Every finding on record at Continuum Care of Broward LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 4 of 19 (21%) clinical records reviews and home visits observations completed revealed that the agency did not ensure the agency provided medication profiles were updated to the patient's current medication regimen. Agency Policy titled Medication Profile (effective 3/1/2019) sub-section one (1) stated in part, "Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date, and time of administration. Sub-section seven (7) stated in part, A drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to the comprehensive assessments are performed when care is resumed after a patient has been placed on hold, or with the addition of a new medication." Home Visit 1/Clinical Record 1: A home visit with the aide [Personnel Record 6] was completed on 12/19/2023. The patient election of benefit was dated 4/10/2023. A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The patient's caregiver confirmed during the home visit that the patient was taking the medication Fish oil one-thousand milligrams one capsule daily and Methenamine one gram, one tablet two times daily. The Fish Oil and the Methenamine were not on the agency provided medication profile. Home Visit 2/Clinical Record2: A home visit with the aide [Personnel Record 7] was completed on 12/19/2023. The patient election of benefit was dated on 6/1/2023 and resided in Assisted Living Facility (ALF). A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The Assisted Living Facility (ALF) medication administration record/medication list dated 12/19/2023 stated in part, "Carafate tablet one gram, take one tablet three times a day; Crestor twenty milligrams take one tablet every night at bedtime." The hospice agency medication profile did not contain the medications Carafate or Crestor. Home Visit 3/Clinical Record 3: A home visit with the registered nurse [Personnel Record 4] was completed on 12/19/2023. The patient election of the hospice benefit was dated 3/29/2023 and resided in Assisted Living Facility (ALF). A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The ALF medication administration record/medication list stated in part, "Vitamin D 3 one thousand international units, take one capsule daily. Sertraline fifty milligrams, take one tablet daily. The hospice agency medication profile/list did not contain Vitamin D 3 or Sertraline. Home Visit 4/Clinical Record 4: A home visit with the Chaplain [Personnel Record 9] was completed on 12/19/2023. The patient election of hospice benefit was dated 8/29/2023 and resided in Assisted Living Facility (ALF). A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The ALF medication administration record/medication list dated 12/19/2023 stated in part, "Amlodipine five milligrams, take one tablet once daily. Atorvastatin forty milligrams, take one tablet by mouth once daily". The hospice agency medication profile did not contain the medications Amlodipine or Atorvastatin. A joint record review, observation, and interview with the Patient care Manager on 12/19/2023 confirmed the hospice agency medication profiles dated 12/19/2023 did not match the patient's current medication regimens.

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 clinical record review, document review, and interview. In 1 of 7 (14%) records reviewed where wounds were identified revealed that the hospice agency did not ensure the registered nurse (RN) provided care coordination to ensure the implementation of the interdisciplinary plan of care. Agency Policy titled Coordination of Services (effective 3/1/2019) sub-section policy statement stated in part, "It will be the responsibility of the RN Case Manager to facilitate communication about changes in the patient status. Sub-section four (4) stated in part, Care coordination will include, but not be limited to (A) Clearly outlining each clinician's responsibilities to avoid a duplication of services. Sub-section six (6) stated in part, Organization personnel will communicate in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note." Agency Policy titled Plan of Care (effective 3/1/2019) sub-section titled Policy stated in part, " The care provided to the patient must be in accordance with the plan of care." Clinical Record 8: The election of the hospice benefit was dated 6/20/2023. The benefit period of 9/18/2023-12/16/2023 contained a visit frequency order signed and dated 9/13/2023 that stated, "RN two times a week for thirteen weeks, and three as needed (PRN) visits. A physician order dated 10/3/2023 stated, "Hospice nurse to provide wound care three times a week and PRN (as needed) if soiled or dislodged. Cleanse wound with wound cleanser. Apply skin prep to the peri-skin of the wound. Apply silver anti-bacterial gel to the wound base and cover with bordered gauze dressing." During the weeks from 10/8/2023 through 11/11/2023, the RN completed wound care visits twice a week. There was no documented evidence of a third RN visit for those weeks and no documented evidence that the physician was notified that wound care was provided twice a week and not three times a week as ordered. A joint record review and interview with the Clinical Educator on 12/20/2023 confirmed the hospice RN did not provide wound care three times a week as ordered by the physician. The Clinical Educator phoned the RN Case Manager to provide education regarding the need to follow physician orders. During the phone interview, the RN Case Manager reported that the Assisted Living Facility (ALF) provided wound care one day a week until recently when the ALF nurse went on leave. Further interviewing revealed that the patient's hired personal caregiver was currently performing the wound care one time per week. The Clinical Educator confirmed the record did not contain any evidence of the care coordination of when the hospice would be performing wound care and when the caregiver would be providing the wound care.

It is required that each patient’s individualized written plan of care includes all drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 4 of 19 (21%) clinical records reviewed and home visits conducted revealed the hospice agency did not ensure all drugs necessary to meet the needs of the patient were included in the plan of care (POC). Agency Policy titled Plan of Care (effective 3/1/2019) sub-section twelve (12) stated in part, "The written plan of care will contain, but will not be limited to the following: (Q) drugs and treatments." Home Visit 1/Clinical Record 1: A home visit with the aide [Personnel Record 6] was completed on 12/19/2023. The patient election of benefit was dated 4/10/2023. A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The patient's caregiver confirmed during the home visit that the patient was taking the medication Fish oil one-thousand milligrams one capsule daily and Methenamine one gram, one tablet two times daily. The Fish Oil and the Methenamine were not on the agency provided medication profile. The medication Methenamine was not on the hospice agency's POC dated 12/6/2023-2/3/2024. Home Visit 2/Clinical Record2: A home visit with the aide [Personnel Record 7] was completed on 12/19/2023. The patient election of benefit was dated on 6/1/2023. A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The Assisted Living Facility (ALF) medication administration record/medication list dated 12/19/2023 stated in part, "Carafate tablet one gram, take one tablet three times a day; Crestor twenty milligrams take one tablet every night at bedtime." The hospice agency medication profile and the POC dated 11/26/2023-01/26/2024 did not contain the medications Carafate or Crestor. Home Visit 3/Clinical Record 3: A home visit with the registered nurse [Personnel Record 4] was completed on 12/19/2023. The patient election of the hospice benefit was dated 3/29/2023. A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The ALF medication administration record/medication list stated in part, "Vitamin D 3 one thousand international units, take one capsule daily. Sertraline fifty milligrams, take one tablet daily. The hospice agency medication profile/list and the POC dated 11/24/2023-1/22/2024 did not contain Vitamin D 3 or Sertraline. Home Visit 4/Clinical Record 4: A home visit with the Chaplain [Personnel Record 9] was completed on 12/19/2023. The patient election of hospice benefit was dated 8/29/2023. A medication reconciliation was performed by comparing the hospice agency medication profile dated 12/19/2023 to the patient's current medication regimen. The ALF medication administration record/medication list dated 12/19/2023 stated in part, "Amlodipine five milligrams, take one tablet once daily. Atorvastatin forty milligrams, take one tablet by mouth once daily". The hospice agency medication profile and the POC dated 11/27/2023-2/24/2024 did not contain the medications Amlodipine or Atorvastatin. A joint record review, observation, and interview with the Patient care Manager on 12/19/2023 confirmed the hospice agency's plans of care did not contain all the drugs needed for the palliation of the patients.

It is required that bereavement services are available to the family and other individuals for up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 3 (33%) records reviewed where bereavement services were accepted revealed that the hospice agency did not ensure bereavement services reflected the needs of the primary bereaved. Agency Policy titled Bereavement Services (effective 3/1/2019) sub-section policy stated in part, "The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patient's death in accordance with the written plan of care. Sub-section one (1) stated in part, A bereavement risk assessment will be completed at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. Sub-section five (5) stated in part, fter a death has occurred, the bereavement assessment will be updated, and the family caregiver needs will be discussed in the next interdisciplinary group meeting. Sub-section nine (9) stated in part, after one (1) month, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. Sub-section twelve (12) stated in part, in addition to the services outlined above, a person deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered as noted in the plan of care. Persons identified will be referred to the Bereavement Coordinator, and intervention will be provided as follows: (A) The Bereavement Coordinator will evaluate each bereaved on a case-by-case basis and evaluate the need for individual counseling. Sub-section thirteen (13) stated in part, A bereavement file will be maintained on each family/caregiver unit of care, in addition to the electronic health record. Together the complete file will contain the following information: (A) a Copy of the patient referral and initial bereavement assessment, (B) a Bereavement Service Report, (C) All bereavement assessments made, (D) a Bereavement Plan of care, (E) All bereavement clinical notes that have been written and/or sent to the bereaved." Clinical Record 17: The election of hospice benefit was dated 7/6/2023 and the patient died on 07/25/2023. There was an initial bereavement risk assessment for the primary bereaved dated 7/8/2023, which identified a moderate bereavement risk. A second bereavement risk assessment was dated 7/12/2023, which identified the primary bereaved person as a moderate risk again. A third bereavement risk assessment was dated 7/24/2023. There was no documented evidence that the bereaved person was reassessed after the patient’s death on 07/25/2023. There was a bereavement care plan dated 7/8/2023 and modified on 7/24/2023, which identified the interventions of send a sympathy card with a due date of 7/30/2023, send one month letter by 8/24/2023, send three-month letter by 10/23/2023, and send memorial letter/invitation by 8/24/2023, and all interventions were complete. There was no documented evidence that the bereavement care plan had been updated since 7/24/2023. A joint record review and interview with the Clinical Educator on 12/21/2023 confirmed the record did not contain an updated bereavement risk assessment after the patient's death. In addition, the Clinical Educator confirmed the record contained three (3) bereavement risk assessments, which identified the primary bereavement as a moderate risk. The Clinical Educator confirmed the record did not contain any evidence of increased bereavement services, any proof of referral to the bereavement coordinator, or any updates to the bereavement care plan since 7/24/2023, one (1) day before death. In addition, the interdisciplinary (IDG) meeting post-death date of 8/2/2023 did not contain any evidence the bereavement needs were reassessed or discussed by the IDG. The Clinical Educator reported that while the record did not contain evidence that bereavement services were being provided at an increased rate, they felt like the care was being provided, just not documented. The Clinical Educator reached out to the Chaplain, acting as both a Chaplain and a Bereavement Coordinator during July and August of 2023. The Chaplain provided an email to the Clinical Educator on 12/21/2023, which stated in part, "On 8/28/2023 the Bereavement coordinator contacted son (bereaved person) who had recently returned to (home state) and was currently surrounded by family. Has family support. The bereaved is now doing better and has returned to work. No signs of complicated grief currently, at a low risk. In addition, on 9/29/2023, the Bereavement Coordinator attempted to contact (the bereaved person) but could not leave a message because the mailbox was full.

It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 3 of 19 (16%) records reviewed where hospice aide services were accepted revealed that the agency did not ensure the hospice aide provided all services and tasks included in the plan of care. Agency Policy titled Plan of Care (effective 3/1/2019) sub-section titled Policy stated in part, " The care provided to the patient must be in accordance with the plan of care." Home Visit 1/Clinical Record 1: A home visit observation with the aide [Personnel Record 6] was conducted on 12/19/2023. The hospice benefit election was dated 4/10/2023. The hospice aide care plan dated 12/6/2023-2/3/2024 included an order for the hospice aide visit frequency of five times a week and stated in part, " bathing type-bed bath every visit, hair care every visit, skin care every visit, and dressing every visit." The hospice aide performed a shower during the home visit. The hospice aide stated, " I always give (her) a shower. I have never given (her) a bed bath." The hospice aide stated when asked about the type of bath provided last week, 12/10/2023-12/16/2023, the hospice aide stated, "I showered (her) every day last week." During the week of 12/10/2023-12/16/2023, the hospice aide documented that a bed bath was completed on all hospice aide visits. The record did not contain any evidence that the hospice aide updated the RN regarding administering a shower and not completing the bed bath. A joint observation and record review with the Patient Care Manager on 12/19/2023 confirmed the hospice aide did not perform a bed bath as ordered on the care plan but performed a shower. The Patient Care Manager confirmed the hospice aide did not update the RN about tasks not completed. A joint record review and interview with the Clinical Educator on 12/19/2023 confirmed the care plan ordered a bed bath every visit, and in addition, the Clinical Educator confirmed the record did contain any evidence the Interdisciplinary Group (IDG) was updated regarding hospice aide interventions not performed. Home Visit 2/Clinical Record 2: A home visit observation with the aide [Personnel Record 7] was conducted on 12/19/2023. The hospice benefit election was dated 6/1/2023 and resided in Assisted Living Facility (ALF). The hospice aide care plan dated 11/28/2023-1/26/2023 included an order for the hospice aide visit frequency of five times a week and stated in part, "bathing type-bed bath every visit, turn and position in bed every visit, shampoo every visit, perineal care every visit, and nail care every visit." The hospice aide performed a shower during the home visit. The aide stated when asked if the patient ever received a bed bath, and the hospice aide reported they always provide a shower, not a bed bath. During the week of 12/10/2023-12/16/2023, the hospice aide documented that a bed bath was completed on all hospice aide visits. The record did not contain any evidence that the hospice aide updated the RN regarding administering a shower and not completing the bed bath. A joint observation and record review with the Patient Care Manager on 12/19/2023 confirmed the hospice aide did not perform a bed bath as ordered on the care plan, but the hospice aide performed a shower. The Patient Care Manager confirmed the hospice aide did not update the RN about tasks not completed. A joint record review and interview with the Clinical Educator on 12/19/2023 confirmed the care plan ordered a bed bath every visit, and in addition, the Clinical Educator confirmed the record did not contain any evidence the Interdisciplinary Group (IDG) was updated regarding hospice aide interventions not performed. Clinical Record 12: The patient election of hospice benefit was dated 7/5/2023. The hospice aide care plan dated 10/3/2023-12/31/2023 included a frequency order for the aide three times a week and stated in part, "Turn and position every visit, skin care every visit, perineal care every visit, a bathing-bed bath every visit, and companionship every visit." The week of 12/10/2023-12/16/2023, the hospice aide documented interventions not completed on 12/16/2023 "Turn and position, skin care, perineal care, and bathing-bed bath." The record did not contain evidence the RN was updated about interventions not performed. A joint record review and interview with the Clinical Educator on 12/20/2023 confirmed the hospice aide did not provide all interventions ordered by the Interdisciplinary Group (IDG). In addition, the Clinical Educator confirmed the record did not contain any evidence that the Interdisciplinary Group (IDG) was updated about interventions not completed.

It is required that hospice aides report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 3 of 19 (16%) records reviewed in which hospice aid services were accepted revealed that the agency that the aide reported changes in the patient’s needs to the registered nurse (RN). Agency Policy titled Plan of Care (effective 3/1/2019) sub-section nine (9) stated in part, "The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every fifteen (15) days. Sub-section ten (10) stated in part, "Any change in the patient's condition must result in a change in the plan of care, prior to the implementation of the new service." Agency Policy titled Coordination of Services (effective 3/1/2019) sub-section statement stated in part, "It will be the responsibility of the RN Case Manager to facilitate communication about changes in the patient status among assigned personnel. Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient and relevant to the care/services provided. The clinician will facilitate communications about patient status changes among assigned personnel. Sub-section six (6) stated in part, "Organizational personnel will communicate changes in a timely manner via telephone, one-on-one meetings, and home visits. Documentation of all communication will be included in the clinical record." Home Visit 1/Clinical Record 1: A home visit observation with the aide [Personnel Record 6] was conducted on 12/19/2023. The hospice benefit election was dated 4/10/2023. The hospice aide care plan dated 12/6/2023-2/3/2024 included an order for the hospice aide visit frequency of five times a week dated and stated in part, " bathing type-bed bath every visit, hair care every visit, skin care every visit, and dressing every visit." The hospice aide performed a shower during the home visit. The hospice aide stated, " I always give (her) a shower. I have never given (her) a bed bath." The hospice aide stated when asked about the type of bath provided last week, 12/10/2023-12/16/2023, the hospice aide stated, "I showered (her) every day last week." During the week of 12/10/2023-12/16/2023, the hospice aide documented that a bed bath was completed on all hospice aide visits. The record did not contain any evidence that the hospice aide updated the RN regarding administering a shower and not completing the bed bath. During the week of 12/10/2023-12/16/2023, the hospice aide documented that a bed bath was completed on all hospice aide visits. The record did not contain any evidence that the hospice aide updated the RN regarding administering a shower and not completing the bed bath. A joint observation and record review with the Patient Care Manager on 12/19/2023 and interview on 12/20/2023 with the Clinical Educator confirmed the hospice aide did not perform a bed bath as ordered on the care plan and did not update the RN about tasks not completed. Home Visit 2/Clinical Record 2: A home visit observation with the aide [Personnel Record 7] was conducted on 12/19/2023. The hospice benefit election was dated 6/1/2023. The hospice aide care plan dated 11/28/2023-1/26/2023 included an order for the hospice aide visit frequency of five times a week and stated in part, "bathing type-bed bath every visit, turn and position in bed every visit, shampoo every visit, perineal care every visit, and nail care every visit." The hospice aide performed a shower during the home visit. The aide stated when asked if the patient ever received a bed bath, and the hospice aide reported they always provide a shower, not a bed bath. During the week of 12/10/2023-12/16/2023, the hospice aide documented that a bed bath was completed on all hospice aide visits. The record did not contain any evidence that the hospice aide updated the RN regarding administering a shower and not completing the bed bath. A joint observation and record review with the Patient Care Manager on 12/19/2023 confirmed the hospice aide did not perform a bed bath as ordered on the care plan, but the hospice aide performed a shower. The Patient Care Manager confirmed the hospice aide did not update the RN about tasks not completed. A joint record review and interview with the Clinical Educator on 12/19/2023 confirmed the care plan ordered a bed bath every visit, and in addition, the Clinical Educator confirmed the record did contain any evidence the Interdisciplinary Group (IDG) was updated regarding hospice aide interventions not performed. Clinical Record 12: The patient election of hospice benefit was dated 7/5/2023. The hospice aide care plan dated 10/3/2023-12/31/2023 included a frequency order for the aide three times a week and stated in part, "Turn and position every visit, skin care every visit, perineal care every visit, a bathing-bed bath every visit, and companionship every visit." The week of 12/10/2023-12/16/2023, the hospice aide documented interventions not completed on 12/16/2023 "Turn and position, skin care, perineal care, and bathing-bed bath." The record did not contain evidence the RN was updated about interventions not performed. A joint record review and interview with the Clinical Educator on 12/20/2023 confirmed the hospice aide did not provide all interventions ordered by the Interdisciplinary Group (IDG). In addition, the Clinical Educator confirmed the record did not contain any evidence that the Interdisciplinary Group (IDG) was updated about interventions not completed.

Based on record review and interview the Hospice failed to ensure the plan of care was individualized and complete to meet the patient's needs and goals for care, included measurable outcomes, and was updated as conditions changed for 2 of 3 patients (Patients# 1 and 2). The findings included: 1) Review of the record revealed Patient #1 resided in a nursing facility and was admitted to the hospice on 05/12/22 with a terminal diagnosis of senile degeneration of brain. Patient #1's Hospice "Start Of Care" nurse visit note dated 05/12/22 documents she had a Stage 4 pressure ulcer to the sacrum and Stage 3 pressure ulcers to both heels. Stage 3 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage, or bone. Upon further review, Patient #1's "Start Of Care" nurse visit note also documents her diagnoses included chronic obstructive pulmonary disease, that she required total care for all activities of daily living and had poor food intake despite much encouragement and assistance to eat. Upon further review, Patient #1's "Start Of Care" nurse visit note documents pain was an active problem for her that affected functional status and the ability to enjoy activities/hobbies, and pain was helped by "medications" and "positioning," without identifying the medications that provided relief or evidence of inquiry to Patient #1's goals for pain management. Review of Patient #1's "Hospice Certification and Plan of Care" (HCPOC) for the certification period of 05/12/22 to 08/09/22 reveals it does not include orders, plans, supplies needed, or goals for wound care or specify who would be responsible to perform wound care but documents under goals, "a nursing plan of care will be established." Furthermore, Patient #1's HCPOC does not include a measurable goal for pain management according to the patient's preference but documents "pain will be managed at a level acceptable to the patient." Patient #1's HCPOC documents under goals "patient will have safety needs met" and "Medications will be managed appropriately as evidenced. Facility nurse will verbalize/demonstrate compliance with medication regimen" (sic) but does not include measurable patient outcomes. Further review of the HCPOC reveals all of Patient #1's medications were oral capsules and pills, with no medications ordered by alternate routes or plans to manage potential anticipated end of life symptoms such as inability to swallow solid medications, pain, shortness of breath, nausea or vomiting, agitation or anxiety, or excess secretions. Further review of the HCPOC reveals a nebulizer was provided but there were no orders or documented plans for nebulizer treatments. Further review of the record documents Patient #1 was discharged from the nursing facility and went home to a private residence with family to provide care on 05/16/22 and had verbal orders dated 05/17/22 for wound care to the sacrum, left heel, and right ankle that was to be completed by the caregiver (family member) twice weekly and PRN (as needed), and by the hospice nurse "as needed." A physician verbal wound care order documented on "Continuum Care Multi-Discipline Notes" for a left ankle wound dated 06/08/22, co-signed by the physician on 08/15/22, documents for the nurse to educate the family member to do this wound care twice a week and "as needed" and the hospice nurse would do wound care "as needed" and assess and obtain weekly measurements. This order also documents on the same page "return demonstration observed by (family member)", education provided and "verbalized understanding." However, there was no documentation that the family member was willing and in agreement to provide wound care and no evidence of updates to the "plan of care" to include the presence and care of wounds, and weekly wound measurements. Furthermore, review of the "Wound Record Report" revealed no measurements of wounds documented after 06/08/22 and the reasons measurements were not taken during the twice weekly nurse visits were documented as "not due," with one exception as "unable" without further explanation on 06/29/22. Further review of the record revealed no evidence of revision to the plan of care, other than new wound care orders, to address Patient #1's changing care needs with the 05/16/22 transition from the nursing facility to home with family. During the survey, the Registered Nurse/Advanced Practice Registered Nurse who had visited Patient #1, Staff A, provided "late documentation" dated 08/15/22 that she provided education to the caregiver regarding wound care, medications, and repositioning the patient and that the caregiver declined a "comfort kit" or any change in medications for symptom management on 05/17/22; that "comfort meds (medications) for advanced pain or shortness of breath" were explained again and declined by the caregiver on 06/24/22; but no evidence that the reasons for the caregiver's reservations were explored so that alternatives could be considered or offered in order to maintain comfort at the end of life. During telephonic interview on 08/16/22 at 1:38 PM, Staff A initially stated the family member did Patient #1's wound care and she (Staff A) had taught her how to do it. Further into this conversation Staff A stated she herself did Patient #1's wound care on her twice weekly visits during which the family member was present, and that she measured the wounds and put that in her notes when she did, but Staff A didn't remember how often she did these measurements and it was "maybe every week." During this interview, Staff A also stated the family member refused a comfort kit and did not want morphine in the home, despite education on its benefits at the end of life, since Patient #1 was still comfortable. Staff A did not report inquiry or discussion of specific reasons for the objection, discussing alternatives to manage end of life symptoms, or consideration of medications that could be given by other routes to have on hand. A nurse visit note for an "as needed" visit 07/02/22 at 4:42 PM documented Patient #1 was unresponsive (and therefore would have been unable to take pills or tablets by mouth) and had dyspnea with severity of 5 out of 10 (10 being the worst), and "gurgling," irregular respirations but there was no comfort kit in the home and the nurse could not find a local pharmacy open at that time, so would have to attempt pharmacies in a larger area. Patient #1's "Coordination Note" on 07/02/22 at 8:47 PM documented a family member (not previously mentioned) called the hospice and described Patient #1's labored breathing, requesting intervention for comfort, and staff called (name of mail-order pharmacy) to help search for a local pharmacy. Patient #1's "Coordination Note" on 07/02/22 at 9:04 PM documented the family member called back to report Patient #1 had died. There was no evidence that orders for symptom management were placed or that a means for after-hours provision of medications to Patient #1 was identified. 2) Review of the record revealed Patient #2 started care with the hospice on 07/21/22 with a terminal diagnosis of cerebral atherosclerosis. Patient #2's Hospice "Start Of Care" nurse visit note dated 07/21/22 documented he had wounds to both legs from external fixator devices for multiple fractures and a wound to his right buttock. Upon further review, Patient #2's "Start Of Care" visit note documents pain was an active problem that affected his appetite, emotions, and mobility, that the pain was continuous aching that interfered with activity or movement "all of the time", and the pain was helped by distraction, medications, and positioning, without identifying the medications that provided relief. Review of Patient #2's "Hospice Certification and Plan of Care" (HCPOC) for the certification period of 07/21/22 to 10/18/22 reveals it does not include orders, plans, supplies needed, or goals for wound care or specify who would be responsible to perform wound care but documents under goals, "a nursing plan of care will be established" and "caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown." Furthermore, Patient #2's HCPOC does not include a measurable goal for pain management but documents "patient will demonstrate improved comfort through massage therapy services." Patient #2's HCPOC documents under goals "Patient/caregiver will administer medications as prescribed as evidenced by no adverse effects from medication error." Further review of Patient #2's HCPOC reveals it does not include any medications for pain, or evidence that the patient declined such medications and alternatives were explored.