Every finding on record at Care Initiatives, Inc

Based on review of emergency preparedness training rosters, review of the emergency preparedness plan and staff interview, the hospice failed to ensure training in emergency preparedness for 1 of 1 contracted staff  consistent with their expected roles for the calendar years of 2023 and 2024. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. --- During interview on 11/4/25 at 9:20 AM, Staff A, Administrator, gave the surveyor the most current emergency preparedness training documentation for contracted Staff J, massage therapist. The Emergency preparedness training was dated 3/30/2020.. The agency failed to provide emergency preparedness training to their contracted staff every 2 years.  The above findings were reviewed with the Quality and Education Coordinator and Administrator.

Based on hospice staff interview and clinical record review, the hospice failed to ensure the documentation and correct identification, in a prominent part of the patient's clinical record, any advance directives executed by the patient for 1 of 19 sampled patients (Patient #18).    Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out.    Findings include: --- Patient #18 had a hospice admission date of 11/22/24, a death date of 2/1/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 11/22/24 to 2/19/25, identified the patient's advance directive information as do not resuscitate.    b. The resuscitation instruction form, signed by the patient's medical power of attorney on 11/22/24, identified resuscitation measures.    On 10/30/25 at 8:52 AM, the Administrator confirmed the discrepancy with the patient's code status.    The hospice agency failed to include accurate advance directive information on the patient's plan of care.    The above findings were reviewed with the Administrator and Vice President of Clinical Services.

Based on home visit observation, patient interview, staff interview, clinical record reviews and agency policy reviews, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 1 of 4 sampled patients with home observation visits (Patient #1).    Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications.    Findings include: --- According to the agency policy titled Medication-Drug Regimen Review, an initial drug regimen review (DRR) is completed on admission and ongoing with medication changes, changes in patient condition and/or at a minimum of every 14 days.  The DRR includes a review of the patient's medications for side effects of drug therapy, lab monitoring for associated drug therapy, actual or potential drug interactions, duplicate drug therapy and effectiveness of drug therapy.    During an interview on 10/28/25 at 10:00 AM, Staff C, Registered Nurse (RN), stated DRR's are completed a minimum of every 14 days.    Patient #1 had a hospice admission date of 11/29/23 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 9/19/25 to 11/17/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for medication and skilled nursing services.    b. The recertification comprehensive assessment, dated 9/9/25, completed by Staff C, RN, included documentation a DRR was completed and no discrepancies were identified.   c. During a home observation visit on 10/28/25 at 8:55 AM with Staff C, RN, interview with the patient stated he/she takes medication independently from the bottles.  The following medication discrepancies were identified:   1) The IDG POC, dated 10/15/25, identified patient takes milk of magnesia 8% oral suspension as needed for constipation.  The patient reported he/she does not take milk of magnesia and he/she does not have the medication in the home.    2) The IDG POC, dated 10/15/25, identified the patient takes hexylresorcinol 2.4 milligram (mg) mucous membrane lozenges (relieves sore throat).  The patient reported he/she has not used these lozenges for a long time and he/she does not have any in the home.    3) The IDG POC, dated 10/15/25, identified the patient utilizes fluticasone 50 micrograms (mcg)/inhalation nasal spray with instructions to administer 1 spray in each nostril 1 time a day.  The bottle in the home identifies fluticasone 50 mcg/inhalation spray with instructions to administer 2 sprays in each nostril 1 time a day, last filled on 9/29/25.   The patient reported he/she sprays 2 sprays in each nostril 1 time a day per the instructions on the bottle.      The DRR failed to include an accurate review of all medications taken by the patient.    The above findings were reviewed with the Administrator and Vice President of Clinical Services.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 2 of 7 sampled patients (Patients #2 and #3) with wounds.    Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient.    Findings include: --- Review of the hospice policy, titled Palliative Wound Care Management and Treatment, dated 9/5/24, identified the hospice nurse collaborates with the patient’s provider to determine wound care treatment and wound care is administered as ordered by the patient’s attending physician, physician designee or nurse practitioner.  1. Patient #2 had a hospice admission date of 4/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The recert Plan of Care (POC), dated 7/23/25 to 10/20/25, included primary diagnosis of osteomyelitis of vertebra thoracic region, and identified skilled nurse to provide wound care per physician orders.  b.  The IDG (Interdisciplinary Group) update to the POC, dated 10/1/25, included orders for skilled nursing services one time per week and midline upper posterior superior buttocks coccyx pressure ulcer, apply foam dressing to open area and change every 3 days and as needed, apply calmoseptine to rest of moisture-associated skin damage 3 times a day.  c. Skilled nurse visit note, dated 10/11/25, included documentation of an open wound to the midline upper posterior superior buttocks coccyx and wound cleansed with soap and water.    d. The clinical record failed to identify an interim physician order to cleanse the wound.  The hospice nurse failed to obtain an order to cleanse the wound prior to cleansing the wound on 10/11/25.  2. Patient #3 had a hospice admission date of 9/23/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 9/23/25 to 12/210/25, included primary diagnosis of malignant neoplasm of left kidney; identified right posterior foot heel pressure ulcer, clean with wound cleanser and leave open to air; left lower distal leg shin abrasion, clean with soap and water and leave open to air.  b.  Skilled nurse comprehensive assessment, dated 9/23/25, included wound care to right posterior foot heel pressure ulcer, cleaned with soap and water; and left lower distal leg shin abrasion, cleaned with wound cleanser.  The hospice nurse failed to clean the wounds as ordered by the plan of care.  The above findings were reviewed with the Quality and Education Coordinator and Administrator.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure interventions completed by hospice staff included in the patient's plan of care for 1 of 2 sampled patients with home observation visits in a nursing home (Patient #4).  Failure to follow the interventions in patient's Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient.  Findings include: --- Review of the hospice policy, titled Plan of Care, dated 2/1/23, the content of the plan of care includes, but is not limited to: interventions to facilitate the management of pain and symptoms, drugs and treatment necessary to meet the needs of the patient and documentation from the IDG of the patient and/or caregiver's understanding, involvement, and agreement with the care plan. Patient #4 had a hospice admission date of 12/17/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 10/13/25 to 12/11/25, included primary diagnosis of hemiplegia post cerebral vascular accident, and identified skilled nursing services per physician orders.  b.  The IDG update to the POC, dated 10/15/25, included orders for skilled nursing services one time per week to provide assessment of pain management, fatigue and response, falls, neurological status, nutritional status, speech, and equipment and assistive device needs.  c. The home visit on 10/28/25 at 9:30 AM with Staff H, Registered Nurse (RN), the surveyor observed Staff H received medication in a medication cup, mixed in applesauce, from the nursing home RN. During an interview at the same observation home visit, Staff H stated the nursing home RN identified the patient's pain medication hydrocodone was mixed in the applesauce. Staff H administered the medication and later identified the applesauce contained additional medication and must have been the morning medications, that included the hydrocodone and all of patient # 4's scheduled morning medications.  d. The clinical record failed to identify a physician order for the hospice nurse to administer medications.  The hospice nurse failed to obtain an order to administer medications prior to 10/28/25.  The above findings were reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services.

Based on clinical record review, hospice policy review, home visit observation and hospice staff interview, the hospice failed to ensure the Plan of Care (POC) for 3 of 19 sampled patients (Patient #2, #4 and #8) included all medical equipment and supplies necessary to meet identified patient needs.    Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met.  Findings include: --- 2. Patient #4 had a start of care date of 12/17/24. Record review revealed the following: a. The plans of care (POCs), dated 8/14/25 to 10/12/25 and 10/13/25 to 12/11/25, included the following medical supplies and appliances: adult diapers, blue pads, wheelchair, wheelchair cushion, gait/transfer belt, shower chair, hand-held shower, grab bars/safety rails, nebulizer tubing/supplies, wipes, and lift chair. b. During a home observation visit on 10/28/25 at 9:30 AM, with Staff H, RN, the patient had a reacher on the table next to the lift chair. The patient stated the reacher required at times. The hospice failed to list all medical supplies and appliances required by the patient on the POC. 3. Patient #8 had a start of care date of 8/14/25. Record review revealed the following: a. The POC, dated 8/14/25 to 11/11/25, identified the patient had a diagnosis of Myelodysplastic syndrome and included the following medical supplies and appliances: Moisture barrier, scooter/power chair, shower chair, hand-held shower, cane, gloves, rolling walker and grab bars/safety rails. b. The comprehensive skilled nurse visit at start of care, dated 8/14/25, identified the patient required use of a medication planner to set up medications. The hospice failed to list all medical supplies and appliances required by the patient on the POC.  The above findings were reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services. Review of the hospice policy, titled Plan of Care, dated 2/1/23, identified the content of the POC includes medical supplies and appliances necessary to meet the needs of the patient.  1. Patient #2 had a hospice admission date of 4/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 4/24/25 to 7/22/25, included primary diagnosis of osteomyelitis of vertebra thoracic region, and identified the patient used the following medical equipment and supplies: hospital bed with bed rails, overbed table, bedside drainage bag, adult diapers, blue pads/chux, hoyer lift, gloves, wheelchair, pressure release mattress, wheelchair cushion, shower chair, foley catheter, hand-held shower, and long handled sponge.  b.  The recert POC, dated 7/23/25 to 10/20/25, identified the patient used the following medical equipment and supplies: hospital bed with bed rails, overbed table, bedside drainage bag, adult diapers, blue pads/chux, hoyer lift, gloves, wheelchair, pressure release mattress, wheelchair cushion, shower chair, foley catheter, hand-held shower, and long handled sponge.  c.  The recert POC, dated 10/21/25 to 12/19/25, identified the patient used the following medical equipment and supplies: hospital bed with bed rails, overbed table, adult diapers, blue pads/chux, hoyer lift, wheelchair, pressure release mattress, wheelchair cushion, shower chair, hand-held shower, and long handled sponge.  d.  During a home visit observation with Staff F, RN (Registered Nurse) on 10/28/25 at 9:40 AM, the surveyor observed Patient #2 resting in bed with waffle boots (heel protectors to prevent pressure ulcers) on bilateral feet.  Staff F reported the patient had been wearing waffle boots “for a while now”.  The waffle boots were added to the plan of care, dated 10/27/25, one day prior to the home visit observation.  The Plans of Care failed to identify all necessary medical equipment and supplies used by the patient, including the waffle boots.

Based on home observations, staff interviews, record review, and policy review, the agency failed to maintain and develop a system of communication and integration in accordance with the hospices’ own policy to ensure the interdisciplinary group maintains responsibility for directing coordination and supervising the care and services provided for 2 of 7 with wounds. (Patient #4 and #9).  Failure of the interdisciplinary team to collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. Findings include: --- 2. Patient #9 had a hospice admission date of 8/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 8/19/25 to 10/17/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nursing services.    b. Skilled nurse visit note, dated 9/7/25, completed by Staff F, RN, included documentation the patient had a new wound to the left anterior foot, 2nd toe. Staff F, described the wound bed as clean, dry and red, normal peri wound skin, noted a small amount of sanguineous/bloody drainage and identified the wound measured 1.3 cm X 0.1 cm X  0 cm.  The measurements lacked an accurate depth measurement for the open wound.    The clinical record lacked accurate wound measurements including length, width and depth in centimeters.    The above findings were reviewed with the Administrator and Vice President of Clinical Services.    According to the policy titled Interdisciplinary Team Meetings, dated 7/28/2021, Interdisciplinary team (IDT) members review each patinet care plan at least every 15 days, or more frequently if needed, to continually monitor care and services and continued eligibility for hospice care. During IDT meetings patinet care plans are reviewed and updated and changes are communicated to primary (attending) physicians with requests for new orders as needed, IDT documentation reflects team discussion and changes in the care plan. According to the hospice policy titled Palliative Wound Care Management and Treatment, dated 9/5/24,wound assessment is performed by the Registered Nurse (RN) Case Manager during initial assessment and by a hospice nurse a minimum of every 7 days and as necessary to meet patient needs.  The wound assessment documented in the electronic health record and includes location, length, sidth, depth and description. Description includes color, odor, exudate and appearance of wound/peri-wound area. During an interview on 10/29/25 at 10:40 AM, the Clinical Manager stated the expectation for wound assessment completed every 7 days and to include length, width and depth, drainage, odor, tunneling and pain. 1.Patient #4 had a start of care date of 12/17/24.  Clinical record revealed the following: a. The Plan of Care (POC), dated 8/14/25 to 10/12/25 and 10/13/25 to 12/11/25 included a diagnosis of hemiplegia post cerebral vascular accident. The POC included physician orders for skilled nurse visits 1 time a week. The POC included orders for the skilled nurse to appy triad ointment to the abrasion on the left buttock every shift until healed. b. The skilled nurse note, dated 10/23/25, Staff H, RN, documented the patient had a wound on the upper left buttock. The wound bed described clean and granulating and pink in color. The wound measurements documented length 0.69 centimeters (cm) by width 1 cm and depth 0 cm.  c. During an home visit on 10/28/25 at 9:00 AM, Staff H, RN stated the abraision had been a superficial open wound. The IDG team failed to maintain responsibility for coordinating and supervising the care and services provided to meet the individualized needs of the patient.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patient's needs for 5 of 19 sampled patients receiving hospice aide services (Patients #9, #11, #12, #16 and #18).    Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task increases the potential risk that patients may fail to receive necessary services ordered on the plan of care in a safe and effective manner.    Findings include: --- 4. Patient #12 had a hospice admission date of 6/20/25 and received hospice services while residing in a nursing home.   Clinical record review revealed:  a. The POCs, dated 6/20/25 to 9/17/25 and 9/18/25 to 12/16/25, identified the patient had a diagnosis of hypoxic ischemic encephalopathy and included physician orders for skilled nurse and hospice aide services.   b. Hospice aide care plan, dated 6/26/25, included aide instructions to provide the following: file fingernails, file toe nails and nail care.  The hospice RN failed to include specific instructions to provide patient nail care. 5. Patient #16 had a hospice admission date of 2/20/25 and received hospice services while residing in a nursing home.   Clinical record review revealed:  a. The POCs, dated 2/20/25 to 5/20/25, identified the patient had a diagnosis of senile degeneration of the brain and included physician orders for skilled nurse and hospice aide services.  The POC included medical supplies and appliances for Hoyer lift, gait belt and EZ stand lift. b. The comprehensive assessment at start of care, dated 2/20/25, identified the patient chair bound/bed bound and required the use of an EZ stand to transfer. c. Hospice aide care plan, dated 2/24/25, provide included aide instructions to assist with transfers and transfer to bed/chair with assistance. The care plan did not identify equipment to be used for transfer. The hospice RN failed to include specific instructions to use equipment to transfer the patient. The above findings reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services.    According to the hospice policy titled Hospice Aide Services, last revised November 2023, hospice aide services are provided under the supervision of a Registered Nurse (RN).  The RN case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided.  The hospice aide care plan is reviewed as often as necessary and at a minimum every 14 days by the RN case manager.    1.Patient #9 had a hospice admission date of 8/19/25 and received hospice services while residing in a nursing home.   Clinical record review revealed:   a. The Plan of Care (POC), dated 8/19/25 to 10/17/25, identified the patient had a diagnosis of parkinsonism and included physician orders for skilled nurse and hospice aide services.    b. The skilled nurse initial assessment, dated 8/19/25, completed by Staff C, RN, identified the patient requires the use of a gait belt during transfers.   c. Hospice aide care plan, dated 8/21/25, included aide instructions to assist with transfers x 2 assist and assist to toilet.  The assignment did not include specific instruction on what assistive device should be used when transferring the patient.    During an interview on 10/29/25 at 8:52 AM, Staff D, Hospice Aide, reported the patient is a pivot transfer and he does not use a gait belt when transferring the patient.    During an interview on 10/29/25 at 9:25 AM, Nursing home Administrator reported the patient requires the assistance of 1 for a stand pivot transfer using a gait belt and front wheeled walker.    The hospice RN failed to include what specific assistive device the aide should use when transferring the patient.    2.Patient #11 had a hospice admission date of 10/2/25 and received hospice services while residing in a nursing home.   Clinical record review revealed:   a. The POC, dated 10/2/25 to 11/30/25, identified the patient had a diagnosis of pancreatic cancer and included physician orders for skilled nurse and hospice aide services.    b. The skilled nurse initial assessment, dated 10/2/25, completed by Staff G, RN, identified the patient requires the use of a gait belt during transfers.   c. Hospice aide care plan, dated 10/7/25, included aide instructions to ambulate patient using rollator.  The assignment failed to include the patient required the use of a gait belt.    During an interview on 10/29/25 at 8:53 AM, Staff D, Home Health Aide, reported he has not transferred the patient due to patient being in bed at the time of visit.    During an interview on 10/29/25 at 9:18 AM, Nursing home RN reported the patient requires the assistance of 1 using a gait belt.    The hospice RN failed to include all specific assistive devices the aide should use when transferring the patient.    3.Patient #18 had a hospice admission date of 11/22/24, a death date of 2/1/25 and received hospice services while residing in a nursing home.   Clinical record review revealed:   a. The POC, dated 11/22/24 to 2/19/25, identified the patient had a diagnosis of hypertensive heart disease with heart failure and included physician orders for skilled nurse and hospice aide services.    b. Hospice aide care plan, dated 11/27/24, included aide instructions to provide skin care.  The assignment did not include specific instructions on what skin care the aide should provide.    The hospice RN failed to include specific skin care instructions for the patient.

Based on hospice staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 6 of 17 sampled patients receiving hospice aide services (Patients #1, #4, #8, #9, #18 and #19).   Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients' personal care needs were not adequately met.    Findings include: --- 6. Patient #19 had a hospice admission date of 11/4/24, a death date of 2/15/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 11/4/24 to 2/1/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services.  Hospice aide intervention included the task vital signs: weight.  b. IDG updates to the POC, dated 1/29/25 and 2/12/25, included the hospice aide intervention: vital signs: weight.  c. Hospice aide visit notes, dated 12/17/24, 19, 23, 26, 30, 1/2/25, 7, 10, 14, 15, 16, 20, 22, 23, 27, 29, 30, 2/3, 5, 7, 11, 12 and 2/13/25, identified the task vital signs: weight “not required today”.  The hospice aide failed to obtain a weight as ordered.  The above findings were reviewed with the Administrator, Clinical Manager, Vice President of Clinical Services and Quality and Education Coordinator.   4. Patient #4 had a hospice admission date of 12/17/24 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POCs, dated 8/14/25 to 10/12/25 and 10/13/25 to 12/11/25, identified the patient had a diagnosis of hemiplegia post cerebral vascular accident and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 12/20/2024, identified the task to provide a shower. On 3/10/25, the aide care plan updated to include the task to provide a whirlpool bath. c. Hospice aide visit note, dated 9/9/25, completed by Staff D, Hospice Aide, identified the task of both a shower and whirlpool provided during the visit. The hospice aide failed to identify which bath provided per RN instruction.   5. Patient #8 had a hospice admission date of 8/14/25 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 8/14/25 to 11/11/25, identified the patient had a diagnosis of Myelodysplastic syndrom and included physician orders for skilled nurse and hospice aide services.   b. Hospice aide care plan, dated 8/15/2025, identified the following tasks: ambulate using a cane, clean bathroom, patinet laundry, shower chair built into walk in shower, file long or uneven finger nails once a week, file long or uneven toe nails once a month, apply polish, oral care, shampoo with showers, lotion to extremities, fall precautions and standard precautions. c. The hospice aide note, dated 8/29/25 and 9/15/25, identified the patinet refusedd all tasks assigned to the hospice aide. The clinical record lacked documentation the hospice aide notified the case manager. The hospice aide failed to notify the case manager of lack of completion of the task per RN instruction.   According to the hospice policy titled Hospice Aide Services, last revised in November 2023, the registered nurse (RN) case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided.    1.Patient #1 had a hospice admission date of 11/29/23 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. IDG update to the Plan of Care (POC), dated 9/17/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services.    b. Hospice aide care plan, dated 9/19/2025, identified the task of weigh patient by the 7th of each month.    c. Hospice aide visit note, dated 9/4/25, completed by Staff D, Hospice Aide, identified the task weigh patient by the 7th of the month as not required today.    The hospice aide failed to complete the task of obtaining the patient's weight by the 7th of the month per RN instruction.    2. Patient #9 had a hospice admission date of 8/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 8/19/25 to 10/17/25, identified the patient had a diagnosis of parkinsonism and included physician orders for skilled nurse and hospice aide services.    b. Hospice aide care plan, dated 8/21/25, identified the following tasks: assist with transfers x2 assist, companionship, assist with meal set up, offer snacks and fluids between meals, assist to toilet, change adult diapers, provide incontinent care, change patient linen when soiled, assist patient with dressing, file any long or uneven fingernails and toenails and weigh patient between the 1st and 7th of each month.    c. Hospice aide visit note, dated 9/3/25, completed by Staff D, Hospice Aide, identified the task weigh patient by the 7th of the month as not required today.    d. Hospice aide visit note, dated 10/1/25, completed by Staff D, Hospice Aide, identified the hospice aide shaved the patient.  The hospice aide failed to complete the task of obtaining the patient's weight by the 7th of the month and failed to provided services only as ordered on the plan of care.    3. Patient #18 had a hospice admission date of 11/22/24, a death date of 2/1/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 11/22/24 to 2/19/25, identified the patient had a diagnosis of hypertensive heart disease with heart failure and included physician orders for skilled nurse and hospice aide services.    b. Hospice aide care plan, dated 11/27/24, included aide instructions to shampoo the patient and shower the patient.    c. Hospice aide visit note, dated 1/27/25, completed by Staff D, Hospice Aide, documented the tasks of shampoo and shower not required today.    d. Hospice aide visit note, dated 1/31/25, completed by Staff I, Hospice Aide, documented the tasks of shampoo and shower not required today.    The hospice aides failed to complete tasks of shampoo patient and shower patient per RN instruction.

Based on review of written hospice agreements for services under arrangement, the hospice failed to ensure written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 2 sampled services (Medical supply and equipment provider).    Failure to include this provision within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. --- Review of the contract between the hospice and sampled medical supply and equipment provider, dated 10/23/25, identified the contract lacked the following required components:   a. The hospice retains administrative management, b. The hospice retains financial management and c. The hospice retains oversight of staff and services.  The hospice failed to include all required contract components in written agreements between the hospice agency and agency providing services under arrangement.    The above findings were reviewed with the Quality and Education Coordinator and Administrator.

Based on hospice staff interview and clinical record reviews the hospice failed to ensure the hospice staff sent a copy of the patient's transfer summary to the receiving facility for 1 of 1 sampled, live transferred patients (Patients #16).   Failure to ensure the hospice staff included the receiving facility in the process of transfer placed the patients at risk for not receiving ongoing medical care and services to meet the needs of the patient.   Findings include: --- According to the hospice policy titled Discharge Summary, dated 2/1/23, the discharge summary is completed for any hospice discharge, patient revocation of services, or patient transfer to another hospice or care provider, by the registered nurse case manager or designee by adding the discharge summary form, clinical document discharge summary identifying a transfer in the electronic health record. Patient #16 had a start of care date of 2/20/25, a discharge date of 4/28/25 and received hospice services while residing in a private residence. a. The Plan of Care (POC), dated 2/20/25 to 5/20/25, identified the patient had a primary diagnosis of senile degeneration of the brain.  The POC included orders for skilled nursing services.   b. The physicians order dated 4/28/25, included an order to transfer the patient to another hospice. The communication note note, dated 4/30/25, identified a discharge summary forwarded to the Medical Director and the personal care Physician. c. The transfer summary, dated 4/30/25, included a summary of hospice services and a list of the patient's current medications.   d. Clinical record review lacked documentation the transfer summary was forwarded to the receiving hospice.  The hospice failed to forward the transfer summary to the receiving hospice. The above findings reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services.

Based on staff interview, clinical record reviews and review of nursing home medication administration records, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient's medications with the nursing home for 2 of 3 sampled patients (Patients #3 and #4) with a nursing home medication review. Failure to ensure the hospice staff provided overall coordination of the patient's medications with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient.   Findings include: --- 2. Patient #3 had a hospice admission date of 9/23/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 9/23/25 to 12/210/25, included primary diagnosis of malignant neoplasm of left kidney, orders for skilled nursing services and medications: Protonix 40 milligrams (mg) 1 tablet once a day, Sertraline 25 mg 1 tablet once a day, Miconazole Nitrate topical cream 2 times a day left breast.  b. IDG updates to the POC, dated 10/1/25 and 10/15/25, include medication orders Protonix 40 mg 1 tablet once a day, Sertraline 25 mg 1 tablet once a day, Miconazole Nitrate topical cream 2 times a day left breast.  c. Review of the nursing facility MAR revealed:  i. Protonix 40 mg 1 tablet by mouth two times a day with a start date of 8/29/25;  ii. Sertraline 25 mg discontinued 10/23/25; and  iii. Miconazole Nitrate topical cream discontinued on 10/1/25.  Hospice skilled nurse failed to accurately update the POC with medication orders on the nursing facility MAR.  The above findings were reviewed with the Quality and Education Coordinator and Administrator.      Review of the hospice policy, titled Nursing Facility Care Plan, Coordination and Communication, dated 4/2/25, identified registered nurse case managers for patients are responsible for coordinating and implementing patient care plans in collaboration with members of the IDG, facility representatives and the attending physician.  All care provided to facility patients must be in accordance with a written care plan that includes the patient’s current medical, physical, social, emotional, and spiritual needs.  1.Patient #4 had a hospice admission date of 12/17/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 10/13/25 to 12/11/25, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 time per week and included physician orders for medications.    b. Review of the patient's nursing home Medication Administration Record (MAR), dated 10/1/25, identified the following medication discrepancy with the hospice's POC and Medication Profile for  patient #4:1) The hospice POC had an order for Ondanstron 4 milligram (mg) tablet with instructions to take 4 mg by mouth every 8 hours as needed for agitation or anxiety.  The hospice's Medication Profile identified a start date for the medication, dated 7/14/25.  The nursing home's MAR had an order for Ativan (Lorazepam) 4 mg oral tablet with instructions to give 4 mg by mouth every 6 hours as needed for nausea".  The nursing home MAR identified a start date for the medication, dated 7/14/25.  2) The nursing home's MAR had an order for Senna 8.6 mg every 12 hours as needed for constipation. The hospice POC and medication list failed to include orders for Senna.3) The hospice had an order for Gieaofemeson 100 mg/5 milliliters (ML) 10 ml every 8 hours. The nurisng home's MAR failed to include an order for Gueaifenesin.3)  The hospice POV had an order for Escitaloprm 20n mg daily. The nursing home's MAR had an order for Escitalopram 30 mg daily.4) The hospice POC and medication list included an order for Tylenol HR arthritis pain give 650 mg oral tablet 2 times a day. The POC and medication list also included a duplicate order for Acetaminophen 650 mg 2 times a day. Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home.

Based on clinical record review, nursing home clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the nursing home received copies of the physician certification of terminal illness and the physician recertification of terminal illness for 1 of 3 sampled patients (Patient #3) with home visit observations in nursing homes.  Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient.  Findings include: --- Review of the hospice's policy, titled Nursing Facility Care Plan, Coordination and Communication, dated 4/2/25, revealed when the CTI (Certification of Terminal Illness) and POC (Plan of Care) have all of the required signatures, within 3 business days, the business office manager is responsible for patients with access to the EHR (electronic health record), create a PDF (portable document format) of the completed CTI and POC and upload them into the patient’s nursing facility clinical record according to the Scanned Documents Crosswalk.  Patient #3 had a hospice admission date of 9/23/25 and received hospice services while residing in a nursing home.    Clinical record review revealed the POC, dated 9/23/25 to 12/210/25, included primary diagnosis of malignant neoplasm of left kidney and orders for skilled nursing services.  Before a home visit observation on 10/28/25 at 9:40 AM, Staff F, RN (registered nurse), reported the business office manager is responsible for uploading completed CTIs and POCs to the nursing facility EHR.  Staff F reviewed the nursing facility EHR and was unable to find the CTI and POC for Patient #3, she was unsure why documents had not been uploaded yet.  The above findings were reviewed with the Quality and Education Coordinator and Administrator.

Based on clinical record review, hospice policy review, nursing home record review, nursing home staff interview and hospice staff interview, the hospice failed to: 1) ensure the hospice nurse member of the interdisciplinary group (IDG) completed a comprehensive assessment which included a complete assessment of the patient's physical condition including alterations in skin integrity (wounds) (see L0524); 2) ensure the hospice interdisciplinary group completed a drug regimen review that included the required components with each comprehensive and update to the comprehensive assessment (see L0530); and, 3) ensure the hospice nurse member of the interdisciplinary group updated the comprehensive assessment with changes to the patient condition and included wound assessment and measurements per hospice policy (see L0533). --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and treatment needs to their hospice patients.

Based on clinical record review, hospice policy review, nursing facility record review and staff interview, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements within 5 days after the patient's election of the hospice care for 2 of 4 sampled patients (Patient #7, #8) with a wound at the time of admission to hospice services. Failure to complete an initial wound assessment increased the risk that patient's needs would not be identified and/ or addressed appropriately and the hospice would have an incomplete baseline assessment for comparison in order to determine effectiveness of wound treatments and interventions. Findings include: --- 2. Patient #8 had a hospice admission date of 1/24/2023 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care dated 1/24/2023 to 4/24/23 lacked identification of wound orders. b. The initial skilled nursing assessment, completed by Staff F, RN, dated 1/24/2023, documented an integumentary assessment of color/condition-pallor, temperature-warm, moisture-dry, risk factors for skin breakdown-healing of bony prominences, bowel incontinence, external factors of pressure, physical mobility, poor circulation, and urine incontinence. The assessment included a narrative note stating the skin was cool, dry, and intact. c. The initial social worker visit note, dated 1/25/23, documented collaboration with nursing facility staff and the patient had several wounds/skin breakdown including coccyx, bilateral buttocks, left heel and a blister to right hip. d. The subsequent skilled nurse visit note, dated 1/27/23,completed by Staff F, RN, dated 1/27/2023, documented an integumentary assessment of color/condition-pallor, temperature-cool, moisture-dry, risk factors for skin breakdown-bowel incontinence, external factors of pressure, physical mobility, inability to change positions, poor circulation, and poor nutrition. e. The nursing home Treatment Administration Record, identified a right hip blister wound, starting 1/8/23 and healed 2/8/23 with treatment of cavilon no sting barrier film to be applied until healed. f. The skin and wound evaluation sheets completed by the nursing facility staff, dated 1/18/23 identified an abrasion to the sacrum with wound measurements of length and width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, pressure ulcer to left heel with measured length 7.4 centimeters(cm), width 3.5 cm, and depth 2.8cm, blister to right lateral thigh with measurement of length and width but no depth, abrasion to left thigh with measurement of length, width, and no depth, but presence of granulation tissue. g. The skin and wound evaluation sheets completed by the nursing facility staff, dated 1/25/23 identified an abrasion to the sacrum with wound measurements of length and width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, unstageable pressure ulcer to left heel with measured length 1.9 cm, width 2.6 cm, and depth not applicable due to eschar, 2.8cm, blister to right lateral thigh with measurement of length and width but no depth, abrasion to left thigh with measurement of length, width, and no depth, but presence of granulation tissue. Interview with Staff F, RN on 3/15/23 at 1:35 PM revealed the nurse could not recall the patient and if the patient had wounds at the time of the initial assessment and subsequent visit completed by the RN. The Plan of Care, dated 1/24/2023 to 4/24/23, lacked identification and assessment of any wounds by the hospice staff. The surveyors reviewed the above findings with the hospice Administrator and Clinical Manager. Agency staff provided no additional details prior to the end of the survey. Review of the hospice policy, titled Comprehensive Assessment, dated 3/1/2020, identified the need for registered nurse (RN) Case Manager in coordination with members of the interdisciplinary group (IDG) to complete an initial comprehensive assessment within 5 calendar days of the patient's election to the hospice benefit which includes an assessment of the patient's physical, psychosocial, emotional, spiritual and bereavement needs. The IDG treats and prevents symptoms of the patient's disease and/or co-morbidity factors based on findings in the comprehensive assessment. The IDG uses information obtained from the comprehensive assessment for the development of the patient's individualized Plan of Care. Review of the hospice policy, titled Palliative Wound Care, dated 3/17/21, revealed the goals of wound care are comfort for the patient and limiting the impact of the wound on the quality of life. Hospice RNs will assess and measure, at a minimum, of every 14 days and document the findings in the clinical record. They will collaborate with the facility nurse to determine wound care treatment. On 3/13/23 at 3:34 PM, during an interview, Staff H, Quality Assessment and Performance Improvement (QAPI) Coordinator, reported the hospice nursing staff typically assess and measure wounds on discovery and weekly unless patient refuses. If the hospice patient is residing in a nursing home, the hospice registered nurse coordinates wound care and assessment with the facility's head nurse and reviews orders and care. If the hospice gets new orders, they make sure the facility gets those orders. 1. Patient #7 had a hospice admission date of 1/12/23 and received hospice routine home care services while residing in a nursing facility (nursing home). Review of the clinical record revealed the following: a. The comprehensive assessment completed by Staff F, Registered Nurse (RN), dated 1/12/23, identified the patient's skin was cool, dry, with loose turgor lacking tone. The assessment did not identify if the patient had any skin issues. The assessment identified the patient had several risk factors associated with potential skin breakdown including bony prominences, bowel and urine incontinence, external factors of pressure, peripheral neuropathy, poor circulation and poor nutrition. b. The Plan of Care (POC), dated 1/12/23 to 4/11/23, included an IDG order for Calmoseptine topical ointment 0.44 percent to 20.6 percent, apply two times per day for wound. The POC identified the nursing home staff were responsible for administering all medications and treatments. The POC lacked any further information about a wound. c. The initial social worker assessment, dated 1/13/23, identified the patient had a lesion on the left buttock. d. A skilled nursing visit within the first 5 days of care, dated 1/16/23, only identified the patient's skin was cool, dry, with loose turgor lacking tone. Review of the nursing home's clinical record documentation revealed the following: a. A skin and wound evaluation, dated 1/3/23, identified the patient had an open lesion on the left buttock measuring 1.6 centimeters (cm) in length and 1.1 cm in width and no depth. b. A skin and wound evaluation, dated 1/10/23, identified the patient had an open lesion on the left buttock measuring 0.9 cm in length and 0.7 cm in width and no depth. c. A skin and wound evaluation, dated 1/17/23, identified the patient had an open lesion on the left buttock measuring 0.7 cm in length and 0.4 cm in width and no depth. d. The nursing home's Medication Administration Record for January 2023 included an order for Calazinc cream twice per day to open wound on the left buttock and an order start date of 1/9/23. On 3/14/23 at 4:17 PM, during an interview, Staff G, Hospice Aide, reported providing hospice aide services to the patient in January (starting 1/19/23) and February 2023. Staff G, Hospice Aide, reported the patient had a red area area on the left buttock, never a wound. Staff G, Hospice Aide, reported the nursing home staff applied barrier cream to the patient's left buttocks. On 3/15/23 at 1:25 PM, during an interview, Staff F, RN, denied the patient had any wounds at the start of care. Staff F, RN, reported the patient had some scabbed areas, but they generally only document on open skin areas. When asked if Staff F, RN, ever assessed the patients buttocks, Staff F, RN, reported they would look, but there was a difference in how hospice assesses a patient in comparison to how nursing home staff assess a patient. Staff F, RN, denied the patient ever had an open wound or blood; they explained the patient just had an area that was scabbed and coated in Calmoseptine. On 3/15/23 at 1:45 PM, during an interview, the Interim Clinical Manager explained nursing staff should also measure scabbed areas. On 3/16/23 at 9:00 AM, during an interview, the Director of Nursing (DON) for the nursing home reported nursing home staff assessed the patient's buttock wound every week. The DON reported the area had been scabbed and not open until 1/31/23. The wound treatment changed to Cavilon barrier cream on 1/31/23. The DON reported the left buttock was now scabbed and healing well. The patient is still getting Cavilon barrier cream to the area. The hospice's comprehensive assessment completed by the RN lacked any information regarding a wound on the patient's left buttock.

Based on clinical record review, hospice policy review, patient/family interivew and staff interview, the hospice failed to ensure the completion of a drug regimen review which included all the required components with the comprehensive assessment within the first 5 days after election of the hospice benefit and at least every 15 days with the update to the comprehensive assessment for 5 of 19 sampled patients (Patients #2, #4, #7, #9, and #10). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed all components of the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. Findings include: --- 5. Patient #10 had a admission of 1/13/22 and received hospice services while residing in a nursing home. The clinical record revealed the following: a. The initial Plan of Care, dated 1/13/2022 to 4/12/2022, subsequent Plans of Care, dated 1/8/23 to 3/8/23, 3/9/23 to 5/17/23 and IDG updates to the Plans of Care dated 1/25, 2/8, 2/22, and 3/8/23 included orders for the patients medications. The orders included levothyroxine (thyroid medication) and metformin (diabetes). b. Initial DRR completed by the pharmacist, dated 1/17/21, documented drug profile review for this patient included review of known allergies, effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicative drug therapy and drug therapy currently associated with laboratory monitoring. The DRR lacked identification of what drugs were associated with laboratory monitoring. c. The subsequent DRR completed with the IDG updates to the Plan of Care for this patient included review of known allergies, effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicative drug therapy and drug therapy currently associated with laboratory monitoring. The DRR lacked identification of what drugs were associated with laboratory monitoring. The hospice failed to document what drugs were associated with laboratory monitoring. The above findings were reviewed with hospice Administrator and Clinical Manager. Hospice staff provided no additional information. Patient #2 had a admission of 1/7/22 and received hospice services in a private home setting. The clinical record revealed the following: a. The plan of care dated 1/2/23 to 3/2/23 and 3/3/23 to 5/1/23, included orders for the patients medications. The orders included lorazepam (antianxiety medication). b. The medication list, dated 3/14/23, included lorazepam. c. During a home observation visit on 3/24/23 at 10:00 AM with Staff C, Registered Nurse (RN), the surveyor noted the patient currently taking Risperdal 0.25 mg at HS (antipsychotic medication). Staff C stated during the same home visit she had not been aware of the medication addition. d. During an interview on 3/25/23 at 1:55 PM the assisted living Nurse Manager stated the order for Risperdal effective on 6/30/22. e. The IDG notes, dated 1/18, 2/5 2/15, 2/22 and 3/3/34, failed to include review of the Risperdal or its interactions. Risperdal and Lorazepam can have a potentially drug interaction. Hospice staff failed to identify Risperdal part of the patients current medication regimen during drug regimen review. Review of the hospice policy, titled Drug Regimen Review (DRR), Initial and Ongoing, last revised 2/1/23, revealed upon admission a nurse documents all medications in the patient's Electronic Health Record (EHR) medication profile. Within 5 days, the Registered Nurse (Registered nurse) Case Manager consults the pharmacist to review the medication profile. The pharmacist documents the consult. Or within 5 days, the RN Case Manager will review the medication profile. The review of the patient's current medications includes: therapeutic effectiveness, therapeutic duplication, appropriate dose, frequency and route of administration, adherence to drug regimen, potential drug/food/diagnostic test interactions/disease limits, lab or clinical monitoring methods to detect drug effectiveness, side effects, toxicity or adverse effects, storage specifics/availability/tracking issues, quality versus cost effectiveness and appropriate alternatives. The comprehensive assessment findings which included the consult/review findings are presented to create the individualized care plan during the first comprehensive care interdisciplinary group meeting (IDG). The RN is responsible to review the patient medications with medication changes, changes in patient condition, or at a minimum of every 14 days. 1. Patient #4 had a hospice admission date of 9/15/21 and received routine home care hospice services while residing in a private residence. On 3/15/23 at 1:30 PM, during a home visit observation with Staff J, Registered Nurse (RN), the patient's family member responsible for setting up the patient's medications discussed with nurse the patient's need to regularly take medications to prevent constipation. The family member showed the nurse a bottle of Stool Softener (Senna S- 8.6 mg Senna with 50 mg Docusate). The family member reported the patient had been taking the Docusate Sodium 1 tab per day every day along with the Stool Softener 1 tab per day every day for the last 3 months, but the patient had been taking the Stool Softener for more than a year. Review of the clinical record revealed the following: The POCs, dated 1/8/23 to 3/8/23 and 3/9/23 to 5/7/23, lacked an order for the Stool Softener and the IDG members failed to include this medication in the DRRs. 2. Patient #7 had a hospice admission date of 1/23/23 and received routine home care services from hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/12/23 to 4/11/23, identified the patient had a diagnosis of diabetes and included orders for 3 different oral medications to treat diabetes (Metformin, Glipizide and Januvia). The POC failed to include an order for blood sugar testing. b. The comprehensive assessment completed by the registered nurse, dated 1/12/23, identified the patient had a diagnosis of diabetes, took oral medication to treat the diabetes, and used a glucometer for as needed blood sugar checks. The DRR in the assessment identified the nurse reviewed all of the components, but did not find any concerns. c. The IDG meeting, dated 1/18/23, included documentation of a DRR completed by the IDG members, but lacked documentation the IDF reviewed or was aware of the patient's ongoing blood sugar testing related to the patient's diabetic medications. d. A pharmacy DRR, dated 1/19/23, included documentation the pharmacist reviewed the required components of the DRR, but did not identify the patient took 3 medications associated with laboratory monitoring of the patient's blood sugars. 3. Patient #9 had a hospice admission date of 10/20/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 10/20/22 to 1/17/23, included a medication orders for Levothyroxine (a medication used to treat hypothyroidism and associated with routine lab testing for thyroid hormone levels). b. The comprehensive assessment completed by the registered nurse, dated 10/20/22, included documentation the nurse completed a DRR and identified no concerns. c. The initial IDG meeting note, dated 10/26/22, and the pharmacy DRR, dated 10/26/22, failed to identify the patient took a medication with potential lab monitoring and determine whether the patient would need to continue with lab monitoring. The POC and Interdisciplinary Group meetings to update the POC, dated 1/18, 1/25, 2/8, 2/22 and 3/8/23, failed to identify the patient had blood sugar testing.

Based on clinical record review, hospice policy review, nursing home record review, nursing home staff interview and hospice staff interview, the hospice failed to ensure the hospice registered nurse completed a reassessment at a minimum of every 15 days (21 days during the pandemic 1135 blanket waiver) of the patient's physical condition related to the patient's disease and/or co-morbidity factors for 2 of 4 sampled patients (Patients #7 and #8) with wounds. Failure to complete ongoing wound assessment increased the risk that patient's needs would not be identified and/ or addressed appropriately and the hospice would have an incomplete assessment for comparison in order to determine effectiveness of wound treatments and interventions. Findings include: --- 2. Patient #8 had a hospice admission date of 1/24/2023 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care dated 1/24/2023 to 4/24/23 lacked identification of wound orders. b. IDG updates to the Plan of Care, dated 1/25/23 and 2/8/23, documented orders for wound care to complete to the left heel, and buttocks to be completed by the nursing facility. c. The initial skilled nursing assessment, completed by Staff F, RN, dated 1/24/2023, documented an integumentary assessment of color/condition-pallor, temperature-warm, moisture-dry, risk factors for skin breakdown-healing of bony prominences, bowel incontinence, external factors of pressure, physical mobility, poor circulation, and urine incontinence. The assessment included a narrative note stating the skin was cool, dry, and intact. d. The initial social worker visit note, dated 1/25/23, documented collaboration with nursing facility staff and the patient had several wounds/skin breakdown including coccyx, bilateral buttocks, left heel and a blister to right hip. e. The skilled nurse visit note, dated 1/27/23,completed by Staff F, RN, dated 1/27/2023, documented an integumentary assessment of color/condition-pallor, temperature-cool, moisture-dry, risk factors for skin breakdown-bowel incontinence, external factors of pressure, physical mobility, inability to change positions, poor circulation, and poor nutrition. f. The skilled nurse visit note, dated 2/3/23,completed by Staff F, RN, documented skin was cool, dry and intact. g. The skilled nurse visit note, dated 2/10/23, documented the skin was pale, warm, and dry. The narrative section documented the patient was started on an antibiotic for wound infection. h. An interim order, dated 2/10/23 documented the patient was started on Keflex for wound infection. i. The skilled nurse visit, dated 2/11/23, documented skin was jaundiced, warm, and dry, however, lacked assessment of any wounds. j. The skilled nurse visit, dated 2/17/23, included documentation of wounds. k. The IDG updates to the Plan of Care, dated 1/25/23 and 2/8/23 lacked orders for wound care to be completed by nursing facility staff. l. The nursing home Treatment Administration Record, dated January 2023 identified a right hip blister wound, starting 1/18/23 and healed 2/8/23 with treatment of cavilon no sting barrier film to be applied until healed. m. The nursing home Treatment Administration Record for January 2023, identified left heel wound, starting 1/5/23 and healed 2/8/23 with ordered treatment of povidone-iodine solution 10% with instructions to apply topically every day shift for wound care and to cleanse with cleanser, patient with betadine, and cover with foam dressing. n. The nursing home Treatment Administration Record for January 2023, identified a buttocks wound, starting 1/10/23 with ordered treatment to cleanses with normal saline, cover open areas with foam dressing daily, apply barrier cream twice daily and as needed to surrounding non open areas, and orders to perform wound care daily. o. The nursing home Treatment Administration Record, dated February 2023 identified a right hip blister wound, starting 1/18/23 and healed 2/8/23 with treatment of cavilon no sting barrier film to be applied until healed. p. The nursing home Treatment Administration Record for February 2023, identified left heel wound, starting 2/9/23 and healed 2/13/23 with ordered treatment to cleanse with cleanser, apply xeroform gauze, cover with foam dressing and change daily during day shift. q. The nursing home Treatment Administration Record for February 2023, identified a buttocks wound, starting 1/10/23 with ordered treatment to cleanses with normal saline, cover open areas with foam dressing daily, apply barrier cream twice daily and as needed to surrounding non open areas, and orders to perform wound care daily. r. The skin and wound evaluation sheets completed by the nursing facility staff, dated 1/18/23 identified an abrasion to the sacrum with wound measurements of length and width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, pressure ulcer to left heel with measured length 7.4 centimeters(cm), width 3.5 cm, and depth 2.8cm, blister to right lateral thigh with measurement of length and width but no depth, abrasion to left thigh with measurement of length, width, and no depth, but presence of granulation tissue. s. The skin and wound evaluation sheets completed by the nursing facility staff, dated 2/1/23 identified an abrasion to the sacrum with wound measurements of 0.9 cm length and 0.5 cm width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, unstageable pressure ulcer to left heel with measured length 3.0 cm, width 2.8 cm, and depth not applicable due to eschar, blister to right lateral thigh intact, abrasion to left thigh not measured. t. The skin and wound evaluation sheets completed by the nursing facility staff, dated 2/15/23 identified an stage 1 pressure ulcer to medial right foot length 2.4cm, width 1.9cm and depth 1.6 cm, unstageable pressure ulcer to left heel, 1.9 cm length, 1.6 cm width, 1.5 cm depth, abrasion to the sacrum with wound measurements of 1.7 cm length and 1.7cm width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, unstageable pressure ulcer to left heel with measured length 3.0 cm, width 2.8 cm, and depth not applicable due to eschar, blister to right lateral thigh intact, abrasion to left thigh not measured. Interview with Staff F, RN on 3/15/23 at 1:35 PM revealed the nurse could not recall the patient and if the patient had wounds at the time of the initial assessment and subsequent visit completed by the RN. The IDG updates to the Plan of Care, dated 2/8/23 lacked identification and assessment of any wounds. The surveyors reviewed the above findings with the hospice Administrator and Clinical Manager. Agency staff provided no additional details prior to the end of the survey. Review of the hospice policy, titled Comprehensive Assessment, dated 3/1/2020, identified the need for registered nurse (RN) Case Manager in coordination with members of the interdisciplinary group (IDG) to complete an initial comprehensive assessment within 5 calendar days of the patient's election to the hospice benefit which includes an assessment of the patient's physical, psychosocial, emotional, spiritual and bereavement needs. The IDG treats and prevents symptoms of the patient's disease and/or co-morbidity factors based on findings in the comprehensive assessment and reassessment. IDG members complete a comprehensive reassessment at least every 14 days (21 days during the 1135 blanket waiver of the pandemic). Review of the hospice policy, titled Palliative Wound Care, dated 3/17/21, revealed the goals of wound care are comfort for the patient and limiting the impact of the wound on the quality of life. Hospice RNs will assess and measure wounds, at a minimum, of every 14 days and document the findings in the clinical record. On 3/13/23 at 3:34 PM, during an interview, Staff H, Quality Assessment and Performance Improvement (QAPI) Coordinator, reported the hospice nursing staff typically assess and measure wounds on discovery and weekly unless patient refuses. If the hospice patient is residing in a nursing home, the hospice registered nurse coordinates wound care and assessment with the facility's head nurse and reviews orders and care. If the hospice gets new orders, they make sure the facility gets those orders. 1. Patient #7 had a hospice admission date of 1/12/23 and received hospice routine home care services while residing in a nursing facility (nursing home). Review of the clinical record revealed the following: a. The comprehensive assessment completed by Staff F, Registered Nurse (RN), dated 1/12/23, identified the patient's skin was cool, dry, with loose turgor lacking tone. The assessment did not identify if the patient had any skin issues. The assessment identified the patient had several risk factors associated with potential skin breakdown including bony prominences, bowel and urine incontinence, external factors of pressure, peripheral neuropathy, poor circulation and poor nutrition. b. The Plan of Care (POC), dated 1/12/23 to 4/11/23, included an IDG order for Calmoseptine topical ointment 0.44 percent to 20.6 percent, apply two times per day for wound. The POC identified the nursing home staff were responsible for administering all medications and treatments. The POC lacked any further information about a wound. c. The initial social worker assessment, dated 1/13/23, identified the patient had a lesion on the left buttock. d. A skilled nursing visit within the first 5 days of care, dated 1/16/23, only identified the patient's skin was cool, dry, with loose turgor lacking tone. e. The skilled nursing visit notes, dated 1/19, 1/23, 1/26, 1/30, 2/2, 2/6, 2/9, 2/13 and 2/16/23, identified the patient's skin was cool, dry, with loose turgor lacking tone. The visit notes lacked documentation of any wound assessment of the left buttock. f. A skilled nursing as needed visit, dated 2/16/23, included documentation, Staff I, Licensed Practical Nurse (LPN), completed the visit. Staff I, LPN, documented the patient's family member called to report a concern that the patient had a wound on the buttock that was bleeding and the patient was wheezing. Staff I, LPN, documented they arrived at 8:08 PM and the patient was in bed The patient was alert and oriented to person, place and month. The patient denied pain or dyspnea. The patient reported facility staff gave them a bath this evening and the patient had small amount of bleeding on the patient's buttock. Staff I, LPN, documented the primary physician saw the patient today with no concerns and was last seen by the wound nurse on 2/14/23. Staff I, LPN, documented a "MASD" on buttock with fragile skin and the facility nurse was applying barrier cream twice per the care plan. Staff I, LPN, assessed the wound measured 3.02 centimeters (cm) in length and 5.62 cm in width. The visit note lacked documentation of a depth assessment. g. A skilled nursing visit, dated 2/20/23, included documentation of a left buttock wound with an onset date of 1/3/23 and a clean wound bed. The visit note lacked any wound measurements. h. A skilled nursing visit, dated 2/23/23, included documentation of a left buttock wound with an onset date of 1/3/23 and a clean, dry, pink wound bed. The wound had indistinct wound edges with excoriation and no drainage. The visit note lacked any wound measurements. The visit note identified the wound cleansing/dressing change was per the care plan. i. A skilled nursing visit, dated 2/27/23, included documentation of a left buttock wound with an onset date of 1/3/23 and a clean, dry wound bed. The visit note lacked any wound measurements. The visit note identified the wound cleansing/dressing change was per the care plan. j. A skilled nursing visit note, dated 3/2/23, included documentation of a left buttock wound with an onset date of 1/3/23 and a clean, dry, pink wound bed. The wound had indistinct wound edges with excoriation and no drainage. The visit note lacked any wound measurements. The visit note identified the wound cleansing/dressing change was per the care plan. k. The skilled nursing visits, dated 3/9 and 3/13/23, included documentation of a left buttock wound with an onset date of 1/3/23 and a clean, dry wound bed. The visit notes lacked any wound measurements. Review of the nursing home's clinical record documentation revealed the following: a. A skin and wound evaluation, dated 1/3/23, identified the patient had an open lesion on the left buttock measuring 1.6 centimeters (cm) in length and 1.1 cm in width and no depth. b. The nursing home's Medication Administration Record for January 2023 included an order for Calazinc cream twice per day to open wound on the left buttock and an order start date of 1/9/23. c. A skin and wound evaluation, dated 1/10/23, identified the patient had an open lesion on the left buttock measuring 0.9 cm in length and 0.7 cm in width and no depth. d. A skin and wound evaluation, dated 1/17/23, identified the patient had an open lesion on the left buttock measuring 0.7 cm in length and 0.4 cm in width and no depth. e. A skin and wound evaluation, dated 1/24/23, identified the patient had an open lesion on the left buttock measuring 0.6 cm in length and 0.9 cm in width, no depth and a light amount of bloody drainage. f. A skin and wound evaluation, dated 1/31/23, identified the patient had an open lesion on the left buttock measuring 2.5 cm in length and 1.6 cm in width, no depth and a scab. g. The nursing home's Medication Administration Record for January 2023 included orders, dated 1/31/23, to discontinue the Calazinc cream and start Cavilon barrier cream two times per day to open left buttock wound. h. A skin and wound evaluation, dated 2/7/23, identified the patient had an open lesion on the left buttock measuring 0.9 cm in length and 2.0 cm in width, no depth and a scab. i. A skin and wound evaluation, dated 2/14/23, identified the patient had an open lesion on the left buttock measuring 3.0 cm in length and 5.6 cm in width and no depth. j. A skin and wound evaluation, dated 2/22/23, identified the patient had an open lesion on the left buttock measuring 1.7 cm in length and 1.5 cm in width and no depth. k. A skin and wound evaluation, dated 2/28/23, identified the patient had an open lesion on the left buttock measuring 1.2 cm in length and 0.9 cm in width, no depth and a scab. l. A skin and wound evaluation, dated 3/7/23, identified the patient had an open lesion on the left buttock measuring 1.2 cm in length and 0.8 cm in width, no depth and a scab. m. A skin and wound evaluation, dated 3/14/23, identified the patient had an open lesion on the left buttock measuring 0.6 cm in length and 0.7 cm in width, no depth and a scab. n. The nursing home's Medication Administration Record for February and March 2023 included documentation nursing home staff applied Cavilon barrier cream two times per day to the open left buttock wound. On 3/14/23 at 4:17 PM, during an interview, Staff G, Hospice Aide, reported providing hospice aide services to the patient in January (starting 1/19/23) and February 2023. Staff G, Hospice Aide, reported the patient had a red area area on the left buttock, never a wound. Staff G, Hospice Aide, reported the nursing home staff applied barrier cream to the patient's left buttocks. On 3/15/23 at 1:25 PM, during an interview, Staff F, RN, denied the patient had any wounds at the start of care. Staff F, RN, reported the patient had some scabbed areas, but they generally only document on open skin areas. When asked if Staff F, RN, ever assessed the patients buttocks, Staff F, RN, reported they would look, but there was a difference in how hospice assesses a patient in comparison to how nursing home staff assess a patient. Staff F, RN, denied the patient ever had an open wound or blood; they explained the patient just had an area that was scabbed and coated in Calmoseptine. On 3/15/23 at 1:45 PM, during an interview, the Interim Clinical Manager explained nursing staff should also measure scabbed areas. On 3/15/23 at 4:15 pm, during an interview, Staff I, LPN, reported they remembered going out on an as needed nursing visit in February to assess the patient. Staff I, LPN, reported the patient had fragile skin and issues with moisture. Staff I, LPN, explained that on the evening of 2/16/23, the nursing facility nurse and aide gave the patient a shower. A piece of skin flecked off during the shower and their was a drop of blood. The patient's skin was macerated when Staff I, LPN, assessed the patient and the wound to the left buttock was superficial in depth. On 3/16/23 at 9:00 AM, during an interview, the Director of Nursing (DON) for the nursing home reported nursing home staff assessed the patient's buttock wound every week. The DON reported the area had been scabbed and not open until 1/31/23. The wound treatment changed to Cavilon barrier cream on 1/31/23. The DON reported the left buttock was now scabbed and healing well. The patient is still getting Cavilon barrier cream to the area. The hospice clinical record lacked any documentation of wound assessment until 2/16/23, and lacked documentation of any wound measurements.

Based on clinical record review, home visit observation, family interview and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 4 of 19 sampled patients (Patients #4, #7, #14 and #19). Failure to ensure the plan of care included complete and accurate physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms. --- 4. Patient #14 had a hospice admission date of 3/7/23 and received hospice services in an assisted living facility. Clinical record review revealed: a. The Plan of Care, dated 3/7/23 to 6/4/23 included orders for medications and treatments. b. An interim verbal order, dated 3/9/23 ordered to give oxygen per nasal canula per assisted living orders. The RN (registered nurse) failed to accurately specify the flow rate per nasal canula to be ordered on the Plan of Care and update to the Plan of Care IDG meeting notes. 5. Patient #19 had a hospice admission date of 2/2/22 and was discharged due to death while receiving hospice services in a nursing home facility. Clinical record review revealed: a. The Plan of care, dated 2/2/23 to 5/2/23, included an order for oxygen 2 liters per nasal canula if shortness of breath. b. The initial comprehensive assessment, dated 2/2/23, identified the patient was on 3 liters of oxygen continuous. c. Skilled nurse visit notes, dated 2/4/23 and 2/5/23, documented the patient's oxygen saturation levels at rest on oxygen, however lacked documentation of the rate of oxygen used by the patient. d. The IDG (interdisciplinary group) meeting notes, dated 3/8/23, lacked an update to the IDG with an order for the oxygen used by the patient. The RN (registered nurse) failed to accurately specify the flow rate per nasal canula to be ordered on the update to the Plan of Care IDG meeting notes. The surveyors reviewed the above findings with the hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey. Findings include: 1. Patient #5 had a hospice admission date of 2/10/23 and received hospice services in a private residence. Clinical record review revealed: a. The plan of care, dated 2/10/23 to 5/10/23, included medication order for metoprolol 12.5 milligrams (mg) orally twice daily, 10 mg tablet, take 1 tablet orally every 6 hours. b. The IDG (interdisciplinary group) meeting notes, dated 2/15/23 and 3/1/23, included order for metoprolol 12.5 mg orally twice daily, 10 mg tablet, take 1 tablet orally every 6 hours. The RN (registered nurse) failed to accurately document the correct dose of metoprolol on the plan of care and IDG meeting notes. Review of the hospice's policy, titled Plan of Care (POC), dated 2/1/23, identified the Interdisciplinary Group (IDG) gathers the information from the initial and comprehensive assessment to develop the POC. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the IDG reviews and updates each patient's Plan of Care (POC) at least every 15 days, or more frequently, if needed. 2. Patient #4 had a hospice admission date of 9/15/21 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: The POCs, dated 1/8/23 to 3/8/23 and 3/9/23 to 5/7/23, included the following medication orders: Zantac 360 10 milligrams (mg) oral tablet, take 1 tab orally once for heartburn (no identification if this is once a day or a one time medication); and, Famotidine 20 mg oral tablet, take 1 tab oral once a day for heartburn. The POCs also included an order for Docusate Sodium sodium 100 mg oral capsule, take 1 cap oral every 8 hours as needed for constipation. On 3/15/23 at 1:30 PM, during a home visit observation with Staff J, RN, the patient's family member responsible for setting up the patient's medications discussed with nurse the patient's need to regularly take medications to prevent constipation. The family member showed the nurse a bottle of Stool Softener (Senna S- 8.6 mg Senna with 50 mg Docusate). The family member reported the patient had been taking the Docusate Sodium 1 tab per day every day along with the Stool Softener 1 tab per day every day for the last 3 months, but the patient had been taking the Stool Softener for more than a year. The family member also reported the patient was currently taking Famotidine 20 mg, the generic medication for Zantac, one every day. The family member explained they sometimes switched back and forth between the Zantac and Famotidine depending on the cost and availability of the medications. The family reported the patient does not take both the Zantac and Famotine at the same time; only one or the other. 3. Patient #7 had a hospice admission date of 1/23/23 and received routine home care services from hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/12/23 to 4/11/23, included an IDG order for Calmoseptine topical ointment 0.44 percent to 20.6 percent, apply two times per day for wound. The POC identified the nursing home staff were responsible for administering all medications and treatments. The Calmoseptine order failed to identify the location of the wound. b. The comprehensive assessment completed by the registered nurse, dated 1/12/23, identified the patient had a diagnosis of diabetes, took oral medication to treat the diabetes, and used a glucometer for as needed blood sugar checks. c. The POC, dated 1/12/23 to 4/11/23, identified the patient had a diagnosis of diabetes and included orders for 3 different oral medications to treat diabetes (Metformin, Glipizide and Januvia). The POC failed to include an order for blood sugar testing. d. The skilled nursing visit notes, dated 2/17, 2/23 and 2/27/23, identified facility staff completed blood sugar testing before meals and as needed on the patient. The POC and Interdisciplinary Group meetings to update the POC, dated 1/18, 1/25, 2/8, 2/22 and 3/8/23, failed to identify the patient had blood sugar testing.

Based on clinical record review, home visit observation and patient/ family member interview, the hospice failed to ensure the Plan of Care included all medical equipment and supplies necessary to meet identified patient needs for 6 of 19 sampled patients (Patients #1, #4, #7, #8, #10 and #19). Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: --- 3. Patient #1 had a hospice admission date of 12/21/2022 and received routine home care services from hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care dated 12/21/22 to 3/20/23 documented supplies for patient as none. b. The initial comprehensive assessment completed by the registered nurse, dated 1/12/23, identified the patient had no durable medical equipment (DME) or supplies. c. The IDG update to the Plan of Care, dated 1/4/23 identified a wheelchair as equipment/supplies needed to meet the patients needs. d. The nursing home Treatment Administration record for January, February and March 2023 identified use of a roho cushion in recliner and wheelchair starting 1/13/23. e. The IDG update to the Plan of Care, dated 1/18/23 identified a wheelchair, EZ stand, and adult diapers as equipment/supplies needed to meet the patients needs. f. The IDG updates to the Plan of Care, dated 2/1/23, 2/15/23, and 3/1/23 identified no changes to DME. During an observation visit at the nursing facility on 3/14/23 at 1:05 PM with Staff F, RN, the surveyor observed the following in the patient's room : a wheelchair with a roho cushion placed next the to patient's hospital bed with pressure relief mattress, raised toilet seat with grab bars in the patient's bathroom. Staff F, RN provided the surveyor a copy of the active orders effective 3/14/23 which included the pressure reduction cushion, pressure reduction mattress. The RN failed to identify all equipment and supplies used to meet the patient's needs including the roho cushion, hospital bed with pressure relief mattress, and raised toilet seat with grab bars. 4. Patient #8 had a hospice admission date of 1/24/2023 and received routine home care services from hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care dated 1/24/2023 to 4/2/23 included diagnosis of Type 2 diabetes and documented supplies used by the patient included over the bed table, catheter supplies, Hoyer lift, pressure relief mattress, wheelchair cushion, hospital bed, compression stockings, and heel boots. b. The initial comprehensive assessment completed by the registered nurse, dated 1/24/23, identified the patient used a blood glucose monitor for diabetes. c. The IDG update to the Plan of Care, dated 2/22/23 identified the nursing facility staff are to check blood sugars if the patient is symptomatic and report if blood sugars are less than 60 or greater than 400 milligrams/decilter (mg/dl). d. The IDG updates to the Plan of Care, dated 3/8/22, lacked identification of the blood glucose monitor used by the nursing facility to obtain blood sugar assessments. 5. Patient #10 had a hospice admission date of 1/13/23 and received routine home care services from hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care dated 1/24/2023 to 4/2/23 included diagnosis of Type 2 diabetes and documented supplies used by the patient included over the bed table, hospital bed, hoyer lift, pressure relief mattress, adult diapers, shower chair, wheel chair, and wheel chair cushion. The Plan of Care ordered the nursing facility staff to check blood sugars as needed. b. The initial comprehensive assessment completed by the registered nurse, dated 1/13/23, identified the patient used a blood glucose monitor for diabetes. c. The IDG updates to the Plan of Care, dated 1/25/23, 2/8/23, 2/22/23, and 3/8/23, lacked identification of the blood glucose monitor used by the nursing facility to obtain blood sugar assessments. 6. Patient #19 had a hospice admission date of 2/2/2023 and discharged from the agency on 2/7/23 while receiving routine home care services from hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care dated 2/2/2023 to 5/2/23 included diagnosis of Type 2 diabetes and documented supplies used by the patient included over the bed table, hoyer lift, oxygen and hospital bed with pressure relief mattress,\The Plan of Care ordered the nursing facility staff to check blood sugars as needed. b. The initial comprehensive assessment completed by the registered nurse, dated 1/13/23, identified the patient had type 2 diabetes c. The IDG updates to the Plan of Care, dated 2/8/23, lacked identification of the blood glucose monitor used by the nursing facility to obtain blood sugar assessments. The surveyors reviewed the above findings with the hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey. Review of the hospice's policy, titled Plan of Care (POC), dated 2/1/23, the Interdisciplinary Group (IDG) gathers information during the initial and comprehensive assessment to be used in creating the POC, including identification of the (medical) supplies and durable medical equipment used by the patient. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/2021, identified the IDG reviews and updates each patient's POC at least every 15 days, or more frequently, if needed. 1. Patient #4 had a hospice admission date of 9/15/21 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: The POCs, dated 1/8/23 to 3/8/23 and 3/9/23 to 5/7/23, identified the patient used the following medical equipment and supplies: a walker. On 3/15/23 at 1:30 PM, during a home visit observation with Staff J, RN, the surveyor observed a gel cushion in the chair the patient was sitting in and a medication box used by the patient. In an interview, during the same home visit observation, the patient and patient's family member reported the patient had been using the gel cushion to relieve bony prominences and the medication box for a couple years. They reported the patient used a shower chair on the days the patient felt weak, safety bars by the toilet and shower and a half bedrail. The family member reported the patient had the equipment for a year. The POCs failed to identify the medical equipment and supplies used by the patient. 2. Patient #7 had a hospice admission date of 1/23/23 and received routine home care services from hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed by the registered nurse, dated 1/12/23, identified the patient had a diagnosis of diabetes, took oral medication to treat the diabetes, and used a glucometer for as needed blood sugar checks. c. The POC, dated 1/12/23 to 4/11/23, identified the patient had a diagnosis of diabetes and included orders for 3 different oral medications to treat diabetes (Metformin, Glipizide and Januvia). The POC failed to identify the patient used a glucometer. d. The skilled nursing visit notes, dated 2/17, 2/23 and 2/27/23, identified facility staff completed blood sugar testing before meals and as needed on the patient. The Interdisciplinary Group meetings to update the POC, dated 1/18, 1/25, 2/8, 2/22 and 3/8/23, failed to identify the patient used a glucometer.

Based on clinical record review, hospice policy review, nursing home record review, nursing home staff interview and hospice staff interview, the hospice failed to ensure coordination and collaboration among Interdisciplinary Group members occurred to ensure updates to the plan of care and the services provided to the patients were according to assessed needs and team decisions established on the plans of care for 3 of 10 sampled patients (Patients #7, #8 and #15) residing in nursing homes. Failure of the hospice team members to accurately update the plan of care and collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. --- 3. Patient #8 had a hospice admission date of 1/24/2023 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care dated 1/24/2023 to 4/24/23 lacked identification of wound orders. b. IDG updates to the Plan of Care, dated 1/25/23 and 2/8/23, documented orders for wound care to complete to the left heel, and buttocks to be completed by the nursing facility. c. The initial skilled nursing assessment, completed by Staff F, RN, dated 1/24/2023, documented an integumentary assessment of color/condition-pallor, temperature-warm, moisture-dry, risk factors for skin breakdown-healing of bony prominences, bowel incontinence, external factors of pressure, physical mobility, poor circulation, and urine incontinence. The assessment included a narrative note stating the skin was cool, dry, and intact. d. The initial social worker visit note, dated 1/25/23, documented collaboration with nursing facility staff and the patient had several wounds/skin breakdown including coccyx, bilateral buttocks, left heel and a blister to right hip. e. The skilled nurse visit note, dated 1/27/23,completed by Staff F, RN, dated 1/27/2023, documented an integumentary assessment of color/condition-pallor, temperature-cool, moisture-dry, risk factors for skin breakdown-bowel incontinence, external factors of pressure, physical mobility, inability to change positions, poor circulation, and poor nutrition. f. The skilled nurse visit note, dated 2/3/23,completed by Staff F, RN, documented skin was cool, dry and intact. g. The skilled nurse visit note, dated 2/10/23, documented the skin was pale, warm, and dry. The narrative section documented the patient was started on an antibiotic for wound infection. h. An interim order, dated 2/10/23 documented the patient was started on Keflex for wound infection. i. The skilled nurse visit, dated 2/11/23, documented skin was jaundiced, warm, and dry, however, lacked assessment of any wounds. j. The skilled nurse visit, dated 2/17/23, included documentation of wounds. k. The IDG updates to the Plan of Care, dated 1/25/23 and 2/8/23 lacked orders for wound care to be completed by nursing facility staff. l. The nursing home Treatment Administration Record, dated January 2023 identified a right hip blister wound, starting 1/18/23 and healed 2/8/23 with treatment of cavilon no sting barrier film to be applied until healed. m. The nursing home Treatment Administration Record for January 2023, identified left heel wound, starting 1/5/23 and healed 2/8/23 with ordered treatment of povidone-iodine solution 10% with instructions to apply topically every day shift for wound care and to cleanse with cleanser, patient with betadine, and cover with foam dressing. n. The nursing home Treatment Administration Record for January 2023, identified a buttocks wound, starting 1/10/23 with ordered treatment to cleanses with normal saline, cover open areas with foam dressing daily, apply barrier cream twice daily and as needed to surrounding non open areas, and orders to perform wound care daily. o. The nursing home Treatment Administration Record, dated February 2023 identified a right hip blister wound, starting 1/18/23 and healed 2/8/23 with treatment of cavilon no sting barrier film to be applied until healed. p. The nursing home Treatment Administration Record for February 2023, identified left heel wound, starting 2/9/23 and healed 2/13/23 with ordered treatment to cleanse with cleanser, apply xeroform gauze, cover with foam dressing and change daily during day shift. q. The nursing home Treatment Administration Record for February 2023, identified a buttocks wound, starting 1/10/23 with ordered treatment to cleanses with normal saline, cover open areas with foam dressing daily, apply barrier cream twice daily and as needed to surrounding non open areas, and orders to perform wound care daily. r. The skin and wound evaluation sheets completed by the nursing facility staff, dated 1/18/23 identified an abrasion to the sacrum with wound measurements of length and width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, pressure ulcer to left heel with measured length 7.4 centimeters(cm), width 3.5 cm, and depth 2.8cm, blister to right lateral thigh with measurement of length and width but no depth, abrasion to left thigh with measurement of length, width, and no depth, but presence of granulation tissue. s. The skin and wound evaluation sheets completed by the nursing facility staff, dated 2/1/23 identified an abrasion to the sacrum with wound measurements of 0.9 cm length and 0.5 cm width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, unstageable pressure ulcer to left heel with measured length 3.0 cm, width 2.8 cm, and depth not applicable due to eschar, blister to right lateral thigh intact, abrasion to left thigh not measured. t. The skin and wound evaluation sheets completed by the nursing facility staff, dated 2/15/23 identified an stage 1 pressure ulcer to medial right foot length 2.4cm, width 1.9cm and depth 1.6 cm, unstageable pressure ulcer to left heel, 1.9 cm length, 1.6 cm width, 1.5 cm depth, abrasion to the sacrum with wound measurements of 1.7 cm length and 1.7cm width, but no depth and granulation tissue present, an abrasion to the left calf with no depth, unstageable pressure ulcer to left heel with measured length 3.0 cm, width 2.8 cm, and depth not applicable due to eschar, blister to right lateral thigh intact, abrasion to left thigh not measured. Interview with Staff F, RN on 3/15/23 at 1:35 PM revealed the nurse could not recall the patient and if the patient had wounds at the time of the initial assessment and subsequent visit completed by the RN. The IDG updates to the Plan of Care, dated 1/25/23 and 2/8/23 lacked identification and assessment of wounds. The surveyors reviewed the above findings with the hospice Administrator and Clinical Manager. Agency staff provided no additional details prior to the end of the survey. Findings include: 1. Patient #15 had a hospice admission date of 8/23/22, a discharge date of 9/21/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The plan of care, dated 8/23/22 to 11/20/22, included physician order for morphine sulfate 20 milligram/milliliter (mg/ml), administer 0.25 ml oral every 2 hours as needed for pain. b. The on call skilled nursing note, dated 9/1/22, revealed the hospice registered nurse (RN) placed a phone call to the physician and received a verbal order for morphine sulfate 0.5 ml every 4 hours scheduled, hold if patient is sleeping. c. The interdisciplinary group (IDG) meeting notes, dated 9/14/22 and 9/21/22, included physician order for morphine sulfate 20 mg/ml, administer 0.25 ml oral every 2 hours as needed for pain. During an interview on 3/20/23 at 11:24 AM with the Administrator and Interim Clinical Manager, they reported the hospice had obtained a copy of the interim physician order for the change in dose and frequency of morphine sulfate on 9/1/22 from the nursing home after the surveyors gave findings on 3/16/23 and confirmed the order was not in the hospice clinical record. The hospice RN failed to ensure the change in morphine sulfate dose and frequency was updated on the IDG meeting notes, the hospice clinical record and coordination with nursing home and hospice staff involved with the patient. Review of the hospice's policy, titled Plan of Care (POC), dated 2/1/23, identified the Interdisciplinary Group (IDG) gathers the information from the initial and comprehensive assessment to develop the POC. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the IDG reviews and updates each patient's Plan of Care (POC) at least every 15 days, or more frequently, if needed. 2. Patient #7 had a hospice admission date of 1/12/23 and received routine home care hospice services while residing in a nursing home. See L0533 The IDG meetings, dated 1/18, 1/25, 2/8 and 3/8/23, lacked any information regarding the location or description of the patient's left buttock wound. The POC, dated 1/12/23 to 4/11/23, included an order for Calmoseptine barrier ointment to a wound twice per day, but failed to identify the location of the wound. The POC and IDG orders did not match the nursing home orders for treatment of the left buttock wound, which included Calzinc 1/9 to 1/31/23 and Cavilon cream twice per day starting 1/31/23.

Based on review of hospice policy review, nursing home and hospice staff interview, nursing home record review and hospice clinical record review, the hospice failed to: 1) ensure hospice staff coordinates with nursing home staff in development of the plan of care (see L0778) and providing treatment; 2) ensure the hospice provides the nursing home with patient's POC, hospice election form, CTI, names and contact information, instructions to access the hospice 24 hours on call system, medication information and hospice physician and attending physician (see L0781); and 3) ensure the hospice provides orientation and training of nursing home staff (see L0782). --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure nursing homes provided patient care in a manner to meet the individualized needs of all patients effectively and safely.

Based on clinical record review, onsite visit observation, nursing home medication and treatment administration records, nursing home staff interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 3 of 10 sampled patients (Patients #3, #7 and #8) residing in a nursing home. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. --- 3. Patient #8 had a hospice admission date of 1/24/2023 and received services while residing in a nursing home. Clinical record review revealed: See L0554. The Plan of Care dated 1/24/2023 to 4/24/23 and IDG updates to the POC, dated 1/25/23 and 2/8/23, lacked identification of wound orders completed by the nursing facility staff for the right hip blister. During an interview on 3/14/23 at 8:55 AM, Staff F RN, reported the nurse prints out the current medication and treatment administration records to check with the facility's updated list to see if there have been any changes and talks to staff to make sure there are not any new changes with the patients medications and treatments. Interview with Staff F, RN on 3/15/23 at 1:35 PM revealed the nurse could not recall the patient and if the patient had wounds at the time of the initial assessment and subsequent visit completed by the RN. The IDG updates to the Plan of Care, dated 1/25/22 and 2/8/23 lacked identification of orders for wound treatments to the right hip blister. Hospice staff failed to ensure coordination of care for treatment orders with the nursing home. The surveyors reviewed the above findings with the hospice Administrator and Clinical Manager. Agency staff provided no additional details prior to the end of the survey. Findings Include: 1. Patient #3 had a hospice admission date of 1/19/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed: a. The hospice Plan of Care, dated 1/19/2023 to 4/18/2023, included orders for risperidone 0.25 milligram (mg) oral tablet, take 1 tablet orally two times a day. b. The nursing home's medication administration record included an order for risperidone 0.5 mg, 1 tablet orally two times a day starting 2/14/23. c. The interdisciplinary group (IDG) meeting notes, dated 2/1/23, 2/15/23 and 3/1/23, included the order for risperidone 0.25 mg, take 1 tablet orally 2 times a day. During an interview on 3/14/23 at 8:55 AM, Staff D, RN (registered nurse), reported reviewing the nursing home medication list and coordinates with the nursing home staff every visit for medication changes. Hospice staff failed to ensure coordination of care, medication and treatment orders with the nursing home. Review of the hospice's policy, titled Nursing Facility Care Plan, Coordination and Communication, dated 2/3/2023, revealed staff provide patient care in accordance with a written plan of care established by the IDG. The hospice assumes full responsibility for professional management and coordination and the registered nurse case manager is responsible for coordinating and implementing patient care plans in collaboration with members of the IDG, facility staff and the attending physician. 2. Patient #7 had a hospice admission date of 1/12/23 and received routine home care hospice services while residing in a nursing home. See L0533 The IDG meetings, dated 1/18, 1/25, 2/8 and 3/8/23, lacked any information regarding the location or description of the patient's left buttock wound. The POC, dated 1/12/23 to 4/11/23, included an order for Calmoseptine barrier ointment to a wound twice per day, but failed to identify the location of the wound. The POC and IDG orders did not match the nursing home orders for treatment of the left buttock wound, which included Calzinc 1/9 to 1/31/23 and Cavilon cream twice per day starting 1/31/23.

Based on clinical record review, nursing home clinical record review, admission packet review and hospice staff interview, the hospice failed to ensure the nursing home received copies of the most recent hospice plan of care specific to the patient, physician certification of terminal illness specific to the patient, names and contact information for hospice personnel, and instructions on how to access the hospices 24 hour on call system for 1 of 2 sampled patients (Patient #3) with home observation visits in nursing homes. Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. --- Findings include: During an interview on 3/16/23 at 10:30 AM, Staff E, QAPI Coordinator, reported the admission packet has a form that is to be left in the nursing home chart, the form has spaces to document staff names and includes 24 hour on call system phone number. Patient #3 had a hospice admission date of 1/19/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed: The hospice Plan of Care, dated 1/19/2023 to 4/18/2023, included orders for skilled nursing, hospice aide, social worker, massage therapy and spiritual care services. During a home observation visit with Staff D, RN (registered nurse), on 3/14/23 at 8:55 AM, the surveyor reviewed the nursing home chart for required documents provided by the hospice. The surveyor was unable to locate a copy of the initial plan of care, the initial certification of terminal illness (CTI) form, the interdisciplinary group (IDG) meeting note, dated 2/15/23, the names and contact information for the hospice personnel and the information for the hospice 24 hour on call system. During an interview on 3/14/23 at 8:55 AM, Staff D, RN, reported office staff print off the plan of care, CTI form, and IDG meeting notes after the IDG meetings and the RN picks them up every week to hand deliver to the facilities. Staff D reviewed the nursing home chart and was unable to find copies of the initial plan of care; initial CTI form; IDG meeting note, dated 2/15/23; and the form with names and contact information of hospice personnel and the hospice 24 hour on call system information. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on patient clinical record review, review of hospice documentation in nursing facilities, and hospice and facility staff interviews, the hospice failed to assess the education and training needs for staff of a long term care facility where 1 of 2 sampled patients with visits (Patient #1) residing in a nursing home facility at the time of the survey. Failure to educate and train the nursing home facility staff where a patient resides potentially puts the patient at risk for receiving substandard care hospice philosophy based care. Findings include: --- Patient #1 had a hospice admission date of 12/21/2022 and received services while residing in a LTC facility. The patient's terminal diagnosis was hypertensive heart disease with chronic kidney disease. During an onsite visit to the facility on 3/14/23 at 1:36 PM, the surveyor discussed staff training with the Charge Nurse/LPN. The Charge Nurse/LPN reported not remembering receiving any training from the hospice staff about the hospice philosophy and hospice management. Review of the Hospice Services Contract with the facility, dated 8/16/18, revealed the hospice is ultimately responsible for ensuring the facility's personnel who provide patient services under this agreement receive appropriate training and to require and maintain documentation of this training. Interview on 3/16/23 at 9:45 PM with hospice Administrator reported he was waiting for nursing home Administrator to review training to see if the Charge Nurse completed hospice training. Interview on 3/20/23 at 1:04 PM with hospice Administrator reported no training has occurred since previous outreach educator left the hospice. They have a plan in place to ensure all staff at the facility receive training moving forward. The above findings were reviewed with the Hospice Administrator. Hospice staff did not provide any additional information prior to the end of the survey.