Every finding on record at Care One Hospice

Based on interview and record review, the Hospice Agency (HA) failed to ensure four of 14 sampled patients (Patient 1, Patient 2, Patient 8 and Patient 9) were provided information on how and where to file a complaint with the State Department. This deficient practice resulted in the patients not having the information necessary to exercise their rights to voice their concern regarding their care. --- a. A record review of Patient 1's ";Personal Information" sheet indicated a start of care date of 2/10/23, with diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a concurrent observation and interview during a home visit on 9/12/23, at 12:15 p.m. an agency folder (a folder containing information about the agency services and other reference material) was observed. Patient 1s caregiver 1 (CG 1) reviewed the contents of the folder and stated she did not have the information to call the health department, if she had to voice any concerns, about the care being provided by the Hospice agency to Patient 1. b. A record review of Patient 2's ";Personal Information" sheet indicated a start of care date of 8/30/23, with diagnoses that included cancer of the colon (a growth of cells that begins in a part of the large intestine called the colon). During an interview on 9/12/23, at 2:10 p.m., Patient 2 stated she did not know how to contact the Health Department to voice concerns about her care, should they arise. c. A review of Patient 8s (P8) medical record form titled ";Personal Information" indicated Patient 8 had a start of care (SOC) date of 6/23/23, with diagnoses that included Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). During a joint home visit on 9/12/2023 at 10 a.m. with License Vocational Nurse 2 (LVN2) to Patient 8s home, LVN2 was unable to locate information on the State Department complaint number or address in Patient 8s hospice folder. LVN2 stated that information on how to file a complaint with the State Department should be at Patient 8s home and it was important to provide that information to both the patient and their caregivers. During an interview on 9/12/23 at 10:20 a.m. with Caregiver 3 (CG3), CG3 stated she has not seen the State Departments number. Caregiver 3 stated all Patient 8s hospice papers were in her hospice folder. The Hospice Agency failed to provide Patient 8s Caregiver 3, the State Department complaint number and address. d. A review of Patient 9's medical record form titled ";Personal Information" indicated Patient 9 had a SOC date of 1/31/23, with diagnoses that included trauma subdural hematoma (head trauma) with LOC (Loss of conscious). During a joint home visit on 9/12/23 at 11:15 a.m. with LVN2 to Patient 9s home, LVN2 was unable to locate information on the State Department complaint number or address in Patient 8s hospice folder. LVN2 stated ";They need to know who they should contact in case they have a complaint." During an interview on 9/12/23 at 11:15 a.m. with Caregiver (CG2), CG2 stated he does not know if the State Departments number is in her folder. CG2 stated it should be in there. The HA failed to provide Patient 9s Caregiver (CG2) the State Department complaint number and address. During an interview on 9/13/23 at 12:52 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated it was the patients and their family/caregivers right to know where to call to file a grievance. A record review of the Hospice Agencies undated policy and procedure titled, ";Patient Rights and Responsibilities," indicated, it is the policy of Hospice to inform patients of their rights, and protect and promote the exercise of the rights...3. The notice of patients rights and responsibilities includes but is not limited to, the patients right:...e to voice grievances regarding treatment of care..."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure one of 14 sampled patients (Patient 1) was informed about the supplies covered by hospice services. This deficient practice resulted in the patient paying for medical supplies that should have been covered by the hospice agency. --- A record review of Patient 1's (P1) ";Personal Information" sheet indicated a start of care date of 2/10/23, with diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a concurrent observation and interview during a home visit on 9/12/23, at 11:45 p.m. Patient 1s caregiver (CG 1) presented medical supplies used by Patient 1. An observation of the medical supplies indicated several urinary catheters (a tube placed in the body to drain urine from the bladder), each in its own individual packaging. CG 1 stated she did not understand why the Hospice Agency was not covering the cost of the catheters because the previous hospice agency Patient 1 was in, was covering the costs of the catheters. CG 1 stated she was paying from her own funds for the cost of the urinary catheters. CG 1 stated she catheterized Patient 1 because Patient 1 was unable to do so anymore. During an interview on 9/14/23, at 11:37 a.m., the Director of Patient Care Services (DPCS) stated, ";I was not aware we were not covering his catheter. We should be covering. I will look into it." A record review of Patient 1s document titled, ";Physicians Certification for Hospice Benefit", for certification period 8/1/23 to 9/29/23, indicated, self-catheterization due to dementia. A record review of the Hospice Agency undated policy and procedure titled, ";Patient Rights and Responsibilities", indicated, it is the policy of the Hospice to inform patients of their rights, and protect and promote the exercise of the rights, to receive information about the services covered under the Medicare Hospice Benefit or by other payor sources and the services the hospice will provide and any specific limitation(s) on those services, and to be informed of any charges/services not covered by insurance."

Based on interview and record review, the Hospice Agency (HA) staff failed to conduct a comprehensive assessment that reflected the patients current health status and identify the patients need for hospice care and services related to hospice eligibility and management of terminal illness for one of 14 (Patient 5). This deficient practice resulted in the hospice agency providing services without having information about the needs of the patient to formulate a plan of care (POC). --- A record review of Patient 5 (P5) ";Personal Information" sheet indicated a start of care on 9/1/23, with diagnoses that included heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). During a concurrent interview and record review on 9/13/23 at 11:59 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 5s record titled, ";Comprehensive Nursing Assessment", dated 9/1/23. The record was not completed. There was no signature to identify who had completed the assessment. The DPCS stated the comprehensive assessment was supposed to be completed on the day of the visit, which was 9/1/23. The DPCS stated the importance of the assessment was to identify the patients needs and know what care to provide. During an interview on 9/11/23 at 1 p.m. with the Director of Patient Care Services Designee (DD), DD stated that the initial comprehensive nursing assessment should be completed and documented within 48 hours of admission. During an interview on 9/11/23 at 1:35 p.m. with the Administrator Designee (AD), the AD stated that the IDG meets every 14 days, and their meetings are documented in their Electronic Medical Record (EMR) system, ";beforehand". During an interview on 9/13/2023 at 10:15 a.m. with the DPCS, the DPCS stated the admission process, included creating a care plan is done at the start of service. DPCS stated the documentation is expected to be completed within 24 hours. The DPCS stated this process is in the hospice agency's policy and procedures. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated that every patient should have a care plan, which is a ";road map" of how to treat patients and covers all their diagnosis. DPCS stated, ";Every need has to have a care plan." DPCS stated that pain would be included in their care plans, and that if the patient did not have or complained of pain, then the care plan should state ";Potential for pain." The DPCS stated that the POC should be completed and submitted within 24 hours. The DPCS stated all the disciplines have five days to complete a patient's care plan. The DPCS stated she was aware that the sampled patients care plans were incomplete. During an interview on 9/13/2023 at 11:28 a.m. with the DPCS, the DPCS stated that all patients visit should be documented in the electronic medical record (EMR) system within 24 hours. DPCS stated that their signatures should be documented when they submit their notes. The DPCS stated that their signature indicates that they verify they saw the patient that day. A record review of the HAs undated policy and procedure titled, ";Comprehensive Assessment-Initial", indicated, it is the agency's policy that an initial assessment be conducted by the hospice RN (Registered Nurse) to determine the patients immediate care and support needs within 48 hours of the patients election of hospice care. The hospice RN completes the initial assessment tool and ensures that orders for treatment and services are obtained to meet the immediate care and support needs of the patient."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – a Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians) completed and documented the initial comprehensive assessment no later than five calendar days after hospice election for six of fourteen sample patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 13, and Patient 14). This deficient practice had the potential to result in a delay in identifying the patients needs and developing a plan of care catering to those needs. --- a. A review of Patient 8s (P8) medical record form titled ";Personal Information" indicated P8 had a start of care (SOC) date of 6/23/23, with diagnoses including Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). During a concurrent interview and record review on 9/13/23 at 12:52 p.m. with the Director of Patient Care Services (DPCS) of Patient 8s Electronic Medical Record (EMR) medical form titled ";POC/IDG Review" dated 6/23/23. The DPCS stated the form was blank, ";It was not entered." The HA failed to complete and document Patient 8s plan of care no later than five days after SOC. b. A review of Patient 9's medical record form titled ";Personal Information" indicated Patient 9 had a SOC date of 1/31/23, with diagnoses that included trauma subdural hematoma (head trauma) with LOC (Loss of conscious). During a record review of Patient 9s EMR form titled, ";POC/IDG Review" dated 1/31/23, indicated the form was incomplete. During an interview on 9/12/23 at 11:15 a.m. with License Vocational Nurse 2 (LVN2), LVN2 stated that Patient 9s POC was not complete. LVN2 stated ";It should have all the bodys systems, that we need to assess and concentrate on. For her, we would need to focus on her neurological system because of her diagnosis. POC is the plan, this is not complete, it does not say much." During a concurrent interview and record review on 9/13/223 at 1:22 p.m. with the DPCS of Patient 9s EMR form titled ";POC/IDG Review" dated 1/31/23, the DPCS stated the initial IDG was incomplete. The HA failed to complete and document Patient 9s plan of care no later than five days after SOC. c. A review of Patient 10's medical record form titled ";Personal Information" indicated Patient 10 had a SOC date of 7/23/22, with diagnoses including Alzheimers Disease (a progressive memory loss). During a record review of P10s EMR form titled, ";POC/IDG Review" dated 7/23/2023, indicated form was incomplete. During a concurrent interview and record review on 9/13/23 at 1:42 p.m. with the DPCS of Patient 10s EMR form titled ";POC/IDG Review" dated 7/23/23, the DPCS stated the initial IDG was incomplete. The HA failed to complete and document Patient 10s plan of care no later than five days after SOC. d. A review of Patient 11's medical record form titled ";Personal Information" indicated Patient 11 had a SOC date of 8/29/23, with diagnoses that included liver disease (a condition that damages and affect the liver). During a record review of Patient 11s EMR form titled, ";POC/IDG Review" dated 8/29/23, indicated the form was incomplete. During a concurrent interview and record review on 9/13/23 at 12:24 p.m. with the DPCS of Patient 11s EMR form titled ";POC/IDG Review" dated 8/29/23, the DPCS stated the initial IDG had nothing documented because they did not transcribe the teams discussion into their EMR system. The HA failed to complete and document Patient 11s plan of care no later than five days after SOC. e. A review of Patient 13's medical record form titled ";Personal Information" indicated Patient 13 had a SOC date of 8/22/23 and an end of care (EOC) date of 8/30/23, with diagnoses that included Alzheimers disease (a progressive memory loss). During a record review of Patient 13s EMR form titled, ";POC/IDG Review" dated 8/22/23, indicated the form was incomplete. The HA failed to complete and document Patient 13s plan of care no later than five days after the start of care date. f. A review of Patient 14's medical record form titled ";Personal Information" indicated Patient 14 had a SOC date of 8/8/23 and an End of Care (EOC) date of 8/13/23, with diagnoses that included acute kidney failure (kidneys unable to filter waste products from your blood). During a record review of Patient 14s EMR form titled, ";POC/IDG Review" dated 8/8/23, indicated the form was incomplete. The HA failed to complete and document Patient 14s plan of care no later than five days after the SOC date. During an interview on 9/11/23 at 1 p.m. with the Director of Patient Care Services Designee (DD), the DD stated the interdisciplinary group (IDG) meets on a weekly basis to discuss patients issues and the plan of action. The DD stated the IDG documents a ";small summation" into their EMR system before the meetings to ";Have everything ready." The DD stated the admission, including the POC should be completed within 48 hours of admission. During an interview on 9/12/23 at 10 a.m. with LVN2, LVN2 stated the POC lets HA staff know what needs to be done for the patients. During an interview on 9/13/2023 at 10:15 a.m. with the DPCS, the DPCS stated the admission process, including creating a care plan is done at the start of service. The DPCS stated that the documentation is expected to be completed within 24 hours. The DPCS stated this process is in the HAs policy and procedures. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated that every patient should have a care plan, which is a ";road map" on how to treat patients and that covers all their diagnosis. The DPCS stated, ";Every need has to have a care plan." DPCS stated pain should be included in their care plans and that if the patient did not have or complained of pain, then the care plan should state ";Potential for pain". The DPCS stated the POC should be completed and submitted within 24 hours. The DPCS stated all the disciplines have five days to complete a patient's care plan. The DPCS stated she was aware that the sampled patients care plans were incomplete. During an interview on 9/13/23 at 10:55 a.m. with the DPCS, the DPCS stated the IDG meetings are documented on the IDG forms in their EMR system. The DPCS stated, ";We put the general documentations, patient condition, what changes, progress, declines and issues happening in that time frame." The DPCS stated the discussion sections in the IDG are to be filled out by the corresponding disciplines. The DPCS stated the IDG members are to sign the IDG meetings ";live" at the time of the meeting. The DPCS stated their signatures mean they certify they wrote their discussion. A record review of the HAs undated policy and procedure titled, ";Comprehensive Assessment-Initial", indicated, based on the patients needs and findings from the initial assessment, the hospice RN (Registered Nurse) coordinates and designates disciplines that must participate in the comprehensive assessment of the patient within five days of the patients election of hospice care." A record review of the HAs undated policy and procedure titled, ";Spiritual Care Services", indicated", the comprehensive assessment of the patient includes a spiritual assessment conducted by the Spiritual Counselor to evaluate the patients/familys spiritual needs and identify appropriate spiritual problems, interventions, and goals for the patients plan of care."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to review and update the patients current medication profiles with the currently used medications for three of fourteen sample selected patients (Patient 1, Patient 8 and Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- a. A record review of Patient 1's ";Personal Information" sheet indicated a start of care date of 2/10/23, with diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement) and Dementia (a group of thinking and social symptoms that interferes with daily functioning). During an observation of the home visit on 9/12/23 at 11:30 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed providing care to Patient 1. During an interview on 9/12/23, at 11:45 a.m., Patient 1s Caregiver (CG 1) stated LVN 1 visited Patient 1 two times a month, a visit occurring every two weeks. During an interview on 9/12/23, at 12:25 p.m., the home visit was concluded. LVN 1 stated she did not reconcile the medications Patient 1 was taking because she forgot. LVN 1 stated medication reconciliation involved reviewing the medication for name, dose, route, expiration date and comparing it with the medication list to make sure it was accurate. LVN 1 stated the frequency of medication reconciliation was every week because it was important to check if any medications expired, if there are new medications, or to identify if the patient needs a refill on any medication. b. A review of Patient 8s (P8) medical record form titled ";Personal Information" indicated Patient 8 had a start of care (SOC) date of 6/23/23, with diagnoses that included Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). A review of Patient 8s medical record form titled, ";Current Treatment/Mediation/DME List" indicated, Acephen (Tylenol – pain/fever reducer medication) – Suppository 650 mg 1 Supp rectal every four hours PRN (as needed) for pain/fever and Zofran (anti-nausea/vomiting medication) ODT 4 mg 1 tab oral/SL (sublingual-under the tongue) every 8 hours PRN nausea/vomiting". During a joint home visit on 9/12/23 at 10 a.m. with LVN2 of Patient 8s home, the medication bottle labels indicated: Acephen (Tylenol) – Suppository 650 mg 1 Supp rectal every 6 hours PRN for pain and Zofran ODT 4 mg dissolve one tablet on top of tongue every 6 hours PRN nausea/vomiting. LVN2 stated that medication labels need to be correct. LVN2 stated that the medication list needs to be reconciled with the medication labels to prevent medication errors. LVN2 also stated that the medication list needs to be updated so that all medical personnel that encounter Patient 8 are aware of her current medications. The HA failed to ensure P8s medication list reflected her current medications. c. A review of Patient 9s (P9) medical record form titled ";Personal Information" indicated Patient 9 had a SOC date of 1/31/23, with diagnoses that included trauma subdural hematoma (head trauma) with LOC (Loss of conscious). A review of Patient 9s medical record form titled, ";Current Treatment/Mediation/DME List" indicated, Antifungal 1% topical cream apply under right breast BID (twice a day) antifungal – start date 1/31/23. Airborne Immune Support tab's chew oral (4) tablets daily immune support and Zithromax (anti-infective medication) Z-PAK 250 mg (milligrams) 1-tab oral take 2 tabs on day one, then 1-tab days 2-5 – start date 4/5/2023. Lotrisone (anti-fungal medication) topical cream 1% apply cream BID x14 days redness – start date 6/12/2023. Debrox 6.5% Otic Drops Earwax Removal Kit 5 drops auricular 1 time a day x5 days – start date 8/3/2023." It also indicated ";Lasix" (anti water retention medication) order was written twice. During a joint home visit on 9/12/23 at 11:15 a.m. with LVN2 of Patient 9s home medication bottle labels, the labels indicated antifungal 1% topical cream apply under right breast BID antifungal – start date 1/31/2023 and Airborne Immune Support tabs chew one tablet by mouth 4 times daily for immune support. LVN2 was unable to find:1. Zithromax Z-PAK, Lotrisone topical cream. 3. Debrox 6.5% Otic Drops. LVN2 stated that she had not noticed the label on the medication Airborne. LVN2 stated that she needs to call the office to clarify the dosage. LVN2 stated that she reconciles the patients medications at every visit. LVN2 stated that she must have missed it. LVN2 stated that the medications need to be reconciled to prevent medication errors. During an interview on 9/12/23 at 11:40 p.m. with Patient 9s Care Giver 2 (CG2), CG2 stated that Patient 9 was no longer taking the Z-PAK, antifungal, Lotrisone, or ear wax medication. CG2 stated that those medications were prescribed for a ";short amount of time". The HA failed to ensure Patient 9s medication list reflected her current medications. During an interview on 9/11/23 at 1 p.m. with the Director of Patient Care Services Designee (DD), DD stated that the reconciliation of the medication list is an ongoing process. DD stated that the medication list should be looked at every time a nurse visits. During an interview on 9/13/2023 at 10:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that at every visit, the nurse is expected to review the medication. A record review of the HAs undated policy and procedure titled, ";Medications-Management", indicated a medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patients terminal illness."

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), care planning, and coordination of services as follows: --- 1. The HA failed to ensure, the plan of care (POC, maps out needs and services given to a patient facing a terminal illness), included an education (process of receiving or giving systematic instruction) on self-catheterization (a method of inserting a clean, thin, flexible plastic tube (catheter) into the bladder to empty urine) for one of 14 sampled patients (Patient 1). This failure had the potential for Patient 1 at risk for bladder infection, pain, and perforation (a hole that develops through the wall of a body organ). (Refer to L544). 2. The HA failed to developed and implemented a plan of care that reflected patients goals and interventions based on the problems identified in the initial and updated comprehensive assessment for four of 14 sampled patient (Patient 5, Patient 8, Patient 9, and Patient 11). This deficient practice resulted in the HA providing care without written information on the patients needs, goals, and interventions needed to meet the patient's care goals. (Refer to L545). 3. The HA failed to ensure the plan of care included an interventions for pain management for three of 14 sampled patients (Patient 2, patient 8, and Patient 9). This deficient practice had a potential for the patient not receiving an information and intervention for pain management and placed the patient at risk for not meeting their care goals. ((Refer to L546). 4. The HA failed to ensure the plan of care included scope and frequency for four of 14 sampled patients (Patient 1, Patient 5, Patient 8, and Patient 9). This deficient practice had the potential to result in patients having missed visits from the prescribed disciplines and not meeting the patients' care goals. (Refer to 547). 5. The HA failed to ensure the plan of care included a desired and expected care goals for four of 14 sampled patients (Patient 5, Patient 8, Patient 9, and Patient 11). This deficient practice had the potential to result in patients not meeting their care goals. (Refer to 548). 6. The HA failed to ensure the interdisciplinary group revised the plan of care that reflected the patients condition, for six of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, and Patient 7). This deficient practice had a potential for the patients not meeting their care goals. (Refer to L552). 7. The HA failed to ensure that all care services furnished followed an individualized plan of care established by the interdisciplinary team (IDT) by not conducting home visits as indicated in the plan of care for one of 14 sampled patients (Patient 8). This deficient practice resulted in the patient did not received home visit and had a potential for the patient not to receive care/services from the home visits to meet the patient care goals. (Refer to L555). 8 8. The HA failed to ensure the patient's caregiver was provided with the patients POC with information of the services and care being provided by the HA and included the patient's medication list for two out of 14 sampled patients (Patient 8 and Patient 9). This failure had the potential to result in placing the patients at risk for not receiving the services/care as indicated in their individualized POC. (Refer to L558) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure, the plan of care (POC, maps out needs and services given to a patient facing a terminal illness) ) included an education (process of receiving or giving systematic instruction) on self-catheterization (a method of inserting a clean, thin, flexible plastic tube (catheter) into the bladder to empty urine) for one of 14 sampled patients (Patient 1). This deficient practice had the potential for Patient 1 at risk for bladder infection, pain, and perforation (a hole that develops through the wall of a body organ). --- A review of Patient 1 (P1) ";Personal Information" sheet indicated a start of care (SOC) dated 2/10/2023, with diagnoses included Parkinsons disease (a disorder of the central nervous system that affects movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a concurrent observation and interview of the home visit on 9/12/2023, at 11:45 p.m. P1s caregiver (CG 1) presented medical supplies used by Patient 1. The patient's medical supplies was observe with several urinary catheters (a tube placed in the body to drain urine from the bladder), each in its own individual packaging, sterile (free from bacteria), intended to be used once only. CG 1 stated, due to the out-of-pocket expense of paying for the catheters, she reused each catheter twice. CG 1 stated, she would wash the catheter and place it in a bag with alcohol (used as a disinfectant). CG 1 stated, P1 was getting a bladder infection every three months. During a concurrent interview and record review on 9/14/2023, at 11:37 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 1s records "Plan of Care (POC)/Interdisciplinary Group (IDG) Review", dated 7/12/2023, 7/26/2023, 8/9/2023, 8/23/23, and 9/6/2023. The records did not indicate education was provided to Patient 1s CG 1 for the use of the catheter. The DPCS stated Patient 1s catheter was intended for single use and was not meant to be reused. The DPCS stated, single use of catheter could prevent bladder infection. The DPCS stated, Patient 1s records did not indicate the HA provided education about the catheter and it was important to educate Patient 1 and CG1 as part of providing proper care. During an interview on 9/11/2023 at 1 p.m. the Director of Patient Care Services Designee (DD) stated, ";The whole admission process should be done within 48 hours, including the POC." During an interview on 9/12/2023 at 10 a.m. with License Vocational Nurse 2 (LVN2), LVN2 stated that the POC lets HA staff know what needs to be done for the patients. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated every patient should have a care plan, which is a ";road map" on how to treat patients and covers all their diagnosis. The DPCS stated, ";Every need has to have a care plan." The DPCS stated the POC should be completed and submitted within 24 hours. The DPCS stated all the disciplines have five days to complete a patient's care plan. The DPCS stated she was aware the sampled patients care plans were incomplete. A record review of the HAs undated policy and procedure titled, ";Plan of Care", indicated, the care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician (if any), and, if appropriate, the patient and/or his/her representative. Each patient and his/her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care."

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to develop and implemented a plan of care (POC, an individualized care plan, indicating what interventions are needed for patient care)that reflected patients goals and interventions based on the problems identified in the initial and updated comprehensive assessment for four of 14 sampled patient (Patient 5, Patient 8, Patient 9, and Patient 11). This deficient practice resulted in the HA providing care without written information on the patients needs, goals, and interventions needed to meet the patient's care goals. --- a. A review of Patient 5's ";Personal Information" sheet indicated a start of care (SOC) dated 9/1/2023, with a diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). During a concurrent interview and record review, on 9/14/2023, at 11:20 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 5s ";POC Summary, printed on 9/11/2023. The document did not indicate the interventions needed based on Patient 5s diagnosis. The DPCS stated the POC was incomplete and was missing the focus of pain which was Patient 5s heart and lung problem and pain. The DPCS stated the POC did not include Patient 5s problems identified in the comprehensive assessment. There was no interventions for staff to follow, and there were no goals of care. The DPCS did not respond when asked of the potential effect on Patient 5 when the HA did not develop and implemented the patient's POC. b. A review of Patient 8s (P8) ";Personal Information" indicated Patient 8 had a start of care (SOC) date of 6/23/2023, with diagnoses that included Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). A review of Patient 8s ";Physician's Certification for Hospice Benefit" dated from 6/28/2023 to 8/26/2023, indicated ";Comorbidities (occurs when a person has more than one disease or condition at the same time) include advance dementia with behavioral disturbance." A review of Patient 8s medical record form titled, ";POC/IDG Review" dated 9/6/2023, indicated there were three documented issues under ";Problem/intervention/goal/status". These included: 1. Mobility 2. Nutrition 3. Sleep. During a concurrent interview and record review on 9/13/2023 at 12:52 p.m., the Director of Patient Care Services (DPCS) or Patient 8s Electronic Medical Record (EMR), DPCS stated, that Patient 8s POC was not complete. DPCS did not elaborate on why Patient 8s POC was incomplete when asked. The HA failed to include ";problem/intervention/goal/status" that were associated with P8s comorbidities of dementia and behavioral disturbance. c. A review of Patient 9 ";Personal Information" indicated Patient 9 had a SOC date of 1/31/2023, with diagnoses including trauma subdural hematoma (head trauma) with level of conscious (LOL). A review of P9s ";Physician's Certification for Hospice Benefit" dated from 7/30/23 to 9/27/2023, indicated comorbidities diagnoses including hypertension (high blood pressure), anxiety, hypoxemia (low oxygen circulating in blood), and atherosclerosis of aorta (plaque build-up in aorta). A review of Patient 9s ";POC/IDG Review" dated ";9/6/2023 – Cert #3" indicated ";Mobility" was the only issue care planned under section ";problem /intervention/ goal/status". During an interview on 9/12/2023 at 11:15 a.m. with License Vocational Nurse 2 (LVN2), LVN2 stated that Patient 9s POC was not complete. LVN2 stated ";It should have all the bodys systems, that we need to assess and concentrate on. For her, we would need to focus on her neurological system because of her diagnosis. POC is the plan, this is not complete, it does not say much." The HA failed to include ";Problem/intervention/goal/status" that were associated with Patient 9s comorbidities of hypertension, anxiety, hypoxemia, and atherosclerosis of aorta. d. A review of Patient 11s (P11) ";Personal Information" indicated Patient 11 had a SOC date of 8/29/2023, with diagnoses including liver disease (a condition that damages and affect the liver). A review of P11s ";Physician's Certification for Hospice Benefit" dated from 8/29/2023 to 11/26/2023, indicated comorbidities diagnoses including hypothyroid (low thyroid hormone), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and osteoarthritis. During a concurrent interview and record review on 9/13/2023 at 12:24 p.m. with the DPCS of Patient 11s EMR form title ";POC/IDG Review", the DPCS stated there were no documented IDG forms for Patient 11. DPCS did not elaborate on why there were no documentation of Patient 11s IDG when asked. The HA failed to include ";Problem/intervention/goal/status" associated with P11s primary diagnosis and comorbidities. During an interview on 9/11/2023 at 1 p.m. with the Director of Patient Care Services Designee (DD), DD stated, ";The whole admission process should be done within 48 hours, including the POC." During an interview on 9/12/2023 at 10 a.m. with LVN2, LVN2 stated the POC lets HA staff know what needs to be done for the patients. During an interview on 9/13/2023 at 10:15 a.m. with the DPCS, the DPCS stated the admission process, including creating a care plan is done at the start of service. DPCS stated the documentation is expected to be completed within 24 hours. DPCS stated that this process is in the HAs policy and procedures. During an interview on 9/13/2023 at 12:52 p.m. with the DPCS, the DPCS stated the POC elements include level of care, frequency of discipline visits, DME, treatments, medications, and diet. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated that every patient should have a care plan, which is a ";road map" on how to treat patients and covers all their diagnosis. DPCS stated, ";Every need has to have a care plan." DPCS stated that pain would be included in their care plans and that if the patient did not have or complained of pain, then the care plan should state ";potential for pain". DPCS stated the POC should be completed and submitted within 24 hours. DPCS stated that all the disciplines have five days to complete a patient's care plan. DPCS stated she was aware the sampled patients care plans were incomplete. A record review of the HAs undated policy and procedure titled, ";Plan of Care-Content", indicated, the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. The procedures indicate the patients plan of care should include all services necessary for the palliation and management of the terminal illness and its related conditions." A record review of the HAs undated policy and procedure titled, ";Plan of Care", indicated, the care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician (if any), and, if appropriate, the patient and/or his/her representative."

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure a Plan of Care (POC, an individualized care plan, indicating what interventions are needed for patient care) included an interventions for pain management for three of fourteen sample patients (Patient 2, Patient 8, and Patient 9). This deficient practice had a potential for the patient not receiving an information and intervention for pain management and placed the patient at risk for not meeting their care goals. --- a. A record review of Patient 2's (P2) ";Personal Information" sheet indicated a start of care date on 8/30/2023, with diagnoses that included cancer of the colon (a growth of cells that begins in a part of the large intestine called the colon). During an interview on 9/13/2023 at 10:30 a.m., the Director of Patient Care Services (DPCS) stated the HA had five days from the start of care to complete the POC. The DPCS stated the POC was a road map, a guide on how to take care of the patient based on the needs of the patient, which is why the POC is important to have. The DPCS stated she felt ";really bad" because she realized there were patients charts without a care plan. During a concurrent interview and record review on 9/14/2023, at 11:10 a.m., the DPCS reviewed Patient 2s record titled, ";POC Summary", printed on 9/11/2023. The record did not indicate interventions to manage pain. The DPCS stated Patient 2s focus of care was pain management because she had gastrointestinal (organs including stomach, intestines) and genitourinary (organs involving the bladder) issues. The DPCS reviewed the document and stated the POC was incomplete and did not indicate what the focus of care was. The DPCS stated the nurses did not have a written POC to refer to. The DPCS did not offer a response when asked what potential outcome this deficient practice can have on Patient 2. The HA failed to ensure Patient 2s POC included interventions to manage pain. b. A review of Patient 8s (P8) medical record form titled ";Personal Information" indicated P8 had a start of care (SOC) date of 6/23/2023, with diagnoses including Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). A review of Patient 8s medical record form titled ";Current Treatment/Mediation/DME List" indicated Patient 8 was prescribed Norco (narcotic pain medication) 10mg/325 mg (milligrams) one tab oral four times per day. A review of Patient 8s medical record form titled, ";Physician's Certification for Hospice Benefit" dated from 6/28/2023 to 8/26/2023, indicated under the ";Physician Narrative – Patient has a lot of pain which requires scheduled Norco." A review of Patient 8s medical record form titled, ";POC/IDG Review" dated 9/6/2023, indicated there were three issues documented under ";problem/intervention/goal/status." These issues included 1. Mobility 2. Nutrition and 3. Sleep. During a concurrent interview and record review on 9/13/2023 at 12:52 p.m. with the DPCS of Patient 8s Electronic Medical Record (EMR), DPCS stated that Patient 8s POC is not complete. DPCS did not elaborate on why Patient 8s POC was incomplete when asked. DPCS stated, ";We met, we just didnt write it in (EMR)." The HA failed to care plan Patient 8s interventions, goals, and status related to her pain. c. A review of Patient 9 medical record form titled ";Personal Information" indicated Patient 9 had a SOC date of 1/31/2023, with diagnoses including trauma subdural hematoma (head trauma) with LOC (level of conscious). A review of Patient 9s medical record form titled, ";Current Treatment/Mediation/DME List" indicated Patient 9 was prescribed Tramadol (pain medication) 50 mg one tab oral three times per day and Tramadol 50mg every six hours if needed. A review of Patient 9s medical record form titled, ";Physician's Certification for Hospice Benefit" dated from 6/28/2023 to 8/26/2023, indicated under the ";Physician Narrative – Pain, well managed with current meds. Continue pain meds as prescribed." A review of Patient 9s medical record form titled, ";POC/IDG Review" dated 9/6/2023, indicated there was one issue documented under ";Problem/intervention/goal/status." The issue documented was mobility. During an interview on 9/12/2023 at 11:15 a.m. with License Vocational Nurse 2 (LVN2), LVN2 stated Patient 9s POC was not complete. LVN2 stated ";It should have all the bodys systems, that we need to assess and concentrate on. For her, we would need to focus on her neurological system because of her diagnosis. POC is the plan, this is not complete, it does not say much." During a concurrent interview and record review on 9/13/2023 at 1:22 p.m. with the DPCS or Patient 9s EMR, DPCS stated that Patient 9s POC/IDG were not done. DPCS did not elaborate on why Patient 9s care plan was not completed when asked. DPCS stated, ";Its the same as the other." The HA failed to care plan Patient 9s interventions, goals, and status related to her pain. During an interview on 9/11/2023 at 1 p.m. with the Director of Patient Care Services Designee (DD), the DD stated, ";The whole admission process should be done within 48 hours, including the POC." During an interview on 9/12/2023 at 10 a.m. with LVN2, LVN2 stated that the POC lets HA staff know what needs to be done for the patients. During an interview on 9/13/2023 at 10:15 a.m. with the DPCS, the DPCS stated the admission process, including creating a care plan is done at the start of service. DPCS stated that the documentation is expected to be completed within 24 hours. DPCS stated that this process is in the HAs policy and procedures. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated that every patient should have a care plan, which is a ";road map" on how to treat patients and covers all their diagnosis. DPCS stated, ";every need has to have a care plan." DPCS stated that pain would be included in their care plans and that if the patient did not have a complaint of pain, then the care plan should state ";Potential for pain." DPCS stated that the POC should be completed and submitted within 24 hours. DPCS stated that all the disciplines have five days to complete a patient's care plan. DPCS stated that she was aware that the sampled patients care plans were incomplete. A record review of the HAs undated policy and procedure titled, ";Plan of Care-Content", indicated, ";Policy: The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. The procedures indicate the patients plan of care should include all services necessary for the palliation and management of the terminal illness and its related conditions." A record review of the HAs undated policy and procedure titled, ";Plan of Care", indicated, the care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician (if any), and, if appropriate, the patient and/or his/her representative." A record review of the HAs undated policy and procedure titled, ";Plan of Care-Content", indicated, the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. The procedures included: 1. The patients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The plan of care includes but is not limited to: a. interventions to manage pain and symptoms."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the plan of care (POC, maps out needs and services given to patient facing a terminal illness) included an interventions for pain management for three of 14 sampled patients (Patient 2, patient 8, and Patient 9). This failure had the potential to result in patients having missed visits from the prescribed disciplines and not meeting the patients' care goals. --- a. A record review of Patient 1's (P1) ";Personal Information" sheet indicated a start of care date of 2/10/2023, with diagnoses including Parkinsons Disease (a disorder of the central nervous system that affects movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a home visit on 9/12/2023, at 11:48 a.m., P1s Caregiver (CG 1) stated the services and frequencies received from the HA were as follows: Skilled nurse (SN-a licensed nurse) visited P1 once every two weeks. Registered Nurse (RN) once every two weeks, alternating with the SN. Home Health Aide (HA) 3 times a week. Spiritual Counselor and Medical Social worker as needed. During a concurrent interview and record review on 9/14/2023, at 11:30 a.m., the Director of Patient Care Services (DPCS) reviewed P1s record titled, ";POC Summary", printed on 9/11/2023. The record indicated, the HA visit frequency was two times a week, and the RN visit two times per week and three PRN (as needed) visits. The DPCS stated P1s POC did not reflect the current visit frequencies by the SN, HA, and RN. The DPCS stated the POC was to be updated as frequently as needed to provide the proper care. The DPCS did not offer a response when asked what the potential outcome would be for Patient 1 as a result of the deficient practice. The HA failed to ensure Patient 1s POC indicated the frequency of services the agency was currently providing. b. A review of Patient 5's ";Personal Information" sheet indicated a start of care date of 9/1/2023, with diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). During a concurrent interview and record review, on 9/14/2023, at 11:20 a.m., the DPCS reviewed Patient 5s record titled, ";POC Summary" printed on 9/11/2023. The document did not indicate the frequency of services being provided. The DPCS stated the POC was incomplete and was missing the frequency of services and treatment provided. The DPCS did not offer a response when asked what potential outcome this deficient practice could have on Patient 5. HA failed to ensure Patient 5s POC indicated the frequency of services the agency was currently providing. c. A review of Patient 8s (P8) ";Personal Information" indicated P8 had a start of care (SOC) date of 6/23/2023, with diagnoses including Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). A review of Patient 8s ";POC Summary" indicated sections ";Frequency of Visit – RN (Registered Nurse) two per week and three PRN (as needed) Visits." During an interview on 9/12/2023 at 9:45 a.m. with License Vocational Nurse 2 (LVN2), LVN 2 stated that Patient 8 is seen by a hospice CHHA (Certified Home Health Aide) twice a week. During a concurrent interview and record review on 9/13/2023 at 12:52 p.m. with the DPCS of Patient 8s Electronic Medical Record (EMR) medical record form titled, ";POC/IDG Review", DPCS stated that Patient 8s POC should have all the disciplines scheduled visits. DPCS stated that Patient 8s POC is incomplete and did not elaborate further as to why, when asked. d. A review of Patient 9s (P9) medical record form titled ";Personal Information" indicated Patient 9 had a SOC date of 1/31/2023, with diagnoses that included trauma subdural hematoma (head trauma) with LOC (Loss of conscious). A review of Patient 9s medical record form titled, ";POC Summary" indicated the frequency of visit by the medical social worker was one as needed and Recert." During an interview on 9/12/2023 at 10:50 a.m. with LVN2, LVN 2 stated that Patient 9 is seen by a hospice CHHA twice a week. LVN2 also stated that she visits Patient 9 twice a week. During an interview on 9/12/2023 at 11:15 a.m. with LVN2, LVN2 stated that Patient 9s POC was not complete. LVN2 stated ";POC is the plan, this is not complete, it does not say much." The HA failed to document schedule visits by all disciplines providing care to Patient 9. During an interview on 9/11/2023 at 1 p.m. with the Director of Patient Care Services Designee (DD), DD stated, ";The whole admission process should be done within 48 hours, including the POC." During an interview on 9/12/2023 at 10 a.m. with LVN2, LVN2 stated that the POC lets the HA staff know what needs to be done for the patients. During an interview on 9/13/2023 at 10:15 a.m. with the DPCS, the DPCS stated the admission process, including creating a care plan is done at the start of service. The DPCS stated the documentation is expected to be completed within 24 hours. The DPCS stated this process is in the HAs policy and procedures. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated that every patient should have a care plan, which is a ";road map" on how to treat patients and covers all their diagnosis. The DPCS stated, ";Every need has to have a care plan." The DPCS stated that the POC should be completed and submitted within 24 hours. DPCS stated that all the disciplines have five days to complete a patients care plan. DPCS stated that she was aware that the sampled patients care plans were incomplete. A review of the HAs undated policy and procedure titled, ";Plan of Care-Content", indicated, ";Policy: The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. Procedures: 1. The patients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The plan of care includes, but is not limited to:...b. a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs..."

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) ) failed to ensure a plan of care (POC -maps out needs and services given to a patient facing a terminal illness) indicated a desired and expected care goals for four of 14 sampled patients (Patient 5, Patient 8, Patient 9, and Patient 11). This deficient practice had the potential to result in patients not meeting their care goals. --- a. A record review of Patient 5 (P5) ";Personal Information" sheet indicated a start of care on 9/1/2023, with diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). During a concurrent interview and record review, on 9/14/2023, at 11:20 a.m., the Director of Patient Care Services (DPCS) reviewed P5s record titled, ";POC Summary", printed on 9/11/23. The DPCS stated the POC did not indicate P5s needs (problems), interventions and goals of care. The DPCS stated the POC was incomplete. The DPCS did not offer a response when asked what potential outcome this deficient practice can have on P5. HA failed to ensure P5s POC indicated the goals and measurable outcomes of care. b. A review of Patient 8s (P8) ";Personal Information" indicated P8 had a start of care (SOC) date of 6/23/2023, with diagnoses including Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). A review of P8s ";Physicians Certification for Hospice Benefit (the hospice physician certifies an individual as terminally ill, with a medical prognosis of 6 months or less to live if the illness runs its normal course)" dated from 6/28/2023 to 8/26/2023, indicated ";Co morbidities include advance dementia ( loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance." A review of P8s ";POC/IDG Review" dated 9/6/2023, indicated there were three issues documented under ";problem/intervention/goal/status". These issues included 1. Mobility 2. Nutrition and 3. Sleep. During a concurrent interview and record review on 9/13/2023 at 12:52 p.m. with the DPCS or P8s Electronic Medical Record (EMR, a digital record of health information..), DPCS stated that P8s POC is not complete and did not elaborate further when asked about the importance of completing all the sections. c. A review of Patient 9's ";Personal Information" indicated P9 had a SOC date of 1/31/2023, with diagnoses that included trauma subdural hematoma (head trauma) with LOC (Loss of conscious). A review of Patient 9s ";Physician's Certification for Hospice Benefit" dated from 7/30/2023 to 9/27/2023, indicated comorbidities diagnoses including hypertension (high blood pressure), anxiety, hypoxemia (low oxygen circulating in blood), and atherosclerosis of aorta (plaque in main heart artery). A review of Patient 9s ";POC/IDG Review" dated ";9/6/23 – Cert #3" indicated ";Mobility" was the only issue documented under section ";Problem/ intervention/ goal/status." During an interview on 9/12/2023 at 11:15 a.m. with License Vocational Nurse 2 (LVN2), LVN2 stated that Patient 9s POC was not complete. LVN2 stated ";It should have all the bodys systems, that we need to assess and concentrate on. For her, we would need to focus on her neurological system because of her diagnosis. POC is the plan, this is not complete, it does not say much." d. A review of Patient 11s (P11) ";Personal Information" indicated P11 had a SOC date of 8/29/2023, with diagnoses that included liver disease (a condition that damages and affect the liver). A review of P11s ";Physician's Certification for Hospice Benefit" dated from 8/29/23 to 11/26/2023, indicated comorbidities diagnoses including hypothyroid (low thyroid hormone), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and osteoarthritis. During a concurrent interview and record review on 9/13/2023 at 12:24 p.m. with the DPCS of Patient 11s EMR form title ";POC/IDG Review", the DPCS stated that there were no documented IDG forms for Patient 11. DPCS did not elaborate further on why there were no documented IDG/POC for P11 when asked. During an interview on 9/11/2023 at 1 p.m. with the Director of Patient Care Services Designee (DD), the DD stated, ";The whole admission process should be done within 48 hours, including the POC." During an interview on 9/12/2023 at 10 a.m. with LVN2, LVN2 stated the POC lets HA staff know what needs to be done for the patients. During an interview on 9/13/2023 at 10:15 a.m. with the DPCS, the DPCS stated the admission process, including creating a care plan, is done at the start of service. DPCS stated the documentation is expected to be completed within 24 hours. DPCS stated that this process is in the HAs policy and procedures. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated that every patient should have a care plan, which is a ";road map" on how to treat patients. that covers all their diagnosis. DPCS stated, ";every need has to have a care plan". DPCS stated that the POC should be completed and submitted within 24 hours. DPCS stated that all the disciplines have five days to complete a patients care plan. DPCS stated that she was aware that the sampled patients care plans were incomplete. During an interview on 9/13/2023 at 12:52 p.m. with the DPCS, the DPCS stated the POC elements include level of care, frequency of discipline visits, DME, treatments, medications, and diet. A record review of the HAs undated policy and procedure titled, ";Plan of Care-Content", indicated, the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. The patients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. The plan of care includes, but is not limited to measurable outcomes anticipated from implementing and coordinating the plan of care.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) ) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) revised the Plan of Care (POC - an individualized care plan, indicating what interventions are needed for patient care) that reflected the patients condition, for six of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, and Patient 7). This deficient practice had a potential for the patients not meeting their care goals. --- a. A record review of Patient 1 (P1) ";Personal Information" sheet indicated a start of care on 2/10/2023, with diagnoses including Parkinsons Disease (a disorder of the central nervous system that affects movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a concurrent observation and interview of the home visit on 9/12/2023, at 11:49 a.m. P1s living area included a step to the restroom. P1s Caregiver (CG 1) stated P1 was able to get up from the bed to walk and use the restroom. CG 1 stated P1 forgot there was a step in the living area and fell. CG 1 stated P1 fell in July and August of 2023. A record review on 9/14/2023, of P1s ";Updated Assessment" dated 7/20/2023, indicated P1 had a fall on 7/15/2023. During a concurrent interview and record review on 9/14/2023, at 11:55 a.m., the Director of Patient Care Services (DPCS) reviewed P1s record titled ";POC/IDG Review", dated 7/26/2023. The record did not indicate P1s fall was discussed in the IDG meeting. Further review of the record indicated, ";Environment/Safety...Goal: No fall episode while under hospice service, Pt. (patient) will remain free of injury...Status: Controlled." The DPCS stated the IDGs discussion about P1s fall was not documented in the record and the POC was not updated. The DPCS stated P1s safety was not controlled and there was a need to update the POC with new interventions and goals such as assessing the reason for falls, need for any assistive device to adjust, to add a fall pad, provide additional teaching, follow up on pain management, and injury prevention. A review of P1s ";Communication Log" dated 7/20/2023, indicated P1 had a fall on 8/2/2023. A review on 9/14/2023, of P1s ";Visit Note" dated 8/2/2023, indicated P1 had a small right elbow skin tear. During a concurrent interview and record review on 9/14/2023, at 11:57 a.m., the DPCS reviewed P1s record titled ";POC/IDG Review", dated 8/9/23. The record did not indicate P1s fall was discussed in the IDG meeting. Further review of the record indicated, ";Environment/Safety ...Goal: No fall episode while under hospice service, Pt. will remain free of injury...Status: Controlled." The DPCS stated she did not remember if P1s fall of 8/2/2023 and need of new interventions was discussed in the IDG meeting on 8/9/23. The DPCS stated the HA should have had a conference with the family, Medical Social Worker to assess and identify why P1 continues to fall. The DPCS stated the HA did not have a conference. The HA failed to ensure the IDG updated the POC to ensure new interventions were implemented to help P1 from experiencing another fall. b. A record review of Patient 2 (P2) ";Personal Information" sheet indicated a start of care on 8/30/2023, with diagnoses including cancer of the colon (a growth of cells that begins in a part of the large intestine called the colon). During an interview on 9/13/2023, at 12:28 p.m., the DPCS reviewed P2s electronic medical records and stated there were no documented IDG meetings in the records. The DPCS stated the IDG group met to discuss the plan of care for P2 ";but unfortunately, the staff did not input their discussion." The DPCS did not offer a response when asked what potential outcome this deficient practice can have on P2. The HA failed to ensure the IDG revised P2s POC at least every 15 days. c. A review of Patient 3 (P3) ";Personal Information" sheet indicated a start of care on 1/25/2022, with diagnoses including Alzheimers Disease (a disease that destroys memory and other important mental functions). During a concurrent interview and record review on 9/13/2023, at 12:29 p.m., the DPCS reviewed P3s records titled ";POC/IDG Review", dated 7/12/2023, 7/26/2023, 8/9/2023, and 9/6/2023. The records did not indicate the IDG group review and need to update the POC for P3. The DPCS stated the records were missing the discussion and input of the IDG members. The DPCS did not offer a response when asked what potential outcome this deficient practice can have on P3. The HA failed to ensure the IDG revised P3s POC at least every 15 days. d. A review of Patient 4 (P4) ";Personal Information" sheet indicated a start of care on 4/17/2022, with diagnoses including cerebral infarction (brain attack). During a concurrent interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed P4s records titled ";POC/IDG Review", dated 7/12/2023. The records did not indicate the IDG group review and need to update the POC for P4. The DPCS stated the records were missing the discussion and input of the IDG members. During a concurrent interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed P4s records titled ";POC/IDG Review", dated 7/26/2023. The records did not indicate the IDG group review and need to update the POC for P4. The DPCS stated the records were missing the discussion and input of the Spiritual Counselor (SC) and Medical Social Worker (MSW). During an interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed P4s records titled ";POC/IDG Review", dated 8/9/2023. The records did not indicate the IDG group review and need to update the POC for P4. The DPCS stated the records were missing the discussion and input of the SC and MSW. During a concurrent interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed P4s records titled ";POC/IDG Review", dated 8/23/2023. The records did not indicate the IDG group review and need to update the POC for P4. The DPCS stated the records were missing the discussion and input of the SC and MSW. The HA failed to ensure the IDG revised P4s POC at least every 15 days. e. A review of Patient 6 (P6) ";Personal Information" sheet indicated a start of care on 12/1/2022, with diagnoses including cerebral infarction (brain attack). The record also indicated an end of care date of 7/13/2023 due to death. During a concurrent interview and record review on 9/13/2023, at 12:39 p.m., the DPCS reviewed P6s records titled ";POC/IDG Review", dated 5/17/2023, 5/31/2023, 6/14/2023, 6/28/2023 and 7/12/2023. The records did not indicate the IDG group review and need to update the POC for P6. The DPCS stated the records were missing the discussion and input of the IDG members. The HA failed to ensure the IDG revised P6s POC at least every 15 days. f. A review of Patient 7 (P7) ";Personal Information" sheet indicated a start of care on 7/12/2023, with diagnoses including Alzheimers disease (a disease that destroys memory and other important mental functions). The record also indicated an end of care date of 9/9/2023 due to an extended prognosis (patient has a life expectancy of greater than 6 months). During a record review on 9/13/2023, P7s records titled ";POC/IDG Review", dated 7/12/2023, 7/26/2023, 8/9/2023, 8/23/2023 and 9/6/2023, did not indicate the IDG group review and need to update the POC for P7. The HA failed to ensure the IDG revised P7s POC at least every 15 days. During an interview on 9/13/2023 at 10:15 a.m. with the DPCS, the DPCS stated the admission process, including creating a care plan is done at the start of service. DPCS stated that the documentation is expected to be completed within 24 hours. DPCS stated that this process is in the HAs policy and procedures. During an interview on 9/13/2023 at 10:40 a.m. with the DPCS, the DPCS stated that every patient should have a care plan, which is a ";road map" on how to treat patients. that covers all their diagnosis. DPCS stated, ";every need has to have a care plan". DPCS stated that the POC should be completed and submitted within 24 hours. DPCS stated that all the disciplines have five days to complete a patients care plan. DPCS stated that she was aware that the sampled patients care plans were incomplete. A record review of the HAs undated policy and procedure titled, ";Comprehensive Assessment-Updates", indicated, ";Procedures:...3. Documentation of the IDGs care planning meetings reflects the ongoing reassessment of the patient/familys status and needs." A record review of the HAs undated policy and procedure titled, ";Plan of Care", indicated, ";Policy: The care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician (if any), and, if appropriate, the patient and/or his/her representative. Procedures:...5. The plan of care is reviewed and updated by the IDG every 15 days or more frequently if the patients condition warrants."

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) ) failed to ensure all care services furnished followed an individualized Plan of Care established by the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) by not conducting home visits as indicated in the POC for one of 14 sampled patients (Patient 8). This deficient practice resulted in the patient did not received home visit and had a potential for the patient not to receive care/services from the home visits to meet the patient care goals. --- A review of Patient 8s (P8) ";Personal Information" indicated P8 had a start of care (SOC) date of 6/23/2023, with diagnoses including Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). A review of P8s ";Plan of Care (POC) Summary" indicated sections ";Frequency of Visit – RN 2 per week +3 PRN (as needed) Visits". During a concurrent interview and record review on 9/13/2023 at 12:52 p.m. with the Director of Patient Services (DPCS) of P8s Electronic Medical Record (EMR, a digital record of health information) form titled, ";Visit Notes", DPCS stated that nursing visit notes dated 7/19/2023 and 8/3/2023 were not signed. DPCS stated that the visiting ";nurse signatures mean that she was there, authentication". During an interview on 9/12/2023 at 10 a.m. with License Vocational Nurse 2 (LVN2), LVN2 stated that the POC lets HA staff know what needs to be done for the patients. A review of the HAs undated policy and procedure titled, ";Coordination of Services", indicated, ";Procedures:...5. All members of the IDG, volunteers, and contracted personnel have access to the patients plan of care and are expected to provide care in accordance with it."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the patient's caregiver was provided with the patients Plan of Care (POC - an individualized care plan, indicating what interventions are needed for patient care) with information of the services and care being provided by the HA and included the patient's medication list for two out of 14 sampled patients (Patient 8 and Patient 9). This failure had the potential to result in placing the patients at risk for not receiving the services/care as indicated in their individualized POC. --- a. A review of Patient 8s (P8) medical record form titled ";Personal Information" indicated Patient 8 had a start of care (SOC) date of 6/23/2023, with diagnoses that included Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). During a joint home visit on 9/12/2023 at 10 a.m. with License Vocational Nurse 2 (LVN2) to Patient 8s home, LVN2 demonstrated Patient 8s POC, which had a print date on the bottom right of the form of 9/11/2023. LVN2 stated ";The POC should be here so we can follow the POC. It states the care we need to give the patient." LVN2 stated that she did not know when they brought Patient 8s current POC. b. A review of Patient 9 medical record form titled ";Personal Information" indicated Patient 9 had a SOC date of 1/31/2023, with diagnoses including trauma subdural hematoma (head trauma) with LOC (level of conscious). During a joint home visit on 9/12/2023 at 11:15 a.m. with LVN2 to Patient 9s home, LVN2 demonstrated Patient 9s POC, which had a print date on the bottom right of the form of 9/11/2023. LVN2 stated ";The POC should be here, we need to follow it. Its the patient's care plan." LVN2 stated she did not know when they brought Patient 9s current POC. A record review of the HAs undated policy and procedure titled, ";A ";Patient Rights and Responsibilities", indicated, Hospice informs patients of their rights, protects and promotes the exercise of the rights and are involved in developing his/her plan of care;"

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical Records was met as follows: --- 1. The HA failed to ensure the clinical records of ten of 14 sampled patients (Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) had the initial plan of care (POC, an individualized care plan, indicating what interventions are needed for patient care), comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), and clinical notes. (Refer to 672). 2. The HA failed to ensure the clinical records for seven of 14 sampled patients (Patients 2, 3, 4, 5, 6, 7, and 14) were complete and authenticated by the HA staff (in general). (Refer to L679). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (State law) compliance with Federal regulations for Clinical Records to ensure the patients medical records were completed and authenticated by any individuals or HA staff.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the clinical records of ten of 14 sampled patients (Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) had an initial plan of care (POC, an individualize care plan, indicating what interventions are needed for patient care), comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), and clinical notes. (Refer to 672). This deficient practice had the potential to result in Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 to not receive the care and services needed which could affect the patients' quality of care and well-being. --- Findings: a. A record review of Patient 2's ";Personal Information," record indicated a start of care date of 8/30/2023, with a diagnosis of cancer of the colon (a growth of cells that begins in a part of the large intestine called the colon). During an interview on 9/13/2023, at 12:28 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 2s Electronic Medical Records (EMR) and stated there were no documented IDG meetings in the records. The DPCS stated the IDG group met to discuss the plan of care for Patient 2 (unidentified date and time) ";But unfortunately, the staff (unidentified) did not input their discussion." The DPCS did not offer a response when asked what potential outcome this deficient practice could have on Patient 2. b. A record review of Patient 3's ";Personal Information" record indicated a start of care date of 1/25/2022, with a diagnosis of Alzheimers disease (a disease that destroys memory and other important mental functions). During a concurrent interview and record review on 9/13/2023, at 12:29 p.m., the DPCS reviewed Patient 3s records titled ";POC/IDG Review," dated 7/12/2023, 7/26/2023, 8/9/2023, and 9/6/2023. The DPCS stated the record did not indicate the IDG group reviewed and needed to update the POC for Patient 3. The DPCS stated the records were missing the discussion and input of the IDG members. The DPCS did not offer a response when asked what potential outcome this deficient practice can have on Patient 3. c. A record review of Patient 4's ";Personal Information," record indicated a start of care date of 4/17/2022, with a diagnosis of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a concurrent interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed Patient 4s records titled ";POC/IDG Review," dated 7/12/2023. The DPCS stated the record did not indicate the IDG group reviewed and needed to update the POC for Patient 4. The DPCS stated the records were missing the discussion and input of the IDG members. During a concurrent interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed Patient 4s records titled ";POC/IDG Review," dated 7/26/2023. The DPCS stated the record did not indicate the IDG group reviewed and needed to update the POC for Patient 4. The DPCS stated the records were missing the discussion and input of the Spiritual Counselor (SC) and Medical Social Worker (MSW). During a concurrent interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed Patient 4s records titled ";POC/IDG Review," dated 8/9/2023. The DPCS stated the record did not indicate the IDG group reviewed and needed to update the POC for Patient 4. The DPCS stated the records were missing the discussion and input of the SC and MSW. During a concurrent interview and record review on 9/13/2023, at 12:34 p.m., the DPCS reviewed Patient 4s records titled ";POC/IDG Review," dated 8/23/2023. The DPCS stated the record did not indicate the IDG group reviewed and needed to update the POC for Patient 4. The DPCS stated the records were missing the discussion and input of the SC and MSW. d. A record review of Patient 5's ";Personal Information" record indicated a start of care date on 9/1/2023, with diagnosis of heart failure (the heart cannot pump enough blood, a weakened heart condition). During a concurrent interview and record review on 9/13/2023 at 11:59 a.m., the DPCS reviewed Patient 5s record titled, ";Comprehensive Nursing Assessment," dated 9/1/2023. The DPCS stated the record was not completed. The DPCS stated the comprehensive assessment needed to be completed on 9/1/2023. The DPCS stated the importance of the assessment was to identify Patient 5s needs and to know the care to provide. e. A record review of Patient 6's ";Personal Information," record indicated a start of care date of 12/1/2022, with diagnoses that included cerebral infarction. The record also indicated an end of care date of 7/13/2023 due to death. During a concurrent interview and record review on 9/13/2023, at 12:39 p.m., the DPCS reviewed Patient 6s records titled ";POC/IDG Review," dated 5/17/2023, 5/31/2023, 6/14/2023, 6/28/2023 and 7/12/2023. The DPCS stated the records did not indicate the IDG group reviewed and needed to update the POC for Patient 6. The DPCS stated the records were missing the discussion and input of the IDG members. f. A record review of Patient 7's ";Personal Information," record indicated a start of care date of 7/12/2023, with a diagnosis of Alzheimers disease. The record also indicated an end of care date of 9/9/2023 due to an extended prognosis (patient has a life expectancy of greater than six months). During an interview and a record review on 9/13/2023, at 12:39 p.m., the DPCS stated Patient 7s records titled ";POC/IDG Review," dated 7/12/2023, 7/26/2023, 8/9/2023, 8/23/23, and 9/6/23, did not indicate the IDG group reviewed and needed to update the POC for Patient 7. g. A review of Patient 8s medical record form titled ";Personal Information," indicated Patient 8 had a start of care date on 6/23/2023, with a diagnosis of Parkinsons Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking and difficulty with balance and coordination). During a concurrent interview and record review on 9/13/2023, at 12:52 p.m. with the DPCS of Patient 8s medical record titled ";POC/IDG Review," dated 7/12/2023, 7/26/2023, 8/9/2023, 8/23/2023, and 9/6/2023, the DPCS stated the record indicated the POC/IDG records were not completed. The DPCS stated the IDG members discussed Patient 8s case but did not transcribe (wrote) their discussion onto the forms. The DPCS was unable to state the possible outcome to Patient 8 due to the lack of revision and documentation of the IDG medical forms. h. A review of Patient 9's medical record form titled ";Personal Information," indicated Patient 9 had a start of care date on 1/31/2023, with diagnosis of subdural hematoma (a collection of blood that forms on the surface of the brain). During a concurrent interview and record review on 9/13/2023 at 1:22 p.m., with the DPCS of Patient 9s medical record forms titled ";POC/IDG Review," dated 7/12/2023, 7/26/2023, 8/9/2023, 8/23/2023, and 9/6/2023, the DPCS stated the forms were not completed. DPCS stated the ";POC/IDG Review," records were ";Not done." The DPCS was unable to state the possible outcome to Patient 9 due to the lack of revision and documentation of the IDG medical forms. i. A review of Patient 10's medical record form titled ";Personal Information," indicated Patient 10 had a start of care date of 7/23/2022, with diagnosis of Alzheimers Disease. During a concurrent interview and record review on 9/13/23 at 1:42 p.m., with the DPCS of Patient 10s medical record titled ";POC/IDG Review," dated 7/12/2023, 7/26/2023, 8/9/2023, 8/23/2023, and 9/6/2023, the DPCS stated the forms were not completed. DPCS stated ";None are done." The DPCS was unable to state the possible outcome to Patient 10 due to the lack of revision and documentation of the IDG medical forms. j. A review of Patient 11 medical record form titled ";Personal Information," indicated Patient 11 had a start of care on 8/29/2023, with diagnosis of liver disease (a condition that damages and affect the liver). During a concurrent interview and record review on 9/13/2023, at 12:24 p.m., with the DPCS of Patient 11s EMR medical form titled ";POC/IDG Review," the DPCS stated there were no POC/IDG notes documented for Patient 11. The DPCS was unable to state the possible outcome to Patient 11 due to the lack of initiating a plan of care. During an interview on 9/11/2023 at 1 p.m., with the Director of Patient Care Services Designee (DD), the DD stated the initial comprehensive nursing assessment needed to be completed and documented within 48 hours of admission. During an interview on 9/11/2023 at 1:35 p.m., with the Administrator Designee (AD), the AD stated the IDG met every 14 days, and their meetings needed to be documented in the EMR system, ";beforehand." During an interview on 9/13/2023 at 10:15 a.m., with the DPCS, the DPCS stated the admission process, including creating a care plan needed to be done at the start of service. The DPCS stated the documentation was expected to be completed within 24 hours according to the HA's policies and procedures. During an interview on 9/13/2023 at 10:40 a.m., with the DPCS, the DPCS stated every patient needed to have a care plan. DPCS stated, ";Every need has to have a care plan." The DPCS stated the Patients' POCs needed to be completed and submitted within 24 hours. The DPCS stated all the disciplines had five days to complete a patients care plan. DPCS stated the HA did not complete Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11's POC, comprehensive assessment, and the clinical notes. During an interview on 9/13/2023 at 11:28 a.m. with the DPCS, the DPCS stated all patient visits needed to be documented in the EMR system within 24 hours. The DPCS stated the staff's signatures needed to be documented when they submitted their notes. The DPCS stated the staff's signature indicates they verified they saw the patients. A record review of the HAs undated policy and procedure titled, ";Clinical Records", indicated, entries are made at the time of the visit and are expected to be submitted within twenty-four hours in the EMR. All services provided...in a standardized format are legible, clear, complete, and signed and dated by the person providing the services...Each patients clinical record includes, at a minimum the initial assessment and comprehensive assessments and the initial plan of care and updated plans of care and clinical note. A record review of the HAs undated policy and procedure titled, ";Comprehensive Assessment-Updates", indicated documentation of the IDGs care planning meetings reflects the ongoing reassessment of the patient/familys status and needs.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the clinical records for seven of 14 sampled patients (Patients 2, 3, 4, 5, 6, 7, and 14) were completed and authenticated by the author/HA staff (in general). This deficient practice resulted in clinical information entered in the patients records without validation of the accuracy of information and had the potential to affect the care and services for Patients 2, 3, 4, 5, 6, 7, and 14. --- Findings: a. A record review of Patient 2's ";Personal Information," record indicated a start of care date of 8/30/2023, with a diagnosis of cancer of the colon (a growth of cells that begins in a part of the large intestine called the colon). A record review of Patient 2s document tiled, ";Comprehensive Nursing Assessment," dated 8/30/2023, did not indicate the author/HA staff (unidentified) of the assessment. b. A record review of Patient 3's ";Personal Information" record indicated a start of care of 1/25/2022, with diagnosis of Alzheimers disease (a disease that destroys memory and other important mental functions). During a concurrent interview and record review on 9/13/2023, at 11:45 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 3s record titled, ";Comprehensive Nursing Assessment," dated 1/25/2022. The DPCS stated the record did not indicate the author of the note. The DPCS stated a Registered Nurse (RN, unidentified) had completed the assessment. When asked how she determined an RN completed the assessment, the DPCS stated, ";There is no signature of the nurse. I really do not know what that means." The DPCS stated the purpose of the signature was to authenticate the information written. The DPCS stated the licensed nurses (in general) needed to complete and sign the documentation within 24 hours. The DPCS did not offer a response when asked what the potential outcome of the deficient practice can have on Patient 3. c. A record review of Patient 4's ";Personal Information," record indicated a start of care on 4/17/2022, with a diagnosis of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a concurrent interview and record review on 9/13/2023, at 11:53 a.m., the DPCS reviewed Patient 4s record titled, ";Comprehensive Nursing Assessment," dated 4/17/2022. The DPCS stated the record did not indicate the author (staff/unidentified staff) of the assessment. The DPCS stated there was no indication who assessed Patient 4 because the record was not signed and stated she did not know if Patient 4's assessment was accurate. The DPCS did not offer a response when asked what the potential outcome of the deficient practice can have on Patient 4. d. A review of Patient 5's ";Personal Information," record indicated a start of care on 9/1/2023, with a diagnosis of heart failure (the heart does not pump blood as well as it should). During a concurrent interview and record review on 9/13/2023 at 11:59 a.m., the DPCS reviewed Patient 5s record titled, ";Comprehensive Nursing Assessment," dated 9/1/2023, and the DPCS stated there was no signature to identify who had completed the assessment. The DPCS stated the comprehensive assessment was supposed to be completed on the day of the visit, which was 9/1/2023. The DPCS stated the importance of the assessment was to identify Patient 5s needs and know what care to provide. e. A record review of Patient 6 's ";Personal Information," record indicated a start of care on 12/1/2022, with a diagnosis that included cerebral infarction. The record also indicated an end of care date of 7/13/2023 due to death. A record review on of Patient 6s document tiled, ";Comprehensive Nursing Assessment," dated 12/1/2023, did not indicate the author of the assessment. f. A record review of Patient 7's "Personal Information," record indicated a start of care date on 7/12/2023, with a diagnosis of Alzheimers disease. The record also indicated an end of care date of 9/9/2023 due to an extended prognosis (patient has a life expectancy of greater than 6 months). A record review on of Patient 7s record tiled, ";Comprehensive Nursing Assessment," dated 7/12/2023, did not indicate the author of the assessment. g. A review of Patient 14s record titled ";Personal Information," indicated Patient 14 had a start of care date of 8/8/2023 and an end of care (EOC) date of 8/13/2023, with a diagnosis that included acute kidney failure (kidneys unable to filter waste products from your blood). A review on Patient 14s Electronic Medical Record (EMR) form titled ";POC/IDG Review," dated 8/8/2023, indicated the RN discussion section was left blank. During an interview on 9/13/2023 at 11:28 a.m. with the DPCS, the DPCS stated all HA personnel had their own Electronic Medical Record (EMR) log in. The DPCS stated she documented on Patient 14s EMR medical record form titled ";POC/IDG Review," dated 8/8/2023 on either 9/11/2023 or 9/12/2023. The DPCS stated she completed the ";RN" discussion portion of the IDG because she realized the records were being looked at. The DPCS stated she did not document the note was a late entry. The DPCS stated the date a note was entered needed to be documented if there was a late entry made into the patients medical record. The DPCS stated ";Every visit should be documented in the patient's EMR within 24 hours." DPCS stated the authors' signature needed to be on the record when it was submitted. The DPCS stated, ";Their signature means that they verify they saw the patient that day." A record review of the HAs undated policy and procedure titled, ";Clinical Records", indicated, entries are made at the time of the visit and are expected to be submitted within twenty-four hours in the EMR. All services provided...in a standardized format are legible, clear, complete, and signed and dated by the person providing the services... Each patients clinical record includes, at a minimum the initial assessment and comprehensive assessments, the initial plan of care and updated plans of care and clinical notes..." A record review of the HAs undated policy and procedure titled, ";Documentation Requirements", indicated, members of the interdisciplinary group document the interventions provided to the patient/family, their response to care, services provided, and the goals or outcomes achieved. Writing ";late entry" with the date and time next to the actual documentation that is being added correctly identifies late entries.