Every finding on record at Care Initiatives, Inc

Based on staff interview, clinical record reviews and agency 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 4 of 6 sampled patients (Patients #1, #2, #4 and #5).    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 ineffective medications, side effects and actual or potential drug interactions.    Findings include: --- 2. Patient #2 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home setting.  Clinical record review revealed:   a. IDG meeting note, dated 1/8/26, included documentation a DRR completed.    b. IDG meeting notes, dated 1/22/26 and 2/5/26, included documentation any new medications that would require DRR: no.  The notes failed to include a DRR.   IDG meeting notes failed to include a DRR every 15 days as required.   3. Patient #4 had a hospice admission date of 10/24/25 and received hospice services while residing in an assisted living facility.  Clinical record review revealed:   a. IDG meeting note, dated 12/24/25, included documentation diagnoses/medication relatedness reviewed and DRR discussed with physician, no suggested changes at this time.    b. IDG meeting notes, dated 1/8/26 and 1/22/26, included documentation any new medications that would require DRR: none.  The notes failed to include a DRR.    IDG meeting notes failed to include a DRR every 15 days as required.    4. Patient #5 had a hospice admission date of 4/14/25 and received hospice services while residing in a nursing home setting.  Clinical record review revealed:   a. IDG meeting note, dated 12/24/25, included documentation diagnoses/medication relatedness reviewed and DRR discussed with physician, no suggested changes at this time.    b. IDG meeting notes, dated 1/8/26 and 1/22/26, included documentation any new medications that would require DRR: none.  The notes failed to include a DRR.    IDG meeting notes failed to include a DRR every 15 days as required.    The above findings were reviewed with the Administrator, Interim Administrator, Clinical Manager, Interim Clinical Manager, Vice President (VP) of Hospice and VP of Clinical Services for Hospice.   According to the hospice policy, titled Medication – Drug Regimen Review – Initial and Ongoing, dated 12/29/08, identified on admission a nurse documents all medications in the patient’s electronic health record medication profile.  The registered nurse (RN) case manager is responsible to review the patient medications with medication changes, changes in patient condition or at a minimum of every 14 days.  Medications are reviewed for side effects of drug therapy; lab monitoring for associated drug therapies; interactions of drug therapy, actual or potential; duplicate drug therapy and effectiveness of drug therapy.  The RN at a minimum reviews findings of the drug review with the IDG at least every 14 days.  Documentation of the drug regimen discussion is captured in the IDG note.  During an interview on 3/3/26 at 3:43 PM, Interim Clinical Manager reported the DRR is typically done with new patients, new medications, recertifications and every 14 days.  The DRR is documented under the visit note or a prep note (communication note), the notes are pulled into the IDG notes and discussed at IDG meeting.  1.  Patient #1 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home setting.  Clinical record review revealed:  a.  IDG meeting note, dated 12/24/25, included documentation diagnoses/medication relatedness reviewed and DRR discussed with physician, no suggested changes at this time.  b.  IDG meeting notes, dated 1/8/26 and 1/22/26, included documentation any new medications that would require DRR: none.  The notes failed to include a DRR.  IDG meeting notes failed to include a DRR every 15 days as required.

Based on clinical record review and agency policy review,  the hospice failed to ensure the hospice completed a comprehensive spiritual assessment on admission for 1 of 19 sampled patients (Patient #7).  Failure to complete an initial comprehensive spiritual assessment increased the risk patient's spiritual needs would not be identified and/or addressed appropriately. Findings include: --- Patient # 7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 8/21/25 to 11/18/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nurse and social work services.  b. Registered Nurse (RN) initial comprehensive assessment, dated 8/21/25, completed by Staff D, RN, documented spiritual assessment: not assessed.    c. Social Worker (SW) initial assessment, dated 8/26/25, completed by Staff J, SW, documented spiritual assessment: not assessed.    The hospice team failed to complete a comprehensive assessment within 5 days of the hospice admission that assessed spiritual needs.    The above findings were reviewed with the Clinical Documentation Coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services.       According to the hospice policy titled Comprehensive Assessment, dated 7/19/23, the hospice conducts and documents a patient specific initial assessment within 48 hours after the election of hospice care unless the physician, patient or representative requests the initial assessment be completed in less than 48 hours. This initial assessment may be combined with a comprehensive assessment that identifies the patient's and caregiver's needs for hospice care, including medical nursing, psychosocial, emotional and spiritual care. The comprehensive assessment of the patient is completed by members of the interdisciplinary team in consultation with the patient's attending physician no later than five (5) calendar days after the patient elects the hospice benefit (admission to hospice).

Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to perform an initial bereavement assessment within 5 days of the patient's election of the hospice benefit as part of the initial comprehensive assessment in order to determine patient and/or family bereavement needs, goals and interventions to be identified on the Plan of Care for 2 of 19 sampled patients (Patients #12 and #18) receiving hospice services for more than 5 days.   Failure to complete an initial bereavement assessment increased the risk that patient's or family's/caregiver's grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors.   Findings include: --- According to the hospice policy titled Comprehensive Assessment, dated 7/19/23, the hospice conducts and documents a patient specific initial assessment within 48 hours after the election of hospice care unless the physician, patient, or representative requests that the initial assessment be completed in less than 48 hours. This initial assessment may be combined with a comprehensive assessment that identifies the patient's and caregiver's needs for hospice care, including medical nursing, psychosocial, emotional and spiritual care. The comprehensive assessment of the patient is completed by members of the interdisciplinary team in consultation with the patient's attending physician no later than five (5) calendar days after the patient elects the hospice benefit (admission to hospice). The comprehensive assessment of the patient consists of at least the following assessment tools: the nursing assessment, with psychosocial, spiritual and bereavement components or the components assessed separately. 1.Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 10/24/25 to 1/21/25, identified the patient had a diagnosis of idiopathic pulmonary fibrosis and included orders for skilled nurse, social work, chaplain and hospice aide services.   b. Skilled nurse initial comprehensive assessment, dated 10/24/25, completed by Staff H, Registered Nurse, (RN) lacked an initial bereavement risk assessment.   c. Chaplain initial comprehensive assessment, dated 10/27/25, lacked an initial bereavement risk assessment. d. Social work initial comprehensive assessment, dated 10/28/25, lacked an initial bereavement risk assessment.  The hospice failed to complete an initial bereavement risk assessment.   2. Patient #18 had a hospice admission date of 4/11/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 6/28/25 to 9/25/25, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nurse, social work, chaplain and hospice aide services.   b. Skilled nurse initial comprehensive assessment, dated 4/11/25, completed by Staff H, RN, lacked an initial bereavement risk assessment.   c. Social work initial comprehensive assessment, dated 4/14/25, lacked an initial bereavement risk assessment.  d. Chaplain initial comprehensive assessment, dated 4/16/25, lacked an initial bereavement risk assessment. The hospice failed to complete an initial bereavement risk assessment.   The above findings reviewed with the Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice 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 1 of 3 sampled patients (Patient #14) 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 wound care is performed by the Registered Nurse Case Manager (RNCM) during the initial assessment, and by a hospice nurse a minimum of every 7 days and as necessary to meet patient needs. Wound care is administered as ordered by the patient’s attending physician, physician designee or nurse practitioner.  Review of the hospice policy, titled Plan of Care, dated 2/1/23, identified the patient’s plan of car specifies the care and services necessary to meet the needs of the patient, caregiver and family as identified in the comprehensive assessment and reassessments of the patient.  The content of the plan of care incudes interventions to facilitate the management of pain and symptoms; and a detailed statement of the scope and frequency of services necessary to meet the needs of the patient, caregiver and family.  Patient #14 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The IDG meeting notes, dated 9/18/25, 10/2/25, 10/16/25 and 10/30/25, included physician orders decubitus/pressure ulcer/midline inner buttocks gluteal fold: facility nurse to apply mepilex dressing to wound and change every 72 hours and as needed if soiled or dislodged. Hospice RN to assess every 7 days.    b. Skilled nurse visit notes, completed by Staff H, RN, dated 9/25/25, 10/6/25, included documentation of an open wound with wound treatment and measurements.  The visits were 11 days apart, 4 days greater than the required 7 days.   c. Skilled nurse visit notes, completed by Staff H, RN, dated 10/9/25, 10/20/25, included documentation of an open wound with wound treatment and measurements.  The visits were 11 days apart, 4 days greater than the required 7 days.   The hospice nurse failed to assess patient wounds every 7 days as ordered and per hospice policy.  Findings reviewed with Clinical documentation coordinator, Vice President (VP) of Clinical Services, Quality Education Coordinator and VP of Hospice Services.

Based on hospice staff interview, home visit observation, clinical record review and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments to meet the needs of the patient for 4 of 18 sampled patients (Patients #3, #4, #7 and #12).  Failure to ensure the plan of care included physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms.  Findings include: --- 3. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma and included orders for skilled nurse visits and included physician orders for medications and treatments.    b. Skilled nurse visit note, dated 10/18/25, completed by Staff E, RN, identified the patient utilized 2 liters of oxygen via nasal cannula, continuously.    c. The IDG update to the POC, dated 10/30/25, lacked physician orders for oxygen therapy.    The hospice failed to include all physician orders for necessary drugs and treatment including oxygen therapy on the patient's plan of care.    4. Patient #7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 8/21/25 to 11/15/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nurse visits and included physician orders for medications and treatments.    b. The RN comprehensive assessment, dated 8/21/25, completed by Staff D, RN, identified the patient had a catheter.    c. The IDG update to the POC, dated 9/4/25, lacked orders for catheter type, size and balloon volume.    The hospice failed to include all physician orders for necessary drugs and treatment including catheter orders on the patient's plan of care.    The above findings were reviewed with the Clinical Documentation Coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services.   2. Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 10/24/25 to 1/21/25, identified the patient had a diagnosis of idiopathic pulmonary fibrosis, and included orders for skilled nurse visits and included physician orders for medications and treatments.   b. The comprehensive skilled nurse visit note, dated 10/24/25, completed by Staff H, Registered Nurse (RN), identified the patient utilized oxygen at 2 liters at hours of sleep.   c. The IDG update to the POC, dated 10/30/25, lacked physician orders for oxygen therapy.   The hospice failed to include all physician orders for necessary drugs and treatment including oxygen therapy on the patient's plan of care.    According to the hospice policy, titled Plan of Care, dated 2/1/23, identified the content of the plan of care includes drugs and treatment necessary to meet the needs of the patient.  1. Patient #4 had a hospice admission date of 11/3/25 and received hospice services in a private home.     a. During a home visit observation on 11/17/25 at 3:40 PM, with Staff A, Administrator, the surveyor reviewed the patient's medications with Staff A.  The current medication profile provided to the surveyor included duplication of medications and medications the patient was no longer taking.  Staff A reported the medications patient was no longer taking and the duplicate medications had been discontinued and was unsure why these medications printed on the current medication profile.    b. Medication Profile, printed date 11/17/25, provided to surveyor for home visit observation, included current medications: aspirin 81 mg, Novolog (insulin), torsemide 20 mg daily, all with a start date of 11/3/25, and medications identified as discontinued by Staff A: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine, all with a start date of 11/3/25.    Clinical record review revealed:  c. Plan of Care, dated 11/3/25 to 1/31/26, included primary diagnosis of heart failure and medications: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine.  d. Interdisciplinary Group (IDG) meeting note, dated 11/13/25, included medications: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine.  e. Medication Profile, printed date 11/18/25, , included current medications: aspirin 81 mg, Novolog (insulin), torsemide 20 mg daily, all with a start date of 11/3/25, and medications identified as discontinued by Staff A: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine, all with a start date of 11/3/25.; arnica topical cream with a start date of 11/10/25; and lorazepam with a start date of 11/4/25 and discontinued date of 11/10/25.  During an interview on 11/10/25 at 11:38 AM, Staff M, Quality and Education Coordinator, reported the discontinued medications noted above were marked as discontinued but the order to discontinue was marked in error which removed the discontinuation of the medications.  The hospice nurse failed to update the Plan of Care and IDG meeting note with an accurate list of medications.

Based on hospice staff interview, clinical record review and hospice policy review, the hospice failed to ensure the Interdisciplinary Group 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 for 2 of 4 sampled patients with missed visits (Patients #4 and #9).  Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs.  Findings include: --- Review of the hospice policy, titled Interdisciplinary Group Meetings, dated 7/28/21, identified IDG documentation reflects team discussion and changes in the plan of care.  Review of the hospice policy, titled Plan of Care, dated 2/1/23, identified reviews of and changes to the plan of care are documented and communicated to members of the IDG.  1.  Patient #4 had a hospice admission date of 11/3/25, and received hospice services while residing in a private home.  Clinical record review revealed:  a.  Plan of Care (POC), dated 11/3/25 to 1/31/26, included primary diagnosis of heart failure and orders for skilled nursing services weekly and hospice aide services twice a week.  b. Hospice aide visit note, dated 11/7/25, included documentation patient refused visit today.  c. The IDG update to the POC, dated 11/13/25, included documentation missed visits: none.  The hospice failed to provide hospice aide visits as ordered per the POC and IDG update to the POC.  2. Patient #9 had a hospice admission date of 7/17/25, and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POCs, dated 7/17/25 to 10/14/25 and 10/15/25 to 1/12/26, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nurse, social worker, hospice aide, and volunteer services.    b. The IDG updates to the POC, dated 8/7, 8/21/25, 9/4 and 9/18/25, include orders for volunteer services 4 times a month. The notes lacked documentation of missed volunteer visits.  c. The clinical record lacked documentation of volunteer notes for the month of August.   d. The clinical record, dated 9/2/25 and 9/21/25, included documentation of 2 visits volunteer visits completed for the month of September.  The hospice failed to provide volunteer services as ordered per the POC.  The above findings were reviewed with the Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved for 3 of 3 sampled bereavement records (Patients #17, #18 and #19).    Failure to provide bereavement counseling according to identified needs placed the bereaved at an increased risk for worsening or unresolved issues related to grief.    Findings include: --- 3.  Patient #19 had a hospice admission date of 9/25/24, a death date of 11/8/24 and received services while residing in a nursing home.    Clinical record review revealed no bereavement plan of care completed.  During an interview on 11/19/25 at 11:38 AM, Staff M, Quality and Education Coordinator, confirmed the clinical record failed to include a bereavement care plan however the bereaved is receiving bereavement mailings.  Findings reviewed with Clinical documentation coordinator, Vice President (VP) of Clinical Services, Quality Education Coordinator and VP of Hospice Services.   2. Patient #18 had a start of care date of 4/11/25, a death date of 5/21/25 and received hospice services while residing in a nursing home.  Review of the clinical record revealed:  a. A bereavement initial visit/assessent, dated 6/10/25, idenitfied the bereaved would like monthly follow-up concerning grief. b. The bereavement care plan, dated 7/1/25, idneitified the following planned interventions: contact by phone or face to face, facilitate life review and teach coping strategies for dealing with grief. The goal target date identified 7/1/26. c. The bereavement note, dated 7/7/25, documented bereavement visit made. d. The bereavement note, dated 8/7/25, documented the bereaved contacted and would like a follow-up call next month. e. The bereavement note, dated 9/10/25, documented the bereaved contacted and plan a follow up call next month. f. The bereavement communication note, dated 10/3/25, documented no further phone contact required. Continue monthly mailings. g. Clinical record review lacked documentation of mailings to the bereaved. The hospice failed to complete documentation of mailings sent to the bereaved. According to the hospice policy titled Bereavement Services, dated 6/29/23, at the first Interdisciplinary Group (IDG) following the death of a patient, risk factors and needs of family members, caregivers and significant others are considered when identifying bereavement services.  The Spiritual Counselor or Social Worker updates the electronic health record (EHR) and develops the bereavement plan of care noting the kind of bereavement services required.  The Spiritual Counselor or Social Worker initiates contact with the bereaved by telephone within 2-4 weeks of the patient's death; attempting a minimum of two phone calls.  The initial bereavement assessment is completed at the first contact with the bereaved.  Monthly bereavement mailings are provided for all identified bereavement parties unless specifically declined.   1. Patient #17 had a hospice admission date of 4/4/25, a death date of 8/11/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. IDG update to the plan of care, dated 8/21/25, identified the patient died but lacked a bereavement plan of care.    b. Clinical record review lacked documentation of any monthly bereavement mailings sent to the bereaved.    The hospice failed to complete documentation of mailings sent to the bereaved.

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 18 sampled patients receiving hospice aide services (Patients #1, #3, #5, #12 and #17).    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: --- 5. Patient #5 had a hospice admission date of 9/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a.  Plan of Care, dated 9/24/25 to 12/22/25, included primary diagnosis of Alzheimer’s disease and physician orders for hospice aide services twice a week.  b. The hospice aide care plan, dated 9/29/25 included Registered Nurse (RN) instructions to the hospice aide to perform the task of Medication: Other.  c.  The hospice aide visit notes, completed by Staff I, Hospice Aide, dated 9/30, 10/3, 10/7, 10/10, 10/14, 10/21, 10/22, 10/24, 10/28, 11/4 and 11/7/25, included documentation the task Medications: Other: was completed.  The hospice aide care plan failed to provide specific instructions to the hospice aide on what Medications: Other was to be completed by the hospice aide.  Findings reviewed with Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services.   4. Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 10/24/25 to 1/21/26, identified the patient had a diagnosis of ideopathic fibrosis and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 11/12/25, included aide instructions to ambulate with assistance using assistive devise cane, crutches, walker and oxygen. The care plan failed to specify which assistive devise the patient required. The hospice RN failed to include specific instructions on what assistive device the aide should provide for the patient.   According to the hospice policy titled Hospice Aide Services, dated 11/15/23, 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.  Hospice aide services are assigned based on the RN Case Manager's comprehensive assessment and reassessment of the patient's personal care needs and ability to perform activities of daily living.    During an interview on 11/18/25 at 8:15 AM, Staff A, Administrator stated the RN Case Manager develops the hospice aide care plan and supervises the hospice aide services.    1.Patient #1 had a hospice admission date of 10/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 10/10/25 to 1/7/26, identified the patient had a diagnosis of malignant neoplasm of tongue and included physician orders for skilled nurse and hospice aide services.    b. The hospice aide care plan, dated 10/10/25, 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 instructions on what skin care the aide should provide to the patient.    2. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma, included physician orders for skilled nurse and hospice aide services and identified a gait/transfer belt as durable medical equipment the patient uses.     b. The hospice aide care plan, dated 10/20/25, included aide instructions to assist with transfers.  The assignment did not include specific instructions on what assistive device should be used when transferring the patient.    The hospice RN failed to include what specific assistive device the aide should use when transferring the patient.    3. Patient #17 had a hospice admission date of 4/4/25, a death date of 8/11/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POCs, dated 6/3/25 to 8/1/25 and 8/2/25 to 9/30/25, identified the patient had a diagnosis of senile degeneration of the brain and included physician orders for skilled nurse and hospice aide services.    b. The hospice aide care plan, effective 4/8/25 to 8/11/25, included aide instructions to assist with transfers, provide skin care, and weight.  The assignment did not include specific instructions on what assistive device should be used when transferring patient, what skin care the aide should provide the patient and how often the aide should obtain a weight on the patient.   The hospice RN failed to include specific instructions to the hospice aide regarding all tasks assigned.

Based on staff interview, clinical record reviews and hospice agency policy review, the hospice failed to ensure hospice hospices provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 13 of 18 sampled patients receiving hospice aide services (Patients #1, #3, #6, #7, #8, #9, #10, #12, #14, #16, #17, #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: --- 12. Patient #14 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The interdisciplinary group (IDG) updates to the POC, dated 9/18/25, 10/2/25, 10/16/25 and 10/30/25, included physician orders for hospice aide services twice a week.  b. The hospice aide care plan, dated 6/19/25, included Registered Nurse (RN) instructions to the hospice aide to perform the task nail care, clean under nail beds one time weekly and as needed for hygiene.  c. Hospice aide visit notes, completed by Staff I, Hospice Aide (HA), dated 9/19, 9/22, 9/25, 9/29, 10/2, 10/7, 10/13, 10/14, 10/21, 10/24, 10/28, 10/31, 11/4 and 11/7/25, included documentation the task nail care, clean under nail beds one time weekly and as needed for hygiene was completed.  The hospice aide failed to follow the hospice aide care plan.  13. Patient #19 had a hospice admission date of 9/25/24, a death date of 11/8/24 and received services while residing in a nursing home.  Clinical record review revealed:  a. The IDG updates to the POC, dated 10/3/24, 10/17/24 and 10/31/24, included physician orders for hospice aide services twice a week and identified hospice aide task to weight patient with a start date of 9/30/24.  b. Hospice aide visit notes, completed by Staff L, HA, dated 10/1, 10/2, 10/4, 10/17, 10/23, 10/29 and 11/1/24, included documentation the task weight was not required today.  c. Hospice aide visit notes, completed by Staff L, HA, dated 10/16 and 11/6/24, failed to include tasks completed or not completed.  Hospice aide failed to follow the hospice aide care plan.  Findings reviewed with Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services.   6. Patient #6 had a hospice admission date of 10/17/25 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of peripheral vascular disease and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 10/30/25, included aide instructions to clean under the patient's fingernails 1 time weekly. c. Hospice aide visit notes, dated 10/30/25, 11/3, 11/6, and 11/10/25, completed by Staff I, Hospice Aide, documented task completed every visi (2 times per week). The hospice aide failed to complete the task of clean under the fingernails 1 time weekly as instructed by the RN assignment.   7. Patient #8 had a hospice admission date of 5/7/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 8/15/25 to 11/2/25 and 11/3/25 to 1/1/26, identified the patient had a diagnosis of Alzheimer's disease and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 5/9/25, included aide instructions to provide bath: shower.   c. Hospice aide visit note, dated 10/3, 10/7, 10/10/25 and 11/7/25, completed by Staff C, Hospice Aide, documented task not required today. The hospice aide failed to complete the shower task as instructed by the RN assignment.   8. Patient #9 had a hospice admission date of 7/17/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 7/17/25 to 10/14/25 and 10/15/25 to 1/12/26, identified the patient had a diagnosis of congestive heart failure and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 11/5/25, included aide instructions to provide bath: shave and shower.   c. Hospice aide visit note, dated 9/9, 9/12, 9/16/25 and 10/24/25 completed by Staff F, Hospice Aide, documented task not required today. The hospice aide failed to complete the shave and shower task as instructed by the RN assignment.   9. Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 10/24/25 to 1/21/26, identified the patient had a diagnosis of ideopathic pulmonary fibrosis and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 11/12/25, included aide instructions to provide bath: clean under fingernails 1 time weekly.   c. Hospice aide visit notes, dated 10/30/25 and 11/3/25, completed by Staff I, Hospice Aide, documented the task completed every visit (2 times a week). The hospice aide failed to complete the task to clean under the fingernails 1 time weekly as instructed by the RN assignment.   10. Patient #16 had a hospice admission date of 3/25/25 and discharge date of 8/9/25 received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 3/25/25 to 6/22/25 and 6/23/25 to 9/20/25, identified the patient had a diagnosis of sequelae of cerebral infarction and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 5/9/25, included aide instructions to provide bath: weight the first week of every month and bed bath and shampoo every visit.   c. Hospice aide visit note, dated 7/2, 7/3, 7/8/25 and 8/1 and 8/5/25 completed by Staff C, Hospice Aide, documented task of weight the fist week of every month not applicable this visit. d. Hospice aide visit notes, dated 7/28 and 7/29/25, completed by Staff C, Hospice Aide documented the task of bed bath and shampoo not required today. The hospice aide failed to complete the weight, bed bath and shampoo task as instructed by the RN assignment.   11. Patient #18 had a hospice admission date of 4/11/25 and date of death of 5/21/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 4/11/25 to 7/9/25, identified the patient had a diagnosis of congestive heart failure and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 4/24/25, included aide instructions to provide bath: shower.   c. The hospice aide visit notes, dated 4/18/25 and 4/22/25, failed to include documentation of any tasks completed by the hospice aide. d. Hospice aide visit note, dated 5/2, 5/6, 5/13 and 5/19/25, completed by Staff I, Hospice Aide, documented task not required today. The hospice aide failed to complete the shower task as instructed by the RN assignment.    According to the hospice policy titled Hospice Aide Services, dated 11/15/23, 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.  During an interview on 11/18/25 at 8:15 AM, Staff A, Administrator stated the RN Case Manager develops the hospice aide care plan and supervises the hospice aide services.  Staff A also identified the hospice aide notifies the case manager of tasks not completed.    1.Patient #1 had a hospice admission date of 10/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 10/10/25 to 1/7/26, identified the patient had a diagnosis of malignant neoplasm of tongue and included physician orders for skilled nurse and hospice aide services.    b. The hospice aide care plan, dated 10/10/25, included aide instructions to provide bath: shower.    c. Hospice aide visit note, dated 10/23/25, completed by Staff C, Hospice Aide, documented task not required today.  The hospice aide failed to complete the shower task as instructed by the RN assignment.    2. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma and included physician orders for skilled nurse and hospice aide services.     b. The hospice aide care plan, dated 10/20/25, included aide instructions to provide bath: bed and bath: shower chair.    c. Hospice aide visit note, dated 10/24/25, completed by Staff F, Hospice Aide, documented tasks as not applicable this visit.  The hospice aide failed to complete the bath tasks as instructed by the RN assignment.    3. Patient #7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 8/21/25 to 11/18/25, identified the patient had a diagnosis of parkinsonism and included physician orders for skilled nurse and hospice aide services.     b. The hospice aide care plan, dated 8/26/25, included aide instructions to assist patient with dressing, shampoo, bath: shower chair and weigh patient by the 15th of every month.    c. Hospice aide visit note, dated 9/25/25, completed by Staff C, Hospice Aide, documented task of bath: shower chair as not applicable this visit.   d. Hospice aide visit note, dated 10/2/25, completed by Staff C, Hospice Aide, documented tasks of bath: shower chair, shampoo  and obtain weight by the 15th of every month as not required today.    e. Hospice aide visit note, dated 10/10/25, completed by Staff C, Hospice Aide, documented task of bath: shower chair not required today and task of obtain weight by the 15th of every month as unable to document: other reason.    f. Hospice aide visit note, dated 10/15/25, completed by Staff F, Hospice Aide, documented task of obtain weight by the 15th of every month as not applicable this visit.    g. Hospice aide visit note, dated 10/16/25, completed by Staff C, Hospice Aide, documented task of bath: shower chair as not applicable this visit and the task of shampoo as not required today.    h. Hospice aide visit note, dated 10/28/25, completed by Staff C, Hospice Aide, documented tasks of bath: shower chair and shampoo as not applicable this visit.    The hospice aides failed to complete all tasks as instructed by the RN assignment.    4. Patient #10 had a hospice admission date of 6/3/25 and received hospice services while residing in an assisted living facility.  Clinical record review revealed:   a. The POC, dated 8/17/25 to 10/15/25, identified the patient had a diagnosis of hypertensive chronic kidney disease and included physician orders for skilled nurse and hospice aide services.    b. The hospice aide care plan, dated 7/7/25, included aide instructions to apply immobilizer to patient's right arm as patient allows.    c. Hospice aide visit notes, dated 9/8/25, 9/15/25 and 9/18/25, completed by Staff F, Hospice Aide, documented the task of apply immobilizer to right arm as patient allows as not required today.     d. Hospice aide visit note, dated 9/11/25, completed by Staff C, Hospice Aide, documented the task of apply immobilizer to right arm as patient allows as not required today.    Hospice aides failed to complete tasks as instructed by the RN assignment.    5. Patient #17 had a hospice admission date of 4/4/25, a death date of 8/11/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POCs, dated 6/3/25 to 8/1/25 and 8/2/25 to 9/30/25, identified the patient had a diagnosis of senile degeneration of the brain and included physician orders for skilled nurse and hospice aide services.    b. The hospice aide care plan, effective 4/8/25 to 8/11/25, included aide instructions to provide bed bath and obtain weight.   c. Hospice aide visit notes, dated 6/17/25 and 6/18/25, completed by Staff I, Hospice Aide, documented the task of bed bath as not required today.    d. Hospice aide visit note, dated 6/24/25, completed by Staff L, Hospice Aide, documented the tasks of bed bath and obtain weight as not required today.    e.  Hospice aide visit notes, dated 7/2/25 and 7/8/25, completed by Staff I, Hospice Aide, documented the tasks of bed bath and obtain weight as not required today.    Hospice aides failed to complete tasks as instructed by the RN assignment.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date, accurate and complete information in a timely manner for 7 of 19 sampled patients (Patients #3, #7, #8, #10, #13, #14 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: --- 7. Patient #14 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 9/11/25 to 12/9/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social work, chaplain, hospice aide and volunteer services.    b. IDG meeting note, dated 10/2/25, included order for massage therapy services.  c. The EMR included documentation of a volunteer visit note, dated 9/26/25, signed completed on 10/22/25, by Staff S, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit, dated 9/26/25, signed completed by Staff S, Hospice Volunteer on 9/26/25.    d. The EMR included documentation of a volunteer visit note, dated 10/14/25, signed completed on 10/27/25, by Staff S, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit, dated 10/14/25, signed completed by Staff S, Hospice Volunteer on 10/14/25.    e. The EMR included documentation of a volunteer visit note, dated 10/21/25, signed completed on 10/27/25, by Staff S, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit, dated 10/21/25, signed completed by Staff S, Hospice Volunteer on 10/27/25.    f. The EMR included documentation of a volunteer visit note, dated 11/4/25, signed completed on 11/18/25, by Staff S, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit, dated 11/4/25, signed completed by Staff S, Hospice Volunteer on 11/4/25.    g. The EMR included documentation of a massage therapy visit note, dated 10/29/25, signed completed on 11/7/25, by Staff G, Massage Therapist.  The clinical record included paper documentation of the same massage therapy visit, dated 10/29/25, signed completed by Staff G, Massage Therapist on 10/29/25.    The hospice failed to ensure all documentation in the clinical record was accurate.  Findings reviewed with Clinical documentation coordinator, Vice President (VP) of Clinical Services, Quality Education Coordinator and VP of Hospice Services.   3. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma and included orders for skilled nurse, social work, chaplain, hospice aide and massage therapy services.    b. The skilled nurse visit, dated 10/21/25, completed by Staff A, Administrator, identified aide supervision completed; however, aide services had not been implemented yet.    The hospice nurse failed to document accurate information in the patient's clinical record.    4. Patient #7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 8/21/25 to 11/15/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nurse, social work, chaplain, hospice aide, volunteer and massage therapy services.    b. The EMR included documentation of a volunteer visit note, dated 10/2/25, signed completed on 10/13/25, by Staff R, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit note, dated 10/2/25, signed completed by Staff R, Hospice Volunteer on 10/8/25.    c. The EMR included documentation of a volunteer visit note, dated 10/15/25, signed completed on 11/3/25, by Staff R, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit note, dated 10/15/25, signed completed by Staff R, Hospice Volunteer on 10/17/25.    The hospice failed to include accurate, timely and appropriately authenticated documentation in the patient's clinical record of volunteer services provided       5.Patient #10 had a hospice admission date of 6/3/25 and received hospice services while residing in an assisted living facility.  Clinical record review revealed:   a. The POC, dated 8/17/25 to 10/15/25, identified the patient had a diagnosis of hypertensive chronic kidney disease and included orders for skilled nurse, social work, chaplain, hospice aide and volunteer services.    b. The EMR included documentation of a volunteer visit note, dated 9/16/25, signed completed on 9/30/25, by Staff K, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit note, dated 9/16/25, signed completed by Staff K, Hospice Volunteer on 10/6/25.    The hospice failed to include accurate, timely and appropriately authenticated documentation in the patient's clinical record of volunteer services provided.  6. Patient #13 had a hospice admission date of 9/3/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 9/3/25 to 12/1/25, identified the patient had a diagnosis of metabolic encephalopathy and included orders for skilled nurse, social work, chaplain, hospice aide and music therapy services.    b. The skilled nurse visit, dated 9/4/25, completed by Staff H, RN, identified aide supervision completed; however, aide services had not been implemented yet.    The hospice nurse failed to document accurate information in the patient's clinical record.           According to the hospice policy titled Clinical Records, dated 2/1/23, entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers) in a standardized format and are signed by the person providing the servies. All entries into the clinical record must be legible, clear, complete and appropriately authenticated and dated in accordance with the hospice policy and accepted standards of practice.  During an interview on 11/19/25 at  AM the Quality and Education Coordinator stated the administration staff entered the narrative completed by the volunteers in the electronic clinical record. She further stated the practice not allowed and a perfrmance improvement plan put in place as of 11/19/25 and will continue to be monitored. 1.Patient #8 had a hospice admission date of 5/7/25 and received services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 8/5/25 to 11/2/25 and 11/3/25 to 1/1/26, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social work, chaplain, hospice aide, music therapy and volunteer services.   b. The electronic medical Record (EMR) included documentation of a volunteer visit note, dated 9/16/25, signed completed on 9/28/25, by Staff O, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit, dated 9/16/25, signed completed by Staff R, Hospice Volunteer on 9/16/25.   c. The EMR included documentation of a volunteer visit note, dated 9/24/25, signed completed on 10/20/25, by Staff Q, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit, dated 10/20/25, signed completed by Staff P, Hospice Volunteer on 10/20/25.   d. The EMR included documentation of a volunteer visit note, dated 10/9/25, signed completed on 9/28/25, by Staff O, Hospice Volunteer.  The clinical record included paper documentation of the same volunteer visit, dated 9/16/25, signed completed by Staff R, Hospice Volunteer on 9/16/25.   The hospice failed to ensure all documentation completed only by the provider who completed the service.   2. Patient #15 had a hospice admission date of 10/21/25 and discharge date of 3/22/25 and received services while residing in a private residence.  Clinical record review revealed:  a. The POCs, dated 10/21/24 to 1/18/25 and 1/9/25 to 4/18/26, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social work and chaplain services.   b. The POCs included assignment of wound care to the long term care facility nurse c. The Interdisciplinary Group (IDG) notes, dated 1/23/25, 2/6, 2/20/25, 3/6 and 3/20/25, include interventions the nursing facility staff will be primary caregiver providing activities of daily living, administering medications/treatments as weell as providing a safe environment. During an interview on 11/19/25 at 11:20 AM the Quality Education Coordinator stated the patient discharged from the nursing home on 11/18/24 and the documentation failed to change to reflect the appropriate interventions. The hospice failed to ensure all documentation complete and reflect correct services provided.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound measurements for 6 of 7 sampled patients with an open wound (Patients #1, #3, #7, #11, #12 and #14). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- 2. Patient #1 had a hospice admission date of 2/10/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 2/10/23 to 5/10/23, included IDG orders for skilled nursing services 3 to 5 times a week and orders for wound care treatment. b. IDG meeting note, dated 3/2/23, included physician order for wound care/dressing change on Monday, Wednesday and Friday. c. The skilled nurse visit note, dated 3/13/23, identified the patient had a left inner buttock wound. The patient refused the nurse to complete measurement or treatment. The clinical record lacked further wound assessment or documentation the wound had healed. d. The skilled nurse visit note, dated 2/27/23, identified the patient had a new wound to the outer waist (possible open blister). The note lacked documentation of an assessment including measurements of the new open area. The clinical record lacked further wound assessment or documentation the wound had healed. e. The skilled nurse visit note, dated 4/24/23, identified the patient had a new wound to the right outer leg/calf area. The note lacked documentation of an assessment including measurements of the new open area. On 4/24/23 at 2:17 PM, during a home visit observation, Staff C, Registered Nurse (RN), assessed the patient and completed wound care on 4 separate wounds. Staff C, RN, removed the dressing on the right outer calf. The wound was open with obvious depth, superficial, wound bed red and granulating. Staff C, RN, removed the 2x2 non-stick dressing from the left outer mid calf. Staff C, RN, stated the left outer mid calf wound was a blister and was not open. Staff C, RN, reported the wound measured 1 centimeter (cm) in length and 1.5 cm in width. Staff C, RN, did not report a depth, but did state, ";the wound is open". Staff C, RN, did not measure the right outer calf wound and the left outer mid calf wound. Staff C, RN, measured the lower right back wound 0.9 cm in length and 1.4 cm in width. Staff C, RN, did not measure the depth of the wound. The skilled nurse failed to include wound measurements or documentation the wounds healed. 3. Patient #3 had a hospice admission date of 4/13/23 and received hospice services while residing in a private home residence. Clinical record review revealed: a. Plan of Care, dated 4/13/23 to 7/11/23, included IDG orders for skilled nursing services 1 to 3 times a week to assess pressure ulcer status including signs and symptoms of healing and complications. b. The initial skilled nurse visit note, dated 4/13/23, identified the patient had a right posterior heel wound. Measurements included 2 cm length by 2.2 cm width and 0 depth. The note failed to include depth measurements. c. The skilled nurse visit note, dated 4/26/23, identified the patient had a wound on the right posterior heel with black eschar. The wound measured 1.6 cm by 2.4 cm by 0 cm. The dote failed to include depth measurements. d. On 4/26/23 during a home observation visit with Staff F, RN, the surveyor observed staff F complete wound measurements of the right heel wound. The RN measured length and width but failed to measure depth. The wound bed had black eschar the nurse identified as scabbed area. The skilled nurse failed to include wound measurements. 4. Patient #7 had a hospice admission date of 7/28/22 and received hospice services while residing in a private home residence. Clinical record review revealed: a. Plan of Care, dated 3/18/23 to 5/16/23, included IDG orders for skilled nursing services 1 to 3 times a week. b. The skilled nurse visit note, dated 3/13/23, identified the patient had a left inner buttock wound. The patient refused the nurse to complete measurement or treatment. The clinical record lacked further wound assessment or documentation the wound had healed. c. The skilled nurse visit note, dated 4/7/23, identified the patient had a new wound to the right inner buttock. The wound had superficial skin loss with redness. The note failed to include documentation of wound measurements. d. The skilled nurse visit note, dated 4/17/23, identified the wound to the right inner buttock measured 1.0 cm length by 0.7 cm width and no documentation of wound depth measurements. e. The skilled nurse visit note, dated 4/21/23, included wound measurements fo the right inner buttock 1 cm by 0.6 cm width and no documentation of wound depth measurements. The skilled nurse failed to include complete wound measurements. 5. Patient #11 had a hospice admission date of 4/7/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 4/7/23 to 7/5/23, included IDG orders for skilled nursing services 1 to 3 times a week. b. The skilled nurse visit note, dated 4/11/23, identified the patient had a left inner buttock wound. The patient refused the nurse to complete measurement or treatment. The clinical record lacked further wound assessment or documentation the wound had healed. c. The skilled nurse visit note, dated 4/7/23, identified the patient had multiple skin tears present. The note failed to include documentation of wound assessments or wound measurements. The skilled nurse failed to include complete wound assessments. 6. Patient #14 had a hospice admission date of 3/20/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 3/20/23 to 6/17/23, included IDG orders for skilled nursing services 1 to 3 times a week. b. The skilled nurse visit note, dated 3/20/23, identified the patient had bilateral heel ulcers. The clinical record lacked further wound assessment or documentation of wound measurements. c. The skilled nurse visit note, dated 3/21/23, included documentation of left lower posterior medial inner foot heel pressure ulcer that measured 1.9 cm length by 1.7 cm width by 0 cm depth. The right lower posterior medial inner foot heel pressure ulcer measured 3.2 cm by 2.5 cm by 0 cm. The note failed to include documentation of wound depth measurements. d. The skilled nurse visit note, dated 3/24/23, included documentation of left lower posterior medial inner foot heel pressure ulcer that measured 1.9 cm length by 1.7 cm width by 0 cm depth. The right lower posterior medial inner foot heel pressure ulcer measured 3.2 cm length by 2.5 cm width by 0 cm depth. The note failed to include documentation of wound depth measurements. e. The skilled nurse visit note, dated 3/29/23, included documentation of left lower posterior medial inner foot heel pressure ulcer that measured 1.9 cm length by 1.7 cm width by 0 cm depth. The right lower posterior medial inner foot heel pressure ulcer measured 3.2 cm length by 2.5 cm width by 0 cm depth. The note failed to include documentation of wound depth measurements. d. The skilled nurse visit note, dated 4/12/23, included documentation of left lower posterior medial inner foot heel pressure ulcer that measured 1.9 cm length by 1.7 cm width by 0 cm depth. The right lower posterior medial inner foot heel pressure ulcer measured 3.2 cm length by 2.5 cm width by 0 cm depth. The note failed to include documentation of wound depth measurements. e. The skilled nurse visit note, dated 4/17/23, included documentation of left lower posterior medial inner foot heel pressure ulcer that measured 1.9 cm length by 1.7 cm width by 0 cm depth. The right lower posterior medial inner foot heel pressure ulcer measured 3.2 cm length by 2.5 cm width by 0 cm depth. The note failed to include documentation of wound depth measurements. f. The skilled nurse visit note, dated 4/19/23, included documentation of a new open wound found on the left lower posterior medial inner foot heel pressure ulcer that measured 3 cm length by 3 cm width by 0 cm depth. The right lower posterior medial inner foot heel pressure ulcer measured 3.2 cm length by 2.5 cm width by 0 cm depth. The note failed to include documentation of wound depth measurements. The skilled nurse failed to include complete wound measurements. The above findings were shared with the Administrator. No further information provided prior to the end of the survey. Findings include: According to the hospice policy, titled Wound Orders, dated 3/28/23, wound care may only be administered that have been ordered by the patients attending physician, physician designee or nurse practitioner. Wound assessment is performed as part of the initial assessment, a wound flow sheet is initiated in the electronic health record and includes length, width and depth. Ongoing assessment is done minimum of weekly and includes filling out the wound flow sheet above as well as any additional documentation needed in the nurse notes, unless there is a documented reason for not making the weekly visit. During an interview on 4/24/23 at 4:12 PM, the Clinical Director revealed wounds are to be assessed a minimum of 1 time a week and should include length width and depth. 1.Patient #12 had a hospice admission date of 4/6/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 4/6/23 to 6/4/23, included documentation the patient had sacral wounds. b. IDG meeting note, dated 4/13/23, included physician order, sacral wounds. c. Initial comprehensive assessment, dated 4/6/23, included documentation the patient had a pressure sore on sacrum, unstageable. d. Skilled nursing visit notes, dated 4/17/23 and 4/19/23, lacked documentation of a sacral wound or documentation the sacral wound had healed. The skilled nurse failed to include wound measurements or documentation the wound healed.

Based on hospice clinical record review, hospice policy review, home visit observation 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 #1 and #2) with wounds. Failure to follow the patient's Plan of Care (POC) as directed by the Interdisciplinary Group (IDG) puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: --- 2. Patient #2 had a hospice admission date of 2/18/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG meeting notes, dated 2/2/23, 2/26/23, 3/2/23, 3/16/23, 3/30/23, and 4/13/23, include physician orders to cleanse area to left cheek with normal saline, pat dry and apply SSD with lidocaine 5% ointment, with an effective date 11/9/22. b. Skilled nursing visit notes, dated 2/20/23, 2/24/23, 3/1/23, 3/6/23, 3/10/23, 3/14/23, 3/22/23, 3/24/23, 3/28/23, and 4/3/23, included documentation the left cheek wound was cleansed with soap and water but lacked documentation lidocaine ointment was applied. The skilled nurse failed to complete wound care as ordered. The hospice provided no further information prior to the end of the survey. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the Interdisciplinary Group (IDG) is responsible for providing and coordinating care and services in accordance with the POC. Patient #1 had a hospice admission date of 2/10/23 and received routine home care hospice services while residing in an apartment in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 2/10/23 to 5/10/23, included interdisciplinary group (IDG) orders for skilled nursing services 3 to 5 times per week. b. An interim physician order, dated 3/27/23, included an order for the following: as needed wound care, apply Vaseline to open areas when they appear on the bilateral lower legs, cover with Telfa, wrap with "Cling" (gauze roll dressing), apply Tubigrips (type of elastic stocking used to protect the skin) and change daily. On 4/24/23 at 2:17 PM, during a home visit observation, Staff C, Registered Nurse (RN), assessed the patient and completed wound care on 4 separate wounds. Staff C, RN, sanitized hands, gloved, then removed the patients socks, Tubigrips and rolled gauze bilaterally from the lower legs. The patient had 2x2 non-stick Telfa dressings on the right outer upper calf, left outer mid calf and left outer lower leg above the ankle. Staff C, RN, removed the dressing on the right outer calf. The wound was open with obvious depth, superficial, with a red wound bed and granulating tissue. Staff C, RN, covered the wound with a new 2x2 non-stick dressing, applied roll gauze from the knee to just above the ankle on the right leg and then covered the lower leg with a Tubigrip stocking. Staff C, RN, removed the 2x2 non-stick dressing from the left outer mid calf. Staff C, RN, stated the left outer mid calf wound was a blister and was not open. Staff C, covered the wound with a new 2x2 non-stick dressing. Staff C, RN, removed the 2x2 dressing on the left outer lower leg wound and measured the wound. Staff C, RN, reported the wound measured 1 centimeter (cm) in length and 1.5 cm in width. Staff C, RN, did not report a depth, but did state, ";the wound is open". Staff C, RN, covered the left lower leg with a roll gauze and applied a Tubigrip stocking. Staff C, RN, did not apply Vaseline to any open wounds on the lower legs per wound care orders. On 4/25/23 at 1:50 PM, during an interview with the Administrator and Clinical Manager, they confirmed Staff C, RN, was not the patients usual nurse and they reported Staff C, RN had just filled in the last couple visits.

Based on clinical record review, home visit observation, patient and hospice staff interview, the hospice failed to ensure the Plan of Care included all medical equipment and supplies necessary to meet identified patient needs for 4 of 19 sampled patients (Patients #1, #3, #4 and #11). 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 #3 had a hospice admission date of 4/13/23 and received routine home care hospice services while residing in a private home residence. The POC, dated 4/13/23 to 7/11/23, included orders for DME which included the following: overbed table, adult diapers, blue pads, shower bench, pressure release mattress, shower chair, hospital bed and betadine. On 4/26/23 at 1:00 PM, during a home visit observation, Staff F, RN, the surveyor observed staff utilize the patient's profo boots. The surveyor observed the patient had a commode and urinal. In an interview, during the same home visit observation, Staff E, RN, reported the patient had the profo boots due to the wound on the right heel. The patient reported using the commode and urinal since the start of hospice services. The POC failed to identify the patient's use of the profo boots, commode or urinal. 4. Patient #11 had a hospice admission date of 4/7/23 and received routine home care hospice services while residing in a nursing home. The POC, dated 4/7/23 to 7/5/23, included orders for DME which included the following: wheelchair, hospital bed and adult diapers. The initial skilled nurse visit note, dated 4/7/23, identified the patient also utilised a shower bench and walker. The POC failed to identify the patient's use of the shower bench and walker. The above findings were shared with the Administrator. No additional information provided 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 #1 had a hospice admission date of 2/10/23 and received routine home care hospice services while residing in an apartment in an assisted living facility. On 4/24/23 at 2:17 PM, during a home visit observation with Staff C, Registered Nurse (RN), the surveyor observed the patient sitting in an electric lift chair upon entering the patients residence. During the course of the observation, the surveyor observed the patient had a gel cushion in the seat of the lift chair. The surveyor observed the patient use the functions of the lift chair to help the patient stand up. The surveyor also observed a handheld shower, grab bars in the bathroom by the toilet and shower, a walker, 2 reachers and a blood pressure machine. In an interview, during the same home visit, the patient reported use of the gel cushion in the lift chair since the start of services. The patient reported hospice provided it. The patient reported having and using the lift chair, hand held shower, reacher and grab bars for 5 years. The patient reported having had the blood pressure machine for years and reported using it at times. The patient reported while they had the walker in the home, they did not use it. Review of the clinical record revealed the following: a. The POC, dated 2/10/23 to 5/10/23, included interdisciplinary group (IDG) orders for skilled nursing services 3 to 5 times per week. The POC failed to identify the patient's use of the electric lift chair, gel cushion for the lift chair, grab bars, handheld shower and blood pressure machine. b. The IDG meetings, dated 3/2, 3/16, 3/30 and 4/13/23, failed to identify the patient's use of the electric lift chair, gel cushion for the lift chair, grab bars, handheld shower and blood pressure machine. 2. Patient #4 had a hospice admission date of 12/30/21 and received routine home care hospice services while residing in a nursing home. On 4/25/23 at 11:00 AM, during a home visit observation, Staff E, RN, completed an assessment of the patient while the patient sat in an electric lift chair in the patient's room. Staff E, RN, and the facility staff assisted the patient to transfer from the lift chair to the EZ stand to go to the bathroom. The surveyor observed staff utilize the functions of the lift chair to assist the patient with transferring. The surveyor observed the patient had a Roho cushion in the lift chair, a quarter rail on the bed, and left and right side cushions on the arms of the wheelchair. In an interview, during the same home visit observation, Staff E, RN, reported being unaware the patient had a Roho cushion. Staff E, RN, reported the hospice had provided the side cushions for the patients wheelchair for positioning a couple months ago at the same time they got the pommel cushion for the wheelchair. The patient reported use of the quarter bed rail for positioning. The patient reported the hospice aides had been assisting the patient with taking showers and they used a shower chair. Review of the clinical record revealed the following: The POC, dated 4/24/23 to 6/22/23, included IDG orders for skilled nursing services 1 to 3 times per week. The POC failed to identify the patient's use of the electric lift chair, Roho cushion for the lift chair, quarter bed rail, shower chair and side cushions for the arms of the patient's wheelchair.

Based on clinical record review, hospice policy review, patient interview and hospice staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 14 of 18 sampled patients receiving hospice aide services. (Patients #2, #3, #4, #5, #6, #7, #9, #10, #13, #14, #15, #17, #18 and #19). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient's needs. Findings include: --- 9. Patient #6 had a hospice admission date of 10/28/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The hospice aide care plan, dated 11/2/22, included RN instructions to the hospice aide to perform the task of foot care. The aide care plan failed to provide specific instruction on what foot care means. 10. Patient #9 had a hospice admission date of 11/10/22 and received hospice services while residing in a nursing home. Clinical record review revealed: The hospice aide care plan, dated 11/10/22, included RN instructions to the hospice aide to perform the task of ambulate patient using assistive device (cane, crutches, walker, O2). The aide care plan failed to provide specific instruction on what assistive device the aide was to use with the patient. 11. Patient #10 had a hospice admission date of 2/3/23 and received hospice services while residing in a nursing home. Clinical record review revealed: The hospice aide care plan, dated 2/22/23, included RN instructions to the hospice aide to perform the tasks of foot care and diet-other. The aide care plan failed to provide specific instruction on what foot care means and what diet the patient should receive. 12. Patient #15 had a hospice admission date of 9/29/22, a discharge date of 10/18/22 and received hospice services while residing in a nursing home. Clinical record review revealed: The hospice aide care plan, dated 10/5/22, included RN instructions to the hospice aide to perform the task of ambulate patient using assistive device (cane, crutches, walker, O2). The aide care plan failed to provide specific instruction on what assistive device the aide was to use with the patient. 13. Patient #17 had a hospice admission date of 7/5/22, a death date of 7/24/22 and received hospice services while residing in a nursing home. Clinical record review revealed: The hospice aide care plan, dated 7/6/22, included RN instructions to the hospice aide to perform the tasks of foot care and ambulate patient using assistive device (cane, crutches, walker, O2). The aide care plan failed to provide specific instruction on what foot care means and what assistive device the aide was to use with the patient. 14. Patient #19 had a hospice admission date of 12/20/22, a death date of 2/21/23 and received hospice services while residing in a nursing home. Clinical record review revealed: The hospice aide care plan, dated 12/23/22, included RN instructions to the hospice aide to perform the tasks of ambulate patient using assistive device (cane, crutches, walker, O2), bath and bath-shower. The aide care plan failed to provide specific instruction on what assistive device the aide was to use with the patient and who would determine which bath type should be performed. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. 3. Patient #3 had a hospice admission date of 4/13/23 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The POC, dated 4/13/23 to 7/11/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: up in wheelchair when patient desires, assist with meal preparation, set-up, feeding, change adult diapers, incontinent care, establish trusting relationship with patient, change linen, clean bathroom, clean living area, clean up kitchen after meal preparation, make bed, assist with dressing, bed bath, denture care, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo with shampoo cap, shave, skin care and fall precautions. b. The aide care plan, dated 4/18/23, included the following assigned tasks: up in wheelchair when patient desires, assist with meal preparation, set-up, feeding, change adult diapers, incontinent care, establish trusting relationship with patient, change linen, clean bathroom, clean living area, clean up kitchen after meal preparation, make bed, assist with dressing, bed bath, denture care, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo with shampoo cap, shave, skin care and fall precautions. The POC and hospice aide assignment failed to specify what the hospice aide needed to specifically do to complete the assigned task of "foot care". 4. Patient #5 had a hospice admission date of 1/23/23 and received routine home care hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 1/23/23 to 4/22/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: ambulate using assistive devices, assist with positioning, repositioning, alignment, independent ambulation, assist with meal planning, fluid intake, change adult diapers, incontinent care, report if no bowel movement, change linen, clean living area, make bed, do patient laundry, assist with dressing, shower, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, remove throw rugs and universal precautions. b. The aide care plan, dated 1/23/23, included the following assigned tasks: ambulate using assistive devices, assist with positioning, repositioning, alignment, independent ambulation, assist with meal planning, fluid intake, change adult diapers, incontinent care, report if no bowel movement, change linen, clean living area, make bed, do patient laundry, assist with dressing, shower, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, remove throw rugs and universal precautions The POC and hospice aide assignment failed to specify what the hospice aide needed to specifically do to complete the assigned task of "foot care". 5. Patient #7 had a hospice admission date of 7/28/22 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The POC, dated 3/18/23 to 5/16/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, three times per week: ambulate using assistive devices, assist with transfer to bed/chair with assistance, assist with meal preparation, set-up, feeding, give patient soft food snacks during visit, such as pudding, applesauce and ice cream, assist to toilet, change adult diapers, incontinent care, change linen, clean living area, make bed, bed bath, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, electric shave, skin care, fall precautions, standard precautions and transfer belt. b. The aide care plan, dated 2/20/23, included the following assigned tasks: ambulate using assistive devices, assist with transfer to bed/chair with assistance, assist with meal preparation, set-up, feeding, give patient soft food snacks during visit, such as pudding, applesauce and ice cream, assist to toilet, change adult diapers, incontinent care, change linen, clean living area, make bed, bed bath, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, electric shave, skin care, fall precautions, standard precautions and transfer belt. The POC and hospice aide assignment failed to specify what the hospice aide needed to specifically do to complete the assigned task of "foot care". 6. Patient #13 had a hospice admission date of 2/2/23 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 2/2/23 to 5/2/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with transfer to chair/wheelchair, catheter care, change adult diapers, empty foley catheter, incontinent care, change linen, clean , make bathroom, bed bath, assist with dressing, foot care, nail care, oral care, perineal care, shampoo, shave, skin care and standard precautions. b. The aide care plan, dated 2/7/23, included the following assigned tasks: assist with transfer to chair/wheelchair, catheter care, change adult diapers, empty foley catheter, incontinent care, change linen, clean , make bathroom, bed bath, assist with dressing, foot care, nail care, oral care, perineal care, shampoo, shave, skin care and standard precautions. The POC and hospice aide assignment failed to specify what the hospice aide needed to specifically do to complete the assigned task of "foot care". 7. Patient #14 had a hospice admission date of 3/20/23 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 3/20/23 to 6/17/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with positioning, repositioning, alignment, assist with transfers, patient to be non-weight bearing, recognize and report any changes in the patient's skin condition, transfer to bed/chair with assistance, use hoyer lift, turn every 2 hours, up in chair/wheelchair, assist with meal preparation, set-up, feeding, assist to toilet, change adult diapers, incontinent care, change linen, clean bathroom after patient care, make bed, assist with dressing, bath, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, standard precautions, assess pain and report pain to nurse. b. The aide care plan, dated 3/24/23, included the following assigned tasks: assist with positioning, repositioning, alignment, assist with transfers, patient to be non-weight bearing, recognize and report any changes in the patient's skin condition, transfer to bed/chair with assistance, use hoyer lift, turn every 2 hours, up in chair/wheelchair, assist with meal preparation, set-up, feeding, assist to toilet, change adult diapers, incontinent care, change linen, clean bathroom after patient care, make bed, assist with dressing, bath, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, standard precautions, assess pain and report pain to nurse The POC and hospice aide assignment failed to specify what the hospice aide needed to specifically do to complete the assigned task of "foot care". 8. Patient #18 had a hospice admission date of 9/29/22 and date of death of 10/14/22 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The POC, dated 9/29/22 to 12/27/22, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with transfer to bed/chair with assistance, assist to toilet, change adult diapers, incontinent care, change linen, make bed, shower, denture care, foot care, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, standard precautions and transfer belt. b. The aide care plan, dated 9/30/22, included the following assigned tasks: assist with transfer to bed/chair with assistance, assist to toilet, change adult diapers, incontinent care, change linen, make bed, shower, denture care, foot care, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, standard precautions and transfer belt. The POC and hospice aide assignment failed to specify what the hospice aide needed to specifically do to complete the assigned task of "foot care". Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the Interdisciplinary Group (IDG) is responsible for providing and coordinating care and services in accordance with the POC. 1. Patient #2 had a hospice admission date of 2/18/22 and received routine home care hospice services while residing in a nursing home (nursing facility). On 4/25/23 at 9:40 AM, during a home visit observation, Staff D, RN, completed an assessment of the patient while the patient sat in a wheelchair in the patient's room. In an interview, during the same home visit observation, Staff D, RN, reported the hospice aides gave the patient either a bed bath or assisted the patient with a shower. Staff D, RN, further explained the hospice aides typically assisted the patient with a shower. Staff D, RN, reported the hospice aides assisted facility staff with transferring the patient via a Hoyer lift. Review of the clinical record revealed the following: a. The POCs, dated 2/13/23 to 4/13/23 and 4/14/23 to 6/12/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: nail care, oral care, incontinence care, change adult diapers, partial bath, recognize and report any changes in the patient's skin condition. b. The hospice aide assignment (care plan), dated 2/18/22, included the same interventions for the hospice aide to complete each visit (nail care, oral care, incontinence care, change adult diapers, partial bath, recognize and report any changes in the patient's skin condition) as the POCs. c. The IDG meetings, dated 3/2, 3/16, 3/30 and 4/13/23, continued to include the same interventions for the hospice aide to complete each visit (nail care, oral care, incontinence care, change adult diapers, partial bath, recognize and report any changes in the patient's skin condition). The IDG meetings all included documentation the hospice aide reported they continued to assist the patient with dressing, bathing, incontinence cares, transfers and meal prep and assist with showers on shower days if present. The hospice aide assignment developed by the nurse continued to lack direction for the hospice aide to complete the tasks of dressing, meal prep and assist, transfers via Hoyer lift and to shower the patient. The assignment also lacked direction to the hospice aide which explained what the hospice aide needed to specifically do in order to complete the task of "nail care". 2. Patient #4 had a hospice admission date of 12/30/21 and received routine home care hospice services while residing in a nursing home. On 4/25/23 at 11:00 AM, during a home visit observation, Staff E, RN, completed an assessment of the patient while the patient sat in an electric lift chair in the patient's room. In an interview, during the same home visit observation, the patient reported the hospice aides had been assisting the patient with taking showers and they used a shower chair. The patient reported the hospice aide had provided the patient with a shower this morning (4/25/23). Review of the clinical record revealed the following: a. The POC, dated 4/24/23 to 6/22/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with 2 person transfers using the EZ stand, transfer to bed/chair and up in chair/wheelchair, diet as tolerated with soft foods only, meal prep/set up and feeding assistance, skin care, perineal care, tub bath, incontinence care and change adult diapers, nail care may trim or file any uneven or broken finger and toe nails. b. The hospice aide assignment (care plan), dated 1/7/22, included the same interventions for the hospice aide to complete each visit (assist with 2 person transfers using the EZ stand, transfer to bed/chair and up in chair/wheelchair, diet as tolerated with soft foods only, meal prep/set up and feeding assistance, skin care, perineal care, tub bath, incontinence care and change adult diapers, nail care may trim or file any uneven or broken finger and toe nails) as the POC. The POC and hospice aide assignment failed to include directions for the aide to assist with showering the patient and failed to specify what the hospice aide needed to specifically do to complete the assigned task of "skin care".

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Group according to an individualized plan of care for 11 of 18 sampled patients who received hospice aide services. (Patients #1, #2, #3, #4, #5, #6, #9, #13, #14, #16 and #17). Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients' personal care needs were not met. Findings include: --- 7. Patient #2 had a hospice admission date of 2/18/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The hospice aide care plan, dated 2/18/22, included Registered Nurse (RN) instructions to the hospice aide to perform the tasks of recognize and report any changes in the patients skin condition, change adult diapers, incontinent care, bath-partial, nail care and oral care. b. The hospice aide visit notes, dated 2/23/23 and 3/24/23, lacked documentation of assigned tasks and if the tasks were completed or not completed by the aide. c. The hospice aide visit note, dated 4/3/23, included documentation the task of nail care was completed; and lacked documentation the tasks of recognize and report any changes in the patients skin condition, change adult diapers, incontinent care, bath-partial and oral care were completed or not completed. d. The hospice aide visit note, dated 3/3/23, included documentation the tasks of recognize and report any changes in the patients skin condition, change adult diapers and nail care were completed; and lacked documentation the tasks of incontinent care, bath-partial and oral care were completed or not completed. e. The hospice aide visit note, dated 3/16/23, included documentation the tasks of recognize and report any changes in the patients skin condition, change adult diapers, incontinent care, bath-partial and oral care were completed; and lacked documentation the task of nail care were completed or not completed. f. The hospice aide visit notes, dated 2/27/23 and 3/30/23, included documentation the tasks of recognize and report any changes in the patients skin condition, change adult diapers, incontinent care, nail care and oral care were completed; and lacked documentation the task of bath - partial were completed or not completed. The hospice aide failed to complete all assigned tasks on the aide care plan or document a reason why the tasks were not completed. 8. Patient #4 had a hospice admission date of 12/30/21 and received services while residing in a nursing home. Clinical record review revealed: a. IDG meeting note, dated 3/2/23, included hospice aide care plan RN instructions to the hospice aide to perform the tasks of assist with transfers; diet – general diet with all meats ground, regular fluids; transfer to bed/chair with assistance; up in chair/wheelchair; change adult diapers; incontinent care; may trim or file any long or uneven finger nails; may trim or file any long or uneven toe nails; nail care; perineal care; skin care and fall precautions. b. Hospice aide visit note, dated 3/10/23, included documentation the tasks up in chair/wheelchair, diet – general diet with all meats ground, regular fluids; may trim or file any long or uneven finger nails, may trim or file any long or uneven toe nails, nail care, skin care and fall precautions were completed; but lacked documentation the tasks assist with transfers, perineal care, transfer to bed/chair with assistance, change adult diapers and incontinent care were completed or reason why not completed. c. Hospice aide visit note, dated 3/14/23, lacked documentation the tasks of assist with transfers; diet – general diet with all meats ground, regular fluids; transfer to bed/chair with assistance; up in chair/wheelchair; change adult diapers; incontinent care; may trim or file any long or uneven finger nails; may trim or file any long or uneven toe nails; nail care; perineal care; skin care and fall precautions were completed or reason why not completed. The hospice aide failed to complete all assigned tasks on the aide care plan or document a reason why the tasks were not completed. 9. Patient #6 had a hospice admission date of 10/28/22 and received hospice services while residing in a private residence. a. The hospice aide care plan, dated 11/2/22, included Registered Nurse (RN) instructions to the hospice aide to perform the tasks of assist with transfers, transfer to bed/chair with assistance-use hoyer lift, up in chair/wheelchair, feed patient, catheter care, empty foley catheter, incontinent care, bath, denture care, foot care, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, standard precautions and report patient pain to nurse. b. Hospice aide visit notes, dated 2/20/23, 2/23/23 and 3/2/23, lacked documentation the tasks of assist with transfers, transfer to bed/chair with assistance-use hoyer lift, up in chair/wheelchair, feed patient, catheter care, empty foley catheter, incontinent care, bath, denture care, foot care, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, standard precautions and report patient pain to nurse were completed or reason why not completed. c. Hospice aide visit note, dated 3/1/23, included documentation the tasks of catheter care, empty foley catheter, incontinent care, bath, denture care, foot care, nail care, oral care, perineal care, shampoo, skin care, fall precautions, standard precautions and report patient pain to nurse were completed but lacked documentation the tasks of assist with transfers, transfer to bed/chair with assistance-use hoyer lift, up in chair/wheelchair, feed patient and shave were completed or reason why not completed. d. Hospice aide visit note, dated 3/7/23, included documentation the tasks of transfer to bed/chair with assistance-use hoyer lift, catheter care, empty foley catheter, incontinent care, bath, denture care, foot care, nail care, oral care, perineal care, shampoo, skin care, fall precautions, standard precautions and report patient pain to nurse were completed but lacked documentation the tasks of assist with transfers, up in chair/wheelchair, feed patient and shave were completed or reason why not completed. e. Hospice aide visit note, dated 3/15/23, included documentation the tasks of catheter care, empty foley catheter, incontinent care, bath, denture care, foot care, oral care, perineal care, skin care, fall precautions, standard precautions and report patient pain to nurse were completed but lacked documentation the tasks of transfer to bed/chair with assistance-use hoyer lift, assist with transfers, up in chair/wheelchair, feed patient, nail care, shampoo and shave were completed or reason why not completed. f. Hospice aide visit note, dated 3/16/23, included documentation the tasks of nail care, skin care, fall precautions, standard precautions and report patient pain to nurse were completed but lacked documentation the tasks of transfer to bed/chair with assistance-use hoyer lift, assist with transfers, up in chair/wheelchair, catheter care, empty foley catheter, incontinent care, bath, denture care, foot care, oral care, perineal care, feed patient, shampoo and shave were completed or reason why not completed. g. Hospice aide visit note, dated 3/27/23, included documentation the tasks of catheter care, empty foley catheter, incontinent care, foot care, nail care, fall precautions, standard precautions and report patient pain to nurse were completed but lacked documentation the tasks of transfer to bed/chair with assistance-use hoyer lift, assist with transfers, up in chair/wheelchair, bath, denture care, oral care, skin care, perineal care, feed patient, shampoo and shave were completed or reason why not completed. The hospice aide failed to complete all assigned tasks on the aide care plan or document a reason why the tasks were not completed. 10. Patient #9 had a hospice admission date of 11/10/22 and received hospice services while residing in a nursing home. a. IDG meeting note, dated 3/2/23, included hospice aide care plan RN instructions to the hospice aide to perform the tasks of assist with meal preparation, set-up, feeding; may trim or file any long or uneven toe nails, change adult diapers, may trim or file any long or uneven finger nails, ambulate patient using assistive device (cane, crutches, walker, O2), fall precautions, perineal care, nail care, diet-snack, incontinent care, skin care and oral care. b. Hospice aide visit note, dated 3/14/23, included documentation the tasks of ambulate patient using assistive device (cane, crutches, walker, O2), diet-snack, may trim or file any long or uneven toe nails, may trim or file any long or uneven finger nails, nail care, skin care and fall precautions were completed but lacked documentation the tasks of assist with meal preparation, set-up, feeding; change adult diapers, perineal care, incontinent care, and oral care were completed or reason why not completed. The hospice aide failed to complete all assigned tasks on the aide care plan or document a reason why the tasks were not completed. 11. Patient #17 had a hospice admission date of 7/5/22, a death date of 7/24/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The hospice aide care plan, dated 7/6/22, included Registered Nurse (RN) instructions to the hospice aide to perform the tasks of recognize and report any changes in the patients skin condition, fall precautions, assist patient with dressing, may trim or file any long or uneven finger nails, standard precautions, shower chair, assist with transfers, foot care, bath-shower, weight monthly, nail care, ambulate patient using assistive device (cane, crutches, walker, O2), assist with positioning, repositioning, alignment; may trim or file any long or uneven toe nails, shampoo, oral care, change adult diapers, incontinent care, perineal care, transfer to bed/chair, with assistance-use hoyer lift, assist to bedside commode/toilet, skin care, up in chair/wheelchair b. Hospice aide visit notes, dated 7/11/23, 7/12/23, 7/14/23 and 7/19/23, lacked documentation any tasks were completed or a reason why not completed. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the Interdisciplinary Group (IDG) is responsible for providing and coordinating care and services in accordance with the POC. During an interview on 4/24/23 at 4:12 PM the Clinical Manager stated if a hospice aide unable to complete assigned task, they should document the reason why. Patient #1 had a hospice admission date of 2/10/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 2/10/23 to 5/10/23, included IDG orders for skilled nursing and hospice aide services. The POC included directions to the hospice aide to complete the tasks of weight, foot care, skin care, shave, shower and shampoo. b. The hospice aide visit note, dated 3/27/23, included documentation the hospice aide did not complete the assigned tasks of weight, foot care, skin care, shave, shower or shampoo. The note lacked documentation of reason the tasks were not performed. c. The hospice aide visit note, dated 3/29/23, included documentation the hospice aide did not complete the assigned tasks of weight. The note lacked documentation of reason the task not performed. The hospice aide failed to complete the assigned tasks and did not provide an acceptable reason, as the RN had scheduled the tasks. 2. Patient #3 had a hospice admission date of 4/13/23, received hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The POC, dated 4/13/23 to 7/11/23, included IDG orders for skilled nursing and hospice aide services. b. The POC included the following assigned interventions for the hospice aide to complete each visit, two times per week: up in wheelchair when patient desires, assist with meal preparation, set-up, feeding, change adult diapers, incontinent care, establish trusting relationship with patient, change linen, clean bathroom, clean living area, clean up kitchen after meal preparation, make bed, assist with dressing, bed bath, denture care, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo with shampoo cap, shave, skin care and fall precautions. c. The hospice aide visit note, dated 4/20/22, included documentation the aide completed a visit. The visit note lacked documentation the hospice aide completed any of the assigned tasks and failed to include a reason why the hospice aide did not complete the tasks. The hospice aide failed to complete the assigned tasks and did not provide an acceptable reason, as the RN had scheduled the tasks. 3. Patient #5 had a hospice admission date of 1/23/23 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 1/23/23 to 4/22/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: ambulate using assistive devices, assist with positioning, repositioning, alignment, independent ambulation, assist with meal planning, fluid intake, change adult diapers, incontinent care, report if no bowel movement, change linen, clean living area, make bed, do patient laundry, assist with dressing, shower, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, remove throw rugs and universal precautions. b. The hospice aide visit note, dated 3/8/23, included documentation the hospice aide did not complete the assigned tasks of ambulate using assistive devices, assist with positioning, repositioning, alignment, independent ambulation, assist with meal planning, change adult diapers, incontinent care, change linen, clean living area, make bed, do patient laundry, assist with dressing, shower, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave and remove throw rugs. The note lacked documentation of reason the task not performed. c. The hospice aide visit note, dated 3/13/23, included documentation the hospice aIde did not complete the assigned tasks of ambulate using assistive devices, assist with positioning, repositioning, alignment, independent ambulation, assist with meal planning, fluid intake, change adult diapers, incontinent care, report if no bowel movement, change linen, clean living area, make bed, do patient laundry, assist with dressing, shower, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, remove throw rugs and universal precautions. The note lacked documentation of the reason the task not performed. d. The hospice aide visit note, dated 3/15/23, included documentation the hospice aIde did not complete the assigned tasks of ambulate using assistive devices, assist with positioning, repositioning, alignment, independent ambulation, assist with meal planning, fluid intake, change adult diapers, incontinent care, report if no bowel movement, change linen, clean living area, make bed, do patient laundry, assist with dressing, shower, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, remove throw rugs and universal precautions. The note lacked documentation of the reason the task not performed. The hospice aide failed to complete the assigned tasks and did not provide an acceptable reason, as the RN had scheduled the tasks. 4. Patient #13 had a hospice admission date of 2/2/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 2/2/23 to 5/2/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with transfer to chair/wheelchair, catheter care, change adult diapers, empty foley catheter, incontinent care, change linen, clean , make bathroom, bed bath, assist with dressing, foot care, nail care, oral care, perineal care, shampoo, shave, skin care and standard precautions. b. The hospice aide visit note, dated 3/8/23, included documentation the hospice aide did not complete the assigned tasks of catheter care, nail care, oral care, perineal care, shampoo, skin care and standard precautions. The note lacked documentation of reason the task not performed. c. The hospice aide visit note, dated 3/30/23, included documentation the hospice aIde did not complete the assigned tasks of assist with transfer to chair/wheelchair, change linen, clean , make bathroom, bed bath, assist with dressing, foot care, nail care, oral care, shampoo and shave. The note lacked documentation of the reason the task not performed. d. The hospice aide visit notes, dated 2/23, 3/2, 3/13 and 3/29/23, included documentation the aide completed a visit. The visit note lacked documentation the hospice aide completed any of the assigned tasks and failed to include a reason why the hospice aide did not complete the tasks. The hospice aide failed to complete the assigned tasks and did not provide an acceptable reason, as the RN had scheduled the tasks. 5. Patient #14 had a hospice admission date of 3/20/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 3/20/23 to 6/17/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with positioning, repositioning, alignment, assist with transfers, patient to be non-weight bearing, recognize and report any changes in the patient's skin condition, transfer to bed/chair with assistance, use hoyer lift, turn every 2 hours, up in chair/wheelchair, assist with meal preparation, set-up, feeding, assist to toilet, change adult diapers, incontinent care, change linen, clean bathroom after patient care, make bed, assist with dressing, bath, foot care, may trim or file any long or uneven fingernails, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave, skin care, fall precautions, standard precautions, assess pain and report pain to nurse. b. The hospice aide visit note, dated 4/5/23, included documentation the hospice aide did not complete the assigned tasks of assist with positioning, repositioning, alignment, assist with transfers, patient to be non-weight bearing, recognize and report any changes in the patient's skin condition, transfer to bed/chair with assistance, use hoyer lift, turn every 2 hours, assist with meal preparation, set-up, feeding, assist to toilet, change adult diapers, incontinent care, change linen, clean bathroom after patient care, make bed, assist with dressing, bath, foot care, may trim or file any long or uneven toe nails, nail care, oral care, perineal care, shampoo, shave. The note lacked documentation of reason the task not performed. The hospice aide failed to complete the assigned tasks and did not provide an acceptable reason, as the RN had scheduled the tasks. 6. Patient #16 had a hospice admission date of 2/2/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 2/2/23 to 5/2/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with transfer to chair/wheelchair, catheter care, change adult diapers, empty foley catheter, incontinent care, change linen, clean , make bathroom, bed bath, assist with dressing, foot care, nail care, oral care, perineal care, shampoo, shave, skin care and standard precautions. b. The hospice aide visit notes, dated 10/27, 11/17, 11/23 and 12/1/22, included documentation the aide completed a visit. The visit note lacked documentation the hospice aide completed any of the assigned tasks and failed to include a reason why the hospice aide did not complete the tasks. The hospice aide failed to complete the assigned tasks and did not provide an acceptable reason, as the RN had scheduled the tasks.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 3 of 3 sampled patients with ancillary services (#1, #4 and #5). 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: --- 3. Patient #4 had a hospice admission date of 12/30/21 and received services while residing in a nursing home. Clinical record review revealed: a. Plans of Care, dated 12/25/22 to 2/22/23 and 2/23/23 to 4/23/23, included physician orders for Massage Therapy (Complementary Therapy) 1-3 times a month, Music Therapy 3-5 times a month, and Volunteer services 3-5 times a month. b. Massage therapy visit notes, dated 2/21/23, 3/14/23, 3/28/23, 4/14/23 and 4/18/23, identified services were provided. c. Music therapy visit notes, dated 2/23/23, 3/3/23, 3/10/23, 3/24/23, 3/31/23, 4/7/23, 4/14/23 and 4/21/23, identified services were provided. d. Volunteer visit notes, dated 2/28/23, 3/7/23, 3/16/23, 3/22/23, 3/29/23, 4/12/23 and 4/21/23, identified services were provided. On 4/25/23 at 3:46 PM surveyor reviewed patient hard chart (paper documentation) located in hospice office cabinet, volunteer note dated 2/27/23 was identified, no volunteer documentation was present for March or April of 2023 and no Massage Therapy or Music Therapy documentation for January, February, March or April 2023 was present. During an interview on 4/25/23 at 3:56 PM, Clinical Director provided the therapy binder. Clinical Director reported massage and music therapy notes for all hospice patients are kept in this binder. On 5/1/23 at 10:00 AM the Administrator provided the therapy binder, surveyor reviewed the binder and identified Massage Therapy visit notes, dated 2/21/23, 3/14/23, 3/28/23, 4/14/23 and 4/18/23 and Music Therapy visit notes, dated 3/3/23, 3/10/23, 3/24/23, 3/31/23, 4/7/23, 4/14/23, and 4/21/23. On 5/1/23 at 11:53 AM Volunteer Coordinator provided surveyor with volunteer notes, dated 3/7/23, 3/16/23, 3/22/23, 3/29/23, 4/12/23, and 4/21/23. The hospice failed to file the Massage Therapy, Music Therapy and volunteer notes in the clinical record (hard chart) timely. The hospice provided no further information prior to the end of the survey. Review of the hospice policy, titled Clinical Records, dated 2/1/23, identified entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers) in a standardized format and are signed by the person providing the services. During an interview on 4/25/23 at 3:56 PM, Clinical Director provided the therapy binder. Clinical Director reported massage and music therapy notes for all hospice patients are kept in this binder. On 5/1/23 at 1:07 PM, Staff I, Volunteer Coordinator (VC), reported volunteers have until the 10th day of the following month to turn in paperwork for the previous month. VC reported after the notes are turned in to the hospice office, the VC reviews the notes, initials and dates the notes, enters the volunteer time into a log in the electronic medical record system, and files the paper notes in the patients hard chart by the end of the week after receiving the notes or the end of the following week, depending on what day the notes are received. 1. Patient #1 had a hospice admission date of 2/10/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 2/10/23 to 5/10/23, included IDG orders for music therapy services 1 time evaluation. b. On 4/26/23, review of the electronic medical record and paper chart review revealed a lack of visit notes for music therapy services. c. Review of the binder revealed a music therapy visit note, dated 2/23/23, completed for the patient. The hospice staff failed to include documentation of music therapy notes into the clinical record. 2. Patient #5 had a hospice admission date of 1/23/23 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC's, dated 1/23/23 to 4/22/23 and 4/23/23 to 6/21/23, included IDG orders for volunteer services 2 to 4 times per month and massage therapy services 1 to 3 times per month effective 3/29/23. b. Review of the binder revealed massage therapy visit notes, dated 3/28/23, 4/4 and 4/18/23, completed for the patient. c. On 4/26/23, review of the clinical record revealed documentation of volunteer visit notes, dated 2/23/23 and 3/2/23. The clinical record lacked documentation of any massage therapy visit notes and any other volunteer visit notes. The hospice staff failed to include documentation of volunteer visit notes in a timely manner and failed to include massage therapy visit notes into the patient's clinical record.

Based on clinical record review, policy review, patient and staff interview, the hospice failed to ensure patient clinical records included a physician order for all treatments for 5 of 19 sampled patients (Patients #1, #3, #7, #10 and #14). Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings Include: --- 5. Patient #10 had a hospice admission date of 2/3/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 2/3/23 to 5/3/23, included orders for skilled nursing services. b. Skilled nursing visit note, dated 4/7/23, included documentation of a wound on the medial leg with an onset date of 2/2/23 and cleansed per care plan and a wound on the right ankle covered with a mepilex. The clinical record had no wound care orders for the wound on the medial leg or the right ankle. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. 2. Patient #3 had a hospice admission date of 4/13/23 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The POC, dated 4/13/23 to 7/11/23, identified a diagnosis of chronic obstructive pulmonary disease and included interdisciplinary group (IDG) orders for skilled nursing services 1 to 3 times per week. The POC included the skilled nurse intervention to assess pressure ulcer status including signs and symptoms of healing and complications. b. The skilled nurse visit note, dated 4/13/23, identified the patient had a wound on the right posterior foot/heel that measured 2 cm length by 2.2 cm width by 0 cm depth. The dressing included wound cleansing/dressing change per care plan. c. The IDG care plan , dated 4/18/23, included wound care: assess for signs/symptoms of wound infection and assess pressure ulcer status including signs and symptoms of healing and complications. d. The skilled nurse visit note, dated 4/26/23, identified the patient had a wound on the right posterior foot/heel that measured 1.6 cm length by 2.4 cm width by 0 cm depth. No cleansing or wound treatment identified. e. On 4/26/23 at 1:00 PM, during a observation home visit with Staff F, RN, the surveyor observed staff assess the wound which included taking wound measurements of the right heel wound length and width. No treatment of the wound observed f. During the same home visit, the patient identified he/she had a stay at a skilled nursing facility prior to the admission to hospice services. The patient stated orders were in place to paint the heel wound with betadine and wished treatment to the wound to continue. Staff F, RN stated the hospice had no orders in place for treatment to the right heel wound. Review of the medical record revealed no order for treatment to the patient's right heel wound. 3. Patient #7 had a hospice admission date of 7/28/22 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The POC, dated 3/18/23 to 5/16/23, identified a diagnosis of Parkinson's disease and included interdisciplinary group (IDG) orders for skilled nursing services 1 to 3 times per week. b. The skilled nurse visit note, dated 4/7/23, identified the patient had a new wound on the right inner buttock with superficial skin loss with redness. The skilled nurse provided treatment of calmoseptine cream for healing. c. The IDG note , dated 4/13/23, failed to include physician notification of new wound or orders for wound treatment. Review of the medical record revealed no order for treatment to the patient's right inner buttock. 4. Patient #14 had a hospice admission date of 3/20/23 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 3/20/23 to 6/17/23, identified a diagnosis of senile degeneration of the brain and included interdisciplinary group (IDG) orders for skilled nursing services 1 to 3 times per week. The POC included orders for heel boots to feet and check heels every shift for breakdown. b. The skilled nurse visit note, dated 3/21/23, identified the patient had a wound on the left lower posterior medial inner foot/heel that measured 1.9 cm length by 1.7 cm width by 0 cm depth. The skilled nurse cleansed the wound with soap and water. The note also identified a right lower posterior medial inner foot heel wound that measured 3.2 cm length by 2.5 cm width by 0 cm depth. The skilled nurse cleansed the wound with soap and water. c. The IDG note, dated 3/30/23, identified the patient had bilateral heel wounds. The IDG note lacked orders for cleansing or treatment. Review of the medical record revealed no order for cleansing or treatment to the patient's bilateral heel wounds. 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. Review of the hospice's policy, titled Clinical Records, dated 2/1/23, revealed the clinical record will include all physicians orders for treatments and services. 1. Patient #1 had a hospice admission date of 2/10/23 and received routine home care hospice services while residing in an apartment in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 2/10/23 to 5/10/23, identified a diagnosis of heart failure and included interdisciplinary group (IDG) orders for skilled nursing services 3 to 5 times per week. b. The Interdisciplinary Group (IDG) meeting, dated 3/2/23, included an intervention for the skilled nurse to assess the patient's use of oxygen and the effectiveness of the oxygen. The IDG meeting lacked documentation of a patient specific order for the use of oxygen with a liter per minute amount, frequency and route of use (such as nasal cannula or mask). c. The clinical record and subsequent IDG meetings, dated 3/16, 3/30 and 4/13/23, lacked an order for oxygen which specified a liter per minute amount, frequency and route of use. d. The IDG meeting, dated 3/16/23, included documentation the nurse identified on 3/3 and 3/5/23 that the patient used oxygen at a rate of 1 liter. e. The IDG meeting, dated 3/30/23, included documentation the nurse identified the patient used oxygen at a rate of 1 liter on 3/20 and 3/29/23; on 3/27/23, the nurse documented the patient was not using oxygen. f. The IDG meeting, dated 4/13/23, included documentation the nurse obtained a blood oxygen saturation level of 89 percent on 3/31/23 and reminded the patient to leave the oxygen in place. The IDG meeting included documentation the nurse obtained a blood oxygen saturation level of 86 percent on 4/10/23 and placed oxygen on the patient. On 4/24/23 at 2:17 PM, during a home visit observation, Staff C, Registered Nurse (RN), the surveyor observed the patient sitting in an electric lift chair upon entering the patients residence. The patient had oxygen tubing with a nasal cannula laying in the patients lap. The oxygen was connected to an oxygen concentrator which was on and set at 2 liters per minute. In an interview, during the same home visit, the patient reported removing the oxygen for the nurse's visit. The patient reported using the oxygen concentrator and bottles per nasal cannula at 2 liters most of the time during the day and 2 liters per minute continuous at night.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the hospice staff obtained a written signed order for discharge from the hospice's medical director, consulted the patient's attending physician prior to discharge and the attending physician's review and decision (if applicable) was included in the clinical record, in accordance with Code of Federal Regulation 418.26, for 2 of 2 sampled (live) discharged patients (Patients #15 and #16). The hospice reported a total of 37 live discharges in the past 12 months. Failure to ensure the hospice staff included the attending physician in the process for imminent discharge placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patients. Findings include: --- 2. Patient #15 was admitted to hospice on 9/29/22, received services while residing in a nursing home and had a discharge date of 10/18/22. Review of the clinical record included documentation the discharge summary was competed but lacked documentation the discharge summary was forwarded to the patient's attending physician. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice's policy, titled Clinical Records, dated 2/1/23, The clinical record documentation is accurate, timely and complete, readily accessible and systematical organized to facilitate retrieval. Each patient's clinical record includes, at a minimum a death/discharge summary. During an interview on 5/1/23 at 4:10 PM, Administrator reported the Registered Nurse Case Managers should notify the physician of the patient discharge. 1. Patient #16 had a start of care date of 9/1/22 and discharged on 10/18/22. Review of the clinical record revealed the following: a. The Plan of Care, dated 11/30/22 to 1/28/23, included Interdisciplinary Group (IDG) orders for skilled nursing, hospice aide, social worker and spiritual counseling services. b. The communication note, dated 12/8/22, identified the patient discharged due to a face to face visit not completed by the Medical Director. c. Review of the medical record revealed no discharge summary completed and sent to the physician.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to maintain documentation in the patient clinical records as evidence that patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 4 sampled patients (Patients #3 & #6) who received routine home care while living in a private home residence and had a physician ordered controlled medication after the start of hospice services. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: --- 2. Patient #2 had an admission to hospice on 10/28/22 and received services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 1/26/23 to 4/25/23, included orders for Morphine Sulfate and Lorazepam, both controlled substances with start dates of 11/22/22. b. Skilled nursing visit note, dated 11/23/22, included documentation the patient and family were educated on the new medications but lacked documentation of education on disposal of controlled medications policy. The clinical record lacked evidence the hospice provided education on and received a copy of the hospice policy for disposal of controlled medications to the patient/caregiver. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. The hospice policy, titled Medication – Management, Education, Tracking and Disposing of Controlled Drugs, dated 4/25/22, indicated patient and/or family/caregiver education regarding controlled substances in the form of both verbal and written information is provided during the admission visit or if no controlled substances ordered upon admission, the education regarding controlled substances written and verbal will occur at the point a controlled substance is prescribed. All education /information provided to the patient and/or family/caregiver related to controlled substances is documented in the patient electronic health record. During an interview on 5/1/23 at 3:50 PM, Staff G, Administrator for Waterloo/Manchester office, reported the narcotic disposal policy is given to patients/family at start of care or when a narcotic is started if patient not on a narcotic at start of care. 1. Patient #3 had a hospice admission date of 4/13/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/13/23 to 7/11/23, included orders for skilled nursing services and lacked orders for narcotic medication. The verbal order, signed by the physician 4/30/23, included orders for hydrocodone-acetaminophen 5-325 mg (milligram) take 1 tablet every 6 hours for pain. The clinical record lacked documentation of hospice staff providing a discussion of policy for disposal of controlled drugs at the time of ordering the controlled drug.

Based on clinical record review, hospice policy review, nursing home medication administration records and hospice staff interview, 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 #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 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 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. Patient #4 had a hospice admission date of 12/30/21 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 4/24/23 to 6/22/23, included Interdisciplinary group (IDG) orders for skilled nursing services 1 to 3 times per week and included physician orders for medications. Review of the patient's nursing home Medication Administration Record (MAR) for April 2023 identified the following medication discrepancies with the hospice's POC and Medication Profile, dated 4/25/23) for the patient: a. The hospice POC had an order for Calcium-Vitamin D 600 milligrams (mg)- 10 micrograms (mcg) oral tablet one tab daily. The hospice's Medication Profile identified a start date for the medication, dated 12/30/21. The nursing home's MAR lacked an order for this medication. b. The hospice POC had an order for Multivitamin oral tablet one tab daily. The hospice's Medication Profile identified a start date for the medication, dated 12/30/21. The nursing home's MAR lacked an order for this medication. c. The hospice POC had an order for Paroxetine (Paxil) 30 mg oral tablet one tab daily. The hospice's Medication Profile identified a start date for the medication, dated 2/17/22. The nursing home's MAR included an order for Paxil 40 mg oral tab one tab daily and a start date of 4/7/23. d. The hospice POC had an order for Tramadol 50 mg oral tablet one tab every 6 hours as needed (PRN) for pain. The hospice's Medication Profile identified a start date for the medication, dated 10/6/22. The nursing home's MAR lacked an order for this PRN medication. e. The nursing home's MAR had orders for Biotene mouthwash oral solution 15 milliliters (ml) every 4 hours as needed for dry mouth and a 9/27/22 start date. The MAR identified the patient had received a dose of the PRN mouthwash on 4/1, 4/7, 4/9, 4/11, 4/12, 4/14, 4/17, 4/18, 4/19, 4/20 and 4/25/23. The hospice's POC lacked an order for PRN use of Biotene. f. The nursing home's MAR had orders for Biotene mouthwash oral solution 10 ml every 8 hours as needed for dry mouth and a 10/3/22 start date. The MAR identified the patient had received a dose of the PRN mouthwash on 4/2 and 4/10/23. The hospice's POC lacked an order for PRN use of Biotene. 4/25/23 at 12:50 PM, during an interview, Staff E, RN, reported reviewing the patient's medications about once every 3 months. 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 hospice plan of cares for recertification and the physician certification of terminal illness for 1 of 1 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: --- 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. Patient #2 had a hospice admission date of 2/18/22 and received routine home care hospice services while residing in a nursing home (nursing facility). On 4/25/23 at 10:10 AM, after a home visit observation, the surveyor reviewed the information the hospice provided to the facility for the patient with the facilitys Minimum Data Set (MDS) Coordinator. The facility scans or electronically processes all information provided by the hospice into the nursing home system. The facility had an initial Certificate of Terminal Illness (CTI) for the first 3 month hospice certification period 92/18/22 to 5/18/22), but no subsequent CTIs. The facility had the initial Plan of Care (POC), but no subsequent recertification orders or POCs . On 4/25/23 at 3:18 PM, during an interview, the Administrator agreed to try to find evidence the hospice staff had sent the subsequent CTIs and POC recertification orders. The Administrator reported the hospice staff had access to the facilitys electronic medical record system, as this was one of Care Initatives facilities. 4/25/23 at 3:18 PM, during an interview, the Administrator reported the hospice was taking the initial CTI to the nursing facilities. If the nursing home is a Care Initiative facility the CTI is uploaded in the shared EMR, if the facility is not a Care Initiatives facility, the office coordinator will print it out and give to it to the nurse who is responsible for placing copy in the nursing home facility chart. The hospice staff were not doing this process with the subsequent CTI forms.