Every finding on record at Care Initiatives, Inc

Based on review of emergency preparedness training rosters, review of the emergency preparedness plan and policies and staff interview, the hospice failed to ensure training inemergency 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 an interview on 10/15/25 at 8:50 AM, Staff J, Quality & Education Coordinator gave the surveyor the most current emergency preparedness training documentation for contracted Staff K, massage therapist. The Emergency preparedness training was dated 11/19/21. The agency failed to provide emergency preparedness training to their contracted staff every 2 years. The above findings were reviewed with the Vice President of Clinical Services, Administrator and Clinical Manager.

Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group completed a complete and accurate comprehensive assessment at the time of hospice admission for 1 of 19 sampled patients. (Patient #1) Failure by the hospice Interdisciplinary Group (IDG) registered nurses to provide a complete and accurate comprehensive assessment at the time of hospice admission placed the patient at risk for ineffective staff collaboration and communication regarding patient's effectiveness of treatments and interventions. Findings include: --- According to the hospice policy, titled Comprehensive Assessment, last revised 7/19/23, the hospice interdisciplinary group (IDG) conducts and documents a patient-specific comprehensive assessment that identifies the patient's and caregiver's needs for hospice care, including medical, nursing, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to palliation and management of terminal illness and related conditions. Patient #1 had a hospice admission date of 9/22/25, and received hospice services while residing in a private residence.  Clinical record review revealed: a. The Plan of Care, dated 9/22/25 to 11/20/25, included primary diagnosis of senile degeneration of the brain and physician orders for skilled nursing services. b. The comprehensive skilled nurse note at the time of admission, dated 9/22/25, included documentation the patient had a tracheostomy and urinary catheter. c. During a home observation visit on 10/7/25 at 11:45 AM with Staff D, Registered Nurse (RN) the surveyor observed no evidence of a tracheostomy or urinary catheter. The hospice failed to complete an accurate comprehensive assessment at the time of admission. During an interview on 10/14/25 at 3:30 PM, Staff C, VP (Vice President) of Clinical Services, reported the chart was reviewed and she agreed the comprehensive assessment included the inaccurate information. The above findings were reviewed with the VP of Clinical Services, Administrator and Clinical Manager.

Based on staff interview, clinical record reviews and hospice policy reviews, the hospice failed to ensure the completion of a drug regimen review 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 2 of 19 sampled patients (Patients #2 and #15).    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 or potential drug interactions.    Findings include: --- 2.  Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:a.  The Interdisciplinary Group (IDG) meeting note on 7/9/25 revealed a new medication was started on 6/22/25, fleet enema extra 19 g(grams), 7 g/197 mL(milliliters) rectal enema, administer 1 application rectally once a day for constipation.b.  The IDG meeting note on 7/9/25 revealed a new medication was started on 7/8/25, senna plus 50 mg(milligram) - 8.6 mg tablet, take 2 tab(s) orally once a day.The hospice failed to complete a drug regime review (DRR) when the new medications were added.In an interview on 10/14/25 at 4:08 PM, Staff C, Vice President of Clinical Services, reported that she could not find a DRR in the patient's chart when each of these 2 medications were started. The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager.  According to the hospice policy titled Medication-Drug Regimen Review, last revised in February 2023, the drug regimen review (DRR) is completed at admission, with medication changes, changes in patient condition or at minimum of every 14 days.  Documentation of the DRR is captured in the Interdisciplinary Group (IDG) note.  The DRR addresses side effects of drug therapy, lab monitoring for associated drug therapies, actual or potential drug interactions, duplicate drug therapy and effectiveness of drug therapy.    During an interview on 10/6/25 at 3:38 PM, Staff G, Registered Nurse (RN), stated a DRR is completed at admission, recertification and anytime there is a change to the patient's medication.    1.Patient #2 had a hospice admission date of 6/27/25 and received hospice services while residing in an assisted living facility.  Clinical record review revealed:   a. The skilled nurse visit note, dated 9/6/25, completed by Staff I, RN, identified the RN contacted the doctor and received an order for Haloperidol 1 milligram (mg) tablets with instructions to give to the patient 1 tablet orally every 6 hours as needed for agitation but lacked documentation of a DRR at the start of the new medication.        b. The IDG meeting note, dated 9/16/25, identified Haloperidol 1 mg started on 9/6/25 but failed to document completion of a DRR.    The hospice failed to complete a DRR when medication changes occurred.

Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group completed a comprehensive assessment every 15 days at a minimum for 1 of 3 expired sampled patients. (Patient #19)  Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment at a minimum of every 15 days placed the patient at risk for ineffective staff collaboration and communication regarding patient's effectiveness of treatments and interventions.  Findings include: --- According to the hospice policy, titled Comprehensive Assessment, dated 7/19/23, patient, caregiver, and family progress towards desired goals (outcomes) and responses to care are reassessed as often as required by the patient’s condition, but no less frequently than every 15 days.  Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:  a. IDG update to the Plan of Care, dated 1/29/25, included primary diagnosis of chronic diastolic (congestive) heart failure and physician orders for skilled nursing services.  b. Skilled nurse visit note, dated 2/6/25, included a comprehensive assessment.  c. Skilled nurse visit note, dated 2/25/25, included a comprehensive assessment, 19 days after the last comprehensive assessment, 4 days later than the minimum required time frame.  The hospice failed to complete a comprehensive assessment at a minimum of every 15 days.  During an interview on 10/14/25 at 8:44 AM, Staff C, VP (Vice President) of Clinical Services, reported the chart was reviewed and she agreed the comprehensive assessment was completed later than the required time frame.  The above findings were reviewed with the VP of Clinical Services, Administrator and Clinical Manager.

Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or an accurate order for all medications and treatments to meet the needs of the patient for 3 of 19 sampled patients. (Patients #8, #15 and #19).  Failure to ensure the plan of care included physician orders for all necessary medications, treatments and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms.  Findings include: --- 3.  Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:a.  The plan of care (POC) dated 6/13/25 to 9/10/25 included orders for skilled nursing and hospice aide services.  Oxygen was listed on the POC with a start date of 6/13/25 that read, "oxygen to be applied at (liter flow rate) per (mode of delivery) (continuous/prn (as needed) for (reason)."b.  An aide intervention listed in the same POC revealed the patient had oxygen precaution, the patient had oxygen at 2L (liters)/nc (nasal cannula).  The hospice failed to include a specific order for oxygen for the patient.In an interview on 10/15/25 at 8:32 AM, Staff B, Clinical Manager, reported that on 7/22/25 the incomplete oxygen order was noted after the case manager found it and discontinued.   A new oxygen order was then written. The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager. 2. Patient #8 had a hospice admission date of 10/29/24 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:  a.  The Plan of Care, dated 6/25/25 to 8/24/25 and 8/25/25 to 10/23/25, indentified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nursing services and medications including oxygen therapy at 2 liters per minute. The patient goals and hospice aide tasks included oxygen therapy 2 to 4 liters per minute.  b. The IDG update to the plan of care, dated 8/12, 8/26/25, 9/9 and 9/23/25, included orders for oxygen therapy at 2 liters per minte and patinet goals and hospice aide tasks fro oxygen therapy 2 to 4 liters per minute.  The clinical record failed to include a clarifiction order for oxygen administration. According to the hospice policy, titled Interdisciplinary Care Plan Process, dated 7/19/23, identified the plan of care consists of updates to the plan of care from IDG (Interdisciplinary Group) meeting minutes include changes to the medications, treatments, supplies, durable medical equipment, problems, interventions, goals, changes in frequencies of team services, prep notes, discussion notes and other elements of the care plan.  1. Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:  a.  IDG update to the Plan of Care, dated 3/26/25, included primary diagnosis of chronic diastolic (congestive) heart failure, physician orders for skilled nursing services and medications.  b.  Skilled nurse visit note, dated 3/30/25, included documentation oxygen saturation of 80% on room air, shortness of breath at rest, oxygen rate 4 liters continuously, and obtained order for oxygen 4 liters per nasal cannula for comfort.  Clinical record failed to include an interim physician order for oxygen.  During an interview on 10/14/25 at 8:44 AM, Staff C, VP (Vice President) of Clinical Services, reported the chart was reviewed and she agreed there was no order for oxygen.

Based on hospice staff interview, clinical record review, and agency policy, the hospice failed to ensure the interdisciplinary group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care (POC) for 7 of 9 patients reviewed with missed visits.  (Patients #9, #11, #15, #17, #12, #8, and #13).Failure of the IDG to update the comprehensive assessment placed the patients at risk for ineffective staff collaboration and communication regarding patients' status and effectiveness of treatments and interventions. Findings include: --- 6. Patient #8  had a hospice admission date of 10/29/24 and received hospice services while residing in aa skilled nursing facility.  Clinical record review revealed:  a. The POC, dated 8/25/25 to 10/23/25, identified the patient had a diagnosis of chronic obstructive pulmanary disease and included orders for volunteer visits 4 times a month, hospice aide, social worker and skilled nurse visits.   b. The clinical record identified volunteer visit notes, dated 8/20/25 and 8/27/2 ( 2 times a month).  c. The IDG meeting notes, dated 8/26/25 and 9/9/25, lacked documentation the IDG was notified of the missed volunteer visits for the month of August, 2025.   d. The clinical record identified volunteer visit notes, dated 9/3/25 and 9/9/25 (2 times a month).  e. The IDG meeting notes, dated 9/9/25, 9/25/25 and 10/7/25, lacked documentation the IDG was notified of the missed volunteer visits for the month of September, 2025.    The hospice failed to provide hospice aide visits as ordered per the POC.    7. Patient #13 had a hospice admission date of 5/25/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POCs, dated 6/25/25 and 9/23/25 to 12/21/25, identified the patient had a diagnosis of end stage renal disease and included orders for skilled nursed visits 1 time a week and hospice aide and social worker visits.    b. The clinical record identified no skilled nurse visit note documented the week of 8/24/25 to 8/30/25.   c. The IDG meeting notes, dated 8/26/25 and 9/9/25, lacked documentation the IDG was notified of the missed skilled nurse visit for the week of 8/24/25 to 8/30/25.    The hospice failed to provide skilled nurse visit as ordered per the POC.    The surveyor reviewed the above information with the VP of Clinical Services, Administrator and Clinical Manager.    5. Patient #12 had a hospice admission date of 9/19/25 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 12/17/25, identified the patient had a diagnosis of prostate cancer and included orders for hospice aide visits 2 times a week, social worker and skilled nurse visits.    b. The clinical record identified a missed hospice aide visit on 10/1/25.    c. The IDG meeting note, dated 10/7/25, lacked documentation the IDG was notified of the missed hospice aide visit for the week of 9/26/25 through 10/2/25.    The hospice failed to provide hospice aide visits as ordered per the POC.   4. Patient #17 had a hospice admission date of 12/18/24, a death date of 4/9/25 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:   a. IDG update to the Plan of care, dated 3/12/25, included primary diagnosis of Multiple Sclerosis and physician orders for complementary therapy (massage therapy) two times per month.  b.  IDG update to the Plan of care, dated 3/26/25, included documentation of 1 missed massage therapy visit for the month of March.  Clinical record lacked documentation of a second massage therapy visit for the month of March or a reason why a second massage therapy visit was not completed.  During an interview on 10/14/25 at 8:40 AM, Staff C, VP of Clinical Services, reported documents are supposed to be scanned into the electronic medical record within a month.  The clinical record for Patient #17 was reviewed and she agreed there was no documentation regarding the second missed massage therapy visit for March.   According to agency policy, Interdisciplinary Care Plan Process last revised 7/19/23, directed in part, the purpose of the policy was to provide care coordination and an interdisciplinary approach to care planning.  Updates to the POC from IDG meeting minutes include changes to frequencies of team services.  In an interview on 10/7/25 at 1:!5 PM, Staff B, Clinical Manager, reported that when visits are missed a note is put in the prep notes with the date/discipline.  The prep notes are part of the IDG meeting note.  Missed visits are also discussed daily at stand up/stand down meetings. Patient #9 had a hospice admission date of 5/29/25 and received hospice services while residing in a nursing home.  Clinical record revealed the following:          a.  The IDG meeting minutes on 9/16/25 included orders for visits from a hospice volunteer 4 times per month.               1.  Review of the clinical record revealed the hospice volunteer only visited the patient 2 times in September 2025.               2.  The IDG meeting note on 9/30/25 failed to include discussion of the missed volunteer visit.            b.  The IDG meeting note on 98/16/25 included orders for weekly skilled nurse visits.               1.  Review of the clinical record revealed the skilled nurse did not visit the patient in September 2025.                 2.  The IDG meeting note on 9/30/25 failed to include discussion of the missed skilled nurse visit.            c.  The IDG meeting note on 9/2/25 included an order for (spiritual) counselor visits 2 times per month.               1.  Review of the clinical record revealed the patient only had 1 visit from the spiritual counselor in September 2025.               2.  The IDG meeting note on 9/16/25 failed to include discussion of the missed spiritual counselor visit.     2.  Patient #11 had a hospice admission date of 1/5/24 and received hospice services while residing in a nursing home.  Clinical record revealed the following:          a.  The IDG meeting notes on 9/16/25 included orders for visits from a hospice volunteer 4 times per month.          b.  The clinical record revealed a hospice volunteer failed to visit the patient on 9/24/25.          c.  The IDG meeting notes on 9/30/25 failed to include discussion of the missed volunteer visit.       3.  Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:         a.  The IDG meeting note dated 9/2/25 included an order for skilled nursing visits one per week.             1.  Clinical record revealed a skilled failed to visit the patient for the week of 9/5/25.             2.  The IDG meeting note dated 9/16/25 failed to include discussion of the missed skilled nurse visit.          b.  The IDG meeting note on 8/6/25 included orders for 10-12 physical therapy (*PT) sessions from 8/1/25 to 8/31/25.               1.  Review of PT documentation from 8/7/25 to 8/27/25 revealed the hospice failed to provide at least 10 PT session in August 2025.

Based on hospice staff interview, clinical record review, and agency policy, 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 2 of 17 sampled patients receiving hospice aide services (Patients #2 and #15).Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task leads to the potential risk that patients may failed to receive necessary services ordered on the plan of care.  Findings include: --- 2. Patient #2 had a hospice admission date of 6/27/25 and received hospice services while residing in an assisted living facility.   Clinical record review revealed:   a. The Plan of Care (POC), dated 9/3/25 to 12/1/25, identified the patient had a diagnosis of senile degeneration of the brain and included orders for hospice aide services 3 times a week.    b. The aide care plan, dated 6/27/25, include aide instructions to ambulate the patient using assistive device (cane, crutches, walker, oxygen).  The assignment did not include specific instruction on what device the aide should use when ambulating the patient.    During an interview on 10/14/25 at 8:35 AM, the Vice President (VP) of Clinical Services identified the aide care plan does not give specific instructions as to what assistive device should be used when ambulating the patient.   The hospice RN failed to include what specific device the aide should use when ambulating the patient.    The above findings were reviewed with the VP of Clinical Services, Administrator and Clinical Manager.   According to agency policy, Hospice Aide Services revised 11/15/23 directed, in part, hospice aide services are assigned based on the registered nurse case manager's comprehensive assessment and reassessment of the patient's personal care needs and ability to perform activities of daily living.  The registered nurse 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 a soften as necessary and at a minimum every fourteen (14) days by the registered nurse case manager.  1.   Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:a.  The IDG meeting note on 9/2/25 revealed the patient no longer required oxygen as of 8/18/25.b.  The hospice aide care plan interventions listed in the 9/2/25 IDG meeting note included oxygen precautions, the patient wears oxygen at 2 L(liters)/nc (nasal cannula), start dated 6/16/25.The hospice failed to update the hospice aide plan when oxygen was discontinued.c.  The IDG meeting note on 9/2/25 revealed the patient was back to her baseline with ax1 (assist of 1 person with mobility).d.  The hospice aide care plan interventions listed in the 9/2/25 IDG meeting note included that the patient required the assistance of 2 persons with transfers to the bed or wheelchair starting 6/27/25.  The hospice failed to update the hospice aide care plan when the patient had a change in the amount of assistance she needed with transfers.

Based on hospice staff interview, hospice policy review and clinical record 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 3 of 17 sampled patients receiving hospice aide services (Patients #5, #12 and #16).    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: --- 3. Patient #5 had a hospice admission date of 11/20/24 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:   a. IDG update to the POC, dated 8/26/25, identified the patient had a diagnosis of Huntington's disease and included physician orders for skilled nurse and hospice aide services.  b. Hospice aide care plan, dated 9/19/25, identified the tasks of measure the patient's weight by the 7th of the month.    c. Hospice aide visit notes, dated 9/3/25, completed by Staff H, Hospice Aide, lacked documentation of the task to measure the patient's weight.   d. The hospice aide viist note, dated 10/10/25, completed by Staff H, Hospice Aide, included documentation of the task to measure the patient's weight (3 days late).  The hospice aide failed completed the task of obtaining the patient's weight per the RN) assignment.    The surveyor reviewed the above information with the VP of Clinical Services, Administrator and Clinical Manager.    2. Patient #12 had a hospice admission date of 9/19/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. IDG update to the Plan of Care (POC), dated 9/23/25, identified the patient had a diagnosis of prostate cancer and included physician orders for skilled nurse and hospice aide services.  b. Hospice aide care plan, dated 9/19/25, identified the tasks of bed bath and shower.    c. Hospice aide visit notes, dated 10/2/25 and 10/9/25, completed by Staff H, Hospice Aide, identified the task of bed bath completed and identified the task of shower completed.  The visit note lacked documentation of the specific task completed, a bed bath or a shower.    The hospice aide failed to identify the specific services provided as instructed by the Registered Nurse (RN) assignment.   According to the hospice policy, titled Hospice Aide Services, dated 11/15/23, identified the registered nurse case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided.  1. Patient #16 had a hospice admission date of 6/12/24, a discharge date of 9/29/25 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:  a.  IDG update to the Plan of Care, dated 9/2/25, identified a primary diagnosis Alzheimer’s disease and orders for skilled nurse and hospice aide services.  b.  Hospice aide care plan, dated 6/13/24, identified the task weigh by the 7th of the month.  c.  Hospice aide visit note, dated 9/4/25, identified the task weigh by the 7th of the month as not required today.  d.  Hospice aide visit note, dated 9/8/25, identified the task weigh by the 7th of the month as completed, weight 172 pounds.  The task was completed 1 day late.  During an interview on 10/14/25 at 8:49 AM, Staff C, VP of Clinical Services, reported the clinical record was reviewed and she agreed the weight was obtained late.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to document required hospice aide uspervision every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 2 of 17 sampled patients (patients #13 and #19) with hospice aide services for 14 days or longer. Failure to ensure the supervision of hospice aide by registered nurses completed according to regulation increased the risk of agency staff not meeting the patinets' personal care needs. Findings include: --- 2. Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:  a. IDG update to the Plan of Care, dated 1/29/25, included primary diagnosis of chronic diastolic (congestive) heart failure and physician orders for skilled nursing and hospice aide services.  b. Skilled nurse visit note, dated 2/6/25, included hospice aide supervision.  c. Skilled nurse visit note, dated 2/25/25, included hospice aide supervision, 19 days after the last supervision, 5 days later than the required time frame.  The surveyor reviewed the above information with the VP of Clinical Services, Administrator and Clinical Manager.   According ot the hospice policy titled Hospice Aide Supervision, last revised 2/1/23, the Registered Nurse (RN) supervises hospice aides employed by the hospice and any aides working under contract. The nurse makes an on-site visit to the patinet's home no less frequently than every 14 calendar days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the interdisciplinary team are as identified in the hospice aide care plan and meet the patinet's needs. The hospice aide does not have to be present during this visit.  During an interview on 10/7/25 at 1:15 PM the Clinical Manager stated the hospice aide supervision documented in the comprehensive assessment.  1.Patient #13 had a hospice admission date of 6/25/24, and received hospice services while residing in a private residence.  Clinical record review revealed:  a. IDG update to the Plan of Care, dated 8/13/25, included primary diagnosis of end stage renal failure and physician orders for skilled nursing and hospice aide services.  b. Skilled nurse visit note, dated 8/20/25, included hospice aide supervision.  c. Skilled nurse visit note, dated 8/4/25, included hospice aide supervision, 15 days after the last supervision, 1 days later than the required time frame. The hosopice failed to complete hospice aide supervision every 14 days.  According to the hospice policy titled Hospice Aide Supervision, last revised 2/1/23, the Registered Nurse (RN) supervises hospice aides employed by the hospice and any aides working under contract. The nurse makes an on-site visit to the patient's home no less frequently than every 14 calendar days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the interdisciplinary team are as identified in the hospice aide care plan and meet the patient's needs. The hospice aide does not have to be present during this visit.  During an interview on 10/7/25 at 1:15 PM the Clinical Manager stated the hospice aide supervision documented in the comprehensive assessment.  1.Patient #13 had a hospice admission date of 6/25/24, and received hospice services while residing in a private residence.  Clinical record review revealed:  a. IDG update to the Plan of Care, dated 8/13/25, included primary diagnosis of end stage renal failure and physician orders for skilled nursing and hospice aide services.  b. Skilled nurse visit note, dated 8/20/25, included hospice aide supervision.  c. Skilled nurse visit note, dated 8/4/25, included hospice aide supervision, 15 days after the last supervision, 1 days later than the required time frame. The hospice failed to complete hospice aide supervision every 14 days. 2. Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility.  Clinical record review revealed:  a. IDG update to the Plan of Care, dated 1/29/25, included primary diagnosis of chronic diastolic (congestive) heart failure and physician orders for skilled nursing and hospice aide services.  b. Skilled nurse visit note, dated 2/6/25, included hospice aide supervision.  c. Skilled nurse visit note, dated 2/25/25, included hospice aide supervision, 19 days after the last supervision, 5 days later than the required time frame.  The above findings wee reviewed with the VP of Clinical Services, Administrator and Clinical Manager.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 2 of 6 sampled patients with ancillary services (Patients #10 and #15).  Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up-to-date information related to the patient's condition and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care.    Findings include: --- 2.  Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:a.  The interdisciplinary group (IDG) meeting note on 8/6/25 included orders for 10-12 physical therapy (PT) session from 8/1/25 to 8/31/25.b.  The clinical record failed to included PT visit notes for visits held in August 2025.  In an interview on 10/14/25 at 3:10 PM, Staff B, Clinical Manager, reported that the PT documentation from August 2025 should have been uploaded within 30 days.The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager. According to the hospice policy, titled Clinical Records, last revised February 2023, clinical record documentation is accurate, timely, complete, readily accessible and systemically organized to facilitate retrieval.  Entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers).    According to the hospice policy, titled Patient Record Integrity, last revised December 2023, staff using hard copy forms are expected to complete visit notes at the bedside, but no later than one week from the date of service to accommodate for unique challenges.  Ideally, the form is submitted to the office the date of completion but no later than two business days after the date of the documentation.   During an interview on 10/7/25 at 1:15 PM, Staff B, Clinical Manager stated hospice volunteers and hospice therapy providers are expected to complete and turn in handwritten documentation monthly to be scanned into the patient's electronic medical record (EMR).    1.Patient #10 had a hospice admission date of 2/18/25 and received services while residing in a nursing home.  Clinical record review revealed:   a. The Plans of Care (POC), dated 5/19/25 to 8/16/25 and 8/17/25 to 10/15/25 identified the patient had a diagnosis of chronic diastolic (congestive) heart failure and included orders for volunteer services 4 times a month and music therapy services 4 times a month.    b. The music therapy visit notes, dated 8/8/25, 8/15/25, 8/22/25 and 8/29/25, completed by Staff E, Music Therapist, identified the notes were scanned into the EMR on 10/14/25, 44 days late per agency expectation.  c. The music therapy visit notes, dated 9/5/25, 9/11/25, 9/19/25 and 9/26/25, completed by Staff E, Music Therapist, identified the notes were scanned into the EMR on 10/14/25, 14 days late per agency expectation.    d. The volunteer visit note, dated 8/29/25, completed by Staff F, Volunteer, identified the note scanned into the EMR on 10/14/25, 44 days late per agency expectation.    The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe.   According to the hospice policy, titled Clinical Records, last revised February 2023, clinical record documentation is accurate, timely, complete, readily accessible and systemically organized to facilitate retrieval.  Entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers).    According to the hospice policy, titled Patient Record Integrity, last revised December 2023, staff using hard copy forms are expected to complete visit notes at the bedside, but no later than one week from the date of service to accommodate for unique challenges.  Ideally, the form is submitted to the office the date of completion but no later than two business days after the date of the documentation.   During an interview on 10/7/25 at 1:15 PM, Staff B, Clinical Manager stated hospice volunteers and hospice therapy providers are expected to complete and turn in handwritten documentation monthly to be scanned into the patient's electronic medical record (EMR).    1.Patient #10 had a hospice admission date of 2/18/25 and received services while residing in a nursing home.  Clinical record review revealed:   a. The Plans of Care (POC), dated 5/19/25 to 8/16/25 and 8/17/25 to 10/15/25 identified the patient had a diagnosis of chronic diastolic (congestive) heart failure and included orders for volunteer services 4 times a month and music therapy services 4 times a month.    b. The music therapy visit notes, dated 8/8/25, 8/15/25, 8/22/25 and 8/29/25, completed by Staff E, Music Therapist, identified the notes were scanned into the electronic medical record (EMR) on 10/14/25, 44 days late per agency expectation.  c. The music therapy visit notes, dated 9/5/25, 9/11/25, 9/19/25 and 9/26/25, completed by Staff E, Music Therapist, identified the notes were scanned into the EMR on 10/14/25, 14 days late per agency expectation.    d. The volunteer visit note, dated 8/29/25, completed by Staff F, Volunteer, identified the note scanned into the EMR on 10/14/25, 44 days late per agency expectation.    The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe.   2.  Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following: a.  The interdisciplinary group (IDG) meeting note on 8/6/25 included orders for 10-12 physical therapy (PT) session from 8/1/25 to 8/31/25.b.  The clinical record failed to included PT visit notes for visits held in August 2025.  In an interview on 10/14/25 at 3:10 PM, Staff B, Clinical Manager, reported that the PT documentation from August 2025 should have been uploaded within 30 days. 2.  Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:a. The Plans of Care (POC), dated --- to --- and 8/17/25 identified the patient had a diagnosis of ----- and included orders for 10-12 PT visits from 8/1/25 to 8/31/25.b.  The clinical record failed to includedPT visit notes for visits held in August 2025.   In an interview on 10/14/25 at 3:10 PM, Staff B, Clinical Manager, reported that the PT documentation from August 2025 should have been uploaded within 30 days.The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 1 of 1 sampled patients with music therapy services (Patient #10).    Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients.    Findings include: --- According to the hospice policy titled Clinical Records, last revised February 2023, clinical record documentation is accurate, timely, complete, readily accessible and systemically organized to facilitate retrieval.  Entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers).    According to the hospice policy titled Patient Record Integrity, last revised December 2023, staff using hard copy forms are expected to complete visit notes at the bedside but no later than one week from the date of service to accommodate for unique challenges.    During an interview on 10/7/25 at 1:15 PM, Staff B, Clinical Manager stated documentation should be completed the same day as the visit.    a. The Plans of Care, dated 5/19/25 to 8/16/25 and 8/17/25 to 10/15/25, identified the patient had a diagnosis of chronic diastolic (congestive) heart failure and included orders for skilled nurse, social work, hospice aide, volunteer, chaplain and music therapy services.    b. Music therapy visit note, dated 8/15/25, signed completed by Staff E, Music Therapist, 10/10/25, 56 days after the visit and 49 days late per agency policy.    c. Music therapy visit note, dated 8/22/25, signed completed by Staff E, Music Therapist, 10/10/25, 49 days after the visit and 42 days late per agency policy.  d. Music therapy visit note, dated 8/29/25, signed completed by Staff E, Music Therapist, 10/10/25, 42 days after the visit and 35 days late per agency policy.  e. Music therapy visit note, dated 9/9/25, signed completed by Staff E, Music Therapist, 10/13/25, 34 days after the visit and 27 days late per agency policy.  f. Music therapy visit note, dated 9/11/25, signed completed by Staff E, Music Therapist, 10/13/25, 32 days after the visit and 25 days late per agency policy.  g. Music therapy visit note, dated 9/19/25, signed completed by Staff E, Music Therapist, 10/10/25, 21 days after the visit and 14 days late per agency policy.  h. Music therapy visit note, dated 9/26/25, signed completed by Staff E, Music Therapist, 10/10/25, 14 days after the visit and 7 days late per agency policy.  The agency failed to ensure timely completion of routine visit documentation.    The above findings were reviewed with the Vice President of Clinical Services, Administrator and Clinical Manager.

Based on staff interview, clinical record review, review of nursing home medication administration records and policy review, 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 1 of 2 sampled patients (Patient #3) 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: --- According to the hospice policy titled Nursing Facility Care Plan, Coordination of Communication, last revised in April 2025, agency nurse case managers for patients are responsible for coordinating and implementing patient care plans in collaboration with members of the Interdisciplinary Group (IDG), facility representatives and the attending physician.    During an interview on 10/7/25 at 3:38 PM, Staff G, Registered Nurse (RN), identified anytime an update or change to the patient's plan of care occurs, the facility is notified via telephone call or in person regarding the update or change.    Patient #3 had a hospice admission date of 10/3/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   The Plan of Care (POC), dated 10/3/25 to 12/31/25, identified the patient had a diagnosis of lung cancer, included IDG orders for skilled nursing services 2 times per week and included physician orders for medications.    Review of the patient's nursing home Medication Administration Record (MAR), dated 10/8/25, identified the following medication discrepancies with the hospice's POC and Medication Profile for the patient:   a. The hospice POC had an order for Acetaminophen 500 milligrams (mg) tablets with instructions to take 2 tablets orally every 6 hours as needed for mild pain.  The hospice's Medication Profile identified a start date for the medication, dated 10/3/25.  The nursing home's MAR had an order for Acetaminophen 325 mg tablets with instructions to give 2 tablets by mouth every 4 hours as needed for elevated temperature; pain.  The nursing home MAR identified a start date for the medication, dated 10/3/25.     b. The hospice POC had an order for Guaifenesin 100 mg/5 milliliters (ml) oral liquid with instructions to take 10 ml orally every 6 hours as needed for cough.  The hospice's Medication Profile identified a start date for medication, dated 10/3/25.  The nursing home's MAR lacked an order for this medication.    c. The hospice POC had an order for Ondansetron 8 mg tablets with instructions to take 1 tablet orally every 8 hours for nausea or vomiting.  The hospice's Medication Profile identified a start date for the medication, dated 10/3/25.  The nursing home's MAR had an order for Ondansetron 8mg tablets with instructions to give 1 tablet by mouth every 6 hours as needed for nausea/vomiting.  The nursing home's MAR identified a start date for the medication, dated 10/3/25.    Hospice staff failed to ensure the coordination of the patient's medication with the patient's nursing home.    The above findings were reviewed with the Vice President of Clinical Services, Administrator and Clinical Manager.

Based on clinical record review, hospice policy review, home visit observation, family interview 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 9 of 19 sampled patients (Patients #3, #4, #6, #7, #8, #9, #12, #14 and #16). 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 #3 had a hospice admission date of 9/9/22 and received routine home care services from the hospice while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/30/23 to 6/8/23, included IDG orders for skilled nursing services and orders for medications. b. The assisted living's medication administration record (MAR) dated May 2023, included the order for Olopatadine 0.1 % administer 1 drop in each eye one time a day, effective 4/13/23. b. The physician's order, dated 4/17/23, included Olopatadine 0.2 % apply 1 drop in each eye once a day effective 4/17/23. c. The verbal order, dated 4/27/23, included milk of magnesia 30 cc 1 time dose and bisacodyl suppository 10 mg 1 every day as needed. d. The assisted living's MAR failed to include the order for Bisacodyl suppository. e. The IDG meeting note, dated 4/28/23 and 5/12/23, included documentation a drug regimen review completed. The hospice failed to identify the discrepancies in the medication orders. 6. Patient #8 had a hospice admission date of 2/17/22 and received routine home care services from the hospice while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/13/23 to 6/11/23, included IDG orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Fentanyl and tylenol extra strength to treat pain and bisacodyl, magnesium hydroxide and polyethylene glycol to treat/prevent constipation. b. The comprehensive assessment completed by the RN, dated 2/17/22, included the following documentation related to the DRR: "No issues identified." c. The IDG meeting, dated 2/18/22, failed to include documentation of a completed DRR. d. The IDG meeting, dated 3/31, 4/15, 4/28 and 5/12/23, included orders for all current medications. The notes identified DRR continue to monitor and need for changes in medication regimen for symptoms management. 7. Patient #12 had a hospice admission date of 5/3/23 and received routine home care services from the hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/3/23 to 7/31/23, included IDG orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Acetaminophen and tramadol to treat pain and bisacodyl, milk of magnesia, miralax and senokot to treat/prevent constipation. The POC also included orders for levothyroxine which is associated with laboratory monitoring. b. The comprehensive assessment completed by the RN, dated 5/3/23, included the following documentation related to the DRR: "No issues identified." c. The IDG meeting, dated 3/31, 4/15, 4/28 and 5/12/23, included orders for all current medications. The DRR failed to identify duplicate pain and bowel medication or medications associated with laboratory monitoring. 8. Patient #14 had a hospice admission date of 5/9/23 and received routine home care services from the hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/9/23 to 8/6/23, included IDG orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including bisacodyl, fleet enema, milk of magnesia and polyethylene glycol to treat/prevent constipation. b. The comprehensive assessment completed by the RN, dated 5/9/23, included the following documentation related to the DRR: "No issues identified." c. The IDG meeting, dated 5/12 and 5/19/23, included orders for all current medications. The DRR failed to identify duplicate bowel medication. 9. Patient #16 had a hospice admission date of 2/25/23 and discharge date of 3/1/23 and received routine home care services from the hospice while residing in a private home setting. Review of the clinical record revealed the following: a. The POC, dated 2/25/23 to 5/25/23, included IDG orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including docusate sodium, milk of magnesia, polyethylene glycol and senna to treat/prevent constipation. b. The comprehensive assessment completed by the RN, dated 2/25/23, included the following documentation related to the DRR: "No issues identified." c. The IDG meeting, dated 3/3/23, included orders for all current medications. The DRR failed to identify duplicate bowel medication. The above stated finding were presented to the Administrator and Clinical Manager. No further information provided prior to the end of the survey. 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. On 5/18/23 at 10:07 AM, during an interview, the Clinical Manager explained the registered nurse completes the DRR initially on admission and reviews the medications with the Medical Director. The pharmacist completes a DRR within 5 days. The IDG completes a DRR with every IDG meeting and with any medication changes. 1. Patient #4 had a hospice admission date of 4/26/23 and received routine home care services from the hospice while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/26/23 to 7/24/23, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 to 2 times per week. The POC included orders for the the following medications: Belsarma, Ellipta, Cilostazol, Iron 150 Vitamin B-12 with Vitamin C Folic Acid, multiple vitamin, Vitamin C, Metoprolol, Paroxetine, Pirfenidone, Ramipril, Simvastatin, Omeprazole, Prednisone and Zolpidem. b. The comprehensive assessment completed by a registered nurse (RN), dated 4/26/23, included documentation of a drug regimen review (DRR) which identified the RN had reviewed the patient's medications for effectiveness of therapy, side effects, actual/potential interactions, duplicate drug therapy and drug therapy associated with lab monitoring. The RN documented "No issues identified" and "No evidence of change since last review". The DRR failed to identify the patient had duplicate medications to treat insomnia (Belsarma and Zolpidem). The RN also documented the patient used insulin and blood glucose monitoring through an abdominal Dexacom implant. The DRR failed to identify the patient took insulin and did blood glucose monitoring continuously through the Dexacom system. c. The IDG meeting, dated 4/28/23, included the following statement related to the DRR: "DRR noting to monitor pt (patient) ability to utilize inhalers correctly due to advanced pulmonary disease." d. The clinical record included documentation of physician orders for Lorazepam 0.5 milligrams (mg) oral tablet 0.5 mg oral table, take 1 tab oral every 2 hours as needed for anxiety/restlessness; Lorazepam 1 mg oral tablet 1 mg oral tablet, take 1 tab oral 2 times a day for restlessness/anxiety; and, Morphine 20 mg/milliliters (ml) oral concentrate 20 mg/ml oral concentrate, administer 0.5 ml oral every hour asneeded for pain/dyspnea. e. The IDG meeting, dated 5/5/23, included the following information related to the DRR: "Medications and diagnoses reviewed and remain appropriate', "No medication changes made since last IDT (Interdisciplinary Team)", "Drug regimen review completed" and "Medications adjusted as needed for symptom management." The IDG meeting also included a note from the pharmacist, dated 5/1/23. The pharmacist documented they completed a drug profile review for this patient that included review of known allergies, effectiveness of drug therapy, adverse effects, actual or potential drug interactions, duplicative drug therapy and drug therapy currently associated with laboratory monitoring and documented the following concern: "Omeprazole used in combination with Cilostazol increases the toxicities associated with the Cilostazol and bleed risks, suggest at minimum monitoring." Neither the DRR completed by the pharmacist or the DRR completed by the IDG team during the meeting discussed the CNS depressant interactions between Morphine and Lorazepam. f. A skilled nursing visit, dated 5/8/23, included documentation that the patient was no longer using the insulin pump and the patient's spouse was giving the patient insulin as needed. g. A skilled nursing visit, completed by Staff C, Licensed Practical Nurse (LPN), dated 5/15/23, included documentation the patient was taking Milk of Magnesia for constipation. h. The IDG meeting, dated 5/19/23, included documentation that the patient had no medication changes since the last review. On 5/22/23 at 1:00 PM, during a home visit observation, Staff C, LPN, assessed the patient. The patient and patients spouse discussed the patients problems with constipation with Staff C, LPN. The spouse informed Staff C, LPN, that the patient had a bad episode of constipation the previous day. The spouse reported using the stool softener pills, then Milk of Magnesia and then 2 Dulcolax pills. The surveyor observed the patients medication bottles and reviewed the patients medications with the patients spouse. In an interview, during the same home visit observation, the spouse reported the patient had not been taking Belsarma, Ellipta, Cilostazol, Iron and all other vitamin supplements, Metoprolol, Paroxetine, Pirfenidone, Ramipril, Simvastatin and Zolpidem since they chose to start hospice. The spouse explained the patient had seen the patients physician just prior to starting hospice and the physician told them they could discontinue any of the medications causing discomfort or if they felt the patient did not need it. The spouse reported Ellipta caused the patient to cough a lot after use and the Pirfenidone made the patient feel sick. The spouse reported the patients blood pressure and heart had been doing fine since discontinuing the Metoprolol and Ramipril. The spouse reported that the patient has been using Novolog Insulin since the patients pump ran out. The spouse explained they gave the patient different doses of insulin based on the patients blood sugar readings obtained from the implanted device in the patients abdomen. The device continuously reads the patients blood sugar levels. Staff C, LPN, reported they advised the patients spouse last week on Monday (5/15/23) to give the patient Milk of Magnesia if the stool softner plus laxative pills did not work. Staff C, LPN, explained this is what they give patients in the nursing home if they do not have a bowel movement every 2 to 3 days. The spouse reported giving the Milk of Magnesia for the last week. The spouse gives the patient 15 milliliters (ml) every other day and yesterday, they gave the patient 2 doses. Staff C, LPN, reported they had informed the IDG team via email about the Milk of Magnesia and reported they would contact the patients physician today to see what the physician wanted to do. Review of the clinical record on 5/23/23 revealed the Belsarma, Ellipta, Cilostazol, Iron and all other vitamin supplements, Metoprolol, Paroxetine, Pirfenidone, Ramipril, Simvastatin and Zolpidem were still active medications in the patients electronic record. The clinical record lacked an order for Novolog Insulin and lacked an order for the Milk of Magnesia. 2. Patient #6 had a hospice admission date of 3/8/23 and received routine home care services from the hospice while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/8/23 to 6/5/23, included IDG orders for skilled nursing services and orders for medications. The medication orders included medications with duplicate therapies including Acetaminophen and 2 different cannabis tinctures with to treat pain and Fleets Enema, Polyethylene Glycol and Vitafusion Fiber to treat/prevent constipation. The POC included an order for Atropine ophthalmic 1% solution, apply 2-3 drops sublingually 4 times a day as needed for secretions. b. The comprehensive assessment completed by the RN, dated 3/8/23, included the following documentation related to the DRR: "No evidence of change since last review." c. The IDG meeting, dated 3/17/23, included the following documentation related to the DRR: "Medications and diagnosis reviewed with medical director and appropriate. DRR- continue to monitor symptoms and need for changes in medication regimen for symptom management." The IDG meeting included documentation of a pharmacist review, dated 3/13/23, included documentation the pharmacist found the following as a result of a DRR: "Suggest the discontinuation of the supplements providing no palliative benefit." The DRR failed to identify the use of any duplicate medication therapies. d. The IDG meeting, dated 3/31/23, included orders for all current medications. The IDG meeting included an order for Scopolamine 1 mg/72 hour transdermal film, extended release, apply 1 film topically every 72 hours for secretions and a start date of 3/29/23. The meeting included documentation of the following related to the DRR: "Medications and diagnosis reviewed with medical director and remain appropriate. DRR- continue to monitor symptoms and need for changes in medication regimen for symptoms management." The DRR failed to identify the patient now took duplicate medications to treat secretions. e. The IDG meeting, dated 4/13/23, included an order for Senna plus to treat constipation and a start date of 4/5/23 for the medication. The DRR completed by the IDG failed to identify the patient took duplicate medications to treat constipation. 3. Patient #7 had a hospice admission date of 4/21/23 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 4/21/23 to 7/19/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included orders for duplicate medication therapy to treat/prevent constipation including Polyethylene Glycol, Milk of Magnesia and Fleet Enema. b. The comprehensive assessment completed by the RN, dated 4/21/23, included the following documentation related to the DRR: "No issues identified." c. The IDG meeting, dated 4/28/23, included the following documentation related to the DRR: "Medications and diagnosis reviewed with medical director and appropriate. DRR- continue to monitor symptoms and need for changes in medication regimen for symptom management. " The IDG meeting included documentation of a pharmacist DRR, dated 4/26/23, identified potential drug interactions and advised a maximum dosage amount for the use of Acetaminophen. The DRR failed to identify the patient took duplicate medications to treat/prevent constipation. 4. Patient #4 had a hospice admission date of 4/15/23 and received routine home care services from the hospice while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/15/23 to 7/13/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included duplicate therapies to treat constipation (Polyethylene Glycol and Senna Plus), pain (Acetaminophen, Oxycodone and Ibuprofen) and depression (Mirtazapine and Trazadone). b. The comprehensive assessment completed by the RN, dated 4/21/23, included the following documentation related to the DRR: "No pain medication available." The DRR failed to identify any duplicate drug therapies. c. The IDG meeting, dated 4/21/23, included the following documentation related to the DRR: "Medications and diagnoses reviewed and remain appropriate. Drug regimen review completed. Pt is on minimal medications for comfort. Discussed may need to increase pain medication next month if Baclofen pump is unable to be refilled due to the extended travel time. " The IDG meeting included documentation of a pharmacist DRR, dated 4/19/23, identified potential drug interactions and duplicate therapy to treat depression. The DRR failed to identify duplicate bowel and pain medications. The IDG meeting included medication orders for the following medications to treat pain: Acetaminophen, Oxycodone and Ibuprofen d. An interim physician order, dated 4/21/23, included the following medication orders: Roxanol to treat pain/dyspnea, Tylenol suppository to treat pain/fever medication, Ativan to treat anxiety/restlessness and Atropine to treat secretions. e. The subsequent IDG meeting, dated 5/5/23, included the following documentation related to the DRR: "Medications and diagnoses reviewed and remain appropriate. No medication changes made since last IDT. Drug regimen review completed. Medications effective for symptom management." The DRR failed to identify duplicate drug therapy to treat pain and the potential interaction between Morphine and Ativan.

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 treatments to meet the needs of the patient for 2 of 19 sampled patients (Patient #4 and #18). 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. Findings include: --- 2. Patient #18 had a hospice admission date of 7/19/22 and date of death of 7/30/23 and received routine services from the hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a registered nurse, dated 7/19/23, identified the patient was using oxygen at a rate of 2 liters per minute via nasal cannula. b. The POC, dated 7/19/22 to 10/16/22, identified a diagnosis of alcoholic cirrhosis and emphysema and included IDG) orders for skilled nursing services 1 to 2 times per week. The POC identified the patient used oxygen supplies, but failed to include an order for the use of the oxygen. c. The IDG meeting, dated 7/22/22, did not include any information about the patient's use of oxygen. The above stated finding were presented to the Administrator and Clinical Manager. No further information provided prior to the end of the survey. 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. Patient #4 had a hospice admission date of 4/26/23 and received routine home care services from the hospice while residing in a private residence. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a registered nurse, dated 4/26/23, identified the patient was using oxygen at a rate of 4 liters per minute via nasal cannula. b. The Plan of Care (POC), dated 4/26/23 to 7/24/23, identified a diagnosis of pulmonary fibrosis and included Interdisciplinary Group (IDG) orders for skilled nursing services 1 to 2 times per week. The POC identified the patient used oxygen supplies, but failed to include an order for the use of the oxygen. c. The Interdisciplinary Group (IDG) meeting, dated 4/28/23, did not include any information about the patient's use of oxygen. d. A skilled nursing visit, dated 5/3/23, identified the patient used oxygen at a rate of 4 liters per minute. e. The skilled nursing visits, dated 5/4, 5/5, 5/6, 5/8 and 5/15/23, identified the patient used oxygen at a rate of 2 liters per minute. f. The IDG meeting, dated 5/5/23, included documentation of a note from a skilled nursing visit on 5/3 and 5/4/23 about the patient's use of oxygen at 2 liters per minute during the visit. g. The IDG meeting, dated 5/19/23, included documentation of a note from a skilled nursing visit, dated 5/15/23, which identified the patient use of oxygen at 2 liters per minute. h. Review of the clinical record on 5/23/23 revealed the clinical record continued to lack an order for the patient's use of oxygen. On 5/22/23 at 1:00 PM, during a home visit observation, Staff C, Licensed Practical Nurse (LPN), assessed the patient. Staff C, LPN, reviewed the patients oxygen use. The surveyor observed the patients oxygen was set at 2 liters per minute and the patient used the oxygen via a nasal cannula. In an interview, during the same home visit observation, the spouse reported the patient used oxygen at 2 liters per minute continuously.

Based on clinical record review, hospice policy review and hospice staff interview, 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 5 of 17 sampled patients receiving hospice aide services (Patients #2, #3, #8, #11 and #12). 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. --- 3. Patient #3 had a hospice admission date of 9/9/23 and received hospice services while residing in a private home residence. Clinical record review revealed the following: a. The IDG meeting notes, dated, 3/31/23, 4/14/23, 4/28/23 and 5/12/23, included IDG orders for hospice aide services 3 times a week. b. The hospice aide care plan, dated 2/16/23, included RN instructions to the hospice aide to file fingernails 1st visit of the week and file uneven toenails 1st visit of the week. c. Hospice aide visit notes, dated 3/20, 3/22, 3/24, 3/29, 3/31, 4/3, 4/7, 4/10, 4/12, 4/14, 4/19, 4/21, 4/24, 4/26, 4/28, 5/3, 5/5, 5/8, 5/10, 5/12, 5/15, 5/17 and 5/19/23, all identified the aide filed the patient's fingernails and toenails. The hospice aide failed to complete the task as directed by the aide care plan. d. Hospice aide visit note, dated Friday 5/12/23, included documentation the task of assist with bathing 3rd visit of the week had been completed, but this was the 1st visit of the week. The hospice aide failed to complete the task as directed by the aide care plan. The hospice aide failed to provide services as instructed by the RN assignment. 4. Patient #8 had a hospice admission date of 2/17/22 and received hospice services while residing in a private home setting. Clinical record review revealed the following: a. The IDG meeting notes, dated, 3/31/23, 4/14/23, 4/28/23 and 5/12/23, included IDG orders for hospice aide services 2 times a week. b. The hospice aide care plan, dated 2/9/23, included RN instructions to the hospice aide to provide a shower 2 times a week and if patient is having pain or not feeling well, may give a bed bath as patient allows. c. Hospice aide visit notes, dated 3/20, 3/24, 3/28, 3/31, 4/3, 4/7, 4/10, 4/13, 4/17, 4/21, 4/24, 5/5, 5/15 and 5/19/23, included documentation the provided assistance with a shower and bed bath. The hospice aide failed to complete the task as directed by the aide care plan. The hospice aide failed to provide services as instructed by the RN assignment. 5. Patient #12 had a hospice admission date of 5/3/2 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The IDG meeting note, dated 5/12/23, included IDG orders for hospice aide services 2 times a week. b. The hospice aide care plan, dated 2/9/23, included RN instructions to the hospice aide to coordinate with the facility to provide 1 additional bath each week. c. Hospice aide visit notes, 5/15 and 5/17/23, included documentation the aide provided and extra bath on both visits. The hospice aide failed to complete the task as directed by the aide care plan. The hospice aide failed to provide services as instructed by the RN assignment. The above stated finding were presented to the Administrator and Clinical Manager. No further information provided prior to the end of the survey. Findings include: According to the hospice Policy titled Hospice Aide Services, dated 2/1/23, the hospice registered nurse case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. During an interview on 5/18/23 at 10:07 AM, the Clinical Manager reported the registered nurse case manager is responsible for creating the aide care plan and overseeing the aide services. The plan of care weeks start on Friday and end on Thursday. 1. Patient #2 had a hospice admission date of 1/12/23 and received hospice services while residing in a longterm care facility. Clinical record review revealed the following: a. The interdisciplinary group (IDG) meeting notes, dated, 3/17/23, 3/31/23, 4/14/23, 4/28/23 and 5/5/23, included IDG orders for hospice aide services 3 times a week. b. The hospice aide care plan, dated 1/23/23, included Registered Nurse (RN) instructions to the hospice aide to perform the task of aide provide an extra bath on Thursday – Nursing Facility baths are Tuesday and Friday. c. Hospice aide visit note, dated Tuesdays 3/21/23, 3/28/23, 4/4/23, 4/25/23 and 5/2/23; Wednesdays 3/22/23, 3/29/23, 4/12/23, 4/19/23, 4/26/23 and 5/17/23; Fridays 3/31/23 and 4/28/23; and Monday 4/10/23; included the task provide an extra bath on Thursday - nursing facility baths are Tuesday and Friday, was marked as completed even though it was not Thursday. The hospice aide failed to complete the task as directed by the aide care plan. d. Hospice aide visit note, dated Thursday 5/18/23, included the task provide an extra bath on Thursday - nursing facility baths are Tuesday and Friday, was marked as completed, but the narrative portion of the note included documentation, nursing facility already completed bath. The hospice aide failed to accurately document completed tasks. The hospice aide failed to provide services as instructed by the RN assignment. 2. Patient #11 had a hospice admission date of 2/19/23 and received hospice services while residing in a longterm care facility. Clinical record review revealed the following: a. The IDG meeting notes, dated, 3/31/23, 4/14/23, 4/28/23 and 5/5/23, included IDG orders for hospice aide services 3 times a week. b. The hospice aide care plan, dated 3/2/23, included RN instructions to the hospice aide to assist with bathing 3rd visit of the week. c. Hospice aide visit notes, dated Wednesday 4/19/23, Mondays 4/10/23 and 5/15/23, included documentation the task of assist with bathing 3rd visit of the week had been completed, but this was the 2nd visit of the week. The hospice aide failed to complete the task as directed by the aide care plan. d. Hospice aide visit note, dated Friday 5/12/23, included documentation the task of assist with bathing 3rd visit of the week had been completed, but this was the 1st visit of the week. The hospice aide failed to complete the task as directed by the aide care plan. The hospice aide failed to provide services as instructed by the RN assignment.

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 the required copies of the hospice election form and interdisciplinary group updates to the plan of care for 1 of 2 sampled patients (Patient #2) 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: According to the hospice policy titled, Nursing Facility Care Plan, Coordination and Communication, dated 2/1/23, upon admission, the business office manager (BOM)/office coordinator (OC) will ensure the consents (Medicare Hospice Benefit Election and Medicaid Hospice Benefit (if appropriate), the Patient/Family Informed Consent and the Resuscitation Instruction form), are incorporated into the patients nursing facility clinical record within three (3) business days of creation. When the Certification of Terminal Illness form (CTI) and Plan of Care (POC) have all of the required signatures, within three (3) business days, the BOM/OC is responsible to provide a copy of the consents, CTI and POC to the Registered Nurse Case Manager (RNCM). The RNCM is responsible to incorporate the completed POC into the patients facility clinical record on the next nursing visit. The Interdisciplinary Group (IDG) conference notes serve as updates to the POC. Each week, after the IDG meeting, the BOM/OC is responsible to print and provide the IDG conference summary to the RNCM within 24 hours of the meeting. The RNCM incorporates it into the patients facility clinical record on the next nursing visit. The POC is retained on the chart and the IDG conference notes are added on top. The additional IDG conference notes collectively reflect updates to the POC. Patient #2 had a hospice admission date of 1/12/23 and received routine home care hospice services while residing in a nursing home. During a home observation visit on 5/22/23 at 2:45 PM with Staff D, Registered Nurse (RN), Staff D provided surveyor with a hospice binder that included hospice required documents for patient. The surveyor and Staff D reviewed the hospice binder for the required documents. After review of the documents in the binder Staff D agreed the required documents, Medicare hospice benefit election form, and IDG meeting notes, dated 4/28/23 and 5/5/23, were missing. On 5/22/23 at 3:00 PM, Nursing home RN reviewed the hospice documents scanned into the nursing home electronic medical record (EMR) and reported she was unable to identify the missing documents in the EMR. On 5/24/23 at 3:55 PM, the Administrator reported the hospice keeps the current POC and the following IDG meeting notes in the NH patient chart. The previous POC and IDG meeting notes prior to the current POC may be removed. The Administrator and Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey.