Every finding on record at Comfort Care Hospice, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) clinical records reviewed revealed that the comprehensive assessment was not completed within the first five days after the election of hospice care. Clinical Record 4: The patient elected the hospice benefit on 11/23/2022. The initial chaplain assessment was completed on 11/29/2022 (6 calendar days after election of the benefit). There was no documentation to explain why the initial assessment was late. The Administrator was interviewed on 1/4/2022 and agreed that the assessment was late. She had no additional information to add.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interview. In 2 of 2 (100%) applicable clinical records of patients who were discharged from hospice services revealed that the discharge summaries were not forwarded to the receiving facility(ies). Clinical Record 11: The patient elected the hospice benefit on 6/24/2022 and revoked the hospice benefit on 8/19/2022 to seek treatment in the hospital. There was no documentation that the discharge summary was sent to the hospital. Clinical Record 13: The patient elected the hospice benefit on 12/15/2022 and revoked the hospice benefit on 12/21/2022 to seek treatment in the hospital. There was no documentation that the discharge summary was sent to the hospital. The Administrator was interviewed on 1/4/2022 and stated that she was not aware that it was required for the discharge summary to be sent to the hospital. The current policy does not have this listed as a requirement, however, the Administrator stated that a new policy has been developed for live discharges which includes this requirement, but it has not yet been approved or implemented,

Based on review of medical records (MR), agency policy and procedure, observations, and interviews it was determined the agency failed to ensure an accurate and current Medication Profile was maintained for each patient. This deficient practice affected affected 3 of 3 Home Visit (HV) patients including HV # 3, HV # 2, HV # 1, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication/DME (Durable Medical Equipment) Review Policy Number: H701 Revised: April 1, 2020 Procedure: 1. Review all medications ... with the patient and/or family every fifteen (15) days and as needed... 3. List all medications on the Hospice Medication Profile. 4. List any new and/or changes with medications on the Hospice Medication Profile upon occurrence... 1. HV # 3 was admitted on 7/16/21 and recertified for hospice care on 10/14/21 to 1/11/22 with terminal diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction. A HV was conducted on 11/3/21 to observe care provided by Employee Identifier (EI) # 2, RN (Registered Nurse). Review of the Medication Profile dated 10/2/21 revealed orders for Gabapentin 100 mg (milligram) every 8 hours. Review of the medications in the home revealed a prescription bottle for Gabapentin 100 mg TID (three times a day). The caregiver stated HV # 3 had been taking the Gabapentin 2 times a day since June. An interview was conducted on 11/4/21 at 1:55 PM with EI # 1, Administrator, who confirmed the Medication Profile had not been updated per agency policy. 2. HV # 2 was admitted for hospice care on 3/16/21 and was recertified for continued care 9/12/21 to 11/10/21 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. A HV was conducted on 11/2/21 to observe care provided by EI # 3, Chaplain. Review of the Medication Profile printed 11/2/21 revealed orders for Gabapentin 100 mg 1 tab (tablet) oral at hs (bedtime) for pain, and Naproxen 250 mg 1 tab oral twice (BID) daily. Review of the medications in the home revealed Gabapentin 100 mg at hs, filled on 3/2/21. The caregiver (cg) reported HV # 2 had not taken Gabapentin for at least 8 months and Gabpentin was not being given at hs. Further review of home medication prescriptions revealed Naproxen 250 mg 1 tab bid as needed, filled on 11/13/2020. The cg reported HV # 2 does not require Naproxen daily and uses Naproxen only as needed. An interview was conducted on 11/4/21 at 1:00 PM with EI # 1, Administrator, who confirmed the Medication Profile was not accurate and current per agency policy. 3. HV # 1 was admitted to the agency on 7/16/21 and recertified for continued care 10/14/21 to 1/11/22 with terminal diagnoses including Parkinson's Disease and Alzheimer's Disease with Late Onset. A HV was conducted on 11/2/21 at 11:10 AM to observe care provided by EI # 4, Hospice Aide. Review of the Medication Profile provided by the agency dated 10/2/21 and the medications observed in the home revealed the following discrepancies: a. Vitamin D3 5000 IU (International Units) daily was listed on the medication profile. The patient's cg stated he/she had stopped taking the Vitamin D several months ago. b. Spironolactone 25 mg daily as needed was listed on the Medication Profile. There was no bottle of spironolactone observed in the home. The patient's cg stated he/she was not aware of it being ordered, and it was not being used. c. A bottle of OTC (over the counter) Tylenol 500 mg strength capsules was observed on the counter with the patient's other medications. The cg stated when questioned, the patient had received 2 capsules of the Tylenol 2 nights before, and it was used for pain. Tylenol was not listed on the Medication Profile. In an interview conducted 11/4/21 at 12:36 PM, EI # 1, Administrator, confirmed the Medication Profile was not accurate and current per agency policy.

Based on review of agency policies and procedures, medical records (MR) and staff interviews, it was determined the agency failed to ensure the interdisciplinary team (IDT) updated each patient's plan of care (POC) with changes in the patient's condition and patient needs. This deficient practice affected 3 of 13 records reviewed including Home Visit (HV) # 2, MR # 2, and MR # 3 and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy and Procedure: Subject: Plan of Care Revised: June 30, 2021 Policy An individualized Plan of Care (POC) will be established for each...patient prior to provision of care. The POC is developed and reviewed by the IDT every 15 days...providers...informed of changes in the POC as it is reviewed...updated. 7. The content of the POC will include educational needs identified during the Nursing, Social Work, Chaplain...Assessments...monitored and updated as...needs change... 10. The IDT meets every...15 days...review...revise...each individual POC. 13. As the patient's condition deteriorates, needs are addressed... Agency Policy Subject: IDT Revised: Aril 1, 2020 Policy The IDT supervises the care and services provided... Procedure 3. The IDT will communicate daily when necessary regarding changes in the patient...needs and related changes in the POC... 5...the IDT has the responsibility of... c. Reviewing and updating each Care Plan every 15 days at a formal meeting... 1. HV # 2 was admitted for hospice care on 3/16/21 and was recertified for continued care 9/12/21 to 11/10/21 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. Review of the IDT Meeting dated 9/24/21 revealed the nurse "plan for the next 2 weeks to...monitor appetite and weight loss, ...respiratory status...weakness and falls. There was no nursing documentation of patient progress or deterioration in condition over the past 15 days. Review of the IDT Meeting dated 10/8/21 included nurse documentation which revealed the patient continues to have low blood pressure (BP) and HV# 2's main source of nutrition was supplements. There were no weights documented and no documentation of HV # 2's respiratory and mobility status, whether there was improvement or deterioration in the condition over the past 15 days. Further review of the 10/8/21 IDT Meeting documentation revealed the nurse "plan for the next 2 weeks to...monitor...hypotension (low BP)...increase in sob (shortness of breath)....decrease in mobility." Review of the IDT Meeting dated 10/22/21 revealed no documentation of HV # 2's BP/hypotension, respiratory (sob) or mobility status. There was no nursing documentation of patient progress or deterioration over the past 15 days. An interview was conducted on 11/4/21 at 1:00 PM with EI (Employee Identifier) # 1, Administrator, who confirmed the nurse IDT documentation failed to include progress toward goals and/or deterioration in condition. 2. MR # 2 was admitted for hospice care on 9/22/21 with a terminal diagnosis of Adult Failure to Thrive. Review of the IDT Meeting dated 9/24/21 revealed the Social Workers (SW) visit plan was 1 visit per week and the nurse "plan for the next 2 weeks to...monitor weight and nutritional intake." Review of the Psychosocial Clinical Note documentation dated 10/6/21 revealed patient's eyes were bright, yellow and patient reported he/she has a burnt taste in their mouth at times. There was no documentation the nurse or IDT was notified of the patient's change in condition and needs were addressed per policy. Review of the IDT Meeting dated 10/8/21 revealed no documentation of weight and nutritional status. There was no documentation the IDT discussed the 10/6/21 condition changes identified by SW and no POC updates were completed as a result of the condition change. Further review of the 10/8/21 IDT Meeting documentation revealed Ondansetron 8 mg (milligram) q (every) 6 hr (hours) prn (as needed) for nausea, Lorazepam 0.5 mg q 6 hr prn for "increased anxiety related to itching all the time", and Atarax q 6 hr prn itching were prescribed on 9/28/21, but the family had not picked up the 3 prescriptions. The nurse's plan for the next 2 weeks was to monitor itching and anxiety, fluid, and food intake. Review of the IDT Meeting dated 10/22/21 revealed no follow-up documentation to determine if the prescriptions were picked up by the family. There was no documentation of the patients' response to Lorazepam for itching and Atarax for the treatment of anxiety as per the 10/8/21 IDT plan. An interview was conducted on 11/4/21 at 12:54 PM with EI # 1, Administrator, who stated "there is not a lot of documentation for follow up and plan" and confirmed the IDT documentation failed to include progress toward goals and/or deterioration in condition. 3. MR # 3 was admitted for hospice care on 8/20/21 with a terminal diagnosis of Malignant Neoplasm of Cecum and Secondary Malignant Neoplasm of the Right and Left Lung. Review of the IDT Meeting dated 9/10/21 revealed the nurse plan for the next 2 weeks was to monitor pain medication effectiveness, sleep patterns and increased sob. There was no documentation of patient progress and/or deterioration since the 8/10/21 admission. An interview was conducted on 11/4/21 at 1:06 PM with EI # 1, Administrator, who confirmed the 9/10/21 IDT documentation failed to include patient progress toward goals and/or deterioration in condition.

Based on observations during a HV (Home Visit), agency policies and procedures (p/p), and staff interviews, it was determined the agency failed to ensure staff followed the agency p/p for hand hygiene and bag technique. This affected 1 of 1 HV with a HA (Hospice Aide), including HV # 1, and had the potential to negatively affect all patients and agency staff. Findings include: Agency Policy: Bag Technique Policy Number: H907 Revised Date: April 1, 2020 Procedure: 1. Locate a clean area for supplies...Place the bag on a disposable apron or bag barrier or may hang bag... 2. Identify clean and dirty compartment of the bag. Dirty compartments are the exterior pockets; clean compartments are the interior pockets. ...4. Wash hands... 5. Remove all equipment needed for the HV from the clean compartment...and place items on barrier. Close bag. ...7. Hands should be washed immediately when gloves are removed. 8. Clean all equipment used with the alcohol prep or germicidal cleanser. As each item is cleaned, place it in the clean compartment of your bag. 9. Items used for infection control, such as...paper towels, alcohol preps and...hand sanitizer should be on the outside (unclean) area of the bag... ...11. Dispose of all waste by placing items in a plastic bag-trash receptacle.... Agency Policy: Hand Hygiene Policy Number: H906 Revised: April 1, 2020 Policy: To prevent the transmission of microorganisms from patient to patient and from inanimate surfaces to patients by the hands of all healthcare providers.... Procedure: Handwashing: 1. ...wash hands with either a non-microbial soap and water or with an antimicrobial soap and water. ...3. Handwashing may also be used for routinely decontaminating hands in the following clinical situations: ...c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient). d. After contact with body fluids or excretions, mucous membranes ... e. When moving from a contaminated body site to a clean body site during patient care. f. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. g. After removing gloves. Hand Rubbing-Use of Hand Sanitizer: 1. If hands are not visibly soiled, an alcohol based hand rub may be used ... in the following clinical situations: ...c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient). d. After contact with body fluids or excretions, mucous membranes ... e. When moving from a contaminated body site to a clean body site during patient care. f. After contact with inanimate objects (including medical equipment) in the vicinity of the patient. g. After removing gloves.... Gloves and Hand Hygiene: ...2. Change gloves during patient care if moving from a contaminated body site to a clean body site. 3. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces... 4. Decontaminate hands after removing gloves. 1. HV # 1 was admitted to the agency on 7/16/21 and recertified for continued care 10/14/21 to 1/11/22 with terminal diagnoses including Parkinson's Disease and Alzheimer's Disease with Late Onset. A HV was conducted on 11/2/21 at 11:10 AM to observe care provided by Employee Identifier (EI) # 4, HA, including a bed bath, personal hygiene/grooming, and obtaining vital signs. The following observations were made: a. At the beginning of the visit, EI # 4 performed hand hygiene (HH), donned a pair of gloves, and removed equipment from bag to perform vital signs (VS) and placed on barrier. After VS completed, EI # 4 donned a second pair of gloves over the first pair, without performing HH, and proceeded to clean the bedside table with an adult cleansing wipe. EI # 4 then went to the bathroom, gathered and brought out various supplies, including lotion, deodorant and toothbrush with toothpaste to assist patient with brushing teeth and bath, and EI then performed oral care without changing gloves or performing HH. The patient's toothbrush was rinsed and placed back in the bathroom. Still without changing gloves or performing HH, EI # 4 then began the bed bath. EI # 4 washed the face and upper body, patted dry with towel, applied lotion, and placed new gown on the patient. EI # 4 continued the bath wearing the same 2 pair of gloves, washing the feet and legs, drying them and applying lotion. EI # 4 then went to bathroom and changed out water in basins, removed the outer pair of gloves only. EI # 4 came back out with fresh water, bathed the perineum and buttocks, and changed the bed linens. EI # 4 then doffed the single pair of gloves he/she was still wearing, and donned a new pair without performing HH. After combing the patient's hair, gathering and disposing of used linens and trash, EI # 4 removed gloves and then performed HH. b. EI # 4 had placed his/her bag on a disposable apron at the beginning of care. At the end of care, EI # 4 was observed folding the disposable apron used as a barrier between his/her bag and the patient environment, and placing back into the bag. The surveyor asked EI # 4 as about to exit the home if he/she planned to use the barrier again, and if he/she had been provided with additional barriers by the agency? EI # 4 stated, "No. I don't know why I did that. I have more barriers." EI # 4 then went out to his/her vehicle and showed the surveyor more barrier aprons available for use. EI # 4 failed to follow agency policy for hand hygiene and bag technique. In an interview conducted 11/4/21 at 12:36 PM with EI # 1, Administrator, EI # 1 confirmed the HA failed to follow agency infection control polices and procedures for bag technique and hand hygiene.

Based on review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the hospice failed to ensure the Hospice Aide (HA): 1. Performed tasks assigned by the Registered Nurse (RN) and written on the HA POC (plan of care). 2. Notified the RN when vital signs (VS) were outside the accepted parameters. 3. Notified the RN when date of last bowel movement (BM) was outside parameter of greater than 3 days. This affected 3 of 5 records reviewed with HA services ordered, including MR # 7, Home Visit (HV) # 1, and MR # 5, and had the potential to negatively affect all patients with HA services. Agency Policy and Procedure: HA/Homemaker Policy Number H504 Revised: August 13, 2021 Policy ...HA's...work under supervision of a RN and will follow the plan of care for all patient assignments... 4. HA/Homemaker Responsibilities: a...make visits as assigned... c...communicate abnormal signs and symptoms to the RN and document communication on HA/Homemaker Visit Note. d. The RN assigns the HA...duties based on identified patient needs and creates the POC for the HA. Any deviation from the POC from the HA will be communicated to the RN, and the RN will review the patient and family needs... 1. MR # 7 was admitted to the hospice on 9/28/21 with a terminal diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Encounter for Fitting and Adjustment of urinary device and Encounter for Attention to Gastrostomy. Review of MR # 7's HA Care Plan revealed tasks assigned by the RN which included empty catheter bag, document output and urinary catheter care every day. Review of 2 of 2 HA Visits dated 9/30/21 and 10/5/21 failed to reveal documentation for the presence of a urinary catheter. There was no documentation the catheter bag was emptied, no documentation of urinary output amounts and no documentation urinary catheter care was performed every visit as ordered. In an interview on 11/4/21 at 12:45 PM, EI (Employee Identifier) # 1, RN, Administrator confirmed there was no documentation the HA's provided urinary catheter care, emptied the catheter bag and documented urinary output as ordered. 2. HV # 1 was admitted to the agency on 7/16/21 and recertified for continued care 10/14/21 to 1/11/22 with terminal diagnoses including Parkinson's Disease and Alzheimer's Disease with Late Onset. Review of the HA Care Plan revealed tasks assigned by the RN which included: a. obtain blood pressure (BP) every visit, notify RN if BP less than 80/40 or greater than 160-170/100. b. document date of last BM, notify RN if no BM in 3 days or longer. Review of the HA Visit Note dated 10/18/21 revealed the HA documented date of last BM was 10/14/21, which was 4 days. There was no documentation the RN was notified. Review of the HA Visit Note dated 10/22/21 revealed the HA documented a BP of 186/84, which was outside the accepted parameter. Review of the HA Visit Note dated 10/27/21 revealed the HA documented a BP of 195/64, which was outside the accepted parameter. There was no documentation the RN was notified for either visit. In an interview conducted on 11/4/21 at 12:36 PM, EI # 1, Administrator, confirmed their was no documentation the RN was notified and should have been. 3. MR # 5 was admitted to the agency on 8/4/21 for certification period 8/4/21 to 11/1/21 with terminal diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Review of the HA Care Plan revealed tasks assigned by the RN which included to document date of last BM, notify RN if no BM in 3 days or longer. Review of the HA Visit Note dated 10/13/21 revealed the HA documented date of last BM was 10/3/21, which was 10 days. There was no documentation the RN was notified. In an interview conducted on 11/4/21 at 12:30 PM, EI # 1, Administrator, confirmed there was no documentation the RN was notified.

Based on review of medical records, agency policies and procedures and interviews it was determined the agency failed to ensure patient care and assessments were completed and documented within 48 hours of the visit per policy. This deficient practice affected 6 of 13 records reviewed, spanning a 7 month period and had the potential to negatively affect the Interdisciplinary Team's ability to maintain and update the individualized hospice plan of care. Refer to L 674 and L 679 for findings.

Based on medical record (MR) review, agency policy and procedure, Hospice and Palliative Care Handbook Quality, Compliance and Reimbursement Guidelines and interview with staff it was determined the agency failed to ensure the Skilled Nurse (SN) documented site assessment for a new gastrostomy tube (a stomach or gastrostomy tube used to place nutrients into the stomach when a patient can no safely swallow). This affected MR # 7, 1 of 2 records with a G-tube and had the potential to affect all patients who require parental nutrition. Findings include: Agency Policy and Procedure Subject: Gastrostomy Tube (G-Tube) Revised: April 1, 2020 Policy A Registered Nurse (RN)...will perform care of a balloon-retained G Tube including removal/change... Procedure 5. Verify placement... 7. Assess skin condition. Observe for any leakage, erythema, edema, or tenderness. Notify physician for signs of infection. 15. G-Tubes do not routinely require a dressing. If a dressing is used, it should be changed promptly...to prevent skin irritation or infection... Documentation 1. G-Tube...Site Care Skills Validation Hospice and Palliative Care Handbook Quality, Compliance and Reimbursement Second Edition, Copyright 2005 Part Four: Medical-Surgical Care Guidelines page(s) 370, 378 Feeding tube care Patent tube with correct placement, and skin site infection free... Document the gastrostomy site wound, and indicate color, any drainage, amount, and the specific care rendered. Document the specific type and size of the tube... 1. MR # 7 was admitted to the hospice on 9/28/21 with a terminal diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Encounter for Fitting and Adjustment of urinary device and Encounter for Attention to Gastrostomy. Review of the Certificate of Terminal Illness for benefit period 9/28/21-12/26/21 revealed the patient had a recent peg (percutaneous endoscopic gastrostomy) tube placed while in the hospital. Review of the hospice plan of care dated 9/28/21-12/26/21 revealed the presence of a newly placed PEG tube, orders for enteral nutrition, flushes, and verification of feeding tube placement every visit. There was no size of the peg (G-Tube) documented. Review of 5 of 5 SN (skill nurse) Visits dated 9/28/21, 9/29/21, 10/1/21, 10/5/21 and 10/6/21 revealed no documentation of the G-Tube site assessment for the presence/absence of leakage, erythema, edema, tenderness, and infection. In an interview on 11/4/21 at 12:45 PM, Employee Identifier # 1, RN, Administrator confirmed there was no G-Tube size and no assessment of the new G- Tube site documented in the patient's medical record.

Based on review of medical mecords (MR), agency policy and procedure, and interviews it was determined the agency failed to ensure the staff documented direct patient care within 48 hours of the patient visit. This deficient practice affected 5 of 13 MR reviewed including MR # 1, MR # 5, MR # 6, MR # 9, MR # 3, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Documentation Policy Number: H202 Revised: April 1, 2020 Policy: Documentation will be maintained in the individual clinical record for every patient in accordance with professional standards... Procedure: 1. Staff will complete and submit all direct care documentation within 48 hours of the patient visit. 2. Staff will document all other care-related events after the evaluation of the situation and/or communication with others within 48 hours... 8. All documentation should be dated and signed the date it is entered into the medical record, including late entries... 1. MR # 1 was admitted to the agency on 9/3/21 for certification period 9/3/21 to 11/1/21 with terminal diagnoses including Alzheimer's Disease with Late Onset, Anorexia, and Heart Failure. Review of the Hospice Plan of Care dated 9/3/21 revealed orders for Skilled Nurse (SN) visit as 1 per week for 9 weeks. Review of the SN Assessment Note dated 9/3/21 revealed the nurse completed and signed the note on 9/13/21, which was 10 days after the visit. Review of the SN Regular Visit note dated 9/9/21 revealed the nurse completed and signed the note on 10/3/21, which was 24 days after the visit. Review of the SN Regular Visit note dated 9/17/21 revealed the nurse completed and signed the note on 10/13/21, which was 26 days after the visit. Review of the SN Regular Visit note dated 9/22/21 revealed the nurse completed and signed the note on 9/27/21, which was 5 days after the visit. Review of the SN Regular Visit note dated 9/30/21 revealed the nurse completed and signed the note on 10/21/21, which was 21 days after the visit. Review of the SN Regular Visit note dated 10/6/21 revealed the nurse completed and signed the note on 10/20/21, which was 14 days after the visit. Review of the SN Regular Visit note dated 10/16/21 revealed the nurse completed and signed the note on 10/28/21, which was 12 days after the visit. Review of the SN Regular Visit note dated 10/20/21 revealed the nurse completed and signed the note on 10/25/21, which was 5 days after the visit. In an interview conducted on 11/4/21 at 12:43 PM, Employee Identifier (EI) # 1, Administrator, confirmed the visit notes were not completed within 48 hours per agency policy. 2. MR # 5 was admitted to the agency on 8/4/21 for certification period 8/4/21 to 11/1/21 with terminal diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Review of the Hospice Plan of Care dated 8/4/21 revealed orders for SN as 1 visit per week for 1 week, then 2 visits a week for 13 weeks starting 8/4/21. Review of the SN Assessment Note dated 8/4/21 revealed the nurse completed and signed the note on 8/10/21, which was 6 days after the visit. Review of the SN Regular Visit note dated 8/5/21 revealed the nurse completed and signed the note on 8/24/21, which was 19 days after the visit. Review of the SN Regular Visit note dated 8/9/21 revealed the nurse completed and signed the note on 8/30/21, which was 21 days after the visit. Review of the SN Regular Visit note dated 8/12/21 revealed the nurse completed and signed the note on 8/24/21, which was 12 days after the visit. Review of the SN Regular Visit note dated 8/16/21 revealed the nurse completed and signed the note on 8/30/21, which was 14 days after the visit. Review of the SN Regular Visit note dated 8/19/21 revealed the nurse completed and signed the note on 8/30/21, which was 11 days after the visit. Review of the SN Regular Visit note dated 8/24/21 revealed the nurse completed and signed the note on 9/5/21, which was 12 days after the visit. Review of the SN Regular Visit note dated 8/31/21 revealed the nurse completed and signed the note on 9/5/21, which was 5 days after the visit. Review of the SN Regular Visit note dated 9/7/21 revealed the nurse completed and signed the note on 9/22/21, which was 15 days after the visit. Review of the SN Regular Visit note dated 9/14/21 revealed the nurse completed and signed the note on 10/1/21, which was 17 days after the visit. Review of the SN Regular Visit note dated 9/16/21 revealed the nurse completed and signed the note on 10/1/21, which was 22 days after the visit. Review of the SN Regular Visit note dated 9/21/21 revealed the nurse completed and signed the note on 10/15/21, which was 24 days after the visit. Review of the SN Regular Visit note dated 9/23/21 revealed the nurse completed and signed the note on 10/4/21, which was 11 days after the visit. Review of the SN Regular Visit note dated 9/27/21 revealed the nurse completed and signed the note on 10/15/21, which was 18 days after the visit. Review of the SN Regular Visit note dated 9/30/21 revealed the nurse completed and signed the note on 10/4/21, which was 4 days after the visit. Review of the SN Regular Visit note dated 10/5/21 revealed the nurse completed and signed the note on 10/16/21, which was 11 days after the visit. Review of the SN Regular Visit note dated 10/11/21 revealed the nurse completed and signed the note on 10/16/21, which was 5 days after the visit. Review of the SN Regular Visit note dated 10/19/21 revealed the nurse completed and signed the note on 10/24/21, which was 5 days after the visit. In an interview conducted on 11/4/21 at 12:43 PM, EI # 1, Administrator, confirmed the visit notes were not completed within 48 hours per agency policy. 3. MR # 6 was admitted on 11/12/2020 and recertified for hospice 9/8/21 to 11/6/21 with Primary diagnosis of Alzheimers Disease, Unspecified. Review of the Recertification Plan of Care dated 9/8/21 revealed orders of SN 1 visit per week for 9 weeks. Review of the SN Visit note dated 9/30/21 revealed the nurse completed and signed the note on 10/21/21, which was 21 days after the visit. Review of the SN Visit note dated 10/8/21 revealed the nurse completed and signed the note on 10/27/21, which was 19 days after the visit. Review of the SN Visit note dated 10/20/21 revealed the nurse completed and signed the note on 10/25/21, which was 5 days after the visit. In an interview conducted on 11/4/21 at 1:25 PM, EI # 1, Administrator, confirmed the visit notes were not completed within 48 hours per agency policy. 4. MR # 9 was admitted on 3/15/21 with primary diagnosis of Chronic Obstructive Pulmonary Disease. Review of the Hospice Plan of Care dated 3/15/21 revealed orders for SN frequency of 3 visits per week for 1 week then 2 visits per week for 7 weeks. Review of the SN Assessment note dated 3/15/21 revealed the note was completed and signed by the nurse on 3/23/21, which was 8 days after the visit. Review of the SN Assessment note dated 3/16/21 revealed the note was completed and signed by the nurse on 3/31/21, which was 9 days after the visit. Review of the SN Assessment note dated 3/18/21 revealed the note was completed and signed on 4/4/21, which was 11 days after the visit. Review of the SN Assessment note dated 3/22/21 revealed the note was completed and signed on 4/4/21, which was 13 days after the visit. Review of the SN Assessment note dated 3/25/21 revealed the note was completed and signed on 4/4/21, which was 10 days after the visit. An interview was conducted on 11/4/21 at 1:45 PM with EI # 1 who confirmed the visit notes were not completed and signed within 48 hours of the visit per agency policy. 5. MR # 3 was admitted for hospice care on 8/20/21 with a terminal diagnosis of Malignant Neoplasm of Cecum and Secondary Malignant Neoplasm of the Right and Left Lung. Record review revealed the 8/23/21 SN Visit documentation was completed on 8/30/21, which was 7 days later. Review of the 9/7/21 SN Visit documentation revealed the nurse completed the visit documentation on 9/23/21, which was 16 days later. Review of the 9/13/21 SN Visit documentation revealed the nurse completed the visit documentation on 9/30/21, which was 17 days later. An interview was conducted on 11/4/21 at 1:06 PM with EI # 1, who confirmed the nurse failed to complete visit notes per agency policy.