Every finding on record at Community Hospices of America, LLC

It is required that the documented comprehensive assessment include a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but at a minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, document review, and interview. In 5 of 19 (26%) clinical records reviewed it was revealed that the hospice did not ensure that the medication profile included the patient’s current medications or that new medications were added or changes were made to existing medications. POLICY: The agency policy titled, Medication Reconciliation and Management (Procedure: HOS-C_15C), last reviewed and revised 10/28/2025, stated in part, "...For patients in their own residence, it is the responsibility of the hospice nurse to perform the following steps at each scheduled nursing visit: 1. Nurse obtains the most current copy of the medication list (whether this is in the EMR system or on paper), 2. Nurse visually reviews the patient's medication list in the home, comparing it to the medication list from the medical record...If the medication lists do NOT match, the nurse ensures the incorrect list is promptly updated to reflect the correct orders..." CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 10/30/2024 with a terminal diagnosis of atherosclerotic heart disease without angina. During the home visit conducted with the Licensed Practical Nurse (LPN) (Personnel Record 8) on 04/01/2026, the patient's home medications were compared with the hospice medication profile dated 04/01/2026. The patient discussed his ongoing use of Mucinex and Omega-3 fatty acid supplements. Multiple boxes of both products were observed in the home during the visit. Despite the patient’s verbal confirmation of use and the observed presence of these items, neither the medication nor the supplement was documented on the patient’s active medication list. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/03/2025 with a terminal diagnosis of malignant neoplasm of the breast with secondary neoplasms to the lung, bone, and peritoneum. During the Registered Nurse (RN) admission visit on 09/03/2025, the patient was documented as experiencing labored respirations with an oxygen saturation of 95% on 3 liters per minute (LPM) of oxygen via nasal cannula. The oxygen was not included on the patient’s medication list. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/11/2024 with a terminal diagnosis of senile degeneration of the brain and a comorbid condition of atherosclerotic heart disease. On 12/11/2025, the Registered Nurse (RN) documented that the patient was experiencing dyspnea with use of accessory muscles and required intermittent oxygen at 2–4 liters per minute (LPM) PRN and during nighttime, due to oxygen saturation levels dropping into the 80s. On 03/12/2026, nursing documentation indicated that the patient’s wife was administering oxygen via nasal cannula at 2 LPM overnight due to oxygen saturation readings in the upper 80s. During the IDG meeting on 03/17/2026, intermittent oxygen use and periodic oxygen saturation levels in the 80s were again noted. Despite repeated documentation of clinically indicated oxygen use across multiple nursing visits and IDG review, oxygen was not included on the patient’s active medication list. CLINICAL RECORD 15: The patient elected the hospice benefit on 08/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and comorbid conditions of heart failure and lumbosacral radiculopathy. During the Registered Nurse (RN) admission visit on 08/20/2025, the patient was documented as experiencing significant respiratory distress, requiring continuous oxygen at 2 liters per minute (LPM) via nasal cannula. The oxygen was not included on the patient’s active medication list. CLINICAL RECORD 19: The patient elected the hospice benefit on 04/16/2025 with a terminal diagnosis of senile degeneration of the brain. During a Licensed Practical Nurse (LPN) visit on 10/13/2025, the patient was documented as experiencing diarrhea two to three times daily, and the patient’s wife reported that she was initiating Imodium for symptom management. The patient’s wife also reported that she was giving the patient Ivermectin. Despite documented use and administration, neither Imodium nor Ivermectin were listed on the patient’s active medication list. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 3) on 04/02/2026, she confirmed that discrepancies were identified in the patient medication profiles within the active medical records. She further confirmed that the medication listings were not accurate or complete at the time of review. The Director stated that the necessary corrections and updates were entered into the medical records during the site visit.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 19 (21%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's plan of care reflected patient and family problems, interventions, and goals based on problems identified by the assessment data. POLICY: In the hospice's policy "Interdisciplinary Team Meeting (Procedure: HOS-C_09E)" last reviewed and revised 08/11/2025, included in part "...The IDT will follow the cadence of discussing each patient's needs/condition over the previous 2 weeks and plan to meet the patient's needs for the next 2 weeks...Comfort, Safety, and Quality of Life...each team member contributes insight, information, assessment data, and details concerning problems, goals, and interventions. The focus of the discussion is what has happened in the previous 2 weeks and what is expected to happen in the next 2 weeks...includes...changes in the Plan of Care (POC)...and changes in interventions for the patient..." CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2026 with a terminal diagnosis of malignant neoplasm of the ampulla of Vater with secondary malignant neoplasms of other digestive organs, and comorbid conditions including heart failure and chronic obstructive pulmonary disease (COPD). At the time of hospice admission on 01/16/2026, the patient was documented as experiencing anorexia only, with no nausea or chest pain noted. During the Registered Nurse visit on 01/21/2026, the nurse documented that the patient had been experiencing intermittent chest pain over several days, described as sharp pains that varied in duration, along with decreased appetite and nausea. Physician orders were obtained and documented on 01/21/2026 for Isosorbide Mononitrate 30 mg daily for chest pain and Zofran 4 mg every 4 hours as needed (PRN) for nausea. At the Interdisciplinary Group (IDG) meeting on 02/03/2026, these medication additions were noted; however, the IDG did not identify chest pain or nausea as active problems, nor did it develop or revise goals or interventions to address these symptoms within the plan of care. On a visit on 03/02/2026, the patient reported to the nurse that her nausea was worsening and not adequately controlled with the Zofran 4 mg dose. The physician's order was increased to Zofran 8 mg every 8 hours PRN. The patient also continued to experience intermittent daily chest pain. A review of IDG documentation confirmed that the patient’s ongoing and worsening chest pain and nausea were not reviewed or discussed during the IDG meetings held on 02/17/2026 or 03/03/2026. During a nursing visit on 03/04/2026, the patient complained of constant nausea throughout the day and worsening angina. New physician orders were received and documented the same day: Scopolamine 1 mg transdermal patch every 72 hours for nausea, and Nitroglycerin 0.4 mg sublingual tablets PRN for angina, with a maximum of 3 tablets in 15 minutes. At the IDG meeting on 03/17/2026, the medication changes were acknowledged; however, the IDG again did not revise the plan of care to reflect the patient’s increased symptom burden. No new problems were identified, and no updated goals or interventions were developed to address the persistent and worsening nausea and chest pain. A review of the patient’s plan of care for the benefit period from 01/16/2026 through 04/15/2026 revealed a single, generalized comfort-related problem with a broad goal for the patient and caregiver to understand symptom scales, manage symptoms, and report changes to hospice. Interventions remained limited to monitoring pain, shortness of breath, and appetite using scoring scales. Despite the patient’s documented progression of symptoms, including escalating nausea and chest pain requiring multiple medication adjustments, the IDG did not update the comprehensive plan of care. There were no new or revised problems, goals, or interventions documented after 01/20/2026. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/03/2025 with a terminal diagnosis of malignant neoplasm of the breast with secondary neoplasms to the lung, bone, and peritoneum. During a Registered Nurse (RN) visit on 01/06/2026, the patient reported feeling depressed, stated she was utilizing Lorazepam on a PRN (as needed) basis, and was observed to be tearful at times during the visit. A physician’s order was obtained and documented the same day for Lexapro 10 mg daily. On 02/03/2026, a physician's order was entered to increase the Lexapro dose to 20 mg daily. During the RN visit on 02/03/2026, the patient responded “yes” to screening questions indicating she felt overwhelmed, down or depressed, and experienced loss of pleasure and interest in activities. At the Interdisciplinary Group (IDG) meeting on 02/17/2026, the IDG reviewed the increased PRN use of Lorazepam, the initiation and dose increase of Lexapro, and the patient’s reports of depression and tearfulness. Despite this review, no new goals or interventions related to the patient’s depression or emotional distress were added to the plan of care. During the subsequent IDG meeting on 03/03/2026, the documented comfort and pain goals for the following two weeks included “pain, increased confusion, appeared to improve emotionally”, with no further discussion, assessment, or care planning documented related to the patient’s ongoing depression. A review of the patient’s plans of care for the benefit periods 12/02/2025–03/01/2026 and 03/02/2026–04/30/2026 identified a generalized problem related to comfort, with goals for the patient and caregiver to understand symptom scales, manage symptoms, and report changes to hospice. Additional goals included identifying sensory and neurological changes and implementing prompt interventions to minimize discomfort. Interventions were broad, non-specific, and focused on general symptom monitoring. Despite repeated documentation of depression, emotional distress, tearfulness, and reliance on anxiolytic and antidepressant medications, the patient’s plan of care was not revised to include depression as an identified problem. No individualized goals, psychosocial interventions, or interdisciplinary strategies were developed to address or monitor the patient’s mental health needs. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/11/2024 with the terminal diagnosis of senile degeneration of the brain with the comorbid condition of atherosclerotic heart disease. During the Registered Nurse (RN) Admission visit on 01/11/2024, the patient was alert but oriented to person only. He was noted to be pleasantly confused, smiling with no abnormal mood or respiratory findings. On 12/11/2025, the RN documented that the patient had dyspnea with use of accessory muscles with intermittent oxygen use of 2-4 liters per minute (LPM) as needed (PRN) and at night while sleeping as he occasionally dropped his oxygen saturation readings to the 80's. All lung fields were diminished upon auscultation. He exhibited declining neurological status but no abnormal mood or affect. The Interdisciplinary Group (IDG) Meeting on 12/22/2025 echoed the same intermittent oxygen needs. Then, on 03/06/2026, during the nursing visit, it was documented that the "...Wife reports pt restless at times, utilizing Lorazepam some. Refills for Lorazepam concentrate and tabs sent to pharmacy per MD order..." The Social Worker noted on her visit on 03/10/2026 that the primary caregiver had been giving the patient Lorazepam at times for agitated behavior. On 03/12/2026, the nurse documented during her visit that the "...Pt showing signs of slight anxiousness by scratching at the back of his head and face occasionally...Wife reported that she had to utilize pt's O2NC at 2LPM during the night due to pt's O2 sat dropping down in the upper 80's..." The nurse documented on 03/17/2026 that the patient would suddenly become anxious at times. During the IDG Meeting on 03/17/2026, intermittent oxygen use and occasional oxygen saturations in the 80s were documented, but the comfort/pain goal for the next 2 did not identify any respiratory or anxiety/agitation issues. A review of the patient's plans of care from 12/31/2025 to 02/28/2026 and 03/01/2026 to 04/29/2026 identified the need for comfort as a problem with the goals that sensory/neurologic changes are identified promptly and interventions initiated quickly to minimize associated uncomfortable symptoms, as evidenced by the patient/caregiver reporting an acceptable level of comfort within 20 visits. The patient's respiratory and anxiety were not identified, nor were any planned interventions or patient-specific measurable goals documented for their treatment. There were no new problems, interventions, or goals added since 04/14/2025. CLINICAL RECORD 15: The patient elected the hospice benefit on 08/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and comorbid conditions of heart failure and lumbosacral radiculopathy. During the admission visit on 08/20/2025, the patient was documented as experiencing significant respiratory compromise, including use of accessory muscles for breathing, abnormal breath sounds, and a requirement for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. The patient reported a dyspnea score of 8/10, with the worst level in the prior 24 hours reported as 9/10, and identified a personal dyspnea goal of 6/10. At the Interdisciplinary Group (IDG) meeting on 09/02/2025, documentation reflected a progressive decline in respiratory function, increased oxygen dependence, and decreased activity tolerance, with a respiratory rate of 20 breaths per minute, labored with conversation. However, the comfort and care goals for the upcoming two-week period focused primarily on pain and general comfort during activities of daily living, without clear, individualized goals or interventions to address the severity of the patient’s dyspnea. At the time of recertification on 11/05/2025, the patient continued to demonstrate ongoing dyspnea with an increasing respiratory rate, was utilizing continuous oxygen at 2 LPM, and fatigued after ambulating 10 feet, requiring approximately five minutes to recover. The patient was also documented as using non-invasive ventilation at night. Oxygen saturation was 95% on 2 LPM, and dyspnea scores ranged from 3 to 5. On 01/08/2026, a Licensed Practical Nurse (LPN) documented that the patient’s daughter reported the patient had removed oxygen during the night, resulting in oxygen saturation levels dropping into the 60s, accompanied by confusion. Despite this ongoing and severe respiratory symptom burden, the IDG meeting on 11/11/2025 again focused comfort goals for the next two weeks on pain only, without identifying dyspnea as a primary symptom requiring targeted care planning, despite oxygen saturation levels documented as dropping into the 60s–70s on room air and improving only with oxygen therapy. A review of the patient’s plans of care for the benefit periods 08/20/2025 to 11/17/2025 and 11/18/2025 to 01/13/2026 identified a generalized problem related to comfort with goals, specifically that the patient and caregiver need to understand symptom rating scales and report changes to the hospice. Interventions were limited to monitoring pain and dyspnea using appropriate scales. However, the patient’s self-identified dyspnea score and stated dyspnea goal were not incorporated into the plan of care, and no patient-specific, measurable goals or detailed interventions were developed to address the patient’s persistent and severe shortness of breath. After a joint clinical record review and interview on 04/01/2026 with the Area Executive of Clinical Operations (Personnel Record 2) and the Director of Clinical Services (Personnel Record 4), the findings were confirmed.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group, and written patient care instructions for a hospice aide be prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed revealed that the hospice did not ensure that the Registered Nurse provided the Hospice Aide full, complete instructions in the aide's plan of care. CLINICAL RECORD 18: The patient elected the hospice benefit on 08/25/2025. The patient's plan of care for the benefit period from 08/25/2025 to 11/22/2025 included orders for the hospice aide (HA) to visit the patient once a week. For the benefit period from 11/23/2025 to 12/21/2025, the aide was to visit the patient twice weekly. During the Registered Nurse (RN) visit on 10/24/2025, the patient was noted to be incontinent of bowel and bladder with chronic diarrhea. She had developed a stage 2 pressure ulcer on her coccyx measuring 0.5cm x 0.45cm x 0cm. A physician's order on the same date included the treatment orders to clean the wound with normal saline and pat dry. Apply Calmoseptine and cover with a border dressing twice a week and as needed (PRN) if soiled. The order was changed on 10/29/2025 to clean the wound with normal saline, pat dry, and apply sterile honey to the wound. Then cover with a Mepilex border foam dressing twice weekly and PRN if soiled. On 11/03/2025, the nurse noted the wound continued as a stage 2 and measured 1.6cm x 0.5cm x 0cm. During the Licensed Practical Nurse (LPN) visit on 11/24/2025, the patient had experienced an episode of diarrhea, and wound care was performed by facility staff. An order was documented the same day for the dressing to be changed twice daily and PRN if soiled. The HA plan of care dated 08/28/2025 included the interventions for the HA to perform at each visit: a partial sponge bath and perineal care. It was noted that the patient was at high risk for skin breakdown. The aide care plan was not updated on 10/24/2025 to give the aide specific instructions on what to do if the wound dressing fell off or got soiled during the aide visit. During a joint clinical record review and interview with the Area Executive of Clinical Operations (Personnel Record 2) on 03/31/2026, she confirmed that no instructions related to the patient’s wound care had been provided by the Registered Nurse (RN) to the Home Aide (HA). She further acknowledged that wound-related instructions should have been communicated to the HA to support appropriate care delivery.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the hospice Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 03/31/2026, revealed that the hospice did not meet the regulatory requirement that volunteer services account for at least five percent (5%) of the total patient care hours. Review of year-end data showed that volunteer hours averaged 3.03% in 2024 and 4.66% in 2025, both below the required threshold. Additionally, the year-to-date average for 2026 was 4.41%. During the interview, the Volunteer Coordinator acknowledged that the hospice had not consistently met the required 5% minimum. The agency further confirmed that this ongoing deficit led to the initiation and subsequent revision of a QAPI Performance Improvement Project (PIP), beginning in January 2025, to address volunteer recruitment and utilization. During a review of the hospice Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 03/31/2026, it was determined that the hospice did not meet the regulatory requirement that volunteer services account for at least five percent (5%) of the total patient care hours. Review of year-end data showed that volunteer hours averaged 3.03% in 2024 and 4.66% in 2025, both below the required threshold. Additionally, the year-to-date average for 2026 was 4.41%, confirming that the hospice had not achieved sustained compliance with the volunteer utilization requirement across multiple reporting periods. During the interview, the Volunteer Coordinator acknowledged that the hospice had not consistently met the required 5% minimum. The agency further confirmed that this ongoing deficit led to the initiation and subsequent revision of a QAPI Performance Improvement Project (PIP), beginning in January 2025, to address volunteer recruitment and utilization. Documentation reflected multiple volunteer recruitment efforts, including the posting of flyers, use of an online volunteer-matching platform, engagement with local assisted living facilities, and participation in marketing events and health fairs. Most recently, outreach to local colleges and universities resulted in 11 students expressing interest in volunteering, with 3 having completed the background check at the time of the survey. The agency also demonstrated volunteer-retention activities, including a monthly volunteer newsletter, volunteer appreciation luncheons, ongoing communication via phone calls and text messages, and recognition through birthday and holiday cards. Despite these recruitment and retention strategies, the hospice had not yet achieved or maintained volunteer service hours at or above the required 5% level.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of discharged patients, it was revealed that the agency did not ensure that the Discharge Summary was sent to the hospital upon the patient's discharge from hospice and admission to the hospital. CLINICAL RECORD 15: The patient elected the hospice benefit on 08/20/2025 and was discharged from services on 01/13/2026 due to admittance to the hospital. A Discharge-Transfer Summary Report dated 01/13/2026 included the required information on the patient's plan of care, latest orders, and medications, but contained no documentation that the discharge summary was provided to the hospital. The post-discharge Interdisciplinary Group Meeting on 01/20/2026 included "Pt discharged from hospice services on 01/13/2026 due to moving out of service area to hospital location. There was no documentation in the clinical record that the discharge summary was provided to the hospital upon the patient's discharge from hospice and hospital admission in the IDG, a Care Coordination note, or in scanned documentation. During a joint clinical record review and interview with the Area Executive of Clinical Operations (Personnel Record 2) on 04/01/2026, she confirmed that there was no documentation in the medical record indicating that the discharge summary had been provided to the hospital at the time of the patient’s hospital admission and discharge from hospice. She further confirmed that the discharge summary was faxed to the hospital on 04/01/2026, and the fax transmission confirmation was uploaded to the electronic medical record on that same date.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, and includes all services necessary for the palliation and management of the terminal illness. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure that the plan of cares included interventions and goals based on problems identified in the comprehensive assessments and all services necessary to meet the patient's needs. Clinical Record 2: The patient elected hospice care on 5/23/2023, with the primary hospice diagnosis of bladder cancer. The initial Registered Nurse assessment on 5/23/2023 documented that the patient’s blood sugars range from the 50s to the 200s, and staff monitored blood sugars and administered insulin as needed. The physician certification on 5/23/2023 documented that the patient had type 2 diabetes. The plan of care was reviewed for 5/23/2023-6/20/2023 and did not include documentation of interventions and goals for diabetes. Clinical Record 5: The patient elected hospice care on 1/18/2022, with the primary hospice diagnosis of atherosclerosis of the native coronary artery with unstable angina pectoris. The Registered Nurse assessment on 5/17/2023 documented a stage 2 wound to the right inner buttocks, treatment order was provided and collaborated with the facility regarding wound care and orders. The Registered Nurse assessment on 6/7/2023 documented a boil to the right gluteal covered this am with dressing. The Registered Nurse assessment on 6/13/2023 documented a boil to the left buttocks, and 0.3x0.7 dressing was applied. Additionally, on 5/24/2023, the physician ordered Cephalexin 500mg twice daily for seven days for boil. The plan of care was reviewed for 5/17/2023-6/20/2023 and did not include documentation of interventions and goals for the wounds. During the joint record review on 6/20/2023, the Area Director of Clinical Operations confirmed the plans of care did not include documented interventions and goals for diabetes and wounds. Record 2: The patient elected hospice care on 5/23/2023, with the primary hospice diagnosis of bladder cancer. The initial registered nurse assessment on 5/23/2023 documented that the patient’s blood sugars range from 50s-200s, staff monitoring blood sugars and administering insulin as needed. The physician certification on 5/23/2023 documented that the patient had type 2 diabetes. The plan of care was reviewed for 5/23/2023-6/20/2023 and did not include documentation of interventions and goals for the diabetes. Record 5: The patient elected hospice care on 1/18/2022, with the primary hospice diagnosis of atherosclerosis of native coronary artery with unstable angina pectoris. The registered nurse assessment on 5/17/2023 documented a stage 2 wound to right inner buttocks, treatment order provided, collaborated with facility regarding wound care and orders. The registered nurse assessment on 6/7/2023 documented a boil to right gluteal, covered this am with dressing. The registered nurse assessment on 6/13/2023 documented a boil to left buttocks, 0.3x0.7 dressing applied. Additionally, on 5/24/2023, the physician ordered, Cephalexin 500mg twice daily for 7 days for boil. The plan of care was reviewed for 5/17/2023-6/20/2023 and did not include documentation of interventions and goals for the wounds. During the joint record review on 6/20/2023, the area director of clinical operations confirmed, the plans of care did not include documented interventions and goals for the diabetes and wounds.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure that hospice aides were provided specific written instructions. Clinical Record 3: The patient elected hospice care on 5/19/2023 with a primary diagnosis of Cerebral Infarction. The aide care plan dated 5/19/2023 and 5/31/2023 assigned tasks to be completed every visit, “bathing bed” and “bathing shower.” The care plan did not provide specific instructions to the aide on whether to give a bed bath or shower bath. During the joint record review on 6/20/2023, the Area Director of Clinical Operations confirmed the aide care plan did not provide specific written instructions and needed to be updated. Record 3: The patient elected hospice care on 5/19/2023. The aide care plan dated 5/19/2023 and 5/31/2023 assigned tasks to be completed every visit, “bathing bed” and “bathing shower.” The care plan did not provide specific instruction to the aide on whether to provide a bed bath or shower bath. During the joint record review on 6/20/2023, the area director of clinical operations confirmed, the aide care plan did not provide specific written instructions and needed to be updated.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure the clinical record included physician orders for hospice treatments and services. Clinical Record 3: The patient elected hospice care on 5/19/2023. The Registered Nurse visit note dated 6/16/2023 documented, a skin tear right arm 1.5 x 1.5. The physician’s order dated 6/19/2023 documented pt skin tear from the cover causing the skin tear to be cleaned with dermal wound cleanser, apply and cover with dressing daily and prn if missing or compromised. The physician’s order did not include the location of the wound to be treated or the type of dressing to be applied. During the joint record review on 6/20/2023, the Area Director of Clinical Operations confirmed the order was incomplete. Record 3: The patient elected hospice care on 5/19/2023. The registered nurse visit note dated 6/16/2023 documented, skin tear right arm 1.5 x 1.5. The physician’s order dated 6/19/2023 documented, pt skin tear from hover causing skin tear clean with dermal wound cleanser, apply tao and cover with dressing daily and prn if missing or compromised. The physician’s order did not include the location of the wound to be treated or the type of dressing to be applied. During the joint record review on 6/20/2023, the area director of clinical operations confirmed the order was incomplete.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: actual or potential drug interactions. This standard was not met as evidenced by clinical record review, interview, and observation. 4 of 19 (21%) clinical record reviews, the hospice did not ensure that the comprehensive assessment included a complete review of the drug profile. Clinical Record 1: The patient elected hospice care on 9/24/2021. The Registered Nurse visit note dated 9/29/2021 documented "report redness in AB folds currently using nystatin powder and InterDry dressing PRN." The Licensed Practical Nurse (LPN) visit note dated 10/28/2021 documented, "Nystatin powder refills called into the family pharmacy." The Nystatin powder was not documented in the patient's medication profile. There was no evidence that Nystatin was reviewed as part of the comprehensive assessment. Clinical Record 10/Home Visit 1: The patient elected hospice care on 2/14/2022. During the home visit on 5/9/2023 with the Registered Nurse (RN) [Personnel Record 8], a medication review was completed comparing the hospice medication profile to the patient's medication bottles. The patient was alert and oriented and confirmed his current medications. The hospice medication profile dated 5/9/2023 documented three medications for constipation that were not found in the home, and the patient stated he was not taking them: Bisacodyl 5mg tablet, Milk of Magnesia 400mg/mL oral suspension, and Senna-S 8.6mg-50mg. The patient stated he was taking "Colace 100mg by mouth twice daily." Colace was not documented on the hospice medication profile. Additionally, the patient stated taking Vitamin D3 chewable gummy 50mcg by mouth daily, which was not documented on the hospice medication profile. The RN present for the visit confirmed an update of the hospice medication profile was required. There was no evidence that the Colace and Vitamin D3 were reviewed as part of the comprehensive assessment. Clinical Record 7/Home Visit 2: The patient elected hospice care on 10/25/2022 and resided in a nursing facility. During the home visit on 5/10/2023, a medication review comparing the hospice medication profile dated 5/9/2023 to the facility order summary (provided by the facility nurse) dated 5/10/2023. The facility order summary documented, "Dulcolax 5mg, take two tablets by mouth every 24 hours as needed for constipation," effective 2/20/2023. The hospice medication profile documented "Dulcolax 5 mg, one tablet daily as needed," effective 4/18/2023. The facility order summary documented "Moisture Eye Drops, instilled two drops in both eyes two times a day...Senna-S 8.6mg-50mg, given two tablets by mouth at bedtime for constipation." The hospice medication profile did not include documentation of the eyedrops and Senna. In addition, the hospice medication profile documented "Docusate Sodium 100mg, two capsules daily for constipation...Polytrim 10,000 unit-1mg/mL eye drops, one drop four times daily, were missing from the facility order summary. During an interview and a joint record review with the Administrator on 5/12/2023, the Administrator confirmed the findings and stated that the physician's order for the eye drops antibiotic was documented for seven days. The eye drops were documented as active on the hospice medication profile as of 5/10/2023. Clinical Record 19/Home Visit 4: The patient elected hospice care on 12/16/2021. During the home visit on 5/11/2023 with the Medical Social Worker (MSW) [Personnel Record 3], a medication review was completed comparing the hospice medication profile to the patient's medication bottles. The patient's wife was the primary caregiver and was knowledgeable of the patient's medication regimen. The wife stated the patient used Scopolamine transdermal patches, Fruits and Greens diet supplement pill, Instaflex for joint relief, Turmeric 1000mg, Fish Oil 200mg, and Prostagenix, a prostate supplement. The Scopolamine, Instaflex, and supplements were not documented on the hospice medication profile. There was no evidence that the medications were reviewed as part of the comprehensive assessment. In addition, the hospice medication profile documented Docusate Sodium 250mg and Trazodone 50mg, which the wife stated the patient did not take. After each day, a review of the home visits' findings was conducted with the Administrator and Director of Nursing, and they confirmed the medication profiles were inaccurate and needed to be updated.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 19 (21%) clinical records reviewed, the hospice did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 3: The patient elected hospice care on 4/7/2022. The Medical Social Worker (MSW) completed the bereavement risk assessment on 4/13/2022, six (6) days after the patient's election of hospice care. Clinical Record 9: The patient elected hospice care on 1/22/2023. The initial MSW comprehensive assessment was completed on 1/24/2023. The MSW completed the initial Bereavement Risk Assessment on 1/29/2023, seven (7) days after the patient's election of hospice care. Clinical Record 15: The patient elected hospice care on 12/20/2022. The initial MSW comprehensive assessment was completed on 12/23/2022. The MSW completed the initial Bereavement Risk Assessment on 12/27/2022, seven (7) days after the patient's election of hospice care. During an interview and a joint record review on 5/12/2023, the Administrator confirmed that the initial bereavement assessments were not completed within five days of the election of hospice care.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review, observation, and interview. 3 of 19 clinical records reviewed, the hospice did not ensure that the plan of care included interventions and goals based on problems identified in the comprehensive assessments and all services necessary to meet the patient's needs. Clinical Record 16/Home Visit 3: The patient elected hospice care on 3/9/2023, with the primary hospice diagnosis of rectal cancer. During the home visit with the RN [Personnel Record 7] on 5/11/2023, the patient reported changing the colostomy wafer and cleaning the ostomy site twice weekly. The plan of care did not include documentation of interventions and goals for colostomy care or ostomy site care. Clinical Record 4: The patient elected hospice care on 2/9/2022. The physician's CTI narrative dated 2/9/2022 documented that the patient had sleep apnea and used CPAP. The nurse practitioner's face-to-face encounter dated 7/13/2022 documented diminished breath sounds and CPAP at the bedside for the respiratory exam. The POC did not include documentation of interventions and goals for sleep apnea. Clinical Record 9: The patient elected hospice care on 1/21/2023. The POC dated 1/21/2023 ordered "Skilled Nurse for administering venous stasis ulcer care...Cleanse with NS...Cover with dry dressing using aseptic technique." The plan of care did not include documentation of the frequency of the wound treatment or the location of the wound to be treated. Additionally, on 3/29/2023, the physician ordered, "Cleanse with NS, pat dry, apply Medi honey to nonstick Telfa, and secure in place with a transparent dressing." The physician's order and update to the plan of care did not include documentation of the frequency of the wound treatment or the location of the wound to be treated. During an interview and a joint record review on 5/12/2023, the Administrator confirmed the wound treatment order was incomplete.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient. This standard was not met by evidence of clinical record review and observation. 4 of 19 (21%) clinical records reviewed, the hospice did not ensure that the plan of care (POC) included all drugs necessary to meet the patient's needs. Clinical Record 1: The patient elected hospice care on 9/24/2021. Medication was provided to the patient while on hospice services. The Registered Nurse visit note dated 9/29/2021 documented "report redness in AB folds currently using nystatin powder and InterDry dressing PRN." The Licensed Practical Nurse (LPN) visit note dated 10/28/2021 documented, "Nystatin powder refills called into the family pharmacy." The POC did not include documentation of the Nystatin powder. Clinical Record 10/Home Visit 1: The patient elected hospice care on 2/14/2022. During the home visit on 5/9/2023 with the Registered Nurse (RN) [Personnel Record 8], a medication review was completed comparing the hospice medication profile to the patient's medication bottles. The patient was alert and oriented and confirmed his current medications. The patient stated he was taking "Colace 100mg by mouth twice daily." Additionally, the patient stated taking Vitamin D3 chewable gummy 50mcg by mouth daily. The POC did not include documentation of the Colace and the Vitamin D3. Clinical Record 7/Home Visit 2: The patient elected hospice care on 10/25/2022 and resided in a nursing facility. During the home visit on 5/10/2023, a medication review comparing the hospice medication profile dated 5/9/2023 to the facility order summary (provided by the facility nurse) dated 5/10/2023. The facility order summary documented Senna-S 8.6mg-50mg, given two tablets by mouth at bedtime for constipation." The hospice plan of care did not include documentation of Senna. Clinical Record 19/Home Visit 4: The patient elected hospice care on 12/16/2021. During the home visit on 5/11/2023 with the Medical Social Worker (MSW) [Personnel Record 3], a medication review was completed comparing the hospice medication profile to the patient's medication bottles. The wife stated the patient used Scopolamine transdermal patches, Fruits and Greens diet supplement pill, Instaflex for joint relief, Turmeric 1000mg, Fish Oil 200mg, and Prostagenix, a prostate supplement. The POC did not include documentation of the Scopolamine, Instaflex, and supplements.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. 5 of 19 (26%) clinical records reviewed, the hospice plan of care (POC) did not include the medical supplies and appliances used by the patient for the palliation and management of the terminal illness. Clinical Record 7/Home Visit 2: The patient elected hospice care on 10/25/2022 and received hospice services at a nursing facility. The physician certification of terminal illness narrative dated 10/25/2022 and signed by the medical director on 11/8/2022 documented the patient was incontinent of bladder and bowel and had multiple wounds on her legs. The initial comprehensive assessment completed by the Registered Nurse (RN) on 10/25/2022 documented that the patient had a "high-back wheelchair, shower chair, hospital bed, and the facility requested XL briefs and wipes." During the home visit on 3/10/2023, the patient's use of the listed DME was observed. The plans of care dated 10/25/2022,1/23/2023, and 4/23/2023 documented DME (durable medical equipment) and Supplies as "None." The POC did not include documentation of the patient's DME and supplies provided by the hospice. Clinical Record 16/Home Visit 3: The patient elected hospice care on 3/9/2023 with a primary hospice diagnosis of rectal cancer. The initial comprehensive assessment completed by the RN on 3/9/2023 documented, "... is still able to care for her colostomy and wishes to as long as possible." During the home visit on 3/11/2023, the patient and the Registered Nurse present for the visit confirmed the hospice provided the patient's colostomy supplies. Additionally, the hospice provided a wheelchair cushion, a transfer bench with back, 5-liter oxygen concentrator, and portable E-tanks with a cylinder cart. The POC dated 3/9/2023 documented "DME-Support Services." The POC did not include documentation of the patient's DME and supplies provided by the hospice. Clinical Record 3: The patient elected hospice care on 4/7/2022. The initial comprehensive assessment completed by the RN on 4/7/2022 documented the patient "could no longer walk, used a rollator walker to assist with standing, sat on a pad, and was pushed around the house by the daughter." The RN visit note dated 4/8/2022 documented that the patient used pull-ups for incontinence. The POC dated 4/7/2022 documented "None" for DME and supplies. During an interview and a joint record review on 5/12/2023, the Administrator confirmed the hospice provided the 10-liter oxygen concentrator, hospital bed, bedside commode, gel mattress overlay, and wheelchair with footrests. Clinical Record 5: The patient elected hospice care on 9/21/2022. The initial comprehensive assessment completed by the RN on 9/21/2022 documented, "patient was using diapers for incontinence...Hoyer lift required for the past two months...primary caregiver looking to get a Geri chair...." The physician's order dated 10/3/2022 documented, "Patient has bed frame from the VA which is now his own...Rented low air loss mattress." The POC dated 9/21/2022 documented "None'' for DME and Supplies. During an interview and a joint record review on 5/12/2023, the Administrator confirmed the hospice provided the low-air loss mattress and personal alarm. Clinical Record 18: The patient elected hospice care on 4/14/2023. The initial comprehensive assessment completed by the RN on 4/14/2023 documented the patient "uses an electric wheelchair." The POC dated 4/14/2023 documented "None" for DME and supplies. During an interview and a joint record review on 5/12/2023, the Administrator confirmed the hospice provided a "ROHO" wheelchair cushion, nebulizer setup, and oxygen concentrator.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CONDITION-LEVEL DEFICIENCY. This CONDITION of participation was not met, as evidenced by clinical record review, personnel record review, observation, and interview, which revealed the agency failed to ensure written patient care instructions for the hospice aide [HCDT.15.I/L625]; failed to ensure that hospice aides followed the established aide plan of care [HCDT.16.I/L626]; and failed to ensure that hospice aides completed a competency assessment prior to providing patient care [HSRM.9.I/L615]. The cumulative effect of this issue has resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76: Hospice aide and homemaker services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by document review, interview, and personnel record review. The agency document titled "Home Health/Hospice Aide Competency Evaluation: Basic Skills Test" (effective date of 8/1/2021) read in part, "The registered nurse must observe the aide perform all tasks listed below while providing care to a patient or pseudo-patient as part of a simulation...Enter the date the aide satisfactorily completed the task...Sign each task observed..." 1 of 1 (100%) personnel record reviewed of a hospice aide, the hospice did not ensure that a competency assessment was completed upon hire. Personnel Record 9: The hospice aide was hired on 10/25/2022. The Registered Nurse and hospice aide signed the document "Home Health/Hospice Aide Competency Evaluation: Basic Skills Test" on 11/4/2022 after the statement, "The aide must successfully complete all above tasks to pass the Basic Skills Test. The following tasks were blank on the agency form: "(2) Bathing: (B) Sponge bath and (C) Tub/Shower, (4) Nail Care: (A) File; (6) Oral Care: (B) Natural Teeth, (8) Safe Transfer Technique: (A) Patient-observe transfer technique and use of safety measures by the aide." The agency form titled "Hospice Aide Skills Checklist" was also incomplete, and several skills and instructions were blank under the column documenting satisfactorily performed items. The RN signed the incomplete form on 11/4/2022. There was no documented evidence that that hospice aide successfully completed a competency evaluation upon hire. During an interview and a joint review of the personnel record on 5/11/2023, the Administrator and Director of Nursing confirmed the aide's competency was not completed.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. 5 of 17 (29%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure that hospice aides were provided specific written instructions. Clinical Record 7/Home Visit 2: The patient elected hospice care on 10/25/2022 and resided in a long-term care nursing facility. The Aide Care Plan dated 10/25/2022 assigned the task to be completed every visit "shower bath." The home visit on 5/10/2023 with the hospice aide revealed the patient received a tub bath or "whirlpool" in the facility's shower room. The hospice aide utilized a sit-to-stand Hoyer-type device to transfer the patient from the wheelchair to the whirlpool transport chair. The Aide Care Plan did not include the tub bath and transfer instructions. During an interview, the Administrator and Director of Nursing confirmed that the aide care plan had the incorrect bath type. Clinical Record 3: The patient elected hospice care on 4/7/2022. The hospice Registered Nurse (RN) visit notes dated 7/22/2022, 7/25/2022, and 7/27/2022 documented that the patient was bedbound. The RN visit note dated 8/9/2022 documented a "bedbound patient, PPS 20, and nonresponsive." The patient continued to decline and died on 8/11/2022. The Aide Care Plan, dated 4/7/2022 and updated on 7/27/2022, assigned the aide the tasks to be completed every visit: "shower, assistance to the toilet, turning, and position in bed." The bath type was not changed on the Aide Care Plan to reflect the patient's change in status. During an interview, the Administrator and Director of Nursing confirmed that the Aide Care Plan was inaccurate and should have been updated to reflect the change in the patient's condition. Clinical Record 4: The patient elected hospice care on 2/9/2022. The patient received hospice aide services twice weekly. The hospice aide care plan dated 2/9/2022 assigned the aide the task: shower every visit. The RN visit note dated 7/7/2022 documented the patient was bedbound with a Foley catheter. The Aide Care Plan was not updated to include a different bath type and Foley catheter care due to the patient's change in status. Clinical Record 5: The patient elected hospice care on 9/21/2022. The hospice aide care plan dated 10/24/2022 assigned the aide the task: "partial sponge bath" to be completed every visit. The type of bath did not provide specific instruction to the aide if the sponge bath was in the shower, chair, or bed. The RN visit note dated 10/24/2022 documented the patient's mobility status as "bedbound and total care with all ADLs." During the joint record review on 5/12/2023, the Administrator confirmed the Aide Care Plan needed to state "bed bath." Clinical Record 19/Home Visit 4: The patient elected hospice care on 12/16/2021. The patient received hospice aide services twice weekly and was dependent on supplemental oxygen. The aide care plan dated 12/16/2021 assigned the aide the tasks: stand-by assistance with ambulation, assistance with toilet, tub bath, shampoo, hair care, skincare, perineal care, oral care, dressing (clothing) and position for comfort, all tasks to be completed every visit. The Aide Care Plan did not include details or instructions addressing the patient's use of oxygen during care. During the home visit on 5/11/2023, the patient and spouse were interviewed and stated the hospice aide began bathing the patient in the recliner, then transfers the patient to the hospital bed right next to the recliner to finish the bath. The spouse stated the patient had multiple falls due to weakness and shortness of breath and could not take a tub bath. The Aide Care Plan dated 12/16/2021 assigned task: tub bath was incorrect. In addition, the Aide Care Plan did not include safety precautions for falls or oxygen. During the interview with the Administrator and the Director of Nursing confirmed the aide care plan's bath type was inaccurate and needed to be updated.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, interview, and observation. 1 of 1 (100%) home visit observations with a hospice aide, the hospice did not ensure that the hospice aide provided services included in the plan of care. Home Visit 2/Clinical Record 7: The patient elected hospice care on 10/25/2022 and received hospice services in a long-term care nursing facility. During the home visit on 5/10/2023 with the hospice aide [Personnel Record 9], the hospice aide stated that nail care is performed for the patient by trimming, filing, cleaning, and sometimes nail polish once a week on Mondays. The hospice aide care plan dated 10/25/2022 did not include the assigned task of nail care.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. 3 of 19 (16%) clinical records reviewed, the hospice did not ensure the clinical record included physician orders for hospice treatments and services. Clinical Record 1: The patient elected hospice care on 9/24/2021. The Registered Nurse (RN) visit note dated 9/29/2021 documented "report redness in AB folds currently using nystatin powder and Interdry dressing PRN." The Licensed Practical Nurse (LPN) visit note dated 10/28/2021 documented, "Nystatin powder refills called into family pharmacy." The Nystatin powder was missing from the patient's medication profile, and no physician order was found in the clinical record. During the joint record review on 5/12/2023, the Administrator confirmed that the physician's order was missing. Clinical Record 5: The patient elected hospice care on 9/21/2022. The physician order dated 10/19/2022 documented, "Clean with soap and water, pat dry, apply barrier cream to the area, apply sacral dressing." The physician's order did not include documentation of the frequency of treatment or the type of sacral dressing to be applied. During the joint record review on 5/12/2023, the Administrator confirmed the physician's order was incomplete. Clinical Record 14: The patient elected hospice care on 8/15/2022. The RN visit note dated 9/21/2022 documented the patient had been in a motor vehicle accident the previous day and suffered a burn to her neck due to the airbag's deployment. The patient also sustained multiple bruises to the right foot and rib fractures near the sternum. The physician's order dated 9/21/2022 documented, "Clean with soap and water, apply Desitin cream daily." The physician's order did not include the location of the wound to be treated treatment. During the joint record review on 5/12/2023, the Administrator confirmed the order was incomplete.

It is required that If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward to the receiving facility, a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) record reviewed where the patient was discharged from hospice services and transferred to a local hospital revealed the agency did not forward a copy of the discharge summary for the patient's continuity of care. Clinical Record 2: The patient elected hospice care on 4/19/2022 and transferred to a non-contracted hospital facility on 10/17/2022. A clinical record review revealed no evidence that the discharge summary was sent to the hospital. During an interview and a joint record review on 5/10/2023, the Administrator confirmed the finding.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. 2 of 3 (67%) clinical records reviewed of patients that received hospice services at a nursing facility, the written plan of care was missing the delineation of responsibilities of the hospice and the facility. Clinical Record 7Home Visit 2: The patient elected hospice care on 10/25/2022 and received hospice services at a nursing facility. During the home visit with the hospice aide on 5/10/2023, a review of the facility binder revealed that the form "Hospice and Facility Coordinated Plan of Care" dated 11/7/2022 and signed by hospice and facility on 11/7/2022, 12/8/22, and 1/4/2023 included no documentation of care plan interventions, the section labeled "DME and Medical Supplies" section was blank. The hospice plan of care dated 10/25/2022 included no documented evidence of coordination with the facility or delineation of responsibilities in the patient's identified care. Clinical Record 8: The patient elected hospice care on 5/8/2023 and received hospice services at a nursing facility. The form "Hospice and Facility Coordinated Plan of Care," dated and signed by the Registered Nurse (RN) on 5/8/2023, was incomplete and included sections that were missing information (blank). The initial comprehensive assessment completed by the RN on 5/8/2023 documented that the patient had a fungating breast wound and was currently performing her care and cleaning during the shower. The hospice plan of care dated 5/8/2023 included no documented evidence of coordination with the facility or delineation of responsibilities in the patient's identified care. During an interview and a joint record review on 5/12/2023, the Administrator confirmed that the delineation of responsibilities of the hospice and the facility was missing from the clinical record.