Every finding on record at Christian Health Care Hospice, Inc

Based on policy review, record review, and interview, the provider failed to ensure the patient's right to be free from abuse by failing to immediately conduct an investigation into allegations of potential abuse and by discontinuing hospice aide services without determining validity of the allegation in, one of three records reviewed (Record/Patient #1).  This deficient practice has the potential to affect all patients receiving care from the provider. --- Findings included: Review of the provider's undated policy titled, "Abuse Neglect and Exploitation," showed all allegations are to be immediately and thoroughly investigated until concluded. RECORD/PATIENT #1:Review of the clinical record showed the hospice received notification from the long-term care facility (LTCF) on 03/10/2026 at 5:35 PM that the patient alleged the hospice's certified nursing assistant (CNA) caused harm during a shower and left a bruise.Record review showed the provider failed to initiate and complete an internal investigation into the alleged abuse. The provider failed to provide any documentation that showed a determination regarding the validity of the allegation. Review of the interdisciplinary group (IDG) comprehensive assessment details dated 04/06/2026, showed hospice aide services were discontinued in response to the allegation, without evidence the hospice conducted an investigation or determined the validity of the allegation prior to discontinuing services.During an interview on 04/14/2026 at 11:04 AM, certified nursing assistant (CNA) A stated that:- The patient had bruises on the top of his/her left arm and behind the left elbow;- The patient did not want a shower, but the CNA was persistent, and the patient agreed to take a shower;- During the shower, the patient was vocalizing and moaning;- The LTCF staff reported the patient told them the CNA had abused him/her; and- The CNA subsequently provided showers to the patient with another staff member present; however, on 04/02/2026, the patient made another allegation that the CNA caused harm during care, and the aide visits were discontinued.  During an interview on 04/14/2026 at 11:48 AM, the registered nurse case manager (RNCM) stated that:- The patient reported to LTCF staff that the CNA caused bruising during care; and- Confirmed the hospice did not conduct an internal investigation. During an interview on 04/14/2026, the RN coordinator stated that:- The LTCF conducted its own investigation; and- Confirmed the hospice did not conduct an internal investigation. During an interview on 04/14/2026 at 12:36 PM, the administrator stated that:- The aide was removed from patient care until the allegation was cleared; and- Confirmed the hospice relied on the LTCF and the State (Department of Health and Senior Services) to determine the outcome rather than conducting its own investigation.

Based on policy review, record review, and interview the hospice provider failed to ensure that all patients were notified of the financial liability of services in four of five full records reviewed (Records/Patients #2, #3, #4, and #5).  This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to the hospice provider on 12/27/2024 with Parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and systolic heart failure (a condition where the heart’s main pumping chamber, the left ventricle, weakens and can’t pump enough blood out to meet the body’s needs). The patient lived in a LTCF. Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 12/27/2024, showed:- The form was signed by the patient’s child/DPOA (durable power of attorney);- “Per POC” (per plan of care) was written twice across the area (not specifically for a discipline) where the visit frequency for skilled nursing (SN), home health aide(HHA), physical therapy(PT), occupational therapy(OT), speech therapy(ST) and masters of social work (MSW) should have been listed;- Chaplain and volunteer were not listed as a discipline option on the form; and- The provider failed to notify the patient or the patient’s child in writing of financial liability for visits made by the provider. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 11/07/2024 with a terminal diagnosis of  sarcopenia (a condition characterized by the gradual loss of muscle mass, strength, and function);.  The patient lived in his/her home with a family caregiver.Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 11/07/2024, showed:-"Per POC" (plan of care) was handwritten across the section for "Frequency and Duration" of Skilled nurse, Home Health Aide, Physical therapy, Occupational therapy, Speech therapy, and Medical social work visits; -"Per POC" was handwritten across the section for "cost per visit" of Skilled nurse, Home Health Aide, Physical therapy, Occupational therapy, Speech therapy, and Medical social work visits; and-The provider failed to notify the patient or the patient’s spouse in writing of financial liability for visits made by the provider. Findings included:Review of the provider’s policy titled, “Patient Funding,” dated 03/30/2023, showed in part:- The patient/family admitted to the program under an insurance funding source must be informed of:  * The amount that will be billed against the insurance program; and  * The amount for which the family will be responsible.- An explanation of the purpose of the form is given to the patient/family;- The patient or representative signs and dates the form;- A copy is left in the patient’s home; and- The original is filed in the hospice service record. Review of the provider’s policy titled, “Patient/Family Rights,” dated 03/30/2023, showed in part:- All patients admitted to hospice care receive a copy of the Patient/Family Bill of Rights and Responsibilities; and- Each patient/family information packet contains the most recent copy of the Patient/Family Bill of Rights and Responsibilities document. Review of the provider’s policy titled, “Hospice Information and Patient Rights and Responsibilities,” dated 06/2022, showed in part:- Every patient and family admitted to the hospice program has the right to the following: receive written information, upon admissions, regarding available hospice services, charges and billing processes that are covered and/or not covered by the patient’s Medicare, Medicaid, or insurance program. RECORD/PATIENT #3:Clinical record review showed the patient was admitted to hospice services on 01/31/2025 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity).  The patient lived in a long-term care facility (LTCF) and had a child involved in decision making for the patient.Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 01/31/2025, showed:- The form was not signed by the patient or the child involved in decision making;- The skilled nurse visit cost was listed as “per diem” per visit;- The home health aide visit cost was listed as “per diem” per visit;- The medical social worker visit cost was listed as “per diem” per visit; and- The provider failed to notify the patient or the patient’s child in writing of financial liability for visits made by the provider. RECORD/PATIENT #4:Clinical record review showed the patient was admitted to hospice services on 02/15/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient lived in a LTCF and had a legal guardian.Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 02/14/2025, showed:- The form was not signed by the patient or the guardian;- The skilled nurse visit cost was listed as “per diem” per visit;- The home health aide visit cost was listed as “per diem” per visit;- The medical social worker visit cost was listed as “per diem” per visit; and- The provider failed to notify the patient or the guardian in writing of financial liability for visits made by the provider. During an interview on 05/01/2025 beginning at 10:20 AM, the administrator stated that he/she would expect that the forms would be completed correctly and include the cost information.

Based on policy review, record review, and interview the hospice provider failed to ensure that all patients were notified of the scope of services they were to receive in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5).  This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to the hospice provider on 10/29/2024 with Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long term care facility (LTCF). Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 10/29/2024, showed:- Your hospice care will consist of the following services frequency and duration:  * The skilled nurse visits were listed as “per plan of care (POC)”;  * The home health aide visits were listed as “per POC”;  * The medical social worker visits were listed as “per POC”;- Chaplain and volunteer were not listed as a discipline option on the form- The form was signed by the patient’s spouse (durable power of attorney- DPOA); and- The provider failed to notify the DPOA in writing of the scope and frequency of visits to be made by the provider. RECORD/PATIENT #5:Review of the clinical record showed:- The patient was admitted to the hospice provider on 12/27/2024 with parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and systolic heart failure (a condition where the heart’s main pumping chamber, the left ventricle, weakens and can’t pump enough blood out to meet the body’s needs). The patient lived in a LTCFReview of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 12/27/2024, showed:- Your hospice care will consist of the following services frequency and duration:  *“Per POC” (per plan of care) was written twice across the area (not specifically for a discipline) where the visit frequency for skilled nursing (SN), home health aide(HHA), physical therapy(PT), occupational therapy(OT), speech therapy(ST) and masters of social work (MSW) should have been listed;  *Chaplain and volunteer were not listed as a discipline option on the form; and * The form was signed by the patient’s spouse (durable power of attorney- DPOA); and- The provider failed to notify the DPOA in writing of the scope and frequency of visits to be made by the provider. RECORD/PATIENT #2:Record review showed the patient was admitted to hospice services on 11/07/2024 with a terminal diagnosis of  sarcopenia (a condition characterized by the gradual loss of muscle mass, strength, and function);.  The patient lived in his/her home with a family caregiver.Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 11/07/2024, showed:* The skilled nurse visits were listed as “per plan of care (POC)”;  * The home health aide visits were listed as “per POC”;  * The medical social worker visits were listed as “per POC”;  * The physical therapy visits were listed as “per POC”;  * The occupational therapy visits were listed as “per POC”; and  * The speech therapy visits were listed as “per POC”;The words "Per POC" were handwritten across the section for "cost per visit" of Skilled nurse, Home Health Aide, Physical therapy, Occupational therapy, Speech therapy, and Medical social work visits. Findings included:Review of the provider’s policy titled, “Patient/Family Rights,” dated 03/30/2023, showed in part:- All patients admitted to hospice care receive a copy of the Patient/Family Bill of Rights and Responsibilities; and- Each patient/family information packet contains the most recent copy of the Patient/Family Bill of Rights and Responsibilities document. Review of the provider’s policy titled, “Hospice Information and Patient Rights and Responsibilities,” dated 06/2022, showed in part:- Every patient and family admitted to the hospice program has the right to the following: receive a written plan of care that identifies the scope and frequency of services and the disciplines that will furnish that care. RECORD/PATIENT #3:Clinical record review showed the patient was admitted to hospice services on 01/31/2025 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity).  The patient lived in a long-term care facility (LTCF) and had a child involved in decision making for the patient.Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 01/31/2025, showed:- Your hospice care will consist of the following services frequency and duration:  * The skilled nurse visits were listed as “per plan of care (POC)”;  * The home health aide visits were listed as “per POC”;  * The medical social worker visits were listed as “per POC”;- The form was not signed by the patient or the child involved in decision making; and- The provider failed to notify the patient or the patient’s child in writing of the scope and frequency of visits to be made by the provider. RECORD/PATIENT #4:Clinical record review showed the patient was admitted to hospice services on 02/15/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient lived in a LTCF and had a legal guardian.Review of the provider’s admission form titled, “Consent, Release, Authorization, and Financial Disclosure,” dated 02/14/2025, showed:- Your hospice care will consist of the following services frequency and duration:  * The skilled nurse visits were listed as “per patient POC”;  * The home health aide visits were listed as “per patient POC”;  * The medical social worker visits were listed as “per patient POC”;- The form was not signed by the patient or the guardian; and- The provider failed to notify the patient or the guardian in writing of the scope and frequency of visits to be made by the provider. During an interview on 05/01/2025 beginning at 10:20 AM, the administrator stated that he/she would expect that the forms would be completed correctly and that the patient’s visits should be based on their needs.

Based on review of the provider's medication profile audit tool, record review, home visit observation, and interview, the hospice provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in three of four home visit observations conducted (Records/Patients #1, #3, and #4). This deficient practice has the potential to affect the hospice provider's ability to ensure safe and effective use of medications for all the patients served by the provider. --- Findings included: Review of the provider's audit tool titled, “Medication Audit Tool”, updated 04/18/2024, showed in part:- Medication review completed on admission and recertification, and PRN (as needed); and- “Named” electronic medical record (EMR) profile matches facility medication administration record (MAR) or home patient active list exactly. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to the hospice provider on 10/29/2024 with Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF). Observation on 04/28/2025 at 12:59 PM, during the patient's home visit, showed the following medication discrepancies, after comparing the current medication list provided by the hospice clinical site manager on 04/28/2025 at 11:42 AM with the LTCF monthly physician order sheet (POS), April MAR and April treatment administration record (TAR) requested by the state agent (SA) during the home visit observation:- The POS dated 03/28/2025 – 04/28/2025 and the MAR dated 04/01/2025-04/30/2025 each showed Depakote sprinkles (a medication used to treat seizure disorders, and mental/mood conditions) 250mg (milligrams) three times daily with a start date of 01/13/2025. The hospice provider’s current medication list failed to include Depakote;- The POS dated 03/28/2025 – 04/28/2025 and the TAR dated 04/01/2025-04/30/2025 each showed Benadryl (a topical medication used to relieve pain and itching) gel 2% apply to back of neck and front of chest for redness/itching as needed up to three times daily with a start date of 04/22/2025. The hospice provider’s current medication list failed to include Benadryl gel;- The POS report dated 03/28/2025 – 04/28/2025 and the facility MAR dated 04/01/2025-04/30/2025 each showed Tramadol (medication used to treat moderate to severe pain) 50mg three times daily with a start date of 04/21/2025. The hospice provider’s current medication list showed Tramadol 50mg two times daily;-  The POS dated 03/28/2025 – 04/28/2025 and the MAR dated 04/01/2025-04/30/2025 each failed to show Quetiapine (an antipsychotic medication given to help regulate mood and behaviors) listed. The hospice provider’s current medication list showed Quetiapine 50mg one tablet two times a day; andThe POS dated 03/28/2025 – 04/28/2025 and the MAR dated 04/01/2025-04/30/2025 each showed Boost (a liquid nutritional supplement) 120ml (milliliters) three times daily. The hospice provider’s current medication list showed Boost 80ml three times daily). During an interview on 04/28/2025 starting at 2:30 PM, LPN A stated that:- Medication reconciliation is done once weekly on the first visit of the week; and- The facility has a book that shows what changes and calls have been made. During an interview on 04/28/2025 starting at 2:30 PM, RN A stated that the medication lists should match. During an interview on 05/01/2025 at 10:27 AM, the administrator stated that the medications should match, both the facility list and the hospice list.    RECORD/PATIENT #3:Clinical record review showed the patient was admitted to hospice services on 01/31/2025 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity).  The patient lived in a LTCF.Observation on 04/29/2025 beginning at 12:30 PM, during the patient’s home visit, showed the following medication discrepancies, after comparing the current medication list provided by the hospice administrator on 04/29/2025 prior to the visit with the LTCF physician order sheet (POS) dated 04/01/2025-04/29/2025 requested by the SA during the home visit observation:- The LTCF POS showed an order for Polysaccharide Iron Complex (a medication used as an iron supplement) 150 mg one capsule twice per day every other day with a start date of 12/10/2024.  The hospice provider’s current medication list showed an order for Polysaccharide Iron Complex 150 mg one capsule twice per day;- The LTCF POS showed an order for SPS with sorbitol suspension (a medication used to decrease the potassium level in the body) 15-20 grams/60 milliliters (mL) give 15 mL once a day on Monday and Thursday with a start date of 02/25/2025.  The hospice provider’s current medication list failed to include SPS with sorbitol suspension; and- The LTCF POS failed to show an order for Zoloft (a medication used for depression) 25 mg one tablet every day.  The hospice provider’s current medication list showed an order for Zoloft 25 mg one tablet every day with a start date of 02/20/2025. RECORD/PATIENT #4:Clinical record review showed the patient was admitted to hospice services on 02/15/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient lived in a LTCF.Observation on 04/29/2025 beginning at 10 AM, during the patient’s home visit, showed the following medication discrepancies, after comparing the current medication list provided by the hospice administrator on 04/28/2025 with the LTFC POS dated 03/29/2025-04/29/2025 requested by the SA during the home visit observation:- The LTCF POS showed an order for Omeprazole (a medication used for upset stomach) 20 mg once per day with a start date of 08/30/2024.  The hospice provider’s current medication list failed to include Omeprazole;- The LTCF POS showed an order for Ativan (a medication used for anxiety) 0.5 mg one tablet every 2 hours as needed with a start date of 02/24/2025.  The hospice provider’s current medication list failed to include Ativan 0.5 mg one tablet every 2 hours as needed;- The LTCF POS showed an order for Roxanol (a medication used for severe pain or shortness of breath) 100 mg/5 mL give 0.5 mL every 30 minutes as needed with a start date of 02/24/2025.  The hospice provider’s current medication list failed to include Roxanol;- The LTCF POS showed an order for Oxycodone (a medication used for pain) 5 mg one tablet every 6 hours with a start date of 04/02/2025.  The hospice provider’s current medication list showed an order for Oxycodone 5 mg every 6 hours as needed;- The LTCF POS showed an order for Famotidine (a medication used for upset stomach) 20 mg one tablet twice per day with a start date of 04/16/2025.  The hospice provider’s current medication list showed an order for Famotidine 20 mg one tablet once per day;- The LTCF POS showed an order for Prolia (a medication used to treat brittle bones) 60 mg/mL give 60 mg once a day on the second Wednesday of February and August (every 6 months) with a start date of 02/12/2025.  The hospice provider’s current medication list showed an order for Prolia 60 mg every 4 months; and- The LTCF POS failed to show an order for Esomepra Magnesium (a medication used for upset stomach) 20 mg per day.  The hospice provider’s current medication list showed an order for Esomepra Magnesium 20 mg one capsule every day with a start date of 02/15/2025. During an interview on 05/01/2025 beginning at 10:20 AM, the administrator stated that skilled nurses making visits should ask for new orders at every visit and request a facility medication list at every visit.

Based on policy review, record review, and interview the provider failed to ensure that each patient received an individualized initial or revised plan of care (POC) in three of five full records reviewed (Records/Patients #1, #4 and #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, "Plan of Care", dated approved by the governing body 03/24/2021, showed, in part:- When a patient or family member/caregiver has elected the Medicare hospice benefit, the hospice, physician, facility, patient and/or family/caregiver will communicate, establish and agree upon a coordinated plan of care for all providers which reflects the hospice philosophy, and is based on assessment of the individual's needs and unique living situation in the home or facility;- The plan of care will identify the care and services to which the Hospice will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for Hospice care;- The plan of care will be reviewed and/or revised at minimum every fourteen days by the interdisciplinary group (IDG) (physician, social worker, registered nurse, chaplain, volunteer coordinator);- Any changes to the plan of care will be coordinated with the family/caregiver and/or nursing facility;- The plan of care includes directives for managing pain and other symptoms and physician standing orders;- The hospice shall update the DCS (director of clinical services)/ or designated registered nurse (RN) that oversees the IDG with any changes made to the POC, and any additional needs that may need discussed.  This communication will be scribed into the IDG minutes.  Review of the provider’s policy titled,” Interdisciplinary Team (IDG)”, dated approved by the governing body 03/24/2021, showed in part:- All hospice services are delivered under the direction, supervision, and evaluation of the IDG team per hospice policies;- The IDG team will meet at minimum every two weeks to evaluate, review, and update the patient’s plan of care;- Responsibilities of the IDG team: establish the plan of care, review, assess, and recommend changes in the plan of care, and establish the scope and frequency of services and revise changes when appropriate.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to the hospice provider on 10/29/2024 with Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF)  Review of the hospice plan of care (POC) dated effective 11/03/2024 and last updated 04/28/2025, showed in part, a skilled nurse frequency of one time weekly. Review of IDG comprehensive assessment details dated 03/24/2025, 04/07/2025, and 04/21/2025 all showed a skilled nurse (SN) frequency of one time weekly. The IDG notes failed to be updated with the SN twice a week frequency. Review of coordinated care plans (a form utilized in a LTCF to allow for coordination of services between the hospice and LTCF to collaborate and document which services will be provided by whom, the frequency of these services and updates when changes occur) dated revised March 2025 and revised April 2025 showed SN visits two times weekly. Further review of the clinical record showed routine SN visits two times weekly that were completed on 03/25/2025, 03/28/2025, 04/01/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/18/2025, 04/21/2025 and 04/24/2025. The POC failed to be updated with the SN twice a week frequency.  RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to the hospice provider on 12/27/2024 with Parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and systolic heart failure (a condition where the heart’s main pumping chamber, the left ventricle, weakens and can’t pump enough blood out to meet the body’s needs). The patient lived in a LTCF. Review of the hospice plan of care (POC) dated effective 03/28/2025, showed in part:- Problem: cardiac/circulatory function and volume fluid alteration;- Goal: patient will have peripheral edema controlled/decreased as disease process allows;- It failed to contain an intervention of utilizing compression stockings (specialized garments (stockings/hose) designed to apply gentle pressure to the legs and ankles to help improve blood circulation and reduce swelling) or tubigrips (a multi-purpose elasticated tubular bandage designed to provide continuous support and compression for various medical reasons including swelling).  Review of an IDG comprehensive assessment details dated 03/20/2025 showed compression socks in place. Review of an IDG comprehensive assessment details form dated 04/03/2025 failed to mention any use of compression hose or tubigrips. Review of an IDG comprehensive assessment details form dated 04/17/2025 failed to mention any use of compression hose or tubigrips. Review of SN visit notes dated 03/18/2025, 03/21/2025, 03/25/2025, 04/04/2025, all showed compression socks in place. Review of a RN recertification visit note dated 03/23/2025 and SN visit notes 03/27/2025, 04/08/2025, and 04/21/2025 failed to contain documentation of use of compression socks or tubigrips. Review of SN visit notes dated 04/15/2025, 04/18/2025, 04/21/2025, and 04/23/2025 all showed tubigrips in place. The hospice plan of care failed to be updated with what type of compression the patient was utilizing to their lower extremities, the duration of application, or the type and size of the compression type.  During an interview on 05/01/2025 at 10:32 AM the administrator stated that he/she :- Was not able to locate the use of tubigrips or compression socks on the POC;- Would expect accurate information on the POC; and- Would have expected what the patient was utilizing to have been on the POC.   RECORD/PATIENT #4:Clinical record review showed the patient was admitted to hospice services on 02/15/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient lived in a LTCF.Review of the POC dated 04/29/2025, showed in part:- The patient was receiving Eliquis (a blood thinning medication used to treat blood clots) 5 milligrams (mg) twice per day; and- The POC failed to include interventions to monitor for signs or symptoms of bleeding (such as excessive or abnormal bruising) or active bleeding. Review of the aide task plan last reviewed on 04/28/2025, showed in part:- The aide was to perform nail care including cutting the fingernails and toenails (which is contraindicated in patients on blood thinners); and- The aide task plan failed to include interventions to monitor for signs or symptoms of bleeding or active bleeding. During an interview on 05/01/2025 beginning at 10:20 AM, the administrator stated that he/she would expect bleeding precautions to be on the POC for patient #4.

Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) included the frequency of skilled nursing visits necessary to meet the patient's needs in two of five full records reviewed (Records/Patients #2 and #5). This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to the hospice provider on 12/27/2024 with Parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and systolic heart failure (a condition where the heart’s main pumping chamber, the left ventricle, weakens and can’t pump enough blood out to meet the body’s needs). The patient lived in a long term care facility (LTCF);Review of the skilled nursing (SN) notes showed a recertification SN visit done on 03/23/2025 followed by routine SN visits two times weekly that were completed 03/25/2025, 03/27/2025, 04/01/2025, 04/04/2025, 04/08/2025, 04/111/2025, 04/15/2025, 04/18/2025, 04/21/2025 and 04/23/2025. Review of the plan of care effective 03/28/2025 failed to show a SN visit frequency. Review of the IDG (also known as the interdisciplinary team- IDT) comprehensive assessment details form dated 04/03/2025 and 04/17/2025 each failed to show a SN visit frequency. Findings included:Review of the provider's policy titled, “Nursing Admission/ Plan of Care (POC),” dated 08/31/2021, showed the plan of care will be developed immediately after the initial admission assessment, upon consulting with the Interdisciplinary Group (IDT). RECORD/PATIENT #2:Review of the clinical record showed, the patient was admitted to hospice services on 11/07/2024 with a diagnosis of Sarcopenia (a condition characterized by the gradual loss of muscle mass, strength, and function). Review of the comprehensive assessment, dated 11/07/2024, showed in part: -According to the onset, progression of symptoms, functional status and response to treatment section: The interview with the patient/family/ representative indicated the patient had a terminal diagnosis of Sarcopenia and abnormal weight loss;- The patient was in need of total care and able to make his/her needs known;- In the diagnosis and prognosis assessment: The patient was verbal;- In the pain and comfort assessment:  The patient was able to describe pain;- In the neurological status assessment: The patient’s behavior was hampered by Sundowner’s syndrome (a complex neurobehavioral disorder that affects people with dementia that worsens in the late afternoon, evening or night);- The mental status assessment stated: The patient was confused at all times; and- The immediate needs for problem and symptom management indicated a decline in the patient’s ADL (activities of daily living) and self-care. Review of the plan of care (POC), dated 11/12/2024, showed in part: - The Chaplin would complete home visits two times a month with 30 as needed (PRN) visits every 30 days;- The social worker would complete home visits two times a month, with 30 PRN visits every 30 days;- The Hospice aide would complete home visits two times a month, with 1 PRN visit every seven days; and- The skilled nurse and licensed practical nurse were not designated a frequency of visits. Review of the Interdisciplinary group (IDT) assessment, dated 04/17/2025, showed in part:- The Chaplin, social worker and Hospice aide home visits frequency remained the same; and- The skilled nurse and licensed practical nurse were not designated a frequency  of visits. During an interview on 05/01/2025 at 10:37AM, the Administrator stated the new system had a flaw regarding entry of the nursing visits, however the orders are written for all nursing visits.  He/she stated the visits are determined by the need of care and would expect the financial information to be filled out correctly.

Based on policy review, record review, and interview the hospice provider failed to ensure the hospice aide (HHA) reported changes in the patient’s condition to the registered nurse (RN) in two of five full records reviewed (Records/Patients #3 and #4).  This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Hospice Home Health Aide,” dated 08/13/2021, showed in part:- Hospice HHA services will be delivered and supervised by the RN;- The HHA will follow an individualized assignment for each patient provided in the plan of care (POC);- The HHA will notify the RN of any problems or concerns; and- The HHA will follow all care instructions for taking vital signs. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/31/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity).  The patient lived in a long-term care facility (LTCF).Review of the POC, dated 05/01/2025, showed the following:- Beginning 02/11/2025 the patient’s blood pressure was to be monitored every visit; and- Effective 02/11/2025 the HHA was to obtain the patient’s vital signs every visit and report abnormals to the RN.Review of the HHA task list, last reviewed 02/11/2025, showed the HHA was to obtain the patient’s vital signs every visit and report abnormals to the RN.Review of a HHA visit note, dated 04/10/2025, showed a blood pressure was recorded as 144/100 (a normal blood pressure range is considered to be less than 120/80) and the visit note failed to include documentation that the RN was notified of the abnormal blood pressure. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 02/15/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient lived in a LTCF.Review of the interdisciplinary group (IDG) meeting, dated 03/19/2025, showed the assigned task plan for the HHA included obtain vital signs at each visit and report abnormals to the RN.Review of a HHA visit note, dated 03/24/2025, showed a blood pressure was recorded as 175/100 and the visit note failed to include documentation that the RN was notified of the abnormal blood pressure. During an interview on 04/30/2025 at 11:15 AM, the administrator stated that no documentation was found to show that the HHA had notified the provider’s RN of the abnormal blood pressures for patients #3 and #4, but that the HHA stated that he/she had reported the blood pressures to the LTCF nurse but had failed to document it.During an interview on 05/01/2025 beginning at 10:20 AM, the administrator stated that he/she would expect the HHA to report the abnormal blood pressures to the provider’s RN.

Based on policy review, record review, and interview the provider failed to ensure documentation was accurate and timely in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5).  This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #1:Review of the clinical record showed:- The patient was admitted to the hospice provider on 10/29/2024 with Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF); - Skilled nurse visit (SNV) performed on 03/18/2025, was electronically signed on 03/23/2025 (5 days later);  - SNV performed on 03/25/2025, was electronically signed on 03/31/2025 (6 days later); - SNV performed on 03/28/2025, was electronically signed on 04/28/2025 (31 days later); - SNV performed on 04/01/2025, was electronically signed on 04/06/2025 (5 days later); - SNV performed on 04/04/2025, was electronically signed on 05/01/2025 (27 days later);- SNV performed on 04/08/2025, was electronically signed on 04/18/2025 (10 days later);- SNV performed on 04/11/2025, was electronically signed on 04/28/2025 (17 days later);- SNV performed on 04/15/2025, was electronically signed on 04/20/2025 (5 days later); - SNV performed on 04/18/2025, was electronically signed on 04/28/2025 (10 days later);- SNV performed on 04/21/2025, was electronically signed on 04/28/2025 (7 days later);- SNV performed on 04/24/2025, was electronically signed on 04/27/2025 (3 days later);- Hospice aide (HA) visit performed on 03/18/2025, was electronically signed on 3/26/2025 (8 days later);  - HA visit performed on 03/20/2025, was electronically signed on 03/26/2025 (6 days later); - HA visit performed on 03/25/2025, was electronically signed on 03/30/2025 (5 days later); - HA visit performed on 04/01/2025, was electronically signed on 04/12/2025 (11 days later); - HA visit performed on 04/03/2023, was electronically signed on 04/12/2025 (9 days later); - HA visit performed on 04/11/2025, was electronically signed on 04/16/2025 (5 days later):- HA visit performed on 04/18/2025, was electronically signed on 04/23/2025 (5 days later);   - HA visit performed on 04/22/2025, was electronically signed on 04/27/2025 (5 days later);- HA visit performed on 04/25/2025, was electronically signed on 04/28/2025 (3 days later);- Social worker (SW) visit performed on 03/17/2025, was electronically signed on 03/21/2025 (4 days later); and- Social worker visit (SW) performed on 04/24/2025, was electronically signed on 04/28/2025 (4 days later). RECORD/PATIENT #5:Review of the clinical record showed:- The patient was admitted to the hospice provider on 12/27/2024 with parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and systolic heart failure (a condition where the heart’s main pumping chamber, the left ventricle, weakens and can’t pump enough blood out to meet the body’s needs). The patient lived in a LTCF;- SNV performed on 03/18/2025, was electronically signed on 03/21/2025 (3 days later);  - SNV performed on 03/21/2025, was electronically signed on 03/26/2025 (5 days later); - SNV performed on 04/01/2025, was electronically signed on 04/09/2025 (8 days later); - SNV performed on 04/04/2025, was electronically signed on 04/09/2025 (5 days later);- SNV performed on 04/08/2025, was electronically signed on 04/11/2025 (3 days later);- SNV performed on 04/10/2025, was electronically signed on 04/14/2025 (4 days later);- SNV performed on 04/11/2025, was electronically signed on 04/16/2025 (5 days later); - SNV performed on 04/15/2025, was electronically signed on 04/20/2025 (5 days later);- SNV performed on 04/18/2025, was electronically signed on 04/23/2025 (5 days later);- HA visit performed on 03/18/2025, was electronically signed on 3/28/2025 (10 days later);  - HA visit performed on 03/20/2025, was electronically signed on 03/28/2025 (8 days later); - HA visit performed on 03/24/2025, was electronically signed on 03/28/2025 (4 days later); - HA visit performed on 03/27/2025, was electronically signed on 03/31/2025 (4 days later); - HA visit performed on 04/07/2025, was electronically signed on 04/14/2025 (7 days later); - HA visit performed on 04/10/2023, was electronically signed on 04/14/2025 (4 days later); - HA visit performed on 04/14/2025, was electronically signed on 04/21/2025 (7 days later):- HA visit performed on 04/17/2025, was electronically signed on 04/24/2025 (7 days later);   - HA visit performed on 04/21/2025, was electronically signed on 04/28/2025 (7 days later);- HA visit performed on 04/24/2025, was electronically signed on 04/28/2025 (4 days later); and- SW visit performed on 04/11/2025, was electronically signed on 04/15/2025 (4 days later).   Findings included:Review of the provider’s agency-wide email titled, "Timely Documentation," dated 08/05/2024, showed in part:- Documentation in the clinical record should be completed in a timely fashion; - The entries should be made in 24-48 hours;  and- Visits performed Monday-Friday should have documentation completed within that week. RECORD/PATIENT #2:Review of the clinical record showed:- The patient was admitted to hospice services on 11/07/2024 with a diagnosis of sarcopenia (a condition characterized by the gradual loss of muscle mass, strength, and function); - Skilled nurse (SN) visit performed on 03/17/2025, was electronically signed on 3/21/2025 (4 days later);  - SN visit performed on 03/19/2025, was electronically signed on 03/24/2025 (5 days later); - SN visit performed on 03/21/2025, was electronically signed on 03/30/2025 (9 days later); - SN visit performed on 03/26/2023, was electronically signed on 03/30/2025 (4 days later); and- SN visit performed on 04/15/2025, was electronically signed on 04/20/2025 (5 days later).- Hospice aide visit (HA) performed on 03/10/2025, was electronically signed on 3/19/2025 (9 days later);  - HA visit performed on 03/13/2025, was electronically signed on 03/19/2025 (6 days later); - HA visit performed on 03/18/2025, was electronically signed on 03/28/2025 (10 days later); - HA visit performed on 03/18/2025, was electronically signed on 03/28/2025 (10 days later); - HA visit performed on 03/21/2023, was electronically signed on 03/26/2025 (5 days later); - HA visit performed on 03/24/2025, was electronically signed on 03/31/2025 (7 days later):- HA visit performed on 03/27/2023, was electronically signed on 03/31/2025 (4 days later);  and- HA visit performed on 04/17/2025, was electronically signed on 04/24/2025 (7 days later).- Social worker (SW) visit performed on 11/07/2024, was electronically signed on 11/12/2024 (5 days later). During an interview on 05/01/2025 at 10:29 AM, the administrator stated that he/she would expect documentation to be completed within 24-48 hours, and the HIPPA compliant texting between the HA and the skilled nurses was completed daily.  RECORD/PATIENT #3:Review of the clinical record showed:- The patient was admitted to hospice services on 01/31/2025 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity).  The patient lived in a LTCF;- The comprehensive assessment performed on 01/31/2025, was electronically signed on 02/09/2025 (9 days later);- A SNV performed on 03/18/2025, was electronically signed on 03/28/2025 (10 days later);- A SNV performed on 03/21/2025, was electronically signed on 04/01/2025 (11 days later);- A SNV performed on 03/25/2025, was electronically signed on 03/28/2025 (3 days later);- A SNV performed on 03/28/2025, was electronically signed on 04/01/2025 (4 days later);- A SNV performed on 04/04/2025, was electronically signed on 04/11/2025 (7 days later);- A SNV performed on 04/11/2025, was electronically signed on 04/16/2025 (5 days later);- A SNV performed on 04/15/2025, was electronically signed on 04/21/2025 (6 days later);- A SNV performed on 04/18/2025, was electronically signed on 04/21/2025 (3 days later);- A HA visit performed on 03/17/2025, was electronically signed on 03/23/2025 (6 days later);- A HA visit performed on 03/20/2025, was electronically signed on 03/30/2025 (10 days later);- A HA visit performed on 03/24/2025, was electronically signed on 03/30/2025 (6 days later);- A HA visit performed on 03/27/2025, was electronically signed on 04/01/2025 (5 days later);- A HA visit performed on 04/03/2025, was electronically signed on 04/08/2025 (5 days later);- A HA visit performed on 04/10/2025, was electronically signed on 04/19/2025 (9 days later);- A HA visit performed on 04/14/2025, was electronically signed on 04/27/2025 (13 days later);- A HA visit performed on 04/17/2025, was electronically signed on 04/28/2025 (11 days later);- A SW visit performed on 04/25/2025, was electronically signed on 04/29/2025 (4 days later;- A general visit note (GVN) performed on 02/12/2025, was electronically signed on 02/20/2025 (8 days later);- A GVN performed on 03/12/2025, was electronically signed on 03/17/2025 (5 days later);- A GVN performed on 03/19/2025, was electronically signed on 04/11/2025 (23 days later);- A GVN performed on 03/25/2025, was electronically signed on 04/11/2025 (18 days later); and- A GVN performed on 04/03/2025, was electronically signed on 04/11/2025 (8 days later). RECORD/PATIENT #4:Review of the clinical record showed:- The patient was admitted to hospice services on 02/15/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient lived in a LTCF;- The comprehensive assessment performed on 02/15/2025, was electronically signed on 02/24/2025 (9 days later);- A SNV performed on 03/18/2025, was electronically signed on 03/28/2025 (10 days later);- A SNV performed on 03/21/2025, was electronically signed on 03/28/2025 (7 days later);- A SNV performed on 03/25/2025, was electronically signed on 03/28/2025 (3 days later);- A SNV performed on 03/28/2025, was electronically signed on 04/01/2025 (4 days later);- A SNV performed on 04/04/2025, was electronically signed on 04/11/2025 (7 days later);- A SNV performed on 04/11/2025, was electronically signed on 04/17/2025 (6 days later);- A SNV performed on 04/18/2025, was electronically signed on 04/21/2025 (3 days later);- A SNV performed on 04/22/2025, was electronically signed on 04/28/2025 (6 days later);- A HA visit performed on 03/17/2023, was electronically signed on 03/23/2025 (6 days later);- A HA visit performed on 03/20/2025, was electronically signed on 03/30/2025 (10 days later);- A HA visit performed on 03/24/2025, was electronically signed on 03/30/2025 (6 days later);- A HA visit performed on 03/27/2025, was electronically signed on 04/01/2025 (5 days later);- A HA visit performed on 04/03/2025, was electronically signed on 04/08/2025 (5 days later);- A HA visit performed on 04/10/2025, was electronically signed on 04/19/2025 (9 days later);- A HA visit performed on 04/14/2025, was electronically signed on 04/28/2025 (14 days later);- A HA visit performed on 04/17/2025, was electronically signed on 04/28/2025 (11 days later);- A HA visit performed on 04/22/2025, was electronically signed on 04/30/2025 (8 days later);- A HA visit performed on 04/24/2025, was electronically signed on 04/30/2025 (6 days later);- A GVN performed on 03/12/2025, was electronically signed on 03/18/2025 (6 days later);- A GVN performed on 03/19/2025, was electronically signed on 03/28/2025 (9 days later);- A GVN performed on 04/02/2025, was electronically signed on 04/11/2025 (9 days later); and- A GVN performed on 04/16/2025, was electronically signed on 04/21/2025 (5 days later). During an interview on 05/01/2025 beginning at 10:20 AM, the administrator stated that the expectation for electronically signing visits was within 48 hours of the completion of the visit.

Based on policy review, record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile in two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication Administration Record," dated 08/13/2021, showed in part: - A medication administration record (MAR), which is an exact duplicate of the medication profile in the hospice office, will be kept in the patient's chart in the home or nursing facility; and - The licensed nurse will assure that all changes are reflected in both the medication profile and the office patient chart medication profile. Changes will be updated as new orders are received and filed into the patient record. RECORD/PATIENT #2: Review of the clinical record showed current medications included: - Magnesium (mineral supplement) oral tablet 25 milligrams (mg) one tablet daily; - Melatonin (sleep aid) oral tablet 5 mg one tablet at bedtime; and - Tylenol (pain and/or fever) oral tablet 325 mg two tablets four times per day. Per interview conducted during medication observation, on 06/22/2022, beginning at 10:00 AM, the caregiver stated that: - Dosage on Magnesium bottle is 250 mg; - Melatonin was discontinued, "a few months ago because it was not beneficial"; - Salon Pas patches are used as needed for pain, medication not included on agency medication list; - Vitamin B tablets are given when patient is, "sluggish", not included on agency medication list; and - Tylenol is only being given as needed. During an interview on 06/23/2022 at 11:00 AM, the administrator and the director of clinical services (DCS) stated that they both expected the medications to match and that the medications should be checked on every visit and updated in the computer every two weeks. RECORD/PATIENT #3: Review of the current hospice medication profile showed the following discrepancies with the current long term care facility (LTCF) physician orders: - The LTCF orders showed an order for Flonase allergy relief spray, 50 mcg (micrograms) one spray to both nostrils daily as needed. The hospice medication profile showed an order for Flonase nasal suspension 50 mcg one spray each nostril daily; - The LTCF orders showed an order for Halls cough drops menthol 5.8 mg one as needed. The hospice medication profile did not include this order; - The LTCF orders showed an order for Tums (antacid) one tablet every four hours as needed. The hospice medication profile did not include this order; and - The LTCF orders showed an order for Biofreeze (topical pain reliever) menthol 4% to left shoulder every shift as needed. The hospice medication profile did not include this order. During an interview on 06/22/2022, at 3:15 PM, the administrator stated that at every visit the nurse should check for new or changed orders and update the medication profile. .

Based on policy review, record review, and interview, the agency failed to develop an individualized plan of care (POC) in, but not limited to, three (Records/Patients #2, #3 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care," dated 08/13/2021, showed in part: - The POC will identify the care and services to which the hospice will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care; and - The hospice retains overall professional management responsibility for directing the POC related to the terminal illness. Review of the agency's policy titled, "Nursing services, Registered Nurse (RN)," dated 08/13/2021, showed: - An RN is responsible for the coordination of all hospice services; - Scope and frequency of services are based on initial and ongoing assessments of the patient's needs; - Nursing services are provided in accordance with standard nursing practice and the interdisciplinary team plan of care; and - An RN is responsible for documentation of problems and appropriate goals and interventions. RECORD/PATIENT #2 Review of the clinical record showed: - RN skilled nursing visit dated 05/19/2022 identified that patient must be fed by caretaker; - Interdisciplinary Group Meeting (IDG) dated 06/01/2021 identified under "decrease in appetite" intervention of encouragement needed at meal time dated 12/15/2021; and - RN recertification dated 06/06/2022 showed patient had functional limitations with feeding and required maximum assistance from caregiver. Problem "decrease in appetite" showed intervention of encouragement needed at meal time dated 12/15/2021. During an interview on 06/23/2022 at 11:00 AM, the administrator and director of clinical services (DCS) both stated that they would expect the plan of care to be updated with changes. RECORD/PATIENT #3: Review of the RN initial assessment dated 04/13/2022, showed the patient's terminal diagnosis as combined systolic (congestive) and diastolic heart failure (a condition where the heart does not pump effectively). Review of the POC dated 04/14/2022 failed to include problems, interventions and goals related to congestive heart failure. During an interview on 06/22/2022, beginning at 3:15 PM, the administrator stated that the care plans should include problems, interventions and goals related to the terminal diagnosis. He/she would expect the care plans to be individualized for each patient. RECORD/PATIENT #5: Review of the RN initial visit dated 05/11/2022, showed the patient's terminal diagnosis as heart failure. Review of the POC dated 05/12/2022, failed to include problems, interventions, and goals related to heart failure During an interview on 06/23/2022, at 10:05 AM, the administrator stated that the care plans should include the terminal diagnosis. He/she would need to do staff education on the care plans.

Based on policy review, record review, and interview the agency failed to ensure the plan of care (POC) included the frequency of visits for the social worker in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care," dated 08/13/2021, showed in part, the POC will identify the care and services to which the hospice will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care. RECORD/PATIENT #5: Review of the initial social work visit note dated 05/19/2022, failed to address how often the social worker would visit the patient. Review of the POC's dated 05/12/2022 through 06/21/2022 failed to include the frequency of visits for the social worker. During an interview on 06/23/2022, at 10:10 AM, the administrator stated that the frequency of visits for the social worker should be included on the POC.

Based on home care infection prevention and control program, policy review, home visit observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections and communicable diseases was followed in one (Record/Patient #1) of two nursing home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of official reference: McGoldrick, M. (2015). Home Care Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc. showed that equipment that had direct contact with environmental surfaces should be cleaned and disinfected before use on another patient. Review of McGoldrick, M. Home Care Infection Prevention and Control Program showed also that staff should use a surface barrier of a water-resistant material (e.g., plastic bag [tall kitchen size] on a roll, wax paper, disposable underpads [chux], etc.) under the bag and/or equipment used in patient care. Review of the agency's undated policy titled, "Bag Technique Policy & Procedure," showed in part: - The home care bag should be transported in the car on top of a clean barrier; and - The home care bag should be carried into the patient's home by the shoulder strap leaving both hands free to spread out the barrier (news paper or paper towels may serve as a barrier) between the home environment and medical supplies. RECORD/PATIENT #1: Observation on 06/21/2022, beginning at 11:00 AM, during the patient's home visit at a long term care facility (LTCF), showed the registered nurse (RN A) laid his/her note book on the window sill in the patient's room without placing a barrier underneath. The RN also placed his/her nursing supply bag on the patient's chair without a barrier. The RN left the patient's room without cleaning the note book and his/her nursing bag. The RN then left the facility without cleaning his/her equipment. The RN then placed his/her supplies in his/her car without a barrier. During an interview on 06/23/2022 beginning at 10:00 AM, the director of clinical services stated that staff should have a clean area to set their supplies. No further information was provided.

Based on policy review, record review, and interview the agency failed to ensure the nursing needs were met in two (Records/Patients #3 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Wound Monitoring and Measurements of Wound," revised 04/20/2022, showed: - Describe the wound appearance on admission and monitor the wound for changes throughout hospice care as per the plan of care (POC). The skin should be assessed at a minimum weekly; - If the patient is in a facility, coordinate measurements with facility wound nurse, charge nurse, or director of nursing weekly. Check with facility on their scheduled day for wound measurements so there is appropriate collaboration at a minimum weekly or per the wound POC; and - If patient is a home patient, wounds will be assessed with each visit for changes and signs and symptoms of infection or worsening. RECORD/PATIENT #3: Review of the skilled nurse (SN) visit note dated 05/11/2022, showed the patient complained of a sore spot on his/her bottom. The long term care facility (LTCF) nurse assisted and no open areas noted, only a pressure area. Lantaseptic (skin protectant, no order found for this) applied. There was no further documented assessment of the pressure area. Review of the coordinated care plan with the LTCF showed on 05/11/2022, staff documented there were no changes to the current POC. Review of the SN visit notes showed: - On 05/13/2022, the SN questioned the patient about the sore spot on his/her bottom. He/she says (This sentence was not completed, and there was no further documentation regarding what the patient said or assessment of the area); - On 05/17/2022, no new skin issues (no documentation regarding the pressure area on the bottom), and - From 05/20/2022 through 06/17/2022, there was no further documentation related to the pressure area on the patient's bottom. Review of the POC dated 05/16/2022, showed a problem identified as pain related to altered skin integrity. Goals included that the patient would maintain intact skin as allowed by disease progression. The POC showed interventions related to pain but failed to include interventions related to skin integrity. During an interview on 06/22/2022, beginning at 3:15 PM, the administrator stated that the nurse should document an assessment if the patient had a pressure area. They have a wound note to document wounds which helps them track their wounds. The nurse should assess and document what the wound looks like, measure if able, and put interventions in place. During an interview on 06/23/2022, beginning at 10:25 AM, the administrator stated that the care plan should have included more interventions for skin integrity. He/she did not find a wound assessment for the patient. RECORD/PATIENT #4 Review of the SN visit showed: - Initial assessment dated 06/02/2022 described wound to the scalp as "open, present on admission, full thickness, surgical wound, length 2.5 centimeter (cm - unit of measure), width 2.5 cm, wound bed gray, wound edges attached, no drainage, no odor, surrounding skin calloused"; - SN visit dated 06/03/2022 described wound to the top of the head as "white scalp showing, has two nodules (rounded lump) located around wound expanding bigger in size, wound dry with green dry scab around white scalp. " No physician notification of change; and - SN visit dated 06/07/2022 described wound to the top of the head as "white scalp showing, has two nodules located around wound expanding bigger in size, wound has small amounts of sanguineous (bloody, watery) drainage around the open scalp wound." No physician notification of change. During an interview on 06/23/2022 at 11:00 AM with the administrator and director of clinical services (DCS), they both stated that they would expect changes in condition to be reported to the physician.

Based on policy review, record review, and interview the hospice home health aide failed to follow the plan of care (POC) in two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Hospice home health aide," dated 08/13/2021 showed: -The home health aide will follow an individualized assignment for each patient provided in the POC; and -The home health aide will follow all care instructions for assist with mobility and range of motion (ROM) exercises. RECORD/PATIENT #1: Review of the clinical record, POC showed the patient lived in a long term care facility (LTCF); and the patient's POC/coordinated task plan showed aide visits twice a week on Monday and Thursday. Review of the hospice aide visit notes showed that the aide failed to visit as scheduled on the POC nine of thirteen visits. During an interview on 06/23/2022 at 10:00 AM the director of clinical services (DCS) stated that the aide should follow the POC or should communicate to the agency reason for not following the POC. RECORD/PATIENT #2 Review of the clinical record, POC showed under "ambulation," (identified on 06/02/2021) that "patient will be able to continue walking with gait belt and times (X)1 assist with less difficulty." Review of the aide care visit notes showed: - On 05/19/2022, 05/23/2022, 05/26/2022, 05/31/2022, 06/02/2022, 06/06/2022, 06/09/2022, and 06/13/2022 aide had documented patient could, "walk with assist X 1, assist X 3 for weighing." The aide failed to document he/she used a gait belt when walking the patient. During an interview on 06/23/2022 at 11:00 AM with the administrator and DCS both stated that they would expect the aide to follow the plan of care.

Based on record review, and interview, the agency failed to ensure the coordinated task plan of care (POC) with the long term care facility (LTCF) included the frequency of visits for the chaplain and the volunteer in one (Record/Patient #1) of two records reviewed of patients that resided in a LTCF. This deficient practice has the potential to affect all patients residing in a LTCF. Findings included: RECORD/PATIENT #1: Review of the coordinated task POC maintained in the LTCF hospice binder (first date on the form was 09/03/2021) failed to include the frequency of visits for the chaplain and the volunteer. During an interview on 06/23/2022 at 1:00 PM, the director of clinical services stated that the coordinated task plan should include the frequency of visits for the chaplain and the volunteer.

Based on record review, home visit observation, and interview the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #1) of two applicable records of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: RECORD/PATIENT #1: Review of the hospice record maintained at the LTCF, during a home visit observation on 06/21/2022 beginning at noon, showed it failed to contain the following required information: - Advance directive (patient's end of life wishes); and - Names and contact information for hospice personnel involved in care of the patient. The findings were reviewed with the director of clinical services on 06/23/2022, at 10:00 AM. No further information was provided.

Based on review of Missouri state law, policy review, personnel file review, and interview the agency failed to obtain the results of the employee disqualification list (EDL) checks prior to hire in three (Employee #1, #4, and #5) of seven personnel files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo showed the statement, "No person, corporation, organization or association who received the employee disqualification list under subdivisions (1) to (5) of subsection 11 of this section shall knowingly employ any person who is on the employee qualification list." Review of the agency's undated policy titled, "Employee Disqualification List (Missouri)," showed in part that prior to an applicant being offered a position by the hospice an EDL check will be made. EMPLOYEE #1: - Date of hire - 10/28/2021; and - EDL check 10/28/2021. EMPLOYEE #4: - Date of hire - 11/08/2021; and - EDL check 11/08/2021. EMPLOYEE #5: - Date of hire - 09/30/2019; and - EDL check 10/01/2019. During an interview on 06/22/2022, beginning at 1:40 PM, the business office manager stated that he/she did the EDL checks when he/she got the employee's paperwork. He/she did not know if the EDL results were received prior to hire. During an interview on 06/23/2022, at 10:20 AM, the administrator stated that he/she thought the FCSR (Family Care Safety Registry, a criminal background checks that includes an EDL check) was done prior to hire.