Every finding on record at Compassionate Care Hospice of North Texas, LLC

Upon patient record review, 2 of 19 (Patients #3, 4) did not contain a current/comprehensive medication profile: Patient #3: The 08/12/25 RN visit note reflected that the patient is utilizing oxygen. The most current medication profile did not include oxygen. Patient #4: The clinical record notes reflected that the patient was utilizing oxygen. The most current medication profile did not include oxygen.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #3: The 08/12/25 RN visit note reflected that the patient is utilizing oxygen. The IDG POC dated 08/07/25 reflected oxygen dependency. However, the current POC did not include a full oxygen order.

Upon patient record review, 1 of 19 (Patient #4) did not contain a plan of care that included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #4: During the Surveyor-attended home visit on 08/13/25 it was noted that the patient had a hospital bed, over bed table, and WC. However, these DME were not included on the current POC.

Upon patient record review, 1 of 19 (Patient #1) did not contain evidence that the revised plan of care included all information from the patient's updated comprehensive assessment: Patient #1: The hospice POC dated 07/23/25 reflected that the patient had a foley catheter. During the surveyor-attended home visit it was noted that the patient did not have a foley catheter.

Upon patient record review, 1 of 19 (Patient #1) did not contain evidence that the hospice Aide POC/assignment sheet and duties indicated what tasks are to be done by the Aide, to include any other individualized/pertinent patient information: Patient #1: The current Aide POC reflected that the patient had a foley catheter. During the surveyor-attended home visit it was noted that the patient did not have a foley catheter.

Upon observation there was not evidence that the annual report documented the use of Volunteers, providing day to day administrative and/or direct patient care services, in an amount that at a minimum equaled 5% of the total patient care hours of all paid Hospice employees and contract personnel. The Hospice's Regional Clinical representative provided a report that reflected a 1.07% rate for 2024.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that each patient record contained Advance Directives: Patient #4: The current POC reflected that the patient was a DNR. However, there was no copy of the Texas Out of Hospital DNR in her file.

Based on record review and interview, the agency failed to include physician orders in the clinical record for 2 (#1, #3) of 3 patient records reviewed of patients on service for less than 3 weeks. The failure placed the agency's clients at risk of the omission of care or inappropriate care which could result in a negative outcome. --- Client #1: Record review of Client #1's record revealed a Plan of Care dated 8/2/2023 to 10/30/2023. The Plan of Care indicated that Client #1 started on the agency's services on 8/2/2023. The Plan of Care listed Malignant Neoplasm (cancerous tumor) of Unspecified Kidney, Except Renal Pelvis as the terminal diagnosis. The Plan of Care listed Secondary Malignant Neoplasm of Bone and Secondary Malignant Neoplasm of Brain as secondary diagnoses. Registered Nurse C conducted a skilled nurse visit on 8/10/2023. Registered Nurse C documented "Received a call from patient's spouse that patient was gasping for air and that oxygen was started on 2 liters for comfort. Registered Nurse C conducted a skilled nurse visit on 8/17/2023. Registered Nurse C documented that Client #1 was on oxygen at 2 liters. Registered Nurse D conducted an as needed skilled nurse visit on 8/17/2024 due to Client #1's pain. Registered Nurse D documented that that Client #1 was on oxygen at 2 liters per nasal cannula. Client #1s record did not contain an order for oxygen. Client #3: Record review of Client #3's record revealed a Plan of Care dated 12/18/2023 to 3/16/2024. The Plan of Care indicated that Client #3 started on the agency's services on 12/18/2023. The Plan of Care listed Bacteremia (presence of bacteria in the bloodstream) as the terminal diagnosis. Registered Nurse C conducted a start of care comprehensive assessment skilled nurse visit on 12/18/2023. Registered Nurse C documented that Client #3 was alert, oriented to person, place and time. Registered Nurse C documented that Client #3 reported a pain level of 8 on a pain scale of 0-10, that the pain was to the back and lower extremities, and described the pain as aching, sore, and tingling. Client #3's record contained an order, dated 12/18/2023, for Lyrica (medication used to treat pain caused by nerve damage) 50 milligrams by mouth three times a day. Registered Nurse C conducted a skilled nurse visit on 12/19/2023. Registered Nurse C documented that Client #3 had severe pain that was described as aching, sore, and tender and that the pain was intermittent. Registered Nurse C documented that Client #3 refused pain medication at that time. Registered Nurse C documented that comfort medications were ordered. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam - used for anxiety), Fentanyl Transdermal (used for pain), Hydromorphone (used for pain), and Morphine (used for pain). Client #3's clinical record did not contain a physician order for medications on 12/19/2023. Registered Nurse C conducted a skilled nurse visit on 12/26/2023. Registered Nurse C documented for Client #3 was unable to swallow pills. Client #3 complained of pain when repositioned. Client #3's family requested an increase in dosage of Fentanyl patch due to inability to swallow tablets. Client #3's family were instructed to give morphine for pain and shortness of breath as needed. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse C conducted an as needed skilled nurse visit on 12/27/2023. Registered Nurse C documented instructions to Client #3's family to give Client #3 Morphine as needed for pain. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse C conducted a skilled nurse visit on 12/28/2023. Registered Nurse C documented instructions to Client #3's family to give Morphine as needed. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse C conducted a skilled nurse visit on 12/29/2023. Registered Nurse C documented instructions to Client #3's family to give Morphine as needed. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse E conducted a skilled nurse visit on 12/30/2023. Registered Nurse E documented that Client #3's family reported that the family were giving Client #3 Lorazepam and Morphine. Registered Nurse E documented that controlled substances were counted and listed Ativan (Lorazepam) and Morphine. Registered Nurse C conducted a hospice death at home visit on 12/31/2023. Client #3's client record did not contain orders for Morphine or Lorazepam. During an interview on 2/7/2024 at 12:42 with the Administrator/Alternate Supervising Nurse, the surveyor discussed that orders for medications were not in the client records. The Administrator/Alternate Supervising Nurse was to review the records. The Administrator informed the surveyor that Registered Nurse D was no longer employed at the agency. During an interview on 2/7/2024 at 2:16 p.m. with the Administrator/Alternate Supervising Nurse, the Administrator/Alternate Supervising Nurse informed the surveyor that the Administrator/Alternate Supervising Nurse was not able to reach Registered Nurse C. Registered Nurse C was on sick leave. The surveyor was not able to speak with Registered Nurse C. During an interview on 2/7/2024 at 4:19 p.m. with the Administrator/Alternate Supervising Nurse, the Administrator/Alternate Supervising Nurse informed the surveyor that the nurses were to follow the agency's policy regarding receipt of physician orders, the nurses were to put the order in the client record when the order was received. The Administrator responded "No," when asked if the medication orders were in the client records. The agency had a policy titled "Physician Verbal Orders," labeled TX-002, that was last reviewed on 10/16/2023. The policy read in part; "Policy Verbal or telephone orders may only be taken by appropriately licensed staff members, acting within the scope of their licenses, and shall be immediately recorded, signed and dated by the licensed staff member receiving such an order...Operational Guidelines: 1. The licensed staff member receives the verbal order from the physician either in person or on the phone, verifies the order by 'reading back' the full order then records the verbal order electronically via the PointCare device or directly into the HCHB [Home Care Home Base - electronic medical record].

It is required that the comprehensive assessment includes consideration of the following factors: complications and risk factors that affect care planning, including risk for drug diversion. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients residing in a Skilled Nursing Facility (SNF), the hospice did not ensure the comprehensive assessment included risk factors that affected care planning. Clinical Record 4: The patient elected hospice care on 3/17/23 and resided in a Skilled Nursing Facility (SNF). The initial comprehensive assessment completed by the Registered Nurse (RN) on 3/17/23 documented, "required 2 persons to transfer, Hoyer lift, bed bound and transfer to bed/chair." A review of the clinical record and fall reports revealed patient falls documented on 3/29/23, 3/30/23, and 4/9/23 while the patient resided in the SNF. The Skilled Nursing (SN) assessment dated 3/29/23 documented, "PRN visit, patient fell last night, tried to walk and fell, no pain, fall assessment: confusion and 1-2 falls in past 3 months, and phone call to wife no answer left voice message." The SN visit note dated 3/31/23 documented, "Fell last night, second fall last week, made contact with wife." The SN visit note dated 4/9/23 documented, "Visit reason for fall, facility reported, 1-2 falls in past 3 months, bruises right hip, no pain unless touched, facility ordered x-ray, facility contacted emergency contact." The SN visit note dated 4/11/23 documented, "3 or more falls in past 3 months, non-ambulatory, bed bound, pain right hip, swollen and bruised." For the patient's readmission to hospice, the SN assessment dated 5/1/23 documented, "No falls past 3 months." The SN visit note dated 5/8/23 documented "frequent falls, none past week, message left for wife, patient stated partner no longer answers calls." The SN visit notes 5/14/23 and 5/18/23 documented "1-2 falls past 3 months" and "3 or more falls past 3 months, respectively." The initial and updated comprehensive assessments did not include documentation of a fall risk assessment or safety risk assessment. During an interview on 8/25/23, the Area Director of Operations confirmed the findings and stated the hospice managers and the nurse employed during the patient's hospice stay were no longer working for this hospice.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review. In 2 of 4 (50%) clinical records reviewed, the hospice did not ensure the plan of care reflected patient and family goals and interventions based on the problems identified in the initial and updated comprehensive assessments. Clinical Record 4: The patient elected hospice care on 3/17/23 and resided in a Skilled Nursing Facility (SNF). The initial comprehensive assessment completed by the Registered Nurse (RN) on 3/17/23 documented, "required 2 persons to transfer, Hoyer lift, bed bound and transfer to bed/chair." On 3/29/23, the physician ordered: "floor fall mats and bed alarm." A review of the clinical record and fall reports revealed patient falls documented on 3/29/23, 3/30/23, and 4/9/23 while the patient resided in the SNF. The hospice plan of care did not include documentation of goals and interventions related to the patient's frequent falls and risk for falls. The patient was discharged from hospice care on 4/30/23 due to a change in payor source and readmitted to hospice care on 5/1/23. On 5/17/23, the patient was moved from the SNF to home with his wife as the caregiver. The patient expired on 6/30/23. Clinical Record 3: The patient elected hospice care on 8/2/23. The initial comprehensive assessment completed by the RN on 8/2/23 documented, "fall assessment: 3 or more falls in past 3 months, and high risk for falls." The hospice plan of care did not include documentation of goals and interventions related to the patient's frequent falls and risk for falls identified in the initial comprehensive assessment.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation; [and] provision of care and services. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients residing in a Skilled Nursing Facility (SNF), the hospice did not ensure that the Administrator, appointed by the hospice's governance, assumed responsibility for the provision of care and services of patients residing in the SNF. Clinical Record 4: The patient elected hospice care on 3/17/23 and resided in a Skilled Nursing Facility (SNF). The wife and the daughter were listed in the clinical record as primary caregivers. The initial comprehensive assessment completed by the Registered Nurse (RN) on 3/17/23 documented, "required 2 persons to transfer, Hoyer lift, bed bound and transfer to bed/chair." A review of the clinical record and fall reports revealed patient falls documented on 3/29/23, 3/30/23, and 4/9/23 while the patient resided in the SNF. The Skilled Nursing (SN) assessment dated 3/29/23 documented, "PRN visit, patient fell last night, tried to walk and fell, no pain, fall assessment: confusion and 1-2 falls in past 3 months, and phone call to wife no answer left voice message." On 3/29/23, an order for an x-ray of the hip revealed no fracture. A review of the hospice's durable medical equipment (DME) tracking report revealed that the bed alarm was ordered on 3/29/23, the bed alarm was "out of stock" on 3/31/23 and delivered to the patient on 4/14/234. The SN visit note dated 3/31/23 documented, "Fell last night, second fall last week, made contact with wife." The SN visit note dated 4/9/23 documented, "Visit reason for fall, facility reported, 1-2 falls in past 3 months, bruises right hip, no pain unless touched, facility ordered x-ray, facility contacted emergency contact." A repeated hip x-ray dated 4/9/23 documented no fracture. The SN visit note dated 4/11/23 documented, "3 or more falls in past 3 months, non-ambulatory, bed bound, pain right hip, swollen and bruised". On 4/11/23, an order to repeat the x-ray of the hip revealed no fracture. A clinical record review revealed no documented evidence of the presence of the bed alarm while the patient was in the SNF or at home. The SN visit notes did not include documentation regarding the presence of the bed alarm. The hospice plan of care was not updated to document identified problems, goals, and nursing interventions related to the patient's frequent falls and risk for falls. For the patient's readmission to hospice, the SN assessment dated 5/1/23 documented, "No falls past 3 months." The SN visit note dated 5/8/23 documented, "frequent falls, none past week, message left for wife, patient stated partner no longer answers calls." The SN visit notes 5/14/23 and 5/18/23 documented, "1-2 falls past 3 months" and "3 or more falls past 3 months, respectively speaking." There was no nursing fall assessment or safety risk assessment related to falls documented in the SN visit notes 5/25/23, 6/2/23, 6/9/23, 6/15/23, 6/22/23, 6/26/23, and 6/29/23. The SNF clinical record documentation was not available for review. During an interview on 8/25/23, the Area Director of Operations stated they spoke to the SNF, and the SNF medical record system was down. During interview 8/25/23, the Administrator reviewed the clinical record two times and confirmed the missing fall and/or safety assessments related to falls. The hospice managers and nurse while the patient was on service were no longer working for this hospice and unable to be interviewed.

It is required that the hospice assumes responsibility for the professional management of the SNF/NF or ICF/IDF resident's hospice services in accordance with the hospice plan of care (POC) and the hospice conditions of participation. Any arrangements necessary for hospice-related inpatient care are made in a participating Medicare/Medicaid facility per the inpatient standards (HSIC chapter in this Manual). THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review, document review and interview with the Area Director of Operations which revealed the hospice failed to ensure the Interdisciplinary Group (IDG) maintained responsibility for the professional management for the provision and coordination of all hospice services provided to the patient residing in a Skilled Nursing Facility (SNF) [HSRF.4.I/L762]; and failed to ensure that the Administrator, assumed responsibility for the provision of care and services of patients residing in the SNF [HSLG.2.I/L651]. The cumulative effect of these systemic problems has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42CFR 484.112 Hospices that provide hospice care to residents of a SNF/NF or ICF/IID. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients including ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG); assessment, coordination, and provision of needed general inpatient or continuous care; consultation about the patient’s/resident’s care with the facility staff; coordination by the hospice RN for the implementation of the plan of care for the patient/resident; provision of hospice aide services, if these services are determined to be necessary by the IDG to supplement the nurse aide services provided by the facility; provision, in a timely manner, of all supplies, medications, and durable medical equipment (DME) needed for the palliation and management of the terminal illness and related conditions; financial management responsibilities for all supplies, appliances, medications, and biologicals related to the terminal illness and related conditions; determination of the appropriate level of care to be given to the patient/resident (i.e., routine homecare, inpatient or continuous care); [and] arranging any necessary transfers from the facility of residence in consultation with the facility staff. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the hospice did not ensure the IDG maintained responsibility for the provision and coordination of all hospice services provided to the patient. Specifically the provision, in a timely manner, of all supplies, medications, and durable medical equipment (DME) needed for the palliation and management of the terminal illness and related conditions. Clinical Record 4: The patient elected hospice care on 3/17/23 and resided in a Skilled Nursing Facility (SNF). The patient's terminal diagnosis was documented as intrahepatic cholangial carcinoma. The initial comprehensive assessment completed by the Registered Nurse (RN) on 3/17/23 documented, "required 2 persons to transfer, Hoyer lift, bed bound and transfer to bed/chair." On 3/29/23, the physician ordered: "floor fall mats and bed alarm." A review of the clinical record and fall reports revealed patient falls documented on 3/29/23, 3/30/23, and 4/9/23. A physician's order was obtained on 3/29/23 for "bed alarm and floor mats." The Hospice's durable medical equipment (DME) tracking report documented the bed alarm was called into the DME company on 3/29/23, and the bed alarm was "out of stock" as of 3/31/23. The DME tracking report documented that the bed alarm was delivered to the patient on 4/14/23. A clinical record review revealed no documented evidence regarding the presence of the bed alarm until noted in an IDG note on 5/11/2023.The patient was discharged from hospice care on 4/30/23 due to a change in payor source and readmitted to hospice care on 5/1/23. On 5/17/23, the patient was moved from the SNF to home with his wife as the caregiver. There was no evidence of documentation by the Skilled Nurse (SN) regarding the presence or absence of a bed alarm from 3/29/23 through the patient's death on 6/30/23. There was no evidence of care management oversight provided by the hospice IDG and no evidence that an ongoing exchange of information occurred between the hospice IDG and the SNF for the care and services provided to the patient. During an interview on 8/25/23, the Area Director of Operations stated that they spoke to the SNF, that the SNF medical record system was down, and clinical records could not be accessed. The hospice managers and the nurse employed while the patient was a hospice patient were no longer working for the agency. During interview 8/25/23, the Administrator and Regional Director of Operations stated they located the hospice's DME tracking report and that the bed alarm and floor mats were called into the Hospice's DME company on 3/29/23, the bed alarm was "out of stock" and only the floor mats were delivered to the patient on 3/29/23. The Administrator stated the DME tracking report included that the bed alarm was not delivered to the patient until 4/14/23. During interview 8/25/23, the Administrator reviewed the clinical record twice and confirmed missing nursing documentation that the bed alarm had been provided to the patient and was in place from date of order 3/29/23 through date of death 6/30/23.

It is required that the hospice designates a Registered Nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. 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 (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure the Registered Nurse followed the plan of care as ordered. Record 7: The patient’s date of election of hospice services was 9/21/2022. The plan of care order on 9/21/2022 ordered visit frequency for skilled nurse 3w1, and 7w6. During the week 9/25/2022-10/1/2022, there was a nursing visit on 9/25/2022, 9/27/2022, 9/28/2022, 9/29/2022 and 9/30/2022. There was no documented evidence of a sixth or seventh nursing visit or documented reason for the missed visits. Record 8: The patient’s date of election of hospice services was 6/7/2022. A physician’s order on 6/22/2022 effective 6/19/2022 ordered visit frequency for skilled nurse 2 x weekly. During the week of 6/26/2022-7/2/2022, there was a nursing visit on 6/28/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. During the week of 7/3/2022-7/9/2022, there was a nursing visit on 7/5/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. During the week of 7/10/2022-7/17/2022, there was a nursing visit on 7/15/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. The Director of Operations was interviewed on 11/2/2022 and agreed, the Registered Nurse did not follow the plan of care as ordered. Record 7: The patient’s date of election was 9/21/2022. The plan of care order on 9/21/2022 ordered skilled nurse 3w1, 7w6. During the week 9/25/2022-10/1/2022, there was a nursing visit on 9/25/2022, 9/27/2022, 9/28/2022, 9/29/2022 and 9/30/2022. There was no documented evidence of a sixth or seventh nursing visit or documented reason for the missed visits. Record 8: The patient’s date of election was 6/7/2022. A physician’s order on 6/22/2022 effective 6/19/2022 ordered skilled nurse 2 x weekly. During the week 6/26/2022-7/2/2022, there was a nursing visit on 6/28/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. During the week 7/3/2022-7/9/2022, there was a nursing visit on 7/5/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. During the week 7/10/2022-7/17/2022, there was a nursing visit on 7/15/2022. There was no documented evidence of a second nursing visit or documented reason for the missed visit. The Director of Operations was interviewed on 11/2/2022 and agreed, the registered nurse did not follow the plan of care as ordered.

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse and per the patient's plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. Agency policy, “The Provision of Wound and Skin Care,” stated in part, “Wounds will be measured a minimum of one time a week.” 2 of 3 (67%) clinical records reviewed with a wound identified, the hospice did not ensure the Registered Nurse measured wounds, at a minimum, one time weekly. Record 2: The patient’s date of election of hospice services was 5/3/2021. The Registered Nurse documentation on 5/18/2022 identified “Stage 2 pressure ulcer, coccyx.” The wound record report and nursing visit documentation were reviewed for 8/1/2022-9/26/2022. There was no documented evidence of wound measurements between 8/1/2022-9/26/2022. Record 7: The patient’s date of election of hospice services was 9/21/2022. The Registered Nurse documentation on 9/21/2022 identified “Stage IV pressure ulcer, coccyx.” The wound record report and nursing visit documentation were reviewed for 9/21/2022-10/26/2022. There was no documented evidence of wound measurements between 9/21/2022-10/26/2022. The Director of Operations was interviewed on 11/3/2022 and stated, “we just realized within the last two weeks that measurements weren’t being done weekly.” The Director of Operations agreed, there was no documented evidence of wound measurements in the records identified. Agency policy, “The Provision of Wound and Skin Care,” stated in part, “Wounds will be measured a minimum of one time a week.” Record 2: The patient’s date of election was 5/3/2021. The registered nurse documentation on 5/18/2022 identified “Stage 2 pressure ulcer, coccyx.” The wound record report and nursing visit documentation was reviewed for 8/1/2022-9/26/2022. There was no documented evidence of wound measurements between 8/1/2022-9/26/2022. Record 7: The patient’s date of election was 9/21/2022. The registered nurse documentation on 9/21/2022 identified “Stage IV pressure ulcer, coccyx.” The wound record report and nursing visit documentation was reviewed for 9/21/2022-10/26/2022. There was no documented evidence of wound measurements between 9/21/2022-10/26/2022. The Director of Operations was interviewed on 11/3/2022 and stated, “we just realized within the last two weeks that measurements weren’t being done weekly.” The Director of Operations agreed, there was no documented evidence of wound measurements in the records identified.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by a review of personnel records and interviews. 2 of 2 (100%) personnel records of hospice aides reviewed, the hospice did not ensure that a competency assessment was completed upon hire. Record 8: (Hospice Aide): hire date 3/2/2022. There was no documented evidence that a competency evaluation was completed upon hire. Record 9: (Hospice Aide): hire date 6/16/2021. There was no documented evidence that a competency evaluation was completed upon hire. The Director of Operations was interviewed on 11/3/2022 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Director of Operations confirmed the staff identified have been making visits and stated, “These should have been completed before the staff was making visits on their own.” Record 8 (Hospice Aide): hire date 3/2/2022. There was no documented evidence that a competency evaluation was completed upon hire. Record 9 (Hospice Aide): hire date 6/16/2021. There was no documented evidence that a competency evaluation was completed upon hire. The Director of Operations was interviewed on 11/3/2022 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Director of Operations confirmed the staff identified have been making visits and stated, “These should have been completed before the staff was making visits on their own.”

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 3 of 10 (30%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide followed the plan of care as ordered. Record 4: The patient’s date of election of hospice services was 11/6/2019. A physician’s order effective 12/26/2021 ordered a visit frequency for the hospice aide 2 x weekly for 8 weeks. During the week 1/9/2022-1/15/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visits. During the week 2/13/2022-2/19/2022, there was a hospice aide visit on 2/17/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 6: The patient’s date of election of hospice services was 12/17/2020. A physician’s order on 7/25/2022 effective 8/9/2022 ordered a visit frequency for the hospice aide 1 x weekly for 9 weeks. During the week 8/14/2022-8/20/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visit. Record 8: The patient’s date of election of hospice services was 6/7/2022. A physician’s order on 6/7/2022 ordered a visit frequency for the hospice aide 4w1, 5w12. During the week 6/26/2022-7/2/2022, there was a hospice aide visit on 6/27/2022. There was no documented evidence of a second, third, fourth or fifth hospice aide visit or documented reason for the missed visits. The Director of Operations was interviewed on 11/3/2022 and agreed, the hospice aide did not follow the plan of care as ordered. Record 4: The patient’s date of election was 11/6/2019. A physician’s order effective 12/26/2021 ordered a hospice aide 2 x weekly for 8 weeks. During the week 1/9/2022-1/15/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visits. During the week 2/13/2022-2/19/2022, there was a hospice aide visit on 2/17/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 6: The patient’s date of election was 12/17/2020. A physician’s order on 7/25/2022 effective 8/9/2022 ordered a hospice aide 1 x weekly for 9 weeks. During the week 8/14/2022-8/20/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visit. Record 8: The patient’s date of election was 6/7/2022. A physician’s order on 6/7/2022 ordered a hospice aide 4w1, 5w12. During the week 6/26/2022-7/2/2022, there was a hospice aide visit on 6/27/2022. There was no documented evidence of a second, third, fourth or fifth hospice aide visit or documented reason for the missed visits. The Director of Operations was interviewed on 11/3/2022 and agreed, the hospice aide did not follow the plan of care as ordered.

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. 2 of 3 (67%) clinical records reviewed with a wound identified, the hospice did not ensure the clinical record included a physician’s order for wound care. Record 1: The patient’s date of election of hospice services was 10/19/2022. The Registered Nurse documentation on 10/20/2020 revealed, “Stage IV noted to the coccyx, cleansed with NS, covered with a foam dressing.” There was no documented evidence of a physician's order for wound care. Record 7: The patient’s date of election of hospice services was 9/21/2022. The Registered Nurse documentation on 9/21/2022 identified “Stage IV pressure ulcer, coccyx.” The Registered Nurse documentation on 9/22/2022 revealed, “Wound care performed. Cleaned with wound cleanser spray and applied Therahoney and zinc, covered with new Optifoam.” There was no documented evidence of a physician's order for Therahoney. The Director of Operations was interviewed on 11/3/2022 and agreed, there were no physician orders for the wound care provided. Record 1: The patient’s date of election was 10/19/2022. The Registered Nurse documentation on 10/20/2020 revealed, “Stage IV noted to coccyx, cleansed with NS, covered with foam dressing.” There was no documented evidence of a physican’s order for the wound care. Record 7: The patient’s date of election was 9/21/2022. The Registered Nurse documentation on 9/21/2022 identified “Stage IV pressure ulcer, coccyx.” The Registered Nurse documentation on 9/22/2022 revealed, “Wound care performed. Cleaned with wound cleanser spray and applied Therahoney and zinc, covered with new Optifoam.” There was no documented evidence of a physican’s order for Therahoney. The Director of Operations was interviewed on 11/3/2022 and agreed, there were no physician orders for the wound care provided.