Every finding on record at Curo Health Services LLC

Based on record review and interview, the IDG failed to ensure communication, collaboration, and coordination with patients, caregivers, and/or family occurred as part of the treatment planning process for 2 of 2 patient records reviewed for patients who lived in an assisted living facility and changed hospice agencies (Patients #2 and 3).Findings include: --- 1. The agency policy titled “Interdisciplinary Group Membership and Responsibilities,” revised 12/31/2025, indicated the IDG would collaborate with the patient/ caregiver/ family to develop the POC.2. The agency policy titled “Provision of Care to Residents of SNF/NF [skilled nursing facility/Nursing facility], ICF/IID [Intermediate Care Facility for Individuals with Intellectual Disabilities] or ALF,” revised 12/31/2025, indicated the IDG would establish and update the POC.  The POC should “Reflect the participation of the hospice … and the patient and family ….” The POC should “Document any hospice approved changes in the plan of care and that changes were discussed with the patient or representative ….”3. Review of an agency standard operating procedure, “Conducting an Effective Interdisciplinary Group (IDG) Meeting,” revised 09/15/2025.  The procedure indicated the development of the POC should be a collaboration between the IDG and the patient/ caregiver.4. The agency policy “The Plan of Care,” revised 12/31/2025, indicated “The patient and family/ caregiver will be encouraged to participate in the development of and continued updating of the plan of care.5. Review of an agency policy, “Informed Consent/ Refusal of Treatment,” revised 12/12/2025, indicated the “… patient and family/ caregiver will be given information (verbally and/or in writing that describes … Changes to services … in the care/ service of the patient.”6. Review of the agency complaint log evidenced 11 complaints dated 11/01/2025 through 02/09/2026. Six of the complaints were regarding communication issues between the patient or family/ caregiver and the hospice agency.7. Patient #2’s clinical record evidenced a SOC of 12/30/2025 and a discharge date of 01/22/2026. The record included power of attorney paperwork signed on 03/21/2025 with Person 9 named as the power of attorney. The clinical record indicated Patient #2 lived at Entity 8, an assisted living facility. The record failed to evidence collaboration with Patient #2’s power of attorney related to medication changes.A phone interview occurred 02/10/2026 beginning at 12:53 PM, Person 7, the DON at Entity 8 indicated they were not happy with the Hospice.  Person 7 indicated the hospice kept trying to change Patient #2’s medication orders without the power of attorney’s consent.  Person 7 indicated the hospice had poor follow-through.A phone interview occurred on 02/10/2026 beginning at 01:12 PM with Person 9, the power of attorney for Patient #2.  When asked, Person 9 indicated they changed hospice providers as the hospice would change medication orders without their knowledge or consent. Person 9 indicated they did not agree with the medication changes, especially the changes in narcotics.During an interview on 02/10/2026 beginning at 03:15 PM, the Alternate Administrator indicated the hospice nurse would contact the power of attorney and notify them of the change. The Alternate Administrator indicated the notification may occur after the medication change occurred.   8. Patient #3’s clinical record evidenced a SOC 02/08/2024 and a discharge date of 12/24/2025. The record included coordination notes that detailed hospice visits and after hours calls to the hospice triage service. RN 2’s note on 12/24/2025 detailed Entity 2’s concerns about Patient #3’s stroke-like symptoms and family’s request to send the patient to the hospital. RN 2 indicated Patient #3 had similar symptoms at an earlier hospice visit and the family was upset the hospice did not convey Patient #3 was having stroke-like symptoms at that time.During an interview on 02/09/2026 beginning at 08:31 AM, Person 1 indicated the hospice did not keep the family in the loop regarding Patient #3 and they had to rely on Entity 2 to keep them notified of Patient #3’s status.During an interview on 02/09/2026 beginning at 10:15 AM, the Alternate Administrator indicated Patient #3 had been discharged prior to them knowing the family’s concerns regarding communication.

Based on record review and interview, the IDG failed to provide collaboration with assisted living staff for 2 of 2 patient records reviewed for patients who lived in an assisted living facility and changed hospice agencies due to lack of collaboration and communication (Patients #2 and 3).Findings include: --- 1. The agency policy titled “Interdisciplinary Group Membership and Responsibilities,” revised 12/31/2025, indicated one of the IDG responsibilities included “Coordination of care and sharing of information among … non-hospice care providers.”2. The agency policy titled “Provision of Care to Residents of SNF/NF [skilled nursing facility/Nursing facility], ICF/IID [Intermediate Care Facility for Individuals with Intellectual Disabilities] or ALF,” revised 12/31/2025, indicated the IDG would establish and update the POC.  The plan of care should “Reflect the participation of the hospice, the ALF …” and ensure hospice approved changes were discussed with ALF representatives.  The policy further indicated an IDG representative was responsible for “Providing overall coordination of hospice care of the resident with the facility representative.” The IDG representative was responsible to communicate with the facility representatives “… to ensure the quality of care for the patient and family….”3. Review of an agency standard operating procedure, “Conducting an Effective Interdisciplinary Group (IDG) Meeting,” revised 09/15/2025.  The procedure indicated the development of the POC should be a collaboration between the IDG and the facility.4. Patient #2’s clinical record evidenced a SOC of 12/30/2025 and a discharge date of 01/22/2026. The record included power of attorney paperwork signed on 03/21/2025 with Person 9 named as the power of attorney. The clinical record indicated Patient #2 lived at Entity 8, an assisted living facility.A phone interview occurred 02/10/2026 beginning at 12:53 PM, Person 7, the DON at Entity 8 indicated they were not happy with the hospice.  Person 7 indicated the hospice kept trying to change Patient #2’s medication orders without the power of attorney’s consent.  Person 7 indicated the hospice had poor follow-through. Person 7 indicated Patient #2 changed to a different hospice provider.A phone interview occurred on 02/10/2026 beginning at 01:12 PM with Person 9, the power of attorney for Patient #2.  When asked, Person 9 indicated they changed hospice providers as the hospice would change medication orders without their knowledge or consent. Person 9 indicated they did not agree with the medication changes, especially the changes in narcotics.5. Patient #3’s clinical record evidenced a SOC of 02/08/2024 and a discharge date of 12/24/2025. The record indicated Patient #3 lived at Entity 2. The record indicated Patient #3 had several falls during the month of December 2025. On 12/13/2025, Patient #3’s family requested the patient have blood sugar readings twice a day and receive orders for insulin coverage as they believed this was related to Patient #3’s falls. RN 3 notified Entity 2 about blood sugar checks twice daily. There was no documentation of orders for insulin coverage. On 12/19/25 the facility NP increased Patient #3’s insulin as Patient #3 had a blood sugar level of 598. Documentation of a nursing visit on 12/24/2025 indicated Patient # 3 was at baseline. At 08:10 PM on 12/24/2025, hospice triage was notified by Entity 2 that Patient #3 was experiencing stroke-like symptoms and had a blood sugar level of 43. Patient #3 was transported to the hospital by ambulance.6. An interview with Person 1, one of Patient #3’s family members occurred on 02/09/2026. Person 1 indicated Patient #3’s blood sugar had gone down to 10 while at the hospital. Person 1 indicated the hospice never got a hold order (to hold insulin based on the blood sugar level) and Patient #3 should not have been given the morning insulin as the blood sugar was 80 that morning.An interview occurred 02/09/2026 beginning at 03:55 PM with the hospice Medical Director. The Medical Director indicated it was unlikely the Lantus was the sole reason for Patient #3’s hypoglycemic episode.During an interview on 02/10/2026 beginning at 11:35 AM, the Director of Clinical Services indicated she was unaware of when Patient #3’s Lantus was prescribed and who prescribed it. The Director of Clinical Services indicated that the nursing staff communicated with facility staff at each visit. She indicated the facility staff did not participate in the IDG meetings. She indicated there was no documentation on the overall care of the patient, just updates about each visit. The Director of Clinical Services indicated they were aware of some facilities who wanted more coordination with the hospice.During an interview on 02/09/2026 beginning at 10:15 AM, the Alternate Administrator indicated they were aware of complaints regarding communication and follow-up with patients, families, and facilities. The Alternate Administrator indicated they had several staff changes which caused inconsistent staff for patients, and that may have affected communication.

Based on record review and interview, the IDG failed to ensure social work services were provided as stated by the POC for 1 of 3 active patients reviewed with routine social services orders (Patient #4).Findings include: --- An agency policy, “The Plan of Care,” dated 01/23/2025, stated, “The care provided to the patient must be in accordance with the plan of care.”  The policy further stated the POC should “… state, in detail, the scope and frequency of services needed to meet the patients and family/ caregivers’ needs ….”  Patient 4’s clinical record evidenced a Social Work note dated 05/19/2025, completed by MSW 1.  The note indicated they discussed Entity A’s benefit that pays for caregivers (an aide and an attendant) to assist with supervision, bathing, dressing, personal care, meal preparation, and housekeeping.  Patient #4 currently pays for a caregiver to complete those tasks 5 days of the week.The clinical record evidenced a plan of care update completed by the IDG on 07/09/2025.  The POC update included a goal of “…seek info [information] for setting up aide and attendant benefit in preparation for future care needs.”  The goal was added on 05/19/2025.  During an interview on 07/06/2025 beginning at 01:43 PM, MSW 1 indicated they met with Patient #4 on 05/19/2025 and the patient did not want to pursue a caregiver paid by Entity A.  Upon reading the note, MSW 1 indicated they could have written the note more clearly and that Patient #4 did not want to pursue that goal.  When asked, MSW 1 could not explain why they activated the goal on 05/19/2025, the same date MSW 1 indicated Patient #4 did not want the services.The clinical record included a “Hospice Recertification Plan of Care Update,” completed on 05/28/2025.  The update indicated the MSW would see Patient #4 twice a month for 3 months and an additional 3 visits as needed, effective 06/01/2025. A review of the MSW services indicated visits were completed once a month.   During an interview on 07/06/2025 beginning at 01:43 PM, MSW 1 indicated they saw Patient #4 once a month. MSW 1 indicated there had been orders to reduce MSW visits to once per month.  When asked to find an order after 06/01/2025, MSW 1 was unable to find one.At 3:10 PM, during an interview, the Alternate Administrator was asked to locate the most recent order for MSW visits.  The Alternate Administrator returned at 3:33 PM and indicated that the current order for MSW visits was 2 visits per month for 3 months, with 3 additional visits as needed.  The IDG failed to ensure the MSW provided visits according to the POC and address problems and goals identified on the POC.

Based on record review and interview the agency failed to report a patient death after a fall with serious injury (Patient #2) to the State of Indiana for 1 of 1 unexpected death since March 1, 2025.Findings include: --- 1.     An agency policy, “Incident Reporting” last revised 4/11/2025, defined an incident as an event which was “… unintended, undesirable, and/ or unexpected….”  The policy included criteria for events that required the reporting of an incident to the Indiana Department of Health.  The state-specific incidents included “Reportable unusual occurrence …” which included “… alleged, suspected, or actual abuse…” and “alleged, suspected, or actual assault ….”  The list of incidents also included an unexpected death of an individual. 2.     A review of the agency occurrence report included the fall incident.  Patient #2 had an altercation with Person 3, a resident in the facility where Patient #2 lived.  Person 3 allegedly pushed Patient #2 which caused him/ her to fall and subsequently suffer a femur (thigh bone) fracture.  Patient #2’s death was 4 days after the altercation.  The occurrence reports failed to evidence a report regarding the unexpected death of Patient #2,3.     A review of the Internet Quality Improvement and Evaluation System (iQIES), a system that tracks state reportable incidents reported by hospice (and other) agencies, evidenced a report regarding altercation indicated above.  The system failed to include an incident report of Patient #2’s unexpected death shortly after the alleged push/ fall incident.4.     During an interview on 4/28/2025 beginning at 9:15 AM, the Executive Director, Director of Clinical Services and corporate employees Area Director of Clinical Operations, Regional President of Operations and Regulatory Affairs employees agreed the incident should have been reported to the State of Indiana.  The Executive Director indicated the failure to report the incident was an oversight.

Based on record review and interview, the home health agency failed to ensure the POC included all medications the patient was taking for 2 of 3 patients with home visit observations (Patient #10, 11).Findings include: --- 4. The medical record for Patient #10, with a benefit election date of 3/17/2025 and a diagnosis of Alzheimer’s disease, evidenced a medication profile which did not include an order for donepezil (used to treat symptoms of Alzheimer’s disease),A review of the medication orders for Patient #10, provided by Entity 1, evidenced an order for donepezil, which started on 2/17/2025, prior to Patient #10’s admission to the hospice agency.  During an interview on 4/3/2025 beginning at 11:57 AM, RN 3 indicated a medication reconciliation occurred at admission and every nurse visit.  RN 3 indicated they completed the medication reconciliation by comparing the medications on the agency medication profile with Entity 1’s medication administration record.  RN 3 indicated the admission nurse missed the medication discrepancy and he/ she missed the discrepancy each week. 1. Review of the Medication Profile policy, revised 11/14/2023, indicated “ …  All patients will have a current, accurate medication profile in the clinical record. The medication profile will include all prescription and over-the-counter drugs, including oxygen, herbal remedies and other alternative treatments used by the patient that could affect drug therapy….”2. The Plan of Care policy, revised 01/23/2025, indicated “ …  The written plan of care will contain, but will not be limited to  …  Medications and treatments….”3. A home visit observation of RN 4 providing care for Patient #11 was conducted on 04/02/2025 at 11:33 AM. During the home visit observation, Person 8, a relative of Patient #11, indicated they manage the Patient’s medications. Person 8 provided a copy of Patient #11’s current medication list. Person 8 relayed Patient #11 had been taking all the medications on the list and indicated all medications on the list, including vitamins and herbal supplements, had been started prior to the current year.Review of Patient #11’s home medication list included but not limited to Alfalfa, Vitamin B12, Vitamin C, Calcium, Cranberry, Vitamin D3, Multivitamin, Niacin, Omega 3, and Zinc.The hospice agency’s POC medication list for Patient #11 failed to include Alfalfa, Vitamin B12, Vitamin C, Calcium, Cranberry, Vitamin D3, Multivitamin, Niacin, Omega 3, and Zinc.During an interview on 04/02/2025 at 1:00 PM, RN 4 indicated all medications the Patient was currently taking should be included on the POC medication list. RN 4 relayed she had not been aware of the vitamins and herbal supplements the patient was taking that were not on Patient #11’s agency medication list.

Based on record review and interview, the agency failed to ensure they provided the services required to meet the patient needs for 1 of 1 patient records reviewed for fall precautions and follow-up (Patient #8).Findings include: --- 1. A review of the On Call/Weekend Services Policy numbered 4-036, identified the on call process on weekends.  The policy indicated the on call nurse would visit the patient if needed, obtain physician orders if needed, and document each interaction in a coordination note.  The policy indicated events which could require a visit which included, but was not limited to, a report of a patient fall, a new wound, or the patient, family, caregiver, or facility perceives a problem and requests a visit.2. A review of the coordination note for 2/22/2025 indicated Person 7, a nurse from the contracted triage service, received a call from a nurse at Entity 2, Patient #8’s home, at 10:47 AM.  Person 7 documented Patient had a fall which resulted in a skin tear approximately the size of a softball.  The note indicated a visit was needed.  Person 7 sent a message to RN 5 which stated, “Triage has identified a PRN [as needed] visit need.  Company policy dictates that a visit is now required to be completed….”  The coordination note further indicated RN 5 would schedule the visit.A coordination note, dated 2/23/2025 at 6:31 PM by RN 5 indicated they called a nurse at Entity 2 “… who indicated a follow up visit would be fine to check on patient.”A coordination note, dated 2/23/2025 at 6:50 PM, titled Late Entry for 2/22/2025, included a summary of the fall by a different nurse at Entity 2.  The note indicated the facility declined the visit as Patient #8 was back to normal.A coordination note, dated 2/23/2025 at 7:46 PM by RN 7, indicated they went to Entity 2 and observed Patient #8 sleeping in bed.  A nurse at Entity 2 indicated the patient was at their baseline and asked not to disturb the patient.A review of a SN visit on 2/24/2025, completed by RN 6.  The note indicated RN 6 was doing a follow up visit to Patient #8’s fall on 2/22/2025.  RN 6 documented they received wound care and wound supply orders from the physician.  RN 6 identified the wound as a skin tear on the back of the right forearm, 9 centimeters (approximately 3.5 inches) in length. 3. During an interview on 4/1/2025 at 9 AM, the Administrator indicated the best practice after a fall with an injury was a nursing evaluation of the patient.   When given the above scenario, the Administrator indicated a facility nurse evaluated the patient, so the agency did not have to do a visit.4. During an interview on 4/1/2025 beginning at 2:36, the Family Care Coordinator indicated triage staff were not clinical and could not make clinical decisions and the agency on call RN made the clinical decision about whether a visit was necessary.  When asked about the triage note stating the policy required a visit after a fall, the Family Care Coordinator indicated the decision was still up to the agency on call RN.5. During an interview on 4/2/2025 starting at 2:36 PM, RN 6 indicated there were no wound orders prior to their visit on 2/24/2025.  RN 6 indicated they did not know what wound care was completed by the facility where Patient #8 lived.  RN 6 indicated a visit was expected after a fall, within 24 hours.6. During an interview on 4/3/2025 starting at 12:08 PM, RN 5 was asked to identify the process for addressing falls by on call staff.  RN 5 indicated they did not always have the staff available for visits and there were times when they had to decide which calls were a priority for a visit.  Asked to describe Patient #8’s fall, they indicated they were aware of Patient #8’s fall and injury.  They indicated they dispatched a nurse to complete an assessment.  They were unaware the nurse went to the facility to assess the patient and was asked not to disturb the patient.  RN 5 indicated they documented their note late, so it appeared as if they did not address the fall until 2/23/3035, the day after the fall.  When asked what wound care orders they obtained, they indicated they did not obtain orders.  They indicated Entity 2 followed their own protocol for wound care.

Based on record review and interview, the agency failed to ensure patient concerns and needs were communicated to the RN case manager and IDG, for 1 of 1 record reviewed when patients requested additional services (Patient #7).Findings include: --- 1.A review of the Interdisciplinary Group Membership and Responsibilities, Policy number 4-001, identified the responsibility of IDG members for the coordination of care and sharing of information among IDG members.2. A review of the chaplain visit note for 3/11/2025 for Patient #7, included the observation “Patient wishes to get more care and help but only gets help two days a week.  However, patient understand[s] and accepting [sic] of the situation.”  3. During an interview on 4/2/2025 beginning at 8:50 AM, the Administrator indicated a patient who requests additional services needs to discuss it with the RN case manager.  If brought up to a different staff person, that staff person is responsible for notifying the RN case manager of the request.  The RN case manager discusses the request with the patient to determine the need for additional services.  4. During an interview on 4/2/2025 beginning at 3:10 PM, Chaplain 3 recounted a conversation with Patient #7 that took place on 3/11/2025.  Chaplain 3 indicated Patient #7 wanted more help but understood it was too expensive to have a private caregiver.  When asked, Chaplain 3 indicated they did not notify the RN case manager of the patient’s request.  When asked when they would notify the RN case manager of patient’s needs, Chaplain 3 indicated they had to contact the RN case manager if the patient did not seem to be doing well.  When asked, Chaplain 3 indicated they did not bring this up in IDG but should have.  When asked, Chaplain 3 indicated they would bring this up in IDG if the patient brought it up again.

Upon patient record review 3 of 5 (Patient #2,4,5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 2: The medical record indicated that the patient declined SC services at the time of admit. No evidence that an initial comprehensive SC assessment was completed, spiritual assessment in RN admit assessment addressed the HIS questions only. Assessment completed during survey. Patient 4: The medical record indicated that the patient declined SC services at the time of admit. No evidence that an initial comprehensive SC assessment was completed, spiritual assessment in RN admit assessment addressed the HIS questions only. Assessment completed during survey. Patient 5: The medical record indicates that the patient accepted a Chaplain eval at the time of admission. The documentation on the medical record shows that the patient declined a visit from the SC on 02/18/2025. No evidence that an initial comprehensive SC assessment was completed, spiritual assessment in RN admit assessment addressed the HIS questions only. Assessment completed during survey.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 5: Active medication profile list Polyethylene Glycol powder 3350 17 grams by mouth daily. No evidence that instructions were provided on how to dilute the powder.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 5: Current POC has an order for Polyethylene Glycol powder 3350 17 grams by mouth daily. No evidence that instructions were included on how to dilute the powder before ingesting.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The initial RN narrative documentation indicated that the patient has increased secretions and was requiring more frequent suctioning. No evidence that respiratory/suctioning orders for the DME were included in the plan of care. Corrected on site.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: The medical record contained orders for increasing doses of morphine on 1/12/25 and 1/13/25. The medication profile contained three hourly morphine prn doses with instructions to administer for pain or shortness of breath. There was no evidence the medication profile was updated to discontinue doses previous to 1/13/25 changes. The medication profile also contained oxygen with no defined delivery method.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 5 (Patients #1,#3,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained nursing documentation since admission identifying patient use of a bipap during the day and cpap at night. There was no evidence of orders for the equipment parameters for usage. Corrected on site. Patient 3: The medical record contained nursing documentation since 12/11/24 identifying patient use of an indwelling catheter. There was no evidence of an order for catheter type, size, maintenance, and change frequency. Corrected on site. Patient 4: The medical record contained an order for oxygen with no defined delivery method.

Upon patient record review, 3 of 5 (Patients #2,#3,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The medical record contained nursing documentation 12/20/24 identifying a nebulizer was ordered for delivery from the DME supplier. There was no evidence of an order for a nebulizer included in the plan of care. Patient 3: The medical record contained nursing documentation since admission identifying patient use of a hospital bed, bedrails, commode, and nebulizer. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation since admission identifying patient use of oxygen equipment, hospital bed, full rails, over bed table, and walker. There was no evidence of the DME orders included in the plan of care.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained nursing documentation 1/6/25 identifying the RN changed the patient's catheter. There was no evidence of an order for catheter type, size, maintenance, and change frequency.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 5: There was no evidence that the 6 month and holiday letters due in December were sent timely to one of the bereaved persons. The bereavement activity also reflected that all letters including the 6, 9, 12, and 13 month letters were sent 6/17/24 to a different bereaved family member. Patient died 6/14/24.

Upon patient record review, 1 of 23 (Patient #16) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 16: There was no evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives.

Upon patient record review, 1 of 23 (Patient #16) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 16: There was no evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 1 of 23 (Patient #16) did not have evidence of the appropriate documentation for release of confidential information. Patient 16: There was no evidence of the appropriate documentation for release of confidential information.

Upon patient record review, 1 of 23 (Patient #16) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 16: There was no evidence that the patient received information about the services covered under the hospice benefit.

Upon patient record review, 1 of 23 (Patient #16) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 16: There was no evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services.

Upon patient record review 1 of 23 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7: The comprehensive spiritual assessment was completed 9/26/24 with a start of care 9/18/24.

Upon patient record review 3 of 23 (Patients #4,#17,#18) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 4,17,18: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 3 of 23 (Patients #7,#11,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications Patient 7: Upon medication reconciliation with home visit, the facility and hospice medication profiles did not match. The facility had an extra scheduled baclofen and no PRN. Hospice had a PRN allowable three times a day. Corrected on site. Patient 11: Upon medication reconciliation with home visit, the facility and hospice medication profiles did not match. The facility dose for basaglar insulin was 25 units and hospice was 22 units. Corrected on site. Patient 14: The medication profile contained duplicative listings of Ativan listed as both Ativan and lorazepam.

Upon patient record review, 5 of 23 (Patients #3,#4,#7,#9,#17) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 3: There was no evidence of updates to progress toward goals by the music and massage therapists. Patient 4: There was no evidence of updates to progress toward goals by the registered dietician. Patient 7: There was no evidence of updates to progress toward goals by the massage therapist. Patient 9: There was no evidence of updates to progress toward goals by the music therapist. Patient 17: There was no evidence of updates to progress toward goals by the massage therapist.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 23 (Patients #8,#15,#17) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 8: There was no evidence of left heel wound assessments and measurements between 10/9/24 and 10/30/24 as required per agency policy to complete weekly. Patient 15: The medical record contained nursing documentation identifying a patient change of condition with jaundice from head to abdomen 11/26/24. There was no evidence of follow up on the change in condition until 12/1/24. Patient 17: There was no evidence of left iliac crest wound measurements between 11/4/24 to 11/15/24 and 11/18/24 to 12/2/24 as required per agency policy to complete weekly.

Upon patient record review, 1 of 23 (Patient #15) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 15: There was no evidence of patient and family education regarding care after the dislodgement of the JP drain 11/20/24 documented in nursing visit 11/21/24.

Upon patient record review, 1 of 23 (Patient #18) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 18: The plan of care contained inaccurate nutritional requirements stating medications via g-tube. There was no evidence the patient had a g-tube.

Upon patient record review, 1 of 23 (Patient #15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 15: The medical record contained a wound care order 8/22/24 that does not identify the location of the wound.

Upon patient record review, 9 of 23 (Patients #1,#2,#6,#10,#12,#13,#14,#15,#18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation 10/31/24 identifying patient use of a hospital bed, bedrails, and low air loss mattress. There was no evidence of orders for the DME included in the plan of care. Patient 6: The medical record contained nursing documentation 10/15/24 identifying patient use of fall mats. There was no evidence of an order for the fall mats included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation 10/9/24 identifying patient use of a hospital bed, bolstered mattress, and pressure alarm. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation 11/25/24 identifying patient use of a bolstered mattress, over the bed table, shower chair, and pressure alarm. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, and 9/16/24 identifying use of a Hoyer lift. There was no evidence of orders for the DME included in the plan of care. Patient 15: The medical record contained nursing documentation 10/17/24 identifying patient use of bedrails. There was no evidence of an order for the rails included in the plan of care. Patient 18: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and wheelchair. There was no evidence of orders for the DME included in the plan of care.

Upon patient record review, 1 of 23 (Patient #15) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient 15: There was no evidence of patient or family's level of understanding of patient condition after dislodgement of the JP drain or involvement and agreement with the plan of care.

Upon patient record review, 4 of 23 (Patients #3,#4,#9,#17) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 3: The medical record contained medication orders 11/6/24 identifying patient had a new diagnosis of a DVT. There was no evidence of problems, goals, and interventions related to the DVT. The plan of care also contained interventions for Swedish massage with unidentified troubled area. The interventions do not define appropriate or inappropriate areas for treatment, given the diagnosis of a DVT. Patient 4: The plan of care contained conflicting interventions for Jevity to be administered 980ml over 14 hours with a 40ml/hr flush under a nutrition problem and 80ml/hr for 12 hours with a 60 ml/hr flush under an enteral nutrition problem. The physician order 11/22/24 was for Jevity 50 ml/hr for 12 hours with a 40 ml/hr flush. The plan of care also contained interventions to perform irrigation of 75ml free standing water after every meal and with medication administration. The patient originally was documented upon admission as receiving bolus feedings. Corrected on site. Patient 9: The medical record contained chaplain documentation 11/13/24 identifying the facility nurse reported patient having seizure activity. There was no evidence of problems, goals, and interventions related to seizure precautions and care. Corrected on site. Patient 17: The medical record contained evidence the patient was receiving massage therapy since 11/15/24. There was no evidence of problems, goals, and interventions related to massage therapy.

Upon patient record review, 4 of 23 (Patients #3,#4,#7,#15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained a wound care order 11/11/24 instructing the hospice nurse to complete wound care weekly. There was no evidence of wound care completed by hospice nursing. Patient 4: The medical record contained documentation by the registered dietician 11/29/24 identifying the patient was receiving 60ml/hr Jevity with a 60ml/hr flush. The current order for Jevity dated 11/22/24 was 50ml/hr for 12 hours with a 40ml/hr flush. Patient 7: The medical record contained an order 10/15/24 for social work visits twice for first week. There was no evidence of the two visits completed. Patient 15: The medical record contained nursing documentation 11/21/24 stating the nurse placed a dressing to where a JP drain was pulled out. There was no evidence of a treatment order.

Upon patient record review, 1 of 23 (Patient #15) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 15: There was no evidence a physician was updated following the complete dislodgment of the patient's JP drain 11/20/24 documented in nursing visit 11/21/24, or the change in condition with jaundice from head to abdomen 11/26/24.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Patient 15: There was no evidence a physician was updated following the complete dislodgment of the patient's JP drain 11/20/24 documented in nursing visit 11/21/24, or the change in condition with jaundice from head to abdomen 11/26/24.

Upon patient record review, 2 of 23 (Patients #19,#20) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 19: There was no evidence assigned bereavement tasks to send six and nine month newsletters were completed. Patient 20: There was no evidence a bereavement assessment was completed after the patient died and the assigned bereavement tasks to send six and nine month newsletters were completed.

Upon patient record review, 4 of 23 (Patients #2,#10,#12,#13) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 2: The aide care plan did not contain instructions for use of a wheelchair outside of the patient's room. Patient 10: The aide care plan did not contain transfer instructions for level of assistance needed. Corrected on site. Patient 12: The aide care plan contained instructions for stand by assist with walker for ambulation. Nursing documentation 10/30/24 identified patient as no longer ambulatory. Patient 13: The aide care plan two bath types, and change linens task with contradicting instructions of every visit and weekly. Corrected on site.

Upon patient record review 1 of 23 (Patient #17) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 17: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 11/24/24.

Upon patient record review 2 of 23 (Patients #4,#7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 4: There was no evidence of an aide supervisory visit since start of care 11/5/24. Patient 7: There was no evidence of an aide supervisory visit until 11/5/24. The first aide visit was completed 9/24/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency had a volunteer utilization rate of 3.51% for 2023.

Upon observation, there was no evidence the hospice provides care directly or under contract that optimizes comfort and dignity of the patient and is consistent with the patient/ family needs and goals. The patient needs and goals are a priority. Patient 15: There was no evidence of documentation of physician notification or education with the patient/caregiver regarding changes in patient condition ensuring the comfort and dignity of the patient needs and goals are a priority. On 11/19/24, the JP drain fell out approximately 4 inches. There was no discussion documented with the patient or caregiver regarding instructions if the JP drain were to come out further, stop draining, preferences for maintenance, or treatment options. On 11/20/24, the JP drain fell out completely and there was no MD notification that the drain was completely out and no treatment orders obtained by the nurse. In addition, there was no documentation of education to the patient/caregiver regarding treatment options or signs/symptoms that could result with the potential inability for fluid to drain. On 11/26/24, the nurse documented the patient was jaundiced from head to abdomen. There was no documentation of MD notification or education to the patient/caregiver regarding the change in patient condition on 11/26/24.

Upon personnel record review, 1 of 18 (Personnel #14) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 14: There was no evidence of an initial skills competency assessment.

Upon patient record review, 2 of 23 (Patients #14,#18) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 14: The date of election on the election form states date chosen for hospice services to begin on 2/15/24, signed on 2/16/24 which was start of care and date of all other consents. Patient 18: The consent identifying the patient rights that were received contained an unclear date of signature with original date entered as 11/20/24 which was then written over by admitting nurse initials recognizing error in date. There was no evidence the change to the document was validated by the patient's daughter who signed all consents.

Upon patient record review, 4 of 23 (Patients #10,#15,#17,#18) did not have evidence that each patient record contains Advance Directives. Patient 10,15,17,18: The plan of care identifies the patients as DNR. There was no evidence of a POLST or living will in the medical records.

Upon patient record review, 1 of 23 (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated. Patient 4: The medical record contained nursing documentation upon admission that identified the patient as currently residing at nursing home with plan to transfer to brother's home later that day. After leadership investigation, the nurse stated the documentation was in error and the patient was assessed after discharge from the nursing home, at the brother's home.

Upon patient record review, 1 of 23 (Patient #16) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 16: There was no evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content. There was no evidence of hospice training with Beacon Health Systems, The Milton Home, and Briarcliff Health and Rehab.

Based on record review and interview, the hospice interdisciplinary group (IDG) failed to meet the patients physical, medical, psychosocial, emotional, and spiritual needs for 1 of 1 record reviewed of a patient with a noted change in physical, psychosocial, and emotional condition (Patient #29). Findings include: --- The review of agency policy #4-076 titled ";Live Discharge and Discharge Planning Process," dated 1/22/24, indicated the agency could discharge a live patient if there was ";a basis for a discharge for cause," in which ";circumstances exist which prevents the hospice from safely providing care, or where patient safety is compromised. Discharges for cause are appropriate when the patients (or other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that the delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired." Steps the hospice was to take when discharging a patient for cause included but were not limited to ";Advise the patient (or responsible party) that a discharge for cause is being considered ... Make a serious effort to resolve the problem presented by the situation ... Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the patients medical records ...." The policy also indicated when a patient was discharged for cause, the hospice would ";make a referral to other state/community resources (e.g., Adult Protective Services), if appropriate ...." The review of Patient #29s clinical record indicated a hospice benefit election date of 4/23/21, terminal diagnosis of end-stage congestive heart failure (CHF), and secondary diagnoses including but not limited to ischemic cardiomyopathy (heart damage caused by decreased or blocked blood flow), Chronic Obstructive Pulmonary Disease (COPD), repeated falls, and a history of sudden cardiac arrest (loss of all electrical activity in the heart). Hospice Physician 1 was listed as Patients attending and certifying hospice physician. Patient was to receive skilled nursing, spiritual care, and social work services. Patient had declined hospice aide services as he/she was receiving home health aide services from Entity P, a home health agency. The record included a recertification of terminal illness, signed on 5/29/24 by Hospice Physician 1, which indicated Patient had ";unrealistic judgement," as Patient would express need to ";complete household repairs and then becomes confused with anxiety when things do not go [his/her] way." The physician noted Patients anxiety ";waxes and wanes." The record included spiritual care visit notes, conducted on 7/02/24, 7/10/24, and 7/16/24 by Chaplain 2, which indicated Patient did not exhibit or report anger and ";appears to be handling everything appropriately ...." Chaplain 2s visit note for 7/10/24 indicated when he arrived at the visit, Patient was found ";very confused" with their oxygen disconnected and their power was off. After the chaplain assisted Patient in connecting his/her portable oxygen and the power was restored, Patient was noted to have calmed down. The record included skilled nurse visits conducted on 7/03/24 and 7/17/24 by Registered Nurse (RN) 5, which indicated the nurse completed a ";Depression/Suicide Risk" assessment during the visit. The nurse documented Patient did not have ";thoughts of endangering or harming others" and did not ";present a risk of endangering and/or harming others ...." RN 5 documented she completed an environmental and safety assessment during these visits and no issues were identified. The nurse also documented Patient was ";calm" during these visits. RN 5s visit note for 7/03/24 indicated Patient reported Zyrtec (an allergy medication) was making him/her ";fidgety." The nurse obtained an order from Hospice Physician 1 to discontinue the Zyrtec and begin Claritin (a similar allergy medication). RN 5s visit note for 7/17/24 indicated the nurse was unable to fill Patients medication planner with Patients ordered Dexamethasone (a steroid medication), as he/she was out of the medication. The nurse requested a refill from Patients pharmacy and notified Person O, primary caregiver to Patient #29. The record included a ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 7/10/24, which indicated Patient had been started on ";2 rounds of antibiotics for respiratory congestion [with] sinus drainage," including Levofloxacin for 7 days, started on 6/19/24, and Doxycycline for 7 days, started on 7/03/24. The IDGs goals for Patient included but were not limited to ";... Patient will remain free from infection ... Patient/caregiver will have an increased sense of spiritual security, peacefulness, ability to express love/forgiveness ... [Patients] agitation/restlessness will be reduced/controlled ... Patient will achieve optimal cardiac/cardiovascular function and comfort within disease process ... [Patient] will achieve optimal respiratory function and comfort within disease process ... [Patient] and caregiver will understand safety and care requirements to ensure Patient safety and care needs are met ...." The skilled nursing interventions included but were not limited ";... assess for agitation/restlessness and potential causes ... assess compliance with and barriers to [cardiac] treatment regimen ... assess Patient for signs and symptoms of impaired cardiac/circulatory system and disease progression ... instruct Patient/caregiver on cardiac/circulatory disease progression, common signs/symptoms, and management of disease process/symptoms ... assess for understanding and compliance with interventions and manage respiratory symptoms ...." Patients last 3 blood pressure recordings were noted to be 126/92 on 7/10/24, 122/86 on 7/03/24, 116/80 on 6/26/24. The record included a Coordination Note, dated 7/20/24, which indicated Patient called the agencys after-hours phone line. RN 21 documented Patient requested ";for triage not to say anything and let [him/her] speak first," then reported he/she had ";sputum coming out" of him/her, had slept 18 hours, lost 8 pounds, and his/her skin was ";gray white." Patient requested to have a specific nurse call him/her back. RN 21 documented Patient was ";being abusive ... constantly cursing" while on the phone. When RN 21 informed Patient that the requested nurse was not available, Patient ";became agitated and asked for the supervisor." An on-call message was sent to RN 20, who agreed to conduct a PRN (as needed) visit. The record included a PRN skilled nurse visit, completed by RN 20 on 7/20/24, for Patient being ";worried." RN 20 documented she found Patient with his/her oxygen disconnected and hanging from his/her neck. Patient was smoking a cigarette and ";complaining of not being able to catch [his/her] breath." The nurse documented an environmental and safety assessment was completed during this visit with no issues identified, and a ";Depression/Suicide Risk" assessment indicated Patient did not have ";thoughts of endangering or harming others" and did not ";present a risk of endangering and/or harming others ...." RN 20 documented Patient was agitated, and his/her appearance was ";disheveled." Patient was noted to be ";very chatty, talking nonstop" despite appearing short of breath while talking. Patients blood pressure was 162/98. The nurse documented Patient became upset upon hearing his/her oxygen saturation (vital sign which measures the percentage of red blood cells with oxygen attached) was ";98-99%," stating ";Well, Im not doing anything. Thats why me and you dont get along! Thats why I like [RN 5]." The nurse was able to calm Patient down, but he/she continued with erratic behavior during the visit, including ";complaining about different nurses," yelling at the nurse to ";stop cutting me off," and being ";unable to discuss [his/her] thought in detail ...." Patient also yelled for RN 20 to ";leave and not come back," but prior to the nurse leaving, Patient asked the nurse to stay. The nurse documented Patient had requested Sudafed (a decongestant) and the nurse would ";reach out to [Hospice Physician 1] later in the morning." The record failed to evidence an order for Sudafed was obtained or that the doctor was notified of the Patient's change in condition. The record included a PRN (as needed) skilled nurse visit, completed by RN 5 on 7/22/24, for a follow-up to the PRN visit conducted on 7/20/24 and ";continued client concerns over respiratory congestion." Patient was found sitting in a roommates vehicle ";with the air conditioning on [because] the house is not air-conditioned." The nurse documented Patients skin was pale and diaphoretic (excessive sweating due to an underlying medical condition), his/her breathing was ";labored," and they appeared short of breath. Patient was ";agitated" and had ";abnormal insight and judgement ... bizarre insight and judgement ... unrealistic judgement ...." RN 5 documented Patients ";caregiver unable to de-escalate [Patients] agitation" and Patient was ";unwilling to accept [his/her] symptoms [were] related to CHF ...." The nurse documented RN 20 reported Patient had requested Sudafed ";for chest congestion," Patient had been ";unwilling to listen to teaching regarding CHF exacerbation," and no medications had been ordered after RN 20s visit on 7/20/24. RN 5 documented Patient was ";bouncing around from 1 topic to another." The nurse attempted to educate Patient regarding CHF exacerbation and documented Patient was ";insisting that Sudafed [was the] only thing that would work." RN 5 attempted several times to explain to Patient that Sudafed had a ";high probability of interactions" with Patients current medications and ";would not control" his/her symptoms, as they were related to a CHF exacerbation. The nurse notified Hospice Physician 1 and obtained an order to increase Patients Dexamethasone from 2 milligrams (mg) to 4 mg daily. During the visit, Person O reportedly informed the nurse that Patient was under a ";great deal of stress" due to ";issues within the home that need to be repaired" and the caregiver ";gets most of [Patients] aggression." RN 5 documented she advised Person O to call her ";anytime [Patient] got out of control ... Doctor advised [Person O] not to engage [with Patient] ... at this point [Patient] is unable to control [his/her] reactions ...." The nurse documented Patient denied ";wanting to hurt anyone" and understood his/her ";frustrations are being taken out on [Person O] ...." The visit note indicated the nurse completed a ";Depression/Suicide Risk" assessment, Patient did not have ";thoughts of endangering or harming others," and did not ";present a risk of endangering and/or harming others ...." RN 5 also documented she completed an environmental and safety assessment during the visits and noted Patients home had ";cluttered walkways," but no other safety issues were documented. the record failed to evidence the physician was notified in the patient's change in mental status. The record included a spiritual care visit note, documented by Chaplain 2 on 7/23/24, which indicated Patient was ";having a very bad day ... Patient admitted that [he/she] has not had any sleep, and is very tired ...." The chaplain documented Patient did ";exhibit/report anger" towards Person O ";for not being able to help [Patient] feel better." Patient had reportedly taken their ";morning meds by mistake and is now wide awake and needs to sleep." The chaplain documented Patients ";lack of sleep has effected [his/her] judgment" and Patient ";doesnt want to listen to anyone else." Chaplain 2 documented during the visit, Patients ";small caliber pistol fell out of [his/her] pocket ...." The chaplain documented he ";mentioned that [Patient] needs to put [the] pistol in a safe place, but the patient stated Do you see [the] neighborhood that I live in? I need it to be safe ...." During the visit, Patient brought up ";a lot of different stories and many of [the] stories didnt make sense ...," and when the chaplain asked a question, Patient would ";get confused and more angered ...." Chaplain 2 documented Patient ";ended the conversation by saying that [he/she] is so mad I could choke [Person O] out ...." Chaplain 2 documented he ";did not feel safe going back into the home, or allow anyone else [to] enter [Patients] home without [the chaplain], because [Chaplain 2] was the only [person] who could have success calming [Patient] down when [he/she] was this mad in the past ...." Chaplain 2 also documented ";this is the first time that I finished a spiritual care visit and this Patient kept this state of mind ...." The chaplain notified Branch Executive Director 4, Branch Clinical Manager 6, and RN 5 of his concerns prior to documenting the visit note. During an interview with Chaplain 2 on 7/30/24 beginning at 3:40 PM, he reported Patient had ";never been like" how he/she was acting when the chaplain arrived for his visit on 7/23/24. Patient reportedly ";ranted for over an hour" and was upset with Person O. During the visit, a ";small pistol" slipped out of Patients pocket. Chaplain 2 advised Patient to put the gun ";in a safe place." Patient put the gun back in his/her pocket and reportedly stated, ";Ill calm down," but the chaplain reported Patient remained agitated for the entire visit. Chaplain 2 stated he did not ask Patient to put up the gun again as this would have gotten Patient ";madder." Chaplain 2 was unsure if the gun was loaded and had not seen a gun in the home prior to this visit. The chaplain stated he was ";more scared because of [Patients] anger ... weve always calmed [Patient] down but [he/she] was threatening to choke out [Person O]." Chaplain 2 stated he did not feel unsafe during the visit and did not leave the visit early, as this would have made Patient ";worse." Patient reportedly was slurring his/her words ";as if [he/she] was drunk," however the chaplain stated Patient did not smell of alcohol or drugs. After the visit, Chaplain 2 notified Branch Executive Director 4 of his concerns, as he did not want any other staff going into Patients home ";without protection" or ";a second person." During an interview with RN 5 on 7/30/24 beginning at 3:00 PM, she reported she had been Patients RN case manager for ";3 years." RN 5 reported during the last 3 weeks that Patient was on services, he/she began to have ";a lot of chest congestion" and sinus drainage. Patient was started on 2 rounds of antibiotics but there was no improvement in his/her symptoms. RN 5 had attempted to educate Patient that his/her symptoms were likely related to an exacerbation of their CHF, however Patient thought he/she had pneumonia. The nurse reported Patient had ";always been easily upsettable," however this had worsened during the last 3 weeks as Patients symptoms worsened. RN 5 thought Patient was ";terminally restless" and had been ";blaming everything" on Person O. The nurse had observed Patient and Person O ";argue" in the past but had never observed or heard of violence or threats of violence between them. The nurse reported after her visit with Patient on 7/22/24, she spoke with Branch Executive Director 4 regarding RN 20s visit on 7/20/24. RN 5 stated Patient had got into a ";fight" with RN 20 during the visit, trying to get the nurse to order an antibiotic since RN 5 would not order one, and was ";very disrespectful." After RN 5s visit on 7/22/24, she reportedly received a text message from Person O stating Patient did not want the nurse to return. RN 5 reported this had occurred several times before, however when the nurse would talk to Patient a few days later, he/she would be ";better," and the nurse would continue providing services. RN 5 reported Patient never threatened her, and the nurse did not feel unsafe in Patients home. The nurse stated she had seen a gun in Patients home when she first started caring for him/her. She told Patient to put the gun away and had no further issues or concerns regarding gun safety. The nurse stated when she first saw Patients gun, she ";probably" educated Patient on the potential for discharge from the agency if he/she continued to have guns unsecured in the home but was unsure if she had charted this education. RN 5 reported Hospice Physician 1 had been Patients only physician. The clinical record included a Coordination Note, documented on 7/23/24 by Branch Clinical Manager 6, which indicated during Chaplain 2s visit that day, Patient ";was agitated and had expressed a threat against [Person O] and Patient had a gun in [his/her] pocket that fell out of pocket, [Chaplain 2] requested Patient place gun in a safe place, Patient reported [he/she] needed it to be safe in [the] neighborhood and put it back in [his/her] pocket ...." Branch Clinical Manager 6 documented she and Branch Executive Director 4 notified Corporate Employee 2 and Corporate Employee 3 of the agencys concerns, and ";direction was given to discharge Patient for cause due to safety concerns." Branch Clinical Manager 6 and Branch Executive Director 4 notified Patient of their discharge via phone. Patient was reportedly ";speaking loudly" over Branch Executive Director 4 and then hung up. The agency staff called Patient again and informed him/her of the discharge. The agency staff then notified Person O ";of threat spoken by [Patient], and the Patient being discharged for cause. [Person O was] educated that if [Patient] was placed in a safe controlled environment then hospice would be available to reassess hospice eligibility and readmit if eligible." The agency staff also notified Entity Q, a local police department, of Patients ";spoken threat and presence of firearm." During an interview with Branch Clinical Manager 6 on 7/31/24 beginning at 11:40 AM, when queried on what she considered a ";safe, controlled environment" for Patient would be, the employee stated, ";where we knew [he/she] doesnt have a loaded firearm," such as an assisted living facility. Patient had previously declined to move to a nursing facility. The clinical record included a Discharge Summary, documented on 7/24/24 by Branch Executive Director 4, which indicated ";over the last several months [Patient] has been in denial of [his/her] worsening heart failure insisting ... it is [pneumonia] ... During PRN visit ... on 7/20/24, it is reported that Patient began yelling profanities at the nurse asking her to leave and not come back, then [Patient] asked ... her to stay requesting order for Sudafed. On ... 7/22/24, [Patient] became very upset when Sudafed was not ordered again on request. During chaplain visit on 7/23/24 it was report[ed] that [Patient] became upset and was unable to be calmed during visit; had handgun fall out of pocket that [he/she] refused to put away in secure location; becoming more angry. Chaplain left to report situation to leadership ...." When Branch Executive Director 4 called Patient to inform him/her of the discharge, Patient spoke over the employee then hung up. The employee called Patient again, notified Patient of their discharge for cause, and informed him/her to ";follow up with a PCP [primary care physician] for continued management of care." Branch Executive Director 4 documented Person O reported Patient ";becomes irate with [the caregiver] regularly and [Person O] does not know what to do with [Patient]." During an interview with Branch Executive Director 4 on 7/30/24 beginning at 3:22 PM, she stated Patient was discharged for cause after Chaplain 2 reported Patient had a gun fall out of his pocket during a visit and Patient had ";declined" to secure the gun due to his/her own safety concerns. Branch Executive Director 4 reported Patient had also been ";nasty" to the on-call staff on 7/20/24, had ";fired" his/her RN case manager (RN 5) on 7/22/24, and had threated to ";choke [Person O] out" during Chaplain 2s visit. The employee reported she and Branch Clinical Manager 6 called Patient to inform him/her of the discharge on 7/23/24. During the first call, Patient would not allow anyone else to speak, became upset, and hung up the phone. The administrative staff called Patient back and informed him/her that the agency was discharging Patient for cause immediately. The employee reported Patient was advised he/she would need to find a physician to manage his/her care. Branch Executive Director 4 reported Patient had not been notified prior to his/her discharge that a discharge for cause was being considered, as Patient was discharged the same day of Chaplain 2s visit. When queried what interventions the hospice took to resolve the safety concerns, Branch Executive Director 4 reported the agencys administrative staff felt Patients home was unsafe and did not feel comfortable having staff return. The clinical record included a ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 7/24/24, indicated Patients current medications at discharge included but were not limited to: a. Amitriptyline (a medication used to treat depression and/or nerve pain) ";for pain" b. Cyclobenzaprine (a muscle relaxer) ";for pain" c. Dexamethasone ";for neuropathic pain d. Digoxin (a medication used to treat irregular heart rhythms) "for Afib" (Atrial Fibrillation, an irregular heart rhythm) e. Furosemide (a diuretic used to remove excess fluid from the body) f. Isosorbide Dinitrate (a medication used to treat heart failure and/or chest pain g. Lorazepam (an anti-anxiety medication) to be taken twice a day scheduled and as needed h. Meclizine (a medication used to treat symptoms including nausea, vomiting, and dizziness) ";for vertigo" i. Morphine (a pain medication) in both pill and liquid form j. Oxycodone (a pain medication) During an interview with Patient #29 on 7/29/24 beginning at 5:12 PM, he/she reported after Patients visit with Chaplain 2 on 7/23/24, they were contacted by Branch Executive Director 4 and informed he/she was being discharged from the agency. Patient was reportedly informed he/she was discharged due to ";strangling a caregiver" and ";a gun fell out of my pocket." Patient reported he/she did not have a PCP and/or another physician to order his/her medications, so Patients supply of Digoxin was running low, and Patient was taking their dose every other day to make it last longer. Patient reported having fallen ";11 times" on 7/28/24 due to missing his/her medication. Patient reported he/she did own guns, which were usually locked up, however Patient reported their neighborhood was not safe, as the police were at a neighbors house often, so he/she would intermittently carry a gun. Patient did not recall having a gun out while hospice staff was present. Patient recalled making a statement to hospice staff a few weeks prior that his/her difficulty breathing felt like ";someone was choking you and drinking out of a straw," but did not recall stating he/she wanted to choke or strangle Person O. During an interview with Person O on 7/31/24 beginning at 11:53 AM, he/she reported when agency staff called him/her on 7/23/24, the staff did not discuss how Patients medical needs were to be met going forward. During an interview with Person K, an employee of Entity P, on 7/30/24 beginning at 2:33 PM, he/she reported Patient was receiving home health aide services from Entity P. He/she reported Hospice Physician 1 had been signing the home health agencys orders and Patient did not have any other physicians. During an interview with Person L, an employee of Entity P, on 7/30/24 beginning at 3:56 PM, he/she reported they had conducted a visit with Patient on 7/23/24 after Chaplain 2 had left the home. Person L reported Patient ";sometimes" would carry a gun around the home and would often be ";angry," however the employee denied feeling unsafe in the home. Person L reported on 7/23/24, Patient ";was in a bad mood" and had not slept ";in a few days."

Based on observation, policy review, and interview, the hospice agency failed to ensure all staff followed infection prevention policies and best practices, including standard precautions, for 2 of 2 home visit observations (Patients #26, 27). Findings include: --- 4.) During a home visit observation with Patient #26 on 7/30/24 beginning at 8:44 AM, Registered Nurse (RN) 17 was observed performing an assessment and wound care. RN 17 sat the nurse bag and vitals equipment on Patient #26s bed. RN 17 failed to use a barrier between the nurse bag, vitals equipment and bed. RN 17 washed their hands 4 times throughout the home visit observation for 10 seconds, 9 seconds, 12 seconds and 11 seconds respectively. RN 17 failed to wash their hands for at least 20 seconds each time. During an interview on 7/30/24 beginning at 9:51 AM, RN 17 confirmed there should have been a barrier placed under the nurse bag and vitals equipment and hands should have been washed for a minimum of 20 seconds. During an interview on 7/30/24 beginning at 2:46 PM, the Clinical Manager confirmed that hands should have been washed for at least 20 seconds. 1. The review of agency policy #6-006 titled ";Hand Hygiene," dated 12/20, indicated the employee should wash their hands with soap and water ";when hands are visibly dirty, contaminated with proteinaceous material [fluid which contains proteins, such as urine and stool], or are visibly soiled with blood or other body fluids." The employee was to use an alcohol-based hand rub ";when hands are not visibly soiled ... for routinely decontaminating hands ...." The policy indicated when washing hands with soap and water, the employee should scrub their hands ";for at least 20 seconds." 2. The review of agency policy #6-013 titled ";Bag Technique," dated 8/31/23, indicated the employees supply/nursing bag ";should be placed on a visibly clean, dry surface in the patients environment. If there is no visibly clean, dry surface available, place a barrier under the bag or hang it on a doorknob or the back of a heavy chair ...." Hand hygiene was ";required [to be] performed before entering the nursing bag." 3. During a home visit observation with Patient #27 on 7/30/24 beginning at 8:25 AM, Hospice Aides (HA) 1 and 12 were observed performing a bed bath. During the bath, HA 12 cleaned stool from around Patients rectum and buttocks then continued with the bath, failing to change gloves and perform hand hygiene. At the end of the visit, HA 12 was observed failing to wash his hands for at least 20 seconds. During an interview with HA 1 and HA 12 on 7/30/24 beginning at 9:30 AM, the aides reported gloves should be changed and hand hygiene performed after cleaning up stool. HA 12 stated hands should be scrubbed for ";45 seconds" when washing with soap and water. During an interview with Clinical Manager on 7/30/24 beginning at 1:23 PM, she reported staff should perform hand hygiene prior to patient contact, after removing gloves, and after coming in to contact with ";soilage." Clinical Manager also reported when washing hands with soap and water, staff should scrub their hands for ";at least" 20 seconds.

Based on record review and interview, the hospice agency failed to comply with all applicable Federal, State and local emergency preparedness requirements (E0001); failed to develop and maintain an emergency preparedness plan that must be reviewed and updated at least every 2 years (E0004); failed to develop an emergency plan that included strategies for addressing emergency events (E0006); failed to develop an emergency plan that adequately identified patients / client population at risk during an emergency event, the type of services the hospice agency had the ability to provide during an emergency, how the hospice agency planned to continue to operate during an emergency, and the delegation of authority (E0007); failed to include a current up to date process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospice agencys efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts (E0009); failed to develop and implement emergency preparedness policies and procedures based on the facility-based and community-based risk assessment, utilizing an all-hazards approach (E0013); failed to develop / identify procedures for safe evacuation procedures from residences if needed (E0019); failed to develop a system in writing that secures and maintains availability of records in the event of an emergency (E0023); failed to develop policies and procedures that address the use of hospice employees and other emergency staffing and collaboration efforts with State and Federal designated health care professionals in an emergency (E0024); failed to include arrangements with other facilities and providers to receive patients in the event of an emergency (E0025); failed to include an alternate care site identified by emergency management officials (E0026); failed to develop a written emergency preparedness communication plan specific to the hospice agency that contains how the agency coordinates patient care (E0029); failed to develop and maintain an emergency preparedness communication plan that includes names and contact information for hospice employees, entities providing services under arrangement, physicians and other hospices (E0030); failed to maintain a written emergency preparedness plan that included up to date contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance (E0031); failed to develop and maintain a written emergency preparedness communication plan that included a Primary and alternate means for communicating with hospice staff, Federal, State, tribal, regional, and local emergency management agencies (E0032); failed to develop and maintain an emergency preparedness communication plan that included a method for sharing medical information for patients under the hospice agency's care with other health providers to maintain continuity of care (E0033); failed to develop a written means of providing information about the hospice agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee (E0034); failed to develop and maintain an emergency preparedness training and testing program (core element) based on the emergency plan set forth (E0036); failed to ensure they provided hospice agency specific initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role (E0037). The cumulative effect of this systemic problem resulted in the hospice agency being out of compliance with the Condition of Participation 418.113, Establishment of the Emergency Program. --- The findings include: 1. On 6/19/24, the Administrator provided a document titled, "Home Health & Hospice Promedica Home Health & Hospice Emergency Response Manual", dated 12/19. The plan failed to include a written emergency plan specific to the hospice agency. 2. During an interview on 6/19/24 beginning at 2:45 PM, the Administrator relayed the hospice agency used Entity E's Emergency Preparedness policies and EPP and the hospice agency does not have an individualized written emergency plan specific to the agency.

Based on record review and interview the hospice agency failed to immediately investigate allegations of misappropriation of patient funds (see tag L509), take appropriate corrective action based on the allegations (see tag L510), report the incident within 5 working days of the discovery of the violation (see tag L511), and ensure patients were free from misappropriation of funds (see tag L517). --- The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment and resulted in the agency being found out of compliance with the condition 42 CFR 418.52 Patient Rights.

Based on record review and interview, the agency failed to immediately investigate allegations of misappropriation for 2 of 2 misappropriation allegations (Patients #1 and 2). Findings include: --- 1. A review of an abuse/ neglect policy indicated exploitation by money misuse or theft required immediate action, investigation, and prevention of further exploitation. 2. A review of the complaint process identified a purpose to ";... protect patient and family rights ...." 3. A review of the incident reporting policy indicated a purpose of the policy was to ";... establish a foundation for early investigation of all potentially serious events." The policy indicated the person discovering the incident must follow – up with the patient and family. 4. During an interview on 6/12/2024 at 9:30 AM, the Director of Professional Services (DPS) indicated a law enforcement detective came to the office on 4/15/2024 to have the Administrator identify a picture of an employee accused of theft from Patient #2. The DPS indicated HA 1 was the employee in the picture. The DPS indicated this was the first time the agency was notified of the theft. 5. When asked during an interview on 6/13/2024 at 2:19 PM, the DPS indicated the agency had not completed an investigation into the theft allegations from Patient #2s family. 6. On 6/14/2024 the agency provided documentation of an investigation which included an undated document with a total of 9 patient names. Four patients had brief descriptions of the patient/ family experience with the agency. There were 5 patient names with a note that a message was left regarding the patient/ family experience with the agency. The document ended with ";Per [Administrator]." When asked, the DPS reported the Administrator made calls on 6/13/2024 to active patients who received care from HA 1. 7. During an interview on 6/14/2024 at 11:50 AM, the Administrator confirmed the account of the DPS but added that the detective received another theft report against HA 1 from the family of Patient #1. When asked, the Administrator indicated they did not contact Patient #1s family as the family did not report the theft to the agency. The Administrator confirmed the detective identified Patient #1 as an alleged victim of theft by HA 1. The Administrator indicated they did not follow up with the family as the theft report was ";hearsay." When asked, the Administrator indicated they dont rely on second - hand information. The Administrator indicated they called the active patients who received services from HA 1 to ensure they had concerns about HA 1 as part of the investigation. 8. On 6/20/2024, the Administrator provided a list of family members of 37 active and former patients who received services from HA 1. The Administrator indicated they called them to ensure there were no concerns regarding HA 1 as part of the investigation. The agency failed to investigate allegations of misappropriation until the survey was initiated.

Based on record review and interview, the agency failed to take corrective action when misappropriation allegations occurred for 1 of 1 agency surveyed. Findings include: --- 1. An email sent by the Administrator dated 4/19/2024, sent to all agency staff, included the instruction for employees to review the Patient Bill of Rights. 2. A review of the Patient Bill of Rights failed to include the term ";misappropriation." 3. During an interview on 6/13/2024 at 10:03 AM, the Director of Professional Services (DPS) indicated all employees were re - trained in the patient rights on 4/19/2024. During an interview on 6/13/2024 at 2:10 PM, the DPS was asked to find a reference to the patients right to be free of misappropriation. The DPS indicated they did not see a reference to misappropriation. When asked, the DPS indicated they believed misappropriation was covered by the ";lack of respect for the patients property" section of the patient rights.

Based on record review and interview, the agency failed to report allegations of theft to the State agency within 5 working days for 1 of 2 patients with allegations of theft (Patient #1). Findings include: --- 1. A review of the Internet Quality Improvement and Evaluation System (iQIES) evidenced an incident report received 6/17/2024 regarding misappropriation of funds of Patient #1. The report indicated the agency received notification on 6/16/2024 from Person B that HA 1 made unauthorized purchases using Patient #1s credit card. 2. During an interview on 6/10/2024 at 3:12 PM, Person B reported they believed HA 1 used Patient #1s credit card without permission. Person B indicated they did a police report for the theft on 4/15/2024. 3. During an interview on 6/14/2024 at 11:50 AM, the Administrator indicated a detective notified them on 4/15/2024 that Person B reported the theft from Patient #1 to the police. When asked why they did not act on this information, the Administrator indicated they did not report or investigate the theft as it was not reported by the family but was ";hearsay."

Based on record review and interview, the agency failed to protect patients from misappropriation of funds for 2 of 2 patients with complaints of misappropriation (Patients #1 and 2). Findings include: --- 1. A review of the ";Patient Information for the State of Indiana" obtained from an agency admission packet indicated patients and families had the right to be free from misappropriation of property. 2. A review of the Employee Handbook for Entity E indicated employees would not steal, regardless of the amount. 3. A review of a police report dated 3/20/24 indicated Person G alleged someone used Patient #2s credit card fraudulently for $1468.46. The police report identified HA 1 as the suspect. 4. A review of a police report dated 4/15/2024 indicated Person B alleged HA 1 used Patient #1s credit card fraudulently from 12/25/2023 to 3/25/2024 for $4479.06. 5. During an interview on 6/10/2024 at 3:12 PM, Person B reported they believed HA 1 used Patient #1s credit card without permission. Person B indicated they did a police report for the theft on 4/15/2024. 6. During an interview on 6/14/2024 at 11:50 AM, the Administrator indicated a police detective came on 4/15/2024 about allegations of theft by an employee of the agency. The Administrator identified HA 1 as the person in the photo, taken from a store camera, while they used Patient #2s credit card.

Based on record review, observation, and interview, the interdisciplinary group (IDG) failed to ensure the updated comprehensive assessment included changes that had taken place for 1 of 3 active records reviewed of patient with wounds living in own home (Patient #17). Findings include: --- 1. A review of an agency policy titled ";Wound Assessment, Documentation and Clinical Oversight" indicated at least once weekly the registered nurse (RN) will perform wound assessments, including wound measurements that include the length, width, and depth of wound. 2. A review of an agency policy titled ";Ongoing Assessments" indicated the ongoing hospice assessment will be determined by the patients condition and the skilled nurse will assess skin integrity each visit. 3. A review of the clinical record of Patient #17 included the plan of care for benefit period 05/05/2024 - 7/03/2024 which indicated the skilled nurse visits Patient one time a week. A review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 06/12/2024 for Patient #17 included an order dated 06/07/2024 for the skilled nurse to assess and measure the wound to the right shin weekly. During a home visit on 06/17/2024 beginning at 2:00 PM, RN 4 was observed measuring the length and width of a skin tear wound on the right shin of Patient #17. Observation failed to evidence the RN obtained the depth of the wound. During an interview on 06/17/2024 at 2:40 PM, when asked why the depth of the wound was not measured during the home visit, RN 4 indicated did not measure the depth of the wound because it looked surface level.

Based on record review and interview, the interdisciplinary group failed to ensure the plan of care contained safety precautions and goals and interventions which were based on problems identified in the assessment (see tag L545), included measurable goals (see tag L548), included correct medication and treatment orders (see tag L549), included revocation information (see tag L554), and patients received all ordered services (see tag L555). --- The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment and resulted in the agency being found out of compliance with the condition 42 CFR 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services

Based on record review and interview, the agency failed to ensure the plan of care (POC) included all goals and interventions based on problems identified in the updated comprehensive assessment in 3 of 7 active records reviewed for patients living in own homes (Patient #4, 9, 10) and failed to ensure the POC included all safety precautions in 1 of 7 active records reviewed for patient living in own home (Patient #19). Findings include: --- 1. A review of an agency procedure titled ";Falls Reduction" indicated for a patient identified to be a fall risk the POC will include goals and interventions for safety and fall precautions. 2. A review of an agency policy titled ";The Plan of Care" indicated the POC will focus on identified problems, goals, and interventions and will include safety measures. 3. A review of the clinical record of Patient #4 indicated an election of benefit date on 12/11/2023. A review of a Visit Note Report completed by registered nurse (RN) 3 on 04/03/2024 indicated Patient #4 had a fall at home and sustained a one-inch laceration (deep cut to the skin) to the center back of the head and RN 3 reported to a physician that Patient #4 was a high fall risk. A review of a Hospice Recertification Assessment completed by RN 3 on 05/24/2024 indicated Patient #4 had a high risk for falls with a score of 19 and that a total score of 10 or more indicated a high risk for falls. A review of the POC for benefit period 06/08/2024 – 08/06/2024 failed to evidence goals or interventions to address the high fall risk identified in the updated comprehensive assessment. During an interview on 06/18/2024 at 12:35 PM, when asked where the goals and interventions for fall safety could be found in the POC, RN 3 indicated did not create goals or interventions for fall safety. 4. A review of the clinical record of Patient #9 indicated an election of benefit date on 07/13/2023. A review of a Hospice IDG (Interdisciplinary Group) Assessment and Plan of Care Update Report dated 05/29/2024 indicated Patient #9 had a fall on 05/25/2024 and sustained bruising. Review of the document failed to evidence goals or interventions in the POC to address a fall risk. A review of a Hospice Recertification Assessment completed by RN 5 on 06/14/2024 indicated Patient #9 had a high risk for falls with a score of 22 and that a total score of 10 or more indicated a high risk for falls. Review indicated Patient #9 had a catastrophic fall on 03/14/2024 sustaining bruises, skin tears, and sprains, and additional falls occurred on 03/25/2024, 05/09/2024, 05/11/2024, and 05/25/2024. A review of the POC for benefit period 05/08/2024 – 07/06/2024 failed to evidence goals or interventions to address the high fall risk identified in the updated comprehensive assessment. During an interview on 06/19/2024 at 10:25 AM, when asked where the goals and interventions for fall safety could be found in the POC, RN 5 indicated had not entered them. 5. A review of the clinical record of Patient #10 indicated an election of benefit date on 03/29/2023. A review of a Visit Note Report completed by RN 6 on 05/29/2024 indicated Patient #10 was anorexic (loss of appetite) and cachexic (severe weight loss) in appearance. A review of a Visit Note Report completed by RN 6 on 06/05/2024 indicated Patient #10 was not eating well and was losing between 1 and 3 pounds of weight each week. A review of the Hospice IDG Assessment and Plan of Care Update Report dated 06/12/2024 indicated the appetite of Patient #10 had not improved and had a weight loss of 9.6 pounds since 04/03/2024. Review of the document failed to evidence goals or interventions for decreased appetite in the POC. During an interview on 06/19/2024 at 10:15 AM, when asked where to find the goals and interventions for decreased appetite, RN 6 indicated had not entered goals or interventions in the POC for decreased appetite. 6, A review of the clinical record of Patient #19 indicated an election of benefit date on 05/27/2024 and included a diagnosis, but not limited to, Esophageal Cancer. A review of a Visit Note Report for the start of care completed by RN 15 on 05/27/2024 indicated Patient #19 had increased difficulty in swallowing pills, solids, and liquids. A review of the Hospice IDG Assessment and Plan of Care Update Report dated 06/12/204 indicated RN 7 documented Patient #19 had a decrease in intake due to dysphagia (difficulty in swallowing). Review of the document failed to evidence safety precautions for difficulty in swallowing were in the POC. During an interview on 06/19/2024 at 1:12 PM, when asked where to find safety measures in the POC for difficulty swallowing, RN 7 indicated had not documented difficulty swallowing precautions in the POC.

Based on record review and interview, the interdisciplinary group (IDG) failed to include measurable goals in the plan of care (POC) for 1 of 1 patient records reviewed with care coordinated by registered nurse (RN) 2 (Patient #15). Findings include: --- A review of the POC for Patient #15, with a diagnosis of cerebrovascular disease (affects blood flow and blood vessels in the brain), included a goal of ";Patient will maintain optimal mobility within disease process." During an interview on 6/17/2024 at 9:30 AM, RN 2 indicated optimal mobility for Patient #15 would be to maintain the ability to feed themselves, and the Karnofsky Performance Status (KPS) and Palliative Performance Scale (PPS) scores (both measure a patients functional status). When asked, RN 2 indicated the ability to feed self and the KPS and PPS scores were measurable and specific and maintain optimal mobility was not measurable.

Based on record review and interview, the agency failed to ensure the plan of care (POC) included the correct route of administration of a medication in 1 of 4 active records reviewed for patients from the branch location (Patient #9), failed to ensure the POC included nonduplicate orders of a medication in 1 of 4 active records reviewed for patients from the branch location (Patient #10), and failed to ensure the POC included orders for all treatments provided in 1 of 7 active records reviewed of patients with wounds (Patient #19). --- 1. Review of an agency policy titled ";The Plan of Care" indicated the care provided to the patient must be in accordance with the POC, will meet the documentation requirements of the physician-directed medical orders, and the POC will contain medications and treatments. 2. A review of the clinical record of Patient #9 included a POC for benefit period 05/08/24 – 07/06/24 that indicated the following medication: Voltaren (used for arthritic pain) gel, administer 1 inch by mouth four times a day as needed. The POC failed to evidence the correct route for administration of this medication. During an interview on 06/19/2024 at 10:25 AM, when asked why the route of administration for Voltaren gel was entered as by mouth, registered nurse (RN) 5 indicated the route was not right. 3. A review of the clinical record of Patient #10 included a POC for benefit period 05/22/24 – 07/20/24 that indicated the following medication was entered in duplicate on 04/24/2024 by RN 6 and RN 11: Senna Lax (used for constipation) 8.6 mg (milligram) administer 2 tablets by mouth daily. A review of an agency document titled ";Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report" dated 06/12/2024 included duplicate orders for Senna Lax. During an interview on 06/19/24 at 9:56 AM, when asked why 2 orders for Senna Lax were entered into the POC, RN 6 indicated that is not right. 4. A review of the clinical record of Patient #19 included Visit Note Reports completed on 06/11/2024 and 06/17/2024 that indicated barrier cream (protects skin from irritants) and optifoam (dressing that covers a wound to assist with healing) were applied to multiple skin tears on Patient's buttocks. During an interview on 06/19/24 at 1:35 PM, when asked where the orders for barrier cream and optifoam could be found, Patient Care Manager 1 confirmed an order had not been obtained.

Based on record review and interview, the hospice agency failed to include revocation documentation in the clinical record for 1 of 1 revocation discharged records reviewed (Patient #20). --- Findings include: 1. The agency policy ";Revocation of Hospice Benefit" indicated the case manager will facilitate the patients revocation and assist with a smooth transition to another setting. The policy also indicated the case manager/clinical supervisor will ensure that all relevant information is documented in the clinical record including the reason for revocation and follow-up to be provided by other healthcare providers. 2. Patient #20s clinical record evidenced a discharge date of 5/20/24 due to revocation and included a non-visit discharge summary completed by Patient Care Manager (PCM) 1 dated 5/21/24. The clinical record failed to include documentation regarding the revocation and failed to include collaboration documentation with Entity F. 3. During an interview on 6/19/24 beginning at 12:10 PM, RN 8 indicated they thought Patient #20 revoked hospice services to transfer to another hospice and indicated the revocation information should be documented on a care coordination note in the clinical record. RN 8 referred the Surveyor to discuss the situation with the PCM. 4. During an interview on 6/19/24 beginning at 12:40 PM, Person D relayed that Patient #20 requested the revocation of hospice services on 5/20/24 due to unsatisfaction with the agency. 5. During an interview on 6/19/24 beginning at 2:04 PM, PCM 1 relayed Patient #20 revoked hospice services to transfer to another hospice agency and indicated the clinical record for Patient #20 failed to include any documentation regarding the revocation or collaboration with another hospice.

Based on record review and interview, the hospice agency failed to ensure patients received services as ordered in the plan of care (POC) for 2 of 15 active records reviewed with home health aide (HHA) services ordered (Patient #18 and 20). --- Findings include: T1. he agency policy ";The Plan of Care" indicated the written plan of care will contain but will not be limited to the frequency / amount of services, to include duration as required by state regulation / expectation and indicated every effort should be made to adhere to the ordered visit frequency. Attempts should be made to reschedule a visit within the ordered time frame to avoid a missed visit. 2. Patient #18s clinical record included a POC for the benefit period 4/26/24 to 6/24/24. The POC indicated the patient was to receive Home Health Aide (HHA) services 2 times a week for 1 week; 4 times a week for 8 weeks and then 2 times a week for 1 week. The record evidenced dual HHA Visits were performed on 5/03/24, 5/06/24, 5/10/24, 5/17/24, 5/20/24, 5/24/24, 5/31/24, 6/03/24, 6/07/24, 6/1-/24, 6/14/24 and 6/17/24. The clinical record failed to evidence Patient #18 received the HHA visits as ordered in the POC on 4/26/24, 4/29/24 and 5/13/24. During an interview on 6/19/24 beginning at 10:49 AM, RN 9 indicated the clinical record for Patient #18 did not include any documentation regarding the above missed HHA visits. 3. Patient #20s clinical record included a POC for the benefit period 4/14/24 to 6/12/24. The POC indicated the patient was to receive Home Health Aide (HHA) services 4 times a week for 8 weeks and then 2 times a week for 1 week and a POC Update effective 5/05/24 with orders for HHA services 2 times a week for 5 weeks and then 1 time a week for 1 week. The record evidenced dual HHA Visits were performed on 4/14/24, 4/19/24, 4/29/24 and 5/02/24. The clinical record failed to evidence Patient #20 received the HHA visits as ordered in the POC during the week of 4/21/24 while the patient was in respite. During an interview on 6/19/24 beginning at 12:10 PM, RN 8 relayed they thought Patient #20 received HHA visits during the week of 4/21/24 while in respite however the clinical record did not include any documentation of HHA visits during that week. During an interview on 6/19/24 beginning at 2:04 PM, Patient Care Manager 1 relayed patients should receive all services while in respite care and they were unsure why Patient #20 did not receive HHA visit during the respite stay.

Based on record review and interview, the agency failed to ensure the frequency and detail of data collection was approved by the governing body in 1 of 1 agency. Findings include: --- 1. A review of the annual governing body minutes, dated 04/26/2024, failed to evidence the governing body approved the frequency and detail of data collection of the quality assessment and performance improvement program. 2. During an interview on 06/19/2024 at 3:39 PM, when asked to see the governing body approval of the frequency and detail of data collection, the administrator indicated there was no documentation to evidence the governing body approved the frequency and detail of data collection.

Based on record review and interview, the agency failed to ensure a registered nurse (RN) completed the hospice aide (HA) skill competency for 5 of 5 hospice aide records reviewed with a hire date after 1/1/2023 (HA 1, 4, 5, 7, and 9). Findings include: --- 1. The Hospice Aide Services policy indicated trained hospice aides would provide aide services that were consistent with the aides competency skills. 2. A review of the personnel record for HA 1, hired 9/25/2023, evidenced a competency skill validation form dated 9/25/2023. The form listed 31 skills with a validation date of 10/10/2023. HAs 2 and 10 initialed each skill and signed the form. RN 12 signed the form and was identified by the director of patient services (DPS) as the nurse who used to sign the forms. The record contained a supervisory visit note dated 10/18/2023 by RN 8. 2. A review of the personnel record for HA 4, hired 7/10/2023, evidenced a competency validation form dated 7/10/2023, with individual skills completed from 7/17 – 7/25/2023. HA 11 completed skill validation. RN 12 the signed the form. The initials on the form were not those of The record contained a supervisory visit note dated 7/26/2023 by RN 12. 3. A review of the personnel record for HA 5, hired 1/31/2023, evidenced a competency validation form dated 2/1/2023, with individual skills completed on 2/16/2023 and initialed and signed by HA 2. The record contained a supervisory visit note dated 2/23/2023 by RN 13. 4. A review of the personnel record for HA 7, hired 3/20/2023, evidenced a competency validation form dated 3/27/2023, initialed by RN 14. There was no RN signature on the form at the time of the record review. When a copy of the document was provided, RN 14 had signed and dated the form 6/18/2024. The record included a supervisory visit note dated 3/27/2023 by the DPS of the branch office. 5. A review of the personnel record for HA 9, hired 6/22/2023, evidenced an undated competency validation form initialed by the branch DPS. There was no RN signature at the time of the record review. When a copy of the document was provided, the branch DPS had signed and dated the form 6/18/2024. 6. During an interview on 6/12/2024 at 2:30 PM, the DPS of the parent indicated seasoned HAs completed the skills review with the new HA. The RN validated the skills competency by observing the new HAs performance of a skill at a home visit. 7. During a phone interview on 6/13/2024 at 10:50 AM, HA 11 described the skills competency process for new HAs. HA 11 indicated the new HA would attend visits with the seasoned HA to observe the skills. The new HA would then demonstrate each of the skills. Before the end of training, an RN completed a supervisory visit with the new HA to validate the skills. HA 11 indicated the RN observed the skills pertinent to the patient, not all skills. 8. During a phone interview on 6/13/2024 at 11:27 AM, RN 13 described the skills competency process for new HAs. RN 13 indicated a seasoned HA mentored the new HA then observed the new HA completing the skills. Then the RN completed a supervisory visit to observe the new HA perform skills. RN 13 indicated the new HA demonstrated the skills related to the care of the patient at the visit, not all the skills. 9. During a phone interview on 6/13/2024 at 3:21 PM, HA 10 described the skills competency process for new HAs. HA 10 indicated the seasoned HA observed the skill demonstration by the new HA. An RN then completed a supervisory visit with the new HA to validate the competency. HA 10 indicated the supervisory visit did not include the observation of all skills, just the ones relevant to the individual patient. The agency failed to ensure the RN validated the ability of the hospice aide to perform skills.

Based on record review and interview, the agency failed to ensure the hospice aide (HA) was supervised by a registered nurse (RN) for 1 of 1 record reviews for patients who received care from HAs under the supervision of RN 2 (Patient #15). Findings include: --- A policy on the supervision of clinical services indicated HA supervisory visits would be conducted every 14 days. The plan of care for Patient #15 indicated HA visits for personal care. The record indicated RN 2 completed supervisory visits on 3/29 and 5/7/2024. Nurse visit notes completed on 4/12, 4/19, 4/24, 4/26, 4/30, and 5/3/2024 failed to include documentation of a supervisory visit. The record evidenced HA visits 4/19, 4/26, and 5/3/2024. The record failed to include supervisory visits every 14 days for HAs 7 and 9. During an interview on 6/19/2024 at 3:08 PM, RN 2 indicated they did HA supervisory visits at every nurse visit. RN 2 indicated the supervision note was towards the end of the visit note. During an interview on 6/19/2024 at 3:15 PM, RN 10 was unable to locate supervisory visit notes between 3/30 – 5/5/2024.

Based on observation and interview, the hospice aides (HAs) 7 and 9 failed to transfer patient safely while using a Hoyer lift, for 1 of 1 home visit observations with the use of a Hoyer lift. Findings include: --- During a home visit on 6/17/2024 at 9:30 AM with Patient #15, Surveyor observed HAs 7 and 9 use a Hoyer (mechanical lift) to move the patient from the bed to a chair. Observed the bottom of the bed move while the HAs loaded Patient #15 onto the lift. When the transfer to the chair occurred, Patient #15 requested they be adjusted in the chair as they leaned to the side. Observed both HAs pull patient up and straight in the chair. While in the process, the chair moved, and HA 7 locked the chair. On 6/17/2024 Registered nurse (RN) 2, present during the visit, completed a supervisory visit note which failed to identify the failure to lock the wheels on the bed and wheelchair. During an interview following the home visit, HA 7 reviewed the steps to prepare for the use of the Hoyer. HA 7 failed to identify locking the wheels of the bed as part of the process. HA 7 indicated they are usually at the foot of the bed and lock the wheels then. HA reviewed the steps for adjusting a patient in a wheelchair and indicated the wheels should have been locked prior to placing or moving the patient in the chair.

Based on record review and interview, the hospice agency failed to ensure the use of administrative and/or direct patient care volunteers equaled a minimum of 5% of the total patient care hours for 1 of 1 agency. Findings include: --- 1. A review of the Volunteer Coordinator job description indicated the volunteer coordinator is to maintain the 5% criteria as required in the regulations. 2. A review of an agency document titled ";Volunteer Cost Savings Report" indicated for the year 2023, the parent location had a cost saving figure of 4% and the branch location had a cost saving figure of 1% for the use of volunteers in administrative and/or direct patient care. The document failed to evidence the hospice agency had a minimum of 5% cost savings with the use of volunteers. 3. During an interview on 06/18/2024 at 10:10 AM, the volunteer coordinator indicated the parent location volunteer cost savings figure was 4% for 2023 and the branch location volunteer cost savings was 1% for 2023. The volunteer coordinator indicated the employee responsible for the branch location volunteers was on leave and not available.

Based on record review and interview, the agency failed to ensure hospice aides (HAs) had an active certification for 2 of 6 active HA records reviewed (HAs 8 and 9). Findings include: --- 1. A review of the hiring process policy indicated employee license or certification verification occurred at hire and at the time of renewal. 2. A review of the personnel record for HA 8 failed to evidence a current CNA license. 3. A review of the personnel record for HA 9 evidenced a CNA license with an expiration date of 3/18/2024. During an interview on 6/17/2024 at 3:40 PM, the Executive Director of the branch location indicated HAs 8 and 9 had active CNA licenses. The Executive Director indicated the previous office manager left on bad terms and destroyed some personnel record contents and the verifications for HAs 8 and 9 were part of the destroyed records.

Based on record review and interview, the interdisciplinary group (IDG) failed to ensure the frequency of services on the plan of care (POC) was patient specific in 1 of 1 active record reviewed of patient residing in own home (Patient #4). Findings include: --- 1. Review of an agency document titled ";Individualizing the Hospice Plan of Care Guidebook" indicated the frequency of visits is included in the POC and specific to the patients needs and prn only visits are not considered to be a frequency and may only accompany an ordered frequency. 2. A review of the clinical record of Patient #4 included a POC for 02/04/24 – 04/03/24 that indicated orders for the social worker of 5 prn (as needed) visits, spiritual care counselor of 5 prn visits, massage therapist of 8 prn visits, and music therapist of 4 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs. During an interview on 04/02/24 at 10:00 AM, when asked how the social worker, spiritual care counselor, massage therapist, and music therapist know their visit orders, registered nurse (RN) 1 indicated the social worker and spiritual care counselor enter their own visit orders and the massage therapist and music therapist visit orders are entered by their supervisors. During an interview on 04/02/24 at 10:45 AM, when asked what visit orders are entered, spiritual care counselor 1 indicated enters own visit orders which are reviewed by supervisor and includes frequency orders with prn orders for extra visits. During an interview on 04/02/24 at 1:25 PM, when asked for the frequency of visits for the social worker, spiritual care counselor, massage therapist, and music therapist for Patient #4, the director of nursing indicated the frequency of visits is missing and the order should include the frequency and the number prn visits, if needed.

Based on record review and interview, the agency failed to ensure the interdisciplinary group (IDG) updated the plan of care based on the patient's current needs for 1 of 2 (Patient #5) patient records reviewed with registered nurse (RN) 1 as the primary nurse. Findings include: --- A review of an agency guidebook on individualizing the plan of care indicated the interdisciplinary group (IDG) updates the plan of care (POC) based on the patients changing needs. A review of Patient 5s orders provided by Entity B, where patient resides, did not include any wound care orders. A review of Patient 5s hospice orders indicated wound care orders for the left heel, effective 10/5/2023. A review of the wound record for Patient #5 indicated the left heel wound was inactivated by RN 1on 2/12/2024. A review of the documentation of the IDG meeting on 2/21/2024 included a summary of Patient #5s status by RN 1. The documentation failed to indicate the left heel wound was healed and wound care orders were no longer needed. During an interview on 4/2/2024 at 2:05 PM, RN 1 indicated Patient #5 had a heel wound which was healed 2/12/2024. When asked, RN 1 indicated the wound care orders should have been discontinued when the wound was healed, on 2/12/2024.

Based on record review and interview, the registered nurse (RN) failed to ensure a hospice aide written plan of care (POC) included patient specific instructions for 1 of 5 active records reviewed of patients residing in a nursing facility receiving hospice aide services (Patient #1). Findings include: --- 1. A review of an agency document titled ";Individualizing the Hospice Plan of Care Guidebook" indicated the hospice aide POC is to be patient-specific. 2. A review of the clinical record of Patient #1 included a POC, for benefit period 02/16/24 – 05/15/24, which indicated frequency orders for the hospice aide to visit Patient two times a week. An agency document dated 03/21/24 and titled ";Hospice Interdisciplinary Group (IDG) Assessment and Plan of Care Update Report" included an update to the plan of care interventions for two hospice aides/2 caregivers in the room of Patient #1 when providing care. An agency document titled ";Aide Care Plan Report" failed to evidence the hospice aide care plan included instructions regarding the presence of two persons in the room when providing care. During an interview on 04/02/24 at 11:58 AM, when asked what specific instructions had been entered into the hospice aide care plan regarding the presence of two persons in the room of Patient #1 when providing care, hospice aide 2 indicated hospice had not given any instructions and indicated the nursing facility gave instructions to have 2 persons in the room. During an interview on 04/02/24 at 12:39 PM, when asked to tell where the hospice aide care plan included instructions for the presence of two hospice aides or two caregivers in the room of Patient #1 when providing care, registered nurse (RN) 3 indicated this was a nursing facility policy. When asked if this information should be in the hospice aide care plan, RN 3 indicated yes.

Based on record review and interview, the agency failed to ensure registered nurse (RN) 1 completed aide supervisory visits for 2 of 2 (Patients #3 and 5) patient records reviewed with RN 1 as the primary RN. Findings include: --- 1. A review of a policy on aide supervision indicated a registered nurse must complete a supervisory home visit at least every two weeks for the purpose of evaluating the effectiveness of the hospice aide services. 2. A review of the clinical record for Patient #3 for dates of service 1/14/24 – 4/1/2024 indicated hospice aide visits one time each week. Patient #3 received skilled nurse visits either 2 or 3 times a week. A review of the nurse visit notes failed to evidence supervisory visits every two weeks. Supervisory visits were missing for 2/23/2024 and 3/22/2024. During an interview on 4/2/2024 at 9:30 AM, RN 1 indicated they were the nurse for Patient #3. RN 1 indicated aide supervisory visits were performed every two weeks. When asked about the missing supervisory visits, RN 1 indicated he/ she thought they completed the supervisory visits and documentation. 3. A review of the clinical record for Patient #5 for benefit period 3/3/2024 – 5/1/2024 indicated hospice aide visits and skilled nurse visits one time weekly. A review of the nurse visit notes failed to evidence a supervisory visit every two weeks. A supervisory visit was not completed by 3/22/2024. During an interview on 4/2/2024 at 9:30 AM, RN 1 indicated they were the primary nurse for Patient #5. RN 1 indicated they asked the facility how the aide was doing at each nurse visit and thought they documented the supervisory visit.

Based on record review and interview, the hospice agency failed to provide professional management of patient residing in a nursing facility regarding communication with patients legal representative for 1 of 5 active records reviewed of patients residing in nursing facilities (Patient #1). Findings include: --- 1. A review of an agency document titled ";Nursing Facility Agreement" between the hospice agency and Other A indicated the hospice will retain responsibility for the professional management of hospice patients. An agency document titled ";Hospice Facility Guidebook" indicated the hospice team will communicate with the family about patients conditions and the outcome of visits. 2. A review of the clinical record of Patient #1, benefit election date of 02/16/24, included a plan of care (POC) for 02/16/24 – 05/15/24 that a hospice aide visits Patient two times a week. An agency document titled ";Visit Note Report" and completed by registered nurse (RN) 3 on 03/11/24 indicated Patient #1 neurological status as confused, disoriented, hallucinations, and delusions. Documentation indicated patient reported to RN 3 had been raped by a hospice aide. Documentation indicated RN 3 notified the nursing facility director of nursing, filled out a statement, and attempted to notify Patients power of attorney, Person D (family member) with no return call. The documentation failed to evidence RN 3 notified Person D about the allegations. An agency document titled ";Visit Note Report" and completed by social worker (SW) 1 on 03/14/24 indicated the visit was made because of the allegation of inappropriate touching by a hospice aide. Documentation indicated Patient #1s mental status was forgetful, confused, and had hallucinations and included a SW 1 discussion about the allegation with Patient 1. Documentation indicated Person D arrived during the visit and SW 1, Patient 1, and Person D discussed watching Westerns. The documentation failed to evidence that SW 1 notified Person D about the allegations. 3. During an interview on 04/01/24 at 2:09 PM, when asked to discuss the incident that occurred with Patient #1, Person D indicated he/she did not know an incident had occurred. When asked if the hospice contacted him/her about the allegation of inappropriate touching of Patient #1, Person D indicated neither the hospice nor the nursing facility notified him/her. During an interview on 04/02/24 at 11:26 AM, when asked about the notification of Other D regarding the allegations made by Patient #1, Person E (from Entity A) indicated that Person D contacted him/her the previous day wanting to know what happened. Person E indicated he/she did not find documentation in the nursing facility electronic medical record of the notification of Person D regarding the allegation and indicated the nursing facility director of nursing had contacted Person D about the allegation. During an interview on 04/02/24 at 11:40 AM, SW 1 indicated he/she did not notify nor discuss the allegation with Person D during the visit made on 03/14/24. During an interview on 04/02/24 at 12:39 PM, when asked about the notification of Person D regarding the allegation of inappropriate touch made by Patient #1, RN 3 indicated he/she had attempted to contact Person D and did not receive a response. During an interview on 04/02/24 at 1:25 PM, when asked to see the hospice documentation of notification of Person D about the allegation, the director of nursing indicated the nursing facility contacted Person D and that hospice employees have difficulty in getting Person D to respond to calls. The director of nursing indicated there was no documentation of hospice communication with Person D about the allegations.

Based on record review and interview, the hospital agency failed to involve the patient/family in their hospice plan of care specific to the agency failed notify the patient and/or family that a discharge for cause was being considered, failed to make a serious effort to resolve the problem presented by the patients situation, and failed to document the efforts made to resolve the problem prior to the patients discharge for 1 of 1 closed record reviewed of a patient discharged for cause (Patient #1). --- Findings include: 42 CFR 418.26 indicated the hospice may discharge a patient for cause if the hospice determines, according to its policy addressing discharge for cause, that the patient, or persons in the patients home, ";exhibited behavior which was disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively was seriously impaired." The regulation indicated the hospice must do the following before it sought to discharge a patient for cause: ";(i) Advise the patient that a discharge for cause is being considered; (ii) Make a serious effort to resolve the problem(s) presented by the patient's behavior or situation ... (iv) Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its medical records ...." Review of agency policy #881-H titled ";Discharge/Discharge Planning," dated 05/2023, indicated patients would be discharged for cause if the patient or family members behavior was determined to be ";disruptive, abusive, or uncooperative to the extent that delivery of care to the patient, or the ability of the hospice to operate effectively is seriously impaired." The policy also indicated that prior to discharging a patient for cause, the agency must advise the patient that a discharge for cause was being considered, ";make a serious effort to resolve the problem(s) present by the patients behavior or situation ... [and] document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the patients medical record ...." Review of Patient #1s clinical record indicated the patient was referred to the agency for hospice services on 08/29/2023 while admitted to Local Hospital K. An initial assessment, completed on 08/31/2023 by Registered Nurse (RN) 2, indicated Patient #1 had been taking Methadone and Oxycodone (both opioid pain medications) prior to admission to the hospital. RN 2 documented a review of the patients hospital records revealed when the patient presented to the hospital, they reportedly had ";ran out" of their pain medication. The hospital records also revealed prior to hospitalization, Patient #1 was living with Family Member A at a local motel after the patients former apartment owners placed a restraining order against Family Member A for ";illicit activities." The nurses note indicated upon discharge from the hospital Patient #1 was to move to Family Member Bs residence and that family member would be the primary caregiver. During an interview with the Administrator and Patient and Family Care Coordinator (PCC) on 09/18/2023 beginning at 1:45 PM, the Administrator reported Account Liaison 1, an employee who initially received Patient #1s referral for hospice services, had a discussion with the patient and family regarding a potential discharge if the patient went to live with Family Member A. The Administrator and PCC reviewed Account Liaison 1s intake note and were unable to evidence where the discussion was documented. During an interview with Account Liaison 1 on 09/19/2023 beginning at 11:49 AM, the employee confirmed they received Patient #1s referral for hospice services and spoke with Family Member B to confirm the family member would be the patients primary caregiver. The family member reportedly informed Account Liaison 1 of their own health issues but Family Member B was working two jobs, including one job as an aide for another agency, and confirmed they could provide all of Patient #1s caregiving needs. Account Liaison 1 reported they discussed with Family Member B the need for the patient and/or family to sign a pain contract however they did not discuss the potential for discharge if the patients living situation changed. The record indicated the patient was discharged from the hospital on 09/02/2023 and RN 3 completed a start of care assessment on the same day. RN 3 documented a lock box was present in Family Member Bs home, the patients pain medication was stored in the lock box, and the patient signed a pain contract. During an interview with RN 3 on 09/19/2023 beginning at 4:13 PM, the RN reported they completed their start of care assessment in the patients new residence with Patient #1 and Family Member B. The nurse reported they reviewed the pain contract with the patient and family member and also informed them that if medications were to come missing, the hospice would no longer come into the home. RN 3 denied discussing the potential for discharge if the patients living situation changed. The record included an initial social worker assessment completed on 09/05/2023 by Licensed Social Worker (LSW) 2. The social workers note indicated the patient had limited family members or friends available to provide care and potential family concerns included ";tension involved with family relationship ... family has addiction issues." The visit note also indicated Family Member B stated Patient #1 ";had nowhere safe to go" due to their familys history of drug and alcohol abuse. During an interview with LSW 2 on 09/18/2023 beginning at 4:11 PM, the social worker reported during their visit on 09/05/2023, Family Member B was adamant that Patient #1 had nowhere else to stay due to an extensive family history of drug use. LSW 2 also confirmed Family Member B reported they had their own health issues but the family member was able to act as primary caregiver to Patient #1. The social worker reported they discussed the potential need for respite care if Family Member B required treatment for their health issues. LSW 2 denied informing the patient and/or family member of the potential for discharge if the patients living situation changed. The social worker also reported the agency did not attempt to re-locate a patient in an unsafe location if there was a pain contract in place. The record included a plan of care for benefit period 09/02/2023 – 11/30/2023 which indicated social work interventions included but were not limited to ";community resource planning including for respite ...." The record included a ";Client Coordination Note," documented on 09/10/2023 by Licensed Practical Nurse (LPN) 1, which indicated Family Member B called the agency on 09/10/2023 at 12:30 PM to report they had requested Family Member A stay overnight with Patient #1 due to Family Member B having a medical appointment on 09/11/2023. The note indicated Family Member A declined to stay at Family Member Bs home and instead moved Patient #1 to their own residence at a local motel. The note indicated Family Member B did not know how long the patient would be residing at the motel. The record included a ";Client Coordination Note," documented on 09/10/2023 by RN 4, which indicated Family Member B called the agency later on 09/10/2023 and requested the agency pick up Patient #1s medication lock box and Life Alert. The note also indicated Family Member B reported that due to a worsening of their own health, they could no longer care for Patient #1, and the patient had gone to live with Family Member A at a local motel. The record included a second ";Client Coordination Note," documented on 09/10/2023 by RN 4, which indicated all patient visits were to be conducted with 2 staff members. The record failed to evidence any further patient visits were attempted or conducted at the motel where the patient was residing. The record included a ";Client Coordination Note," documented on 09/10/2023 by RN 5, which indicated the nurse went to Family Member Bs residence and destroyed all the patients opioid pain medication. The record included a ";Client Coordination Note," documented on 09/11/2023 by RN 6, which indicated the nurse collaborated with Hospice Physician 2, Administrator, Patient and Family Care Coordinator, and Corporate Employees 1 and 2, regarding the patients change in living arrangements. The note indicated the agency staff discussed that Patient #1 was now living with Family Member A, who had a reported history of drug diversion and illicit activity. The note indicated that, after collaboration with the above team members, the agency decided to discharge the patient for cause and at that time reached out to the patients family members to discuss the discharge. The record failed to evidence, prior to the decision to discharge, the agency attempted to contact the patient and/or family members, failed to make a serious effort to resolve the home safety problem, and failed to document the efforts made to resolve the problem. During an interview with RN 6 on 09/19/2023 beginning at 12:28 PM, RN 6 confirmed they were responsible for overseeing Patient #1s care. The nurse reported the motel Patient #1 went to live in with Family Member A was known to be unsafe and the agency was concerned for the patient and employees safety conducting visits at the motel. During the interview, RN 6 reviewed their coordination note from 9/11/2023 and reported the conversation documented was the only time they could recall speaking with Family Member B. During an interview with Family Member B on 09/18/2023 beginning at 1:24 PM, the family member confirmed they were not informed by the hospice of a potential discharge for cause prior to Patient #1s discharge from the agency. During a follow-up interview with the Administrator and PCC on 09/19/2023 beginning at 3:40 PM, the Administrator reported a "mini" interdisciplinary group (IDG) discussed the change in the patients living situation on 09/11/2023 and determined the patient was to be discharged for cause due to their move to an unsafe living environment. The Administrator reported Patient #1 did not have a direct phone number and the agency was unable to speak with Patient #1 directly, so the agency informed Family Member A of the discharge. The Administrator confirmed Family Member A was informed of the discharge after the IDG had decided to discharge the patient. Neither the Administrator nor the PCC were able to report any efforts made by the agency to resolve the problem of the patient's unsafe environment prior to discharge. The Administrator stated no efforts could be made to resolve the problem as the patient had already moved to the unsafe location when the hospice was notified. During a follow-up interview with RN 6 on 09/19/2023 beginning at 4:49 PM, RN 6 reported they spoke with Family Member B on 09/11/2023 prior to the IDGs decision to discharge the patient. The nurse reported they informed Family Member B that the agency would need to discharge the patient due to the change in living situation and reportedly was advised by the family member to contact Family Member A. Review of the clinical record failed to evidence documentation of this conversation.

Upon patient record review 1 of 4 applicable patients (Patient #5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5 - Aide care plan visit frequency 2 week 12 effective 01/09/2022 - No visits made week 2. Corrected on site.

Based on record review and interview, the agency failed to ensure patient received effective symptom management for related conditions in 2 of 7 patients (#1 and 6). Findings include: 1. Review of an agency policy dated 6/2016 titled "Patient's Rights and Responsibilities" indicated " ... the patient has the right to the following ... receive effective pain management and symptom control from the hospice for conditions related to the terminal illness ...." 2. Review of an agency document dated 7/2021 titled "Hospice Levels of Care" indicated " ... hospice has four levels of care including routine home care, continuous home care, respite care, and general inpatient care ... general inpatient care ... available during an acute medical ... episode and provides symptom management ... of severe short-term problems related to the terminal condition that cannot be managed in the regular home setting ... continuous care is provided to patients in crisis ... to manage acute medical symptoms ...." 3. Record review for Patient #1 was completed on 1/21/2022, Election date 10/16/2021, for benefit period 10/16/2021-12/14/2021, with a primary diagnosis of unspecified sequelae of cerebral infarction (residual effects of a stroke) and other diagnoses (but not limited to), essential, primary, hypertension (high blood pressure that's not due to a medical condition), and vascular dementia without behavioral disturbances (problems with memory and other thought processes caused by brain damage from impaired blood flow to the brain). Review of a document titled "Client Coordination Note Report" dated 10/26/2021, indicated " ... pt [patient] in bed curled into a fetal position ... patient making moans and groaning sounds ... patient refused any type of care provided ... dtr [daughter] ... attempted to give patient liquid Ativan [for agitation] and liquid morphine [for pain] ... patient would not open mouth ... RNCM [registered nurse case manager] assisted and was not able to get syringe into mouth either ... has not been able to take any routine medications, comfort medications or recently prescribed antibiotics ... patient taken to hospital ER ...." Patient revoked hospice benefit on 10/26/2021. The document failed to evidence the agency provided symptom management by offering to provide another form of administering pain management, general inpatient care or continuous home care level of care to manage patient's symptoms. Review of a document titled "Hospice Certification and Plan of Care" indicated patient was readmitted to hospice on 10/31/2021 with a primary diagnosis of parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination). Review of a document titled "Client Coordination Notes Report" dated 12/1/2021 indicated " ... received direct call from ... daughter ... pt is c/o [complaining of] chest pain, HR [heart rate] 103 and can't take a deep breath ... social worker met daughter ... in emergency department ... daughter signed revocation paperwork ...." The document failed to evidence the agency provided symptom management by offering to provide another form of administering pain management, general inpatient care or continuous home care level of care to manage patient's symptoms. Review of a document titled "Visit Note Report" for Hospice Election date 12/5/2021, indicated " ... went to hospital on 11/30/2021 due to complaints of chest pain, increased confusion and sore on mid chest ...." During an interview on 1/20/2022 at 3:30 PM, when asked what support the agency provides when symptom management isn't controlled, the director of professional services indicated symptom management cards are left in the home and a nurse practitioner can be utilized. When asked who offers the options of other levels of care when having uncontrolled symptoms, the director of professional services indicated the RN case manager. 4. Record review for Patient #6 was completed on 1/19/2022, Election date 1/25/2021, for benefit period 1/25/2021-4/24/2021, with a primary diagnosis of primary pulmonary hypertension (high blood pressure in the lungs) and other diagnoses but not limited to, cor pulmonale (condition that causes the right side of the heart to fail). Review of a document titled "Hospice Certification and Plan of Care" for benefit period 1/25/2021-4/24/2021, indicated " ... medications ... lorazepam intensol ... as needed every 4 hours ... reason ... anxiety or air hunger [feeling of breathlessness] ...." Review of a document titled "Visit Note Report" dated 3/1/2021, indicated " ... breathing very labored ... no Lorazepam available in the home ... unable to chatch [sic] ... breath ... 911 contacted ...." The agency failed to ensure the patient had an adequate supply of medications to manage symptoms. The document failed to evidence the agency provided symptom management by offering to provide another form of administering symptom management such as morphine to assist with shortness of breath, general inpatient care or continuous home care level of care to manage patient's symptoms. During an interview on 1/20/2022 at 3:30 PM, when asked what happened to the Lorazepam that was supposed to be in patients' home, the administrator of Mishawaka indicated the Lorazepam was never delivered. When asked what the RN case managers responsibility was to ensure prescribed medications are in the patients' home, the administrator indicated the RN case manager is responsible to make sure the medication is ordered and in the home.

Based on record review and interview, the agency failed to ensure hospice training was provided to employees providing hospice care in 1 of 2 facilities with written agreements for short term inpatient hospice care (A). Findings include: Review of an agency contract log indicated the agency had a general inpatient agreement with facility A. Agreement indicated annual training with the description of the training and the names of agency staff providing the training was to be completed. During an interview on 1/21/2022 at 9:10 AM, when asked for documentation of the training provided to facility A, the administrator indicated the agency hospital liaison provides the training titled "GIP (general inpatient) Steps and Process" on an individual basis when the agency has a patient in the facility. Director of Professional Services indicated a hospice patient received inpatient hospice care in facility A on 4/9/2021. When asked for the proof of staff training, the administrator indicated the training was provided but not documented.

Upon patient record review, 6 of 20 records (Patients #3,#4,#7,#9,#11,#16) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medication profile contained fentanyl transdermal patch listed as PRN medication. The order was for it to be scheduled. Corrected on site. Patient 4: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 7: The medication profile contained micatin topical cream to apply to undefined affected area. Corrected on site. Patient 9: The medication profile contained miralax oral powder with no instructions for a diluent and docusate with undefined frequency as needed. Corrected on site. Patient 11: The medication profile contained oxygen with no instructions for a delivery method. Corrected on site. Patient 16: The medication profile contained fentanyl transdermal patch listed as PRN medication. The order was for it to be scheduled.

Upon patient record review, 2 of 20 records (Patients #12,#16) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 12: Patient admitted 9-21-21, there was no evidence of an initial bereavement assessment for current dates of service. Patient 16: The initial bereavement assessment was completed 1-22-21. Patient start of care was 12-17-21.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 10 of 20 records (Patients #4,#6,#7,#10,#11,#12,#13,#14,#15#19) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 4: The medical record contained nursing documentation identifying decreased cardiac function. There was no evidence of problems, goals, and interventions related to cardiac included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation identifying patient issues with incontinence of bowel and bladder, and constipation. There was no evidence of problems, goals, and interventions related to incontinence and constipation included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation identifying patient issues with incontinence of bowel and bladder. There was no evidence of problems, goals, and interventions related to incontinence included in the plan of care. Corrected on site. Patient 10: The plan of care identified problem of altered genitourinary function. There was no evidence of goals and interventions related to the problem. Corrected on site. Patient 11: The plan of care identified problem statements of need for home health aide services. Patient evaluation did not indicate a need for aide services and patient was not receiving the service. Problem statement entered in error. Corrected on site. Patient 12: The plan of care identified problem statements of need for spiritual care and social work services. Patient evaluation did not indicate a need for spiritual care or social work services and patient was not receiving the care. Problem statement entered in error. Corrected on site. Patient 13: The medical record contained nursing documentation identifying patient issues with behaviors and combativeness. There was no evidence of problems, goals, and interventions related to behaviors included in the plan of care. Corrected on site. Patient 14: The plan of care identified problems, goals and interventions for social work. There was no evidence of need for social work identified in the plan of care. Corrected on site. Patient 15: The medical record contained nursing documentation upon admission identifying patient issues with placement of pleurx drain and nausea. There was no evidence of problems, goals, and interventions related to pleurx drain care and nausea included in the plan of care. Patient 19: The plan of care identified problem statements of need for spiritual care and home health aide services. Patient evaluation did not indicate a need for spiritual care or aide services and patient was not receiving this care. Problem statement entered in error.

Upon patient record review, 6 of 20 records (Patients #1,#4,#5,#8,#10,#13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient 1: The medical record contained an order for dietician PRN. There was no evidence of the quantity of visits allowable. Corrected on site. Patient 4: The medical record contained a social worker order add on with no frequency. Corrected on site. Patient 5: The medical record contained a social worker order add on with no frequency. Corrected on site. Patient 8: The medical record contained a social worker and spiritual care add on orders with no frequency. Corrected on site. Patient 10: The medical record contained a spiritual care order add on with no frequency. Corrected on site. Patient 13: The medical record contained a social worker order add on with no frequency. Corrected on site.

Upon patient record review, 10 of 20 records (Patients #1#2,#3,#5,#7#12,#13#15,#16,#19) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation identifying the patient use of a cane. There was no evidence of the cane included on DME and supplies in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation identifying the patient use of a hospital bed and rails. There was no evidence of the bed and rails included on DME and supplies in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation identifying the patient use of an oxygen concentrator, table, and commode. There was no evidence of the concentrator, table, and commode included on DME and supplies in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation identifying the patient use of a walker and oxygen concentrator. There was no evidence of the concentrator and walker included on DME and supplies in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation identifying the patient use of an oxygen concentrator and lift. There was no evidence of the concentrator and lift included on DME and supplies in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation identifying the patient use of a nebulizer. There was no evidence of the nebulizer included on DME and supplies in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation identifying the patient use of a nebulizer. There was no evidence of the nebulizer included on DME and supplies in the plan of care. Corrected on site. Patient 15: The medical record contained nursing documentation identifying the patient use of an oxygen concentrator. There was no evidence of the oxygen concentrator included on DME and supplies in the plan of care. Corrected on site. Patient 16: The medical record contained nursing documentation identifying the patient use of a hospital bed, nebulizer, and indwelling catheter. There was no evidence of the bed, nebulizer, and catheter included on DME and supplies in the plan of care. Corrected on site. Patient 19: The medical record contained nursing documentation identifying the patient use of a walker. There was no evidence of the walker included on DME and supplies in the plan of care. Corrected on site.

Upon patient record review, 3 of 20 records (Patient #3,#5,#16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained evidence of RN on-call visits completed 11-20, 11-21, 11-27, 11-28. These visits were not identified as PRN and were outside of scheduled frequency of once weekly. Corrected on site. Patient 5: The medical record contained an RN on call visit completed 12/5/21 and incomplete second visits outstanding from admission to 11-28-21 when frequency order changed. Corrected on site with order clarification. Patient 16: The medical record contained nursing documentation 2-9-21 identifying placement of a foley catheter. There was no evidence of an order for catheter placement in the plan of care and medical record.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During home visit with the social worker, the clinician bag was set on the floor without barrier as required in bag technique policy.

Upon patient record review 1 of 13 applicable (Patient #12) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #12 The record included an order for aide frequency of twice weekly. There was evidence of one missed visit the week of 10-31-21 and no visits completed.

Upon patient record review, 1 of 20 records (Patient #19) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 19: The medical record contained a revocation form dated 11-30-21 and patient was discharged same date. The form identified patient would resume regular coverage effective 12-3-21. The intended date of discharge was unclear.