Every finding on record at Community Hospices of America - Tennessee, LLC

Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician. This standard was not met as evidenced by clinical record review, and observation. 1 of 6 (17%) home visit observations revealed that the agency did not ensure that the clinician followed the plan of care. HOME VISIT 3/CLINICAL RECORD 3: The patient was admitted on 09/16/2025 with a diagnosis of chronic obstructive pulmonary disease. The plan of care dated 09/16/2025 to 12/14/2025 included an order to "Assess upper quadrant, mickey button placement, cleanse with NS and apply dressing as needed, assess for signs and symptoms of skin breakdown." During the home visit with the RN (PERSONNEL RECORD 3) on 10/14/2025, observed the nurse ask the patient and the caregiver questions about the patient's appetite and volume of intake. The nurse did not ask about the mickey button to ensure there were no complications and did not assess the area. The nurse did listen to bowel sounds over the patient's clothing. The nurse did not assess the patient's skin except what was exposed fully clothed.

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 clinical record review and interview. 1 of 27 (4%) clinical record reviewed revealed that the agency did not ensure the individual plan of care included all of the necessary interventions for concerns identified in the initial assessment. CLINICAL RECORD 16: 79 year old elected hospice on 07/14/2025 with a diagnosis of COVID-19, unspecified protein-calorie malnutrition, Chronic kidney disease, hypertension, type 2 diabetes, and hyperlipidemia. SN admission assessment on 07/14/2025 revealed that upon initial assessment, the patient had a documented loss of 8 pounds and had a history of trigeminal neuralgia, which created pain issues at times; she required maximum assistance and a Hoyer lift for mobility. Patient was incontinent, requiring total care with a stage 1 pressure ulcer to the coccyx. The skilled nurse documented that the patient had a drastic decline in appetite, hence the weight loss, and was taking Metformin BID without checking the patient's blood sugars. Oxygen ordered. The plan of care dated 07/14/2025 through 10/11/2025 did not include interventions for skin integrity, pain, diet, or respiratory status. The only interventions on the plan of care were "Admission RN will complete a medication inventory at time of admission, within 48 hours of admission will complete a medication reconciliation including: evaluate ESIDL for meds, discuss with physician possible de-prescribing of non-therapeutic meds, discuss purpose of each medication with patient or caregiver, evaluate that the patient/caregiver is capable of administering medication and ensure that patient has a minimum 7 day supply of medication. The Director of Quality Outcomes reviewed the clinical record on 10/17/2025 and confirmed the findings and stated, "I am kind of glad you cited that because it gives us more evidence for what we have been working with the admission nurses about."

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. 3 of 22 (14%) clinical records with a hospice aide reviewed, revealed that the agency did not ensure that the written care plan for the aide included required specific instructions to the aide to meet the individual patient needs. CLINICAL RECORD 3: The patient was admitted on 09/16/2025 with a mickey button in place. The SN assessment on 09/16/2025 also indicated that the patient had a history of seizures. The plan of care dated 09/16/2025 included orders to assess the upper left abdominal quadrant around the mickey button for signs and symptoms of skin breakdown and included seizure precautions. A hospice aide was ordered on 09/21/2025 for twice per week. The aide care plan initiated on 09/24/2025 and updated on 10/13/2025, did not include notification or instruction to the aide that the patient had a mickey button or that the patient was on seizure precautions. CLINICAL RECORD 7: Patient elected hospice on 10/02/2025 with a diagnosis of chronic obstructive pulmonary disease and chronic respiratory failure. The The plan of care dated 10/02/2025 included significant interventions, safety measures and education related to oxygen safety. An aide was ordered 2 times a week for 12 weeks effective 10/05/2025. An aide care plan was developed on 10/02/2025 and updated 10/03/2025. The SN assessment described that the patient has a colostomy and ostomy supplies are included on the plan of care. The aide care plan did not mention colostomy care. CLINICAL RECORD 15: The patient elected hospice on 07/07/2025 with a diagnosis of heart failure and chronic obstructive pulmonary disease. The SN assessment noted that the patient became short of breath while talking and required oxygen. Oxygen orders and supplies were noted on the plan of care dated 07/07/2025. There was no notation related to oxygen on the aide care plan. The Director of Quality Improvement, reported "OK" and confirmed the findings in an interview and review on 10/14/2025 and stated, "We will be doing a lot of education about aide care plans again."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview, observation, and personnel record review. 1 of 10 (10%) personnel records reviewed revealed that the agency did not ensure documented competency of skills that were provided by a registered nurse. PERSONNEL RECORD (PR) 3: This RN was hired on 03/31/2025 as a case manager. Observed the RN on home visit 3 on 10/14/2025. Per clinical record 3, and home visit 3, the patient has a mickey button. PR 3 did not include any documented evidence of a competency assessment related to feeding tubes of any type. In an interview on 10/16/2025 with the Administrator and Director of Quality Outcomes, it was confirmed that the competency skills checklists did not include any competency reviews for feeding tubes. The Administrator stated, "Feeding tubes are pretty common, I can't believe we don't have a competency for that but we don't, we even checked with corporate. We will put one together and everyone will be competencied by the end of the month."

Based on policy review, medical record review and interview, the agency failed to provide symptom control for 1 patient (#1) of 3 patients reviewed. The findings included: --- Review of the Patient Bill of Rights updated January 2021 revealed ";...to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness..." Medical record review revealed Patient #1 was admitted to the agency on 8/3/2023 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. Medical record review of the Hospice Certification and Plan of Care dated 8/3/2023 to 10/31/2023 revealed a physicians order for Morphine 100 mg/5 ml (milliliters) 0.25 ml every 4 hours as needed for pain or shortness of breath. Continued review revealed a goal which included skilled nurse (SN) to assess patient for respiratory changes and promptly initiate interventions to quickly minimize associated uncomfortable symptoms. Medical record review of Patient #1's medication profile dated 8/3/2023, revealed the Morphine Sulfate was listed as a current medication. Medical record review of the Hospice Recertification Plan of Care Update dated 10/18/2023 for the certification period dated 11/1/2023 to 1/29/2024 revealed the physician ordered a ";Comfort Kit" which included Morphine Sulfate 20mg/ml – may take 0.25 ml by mouth or under the tongue every 4 hours as needed for moderate to severe pain or shortness of breath. Medical record review of the medication profile provided to the physician on 10/18/2023 revealed the Morphine Sulfate was listed on the medication profile as current. Medical record review of the SN (skilled nurse) note dated 11/15/2023 revealed the patient had 7 days of medications on hand and no refills were needed. Further review revealed the patient resided in a nursing facility and the facilitys current medication list was accurate. Continued review revealed the facility managed all controlled drugs. Further review revealed the patient was in bed with the oxygen off, curled into a fetal position, responded slowly to verbal/tactile stimuli, and complained of shoulder pain but was unable to rate the pain level. Her hands were cool, and fingertips were dusky. Oxygen turned on and applied at 3 liters/minute via nasal cannula. The patient had a persistent non-productive cough during visit. The oxygen saturation increased to 87% then to 93% with a pulse of 100. The patient had very poor air movement in the left lung lobes and diminished in the right lobes. The patient dozes off during the visit. The patient continues to smoke cigarettes and lung sounds were decreased in the mornings. Medical record review of Patient #1's physician order dated 11/16/2023 revealed the facility requested a Hospice visit on 11/17/2023 due to increased lethargy and pain. Medical record review of a Patient #1's physician order dated 11/17/2023 revealed the a nursing visit order due to patients decline. Medical record review of a SN visit dated 11/17/2023 revealed the patient was lying in bed, using accessory muscles for breathing and oxygen saturation was 90% on 3 liters of oxygen. Lung sounds were ";wet with crackles". The patient had ";thick sputum white/yellow in color caking mouth and teeth". The SN provided oral care. Heart rate was 133. The patient was encouraged to take slow deep breaths. A request was made to the physician for antibiotics. Medical record review of a Client Coordination Note dated 11/18/2023 revealed a call was received to notify Hospice that the patient was ";imminent" and morphine needed to be ordered. The facility was notified a skilled nurse visit would be made to assess the patient. Medical record review of a physicians order dated 11/18/2023 revealed the agency requested Morphine Sulfate on 11/18/2023 at 7:53 AM. Further review revealed the physician signed the order on 11/18/2023 at 10:51 AM. Medical record review of a SN note dated 11/18/2023 at 12:26 PM revealed a late entry was added for 7:45 AM. Continued review revealed the facility contacted the hospice and stated the patient needed Morphine and was imminent. The physician was notified, and the medication was to be pick up at approximately 11:45 AM and delivered to the facility. Upon the SNs arrival to the facility the patient had expired at 8:45 AM and the Morphine Sulfate was not available to the patient. Medical record review of a Client Coordination Note dated 11/18/2023 revealed the patient had expired before the nurses arrival. The funeral home had retrieved the body. The facility registered nurse declared the patient expired at 8:45 AM. The Morphine Sulfate did not arrive prior to patients death. Review of documentation provided by the agency dated 11/18/2023 revealed the comfort kit was not available at the facility at the time of active decline. Facility stated they requested a comfort kit on 11/17/2023 but the nurse who made the visit denied the facility requested a comfort kit. On the medication profile Morphine Sulfate was listed but the order was never sent to the pharmacy to be filled. Further review revealed this was a service failure and processes were not followed at admission to ensure medications were at the facility post admission. Review of documentation provided by the agency dated 11/20/2023 revealed the governing body and QAPI (quality assurance performance improvement) was notified of the service failure for Patient #1 due to the comfort kit not available to patient. Review of documentation provided by the agency dated 1/4/2024 revealed the agency administration met with Patient #1s family to discuss the service failure related to medications not available at the facility. Continued review revealed the agencys case manager (registered nurse) did not ensure medications ordered by the physician was at the facility. The SN who saw the patient on 11/17/2023 did not ensure the Morphine Sulfate was available after noting active decline. The agency provided re-education one on one to both staff and entire team. Interview with the Director of Clinical Services on 4/23/24 at 11:30 AM, in the conference room, revealed the RN who admitted the patient did not send the prescription for Morphine or Comfort Kit to the pharmacy. Continued interview revealed the patient was on PO (by mouth) pain medications and did not need the Morphine until 11/17/2023. Further interview revealed no one checked with the facility to ensure Morphine was available if needed. The SN who saw the patient on 11/17/2023 and noted the decline did not check with the facility to ensure the Morphine was available. The patient had been diagnosed with Covid 19 approximately 1 week before death. Further interview revealed the patient had been active until 11/17/2023 and continued to go outside to smoke cigarettes. During an interview on 4/23/2024 at 11:45 AM, the Director of Clinical Services confirmed the facility did not have access to the patient's Morphine due to the pharmacy never received the order.

Based on medical record review and interview, the agency failed to provide 24 hour nursing services for 1 patient (#1) of 3 patients reviewed. The findings included: --- Medical record review revealed Patient #1 was admitted to the agency on 8/3/2023 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. Medical record review of a skilled nurse (SN) note dated 11/15/2023 revealed the patient resided in a nursing facility Further review revealed the patient was in bed with the oxygen off. She was curled into a fetal position. She responded slowly to verbal/tactile stimuli. She complained of shoulder pain but was unable to rate the pain level. Her hands were cool, and fingertips were dusky. Oxygen turned on and applied at 3 liters/minute via nasal cannula. The patient had a persistent non-productive cough during visit. The oxygen saturation increased to 87% then to 93% with a pulse of 100. The patient had very poor air movement in the left lung lobes and diminished in the right lobes. The patient dozes off during the visit. The patient continues to smoke cigarettes and lungs were usually decreased in the mornings. Medical record review of a SN visit dated 11/17/2023 revealed the patient was lying in bed, using accessory muscles for breathing. The oxygen saturation was 90% on 3 liters of oxygen. Lung sounds were ";wet with crackles". The patient had ";thick sputum white/yellow in color caking mouth and teeth". The SN provided oral care. Heart rate was 133. The patient was encouraged to take slow deep breaths. A request was made to the physician for antibiotics. Medical record review of a Client Coordination Note dated 11/18/2023 revealed a call was received to notify Hospice that the patient was ";imminent" and morphine needed to be ordered. The facility was notified a skilled nurse visit would be made to assess the patient. Medical record review of a physicians order dated 11/18/2023 revealed the SN requested an order for Morphine on 11/18/2023 at 7:53 AM. Further review revealed the physician signed the order on 11/18/2023 at 10:51 AM. Medical record review of a SN note dated 11/18/2023 at 12:26 PM revealed a late entry was added for 7:45 AM. Continued review revealed the facility contacted the hospice and stated the patient needed Morphine and was imminent. The physician was notified, and the medication was to be pick up at approximately 11:45 AM and delivered to the facility. Upon the SNs arrival on 11/18/2023 at 12:26 PM to the facility the patient had expired at 8:45 AM and the Morphine Sulfate was not available to the patient. Medical record review of a Client Coordination Note dated 11/18/2023 revealed the patient had expired before the nurses arrival. The funeral home had retrieved the body. The facility registered nurse declared the patient expired at 8:45 AM. The Morphine Sulfate did not arrive prior to patients death. The family contacted the agency via telephone and condolences given. The daughter vocalized extremely upset with situation due to facility and self being unable to get through to answering service. Review of documentation provided by the agency dated 11/18/2023 revealed the nursing home facility was unable to contact the On-Call registered nurse to report patients death due to transition from one answering service to another answering service. Review of documentation provided by the agency dated 11/20/2023 revealed the governing body and QAPI (quality assurance performance improvement) was notified of the service failure for Patient #1 due to the change in the answering service. Continued review revealed Emergency Operations Plan Activated which included all patients were contacted and provided an alternate contact to the on-call RNs direct cellular number. Review of documentation provided by the agency dated 1/4/2024 revealed the agency administration met with Patient #1s family to discuss the service failure related to the new answering service. Interview with the Executive Director on 4/23/2024 at 11:30 AM, in the conference room, revealed the answering service started having problems on Friday 17, 2023. The problems included long wait times, no answer to telephone calls and contacting staff members who were not on call. Continued interview revealed the agency became aware of the problems approximately 5 hours after the problems started. She stated the emergency action plan was put into place at that time which included calling all of the patients and giving them the on-call cell phone numbers to contact the on-call nurse if the answering service was unable to help them. The answering service concerns were taken to the Governing Body and QAPI (quality assurance performance improvement). The answering service has been monitored by the staff by calling at all hours to make sure they are answering the telephones in a timely manner. Further interview revealed no other complaints have been brought to her attention since 11/18/2023 with the answering service. Interview with the Executive Director on 4/23/2024 at 11:45 AM confirmed the on call answering service was not taking all calls for approximately 5 hours and resulted in Patient #1 not receiving her medication or support.

It is required that the Hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 20 (5%) clinical records reviewed where the Medical Social Worker (MSW) completed the initial psychosocial comprehensive assessment, the agency did not ensure completion of the initial psychosocial comprehensive assessment by the fifth (5th) calendar day after the patient's election of hospice care. Clinical Record 8: Patient with Hospice Election of Benefit dated 10/23/2022 had the initial comprehensive psychosocial assessment completed ten (10) days after the start of care on 11/2/2022. MSW narrative noted dated 11/2/2022 documented, "patient is 78 y/o male on hospice service....with a terminal diagnosis of heart failure. The patient is alert and oriented x3 and uses a rolling walker to ambulate." There was no documentation of the reason for the delay in the initial comprehensive psychosocial assessment visit. A paper visit dated and signed 11/2/2022 was uploaded on 12/7/2022 by the agency after a discussion of finding with the Regional Director of Hospice Quality Outcomes on 12/6/2022. The Director explained the assigned MSW was on vacation, resulting the visit being missed and completed outside of the 5-day requirement standard window.

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, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 9 of 20 (45%) clinical records reviewed, the agency did not include medical supplies and/or DME provided by the agency on patient's the plan of care. . Clinical Record 3: Hospice RN Start of Care dated 11/29/2021 documented patient used "under pads and pull ups" as protective devices. Hospice certification and plan of care dated 11/29/2021 for benefit period 11/29/2021-2/26/2021, documented functional limitation of bowel/bladder incontinence, endurance, and ambulation. The DME and supplies section was documented as "none". Regional Director of Hospice Quality Outcomes confirmed the agency provided the supplies of blue pads, briefs/bladder control pads and gloves to the patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 2: Hospice RN Start of Care note dated 4/2/2022 documented patient using "pull ups" as protective device and in the narrative documented patient was "incontinent of bladder and occasionally of bowel." Hospice certification and plan of care dated 4/25/2022 for benefit period 4/25/2022 through 7/23/2022 documented "none" under DME and Supplies section. Regional Director of Hospice Quality Outcomes confirmed the agency provided the supplies of blue pads and briefs/bladder control pads to the patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 6: Hospice RN Start of Care note dated 2/9/2022 documented patient "having frequent bowel incontinence and occasional urine incontinence." Hospice certification and plan of care dated 2/9/2022 for benefit period 2/9/2022 through 5/9/2022 documented functional limitations of bowel/bladder incontinence and DME and supplies as "none". Regional Director of Hospice Quality Outcomes confirmed the agency provided briefs/bladder control pads, hospital bed setup and oxygen concentrator and supplies setup to the patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 7: Hospice RN Start of Care note dated 8/19/2022 documented patient used diapers for protective devices and documented wound care assessment of the "skilled nurse for administration of decubitus wound care. Cleanse with wound cleaner. Apply calcium alginate. Cover with foam dressing." Hospice certification and plan of care dated 8/19/2022 for benefit period 8/19/2022 through 11/16/2022 documented functional limitations of bowel/bladder incontinence, endurance, ambulation and speech. DME and supplies section was documented as "none." Director of Hospice Quality Outcomes confirmed the agency provided brief/bladder control pads, blue pads, hospital bed, oxygen and respiratory supplies, suction setup, walker and wound care supplies to the patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 8: Hospice certification and plan of care dated 10/23/2022 for benefit period 10/23/2022 through 1/20/2022 documented functional limitations as bowel/bladder incontinence, hearing, endurance, ambulation, dyspnea with minimal exertion. DME and supplies section was documented as "none." CTI physician narrative signed on 11/8/2022 documented "max assist transfer to bedside commode." RN Visit note dated 10/24/2022 documented the use of walker as assistive device needed for ambulation. Director of Hospice Quality Outcomes confirmed the agency provided hospital bed, oxygen concentrator supplies, shower/tub equipment, suction setup, overbed table, wheelchair and incontinence supplies to patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 5: Hospice RN Start of Care note dated 12/30/2021 documented patient "ambulated with walker with slow, unsteady gait on smooth surface" and Stage II pressure ulcer to right upper buttocks with wound care "cleansed with soap and water/wound cleanser/saline, patted dry and applied skin barrier cream PRN..." Hospice certification and plan of care dated 12/30/2021 and for benefit period 12/30/2021 through 3/29/2022 documented functional limitations of bowel/bladder incontinence, endurance and ambulation. The DME and supplies section was documented as "none." Director of Hospice Quality Outcomes confirmed the agency provided brief/bladder control pads, blue pads, wound care supplies, hospital bed with mattress and oxygen supplies to the patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 11: Hospice RN Start of Care note dated 1/25/2022 documented patient used diapers for protective device of incontinence. Narrative note on same visit documented patient "unable to sit up in chair, requires Geri-chair and leans to left in chair." Hospice certification and plan of care dated 1/25/2022 documented DME and supplies as "none" and functional limitations with bladder/bowel incontinence and speech. Director of Hospice Quality Outcomes confirmed the agency provided hospital bed and incontinence supplies to patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 9: Hospice certification and plan of care dated 7/22/2022 for benefit period 7/22/2022 through 10/19/2022 documented DME and supplies as none. Director of Hospice Quality Outcomes confirmed the agency provided hospital bed, oxygen supplies, suction setup and incontinence supplies to patient and confirmed during the joint record review that the items were missing from the plan of care. Clinical Record 17: Hospice RN Start of Care note dated 11/8/2022 documented "patient has frequent stress incontinence, managed with a pull-up," and patient was oxygen dependent at 3LPM. Coordination note narrative dated 11/9/2022 documented patient used "BIPAP at night and nebulizer treatments 3-4x daily PRN." During home visit (HOME VISIT #2) on 12/6/2022, it was observed the patient had an oral suction machine setup, oxygen concentrator setup and wound care supplies. Hospice certification and plan of care dated 11/8/2022 for benefit period 11/8/2022-1/6/2022 document DME and supplies as "none." Director of Hospice Quality Outcomes confirmed the agency provided oxygen and respiratory supplies, suction machine, and wound care supplies, and confirmed during the joint record review that the items were missing from the plan of care. Interview with the Regional Director of Hospice Quality Outcomes confirmed the medical supplies and/or DME were not included in the plans of care for the identified records (RECORDS 2, 3, 5, 6, 7, 8, 9, 11 and 17) during the joint records review on 12/8/2022.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by observations, document reviews, and interview. In 1 of 2 (50%) observations during home visits where bag technique was performed, the agency did not ensure its bag technique policy was followed. Agency policy C_11G titled "Infection Control: Bag Technique in Home Care and Standard Precautions," was revised 4/20/2022 and stated in part, "(4) Standard Bag Technique: (a) Place hand-carried bags on a clean, dry surface or hang on doorknob...(b) Perform hand hygiene...(c) Remove needed supplies from the bag and place them on a clean, dry surface or on a water-resistant surface barrier as needed (i.e. the surface is visibly soiled or potentially contaminated due to patient's living conditions, etc.). The barrier is discarded after use...(d) Once patient care has started, do not reach into bag without performing hand hygiene. If gloves are worn, remove the gloves, perform hand hygiene, and then you can reach into bag...(e) When care delivery is completed and reusable supplies are to be returned to bag: (i) FIRST, inspect all reusable equipment for visible soil/contamination. (ii) If visible soiled/contaminated, use soap and water to remove the material. (iii) Wipe down with alcohol pad to disinfect. (iv) Remove gloves and discard. (v) Perform hand hygiene and place supplies in bag." Home Visit 4: During a home visit on 12/8/2022, it was observed the RN placed paper towels (not water resistant) onto a chair located in patient's room and placed the nursing bag on top of the paper towels. RN performed hand hygiene and removed reusable equipment from the bag. RN placed a tissue as barrier (not water resistant) on top of bedside table, and placed the equipment on top of the tissue, which included blood pressure cuff, finger pulse oximeter, measurement tape, and stethoscope. During the physical assessment of the patient, the nurse placed the used equipment onto her lap after each use, since she was squatting next to the patient's bed. After the examination, the RN stood up and placed the used equipment next to the nursing bag's barrier (paper towel) located on the chair. The RN performed hand hygiene. The RN cleansed equipment with Sani-Cloth Germicidal disposable individual wipes and placed each piece of equipment immediately back into the bag after wiping and cleansing, without waiting the 2-minute dry time per the manufacturer instructions for disinfecting. RN closed the bag, discarded barriers and performed hand hygiene. Interview with the Regional Directors on 12/8/2022 and 12/9/2022, confirmed the barriers used were not optimal due to its small size and not water resistant, and infection control was not followed due to the 2-minute dry time was not completed to ensure disinfecting of the equipment.

It is required that a patient clinical record containing past and current findings are 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 a review of clinical records. In 3 of 20 (15%), clinical records reviewed with medications and treatments provided by the hospice agency revealed physician orders were missing or not documented accurately. Clinical Record 4: Patient with Hospice Election of Benefit dated 10/26/2021 had a primary diagnosis of COPD. Hospice RN Start of Care note dated 10/26/2021 documented wound assessment of low buttock left pressure ulcer stage II and wound care provided. RN documented "cleansed with wound cleaner, pat dry, applied barrier cream, covered with Mepilex. SN to change dressings 2X a week. The patient tolerated procedure well." Hospice Certification and Plan of Care Order dated 10/26/2021 had no physician orders for the wound assessed and wound care provided by RN 10/26/2022. Physician order dated 11/9/2022 documented "Stage II, cleanse with wound cleanser, apply barrier cream and leave OTA, SN to perform 2x/wk and PRN" was entered fourteen (14) calendar days after the wound care was performed. Clinical Record 12: Patient with Hospice Election of Benefit dated 2/11/2022 had a primary diagnosis of Multiple Sclerosis. Hospice RN subsequent visit dated 2/12/2022 documented in the narrative "Foley placed per patient request r/t immobility/wounds. 22F, 30cc placed using sterile technique. Immediate yellow urine return noted. The patient tolerated well. Leg band placed to the right leg. PCG reports understanding how to empty BSB. PICC to RUE discontinued using sterile technique. A pressure dressing was applied. Education provided." No physician orders were documented for Foley insertion and its maintenance or PICC line discontinuation in the record. Clinical Record 15: Patient with Hospice Election of Benefit dated 4/8/2022 had a primary diagnosis of breast cancer. Physician orders dated 7/11/2022 documented Methadone 7.5mg Q8 HRS PRN for BTP. There was no route for the medication documented in the physician's order. The agency had previously managed the patient's pain with pain medication via a pain pump intravenously, subcutaneously, and then switched to oral medication. Hospice RN's subsequent visit dated 10/21/2022 documented wound assessments for two different locations left posterior upper leg pressure ulcer stage II and posterior right middle upper leg right pressure ulcer stage II. Wound care was documented for both locations, "cleanse with soap and water, pat dry, apply island dressing, Tolerated well." Physician order dated 10/21/2022 documented "cleanse with soap and water, pat dry, apply island dressing." The location(s) or frequency of the wound care treatment was missing and not documented in the physician's order for accuracy. Hospice RN's subsequent visit dated 12/6/2022 written wound assessment to two locations: left post proximal upper leg, pressure ulcer stage II, and mid posterior right mid upper leg pressure ulcer stage I. RN documented that no wound care was provided because the caregiver provided the care. RN documented the measurements of the wounds. Physician order dated 12/6/2022 documented "cleanse with soap and water. Pat dry. Apply betadine and allow to dry and apply gauze island dressing." The location(s) or frequency of the wound care treatment was missing and not documented in the physician's order for accuracy.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40. I and the patient’s record, if requested. This standard was not met, as evidenced by a review of clinical records and interviews. In 1 of 3 (33%) clinical records reviewed with live discharges where the patients were transferred to a Medicare/Medicaid-certified facility, the agency did not forward a copy of the hospice discharge summary to the receiving facility. Clinical Record 14: The patient, with an Election of Hospice Benefit, signed on 8/11/2022, elected discharge from the agency by revocation effective 10/13/2022 to seek curative treatment at a local hospital. The discharge coordination note dated 10/16/2022 documented that the hospice staff met the caregiver at the emergency room (ER) for revocation form signing. The report was called to ER by the Director of Clinical Services. The discharge summary note by RN dated 10/16/2022 documented that the patient's daughter called the office on 10/13/2022 to report that despite the treatment plan for continuous diarrhea, she was taking the patient to the local hospital ER for evaluation due to a history of diverticulitis disease and abscess of the colon. The Discharge summary note by the team coordinator dated 10/17/2022 documented faxing the discharge summary to the family practice office (and attending physician). There was no documentation or evidence provided that the discharge summary was faxed to the local hospital for care coordination. An interview with the Regional Director of Hospice Quality Outcomes on 12/8/2022 confirmed the discharge summary was not sent to the local hospital during the joint record review.