Every finding on record at Carefirst Ny, Inc.

Based on review of hospice Emergency Preparedness Regulation Set Federal-E-1.04- section 418.113(c)(2), agency emergency preparedness plan and staff interview, the hospice failed to maintain an emergency preparedness communication plan that included contact information for state, regional and local emergency preparedness staff.  Failure to maintain emergency contact information has the potential for negative patient outcomes during emergencies. --- Review of the undated agency “Emergency Preparedness Manual” revealed “A contact list of community partners, including the local health department, local emergency management, emergency medical services and law enforcement will be kept current, via The CareFirst Representative on The Southern Tier Health Care Mutual Aide Plan Steering Committee.” Review of the undated agency “Emergency Preparedness Manual” lacks documentation of telephone numbers for the community partners identified in their manual. During interview on 01/08/2026 at 01:44 PM, the Director of Hospice Services stated additional documentation would be looked for that included the community partners telephone numbers.  During interview on 01/09/2026 at 01:17 PM, the Director of Hospice Services stated being unable to locate the identified community partners telephone numbers and would add them to the “Emergency Preparedness Manual” promptly.

Based on review of State Operations Manual Appendix A, section 418.113(d)(2)(i and ii), issued on 04/16/2021, agency emergency preparedness plan, and staff interview, the hospice failed to ensure exercises to test the emergency plan are conducted at least annually. --- Review of the State Operations Manual Appendix A, section 418.113(d)(2)(I and ii) issued on 04/16/2021 revealed “(2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full[1]scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.” Review of the agency policy and procedure entitled “Administration Emergency Preparedness Plan updated 07/2023 revealed “11. The hospice “participates annually in a state-wide or county-wide drill that includes triaging patient needs in an emergency.” Review of the Public Health Emergency Response Simulation dated 04/03/2023 revealed the agency participated in a county wide drill in 2023.  There is a lack of documentation the agency participated in an emergency drill and/or activated their emergency preparedness plan in 2024 and 2025. During interview on 01/08/2026 at 01:45 PM, the Director of Hospice Services acknowledged the hospice failed to participate in an emergency preparedness drill or retained documentation of activating their emergency response plan for 2024, and 2025.

Based on review of clinical records and interviews with agency staff, the hospice failed to ensure in one (1) of nineteen (19) clinical records (Patient #6), the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. --- Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Physician’s Plan of Care from 06/10/2025 to 09/07/2025 revealed an order to discontinue routine maintenance flushing of the implanted mediport in the patient’s right upper chest. Review of the Initial and Comprehensive Assessment dated 06/10/2025 lacks documentation of an assessment of the implanted mediport site to include location, if accessed or deaccessed, and a skin assessment above the implanted mediport. During interview on 01/09/2026 at 11:47 AM, the Registered Nurse (RN) stated patient’s mediport was deaccessed but failed to include an assessment of the port site in the identified assessment. Patient #15 – This 67-year-old patient with a terminal diagnosis of alcoholic cirrhosis of liver with ascites and esophageal varices without bleeding was admitted to the hospice on 12/01/2025.Review of the Physician’s Plan of Care from 12/01/2025 to 03/01/2026 revealed an order for wound care to the coccyx area; cleanse area with soap and warm water and pat dry, apply bag balm and cover with a borded dressing; Frequency: daily and PRN dressing saturated, non-adhered and/or greater than 50% saturated.  Wound care to be managed by family/caregiver and/or CareFirstNY staff.Review of the Initial and Comprehensive Assessment dated 12/01/2025 reveals a Wound Assessment of the coccygeal area; Pressure Ulcer Stage 2; wound status is opened; wound measurements documented and patient reported pain of 5/10. Review of the RN Comprehensive Assessment on 12/11/2025 reveals, “Integumentary:  Skin Conditions (M1190) – Does the patient have one or more skin conditions?:  NO” and “Other Skin S&S:  Intact”.  There is a lack of documentation that the Registered Nurse (RN) completed a Wound Assessment prior to certifying the patient’s wound closure.During interview on 01/09/2026 at 10:00 AM, the RN stated the patient’s wound had healed/closed and acknowledged a Wound Assessment was not completed prior to completing the RN Comprehensive Assessment.

Based on review of clinical records and interview with staff, for two (2) of nineteen (19) patients (Patient #'s: 3 and 18), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group to act on inaccurate information. --- Home visitPatient #3 - This 95 -year-old patient with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 11/25/2025.On 12/03/2025 the hospice nurse (case manager) conducted a comprehensive home visit. The nurse had documented new medications ordered by the physician that included:Lorazepam 0.5mg every 2 hours as needed for dyspnea and restlessness;Senna 8.6mg 2x a day as needed for bowel regime; andMorphine concentrate 5ml every 2 hours as needed for pain, dyspnea, anxiety, and restlessness.Review of the hospice nursing visit dated 12/03/2025 revealed the RN documented the following:Problem – plan of care collaboration requirementGoal- coordinate care with patient, caregiver, attending physician.Intervention- reviewed patient prescription and over the counter drug profile for effectiveness, duplication, drug interactions and actual potential drug side effects.On 01/05/2026 the surveyor conducted an observational home visit with the social worker and patient caregiver present. The surveyor asked the caregiver about the patient’s current medication use. The caregiver stated the medications are in a pill box and filled by a family member. The surveyor asked about the medication MiraLAX that was on the kitchen counter. The caregiver stated that is used for the patient if needed and is not a new medication.On 01/07/2026 the agency provided the surveyor with a policy titled “Standard Operating Procedure for Medication Reconciliation” dated 10/25/2025. That included over the counter medications or treatments taken must be listed on medication list.The hospice nurse failed to complete an accurate comprehensive drug review to identify over the counter medications and frequency of use.Review of the clinical record from 11/25/2025 through 01/05/2026 lacks documented evidence the Hospice Nurse completed a complete medication review and verified all medications including over the counter medications.During interview on 01/09/2026 at 12:20 PM, the Hospice  Registered Nurse (case manager ) for the patient and the Registered Nurse that had conducted the 12/03/2025 visit stated the MiraLAX medication should have been included on the medication list.      Patient #18 – This 68-year-old patient with a terminal diagnosis of acute and chronic respiratory failure with hypoxia was admitted to the hospice on 12/21/2025. Review of the facility summary of care (referral) dated 12/19/2025 revealed the patient was taking the following medication taper:  prednisone 50 milligrams (mg)  one (1) tablet (50 mg total) daily for five (5) days, then prednisone 20 mg tablet, take two (2) tablets (40 mg total) by mouth daily for five (5) days, then take 1.5 tablets (30 mg total) daily for five (5) days, then one (1) tablet (20 mg total) daily. Review of the Physician’s Plan of Care dated 12/21/2025 revealed the following medication taper:- prednisone 50 mg by mouth daily from 12/21/2025 through 12/22/2025;- prednisone 40 mg by mouth daily from 12/23/2025 through 12/27/2025;- prednisone 30 mg by mouth once time weekly from 12/28/2025 to through 01/01/2026; and- prednisone 20 mg by mouth daily beginning 01/02/2026. Review of the clinical record lacks documentation the RN communicated with the physician regarding the prednisone taper discrepancy. During interview on 01/09/2026 at 11:13 AM, the RN stated an error was made on the plan of care orders and the prednisone 30 mg was to be given daily for five (5) days, not weekly.

Based on review of clinical records and interview with staff for one (1) of nineteen (19) patients (Patient #5), the hospice failed to ensure an initial bereavement assessment of the needs of the patient's family and caregivers was conducted. Failure to perform a risk assessment for bereavement places the family and other individuals at risk for not receiving appropriate counseling and supportive services. --- Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung was admitted to the hospice on 10/03/2025. The patient resides in a skilled nursing facility (SNF). Review of the Initial and Comprehensive Assessment dated 10/03/2025 lacks documentation the Registered Nurse (RN) completed an initial bereavement assessment. Review of the Social Worker (SW)- Spiritual Care Counselor (SCC) Initial and Comprehensive Assessment dated 10/06/2025 revealed the SW documented the following bereavement assessment: the bereaved is the patient’s daughter in law who is not present for the visit.  Phone call to daughter in law, no answer message left. Review of the clinical record lacks documentation of the SW speaking to the patient’s daughter-in-law to conduct an initial bereavement assessment. During interview on 01/09/2026 at 09:48 AM, the SW stated that they had been unable to contact the daughter-in-law to conduct a required bereavement assessment.

Based on a review of clinical records and staff interview for five (5) of nineteen (19) clinical records (Patient #'s: 2, 4, 5, 6, and 18), the hospice failed to ensure the patient's comprehensive assessments include changes that have occurred since the initial assessment, are updated every fifteen (15) days, and that the hospice nurses are communicating changes in the patient's condition or treatment to the Interdisciplinary Group (IDG). Failure to ensure that comprehensive assessments are updated and reflect the patient's status has the potential for unmet patient needs. --- Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung, residing in a skilled nursing facility, was admitted to the hospice on 10/03/2025. A.)  Review of the Registered Nurse (RN) Comprehensive Assessment dated 10/23/2025 revealed the RN documented the patient reported a recent fall and sustained a skin tear to the left elbow that is pink with no drainage. Review of the RN Comprehensive Assessment dated 10/30/2025 revealed the RN documented the patient has a skin tear but fails to specify the location and status of the skin tear. During interview on 01/09/2025 at 10:48 AM, the RN stated the skin tear was on the left elbow and was dry but failed to document this in the identified assessment. B.)  Review of the Physician’s Plan of Care from 10/03/2025 to 12/31/2025 revealed an order for oxygen one (1) liter per minute by nasal cannula continuous as directed, may titrate from one (1) to three (3) liters per minute via nasal cannula. Review of RN Comprehensive Assessment dated 12/01/2025 revealed the RN documented the patient’s room air oxygen saturation is 93 percent and has diminished breath sounds in all lung fields bilaterally.  Review of the assessment lacks documentation of the ordered oxygen use. Review of the IDG Report dated 12/03/2025 revealed the RN Case Manager documented the patient’s current problems are with pain that is managed with MS Contin and Roxanol and gas exchange that is managed with Roxanol and oxygen.  Oxygen is ordered at one (1) liter per minute by nasal cannula continuous as directed and may titrate from one (1) to three (3) liters per minute. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient’s room air oxygen saturation is 96% and has diminished breath sounds in all lung fields bilaterally.  Review of the assessment lacks documentation of the ordered oxygen use. During interview on 01/09/2026 at 10:22 AM, the RN stated the patient was not wearing oxygen as ordered during the identified assessments and failed to document this and report the change to the IDG. C.)  Review of the IDG Report dated 12/03/2025 revealed the patient is ordered the following medications for pain:- MS Contin 30 milligrams (mg) every twelve (12) hours for pain;- Acetaminophen 650 mg every six (6) hours as needed for pain;- Morphine Concentrate take 5 mg (100 mg per 5 milliliters) (ml) (20 mg/ml) solution by mouth every two (2) hours as needed for pain; and-  Oxycodone-Acetaminophen (5 mg-325 mg tablet) by mouth every six (6) hours as needed for pain. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient is experiencing ten (10) out of ten (10) severe pain to the abdomen.  Additionally, the RN documented collaborating with the skilled nursing facility (SNF) nurse to medicate the patient for abdominal pain.  The assessment lacks a patient response to the pain medication requested to be administered by the SNF nurse. During interview on 01/09/2026 at 10:34 AM, the RN stated the patient was not assessed after the request for the SNF nurse to administer the pain medication was made to determine if effective pain control was obtained.  The RN stated the patient visit ended when requesting the SNF staff administer pain medication, and no follow-up was made to determine if the patient received effective pain control. Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Initial and Comprehensive Assessment dated 06/18/2025 revealed the Spiritual Care Counselor (SCC) documented visualizing a gun resting in the corner of the patient’s bedroom during the visit and no gun safe was noted. Review of the Patient Related Collaboration Note dated 06/18/2025 revealed the Social Worker (SW) documented the following “Discussion with SCC, shown a gun out in open in upstairs, patient stated she could shoot spouse, did not appear to SCC to have intent to harm, more of a frustration statement.  SW to follow up on friday.” Review of the Focused and Comprehensive Assessment dated 06/20/2025 revealed the SW made a home visit to the patient but lacks documentation of follow-up regarding the presence of a gun being in the home on 06/18/2025 and an assessment of home, hospice staff and patient safety. During interview on 01/09/2026 at 09:06 AM, the SW stated the gun that was visualized in the home was a pellet gun, determined the gun was not a safety risk and failed to document regarding this.  The SW stated the IDG failed to be notified regarding gun and potential safety risk it posed. Patient #18 – This 68-year-old patient with a terminal diagnosis of acute and chronic respiratory failure with hypoxia was admitted to the hospice on 12/21/2025. Review of the Physician’s Plan of Care dated 12/21/2025 revealed the following wound care orders:- wound area one (1):  right elbow- cleanse area with normal saline and pat dry, apply bag balm, cover with non adherent pad, secure with gauze wrap every three (3) days and as needed for dressing saturated, non-adhered and/or greater than fifty (50) percent saturated.- wound area two (2):  coccyx- cleanse area with soap and water and pat dry, apply bag balm, leave open to air daily and as needed if greater than fifty (50) percent saturated. Review of the RN Comprehensive Assessment dated 12/29/2025 revealed the RN documented the following:- Skin condition:    Yes;- Types of skin conditions:   Pressure Ulcer(s)/ injuries;- Skin and ulcer/injury treatments:   Application of nonsurgical dressings (with or without topical medications) other than to feet (patient refused assessment at this visit).The documentation fails to specify which wound, right elbow and/or coccyx the RN is writing about. During interview on 01/09/2026 at 10:54 AM, the RN stated the patient refused an assessment of both the right elbow and coccyx wounds but failed to specify this in the identified visit documentation.   Home visit1. Patient #4 this 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resided in a Skilled Nursing Facility.  On 01/06/2026 the agency provided there wound policy titled "Standard Operating Procedure" dated 02/17/2023 that included:The Registered Nurse (RN) will complete in its entirety a wound assessment including measurement's of width, length, and depth and description in the record. The plan of care to include problems, goals and interventions. Multiple wounds should have a specific order. The 10/28/2025 initial nursing assessment included wound care to the following sites:Back right lower leg, description of deep tissue injury – unable to measure facility staff performed care.Back right lower calf, description deep tissue injury- wound length 11.5cm, width 8.5cm, depth 0.5cm and wound color beefy red.Left forearm – description skin tear- wound status open length 0.5cm, width 0.25cm peri wound pink.Right forearm – description skin tear, see photo in document library. However, there were no measurements with the photo in the record.The 10/28/2025 Hospice plan of care included wound care orders only for right calf site, clean with saline, apply xeroform dressing, cover with abdominal padding secure in place with gauze. Change dressing every 3 days and as needed for saturation, non-adhered and/or greater than 50% saturated. Wound care managed by family, caregiver, and or hospice staff.On 10/29/2025 the hospice nurse documented pressure ulcer dressing performed by facility staff. On 11/03/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff every 3 days.On 11/10/2025 the hospice nurse failed to document location of wounds and who performed wound care.11/17/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.11/24/2025 the hospice nurse failed to document locations of wounds and who performed wound care.12/01/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.12/08/2025 the hospice nurse failed to document locations of wounds and who performed wound care.12/15/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.12/22/2025 2025 the hospice nurse failed to document locations of wounds and who performed wound care.12/29/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.The Hospice nurse failed to perform a comprehensive assessment to address all four wound sites and assess areas to determine if the plan of care needed to be updated and monitor for resolution.During interview on 01/09/2026 at 9:30 AM, the hospice nurse that performed the initial assessment stated they did not measure all the wounds and did not obtain wound care orders for the left elbow, right elbow and back of lower calf. The hospice case manager stated they did not obtain measurements of any wounds since patient was admitted to the hospice and had not changed the dressing to any wounds. The Director of Hospice Services stated the wounds should have been measured and assessed.   Home VisitPatient #2 – This 71-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of lip, oral cavity, and pharynx was admitted to the hospice on 12/01/2025.Review of the RN Comprehensive Assessment dated 12/11/2025 revealed the RN Case Manager documented the patient received wound care to the coccyx area, Pressure Ulcer Stage 1:  cleanse with warm soapy water and pat dry, apply bag balm, cover with island dressing; care completed by patient’s daughter prior to RN’s scheduled visit.Review of the Wound Assessment dated 12/29/2025 revealed the RN Case Manager documented the coccygeal area wound status is closed with wound measurements documented and patient reported pain of 0/10.During a scheduled observational home visit on 01/06/2026 at 08:15 AM, the Licensed Practical Nurse (LPN) and the patient’s daughter assisted the patient with showering/dressing.  When questioned, the LPN stated the patient is no longer receiving wound management to the coccyx area; bag balm is applied as a preventative measure daily and PRN.Review of the current LPN Personal Care/Plan of Care reveals wound management including a borded dressing remain as a tasked Intervention by the LPN at each patient visit and/or managed by family caregivers.Review of the IDT meeting on 01/07/2026 at 08:30 AM revealed no changes in the patient’s Plan of Care.During interview on 01/09/2026 at 11:21 AM, the RN acknowledged the Plan of Care should have been updated to reflect wound closure. Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung, residing in a skilled nursing facility, was admitted to the hospice on 10/03/2025. A.)  Review of the Registered Nurse (RN) Comprehensive Assessment dated 10/23/2025 revealed the RN documented the patient reported a recent fall and sustained a skin tear to the left elbow that is pink with no drainage. Review of the RN Comprehensive Assessment dated 10/30/2025 revealed the RN documented the patient has a skin tear but fails to specify the location and status of the skin tear. During interview on 01/09/2025 at 10:48 AM, the RN stated the skin tear was on the left elbow and was dry but failed to document this in the assessment. B.)  Review of the Physician’s Plan of Care from 10/03/2025 to 12/31/2025 revealed an order for oxygen one (1) liter per minute by nasal cannula continuous as directed, may titrate from one (1) to three (3) liters per minute via nasal cannula. Review of RN Comprehensive Assessment dated 12/01/2025 revealed the RN documented the patient’s room air oxygen saturation is 93 percent and has diminished breath sounds in all lung fields bilaterally.  The assessment lacks documentation of the ordered oxygen use. Review of the IDG Report dated 12/03/2025 revealed the RN Case Manager documented the patient’s current problems are with pain that is managed with MS Contin and Roxanol and gas exchange that is managed with Roxanol and oxygen.  Oxygen is ordered at one (1) liter per minute by nasal cannula continuous as directed and may titrate from one (1) to three (3) liters per minute. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient’s room air oxygen saturation is 96% and has diminished breath sounds in all lung fields bilaterally.  The assessment lacks documentation of the ordered oxygen use. During interview on 01/09/2026 at 10:22 AM, the RN stated the patient was not wearing oxygen as ordered during the identified assessments and failed to document this and report the change to the IDG. C.)  Review of the IDG Report dated 12/03/2025 revealed the patient is ordered the following medications for pain:- MS Contin 30 milligrams (mg) every twelve (12) hours for pain;- Acetaminophen 650 mg every six (6) hours as needed for pain;- Morphine Concentrate take 5 mg (100 mg per 5 milliliters) (ml) (20 mg/ml) solution by mouth every two (2) hours as needed for pain; and-  Oxycodone-Acetaminophen (5 mg-325 mg tablet) by mouth every six (6) hours as needed for pain. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient is experiencing ten (10) out of ten (10) severe pain to the abdomen.  Additionally, the RN documented collaborating with the skilled nursing facility (SNF) nurse to medicate the patient for abdominal pain.  The assessment lacks a patient response to the pain medication requested to be administered by the SNF nurse. During interview on 01/09/2026 at 10:34 AM, the RN stated the patient was not assessed after the request for the SNF nurse to administer the pain medication was made to determine if effective pain control was obtained.  The RN stated the patient visit ended when requesting the SNF staff administer pain medication, and no follow-up was made to determine if the patient received effective pain control. Home VisitPatient #2 – This 71-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of lip, oral cavity, and pharynx was admitted to the hospice on 12/01/2025.  Review of the RN Comprehensive Assessment dated 12/11/2025 revealed the RN Case Manager documented the patient received wound care to the coccyx area, Pressure Ulcer Stage 1:  cleanse with warm soapy water and pat dry, apply bag balm, cover with island dressing; care completed by patient’s daughter prior to RN’s scheduled visit. Review of the Wound Assessment dated 12/29/2025 revealed the RN Case Manager documented the coccygeal area wound status is closed with wound measurements documented and patient reported pain of 0/10. During a scheduled observational home visit on 01/06/2026 at 08:15 AM, the Licensed Practical Nurse (LPN) and the patient’s daughter assisted the patient with showering/dressing.  When questioned, the LPN stated the patient is no longer receiving wound management to the coccyx area; bag balm is applied as a preventative measure daily and PRN (as needed). Review of the current LPN Personal Care/Plan of Care indicates that wound management, including the application of a bordered dressing, remains a tasked intervention for the LPN at each patient visit, or is managed by family caregivers. Review of the IDG meeting on 01/07/2026 at 08:30 AM revealed no changes in the patient’s Plan of Care. During interview on 01/09/2026 at 11:21 AM, the RN acknowledged the Plan of Care should have been updated to reflect wound closure and that only preventative balm is being applied to the area. Home visitPatient #4- This 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resides in a Skilled Nursing Facility (SNF).  The agency policy entitled "Standard Operating Procedure" dated 02/17/2023 revealed: "The RN will complete in its entirety a wound assessment including measurements of width, length, and depth and description in the record. The plan of care to include problems, goals and interventions. Multiple wounds should have a specific order."Review of the initial nursing assessment dated 10/28/2025 revealed the following wound assessments: -Back right lower leg, description of deep tissue injury – unable to measure facility staff performed care.-Back right lower calf, description deep tissue injury- wound length 11.5cm (centimeters), width 8.5cm, depth 0.5cm and wound color beefy red.-Left forearm – description skin tear- wound status open length 0.5cm, width 0.25cm peri wound pink.-Right forearm – description skin tear, see photo in document library. However, there were no measurements with the photo in the record. Review of the Hospice Plan of Care dated 10/28/2025 revealed wound care orders for right calf site to include clean with saline, apply xeroform dressing, cover with abdominal padding secure in place with gauze. Change dressing every three (3) days and as needed for saturation, non-adhered and/or greater than 50% saturated. Wound care managed by family, caregiver, and or hospice staff. There were no additional wound care orders for the right lower leg, or bilateral forearms.  Review of the RN Comprehensive Assessments dated 10/29/2025, 11/03/2025, 11/10/2025, 11/17/2025, 11/24/2025, 12/01/2025, 12/08/2025, 12/15/2025, 12/22/2025, and 12/29/2025 lack assessments of the wounds or information specifying the wound care performed and by whom.During interview on 01/09/2026 at 09:30 AM, the Hospice Nurse that performed the initial assessment stated they did not measure all the wounds and did not obtain wound care orders for the left elbow, right elbow and back of lower calf. The Hospice Case Manager (who completed follow-up assessments) stated they did not assess any of the wounds for worsening or healing and never obtained measurements on any wounds. The Director of Hospice Services stated the wounds should have been measured and assessed and wound care should have been addressed. Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Initial and Comprehensive Assessment dated 06/18/2025 revealed the Spiritual Care Counselor (SCC) documented visualizing a gun resting in the corner of the patient’s bedroom during the visit and no gun safe was noted. Review of the Patient Related Collaboration Note dated 06/18/2025 revealed the Social Worker (SW) documented the following “Discussion with SCC, shown a gun out in open in upstairs, patient stated she could shoot spouse, did not appear to SCC to have intent to harm, more of a frustration statement.  SW to follow up on Friday.” Review of the Focused and Comprehensive Assessment dated 06/20/2025 revealed the SW made a home visit to the patient but lacks documentation of follow-up regarding the presence of a gun being in the home on 06/18/2025 and an assessment of home, hospice staff and patient safety. During interview on 01/09/2026 at 09:06 AM, the SW stated the gun that was visualized in the home was a pellet gun, determined the gun was not a safety risk and failed to document regarding this.  The SW stated the IDG failed to be notified regarding gun and potential safety risk it posed. Patient #15 – This 67-year-old patient with a terminal diagnosis of alcoholic cirrhosis of liver with ascites and esophageal varices without bleeding was admitted to the hospice on 12/01/2025. Review of the Physician’s Plan of Care from 12/01/2025 to 03/01/2026 revealed an order for wound care to the coccyx area; cleanse area with soap and warm water and pat dry, apply bag balm and cover with a bordered dressing; Frequency: daily and PRN dressing saturated, non-adhered and/or greater than 50% saturated.  Wound care to be managed by family/caregiver and/or agency staff. Review of the Initial and Comprehensive Assessment dated 12/01/2025 reveals a Wound Assessment of the coccygeal area; Pressure Ulcer Stage 2; wound status is opened; wound measurements documented, and patient reported pain of 5/10.  Review of the RN Comprehensive Assessment on 12/11/2025 reveals, “Integumentary:  Skin Conditions (M1190) – Does the patient have one or more skin conditions?:  NO” and “Other Skin S&S:  Intact”.  There is a lack of documentation that the RN completed a Wound Assessment prior to certifying the patient’s wound closure. During interview on 01/09/2026 at 10:00 AM, the RN stated the patient’s wound had healed/closed and acknowledged a Wound Assessment was not completed prior to completing the RN Comprehensive Assessment. Patient #18 – This 68-year-old patient with a terminal diagnosis of acute and chronic respiratory failure with hypoxia was admitted to the hospice on 12/21/2025. Review of the Physician’s Plan of Care dated 12/21/2025 revealed the following wound care orders:- wound area one (1):  right elbow- cleanse area with normal saline and pat dry, apply bag balm, cover with non-adherent pad, secure with gauze wrap every three (3) days and as needed for dressing saturated, non-adhered and/or greater than fifty (50) percent saturated.- wound area two (2):  coccyx- cleanse area with soap and water and pat dry, apply bag balm, leave open to air daily and as needed if greater than fifty (50) percent saturated. Review of the RN Comprehensive Assessment dated 12/29/2025 revealed the RN documented the following:- Skin condition:    Yes;- Types of skin conditions:   Pressure Ulcer(s)/ injuries;- Skin and ulcer/injury treatments:   Application of nonsurgical dressings (with or without topical medications) other than to feet (patient refused assessment at this visit).The documentation fails to specify which wound, right elbow and/or coccyx the RN is writing about. During interview on 01/09/2026 at 10:54 AM, the RN stated the patient refused an assessment of both the right elbow and coccyx wounds but failed to specify this in the identified visit documentation.

Based on a review of clinical records and staff interviews for one (1) of nineteen (19) patients (Patient #12), the hospice failed to ensure care and services provided by the hospice follow an individualized written plan of care.  Failure to provide care and services in accordance with the plan of care has the potential for unmet patient needs. --- Patient #12 – This 91-year-old patient with a terminal diagnosis of malignant neoplasm of left upper lobe of lung was admitted to the hospice on 11/05/2025.Review of the Interdisciplinary Group (IDG) Report dated 12/31/2025 revealed the following order:  Chaplain/SCC (Spiritual Care Counselor) start 11/25/2025 one (1) visit every seven (7) to fourteen (14) days and five (5) as needed visits per patient /family request.Review of the clinical record revealed the SCC conducted home visits on:  11/07/2025, 11/14/2025, 11/25/2025, 12/04/2025, and 12/15/2025.Review of the clinical record revealed for the weeks of 12/21/2025 through 12/27/2025 and 12/28/2025 through 01/03/2026 the patient did not receive services from the SCC.Review of the clinical record from 12/21/2025 through 01/03/2026 lacks documentation the patient refused SCC visits and physician notification of not providing visits as ordered.During interview on 01/09/2026 at 11:45 AM, the Admissions Team Manager stated the SCC was unavailable for interview.  The Admissions Team Manager acknowledged the SCC failed to meet the visit frequency for the identified time period and failed to notify the physician/IDG.

Based on review of clinical records and interviews with staff, for two (2) of nineteen (19) patients (Patient #'s: 4 and 6) the hospice failed to develop an individualized written plan of care that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. --- Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Physician’s Plan of Care from 06/10/2025 to 09/07/2025 revealed an order for Chaplain Services with visit frequency to be determined after initial visit. Review of the Telephone Contact Note dated 06/12/2025 revealed the Spiritual Care Counselor (SCC) called and spoke with the patient’s spouse who declined the SCC making a visit on 06/12/2025. Review of the Initial and Comprehensive Assessment dated 06/18/2025 revealed the SCC conducted an initial visit and developed interventions and goals for future visits. Review of the clinical record lacks documentation of a SCC order to include the visit frequency to be provided to the patient. During interview on 01/09/2026 at 12:10 PM, the Admissions Team Manager stated the SCC failed to enter an order to include the anticipated visit frequency after conducting the initial visit.  Home visitPatient #4 this 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resided in a Skilled Nursing Facility.  The Plan of Care from 10/28/2025 from 01/26/2026 failed to include a diet order.The surveyor conducted an observational home visit at the Skilled Nursing Facility (SNF) with the hospice nurse present on 01/05/2026 at 3 PM. Observed were 2 cups of thickened liquid drinks on the patient’s bed side table.The nursing comprehensive assessment conducted on 12/29/2025 included nutrition/dietWith honey thickened liquids and puree diet.Review of the clinical record lacks documentation of an assessment for the need of altered diet of puree foods and thickened liquids.During interview on 01/09/2026 at 12:30 PM, the Registered Nurse (case manager) stated the thickened liquids and diet should have been included in the plan of care.

Based on review of clinical records and interview with agency staff, for one (1) of nineteen (19) patients (Patient #12) the agency failed to ensure the plan of care was revised when the updated comprehensive assessment identified changes in the patient's condition. Failure to update the plans of care based on information from the comprehensive assessment, has the potential for unmet patient needs. --- Patient #12 – This 91-year-old patient with a terminal diagnosis of malignant neoplasm of left upper lobe of lung was admitted to the hospice on 11/05/2025. Review of the Registered Nurse (RN) Comprehensive Assessment dated 12/30/2025 revealed the RN documented the following wound assessment:  left buttock pressure ulcer stage 2, wound open, length-2.5 centimeters (cm), width is 0.5 cm, depth is 0 cm.  Wound is pink, no exudate and periwound tissue is pink. Review of the Physician Orders dated 12/30/2025 revealed the following wound order:  “Wound area:  left buttocks, cleanse area with warm soapy water, pat dry, do not rub, apply bag balm, cover with leave open to air, secure with n/a, frequency twice daily and as needed if dressing saturated, non-adhered and greater than fifty (50) percent saturated”. During interview on 01/09/2026 at 11:55AM, the RN stated the wound was not covered with a dressing and failed to update the identified order to reflect the correct dressing procedure.

Based on review of clinical records and interviews with staff, the hospice failed to ensure in one (1) of nineteen (19) patients (Patient #5) that care and services are provided in accordance with the plan of care. Failure to provide care in accordance with the patient's established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. --- Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung was admitted to the hospice on 10/03/2025. The patient resides in a skilled nursing facility (SNF).Review of the Interdisciplinary Group (IDG) Report dated 12/03/2025 revealed the following orders:- Licensed Practical Nurse (LPN):  offered and declined; and- Professional Nurse, Registered Nurse (RN):  one (1) visit every seven (7) to ten (10) days and five (5) as needed visits per patient and family request.Review of the LPN Observation Note dated 10/04/2025 revealed the LPN made a home visit to perform symptom monitoring of the patient.Review of the clinical record lacks documentation of orders for LPN services.During interview on 01/09/2026 at 10:11 AM, the Admissions Team Manager stated the hospice utilizes LPNs for care in addition to aide services and failed to obtain an order for identified LPN service provided.

Based on review of the agency's Board of Directors Meeting Minutes for 2025 and staff interview, the Governing Authority (GA) failed to ensure involvement in oversight of the Quality Assurance and Performance Improvement (QAPI).  Failure to ensure responsibility and oversight of the hospice’s QAPI program has the potential to result in negative patient outcomes and adversely affect organizational operations. --- Review of the Board of Directors Meeting Minutes provided by the hospice revealed the Board of Directors met the following dates in 2025:  01/30/2025, 04/24/2025, 07/31/2025, and 11/13/2025. Review of the identified 2025 Board of Directors Meeting Minutes lack documentation of involvement and oversight of the hospice’s QAPI program. During interview on 01/08/2026 at 02:53 PM, the Director of Hospice Services stated being present for the identified Board of Directors meetings but fails to see documentation of Board involvement and oversight of QAPI in the identified meeting minutes.

Based on review of Quality Assurance Performance Improvement (QAPI) meeting minutes and staff interview, the hospice failed to ensure the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases is part of the QAPI program.  Failure to ensure infection control is an integral part of the hospice’s QAPI program has the potential to result in negative patient outcomes. --- Review of the QAPI/Compliance Meeting Minutes for the year 2025 revealed the committee met in 2025 on the following dates:  03/20/2025 and 10/15/2025. Review of the identified meeting minutes for 2025 lack documentation of infection control monitoring and investigation. During interview on 01/08/2026 at 02:55 pm, the Director of Hospice Services stated there has been much transition in the staff overseeing QAPI in the last year and acknowledged infection control monitoring has not been part of the 2025 QAPI meetings. During interview on 01/08/2026 at 03:00 PM, the QAPI and Compliance Manager stated being new in the role, has led one QAPI meeting in 2025, which occurred 10/15/2025.  Additionally, the QAPI and Compliance Manager stated that infection control data is currently being tracked but was unaware infection control monitoring must be included in the QAPI program.

Based on review of the hospice’s infection control program, policies and procedures, and staff interviews, the hospice failed to maintain and document a comprehensive infection control program. Failure to maintain and document a comprehensive infection control program has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes and adversely affect hospice operations. --- Review of the hospice's infection control program policies under the general title “Infection Control”; Policy Numbers: B241, P238, E239, P240, p240.1, R242, I243, I244, O245, R246, S247, P248, E249, C250, B251, B252, H253, S254, C5255, CE256, C1257, CT258; all last reviewed 03/2023, revealed the hospice infection control program lacks the following protocols for prevention of infection from:Infusion therapy;Urinary tract care;Respiratory tract care;Multi-drug-resistant organisms;Additionally, the hospice policy lacks language addressing the transmission of infectious agents in all setting where patients reside.During an interview on 01/08/2026 at 03:41 PM, the Director of Hospice Services acknowledged that the components are not included in current policies, and the policies will be updated.

Based on clinical record review and staff interview for one (1) of two (2) patients discharged to the community (Patient #6), the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components. Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice. --- Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the agency policy entitled “Discharge For Reasons Other Than Death” dated 06/2018 revealed “5.  The discharge summary is filed in the clinical record and includes: a.  the reason for the discharge;b.  a summary of the patient’s stay including treatments, symptoms, and pain management;c. a copy of the patient’s current plan of care;d.  The patient’s latest physician orders;e.  any other documentation that will assist in post-discharge continuity of care.”  Review of the Revocation of Hospice Benefits form dated 07/01/2025 revealed the patient was revoking hospice services in order to receive hospitalization, intravenous hydration and explore additional treatment for their cancer. Review of the Discharge Summary and Checklist dated 07/02/2025 lacks the following required components:  the patient’s current plan of care, and the latest physician orders. During interview on 01/09/2026 at 12:15 PM, the Director of Hospice Services stated that the current plan of care and physician orders are often attached to the Discharge Summary but acknowledged the identified Discharge Summary failed to include the required components.

Based on review of clinical records and interviews with staff for two (2) of two (2) patients receiving care in a Skilled Nursing Facility (SNF) (Patient #’s 4 and 5), the hospice failed to coordinate and implement a plan of care with interventions that reflect the needs of the patient and that are consistent with the SNF plan of care (POC).  Failure to communicate, coordinate and provide professional management of hospice patients that reside in a SNF has the potential for the provision of inadequate patient care and unmet patient needs. --- Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung, residing in a skilled nursing facility, was admitted to the hospice on 10/03/2025. Review of the Interdisciplinary Group (IDG) Report dated 12/31/2025 revealed the patient is ordered the following medications for pain:- MS Contin 30 milligrams (mg) by mouth every twelve (12) hours for pain; and- Oxycodone-Acetaminophen (5 mg-325 mg) one tablet by mouth every six (6) hours as needed for pain. Review of the Assessment Visit dated 01/05/2026 revealed the Registered Nurse (RN) documented the patient is reporting abdominal pain rated an eight (8) out to ten (10) pain that is affecting the patient’s ability to perform activities of daily living.  Additionally, the RN documented no collaboration occurred with SNF staff as Nurse Manager was not available. Review of the clinical record lacks documentation of follow-up with the SNF Staff and the patient regarding the 01/05/2026 poor pain control. During interview on 01/09/2026 at 10:40 AM, the RN stated the patient refused for the RN to locate the SNF staff to administer pain medication and no collaboration was conducted with the SNF staff and IDG regarding the patient’s poor pain control during the identified visit.   Home visitPatient #4 this 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resided in a Skilled Nursing Facility.  The 10/28/2025 initial nursing assessment included wound care to the following sites:Back right lower leg, description of deep tissue injury – unable to measure facility staff performed care.Back right lower calf, description deep tissue injury- wound length 11.5cm, width 8.5cm, wound color beefy red.Left forearm – description skin tear- wound status open length 0.5cm, width 0.25cm peri wound pink.Right forearm – see photo, however there were no measurements of wound with photo.The surveyor conducted an observational home visit at the Skilled Nursing Facility (SNF) with the hospice nurse present on 01/05/2026 at 3 PM. Prior to the hospice nursing visit the Skilled facility staff provided a printed medication review report that included wound care orders and medications. The wound care orders included:-Left forearm skin tear- clean with saline soaked gauze, cover with ABD pad and wrap with rolled gauze. Do not remove steri strips, change daily and as needed if soiled.-right calf wound (only change on Wednesday - unless non-adherent) clean the contact layer with normal saline soaked gauze, apply puracol ag (a collagen dressing) to wound bed, cover with ABD pad and wrap with rolled gauze. As needed daily if soiled. The patient was observed to have dressings to the left forearm, right forearm, and right leg calf. The patient had a bed cradle in place to keep bedding off lower legs and there was thickened liquid drinks on the bed side table. The hospice nurse stated the left and right forearm dressing were not there on 12/22/2025 form their last nursing visit. The hospice nurse stated the facility staff provide wound care and dressing changes.After the visit the hospice nurse could not find facility staff to report off to and stated they would send a communication note later that day. However, the communication documented in the recoded dated 01/05/2026 did not include any request for clarification on wound care orders to all 3 sites, an updated status on the wounds, how they developed, or on thickened liquids and the bed cradle in place.The 01/05/2026 hospice wound care orders included:Right calf – clean with saline, apply xeroform dressing, cover with abdominal padding secure in place with gauze. Change dressing every 3 days and as needed for saturation, non-adhered and/or greater than 50% saturated. Wound care managed by family, caregiver, and or hospice staff.There were no wound care orders in the hospice plan of care to the left and right forearm wounds.Hospice nursing visits form 10/29/2025 through 12/29/2026 lacked documentation on status of left and right forearm wounds and status and measurements to right calf wound. The hospice nurse documented the right calf wound care was provided by the facility staff and dressing changes are not completed by the hospice nurse.On 01/06/2026 the surveyor requested for a written agreement the agency has with skilled nursing facilities; On 01/07/2026 at 2 PM, the agency provided the surveyor with a written agreement titled “Agreement for Hospice Care for Skilled Nursing Facility Residents and Respite Care Services” dated 02/03/2025.The agreement included:-Hospice provider will furnish skilled nursing facility with a copy of the Hospice Provider Plan of Care after admission to hospice and will identify the services to be provided by hospice.-IDG meeting updates will be communicated with the skilled nursing facility.-Hospice Provider may request that skilled nursing facility participate in IDG conferences.-Hospice provider will hold case conferences with skilled nursing facility on a as needed basis.Hospice will provide the skilled nursing facility with most recent hospice provider plan of care.The 10/29/2025, 11/12/2025, 11/26/2025, 12/10/2025, and 01/06/2026 IDG meeting plan of care revealed non-healing wound to right calf. No other wounds sites were reviewed or who was providing and managing wound care. There was no evidence the plan was coordinated with the SNF plan of care.The 10/28/2025 hospice plan of care failed to:- Have wound care orders in place to the right and left forearm.- Coordinate wound care orders to ensure hospice plan of care had the same order in place.-Identify all care and services being provided by the hospice and by the SNF. -Clarify whether it was the hospice, or the SNF, that were responsible for performing the respective functions.-Include a copy of the SNF care plan, along with the hospice care plan, to clarify the functions of each.During interview on 01/09/2025 at 9:30 AM, the Director of Hospice Services and Admissions Team Manager  stated the SNF has a wound care team that determines wound care needs for the patient. They stated no one from the skilled facility had been invited to the hospice IDG meetings for case conference and no one from the hospice has participated in the SNF case conferences. The case manager stated they had not coordinated status of wound care with the wound team at the SNF.

Based on clinical record review and interview with agency staff, for one (1) of one (1) patients (Patient #4) receiving services from a non-hospice provider, the hospice failed to ensure ongoing sharing of information and collaboration exists between the hospice and the non-hospice provider. Failure to ensure effective communication occurs between all healthcare providers to facilitate the coordination of care has the potential to result in negative patient outcomes. --- The hospice failed to ensure ongoing sharing of information and collaboration between the hospice and the non-hospice provider as evidenced by the following: Patient #4 – This 89-year-old patient with a terminal diagnosis of nontraumatic intracerebral hemorrhage, residing in a skilled nursing facility, was admitted to the hospice on 11/22/2023. A.) Review of the Physicians Plan of Care dated 11/22/2023 revealed a new order for Morphine Concentrate, 20 milligrams per milliliter solution, take 5 milligrams by mouth every four (4) hours as needed for pain. Review of the Registered Nurse Assessment dated 11/22/2023 revealed the Registered Nurse documented the patient began using liquid morphine as of 11/22/2023 for comfort and has had more grimacing and episodes of sleeping. Review of the clinical record from the 11/22/2023 initial Registered Nurse Assessment and development of the plan of care lacks documentation of collaboration with the skilled nursing facility staff regarding the new morphine being initiated, goals of pain control and signs and symptoms to report to the hospice nurse and/or physician. During interview on 12/12/2023 at 12:25 PM, the Registered Nurse stated collaboration occurred with the skilled nursing facility staff at the 11/22/2023 visit but was not documented. B.) Review of the Registered Nurse Assessment dated 11/22/2023 revealed the Registered Nurse documented the date of the patients last bowel movement was unknown. The assessment lacks documentation of collaboration with the skilled nursing facility staff regarding when the patient last had a bowel movement. During interview on 12/12/2023 at 12:20 PM, the Registered Nurse stated the skilled nursing facility staff were consulted with regarding the patients last tracked bowel movement but was not documented.

Based on review of clinical records, agency policy and procedure, and interviews with agency staff, the hospice failed to ensure in two (2) of thirteen (13) clinical records (Patient #'s: 4 and 13), the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. The findings are: Review of the agencys undated policy entitled ";Wound Assessment and Documentation" revealed ";RN (Registered Nurse) will complete in its entirety a wound assessment including measurements (width (W), length (L), and depth (D) and description within the current Electronic Medical Record (EMR) with every full assessment) that should be completed every 14 (fourteen) days and PRN (as needed) or with every inspection of the wound or wounds." --- Patient #4 – This 93-year-old patient with a terminal diagnosis of atherosclerotic heart disease of native coronary artery was admitted to the hospice on 01/13/2023. Review of the Physicians Plan of Care dated 01/13/2023 revealed the following wound care order: RN/LPN (Licensed Practical Nurse) to perform wound care to wound/ulcer site(s):- Cleanse with NS (normal saline).- Apply non-adherent pad to skin.- Wrap with gauze wrap. Review of Initial and Comprehensive Assessment completed by the RN on 01/13/2023 revealed the RN documented ";the patient has a gangrenous wound extending from the right leg, to foot, to toe." The RN failed to measure the wound in accordance with the agencys policy and failed to document a comprehensive assessment to state specifically where the wound is located and the appearance of the wound. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During interview on 02/02/2023 at 10:46 AM, the RN stated she did not measure the patients wound and will document more clearly going forward. Patient #13 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium was admitted to the hospice on 12/07/2021. A.) Review of the Physicians Plan of Care dated 12/07/2021 revealed the following wound care order: Unstageable tunneling wound on right hip area, remove packing and clean with normal saline, re- pack wound with sterile packing, cover with gauze. Dressing changes daily and PRN (as needed) to be managed by CF (Carefirst). Review of the Initial and Comprehensive Assessment completed by the RN on 12/07/2021 revealed the following: Patient with Wound Vac (negative- pressure wound therapy device) (location not specified); Wound area: Right hip; Wound type: Pressure ulcer stage 4; W (Wound) 1- length (cm) (centimeters): 2 cm round; W1- width (cm): N/A (not applicable); W1- depth (cm): Tunneled; Current wound status: Open. The wound documentation lacks an assessment of the width, the depth, the tunneling direction, tunneling depth and drainage quantity, color and odor. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patients needs to promote the patients well- being and comfort throughout the dying process. During interview on 02/03/2023 at 10:04 AM, the RN stated the patient had a Wound Vac dressing in place to the right hip and cannot recall how the wound was observed for the documentation provided. The RN stated she did not document on the wound drainage in the assessment. B.) Review of the Standards of Practice Protocol entitled ";Central Venous Access Device: Infection Prevention Strategies, Home Care Infection Prevention and Control Program 2017 Edition" revealed the following guidelines are to be followed: ";Assess the catheter- skin junction during each home visit. Instruct the home care patient and caregiver to inspect the site daily for signs of complications and to report any catheter or dressing related problems. Inform the physician if the patient develops signs of an infection at the catheter- skin junction, symptoms of a blood stream infection or has a malfunctioning device." Review of the Physicians Plan of Care dated 12/07/2021 revealed the following order: VAD (vascular access device) flush: Give normal saline pre- flush of 5- 10 cc (cubic centimeter) and normal saline post- flush of 10 cc with 1000 units heparin via implanted port (every thirty days and PRN to be managed by CF). Review of the Initial and Comprehensive Assessment completed by the RN on 12/07/2021 revealed the following: - Vascular Access: Implanted port. The implanted port documentation lacks specification of location, placement date, if currently accessed and date last flushed with normal saline and heparin. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patients needs to promote the patients well- being and comfort throughout the dying process. During interview on 02/03/2023 at 09:58 AM, the RN acknowledged the implanted port assessment lacks the identified components.

Based on review of clinical records and interview with staff, for eleven (11) of thirteen (13) patients (Patient #'s: 1, 2, 3, 4, 5, 6, 8, 10, 11, 12, and 13), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group (IDG) to act on inaccurate information. --- Patient #4 – This 93-year-old patient with a terminal diagnosis of atherosclerotic heart disease of native coronary artery was admitted to the hospice on 01/13/2023. Review of the referral to the agency dated 11/01/2022 revealed the following medications:- multivitamin- skin prep spray: scalp and sacrum- fluticasone propionate 50 mcg (micrograms)/act suspension 1 spray in each nostril nasally once a day- furosemide 20 mg (milligram) tablet take 1 tablet by mouth every other day- potassium chloride ER (extended release) 10 mEq (milliequivalent) tablet take 1 tablet by mouth every other day- pentoxifylline ER 400 mg take 1 tablet by mouth twice a day with meals- donepezil HCL (hydrochloride) 10 mg tablet take 1 tablet by mouth once daily at bedtime- vitamin D 1.25 mg capsule take 1 capsule orally once weekly- atorvastatin calcium 20 mg tablet take 1 tablet by mouth once daily- nystatin 10,000 unit/gm (gram) powder 1 application externally twice a day- aricept 10 mg tablet 1 tablet at bedtime orally once a day Review of the Physicians Plan of Care dated 01/13/2023 lacks orders for the identified medications. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancies with the physician or the IDG (Interdisciplinary Group). The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 10:50 AM, the RN stated she did call the patients physician but did not specifically document which medications were discontinued. Patient #6 – This 55-year-old patient with a terminal diagnosis of malignant neoplasm of colon, residing in a skilled nursing facility, was admitted to the hospice on 01/05/2023. Review of the Order Summary Report dated 12/29/2022 revealed the following medications:- bisacodyl suppository insert 10 mg rectally as needed for constipation- fleet enema 7-19 gm (grams)/118 ml (milliliters) insert 1 application rectally as needed for constipation if no BM (bowel movement) by day 4. - glucose gel 15 gm/32 ml give 1 packet by mouth as needed for fasting blood sugar 40 to 60 (alert resident and able to swallow) Review of the Physicians Plan of Care dated 01/05/2023 lacks orders for the identified medications. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 12:55 PM, the RN stated she thought she correctly matched the patients hospice medications against the medication list the skilled nursing facility was using. Patient #11 – This 83-year-old patient with a terminal diagnosis of malignant neoplasm of pancreas was admitted to the hospice on 01/04/2023. Review of the referral to the agency dated 12/14/2022 revealed the following medications:- vitamin D - tizanidine HCL 2 mg tablet 1 tablet as needed orally twice a day- potassium as needed- omeprazole 20 mg capsule delayed release 1 capsule 30 minutes before morning meal orally twice a day- multivitamin tablet 1 tablet orally once a day- dorzolamide HCL 2% (percent) solution 1 drop into affected eye three times daily- calcium carbonate-vitamin D 500-200 mg-unit tablet 1 tablet with meals orally twice a day- aspirin 81 mg tablet delayed release 1 tablet orally once a day Review of the Physicians Plan of Care dated 01/04/2023 lacks orders for the identified medications. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 10:14 AM, the RN stated she did contact the patients physician to discontinue the patients medications but did not specify which medications were to be discontinued. Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. Review of the referral to the agency dated 12/30/2022 revealed the following medication orders: - albuterol 0.083 % (percent) inhalation nebu (nebulizer) soln (solution) use 1 (one) vial in nebulizer every 6 (six) hours; - clobetasol 0.05% apply externally, 1 (one) appl (application) by topical route two times daily as needed for rash to perineal area; - milk of magnesia 400 mg/ 5 ml (milliliter) oral suspension, take 30 ml by mouth every bedtime as needed; - calmoseptine 0.44- 20.625%, 1 (one) application by topical route twice daily; - nystatin 100000 unit/ gm (gram), 1 gm by apply externally route three times daily to affected area; and - oxycodone 5 mg oral tab, take 0.5 tablets by mouth every four hours as needed for pain, max daily amount 15 mg. Review of the Physicians Plan of Care dated 01/04/2023 lacks orders for the identified medications. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 12:35 PM, the RN stated the family reported the patient was not taking the identified medications and she forwarded the list of medications the patient was taking to the physician but failed to document this. Patient #3 – This 59-year-old patient with a terminal diagnosis of cirrhosis of liver was admitted to the hospice on 01/06/2023. Review of the referral to the agency progress note dated 12/22/2022 revealed the following medication orders: - atorvastatin calcium 80 mg tablet, take 1 (one) tablet by mouth once daily; - eliquis 5 mg tablet, take 1 (one) tablet orally 2x (twice) daily; and - proair HFA (hydrofluoroalkane) 108 mcg (microgram)/ act (actuation) aerosol solution 2 (two) puffs as needed inhalation every 6 (six) hours. Review of the Physicians Plan of Care dated 01/06/2023 lacks orders for the identified medications. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 11:45 AM, the RN stated she clarified the medications the patient was to take with the physician but did not specify which medications were discontinued. Patient #10 – This 68-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 01/03/2023. Review of the referral to the agency progress note dated 11/30/2022 revealed the following medication orders: - potassium chloride 20 meq (milliequivalent) packet, 1 (one) packet with food orally once a day; and - metformin 500 mg tablet, 1 (one) tablet with a meal orally twice a day. Review of the Physicians Plan of Care dated 01/03/2023 lacks orders for the identified medications. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/03/2023 at 10:07 AM, the RN stated she cannot recall performing this medication reconciliation and acknowledged the documentation did not clarify the identified discrepancies. Patient #13 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium was admitted to the hospice on 12/07/2021. A.) Review of the referral to the agency progress note dated 12/02/2021 revealed the medication order for ondansetron 8 mg tablet, take 1 (one) tablet by mouth every eight hours as needed for nausea and vomiting. Review of the Physicians Plan of Care dated 12/07/2021 lacks an order for the identified medication. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancy with the physician or the IDG. B.) Review of the referral to the agency progress note dated 12/02/2021 revealed the medication order for prednisone 20 mg oral tab, take 1 (one) tablet by mouth twice daily. Review of the Physicians Plan of Care dated 12/07/2021 revealed a medication order for prednisone 50 mg tablet, take 50 mg by mouth twice daily. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancy with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/03/2023 at 09:56 AM, the RN stated being unable to recall completing the medication reconciliation but acknowledged the documentation did not clarify the identified discrepancies. Patient #2 – This 71-year-old patient with a terminal diagnosis of malignant neoplasm of upper lobe and right bronchus of lungs was admitted to the hospice on 12/29/2022. Review of the referral to the agency dated 12/27/2022 revealed the following medications:- dexamethasone 4 mg (milligram) tablet take 1 tablet by mouth four times a day as needed for brain swelling- dexamethasone 4 mg tablet take 1 tablet by mouth every day as needed for brain swelling Review of the Physicians Plan of Care dated 12/29/2022 lacks orders for the identified medications. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancies with the physician or the IDG (Interdisciplinary Group). The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 12:47 PM, the RN stated she did call the patients physician but did not specifically document which medications were discontinued. Patient #5 – This 65 -year-old patient with a terminal diagnosis of metastatic adenocarcinoma of left breast was admitted to the hospice on 01/12/2023. Review of the referral to the agency dated 01/09/2023 revealed the following medications:- ascorbic acid 500 mg (milligram) tablet take 1by mouth every evening- atorvastatin 20 mg take 1 tablet by mouth every bedtime- azithromycin250 mg take1 tablet by mouth every day- calcium carbonate -Vitamin D take 1 tablet by mouth every morning- cyanocobalamin-B12 1000 mcg (microgram) take 1 tablet by mouth daily- multiple vitamin take 1 tablet by mouth every evening Review of the Physicians Plan of Care dated 01/12/2023 lacks orders for the identified medications. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 11:25 AM, the RN stated she did call the patients physician but did not specifically document which medications were discontinued. Patient #8 – This 59 -year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 01/05/2023. Review of the referral to the agency dated 12/31/2022 revealed the following medication:- lidocaine urethral/mucosal 2% (percent) apply externally 1application every four hours. Review of the Physicians Plan of Care dated 01/05/2023 lacks an order for the identified medication. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 01:01 PM, the RN stated she did contact the patients physician to discontinue the patients medication but forgot to include that specify medication was to be discontinued. Patient #12 – This 72 -year-old patient with a terminal diagnosis of neurocognitive disorder with Lewy body dementia was admitted to the hospice on 01/07/2023. Review of the referral to the agency dated 12/23/2021 revealed the following medications:- Colace (docusate sodium) capsule 1 capsule as needed orally three times daily for constipation; and- midodrine 2.5 mg tablet 1 tablet orally three times daily. Review of the Physicians Plan of Care dated 01/07/2022 lacks orders for the identified medications. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/02/2023 at 12:06 PM, the RN stated she did contact the patients physician to discontinue the patients medications but did not specify which medications were to be discontinued.

Based on clinical record reviews, agency policy and procedures, and staff interviews, four (4) of thirteen (13) clinical records (Patient #s: 1, 4, 8, and 13) lack documented evidence the hospice nurses and Interdisciplinary Group (IDG) members are performing complete updated comprehensive assessments or that the hospice nurses are communicating changes in the patient's condition or treatment to the IDG. Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient has the potential for the patient's health status to be compromised and result in the provision of poor quality of care. --- Review of the agencys undated policy entitled ";Wound Assessment and Documentation" revealed ";RN (Registered Nurse) will complete in its entirety a wound assessment including measurements (width (W), length (L), and depth (D) and description within the current Electronic Medical Record (EMR) with every full assessment) that should be completed every 14 (fourteen) days and PRN (as needed) or with every inspection of the wound or wounds." Patient #4 – This 93-year-old patient with a terminal diagnosis of atherosclerotic heart disease of native coronary artery was admitted to the hospice on 01/13/2023. Review of the Physicians Plan of Care dated 01/13/2023 revealed the following wound care order: RN/LPN (Licensed Practical Nurse) to perform wound care to wound/ulcer site(s):- Cleanse with NS (normal saline).- Apply non-adherent pad to skin.- Wrap with gauze wrap. Review of Initial and Comprehensive Assessment completed by the RN on 01/13/2023 revealed the RN documented ";the patient has a gangrenous wound extending from the right leg, to foot, to toe." Review of the IDG (Interdisciplinary Group) Report dated 01/25/2023 revealed ";Pt. (patient) has gangrenous wound present on right toe/lower leg. Pt. has decreased sensation in leg." Review of the clinical record from 01/13/2023 through 01/30/2023 (date of survey) revealed the RN conducted home visits on 01/13/2023, 01/16/2023, 01/17/2023, 01/18/2023, 01/20/2023, and 01/30/2023. The RN visit notes lack documented evidence wound measurements were obtained and an indication as to why measurements were not obtained. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/02/2023 at 10:46 AM, the RN stated the patients wound was not measured. Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. A.) Review of the Physicians Plan of Care dated 01/04/2023 revealed the following wound care orders: - RN (Registered Nurse)/ LPN (Licensed Practical Nurse)/ family: Cleanse unstageable wound on buttock with soap and water daily, pat dry. Apply skin prep around surrounding tissue, apply moderate amount of bag balm to wound daily and PRN (as needed). - RN/ LPN/ family: Cleanse skin tear on right shin with saline, pat dry, apply bag balm and leave open to air daily and PRN. May cover for protection as needed. Review of the LPN Personal Care Visit/ Focused and Comprehensive Visit dated 01/12/2023 revealed the following: - Intervention: RN/ LPN/ Family: Cleanse wound with soap and water daily, pat dry. Apply skin prep around surrounding tissue, apply moderate amount of bag balm to wound daily and PRN. - Results/ Outcome: Performed, wound care done per order. Wound is draining around edge of eschar. The documentation fails to address interventions to wounds on buttock and right shin. The response fails to specify the location of the wound/ wounds that wound care was performed to. Review of the clinical record prior to 01/12/2023 lacks documented evidence of resolution to either the right shin and/ or buttocks wounds identified at the hospice admission. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/02/2023 at 10:35 AM, the LPN stated she performed wound care to the patients buttock and could not recall the patient having a skin tear but did not document this. B.) Review of the Telephone Contact Note dated 01/12/2023 revealed the RN documented the patients daughter reports the patient has picked a scab on her leg that is now open and bag balm is being applied to the area. The RN offered to make a home visit to assess and the daughter declined. Review of the Focused and Comprehensive Assessment dated 01/13/2023 lacks documented evidence the RN assessed the new leg wound reported by the daughter on the 01/12/2023 telephone call. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/02/2023 at 11:40 AM, the RN stated she assessed the patients legs and did not note any additional open areas. The RN stated she failed to document this. Patient #13 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium was admitted to the hospice on 12/07/2021. A.) Review of the Physicians Plan of Care dated 12/07/2021 revealed the following wound care order for an unstageable tunneling wound on right hip area: remove packing, clean with normal saline, re- pack wound with sterile packing, cover with gauze daily and PRN (as needed). Review of the LPN Personal Care/ Focused and Comprehensive Assessment dated 12/08/2021 revealed the LPN documented the following: - Intervention: Perform wound care to wound/ ulcer site - Results/ Outcome: Performed The documentation does not specify location and wound care performed to wound bed. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/03/2023 at 09:15 AM, the Team Manager stated it is the expectation that the location and treatment of the wound be specified in the identified documentation. B.) Review of the updated Plan of Care dated 12/09/2021 revealed the RN documented a new wound care intervention to include: - LPN/ RN to change dressing to coccyx area Monday, Weds (Wednesday) and Fri (Friday) unless soiled then PRN clean area with soap and water, pat dry, apply medihoney and then dressing. Use lidocaine if needed prior to dressing changes to hip or coccyx. Review of the Focused and Comprehensive Assessment dated 12/09/2021 lacks an assessment of the coccyx wound. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/03/2023 at 09:23 AM, the RN stated being unable to recall the coccyx wound and acknowledged the identified documentation lacks an assessment of the area. C.) Review of the Physicians Plan of Care dated 12/07/2021 revealed the following wound care order for an unstageable tunneling wound on right hip area: remove packing, clean with normal saline, re- pack wound with sterile packing, cover with gauze daily and PRN (as needed). Review of the Focused and Comprehensive Assessment dated 12/09/2021 revealed the following right hip wound assessment: - Length: 1 cm; - Width: 1 cm; - Depth: Unmeasurable; and - Current wound status: Opened (open circle hole, no redness or discoloration around wound). The assessment lacks documentation of drainage quantity, color and odor. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/03/2022 at 09:25 AM, the RN stated she should have included documentation on the wound drainage in the identified assessment. Review of the agencys undated policy entitled ";Wound Assessment and Documentation" revealed ";RN (Registered Nurse) will complete in its entirety a wound assessment including measurements (width (W), length (L), and depth (D) and description within the current Electronic Medical Record (EMR) with every full assessment) that should be completed every 14 (fourteen) days and PRN (as needed) or with every inspection of the wound or wounds." Patient #8 – This 59 -year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 01/05/2023. Review of the Physicians Plan of Care dated 01/05/2023 revealed the following wound care order: RN/LPN (Licensed Practical Nurse) to perform nephrostomy care to site:- Change dressing every three days or as needed.- Cleanse area gently with water.- Pat dry. Review of Initial and Comprehensive Assessment completed by the RN on 01/05/2023 revealed the RN documented ";the patient has a nephrostomy site right flank lower back." Review of the IDG (Interdisciplinary Group) Report dated 01/11/2023 revealed ";Pt. (patient) has nephrostomy site, and patient is urinating without difficulty." Review of the clinical record from 01/05/2023 through 01/30/2023 (date of survey) revealed the RN conducted home visits on 01/05/2023, 01/09/2023, 01/10/2023, 01/17/2023, 01/22/2023, and 01/23/2023. The RN visit notes lack documented evidence of a complete wound assessment to include wound drainage was documented, and an indication as to why a complete wound assessment was not documented. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/02/2023 at 10:12 AM, the RN stated she did not document an assessment of the drainage from the nephrostomy site.

Based on clinical record reviews and staff interviews for two (2) of thirteen (13) patients (Patient #s 1 and 13), the hospice failed to provide services according to the Plan of Care (POC). Failure to provide services in accordance to the POC has the potential for unmet patient needs. --- Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. Review of the Physicians Plan of Care dated 01/04/2023 revealed the following orders: - Personal care 1 (one) to 3 (three) times per week- Personal care is provided by the Licensed Practical Nurse (LPN) or Registered Nurse (RN); and - Wound/ Ulcer Regimen by RN/ LPN/ Family: Cleanse unstageable wound on buttock with soap and water daily, pat dry, apply skin prep around surrounding tissue, apply moderate amount of bag balm to wound daily and PRN (as needed). Review of the Physicians Plan of Care dated 01/04/2023 revealed the RN/ LPN are to assist the patient with the following interventions at each personal care visit: - Assistance with hair care; - Assistance with mouth care; - Assistance with bed bath; - Assistance with dressing; - RN/ LPN/ Family cleanse wound with soap and water daily, pat dry, apply skin prep around surrounding tissue, apply moderate amount of bag balm to wound daily and PRN; - RN/ LPN / Family cleanse skin tear on right shin with saline, pat dry, apply bag balm and leave open to air daily and PRN, may cover for protection; and - Collaborate with family member/ caregiver. Review of the LPN Personal Care Visit/ Focused and Comprehensive Assessment dated 01/10/2023 lacks documented evidence the LPN completed or offered and the patient refused any of the ordered interventions to be performed at the visit. The LPN failed to provide services in accordance to the POC. During interview on 02/02/2023 at 10:45 AM, the Team Manager stated the LPN no longer works at the agency. The Team Manager stated the LPN documented the patient was sleeping during the visit and believes the LPN did not document on any ordered interventions because the patient was asleep. Patient #13 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium was admitted to the hospice on 12/07/2021. Review of the Physicians Plan of Care dated 12/07/2021 revealed the following orders: - Personal care three (3) to five (5) times per week. Personal care is provided by the LPN or RN; and - Wound/ Ulcer Regimen by RN/ LPN/ Family: Unstageable tunneling wound on right hip area, remove packing and clean with normal saline, re- pack wound with sterile packing, cover with gauze daily and PRN. Review of the Physicians Plan of Care dated 12/07/2021 revealed the RN/ LPN are to assist the patient with the following interventions at each personal care visit: - LPN to communicate with IDT (interdisciplinary team) regarding patients status; - LPN to report any changes in patient/ family status to RN/ CM (Case Manager). - Assistance to commode; - Assistance with dressing; Assistance with nail care; - Assistance with tub bath/ shower/ or chair bath (sponge) as requested by patient/ caregiver; - Perform wound care as per MD order; and - Collaborate with family member/ caregiver. Review of the LPN Personal Care Visit/ Focused and Comprehensive Assessment dated 12/16/2021 lacks documented evidence the LPN completed or offered and the patient refused any of the ordered interventions to be performed at the visit. The LPN failed to provide services in accordance to the POC. During interview on 02/03/2023 at 09:38 AM, the Team Manager stated the LPN no longer works for the agency. The Team Manager stated the LPN failed to document regarding the ordered interventions.

Based on a review of clinical records and interview with agency staff for five (5) of thirteen (13) patients (Patient #'s: 1, 4, 8, 10, and 12), the agency failed to ensure the patient and/or caregiver received education and training identified in the plan of care (POC). Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. --- Patient #4 – This 93-year-old patient with a terminal diagnosis of atherosclerotic heart disease of native coronary artery was admitted to the hospice on 01/13/2023. Review of the Physicians Plan of Care dated 01/13/2023 revealed the following:- RN/LPN (Licensed Practical Nurse) to perform wound care to wound/ulcer site(s): - Cleanse with NS (normal saline). - Apply non-adherent pad to skin. - Wrap with gauze wrap. - Problem: Skin/membrane integrity risk for impairment due to gangrene wound. - Goal: For patient and family, participate in wound care regimen, ongoing. Review of Initial and Comprehensive Assessment completed by the RN on 01/13/2023 revealed the patient has a gangrenous wound extending from the right leg, to foot, to toe, and the patients caregiver is providing wound care. Review of the clinical record lacks documented evidence the patient and/or caregiver was instructed in performing wound care as ordered. The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 02/02/2023 at 10:48 AM, the RN stated she did observe the caregiver providing wound care but did not document it in clinical record. Patient #8 – This 59 -year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 01/05/2023. Review of the Physicians Plan of Care dated 01/05/2023 revealed the following:- RN/LPN (Licensed Practical Nurse) to perform wound care to wound/ulcer site(s): - Change dressing every three days or as needed. - Cleanse area gently with water. - Pat dry. - Problem: Skin/membrane integrity risk for impairment due to present Nephrostomy. - Goal: For patient and family, participate in wound care regimen, ongoing. Review of Initial and Comprehensive Assessment completed by the RN on 01/05/2023 revealed the patient has a nephrostomy right flank, and the patients caregiver is providing wound care. Review of the clinical record lacks documented evidence the patient and/or caregiver was instructed in performing wound care as ordered. The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 02/02/2023 at 10:56 AM, the RN stated she did not perform any wound teaching and did not observe the caregiver providing wound care. Patient #12 – This 72 -year-old patient with a terminal diagnosis of neurocognitive disorder with Lewy body dementia was admitted to the hospice on 01/07/2023. Review of the Physicians Order dated 01/14/2023 revealed the following:- RN/LPN (Licensed Practical Nurse) and family to perform foley catheter care. - Change every 30 days and as needed for obstructions. - May irrigate with NS (normal saline) as needed for lack of urine output leakage, or discomfort. Review of Focused and Comprehensive Assessment completed by the RN on 01/14/2023 revealed the patient has an indwelling catheter with drainage bag, and the patients caregiver is providing catheter care. Review of the clinical record lacks documented evidence the patient and/or caregiver was instructed in performing catheter care as ordered. The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 02/02/2023 at 12:09 PM, the RN stated she did not perform catheter care teaching to the caregiver. Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. Review of the Physicians Plan of Care dated 01/04/2023 revealed the following orders: - Other Wound/ Ulcer Regimen: RN (Registered Nurse) / LPN (Licensed Practical Nurse) / Family: Cleanse unstageable wound on buttock with soap and water, pat dry, apply skin prep around surrounding tissue, apply moderate amount of bag balm to wound daily and PRN (as needed); and - RN/ LPN/ Family: Cleanse skin tear on right shin with saline, pat dry, apply bag balm and leave open to air daily and PRN. May cover for protection as needed. Review of the clinical record from 01/04/2023 to 01/07/2023 revealed the patient received nursing visits on the following dates: 01/04/2023, 01/05/2023 and 01/07/2023. Review of the Initial and Comprehensive Assessment dated 01/04/2023 revealed the RN performed the ordered wound care and lacks documented evidence the family were instructed and re- demonstrated the wound care to the RN. Review of the Personal Care Visit/ Focused and Comprehensive Assessment 01/05/2023 lacks documented the family were instructed and re-demonstrated the wound care to the LPN prior to assuming responsibility for the wound care on 01/06/2023. The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 02/02/2023 at 12:40 PM, the RN stated she instructed the family in performing the wound care but failed to document this. During interview on 02/02/2023 at 10:43 AM, the Team Manager stated the LPN no longer works for the agency and acknowledged documentation was not provided regarding wound care instruction/ re- demonstration during the identified visit. Patient #10 – This 68-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 01/03/2023. Review of the Physicians Plan of Care dated 01/03/2023 revealed an order for the following: Other Wound/ Ulcer Regimen: Gauze and tegaderm (clear occlusive dressing) to cover gallbladder drain insertion site, change every other day and PRN. Review of the clinical record between 01/03/2023 and 01/10/2023 revealed the patient received RN visits on the following dates: 01/03/2023, 01/04/2023 and 01/09/2023. Review of the RN visits occurring on 01/03/2023, 01/04/2023 and 01/09/2023 lack documented evidence the caregiver was instructed and re-demonstrated the wound care to the RN prior to assuming responsibility for completing the wound care. The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 02/03/2023 at 10:10 AM, the RN that made the 01/03/2023 visit stated the family was instructed and demonstrated the wound care but it was not documented. During interview on 02/02/2023 at 12:33 PM, the RN that made the 01/04/2023 and 01/09/2023 visits stated no instruction or re-demonstration of the wound care occurred at the identified visits because the wound care was not complicated.

Based on review of clinical records and interviews with staff, for eleven (11) of thirteen (13) patients (Patient #'s: 1, 2, 3, 4, 5, 6, 7, 9, 10, 12, and 13) the hospice failed to develop an individualized written Plan of Care (POC) that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. --- Patient #4 – This 93-year-old patient with a terminal diagnosis of atherosclerotic heart disease of native coronary artery was admitted to the hospice on 01/13/2023. A.) Review of the Physicians Plan of Care dated 01/13/2023 revealed the following wound care order:RN (Registered Nurse)/LPN (Licensed Practical Nurse) to perform wound care to wound/ulcer site(s):- Cleanse with NS (normal saline).- Apply non-adherent pad to skin.- Wrap with gauze wrap. The order for wound care lacks where the wound care is to be provided as well as a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:47 AM, the RN stated the order is incomplete. B.) Review of the Physicians Plan of Care dated 01/13/2023 revealed the order for vital signs and pulse oximetry to be performed by agency staff and/or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #6 – This 55-year-old patient with a terminal diagnosis of malignant neoplasm of colon, residing in a skilled nursing facility, was admitted to the hospice on 01/05/2023. A.) Review of the Physicians Plan of Care dated 01/05/2023 revealed the order for vital signs and pulse oximetry to be performed by agency staff and/or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. B.) Review of the Physicians Plan of Care dated 01/05/2023 revealed the following intervention: ";Instruct in care of ostomy and appliance usage." Review of the Physicians Plan of Care dated 01/05/2023 lacks orders for the following:- instructions for care and usage of the ostomy and appliance to include a frequency of care- the supplies and sizes needed - when the appliance was last changed or initially inserted and when it is due to be changed again The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 12:53 PM, the RN stated she did not include more information in the order because the patient resides in a skilled nursing facility (SNF) and the staff there manage it. The patient has had the ostomy for a long time and managed it herself prior to admission to the SNF. Patient #7 – This 100-year-old patient with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 01/08/2023. A.) Review of the Physicians Plan of Care dated 01/08/2023 revealed the following wound care order: - Patient caregiver/family/agency staff clean wound on right heel gently with warm soapy water, pat dry, apply bag balm, clean reddened areas on sacral areas on sacral area with warm soapy water, pat gently dry, apply bag balm. The order for wound care lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 1:17 PM, the Team Manager stated the order is incomplete. B.) Review of the Physicians Plan of Care dated 01/08/2023 revealed the order for vital signs and pulse oximetry to be performed by agency staff and/or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #9 – This 76-year-old patient with a terminal diagnosis of chronic congestive heart failure was admitted to the hospice on 12/28/2022. Review of the Physicians Plan of Care dated 12/28/2022 revealed the order for vital signs and pulse oximetry to be performed by agency staff and/or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. A.) Review of the Physicians Plan of Care dated 01/04/2023 revealed the following orders: - Other Wound/ Ulcer Regimen: RN (Registered Nurse) / LPN (Licensed Practical Nurse) / Family: Cleanse unstageable wound on buttock with soap and water, pat dry, apply skin prep around surrounding tissue, apply moderate amount of bag balm to wound daily and PRN (as needed); and - RN/ LPN/ Family: Cleanse skin tear on right shin with saline, pat dry, apply bag balm and leave open to air daily and PRN. The wound care orders fail to identify indications to change the dressings PRN. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 12:28 PM, the RN stated she made an error and left out the identified indicators. B.) Review of the Physicians Plan of Care dated 01/04/2023 revealed the following orders: - Other Wound/ Ulcer Regimen: RN (Registered Nurse) / LPN (Licensed Practical Nurse) / Family: Cleanse unstageable wound on buttock with soap and water, pat dry, apply skin prep around surrounding tissue, apply moderate amount of bag balm to wound daily and PRN (as needed); and - RN/ LPN/ Family: Cleanse skin tear on right shin with saline, pat dry, apply bag balm and leave open to air daily and PRN. - Intervention: RN/LPN/ Family: Cleanse wound with soap and water, pat dry, apply skin prep around surrounding tissue, apply moderate amount of bag palm to wound daily and PRN. The Intervention lacks the location to perform the wound care. The Plan of Care lacks an Intervention for wound care to be performed to the right shin wound. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 12:30 PM, the RN stated it was an oversight that the identified intervention lacks the location to perform the wound care and that she did not include an intervention for the second wound when the POC was developed. C.) Review of the Physicians Plan of Care dated 01/04/2023 revealed the order for vital signs and pulse oximetry to be performed by agency staff/ or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #3 – This 59-year-old patient with a terminal diagnosis of cirrhosis of liver was admitted to the hospice on 01/06/2023. Review of the Physicians Plan of Care dated 01/06/2023 revealed the order for vital signs and pulse oximetry to be performed by agency staff/ or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #10 – This 68-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 01/03/2023. A.) Review of the Physicians Plan of Care dated 01/03/2023 revealed the order for vital signs and pulse oximetry to be performed by agency staff/ or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. B.) Review of the Physicians Plan of Care dated 01/03/23 revealed the following order: Other Wound/ Ulcer Care Regimen: Gauze and tegaderm (clear, occlusive dressing) to cover gallbladder drain insertion site, change every day and PRN. The wound care order fails to identify an indication to change the dressing PRN. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/03/2023 at 10:09 AM, the RN stated the PRN indication to change the dressing is implied and she did not believe it needed to be specified. Patient #13 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium was admitted to the hospice on 12/07/2021. A.) Review of the Physicians Plan of Care dated 12/07/2021 revealed the following order: Other Wound/ Ulcer Regimen: Unstageable tunneling wound of right hip area- remove packing, clean with normal saline, re-pack wound with sterile packing, cover with gauze daily and PRN. The wound care order fails to identify an indication to change the dressing PRN. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/03/2023 at 09:58 AM, the RN stated she omitted the indication to change the dressing PRN. B.) Review of the Physicians Plan of Care dated 12/07/2021 revealed the following order: VAD (vascular access device) Flush: Give normal saline pre- flush of 5- 10 cc (cubic centimeters) and normal saline post- flush of 10 cc with 1000 units heparin via implanted port every 30 (thirty) days and prn to be managed by hospice. The Plan of Care lacks orders for the following: - Location of the implanted port; - Supplies and sizes needed to access and flush the implanted port; - Specification of when the implanted port was last flushed and date next flush is due; and - Identification of an indicator to flush the implanted port PRN. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/03/2023 at 09:59 AM, the RN acknowledged POC lacks the identified orders for the implanted port. C.) Review of the Physicians Plan of Care dated 12/07/2021 revealed the order for vital signs and pulse oximetry to be performed by agency staff/ or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #2 – This 71-year-old patient with a terminal diagnosis of malignant neoplasm of upper lobe and right bronchus of lungs was admitted to the hospice on 12/29/2022. Review of the Physicians Plan of Care dated 12/29/2022 revealed the order for vital signs and pulse oximetry to be performed by agency staff and/or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #5 – This 65 -year-old patient with a terminal diagnosis of metastatic adenocarcinoma of left breast was admitted to the hospice on 01/12/2023. Review of the Physicians Plan of Care dated 01/12/2023 revealed the order for vital signs and pulse oximetry to be performed by agency staff and/or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency. Patient #12 – This 72 -year-old patient with a terminal diagnosis of neurocognitive disorder with Lewy body dementia was admitted to the hospice on 01/07/2023. Review of the Physicians Plan of Care dated 01/07/2022 revealed the order for vital signs and pulse oximetry to be performed by agency staff and/or family members. The order to obtain vital signs and pulse oximetry lacks a frequency. The hospice failed to develop an individualized written POC that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. During interview on 02/02/2023 at 10:50 AM, the Team Manager stated the order is a standard order that needs to be updated by the agency.

Based on review of clinical records and interviews with staff, for two (2) of thirteen (13) patients (Patient #s 1 and 3), the hospice failed to ensure the Interdisciplinary Group (IDG), in collaboration with the physician reviewed and revised the individualized plan of care (POC) as changes occurred, but no less frequently than every fifteen (15) days. --- Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. Review of the Physicians Plan of Care dated 01/04/2023 revealed orders for an unstageable wound on buttock requiring daily and PRN (as needed) wound care to include cleanse with soap and water, pat dry, apply skin prep around surrounding tissue and apply moderate amount of bag balm to wound. Review of the Focused and Comprehensive Assessment dated 01/25/2023 revealed the Registered Nurse (RN) documented the following wound assessment: - Wound area: Right upper buttock; - Wound type: Pressure ulcer stage 3; and - Wound start date: 01/04/2023. Review of the IDG Report dated 02/01/2023 revealed the following plan of care documentation: - Problem: Skin/ membrane integrity impaired due to unstageable pressure ulcer on right buttock; - Goal: Achieve wound healing without complications, ongoing; - Intervention: RN/ LPN (Licensed Practical Nurse and caregiver- wash superficial wound of right buttocks with warm soapy water, rinse, pat dry, apply calmoseptine and bag balm to superficial wound, wash deep wound on right buttocks with normal saline, pat dry and apply medihoney to deep wound only. Wound care to be performed daily and PRN. (The RN failed to update the POC regarding the newly staged wound). The hospice failed to ensure the Interdisciplinary Group (IDG), in collaboration with the physician reviewed and revised the individualized plan of care (POC) as changes occurred, but no less frequently than every fifteen (15) days. During interview on 02/02/2023 at 11:30 AM, the RN stated the identified wound improved from unstageable to stage 3 but she failed to update the POC with the change. Patient #3 – This 59-year-old patient with a terminal diagnosis of cirrhosis of liver was admitted to the hospice on 01/06/2023. Review of the Personal Care Visit/ Focused and Comprehensive Assessment dated 01/24/2023 revealed the LPN documented the caregiver reports the patient is starting an antibiotic after hematuria was observed. Review of the IDG Report dated 01/25/2023 reveals the RNCM documented the patient started taking keflex (antibiotic) on 01/24/2023 that was ordered by the attending physicians office for treatment of a UTI (urinary tract infection). The IDG failed to include the keflex in the updated medication orders. The hospice failed to ensure the Interdisciplinary Group (IDG), in collaboration with the physician reviewed and revised the individualized plan of care (POC) as changes occurred, but no less frequently than every fifteen (15) days. During interview on 02/02/2023 at 11:10 AM, the RN stated she failed to update the POC with the identified antibiotic order.

Based on review of clinical records and interviews with staff, for one (1) of thirteen (13) records (Patient #13), the hospice failed to ensure the care and services are provided in accordance with the plan of care (POC). Failure to provide care in accordance to the patients established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. --- Patient #13 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium was admitted to the hospice on 12/07/2021. Review of the Initial and Comprehensive Assessment dated 12/07/2021 revealed the Registered Nurse (RN) documented the patient was connected to a Wound Vac (vacuum assisted negative pressure device used for wound healing) (location not specified) at the time of the assessment. Review of the 12/08/2021 chart note revealed the Director of Hospice Services documented on meeting with RN, Team Managers and Access Manager to discuss transition from patients Wound Vac therapy to a more appropriate wound plan. The RN and Team Manager were going to make joint visit to the patient to discuss an alternate wound care plan. Review of the Focused and Comprehensive Assessment dated 12/08/2021 revealed the RN documented the patient was receptive to an alternate wound care plan and the Wound Vac was discontinued during the visit. Review of the IDG (Interdisciplinary Group) Report dated 12/08/2023 revealed the RNCM (RN Case Manager) documented the patient has a stage 4 (four) decubitis to the right hip and has a wound vac and dressing changes in place. Review of the clinical record lacks an order for the discontinuation of the Wound Vac therapy. The hospice failed to obtain an order to discontinue the Wound Vac therapy. During interview on 02/03/2023 at 01:10 PM, the Team Manager stated there was not an order to discontinue the Wound Vac therapy.

Based on review of clinical records, agency policy and procedure, and interview with staff, for thirteen (13) of thirteen (13) clinical records (Patient #s: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13), the agency failed to provide documented evidence that a verbal or written certification of terminal illness was obtained by the Attending Physician and the Medical Director. Failure to ensure the written certification of terminal illness is completed by the Attending Physician and the Medical Director has the potential for unmet patient needs. The findings are: Review of the agencys policy entitled ";Certification of Terminal Illness" reviewed 10/2021 revealed ";The Certification of Terminal Illness form specifies that the patients prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course... If the (agencys) Medical Director and the patients attending physician do not sign the Certification of Terminal Illness form within two days of the start of care (by the end of the third day), a verbal certification is obtained from both physicians within the two days and is documented in the patients clinical record." --- Patient #4 – This 93-year-old patient with a terminal diagnosis of atherosclerotic heart disease of native coronary artery was admitted to the hospice on 01/13/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 01/25/2023 (12 days) after election of the hospice benefit; and- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 01/13/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/13/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. Patient #6 – This 55-year-old patient with a terminal diagnosis of malignant neoplasm of colon, residing in a skilled nursing facility, was admitted to the hospice on 01/05/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 01/11/2023 (6 days) after election of the hospice benefit; and- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 01/05/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/05/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. Patient #7 – This 100-year-old patient with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 01/08/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 01/11/2023 (3 days) after election of the hospice benefit; and- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 01/08/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/08/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. Patient #9 – This 76-year-old patient with a terminal diagnosis of chronic congestive heart failure was admitted to the hospice on 12/28/2022. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification lacked the Medical Directors signature (the signature line was blank); and - the Certification was signed by the Attending Physician on 01/04/2023 (7 days) after election of the hospice benefit Review of the Physicians Plan of Care dated 12/28/2022 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 12/28/2022 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. Patient #11 – This 83-year-old patient with a terminal diagnosis of malignant neoplasm of pancreas was admitted to the hospice on 01/04/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 01/11/2023 (7 days) after election of the hospice benefit; and- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 01/04/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/04/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. The hospice failed to ensure the certification of terminal illness was completed by the hospice physician and the attending physician. During interview on 02/03/2023 at 10:45 AM, the Senior Director of Clinical Services stated the agency was unaware that the agencys current verbal order was not acceptable as a verbal order for Certification of Terminal Illness. Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification lacks the hospices Medical Directors signature (the signature line is blank); and- the Certification lacks the Attending Physician's signature (the signature line is blank). Review of the Physicians Plan of Care dated 01/04/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/04/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." The verbal order lacks certification of the terminal illness. Patient #3 – This 59-year-old patient with a terminal diagnosis of cirrhosis of liver was admitted to the hospice on 01/06/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was completed by the hospices Medical Director on 01/11/2023 (five days after the hospice election); and- the Certification was signed by the Attending Physician on 01/10/2023 (four days after the hospice election). Review of the Physicians Plan of Care dated 01/06/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/06/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." The verbal order lacks certification of the terminal illness. Patient #10 – This 68-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 01/03/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was completed by the hospices Medical Director on 01/11/2023 (eight days after the hospice election); and- the Certification lacks the Attending Physician's signature (the signature line is blank). Review of the Physicians Plan of Care dated 01/03/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/03/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." The verbal order lacks certification of the terminal illness. Patient #13 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium was admitted to the hospice on 12/07/2021. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was completed by the hospices Medical Director on 12/08/2021 (one day after the hospice election); and- the Certification was signed by the Attending Physician on 12/17/2021 (ten days after the hospice election). Review of the Physicians Plan of Care dated 12/07/2021 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 12/07/2021 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." The verbal order lacks certification of the terminal illness. Patient #2 – This 71-year-old patient with a terminal diagnosis of malignant neoplasm of upper lobe and right bronchus of lungs was admitted to the hospice on 12/29/2022. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 12/29/2022- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 12/29/2022 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 12/29/2022 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. Patient #5 – This 65 -year-old patient with a terminal diagnosis of metastatic adenocarcinoma of left breast was admitted to the hospice on 01/12/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 01/18/2023 (6 days) after election of the hospice benefit; and- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 01/12/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/12/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. Patient #8 – This 59 -year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 01/05/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 01/11/2023 (6 days) after election of the hospice benefit; and- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 01/05/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/05/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. Patient #12 – This 72 -year-old patient with a terminal diagnosis of neurocognitive disorder with Lewy body dementia was admitted to the hospice on 01/07/2023. Review of the Hospice Initial Certification (of terminal illness) revealed the following:- the Certification was signed by the hospice's Medical Director on 01/10/2023 (3 days) after election of the hospice benefit; and- the Certification lacked the Attending Physician's signature (the signature line was blank) Review of the Physicians Plan of Care dated 01/07/2023 revealed the following: ";Verbal order for POC: Verbal order received for start of care on 01/07/2023 from (attending) and (medical director) to implement Plan of Care (POC) as outlined." However, the verbal order lacks certification of terminal illness. The hospice failed to ensure the certification of terminal illness was completed by the hospice physician and the attending physician. During interview on 02/03/2023 at 10:45 AM, the Senior Director of Clinical Services stated the agency was unaware that the agencys current verbal order was not acceptable as a verbal order for Certification of Terminal Illness.

Based on clinical record review and interview with agency staff, for one (1) of thirteen (13) patient records (Patient #1), the hospice failed to ensure the record was complete and contained all pertinent information related to the care and delivery of service to the patient. Failure to ensure clinical records are complete and contain all pertinent/ accurate information related to patient care and services has the potential to result in inadequate and inappropriate care. --- Patient #1 – This 98-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 01/04/2023. Review of the Physicians Plan of Care dated 01/04/2023 revealed the following: Problem: Gas exchange/ breathing patterns impaired due to disease progression; Goal: For primary caregiver, identify measures to increase respiratory function, ongoing. Intervention: Instruct in nebulizer tx (treatment) and medications. Review of the Physicians Plan of Care dated 01/04/2023 lacks orders for a nebulizer machine and any medications administered by a nebulizer. The hospice failed to ensure clinical records are complete and contain pertinent and accurate information related to patient care. During interview on 02/02/2023 at 12:36 PM, the RN stated she incorrectly added the identified intervention and it should not have been on the POC.