/2/23 of Patient #6 for Benefit Period dated 5/8/23 through 7/6/23, evidenced a wound to the patients knee that was resolved on 6/2/23, with no other wounds identified on the Plan of Care. A review of a Skilled Nursing Visit care note dated 5/15/23, evidenced a wound to Patient #6's left buttock, ";onset date 5/14/23, pressure Injury, stage 1, length 2 cm, width 3 cm, depth 0 cm". A review of an RN IDG note by RN 9 with a submission date of 5/16/23, ";Pt has stage 1 to coccyx. Barrier cream applied to coccyx. Education also given to caregivers on repositioning patient in the bed every 2 hours." The IDG document failed to contain a summary or comments of the IDG meeting and failed to update the Plan of Care in relation to the buttocks and coccyx integumentary impairments. 7. During an interview on 6/5/23 at 3:45, the administrator indicated pictures of wounds were taken, uploaded into the wound care "thread," and sent to Entity V for Person C to consult and send back wound care recommendations on a form labeled "Orders." The nurse was responsible to modify as needed, then the orders were faxed over to the physician for signature. The "wound thread" consisted of secure text messages and photos which were retained for 30 days and not consistently included in the patients' permanent clinical record. During an interview on 6/7/23 at 2:45 PM, the administrator indicated in the IDG meetings typically wounds are not discussed. If something has changed, the nurse will mention it. The administrator indicated the IDG notes did not consistently address assessment of all wound, wound progress/decline, or the need to consider an alternative treatment plan. During an interview on 6/12/23 at 12:24, RN 9 indicated there is a Fall Log in the electronic medical record, to track patients falls, but isnt usually a part of the discussion in IDG meetings. RN 9 further indicated that if there was a change of condition with a patient, it would be noted in the nursing portion of the IDG note and at the end of the note in the summary/comments narrative section of the IDG. During an interview with RN 7 on 6/16/23 at 2:22 PM, RN 7 indicated there was no way to notify nurses that are on call of changes with patients which had not appeared on the plan of care, ";no triggers," a nurse would need to read the last couple of visits to get an idea of what was going on with the patient, any wounds, and that a wound assessment could get missed easily.

Based on record review and interview, the agency failed to ensure it managed and administered its resources, to include having failed to provide oversight of contracted entities and monitoring the staff utilization of a DMEPOS provider to obtain wound care orders, and not acting/implementing measure to correct the agency's inability to track wounds in a way that could be easily accessed or disseminated to staff, in order to consistently and appropriately to provide hospice care/services to patients for the palliation and management of the terminal illness and related conditions in 1 of 1 hospice agency. The cumulative effect of these deficient practices resulted in the agency having an Immediate Jeopardy at 42 CFR 418.100 Organization and Administration and has the likelihood to affect all 118 current patients receiving hospice services from this provider. Findings include: --- 1. An agency document dated 2022, titled 'AD.G10 GOVERNING BODY' stated, "PURPOSE: To provide governance and authority in the management of the agency. POLICY: The Governing Body operates in accordance with its bylaws and assumes full legal and financial authority for determining, implementing and monitoring policies governing the hospice's total operation...The Hospice must organize, manage and provide resources provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions... Duties of the Governing Body include the following: 1. Decision making. 2. Arranging for professional advice. 3. Establishing policies and procedures consistent with organizational mission. 4. Approves new and/or revised policies and procedures as indicated and necessary. 5. Defines corporate structure and clearly indicates lines of authority. 6. Ensures that all services are consistent with acceptable standards of practice and are provided by competent staff. 7. Assumes full legal authority and responsibility for: a. Determining, implementing and monitoring policies governing the hospice's total operations; b. The management of hospice; c. The provision of all hospice services;...12. Ensures that the interdisciplinary group is designated in advance to establish policies and procedures governing day-to-day provision of hospice care and services if a hospice has more than one interdisciplinary group. 13. Ensures that the interdisciplinary group maintains responsibility for directing, coordinating and supervising the care and services provided...15. Ensures that all services provided are consistent with accepted standards of practice. 16. Ensures that care and services are provided in accordance with plans of care and that plans of care are based on assessments of patient/family needs. 17. Ensures that information is shared among disciplines (direct or contractual) in all hospice care/service settings. 18. Ensures that information is shared with non-hospice healthcare providers furnishing unrelated services..." An agency document dated 2022, titled, 'PC.C30 CLINICAL RECORDS' stated, "POLICY: A clinical record is established and maintained for every patient receiving care and services from Care Hospice Services. The record is complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval... 1. Each patient's clinical record contains: ... A. Updated plans of care... including treatment and activity orders; ... d. Comprehensive assessments; ... p. Patient's choice of attending physician; ... v. Evidence of coordination of care/service provided by the hospice with others who may be providing care/services...z. Complete documentation of all known services and significant events. Documentation must show that effective interchange, reporting, and coordination of care occurs as required..." An agency document dated 2022, titled, 'PC.C90 COORDINATION OF SERVICES' stated, "1. The hospice will maintain a system of communication and integration in accordance with the hospice's own policies and procedures to: ...B. Ensure that the care and services are provided in accordance with the plan of care... c. Ensure the care and services provided are based on all assessments of the patient and family needs... E. Provide for ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions... 2. the Director of Clinical Services assumes overall responsibility for ensuring there are effective means of communication that allow for the coordination of the care and services provided by the hospice. 3. An assigned hospice RN Case Manager coordinates the patient's plan of care and facilitates the ongoing sharing of information with the attending physician, ..., vendors, other members of the IDG, and non-hospice healthcare providers furnishing services unrelated to the terminal illness." An agency document dated 2022, titled, 'PC.C85 CONTRACTED SERVICES' stated, "POLICY: To ensure that contracted services are provided by trained and qualified professionals and paraprofessionals the Hospice has a legally binding agreement for the provision of arranged services. Procedure: 1. Written service contracts with individuals and/or entities are signed and dated by authorized principles of each party and are reviewed annually. The executed document stipulates the terms of the contract which include: A. Specific services/products to be provided; ... c. Assurances by the contractor of the education, training, qualifications and identification of personnel designated to provide care, services, and products; ...j. The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice; ...m. stipulation that the services are provided in a safe and effective manner by qualified personnel; ...7. A contracted service shall not absolve the hospice from responsibility for the quality, availability, documentation, or overall coordination of the patient/family unit care or responsibility for compliance with any federal, state, or local law or rules and regulations." An agency document dated 2022, titled, 'PC.C55 COMPREHENSIVE ASSESSMENT CONTENT' stated, "... 3. An update of the comprehensive assessment is conducted by the hospice interdisciplinary team in collaboration with the attending physician as frequently as the condition warrants, but no less than frequently than every 15 days and includes: A. Identification of changes that have occurred since the initial assessment... 5. The IDG uses the information obtained from comprehensive assessment tools to develop and effective plan of care with interventions that address the identified needs of the patient/caregiver. An agency document dated 2022, titled, 'PC.A40 ATTENDING PHYSICIAN' stated, "POLICY: Hospice patients have a right to choose an attending physician to provide initial and ongoing management of the medical component of the patient's care... PROCEDURE: 1. At the time of admission to hospice the patient is encouraged to designate an attending physician who will have the most significant role in the determination and delivery of the patient's medical care... 4. The patient may designate the hospice's Medical Director or other hospice physician as her/her attending physician if the patient is unable or unwilling to designate a previous physician...5. The patient's attending physician is responsible for: a. Management of the patient's medical care, particularly those areas not related to the terminal illness with respect of the patient choices; 6. The hospice nurse notifies the attending physician of all changes in the patient's condition; ..." 2. A review of an agency document dated 6-14-2021, titled, '[Entity V] SERVICE AND BUSINESS ASSOCIATE AGREEMENT TERMS AND CONDITIONS' stated, "... 3. Training and Education. [Entity V] will provide the following: a. Education and training. [Entity V] will train and educate Covered Entity's personnel in the use of products it provides. (1) [Entity V] will on a monthly basis or on demand, do rounds with Covered Entity's personnel in order to train or educate said personnel with the use of provided products and to assist in proper product utilization. {entity V] will not provide any clinical consulting, treatment or handling of any products with any patients..." 3. A review of hospital admission records, dated 5-14-2023 on Patient #1, stated "...Last night around midnight, patient was found facedown in [Patient #1's] facility...sent to ED earlier today in the morning. Upon arrival...appears hemodynamically stable...was noted to have right leg wound with purulent drainage, and also appeared to have maggots in the wound...Severe sepsis, as evident with tachypnea, tachycardia, significant leukocytosis and signs of end organ damage. Multiple potential sources of infection, including right leg wound cellulitis, urinary tract infection, and probable pneumonia...Wound Summary...Patient has 4 wounds to right lower leg... Largest wound on anterior leg is covered with 70% tan adherent slough. Proximal area...eschar with pink moist periwound...Left lower leg wounds...largest wound is on lateral aspect...has dry tan slough present. Iodosorb will assist with gentle cleansing and debridement of slough. Will also offer antimicrobial coverage...Discharge Information...Hospital Course...Patient was admitted to Inpatient hospice for comfort care on May 15, 2023... patient passed away peacefully...May 20, 2023." 4. A review of the clinical record for Patient #1 with an election date of 12-29-2022, with diagnoses which included but were not limited to: senile degeneration of the brain (mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age), atrial fibrillation (an irregular heartbeat that causes the heart to beat faster and irregularly), frequent urinary tract infections, and sinus node dysfunction (disorders that affect the heart's natural pacemaker, causing irregular heart rhythms that can be too slow) with pacemaker (an electronic device that is implanted in the body to monitor heart rate and rhythm and gives the heart electrical stimulation when it does not beat normally). Patient #1 resided at an assisted living facility (ALF), Entity A, in the Memory Care unit. The review indicated edema to the bilateral lower extremities was identified on 2-18-2023 and the cause was determined to be related to the patients preference to remain in their recliner throughout the day and overnight, refusing to lay in bed or recline in the chair. Concerns for the possibility of dependent edema (gravity-related swelling in the lower body), and for unrelieved pressure on the buttocks were also identified. The attending provider, Nurse Practitioner (NP) X with Entity W, and ALF Memory Care staff were jointly consulted and conferenced as to how to further avoid any pressure ulcers and impairment of skin integrity. The clinical record contained a document dated 4-7-2023, titled, ";Visit Report for [Patient #1] on 4/7/2023...Physician Order NORTH Details", contained the name of the attending physician, Dr CC (with Entity W). Stated, ";Wound Orders...Wound #1 – Coccyx – Pressure Ulcer...Wound #2 - Left Lower Leg - Venus Ulcer...Wound #3 – Right Lower Leg – Venous Ulcer...". A section titled Notes detailed the three wounds, Wound #1 coccyx – Cleanse wound per protocol and pat dry, Apply a collagen sheet to wound bed folding to fit. Secure with bordered cover dressing. Change dressing daily. Caregiver may change when hospice nurse not present. Wound #2 left lower leg – Cleanse per protocol and pat dry. Apply collagen sheet to area of get depth on lateral calf. Cover with absorbent dressing. Wrap with cohesive not greater than 50% stretch. Secure with tape. Don knee high stocking over top. Wound #3 right lower leg – Cleanse per protocol and pat dry. Apply collagen sheet to area of great depth on medial calf. Cover with absorbent dressing. Wrap with cohesive no greater than 50% stretch. Secure with tape. Done knee high stocking over top." The order was, ";Entered By: [Person C, with Entity V] on 4/10/2023 02:42:05 PM (ET)". The document was signed by hospice Dr 3 on 4-27-2023. A review of a skilled nursing visit on 4-24-2023, RN 7 documented a new wound to the right lower leg. Indicated the edematous leg had previously blistered and was now opened. ";pictures were taken for WOC [acronym for Wound and Ostomy Nurse, who possesses a baccalaureate degree, has received special training, and is certified in wound and ostomy care]". A photograph associated with this visit revealed a small area of light-colored tissue, indicative of probable slough (an often light-colored, non-viable tissue which, when left in place, can delay healing and create a risk for infection, its removal being a critical part of wound management, accomplished by any number of debridement methods) was located centrally in the right lower leg wound bed. Light-colored tissue was also apparent in the wound bed above the left lateral ankle. A review of a skilled nursing visit on 5-1-2023, RN 7 documented six (6) additional wounds, ";Wound 3 – Left lateral calf...Wound 4 - Left lower leg #1... Wound 5 - Left lower leg #2... Wound 6 - Left lower leg #3... Wound 7 - Right lower leg #1..." Of particular note, ";Wound 8 - Right lower leg #2, Status: Open, Onset date: 5/1/2023, Type: Venous Ulcer, Size: Length: 5cm, Width: 4cm, Depth: 0.2 cm, Wound bed: White..." Photographs associated with this visit indicate increased areas of light-colored tissue to both right and left lower leg wound beds. A review of a skilled nursing visit on 5-5-2023, LPN 1 documented wound care completed to legs and buttocks. Indicated, ";There are no dressings on legs upon arrival... Legs were washed with soap and water and dried with a clean towel. Legs are slightly red. Wound to right leg 100% Epithelial tissue, pearly white in color. Wound to left leg is 100% Epithelial tissue, pearly white in color with some pale pink...Patient has several areas that scabbed over on legs..." A review of a skilled nursing visit on 5-8-2023, LPN 1 documented wound care completed to legs and buttocks. Indicated, ";Patient having [sic]patient to knees and buttocks... Spoke with [Provider X, with Entity W] new order for tramadol every 6 hours. Wound to right leg 100% Epithelial tissue, pearly white in color. With very little pale pink. Wound to left leg is 100% Epithelial tissue, 50% pearly white, 50% pale pink. A photograph associated with this visit was uploaded to the chart on 5-19-2023, indicated the areas of light-colored on both the right and left lower leg wound beds were still present. I 5. In an interview on 6-2-2023 at 10:57 AM, the Administrator indicated Person C with DME provider, Entity V, was an LPN who was wound care certified, and the agency had a contract with them. Indicated the hospice, ";MD will okay" and ";signs off on [Person Cs] order". In an interview on 6-2-2023 at 10:57 AM, the Administrator indicated Nurse Practitioner (NP) X with Entity V, refused to sign off on wound care orders for Patient #1 as NP (X) indicated was not aware of these wounds. In an interview on 6-2-2023 at 11:15 AM, when queried as to where wounds could be found in the record or where they are documented, the Administrator indicated would be found under orders or medication list, and indicated the current EMR does not track wounds, she is having to track wounds herself outside of the system, and the agency is changing EMR systems in the fall. In an interview on 6-2-2023 at 2:35 PM, when queried as to how the order gets written from Person C with DME Entity V, the Clinical Manager indicated Person C makes suggestions and the hospice doctor signs off on it. In an interview on 6-5-2023 at 9:47 AM, the Administrator indicated the DMEPOS, Entity V was initially brought on to help the agency keep an eye on wounds and supplies, as long as the wound was not related to the terminal diagnosis. A former administrator had spearheaded this relationship, citing cost savings as the main reason. Indicated the DME company presented itself as consulting and making recommendations. Indicated Person C has been working with the agency for approximately 1 year. In an interview on 6-5-2023 at 9:47 AM, the Administrator was queried on the wounds on Patient #1, and the areas of probable slough and eschar, indicated the areas had been bigger, they were shrinking and thought the wound was getting better. Person C did not order to debride the tissue. The Administrator when queried as to whether she thought debriding of any sort would have been warranted. Indicated, ";Maybe, if it wasnt continuing to heal". On 6-5-2023 at 9:47 AM, the Administrator indicated if the agency has a patient with a wound, Person C will look at it initially (all wounds except those that are related to the patients terminal diagnosis). If the wound is related to the terminal illness, Person C will just be used as a resource, then the IDG will have a team discussion, especially with cancerous lesions, about what to apply, etc. In an interview on 6-5-2023 at 10:20 AM, Person C indicated Entity V was a Medicare part B provider of wound care supplies. When queried as his/her role indicated title was Clinical Care Representative, and that they gave advice and recommendations as far as wound care supplies and orders supplies. Indicated had a relationship with the hospice agency and used a secure chat server Tiger Text to communicate through a wound thread. When the agency would get a patient they contact Person C, but typically did not communicate by telephone with hospice staff. Person C will then recommend dressings, ";then the MD signs off on the order." When queried, ";In your recommendation do you create an order that would say: cleanse with this, apply this, secure with this, change every so many days?" Person C stated, ";Yes." Indicated further that the process involves the order being created, and sent back through Tiger Text then the hospice office processes this and ensures MD signs. When queried as to the photograph(s) that the last orders were based on, Person C indicated they had received photographs, but that the Tiger Text" deletes the texts and photographs after 30 days. Orders are processed and then reassessed every 28 days to see what supplies are needed. On 6-5-2023 at 3:40 PM, when discussing the wound care thread shared with Entity V, the Administrator indicated this is how the agency communicated with Person C. When queried as to how orders would get to Entity W, the Administrator could not answer. Indicated orders received from Person C were later modified on site so the frequency gets changed related to supplies. Person C writes daily in the orders so the agency gets enough supplies, but the rest of the order remains as written. Indicated this is done as most wound care supplies come through Entity W. Indicated all RN case managers and LPNs have access to this wound thread. All parties are alerted when someone makes an entry into the log. Indicated Dr 3 receives faxes and then signs these orders, Dr 1 and Dr 2 sign orders in the agencys EMR. On 6-5-2023 at 9:04 AM, NP X confirmed that LPN DD worked under NP X. Indicated LPN DD is a client care manager, puts in all orders, and handles third-party communications. When queried as to whether NP X gets to see texts and photographs, indicated does not physically get to see texts. When queried as to whether the hospice agency made mention of wounds on Patient #1 or requested orders for wound care orders for same, NP X indicated ";No, never came to [NPX] for wounds", and LPN DD did not make requests for same on behalf of the agency. as far as wound care supplies and orders supplies. Indicated had a relationship with the hospice agency and used a secure chat server Tiger Text to communicate through a wound thread. When the agency would get a patient with a wound they contacted Person C, who typically did not communicate by telephone with hospice staff. Person C will then recommend dressings, ";then the MD signs off on the order." When queried, ";In your recommendation do you create an order that would say: cleanse with this, apply this, secure with this, change every so many days?" Person C stated, ";Yes." Indicated further that the process involves the order being created, and sent back through Tiger Text then the hospice office processes this and ensures MD signs. When queried as to the photograph(s) that the last orders were based on, Person C indicated they had received photographs, but that the Tiger Text" deletes the texts and photographs after 30 days. Orders are processed and then reassessed every 28 days to see what supplies are needed. On 6-5-2023 at 10:26 AM Person C indicated no longer has photographs of Patient #1, as the last assessment date was 5-1-2023. Indicated Patient #1 started with Entity V on 3-21-2023, would have had 3 different assessments on the patient, and 3 sets of photos were likely to have been received. When queried as to whether probable slough or eschar was noted at that time, Person C indicated on 4-7-2023 what was ordered was collagen and a superabsorbent dressing, wrapping with a cohesive dressing for compression. On 5-1-2023 this was changed to a Tubigrip dressing, related to Patient #1 pushing down the cohesive dressing which could not be resituated. When queried about when debridement or a debriding agent would be recommended for a wound, Person C indicated they do not order debrider, and they do not order pharmaceuticals, that would be up to the MD, ";[Person C] am just an orderer of supplies". Then indicated a wound would have to have heavy slough in order to recommend a debrider. When queried about what recommendation would be made for wound with eschar, indicated they did not base recommendations on one factor, would depend on factors like drainage, where located, if undermining were present, and would need more information. Indicated silver collagen was a good debrider, and a wound with heavy exudate would need alginate. Person C indicated they were a Physical Therapy Assistant (PTA) and had their wound certification through W.C.E.I. (Wound Care Education Institute), further indicated lived approximately 2 hours away from Indianapolis and performed no in-person visits. On 6-5-2023 at 11:15 AM, the Administrator and Clinical Manager confirmed that the Tiger Text wound thread gets deleted on their end every 30 days as well. When asked about probable and eschar being present in the wound the Clinical Manager indicated their goal was to first dry up the wound which had been edematous and weeping, indicated Patient #1s case was so bad that legs were leaking while the patient was walking. Confirmed the 5-8-2023 photograph uploaded to the chart on 5-19-2023 was the last and most recent photograph the agency had taken of Patient #1s wounds On 6-5-2023 at 11:15, the wound photographs for Patient #1 were reviewed with the Administrator and Clinical Manager. The Clinical Manager indicated that dry scabs were apparent and swelling was reduced, indicated Patient #1 would push the dressing down which encircled the calf. The Clinical Manager indicated redness was apparent in the photograph suspicious for cellulitis, and indicated would also look for other factors such as was the area hot. When queried as to whether Person C would be able to detect this from photographs, the Clinical Manager indicated ";no", if not seen in person, and that things could be missed by Person C just going off of photographs. The Administrator and Clinical Manager indicate Person C has become the go-to person for wound care orders and not just a supplier, that lines have been blurred and changes need to be made. The administrator indicated there needed to be more oversight. On 6-5-2023 at 11:15 AM, the Clinical Manager indicated orders from Person C with Entity V are currently signed off on by the hospice doctor, bu t the agency would be changing policy, including having staff go once a week to lay eyes on the wound. The Administrator silently signaled to the Clinical Manager to say nothing more. The Administrator then presented photographs from RN 5s phone and indicated this was proof the wound was progressing. Reiterate had felt strongly the wounds were getting better which is why wound care orders were not asked to be changed. On 6-5-2023 at 1:56 PM, the attending provider, NP X, with Entity W, indicated became the Primary Care Provider (PCP) for Patient #1 in March of 2023, began treating the edema in April with wraps to leg and diuretics, in order to address patients pain and comfort. When queried if NP X had ever seen the wounds on Patient #1s legs indicated was told about them, and saw the patient on 5-4-2023 and there were ";no open areas" but had blistering. When queried if the agency had requested wound care orders from him/her, NP X indicated was not aware of the wounds, and indicated the agency presented orders to be signed after the patient had been hospitalized on 5-14-2023, and so NP X refused to sign them. NP X was queried as to the visit performed on 5-11-2023 by LPN 1 and whether NP X had actually declined to see the wounds. NP X indicated that was an inaccurate statement and indicated had made plans with LPN 1 to meet at the patients at 11:00 AM. LPN 1 was not there when NP X arrived. They spoke later and indicated if LPN 1 had already taken pictures to go ahead and send them. Indicated should have made LPN 1 tear down the dressings to visualize the wounds, it would have been the first time NP X would have seen them. Indicated the pictures did not arrive timely and when they were finally received on 5-15-2023, indicated the wrappings were not appropriate. Stated, ";I was sickened" and indicated had noted a significant wound to the right inferior calf, multiple areas of necrosis, slough covered the wound bed, would not order to have wounds wrapped with necrosis, and significant infection as the right medial anterior calf looked infected to NP X. Had not spoken with hospice agency since Patient #1 was hospitalized, was aware the patient had expired. When queried as to any concerns with the agency, was concerned there was ";always a lack of communication" and had requested to have a copy of the Plan of Care but only ever received the IDG notes. Indicated having spoken to an agency liaison about getting that information. States nursing has since been more communicative but still no Plan of Care received. On 6-5-2023 at 2:39 PM, received a follow-up phone call from NP X who indicated worked with Entity W and was not the facilitys (Entity A) nurse, but rather Entity W had rented out space, an office in the ALF, Entity A. Indicated it is his/her expectation that the hospice agency would run all orders for Patient #1 through [NP X]. It was not NP Xs understanding that there would be a need to co-sign with the hospice physician. NP X also stated she receives most of her communications through LPN DD and/or the LPNs cell phone. On 6-5-2023 at 2:50 PM, the Administrator confirmed wound care orders from Person C (with Entity V) for Patient #1, written 4-7-2023, titled Physician Order NORTH had been signed by Dr 3. Indicated Dr 3 helps with everything. Indicated NP X gets updated on such orders. When queried as to how she was certain NP X saw the orders, indicated ";We verbally will tell her stuff, but [NP Xs] doctor [Dr CC] signs everything". Requested documents showing same, these were not submitted. On 6-5-2023 at 3:40 PM, when discussing the wound care thread shared with Entity V, the Administrator indicated this is how the agency communicated with Person C. When queried as to how orders would get to NP X with Entity W, the Administrator could not answer. Indicated orders received from Person C were later modified on site so the frequency gets changed related to supplies. Person C writes daily in the orders so the agency gets enough supplies, but the rest of the order remains as written. Indicated this is done as most wound care supplies come through Entity W. Indicated all RN case managers and LPNs have access to this wound thread. All parties are alerted when someone makes an entry into the log. Indicated Dr 3 receives faxes and then signs these orders, Dr 1 and Dr 2 sign orders in the agencys EMR. In a telephone interview on 6-5-23 at 4:08 PM, the Medical Director, Dr 1, when queried if he knew of Person C with Entity V (a DME company), indicated 'no, don't know' and indicated had not heard the name before and would have remembered such a name. In a telephone interview on 6-5-23 at 5:38 PM, the Hospice Physician, Dr 3, when queried as to Entity V's role, indicated they provided wound care for several of the hospice's patients, and that Entity V's nurse practitioner performs hands-on care then provides wound care orders. Indicated knew who Person C was, but when queried as to the name of the Nurse Practitioner who performs these visits, indicated 'not off the top of my head'. Further indicated being the physician who usually receives those orders and then signs them. On 6-6-2023 at 9:04 AM, NP X confirmed that LPN DD worked under NP X. Indicated LPN DD is a client care manager, puts in all orders, and handles third-party communications. When queried as to whether NP X gets to see texts and photographs, indicated does not physically get to see texts. When queried as to whether the hospice agency made mention of wounds on Patient #1 or requested orders for wound care orders for same, NP X indicated ";No, never came to [NPX] for wounds", and LPN DD did not make requests for same on behalf of the agency. In a follow-up interview on 6-6-23 at 12:37 PM, the Medical Director, Dr 1 indicated could not tell this surveyor about Entity V. Indicated believed Entity V had a nurse. On 6-7-2023 at 9:55 AM, photographs are presented to the Administrator and Clinical Manager of Patient #1 for 4-24-2023, 5-1-2023, and 5-8-2023 indicating increasing areas of light-colored tissue in the right and left lower leg wound beds. The Clinical Manager and Administrator agree that increasing areas of light-colored tissue are present in the photographs. 6-7-2023 at 10:37 AM, the Administrator states she was able to read through the contract with Entity W last night and the agency would be moving wound care to the Agencys Clinical Manager. Indicated the wounds will stay in-house and the Clinical Manager will be the one who goes through orders. 6-7-2023 at 2:35 PM, the Clinical Manager explains that Person C gets into the Agencys clinical records every two weeks to access data on patients. The Administrator indicated was not aware that Entity V had access to the agencys EMR. When queried as to whether wound care photographs were uploaded to the Agencys EMR, the Administrator indicated ";No" and indicated photos should also be part of the clinical record. On 6-7-2023 at 3:36 PM, during the announcement of the immediate jeopardy related to the organization and administration of services, the Alternate Administrator asks, ";Whats this about a PTA?" and it is explained the agency has been utilizing wound care orders given by a PTA with Entity W. 6-8-2023 at 8:45 AM, RN 5 stated, ";We have a wound care nurse," and indicated Person C makes recommendations, RN 5 then submits them to D 3 or DR 2 and indicated there wasnt any way for NP X to review or sign off on these orders. When queried as to who was being referred to when documenting ";WOC", ";wound care nurse", or ";wound care as following", RN 5 indicated was referring to Person C. 6-8-2023 at 9:53 AM, spoke with Person K, family member of Patient #1, indicated was a struggle from the beginning as to what Care Hospice should do versus what facility, Entity A, should do. Didnt understand why they couldnt coordinate better, and feels Patient #1 didnt receive the care needed. Indicated was not offered a hospice physician as the primary or attending physician, and did not specifically request to maintain NP X as the primary care provider, stated was told this is how they do it. Indicated a nursing home or higher level of care was never suggested to the family, the only recommendation was Memory Care. Indicated was present at some dressing changes. ";They kept telling me they took pictures to send to the wound specialist." Indicated saw no results from this. 6-8-2023 at 10:41 AM, when queried as to whether NP X got to see the wound care orders, the Administrator indicated that there wasnt a way to track faxes that are sent, and admittedly had no proof. 6-8-2023 at 10:45 AM, the Administrator indicated the agency should have contacted NP X directly instead of through LPN DD, there should have been a lot more documentation, more education, more training, and tandem visits with staff. 6-8-2023 at 10:48 AM, when asked to present documentation that the Governing Body had approved the contract for Entity V, the Administrator began to look through the Governing Body binder for a wound care contract approval and indicated had not realized it was only a contract for DME. When queried as to what new employees are told about Entity V, the Administrator indicated they are told Entity V ";helps with wound care and assists with supplies." In a telephone interview on 6-8-2023 at 11:12 AM, the Alternate Medical Director, Dr 2, when queried as to Entity V, indicated "Is that the wound consulting?" and understood this company to provide wound consulting but did not know the details of it. When queried if he dealt directly with Person C, stated, "directly, no". Indicated all recommendations go through IDT and get discussed. Indicated he just signs the orders and doesn't "look at nurses names". In a telephone interview on 6-8-2023 at 11:16 AM, when queried as to Patient #1 and the number of wounds being cared for, LPN indicated could not tell surveyor and referred instead to patients legs and bottom. Further queried, if in documentation LPN 1 had made mention at all of multiple smaller wounds, stated, ";Not 100% sure." Asked LPN 1 to describe what ";pearly white tissue" looks like, indicated looks like epithelial tissue, then described yellow/white tissue as slough, described scab as discoloration but not 100% black, described eschar as 100% black. When queried as to how to treat slough or eschar, indicated with previous patients who had eschar, used betadine and covered it. When queried as to whether Entity V had ever recommended or ordered a debriding agent or debridement when slough/eschar are found in a wound, indicated ";no". When asked if it was determined by LPN 1 that debridement was ever needed for patients wound, indicated ";no". When queried about the wounds that appear in the 5-8-2023 photograph and the appearance of the wound beds, LPN 1 indicated did not notice probable slough in the wound beds, only pearly white tissue. When asked who else saw the photographs, indicated NP X and LPN DD, the Administrator, Person C, and stated had forgotten to send photos to NP X on Monday, 5-8-2023, sent it on Thursday, 5-11-1-203 then realized they didnt go through, and then sent them again on (following) Monday, 5-15-2023. When queried as to what day the NP was told the photo was taken, LPN 1 initially did not answer but then stated, ";NP X could have thought the 11th." LPN 1 also indicated photo was sent to Person C on either Monday, 5-8-2023 or Thursday, 5-11-2023. Indicated could not see photos any longer as they were part of the wound thread. Queried as to how quickly Person C produced orders, LPN 1 indicated did not know the time frame and guessed one or two days. If Person C doesnt reach out, the order stays and LPN 1 lets the RN deal with that. LPN 1 confirmed was under the impression Person C provided wound care orders. On 6-16-2023 at 11:02 AM, the Alternative Administrator stated, ";None of us knew [Person C] was a PTA."

Based on record review and interview, the agency failed to ensure the Medical Director provided oversight of the provision of wound care services by having failed to ensure all wound care orders were based on the recommendation of a qualified clinician such as a registered nurse or nurse practitioner, rather than a physical therapy assistant (PTA, Person C) who was contracted for DMEPOS, Entity V. The Medical Director also failed to ensure all hospice patients medical plans of care were developed and updated based on skilled assessments of their wounds, not photographs and text messages to a (PTA, Person C) employed by Entity V, for 1 of 1 hospice Medical Director. 3). The cumulative effect of these deficient practices resulted in the agency having an Immediate Jeopardy for being out of compliance with 42 CFR 418.102, Medical Director which has seriously affected 1 (Patient #1) of 7 clinical records reviewed, and has the likelihood to present the risk of serious harm to 13 (patients with wounds serviced by Entity V) of a total of 28 patients for whom the hospice provided wound care services. Findings include: --- 1. A review of an agency policy dated 2022 titled, 'PC.M15 - MEDICAL DIRECTOR,' stated, "POLICY: Care Hospice Services designates an individual who is licensed doctor of medicine or osteopathy to serve as the hospice's Medical Director. The hospice Medical Director assumes the overall responsibility for the medical component of the patient program... PROCEDURE: ... 3. When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director... 5. The hospice Medical Director provides oversight of physician services including, but not limited to: a. Complementing attending physician care; b. Supervising all hospice physician employees and contract hospice physicians; c. Acting as a medical resource person to the IDG; d. Assuring overall continuity of the hospice medical services; ... 6. The Medical Director or physician designee is responsible for; a. Collaborating with the IDG to ensure the medical needs of the patient are met. b. Providing oversight of the plan of care... e. Collaborating with the patients attending physician to develop and update the patient's plan of care, to identify needs not met by the attending physician... h. Ensuring the provision of direct medical services to patients either directly or through arrangements, as appropriate in the absence of the patient's attending physician;.. j. Working in a team approach with IDG:... q. Performs home visits, patient assessments, and interventions as requested by the IDG;...s. Attending IDG conferences;...t. Participating in Plan of Care development and managing oversight of medications and treatment: u. Documenting care provided in the patient's clinical record providing evidence of progression of the end-stage disease process; NEED PAGE 143. A review of an agency policy dated 2022 titled, 'PC.P14 PHYSICIAN SERVICES\,' stated, "POLICY: The hospice Medical Director, physician employees and contracted physician(s) of the hospice, in conjunction with the patient's attending physician are responsible for the palliation and management of the patient's terminal illness and related conditions. PROCEDURE: 1. All physician employees and those under contract, function under the supervision of the hospice's Medical Director. 2. All physician employees and those under contract provide services directly or coordinate care with the patient's attending physician. 3. If the attending physician is not available, the Medical Director, contracted physician and/or the hospice physician employee are responsible for meeting the medical needs of the patient... 6. Physician services include; ...b. Medical care interventions targeting unmet general medical needs ..." 2. A review of an agency document dated 6-14-2021, titled, '[Entity V] SERVICE AND BUSINESS ASSOCIATE AGREEMENT TERMS AND CONDITIONS' revealed, "... 3. Training and Education. [Entity V] will provide the following: a. Education and training. [Entity V] will train and educate Covered Entity's personnel in the use of products it provides. (1) [Entity V] will on a monthly basis or on demand, do rounds with Covered Entity's personnel in order to train or educate said personnel with the use of provided products and to assist in proper product utilization. [Entity V] will not provide any clinical consulting, treatment or handling of any products with any patients..." 3. In a telephone interview on 6-5-2023 at 10:26 AM, Person C with Entity V, when queried about when debridement or a debriding agent would be recommended for a wound, Person C indicated they donot order debrider, and they do not order pharmaceuticals, that would be up to the MD." Person C indicated being an orderer of supplies. Then Person C indicated a wound would have to have heavy slough in order to recommend a debrider. When queried about what recommendation would be made for a wound with eschar, indicated they did not base recommendations on one factor. Person C indicated they were a Physical Therapy Assistant (PTA) and had their wound certification through W.C.E.I. (Wound Care Education Institute,) further indicated lived approximately 2 hours away from Indianapolis and performed no in-person assessment/visits but relied on texted messages and photographs of wounds. In a telephone interview on 6-5-23 at 4:08 PM, the Medical Director, Dr. 1 indicated he was 'vaguely' aware of Patient #1, had not seen the patient, and was 'not certain' if the patient had had wounds. Indicated does not 'see' patients. When queried if he knew of Person C with Entity V (a DMEPOS), indicated 'no, don't know' and indicated had not heard the name before and would have remembered such a name. In a telephone interview on 6-5-23 at 5:38 PM, the Hospice Physician, Dr 3, indicated he was the Medical Director when queried as to his title. Indicated that Dr 1 and Dr 2 were also Medical Directors and that they each covered different parts, and the role was shared equally. Indicated he was familiar with Patient #1 and was aware there had been wounds. When queried as to Entity V's role, indicated they provided wound care for several of the hospice's patients, and that Entity V's nurse practitioner performed hands-on care, then provided wound care orders. Indicated knew who Person C was, but when queried as to the name of the Nurse Practitioner who performed these visits, indicated 'not off the top of my head.' Further indicated being the physician who usually received those orders and then signed them. When queried as to the last visit made to Patient #1 by Entity V, indicated was not sure. When queried as to when the last such order was signed, indicated was 5-1-2023 for Patient #1. In a follow-up interview on 6-6-2023 at 12:37 PM, the Medical Director, Dr 1, indicated he and the other hospice physicians 'function independently' and indicated there was no collaboration on patient care. Further indicated he had never seen nor spoken to the other hospice physicians. Indicated could not tell this writer anything about Entity V. Indicated he believed Entity V had a nurse. In a telephone interview on 6-8-2023 at 11:12 AM, the Alternate Medical Director, Dr 2, when queried as to his title indicated he was 'not the Medical Director, per se'. When queried as to who the Medical Director was indicated the Hospice Physician, Dr 3, was the Medical Director, then further indicated did not 'know the hierarchy.' Indicated does not perform face-to-face visits with any patients. Indicated was familiar with Patient #1 and knew about a wound, but no details beyond that. When queried as to Entity V, indicated "Is that the wound consulting?" and understood this company provided wound consulting but did not know the details of it. When queried if he dealt directly with Person C, stated, "directly, no". Indicated all recommendations go through IDT and get discussed. Indicated he just signs the orders and doesn't "look at nurses names."

Upon patient record review, 2 of 5 (Patient #2,#3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient #2: The med profile contains Triamcinolone acetonide cream 1% 1 inch two times a day for rash. There is no evidence of site to apply. Patient #3: The med profile contains Norco oral tab 5-325 1 t po d. This is unclear and 't' and 'd' are not approved abbreviations. Medication start date was 8-9-22. Miralax 17gm/scoop once a day for constipation. There is no evidence of a diluent in the instructions. Medication started 8-9-22. Corrected on site.

Upon patient record review, 2 of 5 (Patient #2,#3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The plan of care contains Triamcinolone acetonide cream 1% 1 inch two times a day for rash. There is no evidence of site to apply. Patient #3: The plan of care contains 8/9/22 order for Norco oral tab 5-325 1 t po d. This order is unclear and 't' and 'd' are not approved abbreviations. 8/8/22 order for Miralax 17gm/scoop once a day for constipation. There is no evidence of a diluent in the instructions. Corrected on site.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The medical record contains documentation by the SN on 9-2-22 Foley catheter changed 9-2-22 18 fr 10cc. The order from the plan of care is for a 16fr 10cc balloon.

Upon patient record review, 2 of 13 records (Patient #5#13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 3 of 13 records (Patients #2,#5,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2:The record indicated an order for Nystatin ointment 2x/day for unspecified aftercare. There was not evidence of a location. Corrected on site. Patient #5: A nurse note dated 6/24/22 indicated, 'Collaborated with LPN regarding need to change Tramadol to Norco per MD order for inadequate pain relief.' There was not evidence of Tramadol on the medication profile. Patient #7: The record indicated 2 orders for Tylenol; Tylenol oral tab 325 mg, 2 q4h as needed for pain and Acetaminophen rectal suppository 650 mg, 1 q6h prn temperature or pain. There was not evidence of a maximum allowable dose per day. Corrected on site.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 13 records (Patient #13) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #13: The pleurix catheter order for drainage, indicated to drain every 2 days and as needed. The note from the nurse dated 3/6/22 indicated that 1000cc was drained, from 3/8/22 indicated that 1 liter was drained using sterile technique and on 4/3/22, drained 700ml of bright yellow fluid. There was not evidence of an assessment of the site or evidence of the complete procedure performed on any of these dates, including any cleansing of the site or redressing.

Upon patient record review, 2 of 13 records (Patient #1,#4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient was admitted with a diagnosis of Alzheimer's Disease with early onset. The patient also had dementia with behaviors, she was bipolar and had anxiety. There was not evidence of a care plan that reflected patient/family goals and interventions based on the patient's neurological disease. Corrected on site. Patient #4: The patient was admitted with a diagnosis of senile degeneration of the brain. The patient was wheelchair bound, required extensive assist with all activities, was a 7C on the FAST scale and was also on risperdol due to behaviors. There was not evidence that the care plan contained goals and interventions based on the patient's neurological disease. Corrected on site.

Upon patient record review, 5 of 13 records (Patient #2,#4,#5,#7,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The record indicated an order for Nystatin ointment 2x/day for unspecified aftercare. There was not evidence of a location. Corrected on site. Patient #4: The record indicated that the patient was on Ensure 2-3x/day. There was not evidence of an order. Corrected on site. Patient #5: A nurse note dated 6/24/22 indicated, 'Collaborated with LPN regarding need to change Tramadol to Norco per MD order for inadequate pain relief.' There was not evidence of an order for Tramadol. Patient #7: The record indicated 2 orders for Tylenol;Tylenol oral tab 325 mg, 2 q4h as needed for pain and Acetaminophen rectal suppository 650 mg, 1 q6h prn temperature or pain. There was not evidence of a maximum allowable dose per day. Corrected on site. Patient #13: The pleurix catheter order for drainage indicated to drain every 2 days and as needed. There was not evidence of a reason for the prn drainage.

Upon patient record review, 1 of 13 records (Patient #1) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The record indicated that the patient used a walker to assist with ambulation. There was not evidence of a walker in the plan of care. Corrected on site.

Upon client record review, 1 of 13 records (Patient #12) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #12: The plan of care was developed on 3/3/22. There was not evidence of a reviewed, revised and documentation of an individualized plan of care until 3/30/22.

Upon client record review, 4 of 8 applicable records (Patients #6,#7,#9,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The social work visit frequency was 2x/month. The record indicated only 1 visit in May on 5/25/22 and 1 visit in June on 6/1/22. In addition, the skilled nurse visit frequency was 3x/week for the benefit period beginning on 4/18/22. From 4/18/22 through 5/30/22, the nurse conducted visits 2x/week. Patient #7: The visit frequency for the nurse from 5/19/22 to 7/1/22 was 2x/week. The record indicated that the nurse was conducting visits 3x/week. Patient #9: The record indicated a visit by the social worker on 6/13/22. The record did not contain evidence of an order for the social worker until 6/23/22. Corrected on site. In addition, The nurse visit frequency was 1x/week, and increased to 2x/week on 6/23/22. The record indicated 2 visits during the week of admission on 6/9/22 and 6/10/22. Then visits were conducted 1x/week including from 6/22/22 to current. Corrected on site. Patient #13: The record indicated that visits were conducted by the skilled nurse on 3/6/22, 3/7/22, 3/8/22, 3/10/22, 3/12/22, 3/14/22, and 3/16/22 without evidence of an order. The patient was admitted on 3/5/22. The record did not contain evidence of orders or an established plan of care until 3/18/22. (PIP in place for no care plan started 4/11/22)

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 applicable record (Personnel #11) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Tub, and shower bath ·(C) Shampoo, sink, tub The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. The competency indicated a verbal response/competency on theses areas.

Upon patient record review, 3 of 11 applicable records (Patients #1,#4,#5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions, including precautions, for a hospice aide that must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • The plan of care specifically indicates what tasks are to be done by the Aide and the frequency of these tasks. Patient #1: The record indicated that patient was a high fall risk. There was not evidence that fall precautions were a part of the aide plan of care. Corrected on site. Patient #4: The nurse admission note indicated that the patient had repeated and frequent falls. There was not evidence that fall precautions were a part of the aide plan of care. Corrected on site. Patient #5: The aide plan of care dated 5/3/22 indicated to shampoo hair as tolerated, peri care every visit prn, assist in transfer every visit prn, turn/position every visit prn, partial bath/shower every visit and complete shower weekly. In addition the certification of terminal illness indicated that the patient had had multiple falls and there was not evidence of fall precautions. Corrected on site.

Upon patient record review 2 of 11 applicable records (Patients #5,#10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #5: The aide visit frequency was 3x/week. The record indicated that the aide was performing visits 2x/week from admission (5/3/22) through 6/27/22. Patient #10: The aide visit frequency beginning on 5/18/22 was 2x/week until 6/24/22 when the aide visits were discontinued. The record indicated only 1 visit on 5/17/22 without evidence of missed visit documentation.

Upon patient record review, 3 of 13 records (Patients #2,#8,#10) did not have evidence that the medical director or physician designee provides written certification which includes correct dates, that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness. Patient #2: The patient was transferred into this hospice during the second certification period on 4/22/22. The record indicated that the certification period was 4/22/22-7/20/22. The second certification period started on 4/21/22 and the certification period dates should have read 4/21/22-7/19/22. Corrected on site. Patient #8: The certification of terminal illness revealed documentation of, a 79 year old with a primary terminal diagnosis of Parkinson's. The plan of care and ICD-10 listed the diagnosis as Sepsis (Initially sepsis-unspecified organism and subsequently sepsis due to streptococcus pneumonia). Patient #10: The certification of terminal illness indicated, 'a 69 year old male with a primary diagnosis of heart disease. Secondary of Parkinson's Disease. Recently diagnosed with multi-vessel coronary disease.' The plan of care and the ICD-10 indicated a diagnosis of malignant neoplasm of the right kidney. Also metastatic disease to the lung, rain, adrenal glands, pleural effusion and ascites. The patient was also noted to be 76 years old.

Upon patient client record review, 1 of 13 records (Patient #11) did not evidence that each patient record contains physician orders. The patient was discharged for no longer being terminally ill. There was not evidence of a discharge order from the medical director.

Upon client record review, 2 of 5 applicable records (Patients #2,#3) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: The skilled nurse visit frequency was 2x/week. From the week starting May 8, 2022, the record indicated that the nurse conducted only 1 visit per week. Patient #3: The record indicated the visit frequency for the social worker (dated 6/9/22), of 1x/month. There was not evidence of a visit during the month of June.