Every finding on record at Community Hospices of America, LLC

Based on policy review, record review, and interview, the hospice failed to ensure physician authorization and oversight for invasive nursing interventions; failed to appropriately assess, coordinate, and report a Foley catheter (a sterile tube placed in the bladder to drain urine) related complication; failed to ensure interdisciplinary and supervisory awareness of significant clinical changes; and failed to ensure follow-up and availability of ordered medication in one of three patient records reviewed (Record/Patient #1). The cumulative effect of these failures resulted in the hospice’s inability to consistently ensure safe and effective provision of core nursing services. --- Findings included: Review of the provider’s policy titled “Core Services,” revised 01/22/2026, showed in part:- Hospice must ensure nursing services are provided by qualified personnel;- Hospice is responsible for ensuring services meet patient needs;- Supervisory staff must be available to provide oversight; and- Hospice retains responsibility for management and coordination of care. Review of the provider’s policy titled, “Nursing Services,” revised 12/09/2025, showed in part, nursing services must be provided in accordance with physician orders, accepted standards of practice, and with appropriate documentation and supervision. Review of the provider’s policy titled, “Indwelling Urinary Catheter (Foley) Care and Management,” reviewed 12/15/2025, showed in part:- Physician direction for catheter use;- Ongoing assessment and monitoring for complications;- Documentation of care and clinical findings;- Removal of catheter when clinically indicated; and- Compliance with infection prevention practices.  Review of the provider’s policy titled, “Patient Adverse Event Reporting,” revised 10/20/2020, showed in part:- Adverse event defined as deviation from normal expected outcome;- Events must be assessed and reported within 24 hours;- Physician and IDT (interdisciplinary team) notification required as indicated;- Events tracked and reviewed through QAPI (Quality Assurance and Performance Improvement); and- Written report required for documentation and trending.  Review of the provider’s policy titled, “Management and Staff Training,” revised 01/20/2022, showed in part:- Direct care staff must receive competency evaluation;- Competency must be discipline-specific;- Competency validation occurs during onboarding and periodically thereafter; and- The provider was responsible for evaluating proficiency in completion of specific skills.  Review of the provider’s policy titled, “Medication Reconciliation and Management,” revised 10/28/2025, showed in part:- Medication reconciliation required at admission and with changes;- Ensure ordered medications are available in the home;- Confirm refills and delivery of medications;- Provide patient and caregiver education; and- Document effectiveness and follow-up.  RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice care on 12/31/2025 with a terminal diagnosis of end stage renal disease (ESRD, a permanent condition in which the kidneys no longer function adequately to sustain life without dialysis or transplant). The record showed dialysis (treatment for kidney failure) was discontinued two days prior to hospice admission. The record showed generalized edema (swelling of the tissues). The patient resided at home with family members. Review of registered nurse (RN) - C’s patient information note dated 01/07/2026 at 2:02 PM, showed an urgent call was received reporting seizure activity. The caregiver was instructed to administer lorazepam (anti-anxiety medication used to treat seizures) 2 mg. Upon arrival, the patient had intermittent arm spasms, was incontinent of bowel and bladder, and had 4+ edema (a clinical classification of fluid retention) in all extremities with significant edema to the scrotum and penis, with edema documented as “moving further up.” The record failed to show physician notification or interdisciplinary group (IDG) coordination following this significant clinical change.  The record failed to show documentation of reassessment or an updated plan of care following the documented seizure activity or worsening edema. Review of RN C’s visit note dated 01/08/2026 at 5:03 PM, showed an 18 French catheter (a larger sized urinary tube used to drain urine from the bladder) was inserted with no urine return and the balloon (a small part at the end of the catheter that is filled with sterile water to keep the catheter in place) would not inflate. RN C documented inability to remove the Foley catheter due to suspected bladder spasms and administered lorazepam 2 mg. RN C, a PRN (as needed) nurse who worked across branches, documented intent to return in 30–45 minutes following unsuccessful catheter insertion. The clinical record failed to reflect a physician order authorizing Foley catheter insertion prior to RN C’s attempt. The clinical record failed to reflect notification of the assigned patient care manager, the patient’s parent branch supervisory staff, or documented physician consultation prior to leaving the patient with an unresolved complication. Review of a physician order dated 01/08/2026 at 6:56 PM, showed an emergency PRN visit for Foley catheter needs, signed by RN coordinator B. The timing indicated the order was obtained after RN C’s insertion attempt. Review of RN coordinator B’s visit note dated 01/08/2026 at 7:11 PM, showed a PRN visit and orders to place the Foley catheter. RN coordinator B attempted placement of the Foley catheter with no urine return. The record failed to reflect physician notification that the initial insertion attempt was unsuccessful prior to the second attempt and failed to include documentation that the complication was reported as an adverse clinical event. While competency documentation was present in personnel files, the record failed to reflect procedure-specific validation related to Foley catheter insertion or documented review following the unsuccessful attempts described above. Review of a physician order dated 01/08/2026 at 8:35 PM showed morphine concentrate was ordered every two hours, as needed. During an interview on 02/17/2026 at 12:49 PM, RN coordinator A stated that RN C performed the 01/08/2026 visit and attempted Foley catheter insertion. RN coordinator B assisted. RN coordinator A stated that he/she was not aware of the Foley catheter complication until the chart was audited. He/she further stated that morphine was not followed up after being called in by the physician and was not delivered prior to revocation. During an interview on 02/17/2026 at 1:38 PM, case manager D stated that he/she was not present during the Foley catheter attempt and was not directly notified of the complication. He/she stated that staff were expected to call the physician with each catheter insertion attempt.  He/she further stated that he/she would not leave a patient with a Foley catheter in place if there were complications or if he/she was unable to remove it. During an interview on 02/18/2026 at 11:41 AM, RN coordinator B stated that RN C informed him/her that he/she had inserted a Foley catheter without urine return and that it was stuck. RN coordinator B attempted placement but did not receive urine return. He/she stated that there were no additional physician orders addressing reinsertion following complication or removal of a non-functioning catheter. During an interview on 02/18/2026 at 11:57 AM, RN C stated that he/she attempted Foley catheter insertion due to urinary incontinence and agitation. He/she stated that he/she did not receive urine return and believed bladder spasms were the cause. He/she administered lorazepam for agitation and possible bladder spasm relief and did not recall a specific order for lorazepam related to bladder spasms. During an interview on 02/18/2026 at 12:39 PM, the administrator stated that Foley catheter insertion was considered a basic nursing skill and competency validation may include verbal explanation rather than demonstration. The administrator stated that he/she was unsure whether the Foley catheter complication qualified as an incident.

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 and interview. In 2 of 17 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide care plan included all written patient care instructions. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/11/2025 with a diagnosis of malignant neoplasm of the lung. The patient resided in a long-term care facility (LTC). On 08/18/2025, the physician ordered wound care with a dressing for a stage 2 pressure ulcer wound to the patient's coccyx. The plan of care dated 08/11/2025 through 11/08/2025 ordered "HHA 2x/week." The HA care plan dated 08/11/2025 assigned the HA the relevant task: "Bed bath every visit." The HA care plan was not updated to document instructions for the HA related to the wound dressing on the patient's coccyx, should it become wet or dislodged during the bed bath. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/24/2025 with a diagnosis of unspecified protein-calorie malnutrition. The patient resided in a long-term care facility (LTC). On 09/24/2025, the physician ordered wound care with a dressing for a wound to the patient's right lateral ankle. The plan of care dated 09/24/2025 through 11/22/2025 ordered "HHA 2x/week." The HA care plan dated 09/24/2025 assigned the HA the relevant task: "shower every visit." The HA care plan did not document instructions for the HA related to the wound dressing on the patient's right lateral ankle, should it become wet or dislodged during the shower. During a joint record review on 10/30/2025, the Area Executive of Clinical Operations confirmed that the wound dressing instructions were not included in the Hospice Aide care plan.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to identify a system of medical documentation that secures and maintains the availability of patient records in case of an emergent event. This failure had the potential to affect 64 of 64 residents receiving care from the agency. Findings include: Review of the agency's EPP, last reviewed by the Governing Body on 03/12/24, with the Business Office Manager (BOM), revealed no policy or procedure that identified the system of medical documentation that preserves resident information; provides for the confidentiality of resident information; and secures, maintains, the availability of resident records in the case of an emergent event. During an interview 02/05/25 at 8:45 AM, the BOM confirmed the EPP does not identify the medical record documentation system.

Based on interview and review of the facility's Emergency Operations Plan (EPP), the facility failed to ensure the EPP policies addressed the use of federal and/or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect 64 of 64 patients receiving care from the facility. Findings include: Review of the facility's EPP, last reviewed by the Governing Body on 03/12/24, with the Business Office Manager (BOM) revealed no policy regarding the use of State and/or Federal healthcare professional volunteers in an emergency as a staffing strategy. Review of page 11 of 45 of the facility's EPP showed:"K. Volunteers (i.e. individuals who volunteer to help you, not your hospice volunteers)i. The program should identify the activities or tasks volunteers can perform during an emergency.1. Task: Supply Runs2. Task: Phone Calls3. Task: Sit with Patientii. Before suspending service to patients, seek guidance from the home office, seek volunteers from local program partners or determine if accessing the state's volunteer database is possible for delivery of services or administrative support." During an interview on 02/05/25 at 8:48 AM, the BOM stated, "I'm not sure we address use of state and federal designated healthcare volunteers."

Based on interview and a review of the facility's Emergency Preparedness Plan (EPP), the facility failed to include the role of the facility if a waiver was declared in accordance with section 1135 of the Social Security Act. This failure had the potential to affect 64 of 64 patients receiving care and services from the organization and hindered the organization's ability to provide care and services and keep patients safe during an emergency. Findings include: Review of the facility's EPP Communication Plan, last reviewed by the Governing Body on 03/12/24, with Business Office Manager (BOM) did not reveal any policy or procedure regarding the role of the facility if the Health and Human Services Secretary should declare a section 1135 waiver. During an interview on 02/05/25 at 8:56 AM, the BOM confirmed the facility role under an 1135 waiver was "not in there [EPP]."

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the Hospice failed to maintain a current list of names and contact information in the "Emergency Preparedness Communication Plan" that included all patients' physicians. This failure had the potential to affect 64 of 64 patients receiving care from the organization and could delay the facility's ability to respond to an emergency. Findings include: Review of the facility's EPP Communication Plan, last reviewed by the Governing Body on 03/12/24, with the Business Office Manager (BOM) revealed no inclusion of a list of patient physicians and their contact information. In an interview on 02/05/25 at 8:59 AM, the BOM confirmed no patient physician names or contact information was contained in the communications plan.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP communication plan addressed the means of communicating with the federal and state emergency management agencies. This failure had the potential to affect 64 of 64 patients receiving care from the facility and hinder the facility's ability to respond to any potential emergency situations. Findings include: Review of the facility's EPP Communications Plan, last reviewed by the Governing Body on 03/12/24, with the facility Business Office Manager revealed an identified alternate form of communication identified in the EPP was an analog phone for use with a land phone line on page 11. In an interview on 02/04/25 at 9:10 AM, the BOM stated, "There is no landline non-electric phone in the facility." During a follow-up interview on 02/04/25 at 10:17 AM, the Administrator confirmed there was no analog phone in the facility for use with the telephone land line.

Based on interview, record review, and policy review, the Hospice agency failed to ensure that the plan of care was reviewed and updated for three of 19 patients (Patients (P) 6, P9, and P16) whose records were reviewed. This failure had the potential to affect the care provided to the patients. Findings include: 1. Review of P6's "Patient Information Report," provided by the facility revealed P6 was admitted to hospice services on 12/27/23 with diagnoses that included protein calorie malnutrition, senile degeneration of the brain, and chronic obstructive pulmonary disease (COPD). Review of P6's "Plan of Care Update Report," provided by the facility and dated 05/02/24, revealed, ". . . Review of P6's "Plan of Care Update Report," dated 12/27/23, revealed, ". . . Caregiver(s) verbalize understanding of lack of appetite and/or dehydration in the dying patient and express comfort with the natural course of the disease process within next 4 visits . . ." Review of P6's "Plan of Care Update Report," dated 05/02/24, revealed, ". . . Patient/Caregiver will demonstrate independence in administration of ordered inhalation therapy and care for equipment as a result of skilled teaching." The intervention was, " SN [Skilled Nursing] – instruct patient caregiver in administration of inhalation therapy including equipment care." Review of P6's "Plan of Care Update Report" revealed no documented evidence that the instruction on inhalation therapy was successful or that P6 demonstrated independence with inhalation therapy. There was no documented evidence that the caregiver's understanding of P6's appetite/dehydration status was achieved within four visits. 2. Review of P9's "Patient Information Report," provided by the facility, revealed P9 was admitted to hospice services on 03/08/24 diagnoses that included cancer of the face, head, neck, lungs, and lymph system, and stage four chronic kidney disease. Review of P9's "Comprehensive Care Plan Report," provided by the facility, revealed a goal of "Personal business problems will be resolved as evidenced by obtaining in-home caregivers and a life alert system." Another goal, dated 05/08/24, was, "Patient/caregiver will demonstrate independence in administration of ordered inhalation therapy and care for equipment as a result of skilled teaching." Another goal, dated 05/08/24, was "Patient/caregiver will verbalize understanding of safe and effective use of oxygen." Review of P9's "Comprehensive Care Plan Report" revealed no documented evidence that the life alert system, inhalation therapy/equipment teaching, or verbalization of safe use of oxygen had been provided or received. 3. Review of P16's "Patient Information Report," provided by the facility, revealed P16 was admitted to hospice services on 04/18/22 with diagnoses that included senile degeneration of the brain and vascular dementia. During a site visit on 02/03/25 at 3:40 PM, Licensed Practical Nurse (LPN) 1 stated that the wound on P16's right shin was healed and the dressing was a protective covering because he/she crossed his/her legs. Review of P16's "Plan of Care Update Report," dated 02/29/24, revealed, ". . . Patient/Caregiver(s) demonstrates proper care for decubitus wound and verbalize/demonstrate preventative measures to include pressure relief, nutrition, skin care, and S/S [signs/symptoms] to report to Hospice as evidenced by teach back by visit number [no number was included]." The intervention was, "SN – Instruct patient/caregiver(s) on symptoms to report including changes in wound size, odor, drainage and/or pain." Review of P16's "Plan of Care Update Report" revealed no documented evidence the plan of care was updated to include healing of the wound. During an interview on 02/05/25 at 3:30 PM, the Administrator confirmed the care plans should have been updated. Review of the facility's policy titled, "Written Interdisciplinary Plan of Care," reviewed 12/24/24, revealed, ". . . The hospice IDG [Interdisciplinary Group], in collaboration with the hospice physician and the patient's attending physician (if the patient has one), reviews and updates the plan of care at least every 15 days or more often as needed as dictated by the patient's condition and this review is documented . . ."

Based on interview, record review, and policy review, the Hospice agency failed to ensure that the plan of care contained measurable goals for two of 19 patients (Patients (P) 6 and P9) whose records were reviewed. This failure had the potential to affect the patient's receipt of necessary care and determination if care plan goals have been met or if a plan of care revision was required. Findings include: 1. Review of P6's "Patient Information Report," provided by the facility, revealed P6 was admitted to hospice services on 12/27/23 with diagnoses that included protein calorie malnutrition, senile degeneration of the brain, and chronic obstructive pulmonary disease (COPD). Review of P6's "Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report," provided by the facility and dated 05/02/24, revealed a problem of " Patients [sic] dyspnea/shortness of breath will be within a desired range of comfort as stated by the patient." The intervention was, "SN [Skilled Nursing] – monitor dyspnea/shortness of breath using the appropriate scale of 1-10." The plan of care did not identify a goal of what P6 found acceptable to ensure the goal was being met. Another problem was recorded as "Patient will have an effective bowel program as evidenced medications [sic] ordered for scheduled or PRN [as needed] use. The intervention was, "SN – Instruct bowel protocol as needed." The plan of care did not identify what was anormal bowel routine for P6 to ensure the goal the bowel program was effective. 2. Review of P9's "Patient Information Report," provided by the facility, revealed P9 was admitted to hospice services on 03/08/24 with diagnoses that included cancer of the face, head, neck, lungs, and lymph system, and stage four chronic kidney disease. Review of P9's "Comprehensive Care Plan Report," provided by the facility and dated 03/18/24, revealed a problem of " Sensory/neurological changes are identified promptly and interventions initiated quickly to minimize associated uncomfortable symptoms." The plan of care did not identify a baseline sensory/neurological status to ensure all providers knew what might constitute a change. Another problem was recorded as, "Skin integrity will be assessed, potential skin issues addressed and measures to prevent breakdown implemented promptly as evidenced by assessment of skin breakdown on each visit." The plan of care did not provide a baseline of skin status to ensure changes could be assessed. During an interview on 02/05/25 at 3:20 PM, the Administrator stated that the agency had identified a concern related to care plan goals being unmeasurable. The Administrator stated a Quality Assurance Performance Improvement Project (PIP) was initiated on 01/02/25, and training had been provided to staff on 01/10/25 and 01/15/25. The Administrator stated it was a work in progress. Review of the facility's policy titled, "Written Interdisciplinary Plan of Care," reviewed 12/24/24, revealed, ". . . The content of the plan includes at minimum . . . Measurable goals and outcomes for planned interventions . . ."

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of clinical records, document review and interview. In 4 of 14 (29%) records, the agency did not ensure full updates were documented at the interdisciplinary meeting for effective coordination of the patients' plans of care. Agency Policy C-09E "Interdisciplinary Team Meeting" [revision date 5/7/2020] states in part, "A summary of the discussion for each patient is documented; the summary includes discussion points, changes in the plan of care, updates to visit frequency, and changes in interventions for the patient for comfort safety and quality of life. The RN reviews findings and recommendations with patient attending physician, the hospice physician, the patient and/or their representative/caregiver if appropriate, the facility team caring for the patient, and any other member of the hospice IDG team for whom the immediate patient/family care needs require intervention." Clinical Record 2: The patient was admitted on 09/13/2022 with a monthly chaplain visit, during which sharing and prayer were provided. The interdisciplinary team (IDT) meetings on 12/02/2022 and 12/16/2022 documentation from the chaplain stated: "No spiritual/religious needs noted. Continue 1 x month visits." The plan for chaplain included goals for a sense of life meaning, sacraments of faith and patient would express security, peacefulness and forgiveness, however, no updates were documented for the care the chaplain provided so that care could be coordinated. Clinical Record 3: The patient was admitted on 11/01/2022. Nursing documented, for the IDT meeting on 12/2/2022, that a muscle relaxer was requested. The IDT meeting notes dated 12/16/2022 documented "continue to see wound care for weeping legs" but was not updated specifically to the status of the legs with individualized interventions or goals. Nursing visit notes documented that the patient's legs were wrapped with Coban (a compression wrap), which was a change, on 12/13/2022. Additionally documented on the 12/16/2022 IDT meeting notes, was muscle relaxer requested. As of the date of review, 12/20/2022, no documentation was evident in the record of a muscle relaxer order, or an update to the medication record, or interventions, or reasons why this was not provided. Clinical Record 5: The patient was admitted 11/2/2022 with diagnoses of HTN (hypertension), Malnutrition, Dementia, and lives in an assisted living residence. The IDT meeting notes dated 11/18/2022 documented a stage 2 left heel ulcer; there were no interventions or goals documented specific to the care of the pressure ulcer. On 11/17/2022, a nursing visit note documented a bandage on the patient's left lower extremity. The nursing visit note dated 12/16/2022 documented that heel protectors were used. On 11/7/2022 Cipro [an antibiotic] was started for a urinary tract infection (UTI). The IDT meeting note dated 11/18/2022 documented no update related to the UTI and no specific intervention or goals updated as of the date of review, 12/20/2022 for the stage 2 heel care or the bandage to the left lower leg. The IDT meeting notes dated 12/2/2022 and 12/16/2022 documented continued stage 2 ulcer on heels bilaterally but there was no update of the status or if the heel protectors helped or were used consistently. Clinical Record 13: The patient was admitted on 11/01/2021 with Senile Dementia, and Diabetes. On 9/15/2022, a Foley catheter was placed and has been in place since with monthly catheter changes. There are no interventions or goals documented for the Foley catheter management, as of the date of review, 12/21/2022. Additionally, the nursing visit documented, on 12/15/2022, that "lime green" was noted around the catheter; the IDT meeting note dated 12/16/2022 did not document this update. The physician had been notified during the visit, but the IDT meeting note does not update any further plan related to this. The Director of Clinical Services, on interview, stated that the plans were not correctly updated during meetings in order to be sure all coordination was documented.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure all interventions and goals were included on the initial plans of care or updated plans of care based on the ongoing assessments. Agency Policy C-09A "Individualized Plan of Care" [revision date 01/20/2020] states in part, "Updates to the plan of care are based on information gathered in the course of the comprehensive and ongoing assessments of the patient and family/caregiver. The updated Plan of Care is a collaborative document which provides a guide to the members of the IDG team for the delivery of care and services which will achieve the patients' goals." Clinical Record 1: The patient was admitted on 10/28/2022 with COPD and Diabetes Mellitus. He was oxygen-dependent and had pain that elevated to a 10, though he was resistant to medication recommendations. His power of attorney reported that he has pushed people away and did not want a caregiver. On 10/30/2022, an extra nursing visit was made to assist with toileting; on 11/1/2022 an extra nursing visit was made as his oxygen was not working. On 11/14/2022 oxycodone was increased as the patient's pain level was increasing. The patient declined continued Social Work or Chaplain services. The Interdisciplinary team (IDT) met on 11/4/2022, 11/18/2022, 12/2/2022, and 12/16/2022. None of the IDT notes are updated to include interventions and goals from the updated assessments regarding the patient's coping or lack of coping, and/or strategies to deal with these behaviors. Clinical Record 3: The patient was admitted on 11/1/2022 with Hepatic Failure and Congestive Heart Failure. The Certificate of Terminal Illness documented by the physician and the updated comprehensive assessment documented that patient had "weeping" legs. The initial plan of care and updated plans of care did not document interventions or goals related to the legs. A nursing visit note on 11/16/2022 documented that the patient's legs were wrapped. A nursing visit note on 12/13/2022 documented that Coban (a compression wrap) was used to wrap the patient's bilateral lower legs. The plan of care had not been updated as of the date of review, 12/20/2022, for interventions or goals specific to the patient's lower legs. The goals that were documented on the initial plan of care and updated plans of care were to "Identify integumentary changes and to verbalize use of durable medical equipment" only. Clinical Record 4: The patient was admitted 12/7/2022 with Alzheimer's, Dementia, and pulmonary disease. The comprehensive assessment documented a fall the previous month that required stitches. The initial plan of care dated 12/07/2022 did not document any individualized interventions or goals related to falls. The patient fell again on 12/16/2022 and 12/18/2022; there were 6 falls documented since June 2022. None of the updated plans of care included interventions or goals related to fall prevention. Clinical Record 5: The patient was admitted 11/2/2022 with diagnoses Hypertension, Malnutrition, and Dementia. The patient lived in an assisted living facility. IDT notes dated 11/18/2022, documented a stage 2 left heel ulcer. No updated interventions or goals were documented specific to the care of the heel ulcer. A nursing visit note on 12/16/2022 documented heel protectors were used bilaterally. On 11/07/2022 Cipro (antibiotic) was started for a urinary tract infection. The IDT meeting on 11/18/2022 documented no update related to the patient's urinary tract infection. There were no specific interventions or goals updated as of the date of review, 12/20/2022, for the stage 2 heel ulcer care. The IDT meeting notes dated 12/2/2022 and 12/16/2022 documented continued stage 2 ulcer on heels bilaterally but no update of the status or if the heel protectors helped. Clinical Record 13: The patient was admitted 11/1/2021 with Senile Dementia, COPD, DM. On 9/15/2022, a Foley catheter was placed and has been in place since that date, with monthly catheter changes. No updated interventions or goals are documented for the foley catheter management, as of the date of review, 12/21/2022. Additionally, a nursing visit note on 12/15/2022 documented "lime green noted around catheter"; the IDT meeting note dated 12/16/2022 did not document this update. The physician had been notified during the home visit, but the IDT note did not evidence any further plan related to this. The Director of Clinical Services, on interview, stated that all interventions and goals were not on the plans of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as Hand hygiene. This standard was not met as evidenced by observation on home visits and document reviews. In 1 of 3 (33%) observations during home visits, the nurse did not follow agency policy for hand hygiene during patient care. Agency Policy C 11 "Bag Technique" [revision date 4/22/2020] states in part, "Hand Hygiene with hand gels: before direct patient contact and after direct patient contact. After contact with inanimate objects in the patient's environment." Home Visit 1: Observed visit 12/21/2022 at 11:00 am with RN at a facility. Hand hygiene was performed after room entry and the equipment bag was placed on a barrier; hand hygiene was performed again. Supplies were removed from the equipment bag, and blood pressure and pulse ox were completed. A computer device was lifted by the RN, and data entry was performed (no hand sanitization). Then a stethoscope was used to evaluate the patient's lung and bowel sounds, and feet were assessed. Hands were sanitized, and data was entered into the device. The equipment was cleaned. The patient's arm was touched as the nurse spoke to the patient. The computer device was accessed for data entry (no hand sanitization). After documentation was entered, hands were sanitized; equipment was returned to the bag.

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 a review of clinical records and interview. 6 of 10 (60%) clinical records, in which hospice aide services were accepted, revealed a lack of clear and specific written instructions for the aide assignment, thus leaving the aide to make decisions outside of the aide's scope of practice. Clinical Record 6: The aide plan, documented on 11/9/2022, assigned a task to apply moisture barrier for a patient with Alzheimer Disease and Dementia; no location for the application was documented. The patient has incontinence but also has a coccyx wound and a sacral wound. It is unclear where the barrier should be applied. Additionally, the wounds are not identified on the aide plan or what to do with the dressings during the shower. Clinical Record 9: The aide plan, documented 11/28/2021, and was updated 11/30/2021. The aide plan did not include guidance for colostomy care, as of the patient's death on 12/31/2021. The ostomy was not identified on the aide plan. Clinical Record 11: The aide plan, documented 12/27/2021, and updated 1/11/2022, assigned the task to "apply moisture barrier". The location of where to apply the barrier was missing. This task continues on the aide plan as of the date of review, 12/20/2022, and continues to be absent the location for the barrier cream. The nursing visit note documented redness on the patient's coccyx at times, as well as the right heel. Clinical Record 12: The aide plan, documented on 7/19/2022, with no additional updated plans, assigned the task to "apply moisture barrier"; The location of where to apply the barrier was missing. The patient has diagnosis of Alzheimer's and Dementia and is in a skilled nursing facility. Clinical Record 13: The aide plan, documented as updated on 10/4/2022, did not include foley catheter care. The foley catheter was placed 09/15/2022 with no update to the aide plan as of the date of review, 12/21/2022. Clinical Record 14: The aide plan, documented on 11/2/2022, with no additional updated plans as of the date of review,12/21/2022, assigned the task to apply moisture barrier without a specific location for the application. The patient has Dementia and was incontinent. The Director of Clinical Services, on interview, stated on 12/21/2022 that the location for moisture barrier has now been updated on the aide plans as it was missing.

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. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes. This standard was not met as evidenced by a review of clinical records, document review and interview. In 1 of 1 (100%) record, in which a patient died, and hospice made the pronouncement of death, the agency did not ensure that policy was followed to document the absence of vital signs and pupillary response in the clinical record. Agency Policy C34 "Responding to Death and Postmortem Care" [revision date 03/26/2021], states in part, "The RN uses at least one and two below, but other standards are available if needed/required by state law: 1. Absence of pulse, respirations, blood pressure; 2. Absence of pupillary response. Clinical Record 8: The patient was admitted on 01/13/2022 and died on 11/18/2022. The death visit note did not document any assessment of an absence of vital signs. The Director of Clinical Services stated that education was completed 12/21/2022 (during the site visit) that absence of vital signs must be documented during a death visit.

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, at a minimum: physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) clinical records reviewed, that required additional physician orders, the agency did not ensure complete orders with clear detail were documented. Clinical Record 9: The patient was admitted on 11/28/2021 with a wound identified on 12/2/2021. Nursing visit notes documented a coccyx wound on 12/2/2021. The order for wound care documented, "cleanse the area with wound cleanser. Pat dry. Apply Calcium alginate and cover with clean day dressing at each visit or prn" The order was incomplete for the location of wound and unclear for number of times a week to perform wound care. The nurse was visiting twice a week. An interview with the Director of Clinical Services confirmed that the order was incomplete for the location of the wound.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 1 (100%) records in which there was a live discharge, the agency did not ensure that the patient's attending physician was sent a copy of the discharge summary or clinical record, if requested. Clinical Record 10: The patient revoked the hospice benefit. The revocation was documented on 01/17/2022. A discharge summary was documented but no evidence was provided by 12/22/2022, the last day of the site visit, that the summary was sent to the attending physician. The Director of Clinical Services stated that no documentation was located that the discharge summary was sent to the attending physician.

Based on record review and interviews, the hospice provider failed to ensure an administrator appointed by the governing body, was responsible for the day-to-day operation of the hospice. The deficient practice has the potential to affect all patients on service with the hospice. Findings included: Review of Missouri Statute 19 CSR 30-35.010 Hospice Programs Operations showed that a hospice administrator is a defined position in a hospice program "the employee designated by the governing body as responsible for the overall functioning of the hospice". Review of Missouri Statute 19 CSR 30-35.010 Hospice Programs Operations showed that a registered nurse coordinator is a defined position in a hospice program "a registered nurse, who is a direct employee, designated by the hospice to direct the overall provisions of clinical services". Review of email communication dated 07/14/2022, showed that the email sent from the state agency (SA) to the administrator on on file was returned undeliverable. The SA contacted the hospice provider by phone and received an email correspondence from the "Area Executive of Clinical Operations" in regards to the current administrator and current registered nurse coordinator. The hospice Area Executive of Clinical Operations (ACO) listed two staff as current registered nurse coordinators (it should be noted the definition is for a provider to have a single registered nurse coordinator). The email reply from the ACO failed to inform the SA who was appointed by the hospice governing body as the administrator. The SA administrative staff contacted the hospice ACO on 07/14/2022 at 2:59 PM to clarify the administrator role from the names listed in the email correspondence. When The SA administrative staff asked who was administrator, the Area Executive of Clinical Operations stated "just pick one". The SA administrative staff informed the hospice ACO that the governing body would have to pick an administrator. The ACO emailed an hour later informing the SA to list him/her as the administrator of the hospice. Review of the organization chart provided by the Hospice Director of Clinical Operations (DCS) on 08/16/2022 showed no designation or assignment of an administrator or registered nurse coordinator within the chart. Review of another organizational chart provided by the ACO on 08/17/2022 showed no designation or assignment of an administrator within the chart. Review of the hospice providers staff roster showed no designation of the hospice administrator. The Hospice Area Executive of Clinical Operations was designated "ACO". The hospice DCS provided his/her job description on 08/16/2022 for review. Review of this description showed this position reports to the "Executive Director". Review of the organization chart provided by the hospice director of clinical operations (DCS) on 08/16/2022 showed no designation for "Executive Director" in the organizational chart. It should be noted that after this was brought to the attention of the hospice administration, another job description was provided showing the hospice DCS reported to the "Hospice Area Executive of Clinical Operations". During interviews with licensed practical nurse (LPN-A), Chaplain-A, Chaplain-B, registered nurse (RN)-A, RN-B, and Social Worker-A on 08/16/22 and 08/17/2022, the staff were asked "who in the hospice administration is responsible for the day-to-day operation of the hospice". All staff responded with the name of the DCS. (It should be noted that the DCS was not listed at the time of survey entrance as the administrator with Centers for Medicare and Medicaid services (CMS) through the SA). During an interview with the administrator on file on 08/17/2022 at 9:30 AM, he/she stated the following: - He/she is listed as the administrator for three hospice provider numbers and five locations; - The locations he/she is responsible for are located in Joplin Missouri, Branson Missouri, Lamar Missouri, Monett Missouri, and Pittsburg Kansas; - He/she visits the hospice provider approximately weekly, the minimum would be monthly; and - He/she corresponds with the DCS electronically frequently to provide oversight. Review of "Governing Body Meeting and Agenda and Minutes" document showed the hospice governing body had a meeting on 08/16/2022. The discussion section showed "Administrator: 5.16.2022 (ACO) was appointed as Area Executive of Clinical Operations and Administrator for Western MO".

Based on policy review, record review and interview the agency failed to: - Develop an individualized plan of care (L545); - Ensure the plan of care included accurate/updated medication orders and profile (L549); and - Provide care and services based on all assessments of patient and family needs (L556). The cumulative effect of these deficient practices has the potential to affect the delivery of safe, effective care for all agency patients.

Based on policy review, record review, and interview, the agency failed to ensure the agency developed an individualized plan of care (POC) in two (Record/Patient #1 and #2) of four records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Written Interdisciplinary Plan of Care," revised 09/27/2019, showed in part: - The agency utilized an interdisciplinary approach to the development, implementation, and evaluation of the individualized POC for each patient. The interdisciplinary group (IDG/IDT) will ensure the provision of care and services according to the POC and that the POC reflects updated patient and family/caregiver needs as determined in the updated comprehensive assessments; - Care is provided to the patient in accordance with the plan; - The content of the plan includes at a minimum an assessment of the patient and family's needs and goals, an identification of the services to be provided, including management of symptoms, detail of the scope and frequency of services necessary to meet the assessed needs safety measures, measurable goals and outcomes for planned interventions; - Staff assignments based on the plan of care will be managed by the director of clinical services or designee according to the identified needs of the patient/family as documented in the comprehensive POC; and - The IDG, in collaboration with the hospice physician and patient's attending physician reviews and updates the POC at least every 15 days or more often as needed as dictated by the patient's condition. Review of the agency policy titled, "Individualized Plan of Care," revised 01/20/2020, showed in part: - The initial POC is intended to address areas of immediate concern based on the initial assessment completed by the RN (registered nurse); - The comprehensive POC developed by the members of the IDG team upon completion of all elements of the comprehensive assessments as described in other policies/procedures; - The updated POC; revisions to the comprehensive POC based on assessment information gathered over the period of time between the last review and the current as well as documentation of the plan going forward for the next 14 days; and - The POC is the complete treatment plan that provides the pathway for the hospice IDG to follow in providing care that is based on the initial and comprehensive assessments of the patient by all of the members of the IDG team as well as input from the patient and/or caregiver as appropriate. Review of the agency policy titled, "Written and Verbal Orders," revised 08/22/2018, showed in part the agency ensures properly recorded orders are in place for the provision or administration of medications, biologicals, durable medical equipment, and treatments. RECORD/PATIENT #1: Review of the RN start of care assessment dated 04/01/2021 showed the patient had a primary diagnosis of hypertensive heart disease without heart failure (heart disease caused by high blood pressure). Co-morbidities included atrial fibrillation (heart arrhythmia) and long term use of anticoagulants (blood thinning medications); - The patient took an anticoagulant; - Hematopoietic assessment (evaluation of a patient's medications and risk factors for clotting or bleeding) showed no problems identified; and - No information regarding who was managing the patient's anticoagulant and PT/INR (a laboratory test to determine if your anticoagulant is working the way it should, whether your blood is clotting normally and whether your anticoagulant dosage needs to be adjusted, normal PT range 11.0-13.5 and normal INR range for patients on warfarin is 2.0 to 3.0) monitoring. Review of the POC dated 04/01/2021 showed: - The patient took warfarin (blood thinning medication) six milligrams (mg) daily; - Safety measures included bleeding/anticoagulant precautions; - No specific interventions regarding assessment for anticoagulant complications; and - No information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of the IDG comprehensive assessment and POC update report dated 04/09/2021 showed no information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of the IDG comprehensive assessment and POC update report dated 04/23/2021 showed no information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of a physician order dated 04/28/2021 showed an order to obtain a PT/INR per fingerstick and notify the physician of results. Review of the IDG comprehensive assessment and POC update report dated 05/07/2021 under the section for orders since last IDG showed the previous order for a PT/INR on 04/28/2021. On 04/28/2021 prothrombin time less than 23.2 and INR less than 1.9. Review of the RN recertification assessment note dated 06/17/2021 showed: - The patient had a diagnosis of hypertensive heart disease. Co-morbidities included long term use of anticoagulants; - No problems identified with the hematopoietic and integumentary assessment; and - No information regarding who was managing the patients anticoagulant monitoring. During an interview on 11/09/2021 beginning at 2:10 PM, when asked whether the assessments and POC should address who is monitoring the patient's anticoagulant, the director of quality outcomes stated that they got an order for a PT/INR on 04/28/2021. RECORD/PATIENT #2: Review of the physician certification dated 12/15/2020 showed the patient had a terminal diagnosis of hypertensive heart disease complicated by respiratory failure, chronic kidney disease and thromboembolic disease which contributes to the patient's decline. The patient is oxygen dependent on five liters of oxygen. Review of the RN start of care assessment dated 12/15/2020 showed: - The patient was on five liters of continuous oxygen; - No edema (swelling); - High risk for falls; - Had an indwelling urinary catheter (a tube inserted into the bladder to drain urine) 16 french (size of catheter)/10 milliliter (ml, the amount of water inserted into the catheter to inflate a balloon at the end of the catheter) that was inserted on 12/08/2020; - Date of scheduled catheter change - monthly; and - Interventions provided showed instructions on catheter care, initiated fall precautions with instruction given to patient/caregiver to minimize incidence of falls. Review of the POC dated 12/15/2020 showed: - Observe and assess genitourinary pattern and teach/reinforce care of catheter, instruct patient/caregiver regarding irrigation of catheter, instruct regarding catheter removal; - No orders regarding irrigation, changing of the catheter or catheter size; - Safety measures showed high fall risk precautions but no specific interventions to address fall risk; and - No oxygen order. Review of physician standing orders dated 12/16/2020 showed: - May insert a 16 french/30 ml balloon indwelling Foley catheter as needed for chronic urinary retention or incontinence with discomfort; - Change every 30 days or sooner due to occlusion or sign of infection; and - May irrigate Foley catheter with 60 mls saline (salt solution) as needed to maintain catheter patency. Review of the hospice IDG comprehensive assessment and POC update report dated 12/18/2020 showed: - The RN note showed the patient was on oxygen at six liters per minute (the start of care assessment and physician certification showed five liters per minute); - The patient was dependent on a Foley catheter for urination; and - No orders/interventions for irrigation, changing of catheter or catheter size. Review of a LPN visit note dated 12/29/2020 showed the patient was on six liters of oxygen per minute. Review of an RN visit note dated 01/08/2021 showed: - Indwelling Foley catheter size 16/10; - Indicate catheter insertion date - 01/08/2021 (unsure if this meant the original insertion date of 12/08/2020 as indicated on the start of care assessment or if this meant the catheter was changed this day. No further documentation to indicate that a catheter change was performed on 01/08/2021); - Indicate date of scheduled catheter change - 30 days from insertion date; - The patient used oxygen at four liters (the start of care assessment and physician certification showed five liters per minute) per minute. Review of a LPN visit note dated 01/13/2021 showed the patient used oxygen at three (another change from what was previously indicated) liters per minute. Review of the hospice IDG comprehensive assessment and POC update report dated 01/15/2021 showed: - No oxygen orders; and - No orders for catheter irrigation, catheter changes or size of the catheter. Review of a LPN visit note dated 01/19/2021 showed the Foley catheter was changed. Patient tolerated. No documentation regarding what size catheter was used. Review of a discharge-transfer summary report dated 01/25/2021 showed the patient and spouse requested to come off hospice. He/she discussed with their physician last week that the patient has improved and is now walking and doesn't feel they need hospice services any longer. The patient has a follow up appointment with his/her urologist on 02/05/2021 regarding the indwelling urinary catheter. The patient was on oxygen at four liters per minute and the oxygen orders will be managed by the patient's attending physician. During an interview on 11/09/2021 beginning at 3:30 PM the director of quality outcomes stated that the interventions provided for falls on the start of care assessment should have flowed to the POC. There should be an order for catheter changes. The regional director of operations stated that they have standing orders for catheter changes. They would need to write the order and it would update to the POC.

Based on policy review, record review, and interview, the agency failed to ensure the plan of care was updated and the medication profile was accurate in two (Record/Patient #1 and #2) of four records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Written and Verbal Orders," revised 08/22/2018, showed in part: - The agency ensures properly recorded orders are in place for the provision or administration of medications; - If the order is verbal the individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with state and federal regulations; and - When a standing order is implemented, the nurse notifies the physician of the start date and documents this in the clinical record. Review of the agency policy titled, "Nursing Services," revised 09/16/2021, showed in part: - The agency provides nursing care and services under the supervision of a registered nurse (RN). Nursing services ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment and updated assessments; - Nursing services include evaluation and review of medication regimen including inventory, management and disposal; and - Implementation of the plan of care (POC) and recommendations for revision to the POC based on assessment data. RECORD/PATIENT #1: Review of the RN start of care assessment dated 04/01/2021 showed the patient had a primary diagnosis of hypertensive heart disease without heart failure (heart disease caused by high blood pressure). Review of a licensed practical nurse (LPN) visit note dated 04/09/2021 showed the patient had mucus in his/her throat that he/she could not clear. Used standing orders for Mucinex (thins mucus to make it easier to clear). Review of the physician orders showed no order for Mucinex. Review of the IDG comprehensive assessment and POC update report dated 04/09/2021 showed no update of the POC or medication profile to include an order for Mucinex. Review of a coordination note report dated 05/06/2021 showed a follow up pain note because the patient was still having pain and went to the walk in clinic on 05/05/2021. The caregiver told the nurse the clinic thought the pain was due to arthritis. The patient was using Voltaren (nonsteroidal anti-inflammatory) cream and Aleve (nonsteroidal anti-inflammatory) for pain and inflammation. The caregiver said the patient did not want to use anything stronger right now and the pain was a little better. Review of the physician orders showed no order for the Voltaren gel and Aleve. Review of the IDG comprehensive assessment and POC update report dated 05/07/2021 showed: - The patient injured his/her arm around 05/02/2021 by trying to brace a door. The patient went to the walk in clinic and they informed him/her it was arthritis. The patient was using Voltaren gel and Aleve to manage pain. The patient doesn't want to take any opioids (narcotic pain medication) for the pain; and - No update to the POC/medication profile to include an order for the Voltaren gel or Aleve. During an interview on 11/09/2021 beginning at 2:10 PM, the director of quality outcomes stated that when the clinician writes an order the medication profile is updated at that time. The RN updates the orders on the POC. He/she did not see an order to update the medication profile. RECORD/PATIENT #2: Review of an RN visit note dated 12/22/2020 showed: - The patient had 4+ edema (when the skin is pressed it leaves a deep indentation) to the right and left lower extremity/ankle; - The patient voiced he/she was concerned about the edema; and - The family voiced they would like to change to warfarin (blood thinning medication) instead of Eliquis (blood thinning medication). The nurse voiced he/she would call the physician's office. Review of a coordination note dated 12/22/2020 showed the nurse called in regards to transferring from Eliquis to warfarin. Message left. Review of a coordination note dated 12/23/2020 showed the nurse called to update about medications. No documentation of what medications he/she referred to. Review of the physician orders showed an order dated 12/29/2021 to draw a monthly INR (a laboratory test to determine if your anticoagulant is working the way it should, whether your blood is clotting normally and whether your anticoagulant dosage needs to be adjusted). Review of a LPN visit note dated 12/29/2020 showed no changes in medication. Review of the hospice IDG comprehensive assessment and POC update report dated 01/01/2021 showed: - The patient was switched from Eliquis to warfarin and the patient was also on a diuretic due to edema; and - The POC medication list/medication profile was not updated with a new order for warfarin or a diuretic. Review of the physician orders showed no orders to discontinue the Eliquis and start warfarin or an order for a diuretic. Review of an RN visit note dated 01/08/2021 showed refills of furosemide (diuretic, helps to decrease edema) and potassium chloride (supplement) called into the pharmacy. Review of the hospice IDG comprehensive assessment and plan of care update report dated 01/15/2021 showed the POC medication list continued to show the patient took Eliquis and no update or orders for warfarin, furosemide or potassium chloride. During an interview on 11/09/2021 beginning at 3:30 PM the director of quality outcomes stated that he/she would expect there to be an order for medication changes and the changes should flow to the medication profile and POC. He/she did not see orders for the medication changes or updates to the POC.

Based on policy review, record review, and interview, the agency failed to ensure that care and services were coordinated and provided based on all assessments of the patient and family needs for one (Record/Patient #1) of four records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Continuation of Care and Services," revised 12/03/2021, showed in part, the agency maintains a consistent approach to the delivery of care and services necessary to meet the needs of the patients on a 24 hour basis seven days per week. Nursing services, physician services, and drugs and biologicals are routinely available 24/7. Other services are made available to the patient and family when necessary to meet identified needs. Review of the agency policy titled, "Nursing Services," revised 09/16/2021, showed in part: - The agency provides nursing care and services under the supervision of a registered nurse (RN). Nursing services ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment and updated assessments; - The RN conducts nursing assessments for all patients at the time of admission and routinely as part of the comprehensive assessment and plan of care process. The Licensed Practical/Vocational Nurse (LPN, LVN) conducts focused assessments intended to gather patient data to support the RN in the ongoing management of the patient's plan of care. An RN is available by phone anytime an LPN/LVN is providing patient care services; - Nursing services are available 24 hours per day, 7 days per week; - Nursing services provided outside of normal business hours will be prioritized based on the urgency of patient/family need. It is expected that all care is delivered in a timely manner and that communication is provided to the patient/family regarding an estimated arrival; and - Nurses will maintain a complete and accurate record of all care provided including assessments, clinical notes, and updates to the POC. RECORD/PATIENT #1: Review of the RN start of care assessment dated 04/01/2021 showed in part the patient had a primary diagnosis of hypertensive heart disease without heart failure (heart disease caused by high blood pressure). Co-morbidities included atrial fibrillation (heart arrhythmia) and long term use of anticoagulants (blood thinning medications); - The patient took an anticoagulant; - Integumentary (skin) assessment showed no problems identified; - Hematopoietic assessment (evaluation of a patient's medications and risk factors for clotting or bleeding) showed no problems identified; and - No information regarding who was managing the patient's anticoagulant and PT/INR (a laboratory test to determine if your anticoagulant is working the way it should, whether your blood is clotting normally and whether your anticoagulant dosage needs to be adjusted, normal PT range is 11.0-13.5 and normal INR range for patients on warfarin is 2.0 to 3.0) monitoring. Review of the plan of care (POC) dated 04/01/2021 showed: - The patient took warfarin (blood thinning medication) six milligrams (mg) daily; - Safety measures included bleeding/anticoagulant precautions; - No specific interventions regarding assessment for signs of anticoagulant complications; and - No information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of an RN visit note dated 04/06/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae (tiny round brown-purple spots due to bleeding under the skin which may be in a small area due to minor trauma or widespread due to a blood clotting disorder). The assessment failed to include any specific information regarding the petechiae. Review of a LPN visit note dated 04/09/2021 and 04/16/2021 showed no problems identified with the hematopoietic or integumentary assessment. Review of an RN visit note dated 04/20/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae but no specific information regarding the petechiae. Review of an LPN visit note dated 04/23/2021 showed no problems identified with the hematopoietic and integumentary assessment. Review of the IDG comprehensive assessment and POC update report dated 04/23/2021 showed no information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of a physician order dated 04/28/2021 showed an order to obtain PT/INR. Review of an LPN visit note dated 04/28/2021 showed: - No problems identified with the hematopoietic and integumentary assessment; and - PT/INR performed and results (no documentation of what the results were) called to the physician. Review of an LPN visit note dated 04/30/2021 showed no problems identified with the hematopoietic and integumentary assessment and no medication changes. Review of an RN visit note dated 05/04/2021 showed: - The patient told the nurse the day before he/she hurt his/her right arm biciep area trying to brace a lock bar against the door that led to the garage. The patient rated his/her pain a seven (pain is rated on a scale of zero to ten with zero meaning no pain and ten meaning the worst pain). We applied a heating pad and the patient took Tylenol. Before the nurse left the patient stated that he/she had relief from his/her pain and was comfortable. No description of what the arm looked like or whether any bruising present; - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; - Integumentary assessment included petechiae but no specific information related to the petechiae; and - No medication changes. Review of a coordination note report dated 05/06/2021 showed a follow up pain note because the patient was still having pain and went to the walk in clinic on 05/05/2021. The caregiver told the nurse the clinic thought the pain was due to arthritis. The patient was using Voltaren (nonsteroidal anti-inflammatory) cream and Aleve (nonsteroidal anti-inflammatory) for pain and inflammation. The caregiver said the patient did not want to use anything stronger right now and the pain was a little better. Review of the IDG comprehensive assessment and POC update report dated 05/07/2021 under the section for orders since last IDG showed the previous order for a PT/INR on 04/28/2021. The vital sign summary report showed on 04/28/2021 prothrombin time less than 23.2 and INR less than 1.9. No information or orders regarding when the next PT/INR would be due. Review of an LPN visit note dated 05/07/2021 showed: - No problems identified with the hematopoietic assessment; - The clinician documented the integumentary was not assessed due to not appropriate at time of evaluation (unsure of what this means); - No medication changes; - The patient denied pain and ambulated independently; and - No specific information regarding the injury to the right arm. Review of an RN visit note dated 05/11/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae but no specific information related to the petechiae. Review of an LPN visit note dated 05/13/2021 and 05/18/2021 showed no problems identified with the hematopoietic and integumentary assessment. On 05/18/2021 the patient and caregiver agreed that once a week visits would be better for them. Review of an LPN visit note dated 05/25/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae but no specific information related to the petechiae. Review of an RN visit note dated 06/03/2021 and 06/10/2021 showed no problems identified with the hematopoietic and integumentary assessment. Review of an RN recertification assessment note dated 06/17/2021 showed: - The patient had a diagnosis of hypertensive heart disease. Co-morbidities included long term use of anticoagulants; - No problems identified with the hematopoietic and integumentary assessment; and - No information regarding who was managing the patients anticoagulant. Review of the physician orders showed an order dated 06/22/2021 for an emergent prn (as needed) visit. Review of an LPN prn (as needed) visit dated 06/22/2021 showed: - The visit was initiated by the caregiver; - Chief complaint or problem as presented by patient and/or caregiver - Bruising; - Endocrine/hematopoietic assessment - Excessive bleeding or bruising right upper arm and left hand; - Care coordination - Indicate if you communicated with other disciplines involved in this case - No; - The narrative portion showed the patient had bruising on the right arm. Ribs sore like may be bruised. Last PT/INR was 3.2 (unsure of when this referred to); - Will return in the AM to complete PT/INR due to clinic not being able to get patient in; and - No documentation that the physician or RN case manager was notified of the bruising or whether orders were obtained for the PT/INR. Review of the record showed a physician order dated 06/23/2021 at 11:49 AM for a PT/INR related to Coumadin (anticoagulant) use. Review of a client coordination note report dated 06/23/2021 documented by the director of clinical services (DCS, who no longer worked for the agency) showed: - 10:30 AM - Spoke to family member this AM regarding the patient's PT/INR. The patient to have PT/INR done by hospice nurse. The family member stated that he/she thought the nurse would be there first thing that morning. Explained that the staff had a brief meeting, then the nurse was going to pick up lab supplies, then would be out; - 12:30 PM the family member called the RN case manager and was upset the nurse had not made it to do the lab draw. The RN explained he/she was on his/her way as he/she had to wait for an order and pick up the supplies. The family member stated that he/she could take care of the patient his/herself and wanted to revoke (discontinue) services immediately. He/she said he/she was going to take the patient to the clinic. The DCS attempted to call the family member but no answer. The RNCM will take the revocation paperwork to the patient this day. During an interview on 11/09/2021 beginning at 1:00 PM LPN A stated that he/she saw the patient on 06/22/2021. The caregiver had tried to get the patient in to see the doctor. LPN A stated that he/she notified the DCS. When asked if he/she documented that anywhere, he/she could not recall but it should have been that day. The patient was supposed to have a PT/INR every 30 days (there was no physician order for this). He/she did not notify the physician or clinic because they already had an order for PT/INRs. During an interview on 11/09/2021 beginning at 2:10 PM, the director of quality outcomes stated that on 06/22/2021 he/she would have expected the nurse to notify the physician of the patient's bruising.