Every finding on record at Carechoices Hospice and Palliative Services, LLC

Based on interview and record review, the hospice failed to ensure the initial training in the emergency preparedness P&P was provided for RN 2.  This failure had the potential for the hospice’s staff not knowing what to do in case of an emergency.  Findings: --- Review of the hospice’s P&P titled Orientation Program (undated) showed the patient care employees receive the orientation appropriate to their job functions that may include but not limited to: k. emergency preparedness.Review of the hospice’s emergency preparedness program documents was initiated on 5/27/25.Review of the personnel file for RN 2 was initiated on 5/27/25.  RN 2 was hired on 5/10/21.  However, there was no documented evidence RN 2 had an initial training in the emergency preparedness P&P.On 5/27/25 at 1410 hours, an interview and concurrent hospice document review was conducted with the Business Manager and DPCS/DQM.  The Business Manager and DPCS/DQM were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the grievance was thoroughly investigated as per the hospice's P&P for one nonsampled patient (Patient A), creating the risk of violating the patient's rights and not providing quality of care and services to this patient. Findings: --- The hospice's P&P titled Complaint Process undated showed the considerations include the supervisor or manager will immediately begin the process of speaking directly with the complainant and summarize the conversation that took place.  The supervisor will follow up by contacting any involved parties to ascertain the type of correction or coaching necessary to satisfy the complaint if needed. The complaints will be resolved in no less than 30 working days.The hospice's grievance log showed a grievance dated 10/4/22, showing the complaint about the agency staff.  However, review of the hospice's documents failed to show documented evidenced of an interview conducted with the alleged staff.  In addition, review of the hospice's document showed a follow-up interview was conducted with the patients' family member on 12/2/22. However, review of the documents failed to show a follow-up interview was conducted timely and the complaint was resolved in no less than 30 days as per the hospice's P&P.On 5/28/25 at 1530 hours, an interview and concurrent document review was conducted with the DPCS/DQM.  The DPCS/DQM was asked if an interview with the alleged staff was conducted.  The DPCS/DQM stated yes, spoke with the staff or maybe an e-mail.  The DPCS/DQM was asked to provide the documents for the staff interview.  The DPCS/DQM could not find the document.  The DPCS/DCQM was also asked regarding the timeline for the follow up.  The DPCS/DQM replied it took awhile.  The DPCS/DQM was further asked if the investigation was conducted timely as per the hospice's P&P.  The DPCS/DQM replied it did not meet the hospice's procedure.   The DPCS/DQM was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessment was completed no later than five calendar days after the election of hospice care for two of 19 sampled patients ( Patients 7 and 18).  This failure had the potential for not addressing the care needs for these patients. Findings: --- Review of the hospice’s P&P titled Assessment-Comprehensive Assessment of the Patient (undated) showed the comprehensive assessment of the patient is completed by designated members of the IDG in consultation with the patient’s attending physician no later than five (5) calendar days after the patient elects the hospice benefits. 1.  Review of Patient 7's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 11/19/24.  The patient was certified for hospice services during the certification periods from 2/17/25 to 5/17/25 and 5/18/25 to 7/16/25.The initial chaplain evaluation visit dated 11/21/24, showed no documented evidence the chaplain completed the assessment for support system and spiritual resources and support.*However, there was no documented evidence the comprehensive spiritual assessment was completed no later than five calendar days after the election of benefits.On 5/29/25 at 1321 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. 2.  Review of Patient 18’s closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was on 4/1/24.  The patient was certified for hospice services during the certification period from 4/1/24 to 6/29/24 and 6/30/24 to 9/27/24.  The initial social worker assessment dated 4/5/24, showed the MSW attempted to reach the patient’s family member on 4/5/24, to schedule an initial visit but the patient’s family member did not pick up her call and she would reattempt to call the patient’s family member.  *However, further review of the clinical record showed no documented evidence the MSW reattempted to call the patient’s daughter.  In addition, there was no documented evidence the comprehensive psychosocial assessment was completed no later than five calendar days after the election of hospice care.On 5/29/25 at 1446 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments identified the emotional, psychosocial, and spiritual needs for two of 19 sampled patients (Patients 7 and 18).  This failure had the potential of not providing care and services to meet the care needs for these patients.Findings: --- 1.  Review of Patient 7's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 11/19/24.  The patient was certified for hospice services during the certification periods from 2/17/25 to 5/17/25 and 5/18/25 to 7/16/25.The initial chaplain evaluation visit dated 11/21/24, showed the assessments for the patient’s support system and spiritual resources and support were incomplete.On 5/29/25 at 1321 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.2.  Review of Patient 18’s closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was on 4/1/24.  The patient was certified for hospice services during the certification period from 4/1/24 to 6/29/24 and 6/30/24 to 9/27/24.  The initial social worker assessment dated 4/5/24, showed the assessments for the patient’s advanced directive, social, cultural, and other needs; psychosocial cognitive and emotional, coping mechanisms, support system, financial resources or needs, hospice interventions, and end of life care planning were incomplete.  On 5/29/25 at 1446 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.

Based on observation, interview, and record review, the hospice failed to include all current medications and include specific indications and parameters for its use for 11 of 19 sampled patients (Patients 1, 2, 3, 5, 7, 11, 12, 13, 14, 16, and 19).  This failure had the potential for the patients to not receive the appropriate care and necessary services and negatively affect the patients' well-being.Findings: --- Review of the hospice's P&P titled Medication - Management undated showed medications are provided on a timely basis and are available 24 hours a day and seven days a week as needed. A drug profile is maintained for every patient and includes a listing of the current medication orders for each patient.  The hospice monitors the medications dispensed to and used by the patient. 1.  Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  The Medication Profile showed the patient’s medications included the following:-phenobarbital (anti seizure) 100 mg suppository administer one suppository rectally Q6H PRN for seizure-acetaminophen (analgesic) 650 mg rectal suppository administer one suppository rectally Q6H PRN for temperature above 100 and for mild pain. Do not exceed 3 gm /24 hours-Bisacodyl (laxative) 10 mg administer one suppository rectally once a day PRN for constipation-hyoscyamine (anticholinergic/antispasmodic ) 0.125 mg sublingual tablet take one tablet orally Q4H PRN for excessive oral secretions NTE 6 doses/24 hours-lorazepam (antianxiety) 0.5 mg oral tablet take one tablet Q6H PRN for dyspnea NTE four doses/24 hours, for anxiety Q6H PRN NTE 2 mg/24 hours and take one tablet PO BID. -morphine (opioid) 20 mg/ml oral concentrate administer 0.25 ml (5 mg) SL Q2H PRN for shortness of breath NTE 12 doses/24 hours and Q4H PRN for pain NTE 6 doses/24 hours-oxygen 2 to 5 liters per minute via nasal cannula PRN for trouble breathing-Zofran (anti emetic) 8 mg oral tablet take one tablet SL Q6H PRN for nausea and vomiting-Norco (opioid) 5/325 mg dose administer one tablet orally Q4H PRN for moderate pain and PO TID for pain management. -Senna Plus (laxative) 50 mg -8.6 mg oral table take two tablets PO BID-amitriptyllin (antidepressant) 50 mg oral tablet take one tablet PO QD at HS-Acetaminophen (analgesic) 325 mg oral tablet take two tablets PO Q6H PRN for fever.On 5/15/25 at 1300 hours, a joint home visit  was conducted with HA 2 to the patients home. The Medication Profile showed the patient was on Acetaminophen (analgesic) 325 mg oral tablet take two tablets PO Q6H PRN for fever, phenobarbital (anti seizure) 100 mg suppository administer one suppository rectally Q6H PRN for seizure and Bisacodyl (laxative) 10 mg administer one suppository rectally once a day PRN for constipation.  However, the medications were not available.  The HA 2 was informed and acknowledged the findings.On 5/29/25 at 1408 hours, the findings were shared with the Director of Continuous Care.   The Director of Continuous Care acknowledged the findings.  2.  Review of Patient 14's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 12/12/24.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.   The Medication Profile showed the patient’s medications included the following:-acetaminophen 500 mg oral tablet take one tablet PO Q8H for pain management-acetaminophen 650 mg rectal suppository administer one suppository rectally Q6H PRN for temperature above. Do not exceed 3 gm /24 from all sources.-Aspirin EC (blood thinner) 325 mg oral delayed release tablet take one tablet orally QD-bisacodyl 10 mg rectal suppository administer one suppository rectally once a day PRN for constipation. NTE one dose/24 hours. -gabapentin (neuropathy) 300 mg  oral capsule take one capsule orally TID-hyoscyamine 0.125 mg SL tablet take one tablet orally Q4H PRN for excessive oral secretions. NTE 6 doses /24 hours-lidocaine topical (pain) 4% topical film apply one patch topically once a day.  Apply to lower back topically one time a day at 9AM and for 12 hours then remove.-lorazepam 0.5 mg oral tablet take one tablet SL Q6H PRN for anxiety. NTE 2 mg/24 hours.-metoprolol succinate ER (blood pressure) 25 mg tablet take one tablet PO QD-Multi-Day Plus Minerals Multiple Vitamins with minerals oral tablet (supplement) take one tablet PO QD-naproxen (pain) 500 mg oral delayed release tablet take one tablet PO BID for pain management-Zofran (antiemetic) 8 mg tablet take one tablet SL Q6H PRN. NTE 4 doses/24 hours-MSIR 7.5 mg dose administer 1/2 tablet of 15 mg tablet SL Q4H PRN for SPB and severe pain 6/10 to 10/10. May crush and give with apple sauce-acetaminophen 325 mg oral tablet two tablets PO Q6H PRN for mild pain 1/10 to 3/10. NTE 3 gms/24 hours-oxygen 2 liters dose inhale two liters per minute inhaled inhalation PRN for SOB-diclofenac 1% topical gel apply one application topical Q8H PRN to knees for mild pain-Senna Plus (laxative) 50 mg -8.6 mg oral tablet take one tablet PO QD for constipation. Hold one dose for loose bowel movement-Seroquel (antipsychotic) 25 mg oral tablet take 25 mg oral one tablet at bedtime -Seroquel (antipsychotic) 25 mg oral tablet take 25 mg oral during the night PRN for agitation-Seroquel (antipsychotic) 25 mg oral tablet take 1/2 tablet (12.5 mg) oral everyday at noon for agitation-mirtazapine (antidepressant) 15 mg oral tablet take 15 mg  PO at bedtime for insomnia-Risperdal (antipsychotic)0.5 mg oral tablet take one tablet BID for agitation-albuterol- ipratropium (bronchodilator) 2.5 mg 0 0.5 mg/3 ml inhalation solution inhale 3 ml by nebulizer Q4H PRN for SOB take first for SOB before MSIR or lorazepam.On 5/15/25 at 0900 hours, a joint home visit  was conducted with MSW 1 to the patients Board and Care. The Medication Profile was reviewed with the ALF Med tech 1 and MSW 1.   The medication profile showed the patient was on Aspirin EC (blood thinner) 325 mg oral delayed release tablet take one tablet orally QD.  However, the medication was not available.In addition, the patient was on bisacodyl 10 mg rectal suppository administer one suppository rectally once a day PRN for constipation.  However, the medication was expired as the expiration date was 01/2025. Moreover, the patient was on lorazepam 0.5 mg oral tablet take one tablet SL Q6H PRN for anxiety. However, the instructions for the route of administration was oral instead of SL as written on the medication profile.Further, the patient was on diclofenac 1% topical gel.  The instruction showed apply to affected area PRN for pain.  However the instruction was not specific for the location of pain as written on the medication profile. On 5/15/25 at 1101 hours, the above findings were verified by the Facility Staff and SW 1.  On 5/29/25 at 1537 hours an interview and concurrent clinical record review was conducted with the DPCS/DQM and with the Director of Continuous Care.  They were informed and acknowledged the findings. 3.  Review of Patient 1's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 8/30/24.  The patient was certified for hospice services during the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25. Review of the Hospice Certification and Plan of Care for the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25, showed the SN interventions and the medication list. The medications list included acetaminophen 500 mg oral tablet take one tablet oral Q6H PRN for mild pain 1/10 - 3/10 and take two tablets orally Q6H PRN for mild pain.However, the medication interventions failed to show how many tablets of acetaminophen 500 mg needed to be given first to address the patients mild pain.On 5/29/25 at 0938 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.    The Director of Continuous Care was asked as to how many tablets of acetaminophen needed to give first to address the patients mild pain.  The Director of Continuous Care replied, it should be the one tablet first, it was not specific. The Director of Continuous Care was informed and acknowledged the findings.   #. Review of Patient 12’s clinical record was initiated on was initiated on 5/15/25.  The clinical record showed the SOC was on 9/17/24.  The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the Medication Profile (undated) showed the following medication orders:- loperamide (anti-diarrhea medication) 2 mg oral capsule, take 2 capsules orally after each loose stools as needed for diarrhea.- morphine sulfate MSIR (pain medication) 15 mg oral tablet, take ½ tablet orally (7.5 mg MSIR) every 4 hours as needed for pain.On 5/15/25 at 0820 hours, a joint home visit was conducted with HA 1 to the ALF where Patient 12 resided.On 5/15/25 at 0905 hours, a medication reconciliation for Patient 12’s was conducted with ALF Medtech 2 and HA 1.  The following was observed:-There was a supply for quetiapine fumarate (antipsychotic drug) 500 mg in a bottle, but there was no order listed in the medication profile.-The medication bubble pack for the morphine sulfate showed an expiration date of 4/2/25 on the printed label.-There was no supply for loperamide in the ALF’s medication cart.-There was no specific instruction for the morphine sulfate order as to what level of pain intensity or scale it should be administered (mild, moderate, severe).On 5/15/25 at 0915 hours, an interview was conducted with ALF Medtech 2.  ALF Medtech 2 stated the patient’s medication supplies were provided by the hospice.  ALF Medtech 2 stated for any changes in medication or refills, she would notify the nurse assigned to the patient, which was RN 1 or would call the hospice number.  ALF Medtech 2 was informed and acknowledged the above findings.On 5/29/25 at 0845 hours, an interview was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 11's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was on 6/14/24.  The patient was certified for hospice services during the certification periods from 2/9/25 to 4/9/25 and 4/10/25 to 6/8/25.Review of the Medication Profile (undated) showed the following medication orders:- lorazepam (antianxiety drug) 0.5 mg oral tablet, take 1 tablet sublingually every 6 hours as needed for dyspnea/ shortness of breath. NTE 2 mg / 24 hours.- lorazepam 0.5 mg oral tablet, take 1 tablet sublingually every 6 hours as needed for anxiety manifested by anxiety, agitation, and restlessness. NTE 2 mg / 24 hours.On 5/15/25 at 1325 hours, a joint home visit was conducted with RN 1 to the ALF where Patient 11 resided.On 5/15/25 at 1350 hours, a medication reconciliation for Patient 11’s was conducted with ALF LVN and RN 1.  ALF LVN verified the supply for lorazepam was expired on 5/12/25.  ALF LVN stated the hospice nurse checks the medication for the supplies, refill, and expiration date or we communicate any changes with the medication with the hospice.On 5/15/25 at 1405 hours, an interview was conducted with RN 1.  RN 1 acknowledged the above finding.  RN 1 stated she last saw the patient on 5/12/25 and missed the expiration date of the lorazepam but will refill for a new supply.  RN 1 stated for every visit or RN comprehensive assessment she would complete a medication profile review.On 5/29/25 at 1000 hours, an interview was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 2's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was on 5/25/24.  The patient was certified for hospice services during the certification periods from 3/21/25 to 5/19/25.Review of the Medication Profile (undated) showed the following medication orders:- acetaminophen (pain medication) 650 mg rectal suppository, administer one suppository rectally every 6 hours as needed for mild pain, 1-3/10 if patient unable to swallow oral tablets. NTE 3 grams/ 24 hours from all sources.- morphine (pain medication) 20 mg/ ml oral concentration, administer 0.25 milliliter (s) sublingually every 4 hours as needed for moderate to severe pain (4-10/10). NTE 6 doses/ 24 hours.- hydrocodone/acetaminophen (pain medication) 5/ 325 mg tablet, administer one tablet orally every 4 hours as needed for moderate to severe pain.*However, there was no specific instructions to specify which pain medication to give first for morphine and hydrocodone/acetaminophen medication indicated for moderate to severe pain.On 5/29/25 at 1254 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 5's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 1/20/24.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25.Review of the Medication Profile (undated) showed the following medication orders:- acetaminophen (pain medication) 650 mg rectal suppository, administer one suppository rectally every 6 hours as needed for mild pain, 1-3/10. NTE 3 grams/ 24 hours.- acetaminophen 500 mg oral tablet, take one tablet orally every 6 hours as needed for pain.  NTE 3 grams/ 24 hours.- morphine 20 mg/ ml oral concentration, administer 0.25 milliliter (s) sublingually every 4 hours as needed for pain. NTE 6 doses/ 24 hours.- morphine 15 mg oral tablet, take ½ tablet orally (7.5 mg MSIR) every 4 hours as needed for pain.  NTE 6 doses/ 24 hours. (Order clarification, caregivers may be instructed t administer for symptom management when SN is not present to give liquid morphine).*However, there was no specific instruction for the acetaminophen 500 mg order or morphine orders as to what level of pain intensity or scale it should be administered for example for moderate or severe pain.On 5/29/25 at 1104 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 3's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was on 12/31/24.  The patient was certified for hospice services during the certification periods from 3/1/25 to 4/29/25 and 4/30/25 to 6/28/25.Review of the Medication Profile (undated) showed the following medication orders:- acetaminophen 650 mg rectal suppository, administer one suppository rectally every 6 hours as needed for mild pain, 1-3/10. NTE 3 grams/ 24 hours.- morphine 15 mg oral tablet, take ½ tablet orally (7.5 mg MSIR) every 4 hours as needed for pain.  NTE 6 doses/ 24 hours.- hydrocodone/acetaminophen 325 mg- 10 mg oral tablet, take one tablet orally every 6 hours as needed for breakthrough pain; NTE 3000 mg in 24 hours from all sources.- gabapentin (relieves nerve pain) 100 mg oral capsule, take one capsule 2 times a day for moderate pain.- Lidocaine (pain medication) 4 % topical film, apply one patch topically for 12 hours on and 12 hours off as needed for leg/ knee pain.- acetaminophen 325 mg oral tablet, take 2 tablets orally every 6 hours as needed for mild to moderate pain and temperature above 100.0.*However, there was no specific instruction for the morphine order as to what level of pain intensity or scale it should be administered for example for moderate or severe pain.On 5/29/25 at 1000 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 7's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 11/19/24.  The patient was certified for hospice services during the certification periods from 2/17/25 to 5/17/25 and 5/18/25 to 7/16/25.Review of the Medication Profile (undated) showed the following medication orders:- Lidocaine 4 % patch 4 % film, apply one patch, extended release, apply transdermally every 12 hours, apply 1 patch topically to lower back every day at 9 am and remove at 9 pm.- morphine 15 mg oral tablet, take ½ tablet orally (7.5 mg MSIR) every 4 hours as needed for pain.  NTE 6 doses/ 24 hours.-Aspercreme unit dose, apply one application, applied topically 2 times a day as needed (comments: apply to bilateral knees topically BID as needed/prn).*However, there was no specific instruction for the morphine order as to what level of pain intensity or scale it should be administered for example for moderate or severe pain.  In addition, there was no indication for what the drug is used for Lidocaine patch and Aspercreme.On 5/29/25 at 1313 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 16’s closed clinical record was initiated on 5/22/25.  The clinical record showed the SOC was on 2/15/24.  The patient was certified for hospice services during the certification period from 2/15/24 to 5/14/24 and 5/15/24 to 8/12/24.Review of the Medication Profile (undated) showed the following medication orders:- acetaminophen 650 mg rectal suppository, administer one suppository rectally every 6 hours as needed for mild pain, 1-3/10. NTE 3 grams/ 24 hours.- acetaminophen 325mg mg oral tablet, take 2 tablets orally every 4 hours as needed for mild pain, 1-3/10. NTE 3 grams/ 24 hours from all sources.- morphine 20 mg/ ml oral concentration, administer 0.25 milliliter (s) sublingually every 4 hours as needed for pain. NTE 6 doses/ 24 hours.*However, there was no specific instruction for the morphine order as to what level of pain intensity or scale it should be administered for example for moderate or severe pain.On 5/29/25 at 1350 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 19’s closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was on 6/7/24.  The patient was certified for hospice services during the certification period from 5/15/24 to 8/12/24 and 9/5/24 to 12/3/24.Review of the Medication Profile (undated) showed the following medication orders:- acetaminophen 650 mg rectal suppository, administer one suppository rectally every 6 hours as needed for mild pain, 1-3/10. NTE 3 grams/ 24 hours.- Norco 5-325 mg tablet, take one tablet by mouth every 6 hours as needed for pain management.- morphine 20 mg/ ml oral concentration, administer 0.25 milliliter (s) sublingually every 4 hours as needed for pain. NTE 6 doses/ 24 hours.- Tylenol (pain medication) 500 mg oral tablet, take one tablet every 6 hours as needed for mild to moderate pain.*However, there was no specific instruction for the morphine and Norco orders as to what level of pain intensity or scale it should be administered for example for moderate or severe pain and to what medication should be administered first between acetaminophen and Tylenol orders for mild pain.On 5/29/25 at 1341 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.  The DPCS/DQM stated the order for morphine prn is generated from the software and upon admission it is the RN’s responsibility to review prn pain medications and specify instructions as to what will be given first based on the scale or intensity of the pain and clarify the prn medication orders.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for nine of 19 sampled patients (Patients 1, 3, 6, 7, 8, 9, 12, 13, and 17).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients. Findings: --- Review of the agency's Wound Care Protocol undated showed all wound will be measured and photograph at the time of initiation of wound care order.  Wounds require a complete review at a minimum every week which includes measurements.  The complete review of wounds (performed in the wound flowsheet a minimum of every week must include the size of the wound. 1.Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  The Hospice Certification and Plan of Care for the certification periods from 2/4/25 to 4/4/25 showed SN to assess and evaluate skin and symptom management during each comprehensive assessments.  The POC also showed the patient had a stage 2 pressure injury to the lower sacrum. Review of the RN notes dated 3/10/24, showed the RN had performed comprehensive assessment.  The assessment included Wound Assessment and Care.  The patient was assessed to have a stage 2 pressure injury to the lower sacrum.  The assessment shows the following: onset date= 10/13/24; wound bed= moist; bed color/percentage=red; wound edges= detached; peri wound skin= erythema; drainage=small; color=serosanguinous and odor =none.However, the assessment failed to include the wound measurement was taken weekly as per agency's wound protocol. In addition review of the RN notes dated 3/17/24 showed the RN had performed comprehensive assessment.  The assessment included Wound Assessment and Care.  The patient was assessed to have an unstageable pressure injury to the lower sacrum.  The assessment shows the following: onset date= 10/13/24; wound bed=slough, moist; bed color/percentage=pink, yellow; wound edges= detached; peri wound skin= erythema; drainage=scant; color=serosanguinous and odor =none.However, the assessment failed to include the wound measurement weekly as per agency's wound protocol. On 5/29/25 at 1450 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.  2.  Review of Patient 1's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 8/30/24.  The patient was certified for hospice services during the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25. a. The Hospice Certification and Plan of Care for the certification period from 4/27/25 to 6/25/25, showed the orders for an SN interventions. Review of the Patient Care Order (Verbal Order) dated 4/4/25 , showed an order for the SN visit frequency cited as  2wk 12wk, 5PRN for unanticipated symptom management. The verbal order had a start date of 4/4/25 end date 6/21/25. Review of the clinical record showed the SN had visited the patient on the following week:-on Week 1 (4/27 to 5/3/25) one time on 4/28/25 instead of two times a week as ordered and-on Week 2 (5/4/ to 5/10/25) no documented evidenced the SN had visited the patient as ordered.On 5/29/25 at 0856 hours an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if there was an SN missed visits on Weeks 1 and 2.  The Director of Continuous Care reviewed the clinical record and replied, yes it was a missed visit.  The Director of Continuous Care was further asked if the physician was notified of the missed visit. The Director of Continuous Care replied, there was no documentation of the physician notification. The Director of Continuous Care was informed and acknowledged the findings. b. The Hospice Certification and Plan of Care for the certification period from 2/26/25 to 4/26/25, showed the orders for an SN interventions. Review of the Patient Care Order (Verbal Order) dated 4/4/25 , showed an order for the SN visit frequency cited as  2wk 12wk, 5PRN for unanticipated symptom management. The verbal order had a start date of 4/4/25 end date 6/21/25. Review of the clinical record showed the SN had visited the patient on the following week:-on Week 6 (3/30 to 4/5/25) one time telephone call missed on 4/4/25 -on Week 7 (4/6 to 4/12/25), no SN visit documented.  The visit  was requested to re-schedule on 4/11/25.  However, review of the clinical record failed to show documented SN visit was conducted as requested by the PCG.  -on Week 9 ( 4/20 to 4/26/25), one time telephone call missed on 4/21/25 On 5/29/25 at 0938 hours an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings. c.   Review of the Physicians Order dated 4/22/25 showed an order for Chaplain visits 7 PRN for spiritual care.  However, review of the clinical record failed to show a documented evidenced of a Chaplain visit as ordered by the physician.On 5/29/25 at 0856 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was asked as to the timeline of the Chaplain visit.  The Director of Continuous Care replied within five days from the physicians order date.  The Director of Continuous Care was also asked if there was a Chaplain visit.  The Director of Continuous Care reviewed the clinical record and replied, no it was a missed visit.  The Director of Continuous Care was informed and acknowledged the finding. 3.  Review of Patient 6's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 6/1/24.  The patient was certified for hospice services during the certification period from 3/28/25 to 5/26/25. The Hospice Certification and Plan of Care for the certification period from 3/28/25 to 5/26/25, cited SN visit 1 to 3wk 9 wk, 7 PRN for unanticipated symptoms management.   SN to assess oxygen saturation as needed. The orders and treatment included oxygen 2 to 5 liters per minute via nasal cannula as needed for trouble breathing.   The interventions showed SN to assess respiratory status including presence of dyspnea.Review of the RN 4 notes dated 5/2/25 showed the SN had performed vital signs and respiratory system assessment.  The respiratory assessment showed the patient has abnormal breath sounds and shortness of breath at rest.Further review of the narrative notes showed the patient was on 3 liters of oxygen and had it on for half an hour.  However, the RN 4 failed to check the patients oxygen saturation when the patient was assessed to have shortness of breath at rest as per POC.Moreover, review of the RN 4 notes dated 5/6/25 showed the RN 4 had performed an assessment.  On the section of the narrative notes showed the patient was assessed to have severe shortness of breath and severe pain.  The patient was on oxygen at 3 l/min.However, the RN 4 failed to check the patients oxygen saturation as ordered in the POC.On 5/29/25 at 1518 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.4.  Review of Patient 17's clinical record was initiated on 5/23/25.  The clinical record showed the SOC was 5/30/23.  The patient was certified for hospice services during the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24.a.  Review of the Verbal Order dated 4/17/24, showed an order for TB test.  The TB test to be done by the hospice SN and then read by hospice SN within 48 to 72 hours, fax the result to ALF.However, review of the clinical record failed to show documented evidenced of the TB testing was completed as ordered by the physician. On 5/29/25 at 1127 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if the TB test was completed.  The the Director of Continuous Care reviewed the closed clinical record and replied no.  The  Director of Continuous Care was informed and acknowledged the findings.     b.   Review of the Hospice Certification and Plan of Care from the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24, showed the SN interventions.  The intervention included to assess oxygen saturation PRN and oxygen 2 to 5 liters per minute via nasal cannula PRN for trouble breathing.  Review of the RN 5 visit notes on the following dates showed:-on 4/8/25,  the RN 5 had performed a comprehensive assessment. The respiratory assessment showed abnormal breath sounds, oxygen saturation of 86% at rest on RA.  However, review of the closed clinical record failed to show documented evidenced of the RN 4 had provided oxygen as ordered in the POC. -on 4/17/25, the RN 5 had performed a comprehensive assessment. The respiratory assessment showed abnormal breath sounds, shortness of breath upon exertion and oxygen saturation of 85% at rest on RA.  However, review of the closed clinical record failed to show documented evidenced of the RN 4 had provided oxygen as ordered in the POC.  -on 5/3/25, the RN 5 had performed a follow up assessment.  The assessment showed the patients oxygen saturation of 86% at rest on RA.  However, review of the closed clinical record failed to show documented evidenced of the RN 4 had provided oxygen as ordered in the POC.  -on 5/13/25, the RN 5 had performed a comprehensive assessment.  The respiratory assessment showed abnormal breath sounds, oxygen saturation of 86% at rest on RA.  However, review of the closed clinical record failed to show documented evidenced of the RN 4 had provided oxygen as ordered in the POC. On 5/29/25 at 1127 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if the patient oxygen saturation needed to be rechecked.  The Director of Continuous Care replied, yes, should be re-checked. The Director of Continuous Care was also asked if the oxygen was provided as per POC.   The Director of Continuous Care reviewed the closed clinical record and replied oxygen was not provided as per POC. The the Director of Continuous Care was informed and acknowledged the findings.   5. Review of Patient 8's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 7/14/23.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25. Review of the  Patient Care Order (Verbal Order) dated 5/15/25, showed an order for Volunteer pet therapy one day.  The order start and end date was 5/15/25. However, review of the clinical record failed to show documented evidenced of the Volunteer has provided pet therapy as ordered.On 5/29/25 at 1501 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The  Director of Continuous Care was informed and acknowledged the findings.    #.  Review of Patient 9's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was on 9/12/22.  The patient was certified for hospice services during the certification periods from 2/28/25 to 4/28/25 and 4/29/25 to 6/27/25.Review of the Hospice Certification and Plan of Care for certification periods from 4/29/25 to 6/27/25, showed a wound care treatment order for a midline buttock/coccyx stage II pressure ulcer.Review of the Skilled Nursing Visit Notes showed the RN assessed the patient’s stage II pressure ulcer to midline buttock coccyx wound bed appearance, bed color/percentages, wound edges, peri wound skin appearance, drainage, and wound measurement on 4/15, 4/17, 4/22, 4/29, and 5/7/25.  *However, review of the Skilled Nursing Visit Notes dated 5/12/25, failed to include the wound measurement of the midline buttock/coccyx stage II pressure ulcer from the RN assessment as per the hospice’s P&P.On 5/29/25 at 1352 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   #.  Review of Patient 12’s clinical record was initiated on was initiated on 5/15/25.  The clinical record showed the SOC was on 9/17/24.  The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the Patient Care Order (Verbal Order) dated 3/16/25, showed a physician’s order to provide Skilled Nursing services 1-3 wk 9 wk, 8 prn for unanticipated symptoms from 3/16/25 to 5/17/25.The Skilled Nursing Visit Notes showed there was no skilled nursing visit conducted for the week of 3/30/25 to 4/5/25 instead of one to three visits per week per physician’s order.On 5/29/25 at 0857 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.  The DPCS/DQM stated the nurse should had followed plan of care for the physician’s order for the frequency visit, documented the missed visit, and notified the physician. #.  Review of Patient 7's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 11/19/24.  The patient was certified for hospice services during the certification periods from 2/17/25 to 5/17/25 and 5/18/25 to 7/16/25.Review of the Patient Care Order (Verbal Order) dated 3/4/25, showed a physician’s order to provide Aide services 2 wk 11wk from 3/4/25 to 5/17/25.The Aide Visit Notes showed the HA conducted one visit in one week from 3/2/25 to 3/8/25 instead of two visits per week per physician’s order.On 5/29/25 at 1308 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed of the HA one missed visit for the month of March for the patient and acknowledged. #.  Review of Patient 3's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was on 12/31/24.  The patient was certified for hospice services during the certification periods from 3/1/25 to 4/29/25 and 4/30/25 to 6/28/25.Review of the Hospice Certification and Plan of Care for the certification periods from 4/30/25 to 6/28/25, showed an order for oxygen 2-5 liters per minute via nasal cannula as needed for trouble breathing and for SN to assess for oxygen saturation.a.  Review of the Skilled Nursing Visit Notes on 4/9, 4/16, 5/1, and 5/19 failed to show the SN assessed for the patient’s oxygen saturation as per the POC.b.  Review of the Skilled Nursing Visit Notes dated 5/2/25, showed a documentation LVN 2 provided the patient oxygen at 6 liters via nasal cannula continuously instead of oxygen at 2-5 liters per minute via nasal cannula as needed per the POC.On 5/29/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.  The DPCS/DQM verified there was no physician’s order for continuous oxygen at 6 liters per minute and stated the nurse should had called the physician to get an order.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for six of 19 sampled patients (Patients 1, 6, 11, 12, 14, and 19).  This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health conditions.Findings: --- 1. Review of Patient 14's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 12/12/24.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.Review of the clinical record showed a physician order dated 3/12/25 for MSW 6 PRN for psychosocial needs.However, review of the Hospice Certification and Plan of Care for the certification period from 3/12/25 to 6/9/25 failed to show documented evidenced of a care plan was developed for MSW visit to address the patients psychosocial needs as ordered. On 5/29/25 at 1554 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if a care plan was developed for MSW visit to address the patients psychosocial needs. The Director of Continuous Care replied no.  The Director of Continuous Care was informed and acknowledged the finding. 2.  Review of Patient 1's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 8/30/24.  The patient was certified for hospice services during the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25.   The patient was admitted for palliative services. Review of the Interdisciplinary  Group Conference Communication dated 4/14/25, showed the patient had a five pounds weight loss on this certification period. Review of the Interdisciplinary Care Plan for the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25, showed the identified problems with goals and intervention.  However, the care plan was not developed to address the patients identified five pound weight loss. On 5/29/25 at 0938 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if a care plan was developed to address the patients weight loss. The Director of Continuous Care reviewed the clinical record and replied no, it should have been developed.  The Director of Continuous Care was informed and acknowledged the finding. 3.  Review of Patient 6's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 6/1/24.  The patient was certified for hospice services during the certification period from 3/28/25 to 5/26/25. The Hospice Certification and Plan of Care for the certification period from 3/28/25 to 5/26/25, cited SN visit 1 to 3wk 9 wk, 7 PRN for unanticipated symptoms management.  The orders and treatment.  The orders included Lantus Solostar Pen 100 units/ml subcutaneous solution, inject 10 units subcutaneous once a day at 1700 for DM type 2.  The order also included Januvia 100 mg oral tablet take one tablet orally once a day for DM type 2. Review of the Interdisciplinary Care Plan for the certification period from 3/28/25 to 5/26/25 , showed the identified problems with goals and intervention.  However, the care plan was not developed to address the patient used of insulin and Januvia for Diabetes type 2.On 5/29/25 at 1518 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the finding.   Review of the hospice’s P&P titled Assessment-Updates to Comprehensive Assessment (undated) showed a patient’s progress toward desired outcomes and response to care is reassessed as often as required by the patient’s condition but no less frequently than every 15 days.  Information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patient’s plan of care as needed.  Documentation of the IDG’s care planning meetings reflects the ongoing reassessment of the patient/caregiver’s status and needs. #.  Review of Patient 12’s clinical record was initiated on was initiated on 5/15/25.  The clinical record showed the SOC was on 9/17/24.  The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the Skilled Nursing Note dated 4/9/25, showed LVN 5 completed a prn visit.  The narrative documentation showed, “Medtech that she found Pt on the floor lying next to bed when she went to Pt’s room to administer medication.  Pt C/O pain on forehead but no injury or discoloration noted.  Pt has skin tear on left arm… Took a picture and contacted (Medical Director) for order.  Received order Left forearm skin tear-…”*However, there was no documented evidence the IDG had developed an individual POC to address Patient 12’s skin tear to left forearm.On 5/29/25 at 0917 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. #.  Review of Patient 19’s closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was on 6/7/24.  The patient was certified for hospice services during the certification period from 5/15/24 to 8/12/24 and 9/5/24 to 12/3/24.a.  Review of the Skilled Nursing Visit Note dated 9/27/24, showed LVN 2 completed a visit per the patient’s daughter request for her concern for the patient’s ingrown toenail.  The narrative documentation showed, “After explaining this nurse visit only allowed to take a picture of affected area (rt toenail) noted with erythema tender to touch.  MD notified and received no for Keflex 500 mg q6 x10 days.”Review of the Patient Care Order (Verbal Orders) dated 9/27/24, showed to administer Keflex (an antibiotic drug) 500 mg capsule, take 1 cap (s) orally every 6 hours for 10 day (s) for ingrown toenail.*However, there was no documented evidence the IDG had developed an individual POC to address Patient 19’s right toenail ingrown infection or used of an antibiotic medication.On 5/29/25 at 1442 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.b.  Review of the Hospice Certification and Plan of Care for certification period 9/5/24 to 12/3/24, showed the patient has a secondary diagnosis of fracture of unspecified part of neck of left femur.Review of Skilled Nursing Note dated 10/16/24, showed RN 1 completed a comprehensive RN visit.  The narrative documentation showed, “She uses walker to ambulate, calls staff for assistance, says I can’t fall again, I fall and I ended up here.”*However, there was no documented evidence the IDG had developed an individual POC to address Patient 19’s history of fall or prevention for fall.c.  Review of Skilled Nursing Visit Note dated 10/23/24, showed LVN completed a routine patient visit.  The narrative documentation showed, “pt has been a bit “off” lately and has been urinating more frequently.  She requested urine to be tested.”Review of Skilled Nursing Note dated 10/29/24, showed RN 7 completed a comprehensive RN visit.  The narrative documentation showed, “Pt has c/o burning on urination but foul odor reported. ”Review of Patient 11's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was on 6/14/24.  The patient was certified for hospice services during the certification periods from 2/9/25 to 4/9/25 and 4/10/25 to 6/8/25.19’s genitourinary status.On 5/29/25 at 1429 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. #.  Review of Patient 11's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was on 6/14/24.  The patient was certified for hospice services during the certification periods from 2/9/25 to 4/9/25 and 4/10/25 to 6/8/25.Review of the Skilled Nursing Visit Notes showed on 4/21 and 4/24/25, the patient has a midline coccyx stage II pressure ulcer.*However, there was no documented evidence the IDG had developed an individual POC to address Patient 11’s midline coccyx stage II pressure ulcer.On 5/29/25 at 0952 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the revised POCs included the visit frequency of the services provided for 12 of 19 sampled patients (Patients 1, 3, 4, 5, 7, 8, 9, 10, 13, 15, 17, and 18).  This failure had the potential of not providing necessary services for these patients.Findings: --- The agency P&P titled Plan of Care undated, showed 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 plan of care includes, but is not limited to interventions to manage pain and symptoms, drugs and treatment necessary to meet the needs of the patient and a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. 1.  Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  The Hospice Certification and Plan of Care for the certification periods from 2/4/25 to 4/4/25 and  4/5/25 to 6/3/25, showed the orders/treatments.  The orders included the intervention for SN, MSW, Chaplain and HA services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P. On 5/29/25 at 1416 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was asked if the POC needed to include the disciplines visit frequency.  The Director of Continuous Care replied, yes, it should.  The Director of Continuous Care reviewed the clinical record and acknowledged the findings. 2.  Review of Patient 1's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 8/30/24.  The patient was certified for hospice services during the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25. Review of the Hospice Certification and Plan of Care for the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25, showed the orders for SN interventions.However, the Hospice Certification and Plan of Care failed to include the visit frequency for the SN visits. On 5/29/25 at 0938 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous care was asked if the POC needed to include the services provided.  The Director of Continuous Care reviewed the clinical record and replied, it should have been included in the plan of care.  The Director of Continuous Care was informed and acknowledged the findings. 3.  Review of Patient 17's clinical record was initiated on 5/23/25.  The clinical record showed the SOC was 5/30/23.  The patient was certified for hospice services during the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24.Review of the Hospice Certification and Plan of Care for the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24, showed the orders/treatments.  The orders included the intervention for SN, MSW, Chaplain and HA services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P. On 5/29/25 at 1059 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.4.  Review of Patient 4's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 3/3/24.  The patient was certified for hospice services during the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25. *Review of the Hospice Certification and Plan of Care for the certification periods from 3/3/25 to 5/1/25, showed the orders/treatments.  The orders included the intervention for MSW and HA services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P.*Review of the Hospice Certification and Plan of Care for the certification periods from 5/2/25 to 6/30/25 , showed the orders/treatments.  The orders included the intervention for MSW and Chaplain services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P.On 5/29/25 at 1026 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.5.  Review of Patient 8's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 7/14/23.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25.*Review of the Hospice Certification and Plan of Care  for the certification periods from 3/15/25 to 5/13/25 , showed the orders/treatments.  The orders included the intervention for and Chaplain services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P.*Review of the Hospice Certification and Plan of Care for the certification periods from 5/14/25 to 7/12/25, showed the orders/treatments.  The orders included the intervention for SN, MSW and Chaplain services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P.On 5/29/25 at 1501 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.6.  Review of Patient 10's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 1/7/24.  The patient was certified for hospice services during the certification periods from 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25. Review of the Hospice Certification and Plan of Care for the certification periods from 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25, showed the orders/treatments.  The orders included the intervention for MSW and Chaplain services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P.On 5/29/25 at 1257 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.7.  Review of Patient 15's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was 10/12/23.  The patient was certified for hospice services during the certification periods from 4/9/24 to 6/7/24. Review of the Hospice Certification and Plan of Care for the certification period from 4/9/24 to 6/7/24 , showed the orders/treatments.  The orders included the intervention for HA and Chaplain services.However, the Hospice Certification and Plan of Care failed to include the visit frequencies for the planned services as per P&P. On 5/29/25 at 1340 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings. #.  Review of Patient 5's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 1/20/24.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25.The Hospice Certification and Plan of Care for the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25, showed orders and treatments.  The orders included interventions for MSW and chaplain services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.On 5/29/25 at 1110 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. #.  Review of Patient 3's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was on 12/31/24.  The patient was certified for hospice services during the certification periods from 3/1/25 to 4/29/25 and 4/30/25 to 6/28/25.a.  The Hospice Certification and Plan of Care for the certification periods from 3/1/25 to 4/29/25, showed orders and treatments.  The orders included interventions for MSW and chaplain services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.b.  The Hospice Certification and Plan of Care for the certification periods from 4/30/25 to 6/28/25, showed orders and treatments.  The orders included interventions for HA, MSW, and chaplain services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.On 5/29/25 at 1006 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. #.  Review of Patient 7's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 11/19/24.  The patient was certified for hospice services during the certification periods from 2/17/25 to 5/17/25 and 5/18/25 to 7/16/25.a.  The Hospice Certification and Plan of Care for the certification periods from 2/17/25 to 5/17/25, showed orders and treatments.  The orders included interventions for SN, MSW and chaplain services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.b.  The Hospice Certification and Plan of Care for the certification periods from 5/18/25 to 7/16/25, showed orders and treatments.  The orders included interventions for SN, HA, MSW, and chaplain services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.On 5/29/25 at 1328 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. The DPCS/DQM stated the frequency visit orders were probably inputted after the POC was established so the frequency visits were not reflected in the POC. #.  Review of Patient 9's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was on 9/12/22.  The patient was certified for hospice services during the certification periods from 2/28/25 to 4/28/25 and 4/29/25 to 6/27/25.a.  The Hospice Certification and Plan of Care for the certification periods from 2/28/25 to 4/28/25, showed orders and treatments.  The orders included interventions for MSW and chaplain services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.b.  The Hospice Certification and Plan of Care for the certification periods from 4/29/25 to 6/27/25, showed orders and treatments.  The orders included interventions for SN, HA, MSW, and chaplain services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.On 5/29/25 at 1337 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. #.  Review of Patient 18’s closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was on 4/1/24.  The patient was certified for hospice services during the certification period from 4/1/24 to 6/29/24 and 6/30/24 to 9/27/24.a.  The Hospice Certification and Plan of Care for the certification periods from 4/1/24 to 6/29/24, showed orders and treatments.  The orders included interventions for HA services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.b.  The Hospice Certification and Plan of Care for the certification periods from 6/30/24 to 9/27/24, showed orders and treatments.  The orders included interventions for SN and HA services.However, the POC failed to include the visit frequencies for the planned services as per the P&P.On 5/29/25 at 1418 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for four of 19 sampled patients (Patients 4,10, 11, and 13).  This failure had the potential of not evaluating the POC and providing the appropriate care and services to these patients.  Findings: --- 2.  Review of Patient 11's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was on 6/14/24.  The patient was certified for hospice services during the certification periods from 2/9/25 to 4/9/25 and 4/10/25 to 6/8/25.The IDG Review dated 2/20, 3/6, 3/20, 3/27, 4/10, 4/24, and 5/8 /25 showed the patient’s identified problems with the established goal and interventions.  However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example, the goal for risk for impaired nutrition included, “will remain comfortable daily as nutritional status changes throughout disease process;” and the goal for risk for skin impairment included, “will remain comfortable daily as skin changes throughout disease process,” wherein there were no measurable goal established for these care plan problems.On 5/29/25 at 0942 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. The agency P&P titled Plan of Care undated, showed 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 plan of care includes, but is not limited to measurable outcomes anticipated from implementing and coordinating the plan of care. 1.  Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  The Interdisciplinary Care Plan for the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25 showed the patients identified problems with the  established goals and intervention.  The identified problem included impaired nutrition - dysphagia and nutritional supplement.  The goal was to tolerate nutritional supplement without signs or symptoms of aspiration.   However, there was no documented evidenced of what a tolerable nutritional supplement was. On 5/29/25 at 1416 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the finding.  2.  Review of Patient 4's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 3/3/24.  The patient was certified for hospice services during the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25.The Interdisciplinary Care Plan for the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25 showed the patients identified problems with the  established goals and intervention.  The identified problem included altered nutrition/hydration status.  The goal was to demonstrate improved nutritional status and the patients nutritional status will be met as patients condition/comfort. However, there was no documented evidenced of what an improved and met nutritional status was. On 5/29/25 at 1026 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.3. Review of Patient 10's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 1/7/24.  The patient was certified for hospice services during the certification periods from 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25.The Interdisciplinary Care Plan for the certification periods from 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25 showed the patients identified problems with the  established goals and intervention.  The identified problem included appetite.  The goal was to have a much or as little nutritional intake as tolerated. However, there was no documented evidenced of what a much or as little nutritional intake as tolerated was.On 5/29/25 at 1257 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.   The hospice’s P&P titled Plan of Care (undated) showed 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 plan of care includes but is not limited to measurable outcomes anticipated from implementing and coordinating the plan of care.  1.  Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  The Interdisciplinary Care Plan for the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25, showed the patient's identified problems with the established goals and intervention.  The identified problem included impaired nutrition - dysphagia and nutritional supplement.  The goal was to tolerate nutritional supplement without signs or symptoms of aspiration.   However, there was no documented evidenced of what a tolerable nutritional supplement was for the patient. On 5/29/25 at 1416 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the finding.  2.  Review of Patient 4's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 3/3/24.  The patient was certified for hospice services during the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25.The Interdisciplinary Care Plan for the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25, showed the patient's identified problems with the established goals and intervention.  The identified problem included altered nutrition/hydration status.  The goal was to demonstrate improved nutritional status and the patient’s nutritional status will be met as the patient’s condition/comfort. However, there was no documented evidence for what the improved nutritional status was and how the patient's nutrition status met. On 5/29/25 at 1026 hours, an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings. 3.  Review of Patient 10's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 1/7/24.  The patient was certified for hospice services during the certification periods from 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25.The Interdisciplinary Care Plan for the certification periods from 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25, showed the patient's identified problems with the established goals and intervention.  The identified problem included appetite.  The goal was to have a much or as little nutritional intake as tolerated. However, there was no documented evidence of what a much or as little nutritional intake as tolerated was.On 5/29/25 at 1257 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.  4.  Review of Patient 11's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was on 6/14/24.  The patient was certified for hospice services during the certification periods from 2/9/25 to 4/9/25 and 4/10/25 to 6/8/25.The IDG Review dated 2/20, 3/6, 3/20, 3/27, 4/10, 4/24, and 5/8/25, showed the patient’s identified problems with the established goal and interventions.  However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example, the goal for risk for impaired nutrition included, “will remain comfortable daily as nutritional status changes throughout disease process;” and the goal for risk for skin impairment included, “will remain comfortable daily as skin changes throughout disease process,” wherein there were no measurable goals established for these care plan problems.On 5/29/25 at 0942 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days for three of 19 sampled patients (Patients 7, 8, and 12), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: --- Review of the hospice’s P&P titled Interdisciplinary Group Meeting (undated) showed the interdisciplinary team reviews each patient’s plan of care every two weeks, or more frequently if needed, in order to continually monitor the care and services provided to the patient and his or her continued eligibility for hospice care.  During the interdisciplinary team meeting the patient’s plan of care is reviewed and updated and changes are communicated to the patient’s attending physician with requests for new orders when needed.  The interdisciplinary team meeting follows a consistent agenda to ensure that all patients are reviewed, and that appropriate care planning occurs.  The agenda follows the D-A-R-E format of patient review:a.  D- dischargesb.  A- admissionc.  R- recertificationsd. E- existing patients (each patient is reviewed, at a minimum of every two weeks and patients receiving continuous care or the general in patient level of care are reviewed at every meeting).  The focus of the interdisciplinary team meeting is on reviewing the patient’s plan of care and revising it as needed, based on updated reassessment information. 1.  Review of Patient 7's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 11/19/24.  The patient was certified for hospice services during the certification periods from 2/17/25 to 5/17/25 and 5/18/25 to 7/16/25.Review of the Patient Care Order (Verbal Order) dated 3/4/25, showed a physician’s order to provide Aide services 2 wk 11wk from 3/4/25 to 5/17/25.The Aide Visit Notes showed the HA conducted one visit in one week from 3/2/25 to 3/8/25 instead of two visits per week per physician’s order.However, the IDG Conference Communication dated 3/18/25 was not updated to reflect the HA one missed visit for the week of 3/2 to 3/8/25 as per the hospice’s P&P.On 5/22/25 at 0920 hours, an observation of the IDG conference was conducted with the IDG team.  The Medical Director, Chaplain 2, MSW 2, RN 1, RN Case Manager, Team Manager, and Patient Care Secretary were present in the conference room.  The Medical Director was present via video call.  RN 1 was observed discussing and providing information regarding patient’s changes in condition, services provided, any updates with the patient’s condition or care needs, and care areas will be monitored continually.  However, the IDG was not observed discussing the frequency visits or missed visits of each discipline services provided nor the discussion of any updates and revision of the plan of care.On 5/29/25 at 1300 hours, an interview was conducted with the DPCS/DQM.  The DPCS/DQM was informed about the observation conducted with the IDG team on 5/22/25 and acknowledged the findings.On 5/29/25 at 1308 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed of the HA one missed visit for the month of March for the patient and acknowledged. 2.  Review of Patient 12’s clinical record was initiated on was initiated on 5/15/25.  The clinical record showed the SOC was on 9/17/24.  The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the Patient Care Order (Verbal Order) dated 3/16/25, showed a physician’s order to provide Skilled Nursing services 1-3 wk 9 wk, 8 prn for unanticipated symptoms from 3/16/25 to 5/17/25.The Skilled Nursing Visit Notes showed there was no skilled nursing visit conducted for the week of 3/30/25 to 4/5/25 instead of one to three visits per week per physician’s order.In addition, the IDG Conference Communication dated 4/10/25 was not updated to reflect the skilled nursing missed visit for the week of 3/30/25 to 4/5/25 as per the hospice’s P&P.On 5/29/25 at 0857 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.  The DPCS/DQM stated the nurse should had documented the missed visit so it would have reflected the changes of the patient’s services and discuss the IDG meeting.  3.  Review of Patient 8's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 7/14/23.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25.Review of the  Patient Care Order (Verbal Order) dated 5/15/25, showed an order for Volunteer pet therapy one day.  The order start and end date was 5/15/25. Review of the clinical record showed an Interdisciplinary Group Conference Communication was conducted on 5/19/25.  The IDG discussion included medication profile, care plans, visit frequencies and progress to goals.However, the IDG failed to discussed the Volunteer one time order visit for pet therapy. On 5/29/25 at 1501 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The  Director of Continuous Care was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to maintain a system of communication and integration in accordance with their P&P to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided for two of 19 sampled patients (Patients 3 and 9).  This failure had the potential of not addressing the care needs for these patients.Findings: --- Review of the hospice’s P&P titled Coordination of Services (undated) the IDG ensures there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers and in all setting.  The Clinical Director assumes overall responsibility for ensuring there are effective methods of communication that allow for the coordination of care and services provided by the IDG.  The RN Case Manager coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness.Review of the hospice’s P&P titled Monitoring Patient’s Response/Reporting to Physician (undated) showed the patient’s physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur:A.     Changes in the patient’s conditionB.     Changes in the patient’s psychosocial statusC.     Changes in family/caregiver support or home environmentD.     Inability to achieve goals with the specified time frameE.      Changes in the patient’s expected response to hospice care or medicationsF.      Changes occur regarding diagnosis, prognosis, or treatmentG.    When results are received for relevant laboratory tests orderedH.    There is any problem implementing the plan of care 1.  Review of Patient 3's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was on 12/31/24.  The patient was certified for hospice services during the certification periods from 3/1/25 to 4/29/25 and 4/30/25 to 6/28/25.Review of the Skilled Nursing Visit Note dated 4/9/25, showed a documentation of a PRN visit for increased lethargy and the nurse reporting to LVN 2 that the patient was refusing her routine medications.  *However, there was no documented evidence the physician was notified of the change of condition on the same day of the visit as per the hospice’s P&P.  In addition, there was no documented evidence the RN had coordinated with the IDG regarding the patient's change of condition related to increased lethargy and refusing routine medications.On 5/29/25 at 1023 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. 2.  Review of Patient 9's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was on 9/12/22.  The patient was certified for hospice services during the certification periods from 2/28/25 to 4/28/25 and 4/29/25 to 6/27/25.a.  Review of the Skilled Nursing Visit Note dated 3/5/25, showed there was a PRN visit for the patient being disoriented, resistive, and refusing medications.  The documentation showed the patient’s family member reported to LVN 3 that the patient refused her medication on this day.  The documentation showed, “she is AOX1 and thinks she’s in hospital. Patient seems anxious and repeatedly saying “what is wrong with me”, mild agitation and anxiety noted but easily redirect-able.”b.  Review of the Skilled Nursing Visit Note dated 5/8/25, showed there was documentation of a PRN visit due to report that the patient was more confused than usual.  The documentation showed the patient’s caregiver stated, “that cognitively, she was “off and on.”  “Patient was very confused today.  Much of her statements/responses were nonsensical and she appeared to be very suspicious and paranoid…Breathing today was more labored and respirations deep in nature…Increased nonproductive cough noted.”*However, there was no documented evidence the physician was notified of the change of condition on the same day of the visit as per the hospice’s P&P.  In addition, there was no documented evidence the RN had coordinated with the IDG regarding the patient's change of conditions with change in cognition and refusal of medications.On 5/29/25 at 1350 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for nine of 19 sampled patients (Patients 1, 3, 6, 7, 8, 9, 12, 13, and 17).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients. Findings: --- Review of the hospice's P&P titled Wound Care Protocol (undated) showed all wound will be measured and photograph at the time of initiation of wound care order.  Wounds require a complete review at a minimum every week which includes measurements.  The complete review of wounds (performed in the wound flowsheet a minimum of every week must include the size of the wound. 1. Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  The Hospice Certification and Plan of Care for the certification period from 2/4/25 to 4/4/25, showed SN to assess and evaluate skin and symptom management during each comprehensive assessment.  The POC also showed the patient had the Stage 2 pressure injury to the lower sacrum. Review of the RN notes dated 3/10/24, showed the RN had performed comprehensive assessment.  The patient was assessed to have a stage 2 pressure injury to the lower sacrum.  The assessment showed the following: onset date = 10/13/24; wound bed = moist; bed color/percentage = red; wound edges = detached; peri wound skin = erythema; drainage = small; color = serosanguinous; and odor = none.However, the assessment failed to include the wound measurements weekly as per the hospice's wound protocol. In addition, review of the RN notes dated 3/17/24, showed the RN had performed comprehensive assessment.  The patient was assessed to have an unstageable pressure injury to the lower sacrum.  The assessment showed the following: onset date = 10/13/24; wound bed = slough, moist; bed color/percentage = pink, yellow; wound edges = detached; peri wound skin = erythema; drainage = scant; color = serosanguinous; and odor = none.However, the assessment failed to include the wound measurements weekly as per the hospice's wound protocol. On 5/29/25 at 1450 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.  2.  Review of Patient 1's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 8/30/24.  The patient was certified for hospice services during the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25. a. The Hospice Certification and Plan of Care for the certification period from 4/27/25 to 6/25/25, showed the orders for an SN intervention. Review of the Patient Care Order (Verbal Order) dated 4/4/25, showed an order for the SN visit frequency as 2wk 12wk (2 visits a week for 12 weeks) and 5 PRN visits for unanticipated symptom management. The verbal order had a start date of 4/4/25, and end date of 6/21/25. Review of the clinical record showed the following SN visits:- For Week 1 (4/27 to 5/3/25), one SN visit on 4/28/25, instead of two times a week as ordered and- For Week 2 (5/4/ to 5/10/25), no SN visit instead of two visits as week as ordered.On 5/29/25 at 0856 hours an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if there was an SN missed visits for Weeks 1 and 2.  The Director of Continuous Care reviewed the clinical record and replied yes, it was a missed visit.  The Director of Continuous Care was further asked if the physician was notified of the missed visit. The Director of Continuous Care replied there was no documentation of the physician notification. The Director of Continuous Care was informed and acknowledged the findings. b. The Hospice Certification and Plan of Care for the certification period from 2/26/25 to 4/26/25, showed the orders for an SN intervention. Review of the Patient Care Order (Verbal Order) dated 4/4/25, showed an order for the SN visit frequency as 2wk 12wk and 5 PRN visits for unanticipated symptom management.  The verbal order had the start date of 4/4/25 and end date of 6/21/25. Review of the clinical record showed the following:-For Week 6 (3/30 to 4/5/25), one time telephone call missed on 4/4/25 -For Week 7 (4/6 to 4/12/25), no SN visit documented.  The visit was requested to be rescheduled on 4/11/25.  However, review of the clinical record failed to show the SN visit was conducted as requested by the PCG.  -For Week 9 (4/20 to 4/26/25), one time telephone call missed on 4/21/25 On 5/29/25 at 0938 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings. c.   Review of the Physicians Order dated 4/22/25, showed an order for Chaplain visits 7 PRN visits for spiritual care.  However, review of the clinical record failed to show a documented evidenced of a Chaplain visit as ordered by the physician.On 5/29/25 at 0856 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was asked as to the timeline of the Chaplain visit.  The Director of Continuous Care replied within five days from the physician’s order date.  The Director of Continuous Care was also asked if there was a Chaplain visit.  The Director of Continuous Care reviewed the clinical record and replied no, it was a missed visit.  The Director of Continuous Care was informed and acknowledged the finding.  3.  Review of Patient 6's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 6/1/24.  The patient was certified for hospice services during the certification period from 3/28/25 to 5/26/25. The Hospice Certification and Plan of Care for the certification period from 3/28/25 to 5/26/25, cited SN visit 1 to 3wk 9 wk (one to three visits a week for nine weeks) and 7 PRN visits for unanticipated symptoms management.   The POC also cited SN to assess oxygen saturation level as needed.  The orders and treatment included oxygen 2 to 5 liters per minute via nasal cannula as needed for trouble breathing.   The interventions showed SN to assess respiratory status including presence of dyspnea.Review of RN 4's note dated 5/2/25, showed the SN had performed vital signs and respiratory system assessment.  The respiratory assessment showed the patient had abnormal breath sounds and SOB at rest.Further review of the narrative notes showed the patient was on 3 liters of oxygen and had it on for half an hour.  However, RN 4 failed to check the patients oxygen saturation level when the patient was assessed to have shortness of breath at rest as per the hospice's POC.Moreover, review of RN 4's note dated 5/6/25, showed RN 4 had performed an assessment.  The section of the narrative notes showed the patient was assessed to have severe SOB and severe pain.  The patient was on oxygen at 3 l/min.However, RN 4 failed to check the patient's oxygen saturation level as ordered in the POC.On 5/29/25 at 1518 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings. 4.  Review of Patient 17's closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was 5/30/23.  The patient was certified for hospice services during the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24.a.  Review of the Verbal Order dated 4/17/24, showed an order for TB test, to be done by the hospice SN and then read by the hospice SN within 48 to 72 hours, and fax the result to the ALF.However, review of the clinical record failed to show documented evidenced of the TB testing completed as ordered by the physician. On 5/29/25 at 1127 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if the TB test was completed.  The Director of Continuous Care reviewed the closed clinical record and replied no.  The Director of Continuous Care was informed and acknowledged the findings.     b.   Review of the Hospice Certification and Plan of Care from the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24, showed the SN interventions.  The intervention included to assess oxygen saturation level PRN and oxygen 2 to 5 liters per minute via nasal cannula PRN for trouble breathing.  Review of RN 5's visit notes showed the following notes:-on 4/8/25, RN 5 had performed a comprehensive assessment.  The respiratory assessment showed abnormal breath sounds and oxygen saturation level of 86% at rest on RA.  However, review of the closed clinical record failed to show documented evidenced RN 4 had provided oxygen as ordered in the POC. -on 4/17/25, RN 5 had performed a comprehensive assessment. The respiratory assessment showed abnormal breath sounds, SOB upon exertion, and oxygen saturation level of 85% at rest on RA.  However, review of the closed clinical record failed to show documented evidence RN 4 had provided oxygen as ordered in the POC.  -on 5/3/25, RN 5 had performed a follow up assessment.  The assessment showed the patient's oxygen saturation level of 86% at rest on RA.  However, review of the closed clinical record failed to show documented evidence RN 4 had provided oxygen as ordered in the POC. -on 5/13/25, the RN 5 had performed a comprehensive assessment.  The respiratory assessment showed abnormal breath sounds and oxygen saturation level of 86% at rest on RA.  However, review of the closed clinical record failed to show documented evidenced RN 4 had provided oxygen as ordered in the POC. On 5/29/25 at 1127 hours, an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if the patient's oxygen saturation level needed to be rechecked.  The Director of Continuous Care replied yes, it should be rechecked. The Director of Continuous Care was also asked if the oxygen was provided as per the POC.  The Director of Continuous Care reviewed the closed clinical record and replied oxygen was not provided as per the POC. The the Director of Continuous Care was informed and acknowledged the findings.    5. Review of Patient 8's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 7/14/23.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25.Review of the Patient Care Order (Verbal Order) dated 5/15/25, showed an order for Volunteer pet therapy one day.  The order had the start and end date of 5/15/25.However, review of the clinical record showed no documented evidence the Volunteer had provided the pet therapy as ordered.On 5/29/25 at 1501 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.  6.  Review of Patient 9's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was on 9/12/22.  The patient was certified for hospice services during the certification periods from 2/28/25 to 4/28/25 and 4/29/25 to 6/27/25.Review of the Hospice Certification and Plan of Care for certification period from 4/29/25 to 6/27/25, showed a wound care treatment order for a midline buttock/coccyx Stage 2 pressure injury.Review of the Skilled Nursing Visit Notes showed the RN assessed the patient’s Stage II pressure injury to midline buttock coccyx, wound bed appearance, bed color/percentages, wound edges, peri wound skin appearance, drainage, and wound measurement on 4/15, 4/17, 4/22, 4/29, and 5/7/25. *However, review of the Skilled Nursing Visit Notes dated 5/12/25, failed to include the wound measurement of the midline buttock/coccyx Stage 2 pressure injury from the RN assessment as per the hospice’s P&P.On 5/29/25 at 1352 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.   7.  Review of Patient 12’s clinical record was initiated on was initiated on 5/15/25.  The clinical record showed the SOC was on 9/17/24.  The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.Review of the Patient Care Order (Verbal Order) dated 3/16/25, showed a physician’s order to provide SN services 1-3 wk 9 wk and 8 PRN visits for unanticipated symptoms from 3/16/25 to 5/17/25.The Skilled Nursing Visit Notes showed no SN visit was conducted for the week of 3/30/25 to 4/5/25 instead of one to three visits per week as per the physician’s order.On 5/29/25 at 0857 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.  The DPCS/DQM stated the nurse should have followed the plan of care for the physician’s order for the frequency visit, documented the missed visit, and notified the physician. 8.  Review of Patient 7's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 11/19/24.  The patient was certified for hospice services during the certification periods from 2/17/25 to 5/17/25 and 5/18/25 to 7/16/25.Review of the Patient Care Order (Verbal Order) dated 3/4/25, showed a physician’s order to provide HA services 2wk 11wk from 3/4/25 to 5/17/25.The Aide Visit Notes showed the HA conducted one visit a week during the week of 3/2/25 to 3/8/25, instead of two visits per week as per the physician’s order.On 5/29/25 at 1308 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed of one HA missed visit for the month of March and acknowledged. 9.  Review of Patient 3's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was on 12/31/24.  The patient was certified for hospice services during the certification periods from 3/1/25 to 4/29/25 and 4/30/25 to 6/28/25.Review of the Hospice Certification and Plan of Care for the certification period from 4/30/25 to 6/28/25, showed an order for oxygen 2-5 liters per minute via nasal cannula as needed for trouble breathing and for SN to assess for oxygen saturation level.a.  Review of the Skilled Nursing Visit Notes on 4/9, 4/16, 5/1, and 5/19/25, showed no documented evidence the SN had assessed for the patient’s oxygen saturation level as per the POC.b.  Review of the Skilled Nursing Visit Notes dated 5/2/25, showed LVN 2 provided the patient oxygen at 6 liters via nasal cannula continuously instead of oxygen at 2-5 liters per minute via nasal cannula as needed per the POC.On 5/29/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.  The DPCS/DQM verified there was no physician’s order for continuous oxygen at 6 liters per minute and stated the nurse should have called the physician to get an order.

Based on interview and record review, the hospice failed to use the quality indicator data including infection control accurately in the design of the QAPI programs for the years of 2023 and 2024.  This created the risk of not including relevant data for performance improvement to improve care and services provided to the patients.   Findings --- Review of the hospice's P&P titled Infection Control Program undated showed the procedure includes but is not limited to the collection and analysis of surveillance among staff, volunteers and hospice patients.  An integral component of the hospice's quality assessment and performance improvement program, infection control data is collected and analyzed to determine trends and areas in need of improvement to minimize the risk of infections.   Data collected may include but not limited to identification of targeted infections.  A summary of all infection control activities performed as well as results of aggregated surveillance data analysis is provided by QAPI Committee. a.  Review of the quarterly QAPI for 2023 and the quarterly Patient Infection Reports for 2023 showed the following inconsistencies of data:-Review of the QAPI Q1 (first quarter) 2023 Infections showed 20 of urinary and 12 COVID-19 cases.  However, review of the Patient Infection Report for Q1 showed 24 UTIs and no Covid case.   -Review of the QAPI Q2 (second quarter) 2023 Infections showed 16 urinary and seven respiratory cases.  However, review of the Patient Infection Report for Q2 showed 11 UTIs and eight respiratory cases. -Review of the QAPI Q3 (third quarter) 2023 Infections showed 22 urinary, five for eyes, six for COVID-19 and two for respiratory cases.  However, review of the Patient Infection Report for Q3 showed 25 UTIs,  four conjunctival, one COVID-19, and three for respiratory cases.-Review of the QAPI Q4 (fourth quarter) 2023 Infections showed 12 urinary, six COVID-19, nine respiratory, and three skin cases; and no cases for gastrointestinal.  However, review of the Patient Infection Report for Q4 showed14 UTIs and six integumentary cases, and no cases for COVID-19 and gastrointestinal. b.  Review of the quarterly QAPI for 2024 and the quarterly Patient Infection Reports for 2024 showed the following inconsistencies of data:-Review of the QAPI Q1 2024 Infections showed four eyes, four respiratory, and six skin cases; and no case for gastrointestinal.  However, review of the Patient Infection Report for Q1 showed six conjunctival, five respiratory, eight integumentary, and one gastrointestinal case.Review of the QAPI Q2 2024 Infections showed seven urinary and six skin cases. However, review of the Patient Infection Report for Q2 showed 10 UTIs and four integumentary cases. Review of the QAPI Q3 2024 Infections showed seven urinary cases. However, review of the Patient Infection Report for Q3 showed six UTI cases. Review of the QAPI Q4 2024 Infections showed 17 urinary, 11 respiratory, and five skin cases. However, review of the Patient Infection Report for Q4 showed 19 UTIs, 12 respiratory, and seven integumentary cases. On 5/28/25 at 1538 hours, an interview and concurrent document review was conducted with the DPCS/DQM.  The DPCS/DQM was asked as to the process of determining the accuracy of data collection. The DPCS/DQM replied by auditing every end of the quarter, making sure the data matched the numbers of infection reported on the patient infection report form.  The DPCS/DQM was informed of the findings.  The DPCS/DQM reviewed the documents and acknowledged the findings.

Based on observation, interview and record review, the hospice failed to ensure the HAs provided HA services in accordance with the POCs for two of 19 sampled patients (Patients 12 and 13).  This failure had the potential for not providing the appropriate, consistent, and quality care to the patients.Findings: --- Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  The POC for the certification period from 4/5/25 to 6/3/25, showed the interventions for HA to provide personal care.  The personal care included oral care.On 5/15/25 at 1300 hours, a joint home visit was conducted with the HA 2. The HA 2 was observed to performed the personal care. However, the HA 2 failed to provide oral care as ordered in the POC. On 5/15/25 at 1500 hours, an interview and concurrent record review was conducted with the HA 2.  The HA 2 was asked if an oral care was provided.  The HA 2 replied, no.  The HA 2 was also asked if the POC was followed.  The HA 2 replied, no.  The HA 2 was informed and acknowledged the finding.   Review of the hospice’s P&P titled Hospice Aide Services (undated) showed 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.  The RN Case Manager develops a written hospice aide plan of care that provides instructions to the hospice aide of the care to be provided.1.  Review of Patient 12’s clinical record was initiated on was initiated on 5/15/25.  The clinical record showed the SOC was on 9/17/24.  The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.A joint home visit with HA 1 to the patient’s ALF in ALF 1 was conducted on 5/15/25 at 0820 hours.  HA 1 offered the patient shower, but the patient refused.  HA 1 provided peri care.  HA 1 collected the trash from the trash can, made the patient’s bed, organized the patient’s clothes, and restock the patient’s peri care supplies.Review of the Patient Care Order (Verbal Orders) dated 3/16/25, showed a physician order cited Aide 3 wk 9 wk (three times a week for nine weeks) from 3/16/25 to 5/17/25.Review of the Hospice Certification and Plan of Care for the certification period 3/16/25 to 5/14/25 dated 3/6/25, showed the HA assignment included for the following:- HA to apply barrier cream and lotion to skin.- HA to assist with dressing.- HA to complete oral care.- HA to dispose of trash.- HA to make the bed and change linens.- HA to provide nail care, clean under nails and file.- HA to provide bed bath or shower as requested by the patient or caregiver.- HA to shampoo hair, towel dry, and comb hair.- HA to provide incontinence care.- Universal precautions for infection control.  Wear gloves when providing care.- Collect score for pain, shortness of breath, and last bowel movement every visit.  Report any score above zero, if no bowel movement for days, and/or any changes in skin integrity.*However, HA 1 failed to ensure the HA assignment was followed as HA 1 was not observed finishing all the tasks listed above per patient’s POC.On 5/15/25 at 0920 hours, an interview was conducted with HA 1.  HA 1 was informed and verified she did not provide oral care, nail care, nor assess for patient’s pain.  HA 1 stated she forgot to assess for patient’s pain.On 5/29/25 at 0845 hours, the DPCS/DQM was informed and acknowledged the above finding.

Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all care provided as follows:-The Administrator failed to ensure the physical examination and tuberculosis screening were completed for three of 11 employee files reviewed (Volunteers 1 and 2 and RN 3).-The Administrator failed to ensure wound care policy was implemented for three of 19 sampled patients (Patients 13,15, and 17).These failures had the potential to negatively impact the hospice’s operational performance.Findings: --- 1.  According to Standards of Quality Hospice Care 2005 Section 6.3 (a) (1) (2):-All persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment. Each examination shall include confirmation by the person performing the examination that the employee is physically and medically qualified to perform the duties to be assigned, and that employee has no health condition that would create a hazard to patients.-The initial health examination shall include a tuberculosis screening.  Tuberculosis screening shall occur annually thereafter.Review of the hospice’s P&P titled Administrator (undated) showed the Administrator is appointed and assumes responsibility for the day-to-day administration of the hospice program.  The hospice Administrator is the chief administrator of the hospice program, is employed by the hospice, reports to the Board of Directors and fulfills the responsibilities outlined in the job description of this position, including but not limited to:-implementing financial policies and procedures;-implementing, monitoring, and reporting on the hospice services;-assuring the quality of patient care;-resolving problems;-assuring the implementation of the QAPI program and safety activities; and-assuring open and timely communication.The hospice Administrator, with the Board of Directors, ensures that all care, treatment, and services provided by the hospice are in accordance with Federal, State, and local laws and regulations and consistent with accepted standards of practice.Review of the hospice P&P titled Health/Physical Requirements (undated) showed all employees and volunteers who work directly with patients and families must provide documented evidence of a medical examination, performed by a qualified physician, within six months of hire or the first day of volunteer service.  All employees and volunteers are required to have documented evidence of a tuberculin screening within six months of hire and prior to patient contact.  In addition: TB screening must be repeated every year for those who have patient contact.a.  Review of the employee file for Volunteer 1 was initiated on 5/27/25.  Volunteer 1 was hired on 2/9/25.  However, there was no documented evidence a health examination was completed as per the hospice’s P&P.b.  Review of the employee file for Volunteer 2 was initiated on 5/27/25.  Volunteer 2 was hired on 10/16/23.  However, there was no documented evidence a health examination was completed as per the hospice’s P&P.c.  Review of the employee file for RN 3 was initiated on 5/27/25.  RN 3 was hired on 10/8/18.  RN 3 was provided the annual TB screening test on 6/25/24.  However, there was no documented evidence the TB skin test screening was read for a result.On 5/27/25 at 1430 hours, an interview and concurrent hospice document review was conducted with the Business Manager.  The Business Manager was informed and acknowledged the above findings.On 5/28/25 at 1345 hours, the DPCS/DQM was informed and acknowledged the above findings.  Review of the agency's Wound Care Protocol undated showed all wound will be measured and photograph at the time of initiation of wound care order.  Wounds require a complete review at a minimum every week which includes measurements.  The complete review of wounds (performed in the wound flowsheet a minimum of every week must include the size of the wound, full flow sheet descriptions and newly uploaded photo. LVNs may obtain information, and must enter it in the flow sheet.2. Review of Patient 17's clinical record was initiated on 5/23/25.  The clinical record showed the SOC was 5/30/23.  The patient was certified for hospice services during the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24.Review of the LVN 7 notes dated 4/4/24 showed the patient was assessed to have a stage 2 pressure injury to the bilateral buttocks /coccyx.    The onset date was 4/4/24. Review of the Wound Flowsheet showed the patient was assessed to have a stage 2 pressure injury to the bilateral buttocks /coccyx.   The pressure injury was documented as active.  The wound flowsheet showed the SN had performed wound measurements  on 4/4, 4/5, 4/9, 4/15, 4/22, 5/6, 5/13, 5/20, 5/22, 5/26, 6/3, 6/10, 6/12, 6/17 and 6/19/24.However, review of the closed clinical record failed to show documented evidenced of the wound measurement was taken weekly from 4/22 to 5/6/24 as per agency's wound protocol. On 5/29/25 at 1127 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if the TB test was completed.  The the Director of Continuous Care reviewed the closed clinical record and replied no.  The Director of Continuous Care was informed and acknowledged the findings.      3.  Review of Patient 15's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was 10/12/23.  The patient was certified for hospice services during the certification period from 4/9/24 to 6/7/24.Review of the Wound Flowsheet showed the patient was assessed to have a suspected "DTI to the left lower torso hip".  The pressure injury was documented as active.  The wound flowsheet showed the SN had performed wound measurements on 4/17 and 5/10/24. However, the wound measurement of the patients suspected "DTI to the left lower torso hip" was taken more than a week as per agency's wound protocol.In addition, wound photographs of the patients suspected "DTI to the left lower torso hip" was taken on 4/17 and 5/8/24. However, review of the closed clinical record showed the wound photographs of the patients suspected "DTI to the left lower torso hip" was taken more than a week as per agency's wound protocol.On 5/29/25 at 1340 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged th e findings. 4.  Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification period from 2/4/25 to 4/4/25.Review of the RN Comprehensive visit notes dated 3/10/25 under the section of Wound Assessment and Care showed the patient was assessed to have a stage 2 pressure injury to the "lower back sacrum".  The wound onset date was 10/13/24.  The assessment showed: Wound bed - moist; bed color/percentage - red; wound edges- detached; peri wound skin - erythema; drainage amount- small; color - serosanguinous; odor- none.Further review of the Review of the RN Comprehensive visit notes dated 3/17/25 under the section of Wound Assessment and Care showed the patients was assessed to have an unstageable pressure injury to the "lower back sacrum". The wound onset date was 10/13/24.  The assessment showed: Wound bed - slough, moist; bed color/percentage - pink, yellow; wound edges- detached; peri wound skin - erythema; drainage amount- scant; color - serosanguinous; odor- none.However, the RN failed failed to include the wound measurement as part of the wound assessment.On 5/29/25 at 1450 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.  Review of the hospice’s P&P titled Administrator (undated) showed the Administrator is appointed and assumes responsibility for the day-to-day administration of the hospice program.  The hospice Administrator is the chief administrator of the hospice program, is employed by the hospice, reports to the Board of Directors and fulfills the responsibilities outlined in the job description of this position, including but not limited to:-implementing financial policies and procedures;-implementing, monitoring, and reporting on the hospice services;-assuring the quality of patient care;-resolving problems;-assuring the implementation of the QAPI program and safety activities; and-assuring open and timely communication.The hospice Administrator, with the Board of Directors, ensures that all care, treatment, and services provided by the hospice are in accordance with Federal, State, and local laws and regulations and consistent with accepted standards of practice. According to Standards of Quality Hospice Care 2005 Section 6.3 (a) (1) (2):-All persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment. Each examination shall include confirmation by the person performing the examination that the employee is physically and medically qualified to perform the duties to be assigned, and that employee has no health condition that would create a hazard to patients.-The initial health examination shall include a tuberculosis screening.  Tuberculosis screening shall occur annually thereafter. Review of the hospice P&P titled Health/Physical Requirements (undated) showed all employees and volunteers who work directly with patients and families must provide documented evidence of a medical examination, performed by a qualified physician, within six months of hire or the first day of volunteer service.  All employees and volunteers are required to have documented evidence of a tuberculin screening within six months of hire and prior to patient contact.  In addition: TB screening must be repeated every year for those who have patient contact. Review of the hospice’s P&P titled Wound Care Protocol undated showed all wound will be measured and photograph at the time of initiation of wound care order.  Wounds require a complete review at a minimum every week which includes measurements.  The complete review of wounds (performed in the wound flowsheet a minimum of every week must include the size of the wound, full flow sheet descriptions and newly uploaded photo. LVNs may obtain information and must enter it in the flow sheet. 1.Review of the employee files for Volunteers 1 and 2, and RN 3 was initiated on 5/27/25.  -Volunteer 1 was hired on 2/9/25.  However, there was no documented evidence a health examination was completed as per the hospice’s P&P.b.  Review of the employee file for Volunteer 2 was initiated on 5/27/25.  Volunteer 2 was hired on 10/16/23.  However, there was no documented evidence a health examination was completed as per the hospice’s P&P.c.  Review of the employee file for RN 3 was initiated on 5/27/25.  RN 3 was hired on 10/8/18.  RN 3 was provided the annual TB screening test on 6/25/24.  However, there was no documented evidence the TB skin test screening was read for a result.On 5/27/25 at 1430 hours, an interview and concurrent hospice document review was conducted with the Business Manager.  The Business Manager was informed and acknowledged the above findings.On 5/28/25 at 1345 hours, the DPCS/DQM was informed and acknowledged the above findings. 2. Review of Patient 17's clinical record was initiated on 5/23/25.  The clinical record showed the SOC was 5/30/23.  The patient was certified for hospice services during the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24.Review of the LVN 7 notes dated 4/4/24 showed the patient was assessed to have a stage 2 pressure injury to the bilateral buttocks /coccyx.    The onset date was 4/4/24. Review of the Wound Flowsheet showed the patient was assessed to have a stage 2 pressure injury to the bilateral buttocks /coccyx.   The pressure injury was documented as active.  The wound flowsheet showed the SN had performed wound measurements on 4/4, 4/5, 4/9, 4/15, 4/22, 5/6, 5/13, 5/20, 5/22, 5/26, 6/3, 6/10, 6/12, 6/17 and 6/19/24.However, review of the closed clinical record failed to show documented evidenced of the wound measurement was taken weekly from 4/22 to 5/6/24 as per agency's wound protocol. On 5/29/25 at 1127 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked if the TB test was completed.  The Director of Continuous Care reviewed the closed clinical record and replied no.  The Director of Continuous Care was informed and acknowledged the findings.       3.  Review of Patient 15's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was 10/12/23.  The patient was certified for hospice services during the certification period from 4/9/24 to 6/7/24.Review of the Wound Flowsheet showed the patient was assessed to have a suspected "DTI to the left lower torso hip".  The pressure injury was documented as active.  The wound flowsheet showed the SN had performed wound measurements on 4/17 and 5/10/24. However, the wound measurement of the patients suspected "DTI to the left lower torso hip" was taken more than a week as per agency's wound protocol.In addition, wound photographs of the patients suspected "DTI to the left lower torso hip" was taken on 4/17 and 5/8/24. However, review of the closed clinical record showed the wound photographs of the patients suspected "DTI to the left lower torso hip" was taken more than a week as per agency's wound protocol.On 5/29/25 at 1340 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.  4.  Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification period from 2/4/25 to 4/4/25.Review of the RN Comprehensive visit notes dated 3/10/25 under the section of Wound Assessment and Care showed the patient was assessed to have a stage 2 pressure injury to the "lower back sacrum".  The wound onset date was 10/13/24.  The assessment showed: Wound bed - moist; bed color/percentage - red; wound edges- detached; peri wound skin - erythema; drainage amount- small; color - serosanguinous; odor- none.Further review of the Review of the RN Comprehensive visit notes dated 3/17/25 under the section of Wound Assessment and Care showed the patients was assessed to have an unstageable pressure injury to the "lower back sacrum". The wound onset date was 10/13/24.  The assessment showed: Wound bed - slough, moist; bed color/percentage - pink, yellow; wound edges- detached; peri wound skin - erythema; drainage amount- scant; color - serosanguinous; odor- none.However, the RN failed to include the wound measurement as part of the wound assessment.On 5/29/25 at 1450 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the patients' clinical records were complete and accurate for five of 19 sampled patients (Patients  4, 6, 12, 13, and 15).  This failure had the potential for the patients to receive a substandard care and disrupt the continuity of care due to the clinical records were incomplete and inaccurate. Findings: --- Review of the hospice P&P titled Documentation Requirements (undated) showed documentation is completed by all hospice staff and volunteers whenever;- patient/caregiver visit occurs;- patient/caregiver phone conversations related to the patient’s condition or care occur;- community resource contact related to a patient/family/caregiver is initiated; and/or- physician or healthcare provider contact is made on behalf of the patient.All documentation contains complete, factual, essential, and accurate information.  Staff and volunteers clearly state what was seen (assessment), what was done (intervention) and how the patient/caregiver reacted (outcome).#.  Review of Patient 12’s clinical record was initiated on was initiated on 5/15/25.  The clinical record showed the SOC was on 9/17/24.  The patient was certified for hospice services during the certification periods from 3/16/25 to 5/14/25 and 5/15/25 to 7/13/25.A joint home visit with HA 1 to the patient’s ALF in ALF 1 was conducted on 5/15/25 at 0820 hours.  HA 1 offered the patient shower, but the patient refused.  HA 1 provided peri care.  HA 1 collected the trash from the trash can, made the patient’s bed, organized the patient’s clothes, and restock the patient’s peri care supplies.Review of the Adie Visit Note dated 5/15/25, showed HA 1 documented the patient refused her shower.  However, HA 1 failed to document the care she provided for the patient such as providing peri care, collecting the trash, making the bed, and organizing the patient’s clothes.  In addition, HA 1 documented 0 for pain.  However, HA 1 did not assess for pain.On 5/29/25 at 0925 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. 1. Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  a. Review of the Hospice Certification and Plan of Care for the certification period from 4/5/25 to 6/3/25, showed a wound care order for the patients stage 2 pressure injury to the lower sacrum. Review of the RN notes dated 4/21, 4/28, 5/5 and 5/12/25, showed on the section of intervention for wound care, showed a wound intervention for the patients stage 2 pressure injury to the lower sacrum.However, on the section of Wound Assessment and Care showed the RN documented "lower back/sacrum/decubitus/pressure ulcer unstageable" which was inconsistent. On 5/29/25 at 1416 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the finding. 2.  Review of Patient 6's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 6/1/24.  The patient was certified for hospice services during the certification period from 3/28/25 to 5/26/25. The Hospice Certification and Plan of Care for the certification period from 3/28/25 to 5/26/25, cited SN visit 1 to 3 wk 9 wk, 7 PRN for unanticipated symptoms management.   Review of the LVN 6 visit note dated 4/25 and 5/2/25 showed the LVN 6 had performed Wound Assessment and Care.   The SN documented a wound on the " left lower posterior medial dorsal inferior buttocks coccyx/skin tear Stage 2".However, the location and description of the wound was inaccurate.On 5/29/25 at 1518 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings. 3.  Review of Patient 4's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 3/3/24.  The patient was certified for hospice services during the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25.Review of the Hospice Certification and Plan of Care for the certification period from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25, showed a wound care order for the patients  skin tears, stage 1 and stage 2 pressure injury.However, the care plan failed to include the location of the patients skin tears, stage 1 and stage 2 pressure injury.On 5/29/25 at 1026 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.4.   Review of Patient 15's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was 10/12/23.  The patient was certified for hospice services during the certification period from 4/9/24 to 6/7/24.Review of the Wound Flowsheet showed the patient was assessed to have a stage 3 pressure injury to the "left lower medial distal outer buttocks coccyx"However, the location of the stage 3 pressure injury was inaccurate. On 5/29/25 at 1340 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the clinical records were authenticated and dated timely in accordance with the hospice's P&P for 12 of 19 sampled patients (Patients 1, 2, 4, 5, 6, 8, 10, 13, 14, 15, 17 and 18).  This failure had the potential risk of substandard care provided to these patients as their clinical information were not completed timely.Findings: --- Review of the hospice’s P&P titled Documentation Requirements (undated) showed documentation should be grammatically correct, accurate, and timely.  All visits should be completed and closed within 72 hours.  All documentation contains complete, factual, essential, and accurate information.  Staff and volunteers clearly state what was seen (assessment), what was done (intervention) and how the patient/caregiver reacted (outcome).#.  Review of Patient 18’s closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was on 4/1/24.  The patient was certified for hospice services during the certification period from 4/1/24 to 6/29/24 and 6/30/24 to 9/27/24.Review of the Medical Social Worker Visit Notes showed the following:- Dated 4/5/24, showed MSW 1 made a visit to the patient.  However, her visit note was electronically signed on 4/15/24, which was more than 72 hours from the visit date.- Dated 4/11/24, showed MSW 1 made a visit to the patient for her initial assessment.  However, her visit note was electronically signed on 4/23/24, which was more than 72 hours from the visit date.On 5/29/25 at 1429 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.#.  Review of Patient 2's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was on 5/25/24.  The patient was certified for hospice services during the certification periods from 3/21/25 to 5/19/25.Review Skilled Nursing Visit Note showed the following:- Dated 3/31/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 4/6/25, which was more than 72 hours from the visit date.- Dated 4/3/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 4/11/25, which was more than 72 hours from the visit date.- Dated 4/10/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 4/17/25, which was more than 72 hours from the visit date.- Dated 4/14/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 4/23/25, which was more than 72 hours from the visit date.- Dated 4/21/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 5/3/25, which was more than 72 hours from the visit date.- Dated 4/28/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 5/7/25, which was more than 72 hours from the visit date.- Dated 5/6/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 5/16/25, which was more than 72 hours from the visit date.- Dated 5/12/25, showed RN 6 made a visit to the patient. However, her visit note was electronically signed on 5/16/25, which was more than 72 hours from the visit date.On 5/29/25 at 1301 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. #.  Review of Patient 5's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was on 1/20/24.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25.Review of Face-to-Face Encounter Communication dated 3/9/25, showed Medical Doctor 2 created a face-to-face narrative documentation note for an encounter on 2/25/25.  However, Medical Doctor 2 electronically signed the face-to-face narrative documentation note on 3/9/25 for an encounter on 2/25/25, which was more than 72 hours from the visit date.Review of Face-to-Face Encounter Communication dated 5/18/25, showed Medical Doctor 2 created a face-to-face narrative documentation note for an encounter on 4/24/25.  However, Medical Doctor 2 electronically signed the face-to-face narrative documentation note on 5/18/25 for an encounter on 4/24/25, which was more than 72 hours from the visit date.On 5/29/25 at 1101 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding. The agency P&P titled Verification of Physician Orders undated, showed the original order is delivered to the physician for his/her electronic signature at regular intervals, typically once a week.Review of the hospice P&P titled Documentation Requirement undated showed documentation should be grammatically correct, accurate and timely.  All visits should be completed and closed within 72 hours.  All documentation contains complete, factual, essential and accurate information.  If late entry is done in the electronic medical record, staff must use the date for the entry was made and indicate "late entry" within the record. 1.Review of Patient 13's clinical record was initiated on 5/16/25.  The clinical record showed the SOC was 4/10/24.  The patient was certified for hospice services during the certification periods from 2/4/25 to 4/4/25 and 4/5/25 to 6/3/25.  a. Review of the Patient Care Order (Verbal Order) for the certification period from 2/4/25 to 4/4/25 showed the RN 4 obtained a verbal orders on the following dates: - on 3/1/25.  However, the MD 1 electronically signed the order on 4/8/25,-on 2/22, 2/18, and 2/9/25.  However, the MD 1 electronically signed the order on 3/27/25 which was more than a week as per P&P. -A Chaplain 2 verbal order on 2/4/25.  The MD 1 electronically signed the order on 3/27/25.  However, the MD 1 electronically signed the orders more than a week as per P&P. b. Review of the Patient Care Order (Verbal Order) for the certification period from 4/5/25 to 6/3/25 showed the following:-An MSW 1 order dated 4/5/25.  The MSW 1 electronically signed the order on 5/14/25. -An RN 3 verbal order dated 4/4/25.  The RN 3 electronically signed the order on 5/14/25.-A Chaplain 2 verbal order dated 4/5/25.  The Chaplain 2 electronically signed the order on 4/10/25However, the verbal orders were electronically signed/completed by the staff more than 72 hours from the verbal order was made as per P&P. c. Review of the RN visit note dated 3/17/25, showed the RN had performed a comprehensive assessment.However, review of the RN note showed the RN completed and electronically signed the visit on 3/22/25 which was more than 72 hours from the visit date.d. Review of Face-to-Face Encounter Communication dated 12/3/24, showed Medical Doctor 1 created a face-to-face narrative documentation note for an encounter on 11/25/24.  However, Medical Doctor 1 electronically signed the face-to-face narrative documentation note on 12/3/24 for an encounter on 11/25/24 which was more than 72 hours from the visit date.Review of Face-to-Face Encounter Communication dated 2/1/25, showed Medical Doctor 1 created a face-to-face narrative documentation note for an encounter on 1/4/25.  However, Medical Doctor 1 electronically signed the face-to-face narrative documentation note on 2/1/25 for an encounter on 1/4/25 which was more than 72 hours from the visit date.Review of Face-to-Face Encounter Communication dated 3/29/25, showed Medical Doctor 1 created a face-to-face narrative documentation note for an encounter on 3/6/25.  However, Medical Doctor 1 electronically signed the face-to-face narrative documentation note on 3/29/25 for an encounter on 3/6/25 which was more than 72 hours from the visit date.On 5/29/25 at 1450 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the findings. 2.  Review of Patient 14's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 12/12/24.  The patient was certified for hospice services during the certification period from 3/12/25 to 6/9/25.a. Review of the Patient Care Order (Verbal Order) for the certification period from 3/12/25 to 6/9/25 showed the following:-An MSW 1 order dated 3/20/25.  The MSW 1 electronically signed the order on 3/26/25. -An MSW 1 order dated 4/4/25.  The MSW 1 electronically signed the order on 4/9/25.  However, the verbal orders were electronically signed/completed by the MSW 1 more than 72 hours from the verbal order was made as per P&P.b. Review of the RN 5 visit notes dated 3/26/25 showed the RN had perform comprehensive assessment.  However, review of the note showed the RN 5 completed and electronically signed the visit on 3/22/25 which was more than 72 hours from the visit date.Further review of the RN 5 notes dated 5/8/25, showed the RN had performed comprehensive assessment.  However, review of the note showed the RN 5 completed and electronically signed the visit on 5/12/25 which was more than 72 hours from the visit date.In addition, review of the LVN 1 visit note dated 4/8/25 showed the LVN had performed a routine visit assessment.  However, review of the note showed the LVN 1 completed and electronically signed the visit on 4/14/25 which was more than 72 hours from the visit date.On 5/29/25 at 1554 hours, an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was informed and acknowledged the finding. 3.  Review of Patient 1's clinical record was initiated on 5/14/25.  The clinical record showed the SOC was 8/30/24.  The patient was certified for hospice services during the certification periods from 2/26/25 to 4/26/25 and 4/27/25 to 6/25/25.  The patient was admitted for palliative service. Review of the RN 3 visit notes dated 4/28/25, showed the RN had performed a comprehensive assessment.However, review of the RN 3 notes showed the RN completed and electronically signed the visit on 5/4/25 which was more than 72 hours from the visit date.In addition, review of the Patient Care Order (Verbal Order) dated 4/4/25, showed a verbal order was written by the RN 3.  However, the RN 3 electronically signed the verbal order on 5/14/25 which was more than 72 hours from the verbal order was made as per P&P.On 5/29/25 at 0856 hours an interview and concurrent clinical record review was conducted with the Director of Continuous Care.  The Director of Continuous Care was asked as to the timeline for the staff to complete the verbal orders.  The Director of Continuous Care replied, it should have been electronically signed on the date and time the order was obtained.  The Director of Continuous Care was informed and acknowledged the findings.4.  Review of Patient 6's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 6/1/24.  The patient was certified for hospice services during the certification periods from 3/28/25 to 5/26/25.a.  Review of the RN 5 visit notes dated 4/3/25, showed the RN had performed a comprehensive assessment.However, review of the RN 5 visit note showed the RN completed and electronically signed the visit on 5/4/25 which was more than 72 hours from the visit date.b.  Review of Face-to-Face Encounter Communication dated 4/14/25, showed Medical Doctor 2 created a face-to-face narrative documentation note for an encounter on 3/16/25.  However, Medical Doctor 2 electronically signed the face-to-face narrative documentation note on 4/14/25 for an encounter on 3/16/25, which was more than 72 hours from the visit date.On 5/29/25 at 1518 hours an interview and concurrent clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the finding.5.   Review of Patient 17's clinical record was initiated on 5/23/25.  The clinical record showed the SOC was 5/30/23.  The patient was certified for hospice services during the certification periods from 3/31/24 to 5/29/24 and 5/30/24 to 7/28/24.Review of Face-to-Face Encounter Communication dated 3/12/23, showed Medical Doctor 1 created a face-to-face narrative documentation note for an encounter on 2/17/23.  However, Medical Doctor 1 electronically signed the face-to-face narrative documentation note on 3/12/23 for an encounter on 2/17/23 which was more than 72 hours from the visit date. Review of Face-to-Face Encounter Communication dated 4/14/24, showed Medical Doctor 2 created a face-to-face narrative documentation note for an encounter on 3/11/24.  However, Medical Doctor 2 electronically signed the face-to-face narrative documentation note on 4/14/24 for an encounter on 3/11/24 which was more than 72 hours from the visit date.On 5/29/25 at 1059 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.6.  Review of Patient 4's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 3/3/24.  The patient was certified for hospice services during the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25.Review of Face-to-Face Encounter Communication dated 3/5/25, showed Medical Doctor 1 created a face-to-face narrative documentation note for an encounter on 2/25/25.  However, Medical Doctor 1 electronically signed the face-to-face narrative documentation note on 3/5/25 for an encounter on 2/25/25 which was more than 72 hours from the visit date.Review of Face-to-Face Encounter Communication dated 4/30/25, showed Medical Director created a face-to-face narrative documentation note for an encounter on 4/5/25.  However, Medical Director electronically signed the face-to-face narrative documentation note on 4/30/25 for an encounter on 4/5/25 which was more than 72 hours from the visit date.On 5/29/25 at 1026 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.7.  Review of Patient 4's clinical record was initiated on 5/20/25.  The clinical record showed the SOC was 3/3/24.  The patient was certified for hospice services during the certification periods from 3/3/25 to 5/1/25 and 5/2/25 to 6/30/25.Review of the HA 3 visit notes showed the the following:-On 3/24/25, HA 3 had visited the patient. However, the HA 3 had completed and electronically signed the visit on 3/29/25 which was more than 72 hours from the visit date.-On 3/26/25, HA 3 had visited the patient. However, the HA 3 had completed and electronically signed the visit on 3/30/25 which was more than 72 hours from the visit date.-On 3/31/25, HA 3 had visited the patient. However, the HA 3 had completed and electronically signed the visit on 4/5/25 which was more than 72 hours from the visit date.On 5/29/25 at 1026 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.8.   Review of Patient 8's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 7/14/23.  The patient was certified for hospice services during the certification periods from 3/15/25 to 5/13/25 and 5/14/25 to 7/12/25.The Hospice Certification and Plan of Care for the certification periods from 3/15/25 to 5/13/25 cited SN visits 1-3 wk 12 wk, 10 PRN for unanticipated symptom management.a.  Review of the RN 3 visit notes on the following date showed:-on 4/3/25 a visit was conducted, the visit notes were completed and signed on 4/8/25,-on 4/17/25 a visit was conducted, the visit notes were completed and signed on 4/29/25,-on 4/28/25 a visit was conducted, the visit notes were completed and signed on 5/4/25,-on 5/2/25 a visit was conducted, the visit notes were completed and signed on 5/15/25 -on 5/6/25 a visit was conducted, the visit notes were completed and signed on 5/20/25,-on 5/16/25 a visit was conducted, the visit notes were completed and signed on 5/21/25 andHowever,  the RN 3 completed and electronically signed the visit notes more than 72 hours from the visit date.b.  Review of the MSW 1visit notes on the following date showed: -on 4/17/25 a visit was conducted, the visit notes were completed and signed on 4/25/25,-on 4/23/25 a visit was conducted, the visit notes were completed and signed on 4/27/25 and-on 4/29/25 a visit was conducted, the visit notes were completed and signed on 5/21/25.However,  the MSW 1 completed and electronically signed the visit notes more than 72 hours from the visit date.On 5/29/25 at 1501 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.9.  Review of Patient 10's clinical record was initiated on 5/21/25.  The clinical record showed the SOC was 1/7/24.  The patient was certified for hospice services during the certification periods from 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25.Review of Face-to-Face Encounter Communication dated 3/2/25, showed Medical Doctor 2 created a face-to-face narrative documentation note for an encounter on 2/4/25.  However, Medical Doctor 2 electronically signed the face-to-face narrative documentation note on 3/2/25 for an encounter on 2/4/25 which was more than 72 hours from the visit date.Review of Face-to-Face Encounter Communication dated 4/26/25, showed Medical Doctor 2 created a face-to-face narrative documentation note for an encounter on 4/13/25.  However, Medical Doctor 2 electronically signed the face-to-face narrative documentation note on 4/26/25 for an encounter on 4/13/25 which was more than 72 hours from the visit date.On 5/29/25 at 1257 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.10. Review of Patient 15's clinical record was initiated on 5/22/25.  The clinical record showed the SOC was 10/12/23.  The patient was certified for hospice services during the certification period from 4/9/24 to 6/7/24.Review of the RN Initial Assessment dated 10/16/23, showed the RN 8, performed the initial assessment.  The RN 8 completed and electronically signed the visit notes on 10/16/23 more than 72 hours from the visit date.Review of the Chaplain 2 Bereavement Visit -After Date, showed the Chaplain 2 performed a visit.  The Chaplain 2 completed and electronically signed the visit notes on 5/31/24  more than 72 hours from the visit date.In addition, review of the of Face-to-Face Encounter Communication dated 3/30/24, showed Medical Doctor 1 created a face-to-face narrative documentation note for an encounter on 3/13/24.  However, Medical Doctor 1 electronically signed the face-to-face narrative documentation note on 3/30/24 for an encounter on 3/13/24 which was more than 72 hours from the visit date. On 5/29/25 at 1340 hours an interview and concurrent closed clinical record review was conducted with the Director of Continuous Care. The Director of Continuous Care was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure a copy of the discharge summary was forwarded to the physician for one of five sampled patients (Patient 18) who revoked the election of hospice.  This failure had the potential of not communicating the post-discharge care needs of the patient to the physician.Findings: --- Review of the hospice’s P&P titled Revocation of the Medicare Hospice Benefit (undated) showed when a revocation occurs, the hospice sends a discharge summary to the attending physician. Review of Patient 18’s closed clinical record was initiated on 5/23/25.  The clinical record showed the SOC was on 4/1/24.  The patient was certified for hospice services during the certification periods from 4/1/24 to 6/29/24 and 6/30/24 to 9/27/24.  The patient was discharged and revoked hospice services on 7/25/24. Review of the clinical record showed a discharge summary was completed on 7/31/25.  However, there was no documented evidence to show the physician was provided a copy of the discharge summary. On 5/29/25 at 1236 hours, an interview and concurrent clinical record review was conducted with the DPCS/DQM.  The DPCS/DQM was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan and P&Ps included the procedures to inform the State officials of any on-duty staff that they were unable to contact in the event of an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. Findings: Review of the hospice's emergency preparedness plan was initiated on 8/24/22. The hospice's emergency preparedness plan and P&Ps included the procedures to inform the local officials of any on-duty staff and patients that they were unable to contact; however, it did not include the procedure to specifically inform the State officials of any on-duty staff they were unable to contact in the event of an emergency. On 8/25/22 at 1152 hours, an interview and concurrent record review was conducted with the DQM. The DQM was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan and P&Ps included the information related to the alternate means for communicating with the Federal and State agencies. This failure created the risk of not being able to communicate to meet the patient and staff needs during an emergency. Findings: Review of the hospice's emergency preparedness plan was initiated on 8/24/22. The hospice's emergency preparedness plan and P&Ps showed the primary and alternate means of communicating with the hospice's own staff and local agencies; however, it did not include the alternate means of communicating with the Federal and State emergency management agencies. On 8/25/22 at 1152 hours, an interview and concurrent record review was conducted with the DQM. The DQM was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments included the assessments for the needs of volunteer services for ten of 13 sampled patients (Patients 1, 2, 3, 5, 6, 7, 8, 10, 11, and 12), creating the risk of not identify care needs for these patients. Findings: Review of the clinical records for Patients 1, 2, 3, 5, 6, 7, 8, 10, 11, and 12 showed no documented evidence the patients' needs for volunteer services were assessed during their initial comprehensive assessments for these patients. For example: 1. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The initial comprehensive nursing, psychosocial and spiritual assessments dated 7/19 and 7/21/22, showed no documented evidence of the assessment of the patient's need for volunteer services. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Patient 3's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The initial comprehensive nursing, psychosocial and spiritual assessments dated 12/4 and 12/7/21, showed no documented evidence of the assessment of the patient's need for volunteer services. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings.

3. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The medication profile dated 9/6/22, showed the patient's medication included hydralazine (antihypertensive) 25 mg one tablet PO Q eight hours PRN. * However, there was no documented evidence of the indication on when to administer hydralazine 25 mg one tablet PO Q eight hours PRN. 4. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The medication profile, for the certification period from 8/11/22 to 11/8/22, showed the patient's medication included lorazepam (anxiolytic) 1 mg one to two tablets Q four hours PRN for agitation/restlessness; morphine sulfate (opioid analgesic) 20 mg/ml 1-2 mg Q one hour PRN for pain/SOB; atropine sulfate (used for excessive secretions) 1% one to two "solution" ophthalmic Q four hours PRN * However, there was no documented evidence on when to administer lorazepam 1 mg one to two tablets; morphine sulfate 20 mg/ml 1-2 mg; and atropine sulfate 1% one to two "solution." On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2. They were informed and acknowledged the findings. 5. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. The medication profile, for the certification period from 1/24/22 to 4/23/22, showed the patient's medication included morphine sulfate 20 mg/ml 1-2 mg Q one hour PRN for pain/SOB; oxycodone (opioid analgesic) 10 mg one tablet PO Q eight hours PRN for pain; and Senna 8.6 mg one to two tablet QD PRN for constipation. * However, there was no directions on which pain medication to be administered first. In addition, there was no documented evidence on when to administer one or two tablet of Senna. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings. Based on interview and record review, the hospice failed to ensure the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use for 10 of 19 sampled patients (Patients 1, 3, 4, 7, 8, 10, 11, 13, 16, and 18). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health condition. Findings: 1. Review of Patient 8's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 2/9/22. The patient was certified for hospice services during the certification periods from 5/10/22 to 8/7/22, and 8/8/22 to 10/6/22. Review of the Medication Profile showed Patient 8 was on multiple pain medications including acetaminophen-hydrocode (medication used to relieve moderate to severe pain) 325 mg-5 mg PO Q six hours PRN for pain and morphine (opioid analgesic) 0.25 ml SL Q four hours PRN for pain. However, there was no specific indication showing when to give acetaminophen-hydrocodone versus morphine. On 8/25/22 at 1010 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the finding. 2. Review of Patient 10's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 11/9/20. The patient was certified for hospice services during the certification period from 7/2/22 to 8/30/22. Review of the Medication Profile showed Patient 10 was on multiple pain medications including the following: -morphine 0.25 ml SL Q four hours PRN for pain; -tramadol (narcotic) 50 mg PO Q six hours PRN for pain management; -acetaminophen (analgesic) 15 ml PO Q six hours PRN for pain; -morphine 7.5 mg PO Q four hours PRN for pain; and -acetaminophen 500 mg PO Q six hours PRN for pain. However, there was no specific indication or parameter showing when to administer each pain medication. On 8/25/22 at 0938 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was and acknowledged the finding. 3. Review of Patient 16's closed clinical record was initiated on 8/22/22. The closed clinical record showed the SOC was 8/23/21. The patient was certified for hospice services during the certification period from 2/19/22 to 4/19/22. Review of the Medication Profile showed Patient 16 was on multiple pain medications including morphine 0.25 ml SL Q four hours PRN for pain and morphine 7.5 mg PO Q three hours PRN. However, there was no specific parameter or indication listed for both pain medications. On 8/25/22 at 0957 hours, an interview and concurrent closed clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the finding. 4. Review of Patient 18's closed clinical record was initiated on 8/18/22. The closed clinical record showed the SOC was 6/7/21. The patient was certified for hospice services during the certification period from 6/7/21 to 9/4/21. Review of the Medication Profile showed Patient 18 was on multiple pain medications including morphine 0.25 ml SL Q four hours PRN for pain and tramadol 50 mg PO Q 12 hours PRN for pain. However, there was no specific parameter or indication listed for both pain medications. On 8/25/22 at 0943 hours, an interview and concurrent closed clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the finding. 9. Review of Patient 1's clinical record was initiated on 8/16/22. The clinical record showed the SOC was 6/10/22. The patient was certified for hospice services during the certification periods from 6/10/22 to 9/7/22. The patient lived in a board and care facility. The Medication Profile for the certification period from 6/10/22 to 9/7/22, showed the patient's medications included the following medications: * acetaminophen 500 mg one tablet PO Q four hours PRN for pain NTE 3 g in 24 hours. * acetaminophen 500 mg oral tablet BID PRN routinely for pain NTE 3 g in 24 hours from all sources * Robafem DM Cough and Chest Congestion 20 mg -200 mg/10 ml oral liquid 10 ml PO Q four hours PRN for cough * imodium A-D (antidiarrheals) 2 mg oral tablet one tablet PO Q four hours PRN for diarrhea * wound compound 0.0024/5/2 cream apply topically three times a week A joint home visit with RN 2 to the patient's board and care facility was conducted on 8/16/22 at 0830 hours. An interview with concurrent clinical record review was conducted with RN 2 and the board and care facility staff. The following was identified: - RN 2 stated the pain level was not written and should be specific in the medication profile for acetaminophen 500 mg one tablet PO Q four hours PRN for pain NTE 3 g in 24 hours. - When asked about the BID PRN frequency for acetaminophen (analgesic) 500 mg oral tablet BID PRN routinely for pain NTE 3 g in 24 hours from all sources. RN 2 stated the instructions should be written as routinely and a PRN should have been removed. - The written instruction on the bottle of Robafem DM Cough and Chest Congestion showed Q six hours instead of Q four hours as per the Medication Profile. - The written instruction on the bottle of imodium A-D was to give two tablets instead of one tablet as per the Medication Profile. - When asked about the wound care frequency, RN 2 stated the wound care was daily since 7/2/22, using the wound compound. RN 2 acknowledged the frequency for wound compound should have been revised to daily instead of three times a week as per the Medication Profile. On 8/25/22 at 0938 hours, the DPCS was informed and acknowledged the findings. 10. Review of Patient 11's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 5/11/22. The patient was certified for hospice services during the certification periods from 5/11/22 to 8/8/22, and 8/9/22 to 11/6/22. The patient revoked hospice service on 8/16/22. The Hospice Certification and Plan of Care, for the certification period 8/9/22 to 11/6/22, showed the patient's medications included morphine (narcotic) 20 mg/ml oral concentrate 0.25 ml sublingual Q four hours PRN and norco (narcotic analgesic) 325 mg - 5 mg oral tablet one tablet PO Q six hours PRN for pain However, there was no specific indication as to which pain level to administer the PRN morphine and norco. On 8/25/22 at 1051 hours, an interview with concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the POC for -- of 13 sampled patients (Patients 8, 13--), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 7/18/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. The physician's order dated 8/19/22, showed Calmoseptine to coccyx and buttocks PRN for skin protection * However, there was no documented evidence the patient's POC included the use of Calmoseptine until 8/19/22. Cross reference L 554 b. The physician's order dated 7/18/22, showed peritoneal drainage with sterile technique once a week not to exceed one liter. The SN note dated 7/19/22, showed the patient had a drain on the right side of the abdomen. Documentation showed with sterile technique 1500 cc was drained of clear fluid. The SN note dated 7/21/22, showed peritoneal catheter was drained. Documentation showed 1600 ml of yellow fluid. The SN note dated 7/25/22, showed peritoneal catheter drained for 1100 ml of yellow fluid. The SN note dated 7/28/22, SN drained peritoneal catheter for 1100 ml of yellow fluid. The SN note dated 8/1/22 at 1230 hours, showed peritoneal drain in place and drained approximately 100 ml yellow fluid. The SN note dated 8/5/22, showed 1750 ml of peritoneal cavity was drained. The SN note dated 8/8/22, showed SN drained 1400 cc of clear liquid with aseptic technique The SN note dated 8/15/22, showed using aseptic technique the SN drained 1.25 liter of abdominal fluid The SN note dated 8/24/22, showed peritoneal catheter was drained for 1200 ml yellow fluid * However, the amount obtained from the peritoneal drainage procedure was more than one liter wherein as per POC, it should not exceed one liter. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1 and LVN 1. RN 1 stated the family member wanted to draw more fluid. c. The physician's order dated 7/18/22, showed SN visit three times a week and 3 PRN * The SN notes showed the SN conducted two visits during Week 2 (7/24/22 to 7/30/22), instead of three visits. The IDG Comprehensive Assessment Details dated 8/23/22, showed SN visits 3W * The SN notes showed the SN conducted two visits during Week & (8/28/22 to 9/3/22), instead of three visits. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1 and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 8's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 2/9/22. The patient was certified for hospice services during the certification period from 5/10/22 to 8/7/22. The POC, for the certification period from 5/10/22 to 8/7/22, showed to assess and evaluate cardiac, respiratory, GI, GU, pain, mobility, skin, nutrition/hydration, comfort level and symptom management, disease progression, safety and family/caregiver needs during each comprehensive assessment. The interventions included SN to monitor the temperature and respiratory symptoms. Review of the SN notes showed the SN did not consistently assess the patient's blood pressure, temperature, and/or oxygen saturation level. For example, the SN note dated 7/20/22, showed the SN visit was conducted to the patient's home after the patient experienced an unwitnessed fall. However, there was no documented evidence showing the SN had assessed the patient's blood pressure, temperature, and oxygen saturation level. On 8/25/22 at 1010 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. 3. Review of Patient 12's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 2/15/22. The patient was certified for hospice services during the certification period from 5/16/22 to 8/13/22. Review of the Verbal Order dated 5/17/22, cited MSW visits one to four times per month for three months and one PRN visit for unmet needs. Review of Patient 12's clinical record showed the MSW visited the patient on 5/17/22. However, further review of the clinical record showed no documented evidence the MSW visited the patient for June and July 2022. On 8/25/22 at 0929 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 acknowledged the findings. Clinical Manager 1 stated it was possible the patient denied the need for MSW services, but verified the MSW should have documented the attempts to visit since the order was not discontinued. 4. Review of Patient 9's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 1/6/22. The patient was certified for hospice services during the certification periods from 4/6/22 to 7/4/22, and 7/5/22 to 9/2/22. The POC, for the certification period from 7/5/22 to 9/2/22, showed to assess and evaluate the cardiac, respiratory, GI, GU, pain, mobility, skin, nutrition/hydration, comfort level and symptom management, disease progression, safety and family/caregiver needs during each comprehensive assessment. a. Review of the SN note dated 7/8/22 showed the SN performed the body system assessment. The assessment included wound assessment and care for Stage 2 pressure injuries on the "Left Buttocks Coccyx" and "Posterior Buttocks Coccyx." However, review of the SN notes dated 7/23 and 7/24/22, failed to show the SN had performed the wound assessments. b. Review of the Hospice Comprehensive Assessment dated 8/2/22, showed the RN had performed body system assessment. The assessment included cardiovascular system showing the patient had grade 2 moderate pitting edema to the calves and thighs. However, review of the SN visit note dated 8/9/22, showed no documented evidence the SN had performed cardiovascular assessment to include edema of the calves and thighs. On 8/25/22 at 1109 hours, an interview with concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. 5. Review of the hospice's P&P titled Wound Protocol undated, showed all pressure wounds must be staged within the flowsheet description. Review of Patient 15's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 12/9/22. The patient was certified for hospice services during the certification period from 2/20/22 to 4/20/22. Review of the Hospice Comprehensive Assessment dated 3/7 and 3/22/22, showed the RN had performed wound assessment. The patient was assessed to have a pressure injury to the right posterior outer heel. Review of the SN visit notes dated 3/17, 3/25, 3/27, and 3/29/22, showed the SN performed wound assessment and care to the patient's pressure injury to the right posterior outer heel. However, there was no documented evidence of the stage of the right outer posterior heel pressure injury. On 8/25/22 at 1220 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings.

Based on interview and record review, the agency failed to ensure the individualized care plans were developed for eight of 13 sampled patients (Patients 2, 3, 4, 5, 6, 7, 10, and 12). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health condition. Findings: Review of the clinical records for Patients 2, 3, 4, 5, 6, 7, 10, and 12 showed no documented evidence the individualized care plans were developed to address the identified problem and care needs for these patients. For example: 1. Review of Patient 2's clinical record was initiated on 9/20/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/18/22, showed the patient had a "Foley catheter" which was last changed on 7/15/22. Review of the patient's care plan showed a care plan problem addressing patient's "Foley/Supra-pubic catheter/Renal issues and or Incontinence" * However, the patient's care plan was not individualized as to what the patient had. The SN note dated 7/19/22, showed the patient had a drain site on the right side of the abdomen The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. Cross reference L554 b. The physician's order dated 7/18/22, showed peritoneal drainage with sterile technique once a week not to exceed one liter. The SN note dated 7/21/22, showed peritoneal catheter was drained. Documentation showed 1600 ml of yellow fluid. The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. The SN note dated 8/1/22, showed the patient's penis had a small amount of yellow drainage. Documentation showed the daughter was educated to use soap and water to clean the penis as the solution she was using is irritating The SN note dated 8/29/22 showed the patient had slight throat pain due to thrush which is being treated with Nystatin (anti-fungal) oral suspension. The SN note dated 9/5/22, showed the patient had hiccups all night long. Documentation showed the physician was notified with new order for Thorazine (antipsychotic) * However, review of the patient's care plan showed no documented evidence the care plan was developed for the identified problem such as peritoneal drainage; coccyx redness; thrush; hiccups and use of Thorazine; On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. a. The physician's order dated 12/4/21, showed lorazepam (anxiolytic) 0.5 mg one tablet PO PRN for anxiety/agitation/SOB. b. The physician's order dated 7/8/22, showed nystatin (antifungal) 100,000 u/gm one application Q 12 hours c. The PT notes dated 8/12, 8/22, and 8/29/22, showed the patient received PT. * However, review of the patient's care plan showed no documented evidence the care plan was developed to address the use of lorazepan, nystatin, and PT services. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. Based on interview and record review, the agency failed to ensure the individualized care plans were developed for 10 of 19 sampled patients (Patients 3, 4, 5, 6, 9, 10, 11, 12, 13, and 15). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health condition. Findings: Review of the clinical records for Patients 3, 4, 5, 6, 9, 10, 11, 12, 13, and 15 showed no documented evidence the individualized care plans were developed to address the identified problem and care needs for these patients. For example: 1. Review of Patient 6's clinical record was initiated on 8/15/22. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification period from 6/9/22 to 8/7/22. Review of the SN note dated 6/10/22, showed the SN had assessed the patient to have contractures with deconditioning, rigidity, and weakness. * However, review of the Interdisciplinary Care Plan showed no documented evidence the care plan was developed for the identified problems. On 8/25/22 at 1027 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. 3. Review of Patient 5's clinical record was initiated on 8/15/22. The clinical record showed the SOC was 3/12/21. The patient was certified for hospice services during the certification periods from 3/12/21 to 6/9/21, 6/10/21 to 9/7/21, 9/8/21 to 11/6/21, 11/7/21 to 1/5/22, 1/6/22 to 3/6/22, 3/7/22 to 5/5/22, 5/6/22 to 7/4/22, and 7/5/22 to 9/2/22. a. Review of the Hospice Comprehensive Assessment dated 7/4, 7/18, and 8/1/22, showed the SN had performed the body system assessment. The cardiovascular assessment included edema which was documented as anasarca (general swelling of the whole body that can occur when the tissues of the body retain too much fluid). Review of the SN notes dated 7/21 and 7/28/22, showed the SN had assessed the patient to have edema. * However, review of the Care Plan Documentation failed to show documented evidence the care plan was developed to address the patient's edema. b. Review of the Medication Profile dated 8/12/22, showed an order for ciprofloxacin (quinolones) 250 mg PO one tablet Q 12 hours for five days for suspected UTI. * However, review of the Care Plan Documentation failed to show documented evidence the care plan was developed to address the patient's suspected UTI. On 8/25/22 at 1030 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 4. Review of Patient 11's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 5/11/22. The patient was certified for hospice services during the certification periods from 5/11/22 to 8/8/22, and 8/9/22 to 11/6/22. The Hospice Certification and Plan of Care for the certification period 5/11/22 to 8/8/22, showed the patient's other pertinent diagnosis included diabetes, essential hypertension, and hypothyroidism. Review of the Interdisciplinary Group Conference Communication dated 5/11/22, showed the patient's comorbidities included Diabetes Type 2, hypertension, and hypothyroidism. * However, review of the Interdisciplinary Care Plan failed to show documented evidenced of of an individualized plan of care to address the patient's hypertension, diabetes and hypothyroidism. On 8/25/22 at 1051 hours, an interview with concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the findings. 5. Review of Patient 9's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 1/6/22. The patient was certified for hospice services during the certification periods from 4/6/22 to 7/4/22, and 7/5/22 to 9/2/22. Review of the Hospice Comprehensive Assessment dated 8/2/22, showed the RN had performed the body system assessment. The assessment included cardiovascular system showing the patient had grade 2 pitting edema to the calves and thighs. The Interdisciplinary Group Conference Communication dated 8/3/22, showed the IDG discussed the patient's medication profile, care plans, and visit frequencies. * However, review of the clinical record failed to show documented evidenced an individualized care plan was developed to address the patient's edema to the calves and thighs. On 8/25/22 at 1109 hours, an interview with concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the POC included the frequency of services necessary to meet specific patient and family needs for two of 19 sampled patients (Patients 12 and 15). This failure created the risk of not providing the necessary services for these patients. Findings: 1. Review of Patient 12's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 2/15/22. The patient was certified for hospice services during the certification period from 5/16/22 to 8/13/22. The initial POC, for the certification period from 5/16/22 to 8/13/22, showed no documented evidence of the visit frequencies for the MSW. The Verbal Order dated 5/17/22, showed MSW visits one to four times per month for three months and one PRN visit for unmet needs. The order showed the start date was 5/17/22, and the end date was 7/31/22. Further review of the clinical record showed no documented evidence of the MSW visit frequencies for the duration from 8/1/22 to 8/13/22. On 8/25/22 at 0929 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. 2. Review of Patient 15's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 12/9/22. The patient was certified for hospice services during the certification period from 2/20/22 to 4/20/22. a. Review of the closed clinical record showed the volunteer provided services on 2/28, 3/20, and 3/27/22. However, review of the Hospice Certification and Plan of Care from 2/20/22 to 4/20/22, failed to show documented evidenced of the Volunteer visit frequency included in the discipline orders. b. Review of the closed clinical record dated 3/31/22, showed the Chaplain provided a post death telephone call. However, the Hospice Certification and Plan of Care from 2/20/22 to 4/20/22, failed to show documented evidenced of the Chaplain visit frequency was included in the discipline orders. On 8/25/22 at 1220 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings.

b. Review of Patient 8's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 2/9/22. The patient was certified for hospice services during the certification periods from 5/10/22 to 8/7/22, and 8/8/22 to 10/6/22. Review of the Interdisciplinary Care Plan showed the patient's identified problems included alteration in urinary elimination and constipation. The goals were established for these identified problems. However, the goals listed were not measurable and specific to the patient's care needs. For example, the goal for alteration in urinary elimination was for the patient/caregiver to verbalize understanding/demonstrate adequate fluid intake. There was no documented evidence showing what was the expected adequate fluid intake for the patient. On 8/25/22 at 1010 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. c. Review of Patient 10's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 11/9/20. The patient was certified for hospice services during the certification period from 7/2/22 to 8/30/22. Review of the Interdisciplinary Care Plan showed the patient's identified problems included altered nutrition/hydration status. The goal listed was for the patient's nutritional needs be met as the patient's condition/comfort allows. There was no documented evidence showing the measurable nutritional needs for the patient. On 8/25/22 at 0938 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. Based on record review and interview, the hospice failed to ensure the POCs included measurable outcomes for six of 13 sampled patients (Patients 1, 4, 5, 7, 11, and 12 ), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: Review of the clinical records for Patients 1, 4, 5, 7, 11, and 12 showed the POCs did not include the measurable outcomes anticipated to evaluate the effectiveness of the plan of care to meet the patients' needs. For example: 1. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The POC, for the certification period from 8/11/22 to 11/8/22, showed patient's identified problems with the established goals and interventions. However, the POC failed to include the measurable outcomes for the patient's identified problems. For example, the expected outcome for disease/diagnosis progression or other specified etiology was for the patient to achieve and maintain optimal/acceptable pain/discomfort relief as evidenced by assessed pain level with each SN visit and/or report from patient/family/caregivers However, there was no measurable outcome as to what the patient's optimal/acceptable pain/discomfort relief would be. On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2. They were informed and acknowledged the findings.

2. Review of Patient 19's clinical record was initiated on 8/22/22. The clinical record showed the SOC was 8/17/22. The patient was certified for hospice services during the certification periods from 6/11/22 to 9/8/22, and 6/6/22 to 9/3/22. The patient was transferred to the agency on 8/17/22. Review of the Hospice Certification and Plan of Care from 6/11/22 to 9/8/22, showed the treatment orders included the following: - Insert an indwelling urinary catheter every four to six weeks and PRN, may insert 16 French with 5 cc balloon catheter- if leaking, may change the size and increase the balloon size to 10 cc for incontinence or retention. Irrigate with 10 cc Normal Saline PRN for blockage or clot. - Insert a straight catheter PRN for urinary retention and bladder distention, or UA culture- 16 French with 5 cc balloon indwelling urinary catheter- if leaking, may change the size and increase balloon to 10 cc. However, review of the Hospice Initial Assessment dated 8/17/22, showed the GU system assessment. The assessment included the patient's urinary incontinence was being managed by diapers and proper skin care. In addition, review of the Hospice Comprehensive Assessment dated 8/18/22, showed the elimination pattern as voiding normally, incontinent, diapers, and proper skin care. On 8/25/22 at 0947 hours, an interview with concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the patient had an indwelling urinary catheter. The DPCS replied she did not know whether or not Patient 19 had an indwelling urinary catheter, the nurses should have not write the order in the POC. The DPCS further stated there were no mention of indwelling urinary catheter in the initial and comprehensive assessment. She was informed and acknowledged the findings. 3. Review of Patient 9's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 1/6/22. The patient was certified for hospice services during the certification periods from 4/6/22 to 7/4/22, and 7/5/22 to 9/2/22. Review of the Hospice Comprehensive Assessment dated 8/2/22, showed the RN had performed the body system assessment. The assessment showed the patient had a grade 2 pitting edema to the calves and thighs. The Interdisciplinary Group Conference Communication dated 8/3/22, showed the IDG discussed the patient's medication profile, care plans, and visit frequencies. However, the IDG failed to revise the POC to address the patient's edema to the calves and thighs. On 8/25/22 at 1109 hours, an interview with concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings. Based on record review and interview, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs at least every 15 days for -- of 13 sampled patients (Patients --), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed peritoneal drainage with sterile technique once a week not to exceed one liter. The SN note dated 8/1/22, showed the patient has been having "moderated ascites with order for peritoneal drainage 2 times a week. Drainage not to exceed 1 liter." On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1, and LVN 1. The Demonstrator stated the physician's order for the peritoneal drainage should be done twice a week and should never have been one a week. They were informed and acknowledged the findings. * The IDG failed to update the POC to address the frequency of the peritoneal drainage. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The IDG Comprehensive Assessment Details dated 8/23/22, showed HA visits 3W The HA notes showed the HA conducted five visits during Week 5 (8/28/22 to 9/3/22) * However, the HA visits conducted were not consistent with the POC On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. The Administrator stated the HA visit frequency should have been increased in the POC. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The patient was transferred to another hospice on 5/23/22. The SOC-Recertification-Continuation of Service Order dated 4/15/22, showed the first week of frequency was HA 3W then for the next eight weeks "Re evaluation for hospice criteria" The HA notes showed the HA conducted two visits during Week 1 (4/15/22 to 4/16/22). However, the visit frequency was not consistent with the HA visits. Further review of the HA notes showed the HA conducted visits on Week 2 (4/17/22 to 4/23/22), Week 3 (4/24/22 to 4/30/22), Week 4 (5/1/22 to 5/7/22), Week 5 (4/8/22 to 4/14/22), and Week 6 (4/15/22 to 4/21/22). However, there was no documented evidence on what was the HA visit frequency after Week 1. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. The Administrator stated the POC related to visit frequency should have been revised. They were informed and acknowledged the findings. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for one of 13 sampled patients (Patient --), creating the risk of not addressing the care needs for this patient. Findings: The hospice's P&P titled Interdisciplinary Group (undated), showed the hospice agency designates an IDG composed of qualified individuals who assess, plan, provide, and evaluate the care and services provided to hospice patients/caregivers. The IDG is responsible for establishing, implementing, reviewing, and revising the plan of care; providing or coordinating care and services in accordance with the patient's plan of care. 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 7/21/22, showed the patient had redness to coccyx. Documentation showed Calmoseptine (moisture barrier) was applied routinely. However, there was no documented evidence the SN had assessed for the size of the redness to coccyx. In addition, The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 5/19/22, showed the family member had concerns about a small healing bed sore at patient's right buttock. Documentation showed the family member was advised "continuing with A&D ointment and cover with dry dressing with no paper tape." However, there was no documented evidence the SN had assessed for the size and wound bed of the small healing bedsore. The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

4. Review of Patient 9's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 1/6/22. The patient was certified for hospice services during the certification periods from 1/6/22 to 4/5/22, 4/6/22 to 7/4/22, and 7/5/22 to 9/2/22. The POC, for the certification period from 7/5/22 to 9/2/22, showed to perform assessment and evaluate the cardiac, respiratory, GI, GU, pain, mobility, skin, nutrition/hydration, comfort level and symptom management, disease progression, safety and family/caregiver needs during each comprehensive assessment. Review of the Hospice Comprehensive Assessment dated 8/2/22, showed the RN had performed the body system assessment. The patient was assessed to have grade 2 moderate pitting edema to the calves and thighs. Review of the SN note dated 8/11/22, showed the SN had performed cardiovascular assessment. The cardiovascular assessment showed the patient had a grade 2 moderate pitting edema to the calves and thighs However, review of the clinical record failed to show documented evidenced of the physician was notified of the patient's grade 2 pitting edema to the calves and thighs. On 8/25/22 at 1127 hours, an interview with concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was asked if the physician was notified of the edema. The Clinical Manager 1 replied there was no documentation of the physicians notification. She was informed and acknowledged the findings. Based on interview and record review, the hospice failed to communicate with the physician regarding the patients' care needs for four of 19 sampled patients (Patients 2, 6, 8, and 9). This failure created the risk of not providing the necessary care and services to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 8/16/22. The clinical record showed the SOC was 6/25/22. The patient was certified for hospice services during the certification period from 6/25/22 to 9/22/22. The POC, for the certification period from 6/25/22 to 9/22/22, showed to perform assessment of the cardiovascular status for signs and symptoms of cardiac complications. Review of the SN note dated 6/28/22, showed the patient's blood pressure was 168/88 mmHg. However, there was no documented evidence showing the SN had reassessed the patient's blood pressure or notified the physician regarding the patient's increased blood pressure. On 8/25/22 at 1035 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings. Clinical Manager 1 stated the SN should have reassessed the patient's blood pressure and notified the physician. 2. Review of Patient 6's clinical record was initiated on 8/15/22. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification period from 6/9/22 to 8/7/22. The POC, for the certification period from 6/9/22 to 8/7/22, showed to perform assessment and evaluate the cardiac, respiratory, GI, GU, pain, mobility, skin, nutrition/hydration, comfort level and symptom management, disease progression, safety and family/caregiver needs during each comprehensive assessment. Review of the SN note dated 8/5/22, showed the patient's blood pressure was 88/54 mmHg. However, there was no documented evidence showing the SN had reassessed the patient's blood pressure or notified the physician regarding the patient's decreased blood pressure. On 8/25/22 at 1027 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings. Clinical Manager 1 stated the SN should have reassessed the patient's blood pressure and notified the physician. 3. Review of Patient 8's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 2/9/22. The patient was certified for hospice services during the certification periods from 5/10/22 to 8/7/22, and 8/8/22 to 10/6/22. The POCs, for the certification periods from 5/10/22 to 8/7/22, and 8/8/22 to 10/6/22, showed to perform assessment and evaluate the cardiac, respiratory, GI, GU, pain, mobility, skin, nutrition/hydration, comfort level and symptom management, disease progression, safety and family/caregiver needs during each comprehensive assessment. Review of the SN notes showed the following: - on 8/10/22, the patient's blood pressure was 98/50 mmHg and the oxygen saturation level was 86%; - on 8/4/22, the patient's oxygen saturation level was 80%; and - on 5/19/22, the patient's blood pressure level was 187/91 mmHg. However, these SN notes showed no documented evidence the SN had reassessed or notified the physician regarding the changes of the patient's blood pressure and oxygen saturation levels. On 8/25/22 at 1010 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to consistently collect and record the infection control data used to track the prevalence of infection at the hospice. This failure had the potential to result in the transmission of infection to the staff, caregivers, and the vulnerable population of patients in their homes. Findings: Review of the hospice's P&P titled Infection Control - Program (undated) showed as an integral component of the hospice's QAPI program, infection control data is collected and analyzed to determine trends and areas in need of improvement to minimize the risk of infections. A summary of all infection control activities performed as well as results of aggregated surveillance data analysis is provided by the QAPI committee and included in reports to the hospice's leaders. Review of the hospice's Infection Control Program binders for 2020, 2021, and 2022 was initiated on 8/24/22, and showed the hospice collected the individualized patient infection data which were recorded on the hospice's form titled "Patient Infection Report." The Patient Infection Report form contained sections for the specific types of infection such as UTI, respiratory, integumentary, GI, and conjunctival (infection of the clear tissue covering the white part of the eye). Under each category of infection, signs and symptoms were listed with a box to be marked. There was also a section for "other infection" where the type of infection could be written. Review of the forms showed the patient infection data was collected; however, the method of documentation for each patient form was inconsistent. For example, there were forms from the Infection Control 2021 binder showing the size of the indwelling urinary catheter was documented under the UTI category; however, the UTI category was not marked nor were there any signs and symptoms marked. There were also forms showed CDIFF documented under GI and some documented under "other infection." On 8/24/22 at 1305 hours, an interview and concurrent record review was conducted with the DQM. The DQM was asked about the hospice's infection control program and how the data was collected. The DQM stated the nurses would fill out the Patient Infection Report form. These forms were collected and submitted to the DQM for review. The data was then aggregated and analyzed for trends and appropriate corrective actions would be taken if necessary. This information would then be reported and discussed during the quarterly QAPI meetings. When asked how the nurses filled out the form, the DQM stated the nurses would place a check mark on the box next to the category and signs and symptoms of infection. The DQM was shown the forms used as examples mentioned above. When asked whether they would count UTI as an infection if the nurse only documented the size of the indwelling urinary catheter and no other signs and symptoms were marked, the DQM replied she would have to look at the patient's clinical record to verify whether this patient actually had a UTI or whether the nurse only documented the size of the indwelling urinary catheter because the patient had a catheter. When asked if CDIFF was counted as a GI versus "other infection" for the QAPI reports, the DQM stated she would have to look in her spreadsheet to see how they categorized CDIFF for that specific quarter. The DQM verified the nurses did not fill out the Patient Infection Report form consistently and that she had to sometimes investigate to determine if the patient had a true infection.

Based on interview and record review, the hospice failed to ensure the RN provided supervisions to the LVN to ensure quality care and services were provided for two of 19 sampled patients (Patients 12 and 14). This failure had the potential to place the patients at risk for receiving substandard care and services. Findings: Review of the hospice's P&P titled Nursing Services (undated) showed nursing care and services are provided to hospice patients by or under the supervision of a registered nurse. When nursing services are delegated to a licensed practical nurse, the RN makes at least bi-monthly home visits to oversee that the LVN is routinely providing nursing services in accordance with the patient's plan of care. 1. Review of Patient 12's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 2/15/22. The patient was certified for hospice services during the certification period from 5/16/22 to 8/13/22. Review of the SN notes showed the LVN visited the patient's home on 5/20, 5/24, 6/16, 7/29, and 8/12/22. Further review of the clinical record showed the RN visited the patient's home multiple times during the certification period; however, there was no documented evidence showing the RN provided supervision to the LVN and whether the LVN provided services in accordance with the patient's POC. On 8/25/22 at 0929 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings. 2. Review of Patient 14's clinical record was initiated on 8/18/22. The clinical record showed the SOC was 2/15/22. The patient was certified for hospice services during the certification period from 5/7/22 to 7/5/22. Review of the SN Visit Notes for this certification period showed the LVN visited the patient's home on 6/30/22. Further review of the clinical record showed the RN visited the patient's home multiple times during the certification period; however, there was no documented evidence showing the RN provided supervision to the LVN and whether the LVN provided services in accordance with the patient's POC. On 8/25/22 at 0900 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed of the findings.

3. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed HA visits two times a week. * The HA notes showed the HA conducted one visit during Week 1 (7/18/22 to 7/23/22), instead of two visits. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 4. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The IDG Comprehensive Assessment dated 7/9/22, showed the HA's assigned tasks included to check if the patient has any pain; and if there was pain, on a scale from 0-10 (0- no pain and 10 -worst pain) what was the pain. The HA note dated 8/16/22, showed the an area in the clinical record to mark if the patient had any pain. Documentation showed the HA and acknowledged and completed the task. * However, there was no documented evidence if the the patient had pain. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 5. Review of Patient 5's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 9/3/21. The patient was certified for hospice services during the certification periods from 6/30/22 to 8/28/22 and 8/29/22 to 10/27/22. Review of the HA Assignment History showed the HA's assigned tasks included to document last BM and output * The HA notes dated 6/30, 7/2, 7/5, 7/7, 7/9, 7/12, 7/14, 7/17, 7/19, 7/21, 7/26, 7/28, 7/31, 8/2, 8/4, 8/9, 8/13, 8/16, 8/18, 8/20, 8/21, 8/23, and 8/25/22, during the certification periods, 6/30/22 to 8/28/22, showed no documented evidence the HA had documented patient's last BM and output. On 9/19/22 at 1100 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 6. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. Review of the HA Assignment History showed the HA's assigned tasks included check if the patient has any pain; and if there was pain, on a scale from 0-10 (0- no pain and 10 -worst pain) what was the pain; and to check temperature, report to Case Manager if abnormal. The HA note dated 1/27/22, showed an area in the clinical record to mark if the patient had any pain; and to check the temperature and report to the Case Manager if abnormal.. Documentation showed the HA and acknowledged and completed the task. * However, there was no documented evidence if the the patient had pain and what was the patient's temperature. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings.

3. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed HA visits two times a week. Further review of the clinical record showed the HA had visited the patient during Week 1 (7/18/22 to 7/23/22), Week 2 (7/24/22 to 7/30/22), Week 3 (7/31/22 to 8/6/22), Week 4 (8/7/22 to 8/13/22) week 5 (8/14/22 to 8/20/22) and Week 6 (8/21/22 to 8/27/21). The SN visit dated 8/22/22, showed the supervision by RN to the HA. * However, there was no documented evidence the RN had conducted supervision every 14 days until 8/22/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 4. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. Review of the clinical record for Patient 3 showed the HA did not provide HA service in accordance with the POC for for this patient. Cross reference L626, Example # The SN note dated 8/19/22, showed the RN conducted a supervisory visit and the HA's follow-through on the POC had been excellent. * However, RN failed to identify the HA did not provide HA services in accordance with the POC. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 5. Review of Patient 5's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 9/3/21. The patient was certified for hospice services during the certification periods from 6/30/22 to 8/28/22 and 8/29/22 to 10/27/22. Review of the clinical record for Patient 5 showed the HA did not provide HA service in accordance with the POC for for this patient. Cross reference L626, Example # The SN note dated 7/4, 8/1, 8/8, and 8/22/22, showed the RN conducted a supervisory visit and the HA's follow-through on the POC had been excellent. * However, RN failed to identify the HA did not provide HA services in accordance with the POC. Review of the clinical record showed the HA had visited the patient during Week 1 (6/30/22 to 7/2/22), Week 2 (7/3/22 to 7/9/22), Week 3 (7/10/22 to 7/16/22), Week 4 (7/17/22 to 8/23/22) Week 5 (7/24/22 to 7/30/22), Week 6 (7/31/22 to 8/6/22), Week 7 (8/7/22 to 8/31/22), Week 8 (8/14/22 to 8/20/22), and Week 9 (8/21/22 to 8/27/22) * In addition, there was no documented evidence the RN had conducted supervision every 14 days until 8/1/22. On 9/19/22 at 1100 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 6. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. Review of the clinical record for Patient 12 showed the HA did not provide HA service in accordance with the POC for for this patient. Cross reference L626, Example # The SN note dated 2/1/22, showed the RN conducted a supervisory visit and the HA's follow-through on the POC had been excellent. * However, RN failed to identify the HA did not provide HA services in accordance with the POC. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings. 3. Review of Patient 15's closed clinical record was initiated on 8/18/22. The closed clinical record showed the SOC was 12/9/22. The patient was certified for hospice services during the certification period from 2/20/22 to 4/20/22. Review of the Hospice Certification and Plan of Care from 2/20/22 to 4/20/22, showed the RN to supervise HA every two weeks. Review of the closed clinical record showed the RN had performed HA supervisory visits on 2/24 and 3/7/22. However, review of the closed clinical record failed to show documented evidenced of the RN performed HA supervisory visit every two weeks. On 8/25/22 at 1220 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the finding. .

Based on interview and record review, the hospice's governing body failed to ensure the responsibility for the management of the hospice and provision of all hospice services. The hospice's governing body failed to ensure P&Ps were reviewed and implemented related to volunteers. The Administrator failed to perform day-to-day operation to ensure the written agreements for the contracted providers included the roles in the bereavement follow-up. These failures had the potential to negatively impact the hospice's operational performance. Findings: The hospice's P&P titled Governing Body (untitled) showed the Board of Directors is the governing body of the hospice that operates in accordance with its bylaws and assumes full legal and financial authority and responsibility for determining, implementing, and monitoring policies governing the hospice's total program. Responsibilities of the Board of Directors include but are not limited to appointing a qualified hospice Administrator and delegating him/her the authority and responsibility for the daily operations of the hospice in accordance with State and Federal regulations; and ensuring that all services are consistent with accepted standards of practice and are provided by competent staff. The hospice's P&P titled Administrator showed the Board of Directors appoints a qualified individual with appropriate education and experience to serve as the Administrator the hospice and assume responsibility for the day to day administration of the hospice program. The hospice Administrator with the Board of Directors ensures that all care, treatment and services provided by the hospice are in accordance with federal, state, and local laws and regulations and consistent with accepted standards of practice. 1. According to Standards of Quality Hospice Care, 2005 under Section 6.2 B (1) (2) (c) (7), when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to: - Roles and responsibilities of the program and the contracted individual or organization in the following: - Bereavement follow-up. Review of the written agreements between the hospice and contracted providers was conducted on 8/23/22, and showed the following: - The written agreement between the hospice and contracted Medical Director/Team Physician 1 providing medical services failed to include the roles and responsibilities of the hospice and Medical Director/Team Physician 1 for the bereavement follow up. - The written agreement between the hospice and contracted Team Physician 2 providing medical services failed to include the roles and responsibilities of the hospice and Team Physician 2 for the bereavement follow up. On 8//25/22 at 1145 hours, the Business Manager was informed of the finding. The Business Manager reviewed the hospice's written agreements and acknowledged the finding. 2. Review of the hospice's P&P titled Volunteers- Assignment (undated) showed a hospice team member provides the patient with information regarding services provided by volunteers. This information may be provided verbally or writing, The P&P titled Volunteers-Personal Records (undated) showed although volunteers do not receive pay for their services, volunteers are considered employees of the hospice and a personnel file is maintained for every volunteer. Each volunteer personnel file contains: volunteer emergency contact information, completed volunteer application. two references, copy of professional license or certification, copy of drivers license, current signed job description, documents relating to performance/ annual performance evaluation, volunteer agreement, orientation checklist, documentation of continuing education, miscellaneous (letters from patients/families), TB mantoux, hepatitis B form, and criminal background check information (for patient care volunteers) Review of the Parent/Guardian Consent for Hospice Teen Volunteers form showed the volunteer's name, and the sections for the parent/guardian's name, signature, and date. The consent was for the child to participate as a Hospice Teen Volunteer for the hospice and provided to the parents/guardians of teen volunteers under the age of 18. The form also showed to have the drug screening, TB test, and background check provided by the hospice. The consent showed as a Hospice Teen Volunteer, the child would be volunteering in the SNF, private patient's homes, ALFs, and/or board and care homes. The consent also included a section for the Parent/Guardian Statement of Confidentiality. a. Review of eight minors' volunteer files was conducted on 8/24/21, and showed the following information: - Volunteer 1 had a start date of 9/4/21. - Volunteer 2 had a start date of 8/13/22. - Volunteer 3 had a start date of 10/9/21. - Volunteer 4 had a start date of 6/16/22. - Volunteer 5 had a start date of 3/14/22. - Volunteer 6 had a start date of 1/22/21. - Volunteer 7 had a start date of 5/15/22. - Volunteer 8 had a start date of 7/27/22. Volunteers 1 , 2, 3, 4, 5, 6, 7, and 8's files showed the volunteers were minor. However, Volunteers 1 and 6's files showed no documented evidence of the parent/guardian consent for hospice teen volunteers. On 8/25/22 at 1130 hours, an interview was conducted with the Volunteer/Bereavement Services Manager. She was informed and acknowledged the finding. She stated for the minor volunteers, there should be a consent obtained from the parent/guardian. Further review of the hospice's P&P showed no documented evidence of a policy related to obtaining consent from parent/guardian for the minor volunteers. b. The Volunteer Agreements for Volunteers 2, 3, 4, 5, and 7 showed while volunteering, the responsibility would include patient/family services as established by the Volunteer Manager and hospice staff. Some of the above volunteers' responsibilities may also include administrative/office services as established by the Volunteer Manager and hospice staff The Volunteer Agreement for Volunteer 1 showed while volunteering, the responsibility would include administrative/office services as established by the Volunteer Manager and hospice staff However, the Volunteer Agreement for Volunteer 6 showed no documented evidence of which services the volunteer had selected to provide. On 8/25/22 at 1110 hours, an interview was conducted with the Volunteer/Bereavement Services Manager. She was asked what the volunteer would do under the administrative/office services included in the Volunteer Agreement form. She stated the volunteer would come in the office and check the assignment for the day, an example would be stocking up the shelves. She was asked what the volunteer would do under the patient/family services included in the Volunteer Agreement form. She stated it would be for patient companionship such as talking to the patient and playing card games. She stated the minor volunteers were always accompanied the whole time by the parent who was also a volunteer. She stated the background checks were not done for the minor volunteers. She stated Volunteers 2, 3, 4, 5, 7, and 8 would like to perform for patient/family services. She stated only Volunteer 7 had performed the patient services wherein a legacy video was done. However, the criminal background checks were not done as per the hospice's P&P for the minor volunteers who volunteered for patient services as per the hospice's P&P. On 8/25/22 at 1130 hours, an interview was conducted with the Volunteer/Bereavement Services Manager. She was informed of the findings.

3. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/19/22, showed the patient had a drain site on the right side of the abdomen. The SN note dated 8/1/22, showed the patient had hospital stay a peritoneal drain was placed in the left abdomen. * However, the location of the peritoneal drain was not consistent. b. The IDG Comprehensive Assessment dated 7/26/22, included PT visit notes dated 8/3 and 8/8/22; SN visit notes 8/5 and 8/15/22; and MSW note dated 8/15/22, instead of visit notes prior to the IDG Comprehensive Assessment dated 7/26/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. LVN 1 stated the peritoneal drain was located on the right side of the abdomen. They were informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The IDG Comprehensive Assessment Details dated 9/6/22, showed SN visits 3W. Further review of the clinical record showed no documented evidence of SN visits during Week 4 (8/28/22 to 9/3/22). On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator. The Administrator stated the patient had a SN visit during Week 4. She stated the SN who visted the patient was a substitute nurse. She was informed of the findings 5.. Review of the clinical records for Patients 1, 2, 3, 6, 7, and 10 showed medications as pending instead of current on the IDG Comprehensive Assessment. For example: a. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The IDG Comprehensive Assessment dated 8/23/22, showed patient's pending medications included the following: - an order dated 7/22/22, showed Actos (anti-diabetic) 30 mg one tablet Q 24 hours - an order dated 7/22/22, showed cholecalciferol (supplement) 2000 u one tablet Q 24 hours - an order dated 7/18/22, showed diclofenac sodium (NSAID) gel 1% 4 gm QID topical PRN - an order dated 7/18/22, showed ertapenem sodium (antibiotic) 500 mg one time a day - an order dated 7/22/22, showed finasteride (urinary retention medication) 5 mg one tablet Q 24 hours - an order dated 7/18/22, showed lactobacillus (probiotic) one package one time a day - an order dated 7/18/22, showed midodrine (antihypotensive) 5 mg one tablet TID - an order dated 8/2/22, showed Norco (opioid analgesic) 5-325 mg one tablet one times a day -an order dated 7/18/22, showed octreotide acaetate (synthetic hormone) 50 mcg/ml Q eight hours SC - an order dated 7/18/22, showed pantoprazole (used to treat GERD) 40 mg Q 24 hours - an order dated 7/22/22, showed sodium bicarbonate (antacid) 650 mg one tablet Q 12 hours - an order dated 7/22/22, showed tamsulosin (urinary retention medication) 0.4 mg two tablet Q 24 hours - an order dated 7/22/22, showed Vitamin B plus C Complex (supplement) one tablet Q 24 hours On 9/20/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator. The Administrator stated the above medications are all current and not pending. She stated the nurse need to click the "software" to remove the medications listed as pending and become current. 3. Review of Patient 19's clinical record was initiated on 8/22/22. The clinical record showed the SOC was 8/17/22. Review of the Physicians Verbal Order dated 8/18/22, showed an order for HA 1W1 starting on 8/18/22, and ending on 8/20/22. However, review of the Hospice Initial Assessment dated 8/17/22, and Hospice Comprehensive Assessment dated 8/18/22, showed the Hospice Aide Referral/Supervision section was documented as No which was inconsistent with the POC. On 8/25/22 at 0955 hours, an interview with concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the patient needed HA services. The DPCS replied the nurses should have documented the patient needed HA services. The DPCS was informed and acknowledged the finding. 4. Review of the hospice's P&P titled Wound Protocol undated, showed always include the location/description of the wound as the first part of the order text for clarity. Review of Patient 9's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 1/6/22. The patient was certified for hospice services during the certification periods from 4/6/22 to 7/4/22, and 7/5/22 to 9/2/22. Review of the Verbal order dated 6/24/22, showed an order for bacitracin/neomycin/polymixin B topical 400 units-3.5 mg-5000 units/g topical ointment topically twice a week and PRN during wound care. However, the verbal order failed to show as to the location for the topical medication to be applied. On 8/25/22 at 1157 hours, an interview with concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was asked which wound needed the topical medication. Clinical Manager 1 replied the order was not specific as to the location of the wound. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of 19 sampled patients (Patient 16). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of Patient 16's closed clinical record was initiated on 8/22/22. The closed clinical record showed the SOC was 8/23/21. The patient was certified for hospice services during the certification period from 11/21/21 to 2/18/22. Patient 16 resided in the SNF. The POC, for the certification period from 11/21/22 to 2/18/22, showed the patient had a Stage 4 pressure injury to the "Posterior Buttocks Coccyx Sacrum extending to bilateral buttocks." The POC also showed to assess and evaluate cardiac, respiratory, GI, GU, pain, mobility, skin, nutrition/hydration, comfort level and symptom management, disease progression, safety and family/caregiver needs during each comprehensive assessment. Review of the SN Visit Notes showed the SN had performed the wound dressing changes during the SN visits. However, the SN did not consistently document the complete assessment of the wound. For example, on 11/30/21 and 12/3/21, there were no documentation of the measurements and characteristics of the wound. On 8/25/22 at 0957 hours, an interview and concurrent closed clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was informed and acknowledged the finding.

2. Review of Patient 3's clinical record was initiated on 8/17/22. The closed clinical record showed the SOC was 12/7/21. The patient was certified for hospice services during the certification periods from 12/7/21 to 3/6/22, 3/7/22 to 6/4/22, 6/5/22 to 8/3/22, and 8/4/22 to 10/2/22. The patient resided in a SNF. The POC, for the certification period 8/4/22 to 10/2/22, showed the patient's identified problems included ADL, anxiety/stress related to terminal illness,communication with the PCG, COVID-19 pandemic, grief process and grieving bereavement, impaired respiratory status, medication management, pain management, potential or actual ineffective patient/PCG coping secondary to impact of COVID-19, risk for falls/injuries, terminal diagnosis, and unrelated conditions. The goals were established for these identified problems. A joint home visit was conducted with RN 3 on 8/16/22 at 1030 hours, to the SNF where Patient 3 resided. During ther review of Patient 3's SNF records showed the identified problem in the POC at the SNF were not consistent in the POC by the IDG at the hospice. The POC at SNF included a care plan problem such as impaired nutritional and hydration status, alteration in skin integrity, at risk for cardiac distress, constipation, high risk from signs and symptom of bruising and bleeding, and bowel and bladder incontinence. The IDG failed to coordinate with the SNF to consistently address the identified problems in the POC at the SNF as well as the hospice to ensure consistent care provided to meet the patient's needs. On 8/16/22 at 1100 hours, a concurrent clinical record review and interview was conducted with RN 3. She was informed of the findings On 8/25/22 at 0915 hours, a concurrent clinical record review and interview was conducted with Clinical Manager 2. She was informed and acknowledged the finding. Based on interview and record review, the hospice failed to coordinate with the SNF related to the POC and care and services for three of 19 sampled patients (Patients 3, 6, and, 9). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 6's clinical record was initiated on 8/15/22. The clinical record showed the SOC was 8/13/21. The patient was certified for hospice services during the certification periods from 6/9/22 to 8/7/22, and 8/8/22 to 10/6/22. The POCs, for the certification periods from 6/9/22 to 8/7/22, and 8/8/22 to 10/6/22, showed for the dietitian to address the patient's hypotension (low blood pressure). The POC showed the patient resided at the SNF. Further review of the clinical record showed no documented evidence of the dietitian's assessments and notes. On 8/25/22 at 1027 hours, an interview and concurrent clinical record review was conducted with Clinical Manager 1. When asked to show the dietitian's assessments and documentation, Clinical Manager 1 stated the patient was residing at the SNF and being followed by the SNF's dietitian. Clinical Manager 1 stated she would look for the documentation in the patient's paper charting as the documentation may not have been scanned into their electronic system. On 8/25/22 at 1404 hours, a follow-up interview was conducted with Clinical Manager 1. Clinical Manager 1 verified she was unable to find any documentation from the SNF's dietitian. 3. Review of Patient 9's clinical record was initiated on 8/17/22. The clinical record showed the SOC was 1/6/22. The patient was certified for hospice services during the certification periods from 1/6/22 to 4/5/22, 4/6/22 to 7/4/22, and 7/5/22 to 9/2/22. Review of the Hospice Certification and Plan of Care from 1/6/22 to 4/5/22, showed the orders for disciplines. The orders for discipline included MSW visit to assess and evaluate. Review of the Social Worker Initial Assessment note dated 1/7/22, showed the reason of the referral/interventions. The referral included an assessment from a Volunteer. However, review of the clinical record failed to show documented evidenced the Volunteer had performed an assessment as referred by the Social Worker. On 8/25/22 at 1109 hours, an interview with concurrent clinical record review was conducted with Clinical Manager 1. Clinical Manager 1 was asked if the referral was coordinated with the Volunteer. Clinical Manager 1 replied there was no documentation of the coordination. She was informed and acknowledged the finding.