Every finding on record at Chautauqua Hospice and Palliative Care

Based on clinical record review and interview with agency staff, for one (1) of five (5) patients (Patient #2), the agency failed to ensure that the care and services provided is based on all assessments of the patient and family needs. Failure to ensure that care and services are provided based on patient/family needs has the potential to result in unmet patient needs. --- The hospice failed to ensure that the care and services provided to patients were based on all the assessments made of the patient and family need as evidenced by the following: Patient #2 – This 66-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease was admitted to the hospice on 05/02/2024. Review of the Registered Nurse Comprehensive Visit Note dated 05/13/2024 revealed the Registered Nurse documented the patient had moderate to severe dyspnea with exertion and a pulse rate of 131. Review of the Registered Nurse Comprehensive Visit Note dated 05/20/2024 revealed the Registered Nurse documented the patient had moderate to severe dyspnea with exertion and a pulse rate of 133. The Registered Nurse documented that the patients spouse reported the patients pulse has been elevated, and that she will notify the physician. Review of the clinical record lacks documentation of notification to the physician. Review of the Interdisciplinary Group Assessment Meeting dated 05/21/2024 revealed the Registered Nurse documented and reported the following: "Patients heart rate has been elevated to 130 over the last week. During interview on 05/22/2024 at 10:40 AM, the Chief of Clinical Operations stated that the Registered Nurse was unavailable for interview. The Chief of Clinical Operations added that the Registered Nurse did notify the physician, but accidentally documented the wrong date in the clinical records.

Based on review of clinical records and staff interview, eight (8) of nineteen (19) patients (Patient #'s: 1, 5, 7, 9, 10, 12, 13 and 14), lack a comprehensive assessment performed by the hospice interdisciplinary group (IDG) within five (5) days after the election of hospice care. Specifically, the Chaplain failed to complete an assessment within five (5) days after the election of hospice care. Failure of the IDG members to participate in completing the comprehensive assessment has the potential to place the patient/family at risk for the development of incomplete and/or inaccurate plans of care (POC). --- Patient #7 – This 89-year-old patient with the terminal diagnosis of brain stem stroke syndrome was admitted to the hospice on 09/20/2023. Review of the Hospice Election Form dated 09/20/2023 revealed the patient elected for hospice services on 09/20/2023. Review of the SN (Skilled Nurse) Admission Visit Note dated 09/20/2023 revealed a spiritual assessment identifying the patient had spiritual/existential concerns to be assessed by the chaplain. Review of the clinical record revealed the chaplains initial contact with the patient occurred on 09/26/2023, six (6) days after the date of election. Patient #9 – This 83-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease (COPD) was admitted to the hospice on 09/21/2023. Review of the Hospice Election Form dated 09/21/2023 revealed the patient elected for hospice services on 09/21/2023. Review of the SN Admission Visit Note dated 09/20/2023 revealed a spiritual assessment identifying the patient had spiritual/existential concerns to be assessed by the chaplain. Review of the clinical record revealed the chaplains initial contact with the patient occurred on 10/11/2023, twenty (20) days after the date of election. Patient #10 – This 72-year-old patient with the terminal diagnosis of malignant neoplasm of esophagus was admitted to the hospice on 09/15/2023. Review of the Hospice Election Form dated 09/15/2023 revealed the patient elected for hospice services on 09/15/2023. Review of the SN Admission Visit Note dated 09/20/2023 revealed a spiritual assessment identifying the patient had spiritual/existential concerns to be assessed by the chaplain. Review of the clinical record revealed the chaplains initial contact with the patient occurred on 10/17/2023, thirty-two (32) days after the date of election. Patient #13 – This 86-year-old patient with the terminal diagnosis of follicular lymphoma was admitted to the hospice on 07/17/2023. Review of the Hospice Election Form dated 07/17/2023 revealed the patient elected for hospice services on 07/17/2023. Review of the SN Admission Visit Note dated 09/20/2023 revealed a spiritual assessment identifying the patient had spiritual/existential concerns to be assessed by the chaplain. Review of the clinical record revealed the chaplains initial contact with the patient occurred on 07/27/2023, ten (10) days after the date of election. The Chaplain failed to complete an assessment within five (5) days after the election of hospice care. During interview on 10/26/2023 at 11:07 AM, the Chief Clinical Operations Officer stated she is aware of the chaplains noncompliance and disciplinary action has been put into motion. Patient #1 – This 70-year-old patient with the terminal diagnosis of stage IV prostrate cancer was admitted to the hospice on 09/19/2023. Review of the Hospice Election Form dated 09/19/2023 revealed the patient elected for hospice services on 09/19/2023. Review of the SN (Skilled Nurse) Admission Visit Note dated 09/19/2023 revealed a spiritual assessment, identifying the patient had spiritual/existential concerns to be assessed by the chaplain. Review of the clinical record revealed the chaplains initial contact with the patient occurred on 09/26/2023, seven (7) days after the date of election. Patient #5 – This 77-year-old patient with the terminal diagnosis of lung cancer was admitted to the hospice on 10/03/2023. Review of the Hospice Election Form dated 10/03/2023 revealed the patient elected for hospice services on 10/03/2023. Review of the SN Admission Visit Note dated 10/03/2023 revealed a spiritual assessment, identifying the patient had spiritual/existential concerns to be assessed by the chaplain. Review of the clinical record revealed the chaplains initial contact with the patient occurred on 10/10/2023, seven (7) days after the date of election. Patient #14 – This 56-year-old patient with the terminal diagnosis of downs syndrome with alzheimers dementia, residing in an intermediate care facility, was admitted to the hospice on 09/12/2023. Review of the Hospice Election Form dated 09/12/2023 revealed the patient elected for hospice services on 09/12/2023. Review of the SN Admission Visit Note dated 09/12/2023 revealed a spiritual assessment, identifying the patient had spiritual/existential concerns to be assessed by the chaplain. Review of the clinical record revealed the chaplains initial contact with the patient occurred on 09/19/2023, seven (7) days after the date of election.

Based on review of clinical records and interviews with agency staff, the hospice failed to ensure in three (3) of nineteen (19) clinical records (Patient #'s: 7, 14 and 19), 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 to include complications and risk factors that affect care planning. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. --- Patient #14 – This 56-year-old patient with the terminal diagnosis of downs syndrome with alzheimers dementia, residing in an intermediate care facility, was admitted to the hospice on 09/12/2023. Review of the Hospice Certification of Terminal Illness with a verbal certification date of 09/12/2023 revealed the patient has a stage 4 ischial pressure wound and a stage 2 left ankle ulcer. Review of the SN Admission Visit Note dated 09/12/2023 revealed the Registered Nurse (RN) documented the following: - Skin Assessment: left ischium pressure area stage 3- with full thickness skin loss involving damage to or necrosis of subcutaneous tissue. The SN failed to document a comprehensive assessment of sufficient scope to identify all the needs to promote the patients well-being and comfort. During interview on 10/26/2023 at 12:02 PM, the Chief Clinical Operations Officer stated the RN assessment of the ischial wound does not correlate with the Certificate of Terminal Illness wound assessment. She also stated there is no documentation that the RN clarified the left ischial wound stage with the physician. Patient #19 – This 86-year-old patient with the terminal diagnosis of heart failure was admitted to the hospice on 01/18/2023 and revoked services on 05/12/2023. A.) Review of the referral from the medical oncologist dated 10/31/2022 revealed the patient was ordered to have labs drawn via an implanted port on 10/31/2022. Review of the SN Admission Visit Note dated 01/18/2023 lacks documented evidence of the patient having an implanted port in place. The SN failed to document a comprehensive assessment of sufficient scope to identify all the needs to promote the patients well-being and comfort. During interview on 01/18/2023 at 10:44 AM, the Chief Clinical Operations Officer stated the patient had an implanted port in place at the time of the hospice admission and it should have been evaluated in the identified assessment. B.) Review of the hospice Medication Orders dated 01/18/2023 revealed the patient is taking Jardiance 12.5 milligrams (mg) by mouth once a day for diabetes. Review of the SN Admission Visit Note dated 01/18/2023 revealed the patient is diabetic but lacks an assessment of the diabetes and if blood sugars are being monitored. The SN failed to document a comprehensive assessment of sufficient scope to identify all the needs to promote the patients well-being and comfort. During interview on 10/26/2023 at 10:30 AM, the RN Case Manager stated a diabetic assessment was not completed at the admission assessment. Patient #7 – This 89-year-old patient with the terminal diagnosis of brain stem stroke syndrome was admitted to the hospice on 09/20/2023. Review of the SN (Skilled Nurse) Admission Visit Note dated 09/20/2023 revealed the patient has a continuous monitoring device which is rotated every two (2) weeks, but the SN failed to assess when the site was last changed and when it is due for change again. The SN failed to document a comprehensive assessment of sufficient scope to identify all the needs to promote the patients well-being and comfort. During interview on 10/26/2023 at 11:57 AM, the Registered Nurse (RN) Case Manager stated the information is not documented in the initial assessment or anywhere in the clinical record, but the family is responsible for rotating the sites.

Based on review of agency policy and procedure, clinical records, and staff interview, six (6) of nineteen (19) clinical records (Patient #'s:1, 2, 5, 8, 14 and 19) lack evidence that assessments are of sufficient scope, reflect the patient's current status, and include documentation of the patient's progress towards goals. Additionally, there is a lack of evidence that assessments are updated every fifteen (15) days and the Interdisciplinary Group (IDG) is kept current on the patient's status. Failure to ensure that comprehensive assessments are updated to reflect the patient's status, and to ensure that the IDG is kept informed, has the potential for unmet patient needs. --- Patient #2 – This 14-year-old patient with the terminal diagnosis of congenital malformation was admitted to the hospice on 10/03/2023. Review of the On-Call RN (Registered Nurse) Phone Call Note written by the RN on 10/09/2023 revealed the RN documented the following: ";Phone call received from mother with concerns that the patient may have a UTI (urinary tract infection)... She wishes to obtain a urine sample prior to staff attempting to complete a straight catheter sample. (Physician) noted of symptoms and present situation." Review of the clinical record from 10/09/2023 to 10/23/2023 (date of survey) lacks documented evidence of follow-up regarding the patients symptoms and the mothers request for a urine sample. The hospice failed to ensure patient's comprehensive assessments included changes that had occurred since the initial assessment or were updated every fifteen (15) days or that the hospice nurses are communicating changes in the patient's condition or treatment to the IDG. During interview on 10/26/2023 at 09:15 AM, the Chief Clinical Operations and RN Case Manager stated they would look for follow-up documentation regarding the UTI. No further information was provided. Patient #8 – This 86-year-old patient with the terminal diagnosis of chronic systolic (congestive) heart failure was admitted to the hospice on 10/06/2023. Review of the agencys policy entitled ";Wound Assessment" approved 02/12/2021 revealed ";wound assessments will be completed at a minimum with every 15-day RN comprehensive assessment." Review of the clinical record revealed the SN provided services on 10/06/2023, 10/12/2023, 10/16/2023, and 10/23/2023. Review of the Skilled Nurse (SN) Admission Visit Note dated 10/06/2023 revealed the SN documented ";Patient has a skin tear that is almost healed" with the following measurements: length 1.8 cm (centimeters) by width 0.3 cm by depth 0. The site is open to air. Review of the clinical record revealed the wound was measured and assessed on 10/06/2023 and10/23/2023, 17 (seventeen) days apart. The hospice nurses failed to complete updated comprehensive assessments of the patient's wound measurements. During interview on 10/23/2023 at 02:30 PM, the RN Case Manager stated she forgot to look at the wound during the previous visit on 10/16/2023 because it was healed. When she realized she forgot to document the wound as resolved during that visit, she marked it as such on 10/23/2023. Patient #1 – This 70-year-old patient with the terminal diagnosis of stage IV prostrate cancer was admitted to the hospice on 09/19/2023. Review of the RN (Registered Nurse) Comprehensive Visit Note dated 10/23/2023 revealed the patients room air oxygen saturation is 85 percent, respirations are 16 per minute, nail beds are cyanotic, patient has increased confusion and is sleeping 20 (twenty) plus hours per day. The assessment lacks a discussion with the patient/ caregiver regarding initiating oxygen therapy and notification to the physician regarding the changes in the patients status identified. Review of the IDG Comprehensive Assessment Details Note dated 10/24/2023 lacks documentation of a discussion regarding the patients identified change in status and discussion of initiating oxygen therapy. The RN failed to ensure comprehensive assessments are updated and reflect changes in the status of the patient and is communicating changes to the IDG. During interview on 10/26/2023 at 09:34 AM, the RN Case Manager stated a discussion regarding initiating oxygen therapy did occur at the identified visit but was not documented. Additionally, she stated she failed to specifically report the changes documented in the identified visit to the IDG and just documented a general statement of the patient declining. Patient #5 – This 77-year-old patient with the terminal diagnosis of lung cancer was admitted to the hospice on 10/03/2023. A.) Review of the hospice Medication Orders dated 10/03/2023 revealed an order for oxygen 4 (four) – 10 (ten) L/min (liters per minute) continuously via nasal cannula. Review of the RN Comprehensive Visit Note dated 10/24/2023 revealed the following documentation: - O2 (oxygen) Sat (saturation)- 97 percent at rest - O2- blank. The assessment lacks specification of the oxygen liter flow the patient is currently using. The RN failed to ensure the comprehensive assessment is updated and reflects changes in the patient status. During interview on 10/26/2023 at 10:18 AM, the Team Leader stated she mistakenly omitted the amount of oxygen the patient was using during the identified visit. B.) Review of the RN Comprehensive Visit Note dated 10/24/2023 revealed the patient has 1+ (one plus) slight pitting edema with a depth of indentation 0- ¼ "; (zero to one fourth an inch). The assessment lacks the location of the edema. The RN failed to ensure the comprehensive assessment is updated and reflects changes in the patient status. During interview on 10/26/2023 at 10:24 AM, the Team Leader stated the edema affected the right lower extremity but was not documented. Patient #14 – This 56-year-old patient with the terminal diagnosis of downs syndrome with alzheimers dementia, residing in an intermediate care facility, was admitted to the hospice on 09/12/2023. A.) Review of the RN Comprehensive Visit Note dated 10/04/2023 revealed the following wound documentation regarding the two pressure ulcers: - left ischium, stage 3 (three), scant drainage, length 1 centimeter (cm), width 1 cm and depth 0.3 cm; and - left lateral ankle, stage 2 (two), no drainage, length 1 cm, width 1 cm and depth 0 cm. Review of the RN Comprehensive Visit Note dated 10/11/2023 revealed the following wound documentation regarding the two pressure ulcers: - left ischium, stage 2 (two), no drainage, length 2.1 cm, width 2.1 cm and depth 0.1 cm; - left lateral ankle wound resolved 10/11/2023. The assessment back-staged the left ischium pressure ulcer. The RN failed to ensure the comprehensive assessment is updated and reflects changes in the patient status. During interview on 10/26/2023 at 12:30 PM, the Chief Clinical Operations officer stated being unaware a pressure ulcer cannot be back-staged and the documentation was incorrect. B.) Review of the RN Comprehensive Visit Note dated 10/04/2023 revealed the following wound documentation regarding the two pressure ulcers: - left ischium, stage 3 (three), scant drainage, length 1 centimeter (cm), width 1 cm and depth 0.3 cm; and - left lateral ankle, stage 2 (two), no drainage, length 1 cm, width 1 cm and depth 0 cm. Review of the RN Comprehensive Visit Note dated 10/11/2023 revealed the following wound documentation regarding the two pressure ulcers: - left ischium, stage 2 (two), no drainage, length 2.1 cm, width 2.1 cm and depth 0.1 cm; - left lateral ankle wound resolved 10/11/2023. Review of the clinical record and IDG Comprehensive Assessment Details Note dated 10/11/2023 lacks documentation reporting the patients left ischium pressure ulcer has doubled in size since the previous comprehensive assessment and the left lateral ankle wound has resolved. The RN failed to ensure comprehensive assessments are updated and reflect changes in the status of the patient and is communicating changes to the IDG. During interview on 10/26/2023 at 12:30 PM, the Chief Clinical Operations Officer stated there was no documentation reporting to the physician and the IDG that the left ischium had increased in size and the left lateral ankle wound was healed during the 10/11/2023 assessment. Patient #19 – This 86-year-old patient with the terminal diagnosis of heart failure was admitted to the hospice on 01/18/2023 and revoked services on 05/12/2023. Review of the RN Comprehensive Visit Note dated 02/07/2023 revealed the RN documented the patient reports blood sugars have been running high and the primary care physician has started the patient on new lantus insulin 10 (ten) units daily. The assessment lacks a diabetic assessment of the patients blood glucose readings and the patients understanding of the action and administration of the new insulin injection. Review of the clinical record lacks documentation the physician and IDG were updated on the patient starting insulin therapy. The RN failed to ensure comprehensive assessments are updated and reflect changes in the status of the patient and is communicating changes to the physician and IDG. During interview on 10/26/2023 at 10:35 AM, the RN Case Manager stated the patients attending physician was managing the diabetes, not the hospice, and the patient had been instructed regarding the insulin and administration by the attending physician but failed to document this and update the IDG.

Based on review of clinical records and interviews with staff for nine (9) of nineteen (19) clinical records (Patient #s: 5, 6, 7, 8, 9, 11, 13, 14, 18), the hospice failed to provide services according to the Plan of Care (POC). The issues are: The hospice failed to provide aide services in accordance with the POC. The hospice failed to provide aide services at the ordered frequency. Failure to provide services in accordance with the POC has the potential for unmet patient needs. --- Patient #9 – This 83-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease (COPD) was admitted to the hospice on 09/21/2023. A.) Review of the Physicians Order dated 09/21/2023 revealed the patient is ordered Home Health Aide (HHA) 5 (five) days a week. Review of the clinical record from 09/21/2023 to 09/27/2023 lacks documented evidence an HHA provided services. Review of the clinical record from 09/24/2023 to 09/30/2023 and 10/08/2023 to 10/14/2023 revealed the HHA provided services four times during each week, one day less than ordered. The hospice failed to provide aide services in accordance with the POC. During interview on 10/26/2023 at 02:45 PM, the Chief Clinical Operations Officer stated the HHA did not meet the ordered frequency. B.) Review of the ";Aide Tasks" sheet last reviewed on 09/27/2023 revealed the HHA is directed to assist with the following tasks during each shift: Activity: - Ambulatory with assistance - Chair as tolerated - Durable Medical Equipment present – walker, oxygen via nasal cannula - Ensure oxygen is in place via nasal cannula at the end of each visit - Fall precautions - keep pathways clear - Range of motion (ROM) – encourage active ROM to upper and lower extremities as tolerated Elimination: - Document last BM (bowel movement) – notify patient caregiver - Draw sheet - Patient independent Nutrition: - Assist with feeding – meal prep and set up if family or patient requests - Diet – as tolerated for comfort and quality of life - Document intake food/fluids – notify caregiver of intake - Encourage fluids Personal Care: - Clothing assist – help with dressing if needed - Complete bed bath – assist with bed bath as requested - Foot care - Nail care – may file or polish - Oral care encourage at each visit - Patient bed bath (patient assist) – as requested - Perineal care - Shampoo – as requested - Shower when requested and as patient tolerates - Skin care – may apply lotion to dry skin after bathing to upper and lower extremities, face, and torso Review of the clinical record from 10/08/2023 to 10/14/2023 revealed the HHA provided services daily 10/10/2023 to 10/13/2023. Review of the HHA Visit Notes dated 10/10/2023 to 10/13/2023 revealed the HHA failed to document the completion of the following tasks: - Ambulatory with assist - Range of motion - Document last BM - Draw sheet - Document intake - Foot care - Perineal care The agency failed to ensure aides follow the POC. During interview on 10/26/2023 at 02:50 PM, the Chief Clinical Operations Officer stated the HHA did not document completion of all tasks but will be educated to free text to say why tasks are not completed going forward. Patient #6 – This 79-year-old patient with a terminal diagnosis of malignant neoplasm of the lung was admitted to the hospice on 09/25/2023. Review of the ";Aide Tasks" sheet last reviewed on 09/25/2023 revealed the HHA is directed to assist with the following tasks during each shift: Activity: - Ambulatory with assistance - Chair as tolerated - Durable Medical Equipment present – walker, oxygen concentrator, nebulizer - Fall precautions - keep pathways clear Elimination: - Document last BM (bowel movement) – notify patient caregiver - Document output - Incontinence pads - Patient independent Nutrition: - Assist with feeding – meal prep and set up if family or patient requests - Diet – as tolerated for comfort and quality of life - Document intake food/fluids – notify caregiver of intake - Encourage fluids Personal Care: - Clothing assist – help with dressing if needed - Oral care encourage at each visit - Perineal care - Shower when requested and as patient tolerates - Skin care – may apply non-medicated lotion to face, trunk, and extremities. Review of the clinical record from 09/25/2023 to 09/30/2023 revealed the HHA provided services on 09/26/2023. Review of the HHA Visit Note dated 09/26/2023 revealed the HHA failed to document the completion of the following tasks: - Document last BM - Document output - Document intake food/fluids - Clothing assist - Oral care - Perineal care The agency failed to ensure aides follow the POC. During interview on 10/26/2023 at 02:50 PM, the Chief Clinical Operations Officer stated the HHA did not document completion of all tasks but will be educated to free text to say why tasks are not completed going forward. Patient #7 – This 89-year-old patient with the terminal diagnosis of brain stem stroke syndrome was admitted to the hospice on 09/20/2023. Review of the ";Aide Tasks" sheet last reviewed on 09/21/2023 revealed the HHA is directed to assist with the following tasks during each shift: Activity: - Ambulatory using transport wheelchair - Bed bound with scheduled repositioning - Chair as tolerated - Durable Medical Equipment present – hospital bed with alternating pressure mattress with full side rails, transport wheelchair - Fall precautions – hospital bed rails, keep pathways clear Elimination: - Bathroom assistance commode or toilet - Document last BM (bowel movement) - Document output - Draw sheet - Incontinence pads - Incontinent bowel and bladder Nutrition: - Assist with feeding – meal prep and set up if family or patient requests - Diet – as tolerated - Document intake food/fluids – notify caregiver of intake - Encourage fluids as tolerated Personal Care: - Clothing assist – help with dressing - Complete bed bath as requested - Foot care - Nail care - Oral care - Perineal care - Shampoo as requested and as patient tolerates - Shower when requested and as patient tolerates - Skin care – may apply lotion to skin after bathing Review of the clinical record from 09/24/2023 to 09/30/2023 revealed the HHA provided services on 09/26/2023 and 09/28/2023. Review of the HHA Visit Note dated 09/26/2023 revealed the HHA failed to document the completion of the following tasks: - Bed bound with scheduled repositioning - Document last BM - Nail care - Oral care The agency failed to ensure aides follow the POC. During interview on 10/26/2023 at 02:50 PM, the Chief Clinical Operations Officer stated the HHA did not document completion of all tasks but will be educated to free text to say why tasks are not completed going forward. Patient #8 – This 86-year-old patient with a terminal diagnosis of chronic systolic (congestive) heart failure was admitted to the hospice on 10/06/2023. Review of the ";Aide Tasks" sheet last reviewed on 10/06/2023 revealed the HHA is directed to assist with the following tasks during each shift: Activity: - Ambulatory with assistance of walker/monitor for safety - Chair as tolerated - Durable Medical Equipment present – walker - Fall precautions Delegated Tasks: - Special task – HHA to assist duties such as but not limited to laundry, bed linen change, vacuum, sweeping, and companionship - Temperature, pulse, respiration, and blood pressure when requested - Weight when requested/weekly Elimination: - Apply barrier cream to peri area/buttocks as needed - Bathroom assistance commode or toilet - Colostomy – empty colostomy bag as needed - Incontinence pads – adult diaper - Incontinent (bladder) - Patient independent with personal care needs – monitor for safety and assist as needed Nutrition: - Assist with feeding – meal prep and set up if family or patient requests - Diet – regular as tolerated - Encourage fluids as tolerated - Feeding assist only if needed/patient gets period of lethargy Personal Care: - Bath assist if needed - Clothing assist - Denture care - Foot care - Nail care - Oral care - Perineal care - Shampoo - Shave - Shower - Skin care Review of the clinical record from 10/15/2023 to 10/21/2023 revealed the HHA provided services on 10/16/2023 and 10/19/2023. Review of the HHA Visit Note dated 10/16/2023 revealed the HHA failed to document the completion of the following tasks: Activity: - Ambulatory with assistance of walker/monitor for safety - Chair as tolerated - Durable Medical Equipment present – walker - Fall precautions Delegated Tasks: - Special task – HHA to assist duties such as but not limited to laundry, bed linen change, vacuum, sweeping, and companionship - Temperature, pulse, respiration, and blood pressure when requested - Weight when requested/weekly Elimination: - Apply barrier cream to peri area/buttocks as needed - Bathroom assistance commode or toilet - Colostomy – empty colostomy bag as needed - Incontinence pads – adult diaper - Incontinent (bladder) - Patient independent with personal care needs – monitor for safety and assist as needed Nutrition: - Assist with feeding – meal prep and set up if family or patient requests - Diet – regular as tolerated - Feeding assist only if needed/patient gets period of lethargy Personal Care: - Bath assist if needed - Clothing assist - Denture care - Foot care - Nail care - Oral care - Perineal care - Shampoo - Shave - Shower - Skin care Review of the HHA Visit Note dated 10/19/2023 revealed the HHA failed to document the completion of the following tasks: Activity: - Ambulatory with assistance of walker/monitor for safety - Chair as tolerated - Durable Medical Equipment present – walker - Fall precautions Delegated Tasks: - Special task – HHA to assist duties such as but not limited to laundry, bed linen change, vacuum, sweeping, and companionship - Temperature, pulse, respiration, and blood pressure when requested - Weight when requested/weekly Elimination: - Apply barrier cream to peri area/buttocks as needed - Bathroom assistance commode or toilet - Colostomy – empty colostomy bag as needed - Incontinence pads – adult diaper - Incontinent (bladder) - Patient independent with personal care needs – monitor for safety and assist as needed Nutrition: - Assist with feeding – meal prep and set up if family or patient requests - Diet – regular as tolerated - Encourage fluids as tolerated - Feeding assist only if needed/patient gets period of lethargy Personal Care: - Bath assist if needed - Clothing assist - Denture care - Foot care - Nail care - Oral care - Perineal care - Shampoo - Shave - Shower - Skin care Review of the clinical record from 10/15/2023 to 10/21/2023 revealed the HHA provided services on 10/16/2023 and 10/19/2023. Review of the HHA Visit Note dated 10/16/2023 revealed the HHA failed to document the completion of the following tasks: Activity: - Chair as tolerated Delegated Tasks: - Temperature, pulse, respiration, and blood pressure when requested - Weight when requested/weekly Elimination: - Apply barrier cream to peri area/buttocks as needed - Bathroom assistance commode or toilet - Colostomy – empty colostomy bag as needed - Incontinence pads – adult diaper - Incontinent (bladder) - Patient independent with personal care needs – monitor for safety and assist as needed Nutrition: - Assist with feeding – meal prep and set up if family or patient requests - Diet – regular as tolerated - Feeding assist only if needed/patient gets period of lethargy Personal Care: - Bath assist if needed - Clothing assist - Denture care - Foot care - Nail care - Oral care - Perineal care - Shampoo - Shave - Shower - Skin care The agency failed to ensure aides follow the POC. During interview on 10/26/2023 at 02:50 PM, the Chief Clinical Operations Officer stated the HHA did not document completion of all tasks but will be educated to free text to say why tasks are not completed going forward. Patient #11 – This 52-year-old patient with a terminal diagnosis of multiple sclerosis residing in a Skilled Nursing Facility was admitted to the hospice on 10/02/2023. Review of the ";Aide Tasks" sheet last reviewed on 10/02/2023 revealed the HHA is directed to assist with the following tasks during each shift: Activity: - Bed bound with scheduled repositioning - Chair as tolerated Elimination: - Barrier products in use - Document last BM (bowel movement) - Draw sheet - Incontinence pads - Incontinent bowel and bladder Personal Care: - Clothing assist – help with dressing if needed - Complete bed bath – assist with bed bath as requested - Denture care - Nail care - Oral care - Perineal care - Shampoo – as requested - Skin care- may apply lotion to dry skin after bathing Review of the clinical record from 10/15/2023 to 10/21/2023 revealed the HHA provided services on 10/16/2023, 10/18/2023, and 10/20/2023. Review of the HHA Visit Note dated 10/16/2023 revealed the HHA failed to document the completion of the following tasks: Activity: - Bed bound with scheduled repositioning Elimination: - Barrier products in use - Document last BM - Incontinent bowel and bladder Personal Care: - Nail care - Oral care Review of the HHA Visit Note dated 10/18/2023 revealed the HHA failed to document the completion of the following tasks: Activity: - Bed bound with scheduled repositioning Elimination: - Barrier products in use - Document last BM Personal Care: - Denture care - Nail care - Oral care - Perineal care Review of the HHA Visit Note dated 10/20/2023 revealed the HHA failed to document the completion of the following tasks: Activity: - Bed bound with scheduled repositioning Elimination: - Barrier products in use - Document last BM - Incontinent bowel and bladder Personal Care: - Nail care - Oral care - Perineal care The agency failed to ensure aides follow the POC. During interview on 10/26/2023 at 02:50 PM, the Chief Clinical Operations Officer stated the HHA did not document completion of all tasks but will be educated to free text to say why tasks are not completed going forward. Patient #13 – This 86-year-old patient with the terminal diagnosis of follicular lymphoma was admitted to the hospice on 07/17/2023. Review of the ";Aide Tasks" sheet dated 07/17/2023 revealed the HHA is directed to assist with the following tasks during each shift: Activity: - Ambulatory with assistance – stand by - Chair as tolerated - Fall precautions – keep pathways clear Elimination: - Bathroom assistance - Document last BM (bowel movement) - Document output - Patient independent Nutrition: - Diet regular as tolerated - Document intake food/fluids - Encourage fluids Personal Care: - Clothing assist - Oral care - Shampoo - Shower - Skin care- may apply non-medicated lotion to extremities and trunk Review of the clinical record from 07/17/2023 to 07/22/2023 revealed the HHA provided services on 07/18/2023 and 07/20/2023. Review of the HHA Visit Note dated 07/17/2023 revealed the HHA failed to document the completion of the following tasks: Elimination: - Bathroom assistance - Document last BM (bowel movement) Personal Care: - Clothing assist - Oral care - Shampoo - Shower - Skin care- may apply non-medicated lotion to extremities and trunk Review of the HHA Visit Note dated 07/22/2023 revealed the HHA failed to document the completion of the following tasks: Personal Care: - Clothing assist - Oral care - Shampoo - Shower - Skin care- may apply non-medicated lotion to extremities and trunk The agency failed to ensure aides follow the POC. During interview on 10/26/2023 at 02:50 PM, the Chief Clinical Operations Officer stated the HHA did not document completion of all tasks but will be educated to free text to say why tasks are not completed going forward. Patient #18 – This 96-year-old patient with a terminal diagnosis of malignant neoplasm of the ascending colon was admitted to the hospice on 10/11/2022. Review of the Physicians Order dated 10/11/2022 revealed the patient is ordered HHA services twice a week. Review of the clinical record from 10/11/2022 to 10/15/2022 revealed the HHA provided services once on 10/13/2022, once less than ordered. The hospice failed to provide aide services in accordance with the POC. During interview on 10/26/2023 at 11:22 AM, the Chief Clinical Operations Officer stated the HHA did not meet the ordered frequency. Patient #5 – This 77-year-old patient with the terminal diagnosis of lung cancer was admitted to the hospice on 10/03/2023. Review of the Physicians Order dated 10/03/2023 revealed the patient is ordered a Home Health Aide (HHA) 5 (five) days a week. Review of the clinical record for the week from 10/01/2023 to 10/07/2023 revealed the HHA provided services one time during the week, four days less than ordered. Review of the clinical record for the week from 10/15/2023 to 10/21/2023 revealed the HHA provided services four times during the week, one day less than ordered. The hospice failed to provide aide services in accordance with the POC. During interview on 10/26/2023 at 11:25 AM, the Chief Clinical Operations Officer acknowledged the HHA did not meet the ordered frequency during the identified weeks. Patient #14 – This 56-year-old patient with the terminal diagnosis of downs syndrome with alzheimers dementia, residing in an intermediate care facility, was admitted to the hospice on 09/12/2023. Review of the Physicians Order dated 09/12/2023 revealed the patient is ordered a HHA 2 (two) days a week. Review of the clinical record for the week from 09/10/2023 to 09/16/2023 lacks documented evidence a HHA provided services. The hospice failed to provide aide services in accordance with the POC. During interview on 10/26/2023 at 02:05 PM, the Registered Nurse (RN) Case Manager stated she wrote the order incorrectly for the date the aide was to start service.

Based on clinical record review and interview with agency staff for three (3) of nineteen (19) patients (Patient #s: 4, 5, 8), the agency failed to ensure the patient and/or caregiver received education and training. Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. --- Patient #4 – This 75-year-old patient with the terminal diagnosis of malignant neoplasm of the prostate was admitted to the hospice on 10/05/2023. Review of the Physicians Orders dated 10/05/2023 revealed the patient monitors blood glucoses daily and takes Tresiba Flextouch 25 (twenty-five) units once a day subcutaneous. Review of the clinical record lacks documented evidence the patient and/or caregiver received education and training regarding obtaining a blood glucose and administering insulin. During interview on 10/26/2023 at 02:16 PM, the Registered Nurse (RN) Case Manager stated she did not provide education to the caregiver regarding the care of a colostomy. Patient #8 – This 86-year-old patient with the terminal diagnosis of chronic systolic (congestive) heart failure was admitted to the hospice on 10/06/2023. Review of the Physicians Orders dated 10/06/2023 revealed the patient has a colostomy and the family is responsible for care. Review of the clinical record lacks documented evidence the patient and/or caregiver received education and training on colostomy care. During interview on 10/26/2023 at 02:24 PM, the RN Case Manager stated the patients caregiver is an RN and she assumed she could provide diabetic care to the patient without further instruction. Patient #5 – This 77-year-old patient with the terminal diagnosis of lung cancer was admitted to the hospice on 10/03/2023. Review of the Physicians Orders dated 10/03/2023 revealed an order for levalbuterol HCL 1 nebulizer solution (0.63 mg (milligram) / 3 ml (milliliter)) every 4 (four) hours as needed for SOB (shortness of breath) and wheezing. Review of the Skilled Nurse (SN) Admission Visit Note dated 10/03/2023 revealed the Registered Nurse (RN) documented the following teaching occurred: DME (durable medical equipment)/ equipment use, medications thoroughly reviewed and family able to administer medications appropriately. The assessment lacks documentation of instruction and demonstration of the patient/caregiver using the nebulizer to administer levalbuterol HCL and if further education is required. Review of the clinical record lacks documentation the patient and/or caregiver received education and training regarding the use of the nebulizer. The agency failed to ensure the patient and/or caregiver received education and training on the use of the nebulizer. During interview on 10/26/2023 at 10:17 AM, the RN Case Manager stated the patient was observed using the nebulizer to administer the levalbuterol HCL but failed to document this specifically. -

Based on review of clinical records and interviews with staff, for six (6) of nineteen (19) patients (Patient #'s: 4, 7, 9, 14, 15 and 19) 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 #14 – This 56-year-old patient with the terminal diagnosis of downs syndrome with alzheimers dementia, residing in an intermediate care facility, was admitted to the hospice on 09/12/2023. Review of the Physicians Order dated 09/12/2023 revealed an order for oxygen 2 liters per minute of 5 liters per minute continuously via nasal cannula. The hospice failed to ensure a comprehensive POC to include a complete oxygen order. During interview on 10/26/2023 at 12:28 PM, the Chief Clinical Operations Officer stated the order was written incorrectly and the oxygen was to be administered in a range from 2 to 5 liters per minute continuously. Patient #19 – This 86-year-old patient with the terminal diagnosis of heart failure was admitted to the hospice on 01/18/2023 and revoked services on 05/12/2023. A.) Review of the Physicians Order dated 01/24/2023 revealed the patient is ordered to take empagliflozin (jardiance) 12.5 mg (milligrams) by mouth daily for diabetes. Review of the clinical record lacks orders specifying who manages the diabetes, if blood sugars are monitored, parameters to call the physician with and any diabetic supplies. The hospice failed to ensure a comprehensive POC to include diabetic management. During interview on 10/26/2023 at 10:33 AM, the Chief Clinical Operations Officer stated the hospice is not managing the diabetes but this failed to be documented and included in the orders. B.) Review of the referral from the medical oncologist dated 10/31/2022 revealed the patient was ordered to have labs drawn via an implanted port on 10/31/2022. Review of the Physicians Order dated 02/14/2023 revealed an order to flush mediport with 20 ml (milliliter) NS (normal saline) followed by 5 ml heparin flush (100 units/ml) using a 22 gauge huber needle and sterile technique. Reapply sterile dressing following the mediport flush and flush to be completed monthly. Review of the clinical record from 01/18/2023 to 02/14/2023 lacks orders for the patients mediport maintenance and supplies. The hospice failed to ensure a comprehensive POC to include mediport maintenance and supplies. During interview on 10/26/2023 at 10:46 AM, the Chief Clinical Operations Officer stated the mediport has been in place since 01/18/2023 but it was not addressed until 02/14/2023 in error. Patient #15 – This 69-year-old patient with a terminal diagnosis of malignant neoplasm of endometrium residing in a Skilled Nursing Facility (SNF) was admitted to the hospice on 12/23/2022. A.) Review of the clinical record revealed the patient is receiving Skilled Nursing (SN), Home Health Aide (HHA), Social Work (SW), and Chaplain services. Review of the clinical record lacks orders for SN, HHA, and SW to include frequencies. The hospice failed to ensure a comprehensive POC to include frequencies for services. During interview on 10/26/2023 at 02:38 PM, the Chief Clinical Operations Officer stated the orders are not there. B.) Review of the Progress Note written by the SN on 12/30/2022 revealed the SN documented ";Recommendation to (physician) to discontinue non end of life scheduled medications as patient demonstrates worsening dysphagia and is declining rapidly." Review of the clinical record lacks documented evidence an order was obtained to discontinue the medications. The hospice failed to ensure a comprehensive POC to include the discontinuation of medications. During interview on 10/26/2023 at 02:40 PM, the Chief Clinical Operations Officer stated there was no order obtained. Patient #4 – This 75-year-old patient with the terminal diagnosis of malignant neoplasm of the prostate was admitted to the hospice on 10/05/2023. Review of the Physicians Order dated 10/05/2023 revealed ";BG (blood glucose) monitoring daily," Review of the clinical record lacks documented evidence of orders to delineate who is responsible for monitoring the patients blood glucoses, parameters to call the physician, and diabetic supplies. The hospice failed to ensure a comprehensive POC to include diabetic management. During interview on 10/26/2023 at 02:16 PM, the Registered Nurse (RN) Case Manager stated the agency physician does not monitor blood glucoses, she will add an order to specify that. Patient #7 – This 89-year-old patient with the terminal diagnosis of brain stem stroke syndrome was admitted to the hospice on 09/20/2023. Review of the Skilled Nurse (SN) Admission Note dated 09/20/2023 revealed the SN documented ";insulin dependent type 2 diabetic. Patient has a continuous glucose monitoring system to right upper arm which is rotated every 2 (two) weeks. Caregivers report that patients blood sugar runs from 150s to low 300s at the highest." Review of the clinical record lacks documented evidence of orders to delineate who is responsible for monitoring the patients blood glucoses, parameters to call the physician, and diabetic supplies. Additionally, there is no order to indicate when the continuous monitoring system is due to be changed. The hospice failed to ensure a comprehensive POC to include diabetic management. During interview on 10/26/2023 at 11:55 AM, the Chief Clinical Operations Officer stated the orders pertaining to the patients diabetes are not there.

Based on clinical record review and interview with staff, for two (2) of nineteen (19) patients (Patient #'s 9 and 14), the hospice failed to ensure that the plan of care (POC) was complete and reflected the medications and treatments necessary to meet the needs of the patient. Failure to ensure that the POC is complete and accurate has the potential to result in negative patient outcomes. --- Patient #14 – This 56-year-old patient with the terminal diagnosis of downs syndrome with alzheimers dementia, residing in an intermediate care facility, was admitted to the hospice on 09/12/2023. Review of the Physicians Order dated 09/12/2023 revealed an order for oxygen 2 liters per minute of (to) 5 liters per minute continuously via nasal cannula. Review of the Intermediate Care Facility (ICF) medication administration record (MAR) dated October 2023 revealed the order initiated on 04/05/2023 for oxygen 2 liters per minute continuous via nasal cannula. Staff to check oxygen saturation and if patient having difficulty breathing may titrate up 1 (one) liter to 3 liters per minute. Recheck in 15 (fifteen) minutes if still 90% or below may titrate up to 4 liters per minute. Recheck in 15 (fifteen minutes and if not above 90% contact the RN (Registered Nurse). The hospice failed to ensure the POC orders were complete and reflected medications and treatments necessary to meet patient needs. During interview on 10/26/2023 at 02:11 PM, the RN Case Manager stated she wrote the oxygen order incorrectly and it should have mimicked the ICF MAR. Patient #9 – This 83-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) was admitted to the hospice on 09/21/2023. Review of the Physicians Order dated 10/05/2023 revealed the order to ";Cleanse skin tear with NS (normal saline) and allow the area to air dry, apply a telfa non-adherent gauze pad, cover with tegaderm dressing, dressing changes to be completed every week and prn (as needed) if dressing is loose or soiled, wound care to be completed by skilled nurse or pcg (patient caregiver)." The order lacks a location. The hospice failed to ensure the POC orders were complete and reflected medications and treatments necessary to meet patient needs. During interview on 10/26/2023 at 02:44 PM, the Chief Clinical Operations Officer stated there is no location in the wound order.

Based on review of clinical records and staff interview, for one (1) of two (2) recertified patients (Patient #19), the agency failed to ensure the Interdisciplinary Group (IDG), in collaboration with the patient's physician, reviewed and revised the individualized plan of care (POC) as changes occurred, but no less frequently than every fifteen (15) days. Failure of the IDG to develop, review and revise the POC has the potential for unmet patient needs and inadequate care. --- The agency failed to ensure the IDG, in collaboration with the patient's physician, reviewed and revised the individualized POC as changes occurred, but no less frequently than every fifteen (15) days as evidenced by the following: Patient #19 – This 86-year-old patient with the terminal diagnosis of heart failure was admitted to the hospice on 01/18/2023 and revoked services on 05/12/2023. A.) Review of the RN Comprehensive Visit Note dated 02/07/2023 revealed the RN documented the patient reports blood sugars have been running high and the primary care physician has started the patient on new lantus insulin 10 (ten) units daily. Review of the clinical record lacks documentation of an order for lantus insulin. During interview on 10/26/2023 at 10:41 AM, the RN Case Manager stated she did not obtain orders for the lantus insulin. B.) Review of the Physicians Order dated 02/14/2023 revealed an order to flush the patients mediport with 20 ml (milliliter) NS (normal saline) followed by 5 ml heparin flush (100 units/ml) using a 22 gauge huber needle and sterile technique. Reapply sterile dressing following the mediport flush and flush to be completed monthly. Review of the clinical record lacks orders for mediport supplies for the second certification period, 04/18/2023 through 05/12/2023 (revocation date). During interview on 10/26/2023 at 10:44 AM, the Chief Clinical Operations Officer stated orders for mediport supplies were never obtained when the patient was recertified to the hospice and should have been.

Based on review of clinical records and interviews with staff, the hospice failed to ensure in one (1) of nineteen (19) clinical records (Patient #16), that care and services are provided in accordance with the Plan of Care (POC). Failure to provide care in accordance with the established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. --- The hospice failed to ensure that care and services are provided in accordance with the POC as evidenced by: Patient #16 – This 80-year-old patient with the terminal diagnosis of vascular dementia without behavioral disturbance was admitted to the hospice on 02/03/2023 and died on 02/15/2023. Review of the Skilled Nurse (SN) Admission Visit Note dated 02/03/2023 revealed the Registered Nurse (RN) documented that the patients entire buttocks is excoriated and calmoseptine (a barrier cream) is in place. Review of the clinical record lacks an order for calmoseptine. Review of the RN Comprehensive Visit Note dated 02/07/2023 revealed the RN documented the patient has oxygen 2 liters per minute in place to be used as needed for shortness of breath. Review of the clinical record lacks an order for oxygen. The hospice failed to ensure that care and services are provided as ordered in the POC. During interview on 10/26/2023 at 11:40 AM, the Chief Clinical Operations Officer stated the RN no longer works for the hospice. The Chief Clinical Operations Officer stated the RN failed to obtain orders for the identified calmoseptine and oxygen being used.

Based on review of clinical records and interviews with staff, for five (5) of fifteen (15) patients (Patient #'s: 1, 2, 7, 9 and 14) receiving Home Health Aide (HHA) services, the hospice failed to ensure the Aide Plan of Care (POC) is complete and accurate. Failure to ensure the Aide POC is complete and accurate has the potential for the patient to receive inappropriate care. --- Patient #2 – This 14-year-old patient with the terminal diagnosis of congenital malformation was admitted to the hospice on 10/03/2023. Review of the ";Aide Tasks" sheet last reviewed on 10/04/2023 revealed the HHA is directed to assist the patient with denture care. Review of the clinical record lacks documented evidence the patient uses dentures. The hospice failed to ensure the Aide POC is complete and accurate. During interview on 10/26/2023 at 09:02 AM, the Registered Nurse (RN) Case Manager stated the task was ordered in error, the patient does not use dentures. Patient #7 – This 89-year-old patient with the terminal diagnosis of brain stem stroke syndrome was admitted to the hospice on 09/20/2023. Review of the Physicians Orders dated 09/20/2023 revealed the patient takes Lantus 8 (eight) units once a day subcutaneously. Review of the SN (Skilled Nurse) Admission Visit Note dated 09/20/2023 revealed the patient has a continuous monitoring device which is rotated every two (2) weeks. Review of the ";Aide Tasks" sheet last reviewed on 09/21/2023 lacks written instructions and observations for the HHA regarding care of an insulin-dependent patient with a continuous monitoring device. The hospice failed to ensure the Aide POC is complete and accurate. During interview on 10/26/2023 at 11:55 AM, the Chief Clinical Operations Officer stated the agency does not monitor the patients blood glucose, so it was left off the care plan. Patient #9 – This 83-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease (COPD) was admitted to the hospice on 09/21/2023. Review of the RN (Registered Nurse) Comprehensive Visit Note dated 10/05/2023 revealed the patient now has a skin tear on the right calf that requires a non-adherent Telfa dressing with tegaderm. Review of the ";Aide Tasks" sheet last reviewed on 09/27/2023 lacks documented evidence the aide plan of care was updated to include instruction and observations regarding a patient with a wound. The hospice failed to ensure the Aide POC is complete and accurate. During interview on 10/26/2023 at 01:22 PM, the Chief Clinical Operations stated the aide plan of care does not include any information regarding the patients wound because the HHA would never do anything with the wound or the dressing. Patient #1 – This 70-year-old patient with the terminal diagnosis of stage IV prostrate cancer was admitted to the hospice on 09/19/2023. A.) Review of the Aide Tasks (aide care plan) dated 10/10/2023 revealed the HHA is directed to assist with elimination and the patient has a 16 french foley urinary catheter in place. Review of the clinical record lacks documentation the patient has a foley urinary catheter in place. The hospice failed to ensure the aide POC is complete and accurate. During interview on 10/26/2023 at 10:26 AM, the Registered Nurse (RN) Case Manager stated the patient did not have a foley catheter and it was mistakenly added to the aide care plan. B.) Review of the Aide Tasks dated 10/10/2023 lack instructions of aide observations that should be reported to the supervising nurse. The hospice failed to ensure the aide POC is complete and accurate. During interview on 10/26/2023 at 09:23 AM, the RN Case Manager stated being unaware the aide care plan was required to have instructions of observations to report to the nurse. Patient #14 – This 56-year-old patient with the terminal diagnosis of downs syndrome with alzheimers dementia, residing in an intermediate care facility, was admitted to the hospice on 09/12/2023. Review of the Physicians Order dated 09/12/2023 revealed an order for oxygen 2 liters per minute of (to) 5 liters per minute continuously via nasal cannula. Review of the Aide Tasks dated 09/13/2023 lacks identification the patient is ordered to use oxygen, instructions of observations to report regarding oxygen use and oxygen safety precautions. The hospice failed to ensure the aide POC is complete and accurate. During interview on 10/26/2023 at 01:05 PM, the Chief Clinical Operations Officer stated the aide care plan does not include the identified oxygen information.

Based on clinical record review, agency policy and procedure and staff interview for one (1) of nineteen (19) patients (Patient #19), the hospice failed to ensure supervision of the bachelors degree Social Worker (BSW). Failure to ensure the BSW is adequately supervised has the potential of providing inadequate care. --- The hospice failed to ensure the BSW was adequately supervised as evidenced by the following: Review of the agency policy and procedure entitled ";Documentation" updated 02/11/2022 revealed ";Social Workers without a Master of Social Work (MSW) degree must have all documentation reviewed and signed by a staff Social Worker with a MSW degree." Employee T – This BSW was hired by the hospice on 07/19/2021. Patient #19 – This 86-year-old patient with the terminal diagnosis of heart failure was admitted to the hospice on 01/18/2023 and revoked services on 05/12/2023. Review of the Social Work Admission Visit Note dated 01/18/2023 revealed Employee T performed the visit. The visit note lacks documentation of being reviewed and signed by a MSW. During interview on 10/26/2023 at 10:28 AM, the MSW stated the previous electronic medical record (EMR) that was being used at the time of the identified visit had no way for visits to be cosigned. The MSW stated the hospice now uses a different EMR that allows for cosignage.