Every finding on record at Caring Hospice Services of Connecticut LLC

Based on clinical record reviews, review of agency documentation and interviews with agency personnel, for four of fourteen patients’ (Patient's #3, 4, 5 & 9) in the survey sample, the hospice agency failed to ensure care and services were provided in accordance with the care plan. The findings include: --- a.     Patient #3 elected the Hospice Benefit on 5/15/25 and resided at home. The patient’s diagnoses included Alsheimer’s disease, protein-calorie malnutrition, dementia and congestive heart failure. The physician’s orders dated 5/15/25 included nursing services once a week, hospice aide services two times a week, medical social worker/MSW, chaplain and volunteer services. Review of the initial nursing assessment visit identified that the family was accepting of all services.  Interview and review of Patient #3’s clinical record with the Administrator/Hospice Program Director and Volunteer Coordinator on 8/04/25 at 10:30 AM failed to identify the provision of volunteer services in accordance with the physician’s orders and in response to the patient’s needs. The Administrator indicated volunteer services were requested by Patient #3 but failed to identify volunteer services had been provided to the patient due to volunteer staff not being available in the patient’s service area. b.     Patient #4 elected the Hospice Benefit on 4/18/25 and resided in an Assisted Living Facility/ALF. The patient’s diagnoses included end stage chronic obstructive pulmonary disease, asthma, depression and dementia. The physician’s orders for the certification periods from 4/18/25 to 10/14/25 included nursing services two times a week, hospice aide services two times a week, medical social worker/MSW, spiritual and volunteer services. Review of the initial nursing assessment visit dated 4/18/25, identified that the family was accepting all services but failed to identify volunteer services were provided. The subsequent physician’s orders dated 7/17/25 identified volunteer services monthly for companionship. Interview and review of Patient #4’s clinical record with the Administrator/Hospice Program Director and Volunteer Coordinator on 8/05/25 at 11:30 AM failed to identify the provision of volunteer services in accordance with the physician’s orders and in response to the patient’s needs.  Subsequent to surveyor inquiry, a missed visit note dated 8/05/25 identified on 8/02/25, a volunteer visit was attempted but the patient was out for lunch with the next of kin. c.     Patient #5 elected the Hospice Benefit on 6/26/25 and resided in an Assisted Living Facility/ALF. The patient’s diagnoses included end stage renal disease, congestive heart failure and type II diabetes mellitus. The physician’s orders dated 6/26/25 included nursing services once a week, hospice aide services two times a week, medical social worker/MSW, spiritual and volunteer services. Review of the initial nursing assessment visit identified that the family was accepting of all services.  Interview and review of Patient #5’s clinical record with the Administrator/Hospice Program Director and Volunteer Coordinator on 8/06/25 at 11:30 AM failed to identify the provision of volunteer services in accordance with the physician’s orders and in response to the patient’s needs. Review of agency policy for plan of care directed the care and services provided to the patient and their families are in accordance with an individualized, written plan of care established by the hospice Interdisciplinary Group/IDG in collaboration with patient's attending physician, the patient and/or his or her representative.Review of agency policy for Volunteer Assignment directed that hospice volunteers are assigned in a timely and appropriate manner and assignments are made as soon as possible after notification of the request. Patient #9 elected the Hospice Benefit on 5/13/25 and resided at home. The patient’s diagnoses included hypertensive chronic kidney disease, atherosclerosis of native coronary artery, hyperlipidemia, and macular degeneration. The physician’s orders for the certification period from 5/13/25 through 8/10/25 included nursing services once a week, hospice aide services once a week, medical social worker/MSW, spiritual, and volunteer services.Review of the initial medical social services assessment dated 5/14/25 identified that the family requested volunteer services to provide companionship and stimulation on admission.  Interview and review of Patient #9’s clinical record with the Administrator/Hospice Program Director and Volunteer Coordinator on 8/06/25 at 10:45 AM failed to identify the provision of volunteer services in accordance with the physician’s orders and in response to the patient’s needs.Review of the clinical record for Patient #9 reflected no documentation that nursing visits were made to Patient #9 during the week of 5/18/25 through 5/24/25 and no hospice aide services provided during the week of 6/29/25 through 7/5/25.Interview and review of Patient #9’s clinical record with the Administrator/Hospice Program Director on 8/6/25 at 10:50 AM failed to identify the provision of nursing and hospice aid services in accordance with the physician’s orders and in response to the patient’s needs.Subsequent to surveyor inquiry, a missed visit note dated 8/05/25 identified on 7/2/25 a home health aide visit was cancelled because the staff member called out and coverage was refused by the patient/family. Review of the Hospice Aide Missed Visit Note policy dated 3/30/18 directed all Hospice Aide call outs will be covered by the Hospice Aide Coordinator unless services refused by the patient/family, the Hospice Aide Coordinator will complete the "Hospice Aide Missed Visit Form," and notes should be filed in the patient record at least weekly.

Based on clinical record reviews, review of agency policies and interviews with hospice personnel, for one of fourteen patients (Patient #4) who received nursing and hospice aide services, the hospice agency failed to complete hospice aide supervisions no less frequently than every fourteen (14) days to assess the quality of care and services provided by the hospice aide. The findings include: --- Patient #4 elected the Hospice Benefit on 4/18/25 and resided in an Assisted Living Facility/ALF. The patient’s diagnoses included end stage chronic obstructive pulmonary disease, asthma, depression and dementia. The physician’s orders for the certification periods from 4/18/25 to 10/14/25 included nursing services two times a week, hospice aide services two times a week, medical social worker/MSW, spiritual and volunteer services. Review of the clinical record identified documentation of Registered Nurse/RN supervision of the hospice aides from 4/18/25 to 7/03/25 but failed to identify any further documentation of hospice aide supervisions.  Interview and review of the clinical record from 7/9/25 to 8/04/25 (twenty-five days) with the Administrator on 8/06/25 at 12:30 PM failed to identify documentation by the RN’s every fourteen days to assess quality of care and services provided by the hospice aides. Review of agency policy for Hospice Aide Supervision directed the registered nurse makes an on-site visit to the patient’s home no less frequently than every fourteen days to ensure that services ordered and provided by the hospice aide are meeting the patient’s needs.

Based on clinical record review, agency policies and interview with hospice personnel, for two of thirteen patients (Patient's #1 & 11) in the survey sample, the hospice agency failed to develop a plan of care that addressed the patient's needs. The finding includes: 1. Patient #1 elected the Hospice benefits on 7/07/22. The patient's diagnoses included liver cirrhosis, esophageal varices and stage IV pressure ulcer of the sacral region. The patient resided in a skilled nursing facility (SNF). The physician's orders dated 7/07/22 included nursing services once weekly for assessments and dressing changes to the stage IV coccyx wound, cleansing with normal saline and covering with hydrofera blue (a wound care product used over wounds) every three days by the facility nurse, hospice aide services, social work services and chaplain services. Review of RN #2's weekly hospice visit notes dated 7/13/22, 7/27/22 and 8/03/22 indicated that the patient's wound care was provided by the facility nurse and/or facility wound care doctor at the time of the hospice nurse's visit. Interview and review of the hospice plan of care with the Hospice Administrator on 8/31/22 at 12:30 PM failed to identify frequency of wound measurement,s and the need to increase visits to twice weekly to ensure performance of wound care and measurements by the hospice nurse. 2. Patient #11 elected the Hospice benefits on 5/11/22. The patient's diagnoses included senile degeneration of the brain, chronic obstructive pulmonary disease and dementia. The patient resided at an assisted living facility. The physician's orders for the certification period of 8/09/22 to 11/06/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of RN #1's nursing noted dated 8/30/22 with the Hospice Administrator on 8/31/22 at 12:50 PM identified a stage I pressure ulcer on the patient's right heel but failed to identify wound measurements and wound care orders were obtained by the hospice nurse. Review of agency policies on wound care documentation directed that wounds will be assessed by an RN every visit and all areas of the skin integrity section of the nursing note will be completed including: location of the wound, type, size, drainage, amount, odor, stage, appearance of surrounding skin and wound care order.. Wound measurements will be documented in centimeters (length, width, depth) weekly by the nurse case manager on the first visit of the week.

Based on clinical record review, agency policies and interview with hospice personnel, for one of thirteen patients (Patient #2) in the survey sample, the hospice agency failed to follow the hospice plan of care. The finding includes: 1. Patient #2 elected the hospice benefits on 06/08/2022, with diagnosis including anemia, atrial fibrillation, depression, and anxiety. The hospice plan of care dated 06/08/2022, identified Patient #2 received skilled nursing visits one time per week for nine weeks for assessments, pain management and wound care, social work visits one time per month for two months, chaplain visits two times per month for two months and home health aide visits three times per week for eight weeks. The physician's wound care order dated 06/08/2022 to Patient #2's left medial leg arterial ulcer directed to cleanse with normal saline, apply Medihoney (wound care product used to treat leg ulcers) to the wound bed and wrap with gauze from the base of the toes to the base of the knee. Interview and review of Patient #2's clinical documentation with the Hospice Administrator on 08/31/2022 at 12:15 PM identified RN #4 failed to follow the physician's order as documented in a nurse's note dated 08/12/2022, by applying Calcium Alginate to the wound bed not Medihoney as directed. Review of agency policies on wound care documentation directed that wounds will be assessed by an RN every visit and all areas of the skin integrity section of the nursing note will be completed including: location of the wound, type, size, drainage, amount, odor, stage, appearance of surrounding skin and wound care order.. Wound measurements will be documented in centimeters (length, width, depth) weekly by the nurse case manager on the first visit of the week.

Based on review of the clinical record, agency policies and interview with hospice personnel, for three of five patients (Patient #1, 2 & 11) who required specialized nursing services, the agency failed to ensure that nursing assessments were accurate and wound measurements were completed in accordance with facility policy. The finding includes: 1. Patient #1 elected the Hospice benefits on 7/07/22. The patient's diagnoses included liver cirrhosis, esophageal varices and stage IV pressure ulcer of the sacral region. The patient resided in a skilled nursing facility (SNF). The physician's orders dated 7/07/22 included nursing services once weekly for assessments and dressing changes to the stage IV coccyx wound cleansing with normal saline and covering with hydrofera blue every three days by the facility nurse, hospice aide services, social work services and chaplain services. Interview and review of RN #2's weekly hospice visit notes dated 7/13/22, 7/27/22 and 8/03/22 with the Hospice Administrator on 8/30/22 at 1 PM indicated that the patient's wound care was provided by the facility nurse and/or facility wound care doctor at the time of the hospice nurse's visit, but failed to identify wound assessments and measurements by the hospice nurse. Interview and review of RN #2's nursing notes dated 8/03/22, 8/10/22 and 8/17/22 with the Hospice Administrator on 8/30/22 at 1 PM identified documentation of a stage IV pressure ulcer on the sacrum measuring 6.3 centimeters/cm x 6.5 cm x 1 cm with 60% slough in the wound bed and failed to accurately identify the wound as unstageable. According to the National Pressure Ulcer Advisory Panel/NPUAP, a stage IV pressure injury is defined as full-thickness skin loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of the tissue loss this is an Unstageable Pressure Injury. 2. Patient #2 elected the hospice benefits on 06/08/2022, with diagnosis including anemia, atrial fibrillation, depression, and anxiety. The hospice plan of care dated 06/08/2022, identified Patient #2 received skilled nursing visits one time per week for nine weeks for assessments, pain management and wound care, social work visits one time per month for two months, chaplain visits two times per month for two months and home health aide visits three times per week for eight weeks. The physician's wound care order dated 06/08/2022 to Patient #2's left medial leg arterial ulcer directed to cleanse with normal saline, apply Medihoney (wound care product used to treat leg ulcers) to the wound bed and wrap with gauze from the base of the toes to the base of the knee. Interview and review of Patient #2's clinical documentation with the Hospice Administrator on 08/31/2022 at 12:15 PM identified RN #4's nurses note dated 08/12/2022 documented the wound location as the left medial foot, not left medial leg. Furthermore, Agency RN #5's nurse's note dated 08/27/2022 identified Patient #2's left medial leg wound as a venous ulcer, and an unstageable pressure ulcer/injury with granular tissue to the wound bed. 3. Patient #11 elected the Hospice benefits on 5/11/22. The patient's diagnoses included senile degeneration of the brain, chronic obstructive pulmonary disease and dementia. The patient resided at an assisted living facility. The physician's orders for the certification period of 8/09/22 to 11/06/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of RN #1's nursing note dated 8/30/22 with the Hospice Administrator on 8/31/22 at 12:50 PM identified a stage I pressure ulcer on the patient's right heel, but failed to identify wound measurements were obtained by the hospice nurse. Review of agency policies on wound care documentation directed that wounds will be assessed by an RN every visit and all areas of the skin integrity section of the nursing note will be completed including: location of the wound, type, size, drainage, amount, odor, stage, appearance of surrounding skin and wound care order. Wound measurements will be documented in centimeters (length, width, depth) weekly by the nurse case manager on the first visit of the week.

Based on clinical record review, review of agency policies and interview with hospice personnel for six of thirteen patient's (#1, 2, 9, 10, 11 &12) the hospice agency failed to ensure an authentic complete record. Refer to tag L 651

Based on clinical record review, review of agency policies and interview with hospice personnel for six of thirteen patient's (Patient's #1, 2, 9, 10, 11 &12), the hospice Administrator failed to ensure adequate oversight of nursing services to ensure timely synchronization of clinical notes. The finding includes: 1.Patient #1 elected the Hospice benefits on 7/07/22. The patient's diagnoses included liver cirrhosis, esophageal varices and stage IV pressure ulcer of the sacral region. The patient resided in a skilled nursing facility (SNF). The physician's orders dated 7/07/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of Patient #1's clinical record with the Hospice Administrator on 08/31/2022 at 11:10 AM, failed to identify Registered Nurse/RN #2's nursing notes for visit dates 7/13/22, 7/20/22, 7/27/22, 8/03/22, 8/10/22 and 8/17/22 were completed and integrated within Patient #1's clinical record. Additionally, the Hospice Administrator failed to identify RN #5's nursing notes for visit date 7/27/2022 were completed and integrated within Patient #1's clinical record in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). Subsequent to surveyor inquiry, RN #2's nursing notes were completed on 8/29/22 and integrated within Patient #1's clinical record. 2. Patient #2 elected the hospice benefits on 06/08/2022 with diagnosis including anemia, atrial fibrillation, depression, and anxiety. The hospice plan of care dated 06/08/2022, identified Patient #2 received skilled nursing visits one time per week for nine weeks for assessments, pain management and wound, social work visits one time per month for two months, chaplain visits two times per month for two months and home health aide visits three times per week for eight weeks. Interview and review of Patient #2's clinical record with the Hospice Administrator on 08/31/2022 at 11:20 AM, failed to identify Agency Registered Nurse (RN) #5's nursing notes for visit dates 08/13/2022 and 08/27/2022 were completed and integrated within Patient #2's clinical record, in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). 3. Patient #9 had a start of care date of 2/8/22, with the diagnoses to include Alzheimer's disease, hypertension, and congestive heart failure. The Hospice Plan of Care dated 8/7/22 indicated that Patient #9 received skilled nursing visits 1 time per week, social work visits 1 time per month, chaplain visits 1 time per month. Review of the clinical record with the Hospice Administrator on 8/31/22, identified that RN #3's nursing visits of 8/11/22, 8/17/22, and 8/26/22, were not completed and integrated within the medical record. 4. Patient #10 had a start of care date of 1/13/22, with the diagnoses to include senile degeneration of the brain, hypertension, seizures, and pressure ulcer stage 2 to left upper back. The Hospice plan of care dated 7/8/22 indicated that Patient #10 received skilled nursing visits 1 time per week, social work visits 2 times per month, chaplain visits 2 times per month, and home heath aide visits 2 times per week. Review of the clinical record with the Hospice Administrator on 8/31/22, identified that RN #3's nursing visits dated 7/14/22, 7/22/2, 7/28/22, 7/28/22, 8/9/22, 8/17/22, and 8/26/22 were not completed and integrated within the medical record. 5. Patient #11 elected the Hospice benefits on 5/11/22. The patient's diagnoses included senile degeneration of the brain, chronic obstructive pulmonary disease and dementia. The patient resided at an assisted living facility. The physician's orders for the certification period of 8/09/22 to 11/06/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of Patient #11's clinical record with the Hospice Administrator on 08/31/2022 at 11:15 AM, failed to identify RN #5's nursing notes for visit date 8/13/22 was completed and integrated within Patient #11's clinical record. Additionally, the Hospice Administrator failed to identify RN #1's nursing notes for visit dates 8/15/22, 8/25/22 and 8/30/22 were completed and integrated within Patient #1's clinical record in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). 6. Patient #12 elected the hospice benefits on 02/24/2022 with diagnosis including type II diabetes, aortic aneurysm, and sleep apnea. The hospice plan of care dated 05/24/2022, identified Patient #12 received skilled nursing visits one time per week for fourteen weeks for assessments and pain management, social work visits one time per month for three months and home health aide visits two times per week for twelve weeks. Interview and review of Patient #12's clinical record with the Hospice Administrator on 08/31/2022 at 11:45 AM, failed to identify RN #3 nursing notes for visit dates 07/08/2022, 07/14/2022, 07/22/2022 and 07/28/2022 were completed and integrated within Patient #12's clinical record in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). Agency expectations directed to synchronize the electronic notes within forty-eight hours after the visit. Review of agency policy for clinical record guidelines directed entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers) in a standardized format and are legible, clear and complete and signed and dated by the person providing the services. Entries must be accurate, relevant, timely, complete and signed promptly but the policy failed to identify incorporating clinical notes no less often than weekly.

Based on clinical record review, review of agency policies and interview with hospice personnel for six of thirteen patient's (Patient's #1, 2, 9, 10, 11 &12) the hospice agency failed to ensure an authentic complete record and failed to follow the Regulations of Connecticut State Agencies. Refer to tag L 679

Based on clinical record review, review of agency policies and interviews with hospice personnel for six of thirteen patient's (Patient's #1, 2, 9, 10, 11 & 12) the hospice agency failed to ensure an authentic complete record and failed to follow the Regulations of Connecticut State Agencies. The finding includes: Patient #1 elected the Hospice benefits on 7/07/22. The patient's diagnoses included liver cirrhosis, esophageal varices and stage IV pressure ulcer of the sacral region. The patient resided in a skilled nursing facility (SNF). The physician's orders dated 7/07/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of Patient #1's clinical record with the Hospice Administrator on 08/31/2022 at 11:10 AM, failed to identify Registered Nurse/RN #2's nursing notes for visit dates 7/13/22, 7/20/22, 7/27/22, 8/03/22, 8/10/22 and 8/17/22 were completed and integrated within Patient #1's clinical record. Additionally, the Hospice Administrator failed to identify RN #5's nursing notes for visit date 7/27/2022 were completed and integrated within Patient #1's clinical record in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). Subsequent to surveyor inquiry, RN #2 ' s nursing notes were completed on 8/29/22 and integrated within Patient #1's clinical record. 2. Patient #2 elected the hospice benefits on 06/08/2022 with diagnosis including anemia, atrial fibrillation, depression, and anxiety. The hospice plan of care dated 06/08/2022, identified Patient #2 received skilled nursing visits one time per week for nine weeks for assessments, pain management and wound managment, social work visits one time per month for two months, chaplain visits two times per month for two months, and home health aide visits three times per week for eight weeks. Interview and review of Patient #2's clinical record with the Hospice Administrator on 08/31/2022 at 11:20 AM, failed to identify Agency Registered Nurse (RN) #5's nursing notes for visit dates 08/13/2022 and 08/27/2022 were completed and integrated within Patient #2's clinical record in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). 3. Patient #9 had a start of care date of 2/8/22, with the diagnoses to include Alzheimer's disease, hypertension, and congestive heart failure. The Hospice Plan of Care dated 8/7/22 indicated that Patient #9 received skilled nursing visits 1 time per week, social work visits 1 time per month, chaplain visits 1 time per month. Review of the clinical record with the Hospice Administrator on 8/31/22, identified that RN #3's nursing visits of 8/11/22, 8/17/22, and 8/26/2, were not completed and integrated within the medical record. 4. Patient #10 had a start of care date of 1/13/22, with the diagnoses to include senile degeneration of the brain, hypertension, seizures, and pressure ulcer stag 2 to left upper back. The Hospice plan of care dated 7/8/22 indicated that Patient #10 received skilled nursing visits 1 time per week, social work visits 2 times per month, chaplain visits 2 times per month, and home heath aide visits 2 times per week. Review of the clinical record with the Hospice Administrator on 8/31/22, identified that RN #3's nursing visits dated 7/14/22, 7/22/2, 7/28/22, 7/28/22, 8/9/22, 8/17/22, and 8/26/22 were not completed and integrated within the medical record. 5. Patient #11 elected the Hospice benefits on 5/11/22. The patient's diagnoses included senile degeneration of the brain, chronic obstructive pulmonary disease and dementia. The patient resided at an assisted living facility. The physician's orders for the certification period of 8/09/22 to 11/06/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of Patient #11's clinical record with the Hospice Administrator on 08/31/2022 at 11:15 AM, failed to identify RN #5's nursing notes for visit date 8/13/22 was completed and integrated within Patient #11's clinical record. Additionally, the Hospice Administrator failed to identify RN #1's nursing notes for visit dates 8/15/22, 8/25/22 and 8/30/22 were completed and integrated within Patient #1's clinical record in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). 6. Patient #12 elected the hospice benefits on 02/24/2022 with diagnosis including type II diabetes, aortic aneurysm, and sleep apnea. The hospice plan of care dated 05/24/2022, identified Patient #12 received skilled nursing visits one time per week for fourteen weeks for assessments and pain management, social work visits one time per month for three months and home health aide visits two times per week for twelve weeks. Interview and review of Patient #12's clinical record with the Hospice Administrator on 08/31/2022 at 11:45 AM, failed to identify RN #3 nursing notes for visit dates 07/08/2022, 07/14/2022, 07/22/2022 and 07/28/2022 were completed and integrated within Patient #12's clinical record in compliance with the Regulations of Connecticut State Agencies Section 19-13-D75 Clinical record system (b) (6). Agency expectations directed to synchronize the electronic notes within forty-eight hours after the visit. Review of agency policy for clinical record guidelines directed entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers) in a standardized format and are legible, clear and complete and signed and dated by the person providing the services. Entries must be accurate, relevant, timely, complete and signed promptly but the policy failed to identify incorporating clinical notes no less often than weekly.

Based on clinical record review, agency policies and interview with hospice personnel, for one of two patients (Patient # 1) who resided in a skilled nursing facility (SNF), the hospice agency failed to maintain professional management of the patient's needs and care under the hospice benefit. The findings include: Patient #1 elected the Hospice benefits on 7/07/22. The patient's diagnoses included liver cirrhosis, esophageal varices and stage IV pressure ulcer of the sacral region. The patient resided in a skilled nursing facility (SNF). The physician's orders dated 7/07/22 included nursing services weekly for assessments and dressing changes to the stage IV coccyx wound, cleansing with normal saline and covering with hydrofera blue every three days by the facility nurse, hospice aide services, social work services and chaplain services. Interview and review of RN #2's hospice visit notes dated 7/13/22, 7/27/22 and 8/03/22 with the Hospice Administrator on 8/31/22 at 12:30 PM indicated that the patient's wound care was provided by the facility nurse and/or facility wound care doctor and failed to identify hospice assessment and management of the patient's wound including documenting the measurements obtained by the facility staff and not directly visualizing the wound. Review of agency policy for Professional Management directed that hospice services requires that all services related to the terminal diagnosis and its related conditions are furnished in a safe and effective manner and delivered in accordance with the patient's plan of care.

1. Patient #1 elected the Hospice benefits on 7/07/22. The patient's diagnoses included liver cirrhosis, esophageal varices and stage IV pressure ulcer of the sacral region. The patient resided in a skilled nursing facility (SNF). The physician's orders dated 7/07/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of the clinical notes with the Hospice Administrator on 8/31/22 at 11:10 AM failed to identify a memorandum of understanding between the skilled nursing facility staff and the hospice agency staff, to delineate responsibility for the patient ' s care and methods of communication to ensure coordination of care, in accordance with the Regulations of Connecticut State Agencies Section 19-13-D77 Administrative organization and records (g) (2). 2. Patient #8 elected the hospice benefit on 12/09/2021 and resided in a skill nursing facility with diagnosis including end stage liver disease, respiratory failure, and type II diabetes. The hospice plan of care dated 12/09/2021, identified Patient #8 received skilled nursing visits one time per week for fourteen weeks for assessments and pain management, social work visits one time per month for four months, chaplain visits two times per month for four months and physical therapy visits one time per week for two weeks. Interview and review of Patient #8's clinical documentation with the Hospice Administrator on 08/31/2022 at 11:30 AM, failed to identify a Memorandum of Understanding was developed between the skilled nursing facility and the hospice agency staff in accordance with the Regulations of Connecticut State Agencies Section 19-13-D77 Administrative organization and records (g) (2). 2. Patient #11 elected the Hospice benefits on 5/11/22. The patient's diagnoses included senile degeneration of the brain, chronic obstructive pulmonary disease and dementia. The patient resided at an assisted living facility. The physician's orders for the certification period of 8/09/22 to 11/06/22 included nursing services weekly for assessments, hospice aide services, social work services and chaplain services. Interview and review of the clinical notes with the Hospice Administrator on 8/31/22 at 11:15 AM failed to identify a memorandum of understanding between the assisted living facility staff and the hospice agency staff, to delineate responsibility for the patient's care, and methods of communication to ensure coordination of care, in accordance with the Regulations of Connecticut State Agencies Section 19-13-D77 Administrative organization and records (g) (2). Review of agency policy for hospice care for nursing facility resident's delineation of services directed prior to the provision of hospice services in a SNF/NF or ICF/MR, the hospice obtains a written agreement signed by authorized representatives of the hospice and the facility. In Connecticut, a Memo of Understanding form will be completed for all hospice patients residing in a SNF/NF or ICF/MR. 3. Review of the agency staffing pattern with the Hospice Administrator and the Regional Director of Quality on 8/30/22 at 1 PM indicated that the Supervisor of Clinical Services/SCS resigned on 8/27/22 and failed to identify a written plan for the delegation of administrative responsibilities and functions in the absence of the Administrator in accordance with the Regulations of Connecticut State Agencies section 19-13-D68 General requirements (d) Administrator (2) (I). 4. Review of the agency staffing pattern with the Hospice Administrator and the Regional Director of Quality on 8/30/22 at 1:05 PM indicated that the Supervisor of Clinical Services/SCS resigned on 8/27/22 and failed to identify the appointment in writing of a registered nurse to act in the absence of the Supervisor of Clinical Services in accordance with the Regulations of Connecticut State Agencies Section 19-13-D68 General requirements (e) Supervisor of Clinical Services (5). 5. At the time of the survey the agency employed 3 hospice aides. Interview and review of the agency staffing pattern with the Hospice Administrator and the Regional Director of Quality on 8/30/22 at 1:10 PM indicated that the position of supervisor of the home health aide program was vacant and failed to identify the appointment in writing of a full-time registered nurse (with other responsibilities) to be responsible for the supervision of the homemaker-home health aide program and staff, when that staff is twenty-four or less persons in accordance with the Regulations of Connecticut State Agencies section 19-13-D69 Services (4) Supervision of homemaker-home health aides(C). 6. Review of the agency staffing pattern with the Hospice Administrator and the Regional Director of Quality on 8/31/22 at 1:15 PM identified the appointment of a part-time Volunteer Coordinator and failed to identify the appointment in writing of a full-time hospice employee who may have other responsibilities in addition to those of volunteer coordinator in accordance with the Regulations of Connecticut State Agencies section 19-13-D72 Patient care policies (b) Patient Care Standards (2) (P). Based on clinical record review, review of agency policies and interview with hospice personnel for three of thirteen patient's (Patient' s #1, 8, & 11) the hospice agency failed to follow agency policies and the Regulations of Connecticut State Agencies. The finding includes: