Every finding on record at Curo Health Services ,LLC

Based on agency policy, clinical record review, and staff interviews, the agency failed to report a patients claim of physical abuse to Adult Protective Services for 1 of 1 patient reporting abuse (patient #3).Findings included: --- A policy, Patient Bill of Rights (approved 11/01/20240, received on 12/29/2025 at 4:12 PM from the director of clinical services stated, “The Patient Bill of Rights statement defines the right of the patient to: … Be free of verbal, mental, sexual and physical abuse…”A policy, Assessment of Possible Abuse/Neglect (revised 12/12/2025) received on 12/29/2025 at 2:52 PM from the director of clinical operations stated, “Any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor… The clinician will submit a verbal report of suspected abuse/neglect to the proper authorities… within 24 hours…”Patient #3 was admitted on 12/08/2025 with a diagnosis of hypertensive heart disease with heart failure (long term high blood pressure causing thickening, leading to inadequate blood flow). The plan of care for 12/08/2025-03/07/2025 included orders for skilled nurse visits 4 times a week for 1 week, 3 times a week for 12 weeks, and 4 PRN (as needed). Review of the clinical record revealed that on 12/15/2025 registered nurse (RN) #7 documented, “Patient becomes tearful during visit and states He [patient’s son] scares me sometimes and hits me sometimes.” Further review revealed that there was no documentation of Adult Protective Services being notified.An interview conducted on 12/29/2025 at 3:32 PM with RN #7 revealed that they were not aware that they were a mandated reporter of abuse and believed that it was necessary to be able to prove that abuse occurred prior to reporting.

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide skilled nursing services as ordered in the plan of care for 1 of 3 patients receiving skilled nurse visits (patient #3).Findings included: --- A policy, The Plan of Care (revised 12/21/2025) received on 12/29/2025 at 3:21 PM from the director of clinical services stated, “Care provided to the patient will be in accordance with the plan of care.”A policy, Patient Bill of Rights (approved 11/01/2024) received on 12/29/2025 at 4:12 PM from the director of clinical services stated, “The Patient Bill of Rights statement defines the right of the patient to: … Receive all services as outline in the plan of care…”Patient #3 was admitted on 12/08/2025 with a diagnosis of hypertensive heart disease with heart failure (long term high blood pressure causing thickening, leading to inadequate blood flow). The plan of care for 12/08/2025-03/07/2025 included orders for skilled nurse visits 4 times a week for 1 week, 3 times a week for 12 weeks, with 4 PRN (as needed). Review of the clinical record revealed that during the week of 12/14/2025-12/20/2025 patient #3 received 2 of 3 ordered SN visits. Further review revealed that there was no documentation of a missed SN visit.An interview conducted on 12/29/2025 at approximately 3:00 PM with the director of clinical services revealed that there were only 2 visits documented that week and there should have been 3.

Based on clinical record review, the medical social workers (MSW) signed job description, and staff interviews, the agency failed to provide resources for a need identified during the MSW assessment (patient #3).Findings included: --- MSW #10’s signed job description stated, “General Responsibilities … Identifies and utilizes appropriate community resources and assesses patient/family ability to access them.”Patient #3 was admitted on 12/08/2025 with a diagnosis of hypertensive heart disease with heart failure (long term high blood pressure causing thickening, leading to inadequate blood flow). The plan of care for 12/08/2025-03/07/2025 included orders for medical social worker (MSW) visits 1 time for an evaluation, 1 time a month for 4 months with 2 PRN (as needed). Review of the clinical record revealed that during the MSW visit on 12/10/2025 MSW #10 documented, “Community Resources… Private Duty Caregiver… needed.” Further review revealed that there was no documentation of the patient/family being provided information or resources on private duty caregivers.During an interview conducted on 12/29/2025 at 2:33 PM MSW #10 stated, “My goal was to provide them with a list of agencies, I was going to follow-up sometime after IDG [interdisciplinary group meeting].”During an interview conducted on 12/29/2025 at 3:13 PM the director of clinical services stated, resources should be provided, “As timely as they could.” The agency director of clinical services did not define or elaborate on the word timely when asked.”

Based on record review, interviews, and review of the agency policy, the hospice agency failed to ensure that two of 23 patients (Patient (P) 3 and P4) had their medications reconciled from either the Skilled Nursing Facility (SNF) and/or Group Home to match the medications that the hospice agency ordered. This deficient practice had the potential to affect the accuracy of medications ordered for the patients. Findings include: Review of the agency policy titled, "Safe/Effective Use and Administration of Medications," revised 07/22/24, indicated, ". . . The clinician will complete and review the medication profile at initial and comprehensive assessments and updates will be considered part of the plan of care . . ." Review of the agency documentation titled, "Medication reconciliation, home care," revised 05/20/24, indicated, ". . . Medication reconciliation is the formal process of comparing all of the prescription and non-prescription medications that a patient is taking (medication regimen) to an external list (medication profile) of the patients ordered medications. This process should take place any time the patient receives a prescription for a new medication and any time a transition of care or a change in therapy occurs. Medication reconciliation is necessary to identify and resolve medication discrepancies, including duplications, omissions, dosing errors, contraindications, and drug interactions, in order to minimize the risk of adverse drug events and poor patient outcomes. This process requires a team approach that includes the nurse whos reconciling the medications, patient and family, patients practitioners, and pharmacist. Medication reconciliation may occur in conjunction with a medication review, which is a comprehensive and ongoing assessment of the patients medication regimen . . ." 1. Review of P3's agency provided "Patient Information Report" indicated that P3 was admitted to hospice services on 07/18/22 with a diagnosis of Alzheimers disease. Review of P3s undated "Client Medication Report," provided by the agency, indicated orders for P3 to receive:acetaminophen 500 milligrams (mg), two capsules every six hours as needed (PRN) for fever/pain,Ativan (used for anxiety) 0.5 mg tablet every four hours PRN,bisacodyl five mg PRN, two tablets daily PRN for constipation, Calmoseptine topical ointment, one inch to perineum with every brief change PRN, Gabapentin (used for neuropathy) 100 mg every eight hours, hydralazine (used for high blood pressure) 25 mg daily, hold for systolic blood pressure less than 110, ipratropium 0.5 mg-albuterol 3 mg/3 milliliters (ml) nebulization solution (used for shortness of breath) give 3 ml every six hours,Levsin (used for excessive secretions) 0.125 mg, one tablet every four hours PRN, Melatonin (used for sleep) 3 mg, one tablet at bedtime (HS), morphine concentrate (used for pain) 100 mg/5 ml, give 0.25 ml PO every four hours PRN, potassium chloride 10 milliequivalent [mEq] three times a week when Lasix administered, andtramadol (used for pain) 50 mg, give one tablet every six hours PRN. Review of P3s SNF provided "Medication Review Report," dated 02/04/25, revealed no orders for the acetaminophen, Ativan, bisacodyl, Calmoseptin, ipratropium, Levsin, melatonin, potassium chloride, or tramadol as listed on the hospice agency physician orders. In addition, the SNF "Medication Review Report" contained orders for:gabapentin 100 mg, one capsule three times a day,hydralazine 25 mg give one tablet two times a day (BID),sodium bicarbonate 650 mg, give one tablet BID for heartburn. These medications were listed in different dosages than on the hospice agency physician orders.There was no documented evidence that a Registered Nurse (RN) completed a medication review. 2. Review of P4's agency provided "Patient Information Report" indicated that P4 was admitted to hospice on 12/31/24 with a diagnosis of Alzheimers disease. Review of P4s undated "Client Medication Report," provided by the hospice agency, indicated orders for P4 to receive:acetaminophen 500 mg, give two capsules PO three times a day (TID), oxygen (given for shortness of breath) two liters (may titrate up to four liters for patients comfort) via nasal cannula PRN, andsenna-s 8.6 mg-50 mg (medication for constipation), give two tablets PO BID PRN. Review of P4s Group Home provided "Physicians Orders," dated 02/04/25, indicated no documented evidence of orders for the acetaminophen or senna-s. In addition, there is documented evidence to give P4 oxygen three liters via nasal cannula PRN. Additionally, P4's Group Home "Physician's Orders," dated 02/04/25 contained physician orders for:quetiapine (medication for agitation) 12.5 mg daily PRN,milk of magnesium (medication for constipation) 30 ml at HS PRN,anti-diarrhea two mg, two tabs after each loose stool PRN, andantacid 30 ml four times a day. These medications were not listed on P4's hospice agency orders. It was documented that the RN had completed a medication review on 01/29/25. During an interview on 02/05/25 at 1:30 PM, the Director of Clinical Services (DCS) confirmed that the nurses were responsible for completing a medication review every visit. The DCS confirmed that the hospice medications did not match the SNF medication orders for P3 and did not match the group home medication orders for P4.

Based on observations, interviews, and record review, the agency failed to provide personal care in a manner to prevent cross contamination for two of six patients (Patient (P) 4 and P15) observed during home visits out of a total sample of 23. This had the potential to increase the risk of infection for the patients. Findings include : 1. Review of P4's "Patient Information Report," provided by the agency, indicated that P4 was admitted to hospice on 12/31/24 with a diagnosis of Alzheimers disease. During a home visit on 02/04/25 at 1:00 PM, Certified Nursing Assistant (CNA) 2 was observed completing a bed bath for P4. CNA2 washed his/her hands, put on gloves, and gathered supplies. CNA2 removed P4s clothing and washed P4s upper body. Wearing the same gloves, CNA2 rinsed P4s upper body and obtained a towel and dried P4. CNA2 removed P4s brief and wiped P4s perineal area with wipes. Without changing gloves, CNA2 washed P4s perineal area with soap on a washcloth, rinsed the perineal area with another washcloth, and then dried the area. CNA2 assisted P4 in rolling over to his/her left side and placed a new brief underneath P4. CNA2 then assisted P4 to his/her right side, washed, rinsed, and dried P4s back area. Wearing the same gloves, CNA2 put lotion on P4s back prior to rolling P4 back to his/her back and fixing the brief. CNA2 washed P4s legs and feet and then took the same cloth and washed P4s face. CNA2 rinsed and dried P4s legs and feet and placed new clothes on P4. Wearing the same gloves, CNA2 removed the basins from the overbed table and wiped down the overbed table with the same gloves on. An attempt to interview CNA2 was made on 02/05/25 at 5:15 PM; however, there was no answer and/or answering machine. There was no return call prior to the survey exit. 2. Review of P15's "Patient Information Report," provided by the agency, indicated that P15 was admitted to hospice on 07/12/24 with a diagnosis of chronic kidney disease (CKD). During a home visit on 02/04/25 at 8:30 AM, CNA1 was observed completing a bed bath for P15. CNA1 washed his/her hands, put on gloves, and gathered supplies. CNA1 washed, rinsed, and dried P15s hair, and then washed P15s face and removed his/her clothing. CNA1 washed, rinsed, and dried the upper front part of P15's body, unfastened the patient's brief and pushed it under the patient, washed the lower half of P15's body, and applied petroleum jelly and lotion to the patient's legs. CNA1 then washed P15s perineal area, and assisted P15 in rolling over to his/her right side. CNA1 removed P15s brief and threw it away. Wearing the same gloves, CNA1 washed, rinsed, and dried P15s back and buttocks. CNA1 then applied lotion. CNA1 applied a new brief, assisted P1 in rolling back over to his/her back and to his/her left side, adjusting the brief, and then back to his/her back. CNA1dressed P15. CNA1 got P15 up once he/she was dressed by the assistance of the stand lift and placed P15 in the recliner. Once P15 was in the recliner, CNA1 removed his/her gloves and washed his/her hands. An attempt to interview CNA1 was made on 02/05/25 at 12:30 PM, and a left voice message; however, there was no return call prior to the survey exit. During an interview on 02/05/25 at 1:30 PM, the Director of Clinical Services (DCS) indicated that gloves should be changed when going from a dirty area to a clean area.

Upon patient record review, 1 of 23 (Patient #14) 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 #14 - Lidocaine topical cream not on medication profile.

Upon patient record review, 2 of 23 (Patient #12, 21) 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 - SOC 10/09/23 - Initial bereavement completed 10/17/23. Patient #21 - SOC 10/10/22 - Initial bereavement completed 12/05/22.

Upon patient record review, 1 of 23 (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • 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 #13 - Comprehensive assessment on 11/20/23 then again on 12/07/23

Upon patient record review, 2 of 23 (Patient #9, 14) 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 #9 - Order written on 10/31/23 "okay to decrease feeding to 3xday instead of 5" did not include type, amount, or bolus, gravity or pump. Patient #14 - Order written on 12/08/23 Dilaudid "....via port via PCA weekly with sterile dressing change with bag change".

Upon patient record review, 4 of 23 (Patient #7,8,13,15) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #7 - Music Therapy visit frequency 2 PRN. Patient #8 - Volunteer visit frequency 1 wk 1, 8 PRN. Patient #13 - MSW 1wk1 6 PRN, SC 2wk1, 5 PRN Patient #15 - MSW 1 wk1 6 PRN, SC 1wk 1, 3PRN

Upon patient record review, 1 of 23 (Patient #14) 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#14 - SN documented in chart she applied Lidocaine ointment prior to accessing port site - no order noted for Lidocaine ointment.

Upon patient record review 1 of 23 (Patient #13) 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 #13 - Aide supervisory visit completed 11/20/23 then again on 12/07/23 - greater than 14 days.

Upon patient client record review, 1 of 23 (Patient #14) 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 #14 - SN visit note on 12/09/23 did not include the specifics of dressing change or size of Huber needle.

Upon client record review, 1 of 23 (Patient #10) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #10 - POC did not specify who would complete blood sugar or wound care.

Based on policy, clinical record review and staff interviews the agency failed to document a complaint and the resolution for 1 of 1 caregiver with a complaint [#1]. The findings included: --- Per the agency policy/ procedure, ";Concerns and Complaints" revised 03/22, provided by the Director of Professional Services [DPS] on 9/20/22 at 5:45PM the procedure was as follows: · The employee: receiving the concern initiates the concern report. · Provides information regarding the concerns to the DPS/ Patient Care Manager [PCM] in a timely manner but no later than the next business day. · The DPS/PCM: reviews all concerns. · Initiates a problem- solving process o Assess with the ... the exact nature of the concern, when necessary o Assess the probable cause of the concern o Plan appropriate action o Implement a corrective action plan o Evaluate the implemented corrective action plan to determine if the concern has been alleviated o Give all concern reports to the Administrator... · Resolution/outcome information is documented on the concern report and communicated to the complainant within 30 days. Patient #1 had a Start of Care 7/14/22 that included diagnoses of Malignant neoplasm [cancerous tumors] of lower lobe, unspecified bronchus [a passage or airway in the lower respiratory tract] or lung; malignant neoplasm of the brain; COPD [chronic obstructive pulmonary disease—a respiratory disease] and anxiety. The Plan of Care for certification period 7/14/22 through 10/11/22 had orders for SN [skilled nurse] 2 times per week for 1 week and 4 times per week for 1 week. Medical Social Worker [MSW] to start 7/17/22 for 1 time per week for 1 week. Documentation by SN #11 stated that patients son had called and on 7/19/22 to report the patients death. A visit was made on 7/19/22 by MSW #7 and SN # 12 due to patient #1 death. MSW#7 documented that the son was outside upon arrival to the home. Stated that the son stated, ";no need to come inside, they did not need SW, he only wanted the nurse to come in pronounce and leave as quickly as possible... said his aunt would take over because he was so angry." Stated also the son asked how to file a grievance. A phone call was made to the PCM #8 for information regarding how to file a grievance. Per documentation, MSW #7 instructed the son that the grievance process was in the admission handbook. SN #12 documented on 7/19/22 that ";the son was very upset with our services [ hospice agency], didnt wish to discuss, didnt let MSW into the home and wanted to file a complaint." In an interview with MSW #7 on 9/20/22 at 4:20PM, stated the agency careline number was given to the son to call and file a complaint. MSW also stated that the son commented that, ";we were promised a Cadillac and we got a Volvo station wagon." MSW #7 stated a report was given to PCM #8 about the sons complaint. PCM #8 stated in an interview on 9/20/22 at 5:10PM, once the call was received from MSW #7 about the son being angry and wanted to know how to file a grievance, the number of the care line was given to MSW. It was also reported by PCM #8 an offer was made to speak to the family, but the son declined. PCM verified not notifying the DPS of the grievance and that ";it did not seem to be a service recovery issue." PCM also verified there was no documentation of this event. An interview with DPS on 9/20/22 at 5:45PM, verified there was no documentation of the caregivers complaint or attempts for resolution.

Based on agency guidebook, clinical record review and staff interviews, agency failed to coordinate care for 1 of 1 patients that requested to not die at home [#1]. The findings included: --- The Hospice Admission Guidebook, RN [registered nurse] Initial Comprehensive Assessment, provided by the Director of Professional Services on 9/20/22 at 5:25 pm stated, ";the assessment identifies... and is an evaluation of the patients physical, psychosocial, emotional and spiritual status related to the terminal illness... the patients immediate care and support needs are identified." Patient #1 had a Start of Care 7/14/22 that included diagnoses of Malignant neoplasm [cancerous tumors] of lower lobe, unspecified bronchus [a passage or airway in the lower respiratory tract] or lung; malignant neoplasm of the brain; COPD [chronic obstructive pulmonary disease-lung disease] and anxiety. The Plan of Care for certification period 7/14/22 through 10/11/22 had orders for SN [skilled nurse] 2 times per week for 1 week and 4 times per week for 1 week. Medical Social Worker [MSW] to start 7/17/22 for 1 time per week for 1 week. A review of documentation from the hospital on 7/14/22 showed patient #1 requested not to die at home... ";when we know [patient name] approaching end of life... would like us [ hospice agency] to arrange respite or transfer to [inpatient] house." The SN comprehensive assessment documented by SN #4 on 7/16/22 revealed patient # 1 stated ";worries about being a burden...does not want to pass in...home and that when it gets close... would like to be moved to a hospice house." Documentation from 7/17/22 at 11:22AM revealed the caregiver called the agency and reported patient #1 had fallen. SN # 5 made a visit to assess patient after a fall. The assessment revealed patient had complained of left hip pain but denied at time of the visit. Numbness in left leg, color of skin was pale and had scattered wheezing throughout her lungs. SN #5 instructed the patient and caregiver to continue to monitor for pain and breathing changes and the case manager would follow up. MSW #7 documented on 7/18/22 at 10:59 AM a phone call to ";family to offer support and schedule a visit... [son] said they had a lot of family over today; said tomorrow wound be a better day. MSW scheduled MSW visit on Tuesday 7/19/22 at 10:30 am." LPN [ licensed practical nurse] #6 made a visit on 7/18/22 at 9:01PM. Documentation revealed patient #1 was exhibiting a decline in status. Vital signs were as follows: temperature 98; pulse 110; respirations 30 and labored; blood pressure 78/48 and oxygen saturation level was 87% on 3 liters of oxygen. The SN assessment questions, did the patients health status necessitate a change in care setting and indicate if you communicated with other disciplines involved in this case...the answer was no to both questions. LPN #6 documented ";... is bedbound, unresponsive, eyes fixed, and unable to make wants and needs known in any meaningful way... has a nasal cannula delivering 3 liters of O2 [oxygen] continuously...currently in respiratory distress and appears imminent...family would like [patient] to pass in a hospice house...notified healthcare team." There was no evidence of communication with other healthcare team members. An interview with Director of Professional Services on 9/20/22 at 5:45PM verified there was no documentation of communication by LPN #6. The Director of Professional Services also stated the expectation would be to communicate with the other team members either by email or verbally. The interview also revealed that the LPN had resources available to contact after hours. On 7/19/22 at 7:10AM, patients son called the agency to notify of patients death. SN #9 conducted at home visit on 7/19/22 to pronounce death. In an interview with SN #4 on 9/20/22 at 4:55PM, it was verified patient #1 had voiced that she did not want to die at home. SN#4 stated that information was shared with the patient/family of a contract with another agency for respite services. SN#4 also verified there was no documentation supporting this conversation with the patient and family.

Based on guidebook instructions, clinical record review and staff interviews, the Skilled nurse [SN] failed to notify the physician of a fall for 1 of 1 patients [#1] with a fall. The findings included: --- The Home Health and Hospice Fall Reduction Guidebook was provided by the Director of Professional Services on 9/20/22 at 5:25PM, stated, ";post-fall...upon completion of this assessment, the physician is notified, and orders are documented, noted and implemented. Patient #1 had a Start of Care 7/14/22 that included diagnoses of Malignant neoplasm [cancerous tumors] of lower lobe, unspecified bronchus [a passage or airway in the lower respiratory tract] or lung; malignant neoplasm of the brain; COPD [chronic obstructive pulmonary disease-lung disease] and anxiety. The Plan of Care for certification period 7/14/22 through 10/11/22 had orders for SN [skilled nurse] 2 times per week for 1 week and 4 times per week for 1 week. Medical Social Worker [MSW] to start 7/17/22 for 1 time per week for 1 week. On 7/17/22 at 11:22AM patient #1 daughter called to report the patient had fallen the night before. SN #10 documented ";will have RNOC [ registered nurse on call] follow up and assess." SN #5 made a visit on 7/17/22 and assessed patient after report of a fall. The assessment revealed patient had complained of left hip pain but denied at time of the visit. Numbness in left leg, color of skin was pale and had scattered wheezing throughout her lungs. SN #5 instructed the patient and caregiver to continue to monitor for pain and breathing changes and the case manager would follow up. There was no documentation of SN#5 notifying the physician of the fall. An interview was conducted with the Director of Professional Services on 9/20/22 at 5:45PM, and reported that the expectation was that staff will communicate with the provider to let them know of the event. The Director of Professional Services also verified there was no evidence of SN #5 notifying the physician.

Based on policy review, clinical record review, and staff interview, the agency failed to document and follow-up on a complaint for 1 of 1 clinical record (Patient #1) reviewed with a documented concern. Findings included: Policy 260, Patient Concerns, was received from Director of Professional Services on 03/03/22 at 7:43 AM. This policy revealed, "The employee ...receiving the concern initiates the patient concern report ..." and "Concerns are evaluated by the agency's Quality Assessment and Performance Improvement Committee ...resolution/outcome information is documented on the concern report and communicated to the complainant within 30 days." Patient #1 was admitted to the agency on 11/05/20 with a principle hospice diagnosis of malignant neoplasm (cancer) of the rectum. For the hospice benefit period beginning 01/19/22 through the time of discharge on 02/22/22, discipline visits were ordered as follows: skilled nursing 2 times per week for 8 weeks and 3 PRN (as needed), home health aide 1 time per week for 9 weeks, medical social worker 1 time every 30 days effective 02/06/22, spiritual care 1 time every 30 days effective 02/06/22, and music therapy services 1 time every 30 days effective 01/30/22. A care coordination note of 02/21/22 at 5:48 PM, was written by Employee #3, Assistant Director of Professional Services. This note revealed, "GOT EMAIL MESSAGE THAT DAUGHTER WANTED TO TRANSFER PATIENT TO [name of transfer hospice agency]. CALLED HER TO FIND REASONS WHY ...SHE STATED THAT THERE HAD BEEN SOME PROBLEMS WITH COMMUNICATION WITH THE FACILITY AND HHA (home health aide) SERVICES. SHE STATED SHE HAD CALLED LAST WEEK WITH REGARDS TO A WOUND AND HE (Patient #1) DID NOT GET A NURSE VISIT UNTIL SATURDAY. (ON RESEARCH THE CALL CAME IN WEDNESDAY, EMAIL WAS SENT AND THE VISIT - AFTER A SECOND CALL - NURSE VISIT ON SUNDAY) ...I APOLOGISED AND ASKED IF THERE WAS ANYTHING ELSE WE COULD DO. SHE SAID NO ..." There was no evidence of a documented concern or follow-up related to this reported concern. In an interview on 02/28/22 at approximately 4:15 PM, Employee #2, Director of Professional Services, confirmed that there was not a patient concern report related to this reported concern and stated, "We probably should have done one ..." Employee #3 was not available for interview at the time of survey.

Based on agency "guidebook" review, clinical record review, and staff interview, the agency failed to coordinate nursing services with the facility/caregiver for 1 of 3 patients (Patient #1). Findings included: Individualizing the Hospice Plan of Care Guidebook was received from the Director of Professional Services on 02/28/22 at approximately 12:00 PM. This guidebook revealed the following regarding facility patients: "The hospice team and facility staff communicate, establish, and agree upon a coordinated POC (Plan of Care) for both providers which reflects the hospice philosophy, and is based on an assessment of the patient's needs and unique living situation in the facility." Patient #1 was admitted to the agency on 11/05/20 with a principle hospice diagnosis of malignant neoplasm (cancer) of the rectum. For the hospice benefit period beginning 01/19/22 through the time of discharge on 02/22/22, discipline visits were ordered as follows: skilled nursing 2 times per week for 8 weeks and 3 PRN (as needed), home health aide 1 time per week for 9 weeks, medical social worker 1 time every 30 days effective 02/06/22, spiritual care 1 time every 30 days effective 02/06/22, and music therapy services 1 time every 30 days effective 01/30/22. Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report from 01/19/22 to 02/22/22 revealed a current problem list that included the need for facility staff care coordination, observation and assessment of skin, and pressure ulcer care. This Plan of Care Update Report also included a hospice order dated 02/05/22, "COVER TO PROTECT BLISTER". A care coordination note of 02/05/22 at 10:47 AM was written by Employee #4, On-Call Triage Nurse. This note revealed, " ...PATCHED CALL FROM [name of caller and facility]. CALLER FRUSTRATED AND STATED SHE HAS BEEN REQUESTING F/U (follow-up) CALL FROM RNCM (registered nurse case manager) X 3 DAYS. FACILITY RN (registered nurse) ASSESSED PT (patient) AND PT HAS NEW LARGE PRESSURE SORE/BLISTER TO RIGHT HEEL. RIGHT TOES ALSO RED. FOOT TENDER TO TOUCH. BLISTER STILL INTACT AT THIS TIME. INSTRUCTED TO FLOAT HEELS AT ALL TIMES TO PREVENT PRESSURE ON AREA. ASSURED HER THAT TRIAGE WILL UPDATE RNOC TO F/U AFTER PREVIOUS OBLIGATIONS. VISIT ASSIGNED TO [name of on-call nurse]". A care coordination note of 02/20/22 at 9:55 AM was written by Employee #6, On-Call Triage Nurse. This note revealed, " ...PATCHED CALLER [name of caller and facility] WHO STATES THAT THE WOUND TO THE RIGHT HEEL HAS OPENED UP AND IS BLEEDING. CALLER STATES THEY HAVE NO SUPPLIES OR ORDERS TO DO WOUND CARE. REVIEWED COORDINATION NOTES. ORDERS WERE PLACED ON THE 15TH AFTER VISIT REGARDING SAME WOUND. CALLER STATES THEY HAVE NOT ARRIVED. INSTRUCTED TO CLEAN WITH SOAP AND WATER AND PAT DRY AND TO KEEP HEEL OFF BED. RNOC (registered nurse on call) NOTIFIED. VISIT ASSIGNED." A care coordination note of 02/21/22 at 5:48 PM, was written by Employee #3, Assistant Director of Professional Services. This note revealed, "GOT EMAIL MESSAGE THAT DAUGHTER WANTED TO TRANSFER PATIENT TO [name of transfer hospice agency]. CALLED HER TO FIND REASONS WHY ...SHE STATED THAT THERE HAD BEEN SOME PROBLEMS WITH COMMUNICATION WITH THE FACILITY AND HHA (home health aide) SERVICES. SHE STATED SHE HAD CALLED LAST WEEK WITH REGARDS TO A WOUND AND HE (Patient #1) DID NOT GET A NURSE VISIT UNTIL SATURDAY. (ON RESEARCH THE CALL CAME IN WEDNESDAY, EMAIL WAS SENT AND THE VISIT - AFTER A SECOND CALL - NURSE VISIT ON SUNDAY) ...I APOLOGISED AND ASKED IF THERE WAS ANYTHING ELSE WE COULD DO. SHE SAID NO ..." In an interview on 02/28/22 at approximately 4:15 PM, Employee #2, Director of Professional Services, confirmed that the registered nurse case manager, Employee #5, should have ensured that the wound care supplies should have been available for facility use and that the nurse should have visited the patient when the caregiver requested an additional visit. Employee #5 was not available for interview at the time of survey.

Based on policy review, clinical record review, caregiver interview, and staff interview, the allegation that the agency did not provide the patient and caregiver adequate notice for coordination of services at the time of discharge for 2 of 3 (Patients #1, #3) is substantiated. Findings included: Policy 881-H, Hospice Discharge/Discharge Planning, dated 06/16 and received from Employee #2, Director of Professional Services, on 11/01/21 at 12:45 PM, reads, "Review of patients on service due for re-certification begins one month prior to the due date ...The hospice obtains a written physician order from the hospice physician for discharge prior to discharging a patient for any reason ...Discharge planning includes plans for any necessary family counseling, patient education, other services and community referrals before the patient is discharged." The policy further reads, "Patients are discharged from hospice for the following reasons: ...Hospice determines the patient is no longer terminally ill ...IDG (interdisciplinary group) develops and documents the discharge plan which may require an ad hoc meeting of the respective group members to facilitate the discharge planning process. If proper discharge planning has not occurred, the patient continues to receive care until required discharge planning is complete." 1. Patient #1 was admitted to the agency on 03/28/19 with a principle hospice diagnosis of chronic diastolic congestive heart failure. Hospice IDG Comprehensive Assessment and Plan of Care Update Report of 09/16/21 revealed the orders for the following hospice services: skilled nursing 1 time per week with 3 PRN (as needed), home health aide 1 time per week, and spiritual care counselor 1 time every 30 days and 3 PRN (as needed). Further review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 09/16/21 revealed discrepancies regarding the upcoming plan for the plan for the next two weeks for Patient #1 documented by the registered nurse, Employee #4, as, "MONITOR WEAKNESS AND FUNCTION, MONITOR PULMONARY FUNCTION, MONITOR CARDIAC FUNCTION, MONITOR COGNITIVE IMPAIRMENT," by the pastor/counselor as, "SCC WILL CONTINUE TO REVIEW SCHEDULE AND PLAN OF CARE FOR PATIENT. CURRENTLY SCC WILL MAINTAIN AS SCHEDULED. WILL CONFIRM WITH IDGE TEAM FOR ANY CHANGES THAT MIGHT BE NEEDED," and by the social worker, Employee #6, as, "NOT ELIGIBLE-DISCHARGING." Clinical Coordination Note Report from the registered nurse case manager, Employee #4, revealed, "(First name of Employee #7) PCM (patient care manager) SENT AN EMAIL ON WEDNESDAY 9/8 TIME STAMPED 6:16 PM. SAW THE PATIENT EARLIER THAT DAY, HOWEVER WAS UNAWARE OF NEEDING LABS UNTIL LATE THAT NIGHT. (Name of Patient #1) LABS WERE DRAWN ON 9/10 FRIDAY AND SENT STAT. THEY RESULTED ON 9/13 ALL WERE WNL (within normal limits). PATIENT WAS SEEN BY NEW HIRE (First name of Employee#8), RN ON 9/14. ADDITIONAL INFORMATION WAS VERBALIZED TO THIS WRITER AND (First name of Employee #8), RN ABOUT INCREASE IN SLEEPING DURING THE DAY AND SEVERAL EPISODES OF DIZZYNESS [sic] WITH INCREASED LASTING GARBLED SPEECH WITH INCREASED TIA'S/SEIZURES EPISODES 4-5 A WEEK ...ON 9/15 I WAS TOLD BY THE PCM TO VERBALIZED [sic] THE PATIENT WAS GOING TO BE DISCHARGED, NO DISCUSSION WAS GOING TO TAKE PLACE IN IDG ON 9/16. SO I CALLED THE DAUGHTER AND EXPLAINED ABOUT THE DISCHARGE PROCESS AS I WAS INSTRUCTED BY (First name of Employee #7 ) TODAY. I THEN CALLED (First name of caregiver) TO GET INFORMATION ABOUT THE PALLIATIVE CARE PROGRAM WHICH I CALLED THE DAUGHTER BACK AND GAVE HER INFORMATION ABOUT HOW IT WORKS. THEN LATER I WAS INFORMED BY EMAIL THE PATIENT NEEDS TO SIGN THE DISCHARGE PAPERWORK TODAY. I WILL BE WILLING TO SPEAK TO THE FAMILY ON 9/15 [sic] AFTER IDG AND EXPLAIN OPTIONS AND HAVE THEM SIGN PAPERWORK. THE DAUGHTER VERBALIZED THAT IT WOULD BE OK IF I COME TOMORROW." There was no evidence in the clinical record of discharge coordination with the patient or her caregiver prior to 09/15/21. There was no evidence in the clinical record of referrals for other services at the time of discharge. In an interview on 11/01/21 at approximately 3:35 PM, Patient #1's caregiver stated that her concern with the agency was, "the way the discharge was handled." Patient #1's caregiver stated that a nurse and nurse practitioner from the agency had been to the home to complete the patient's recertification visit on 09/14/21 and there was no discussion regarding discharge during that visit. Patient #1's caregiver said that the patient is, "on oxygen and needs to have a doctor's order for insurance to pay for it." Patient #1's caregiver stated that she had to call the patient's primary care physician herself to schedule an appointment for the doctor to give the order. Patient #1's caregiver also stated that she did receive verbal information regarding palliative care from Employee #4 but did not receive any referral information for or contact from the palliative care program. In an interview on 11/01/21 at approximately 4:00 PM, Employee #1 stated that the practice for a live discharge is "During the IDG meeting at least two weeks before, they would be discussing recertifications at that IDG meeting ...If the doctor (hospice physician) wants to order lab work or anything of that nature that would occur at that time or that week of IDG ..." Employee #1 agreed that the documentation in the clinical record is confusing and contradictory related to the plan for recertifying or discharging the Patient #1. 2. Patient #3 was admitted to the agency on 04/18/21 with a principle diagnosis of unspecified sequelae of cerebral infarction. Hospice IDG Comprehensive Assessment and Plan of Care Update Report of 09/16/21 revealed the orders for the following hospice services: skilled nursing 1 time per week with 3 PRN (as needed), and spiritual care counselor 1 time every 30 days and 3 PRN (as needed). Clinical Coordination Note Report from Employee #7 of 09/16/21 revealed, "9/15/2021, THE PATIENTS SON ROY WAS NOTIFIED OF THE PATIENTS DISCHARGE FROM HOSPICE, BY (name of Employee #8) SCC. AT THAT TIME HE REFUSED TO SIGN THE DOCUMENT AND HE TOLD THE SCC TO CALL HIS DAUGHTER LAURA. WHEN I LOOKED AT THE PATIENTS CONSENTS, THEY WERE SIGNED BY ROY, SO HE IN FACT NEEDED TO SIGN THE DISCHARGE PAPERWORK. I CALLED AND NOTIFIED HIM, HE DID NOT ANSWER, I LEFT A VOICE MESSAGE WITH MY NAME, THE NUMBER FOR THE OFFICE AND THE INFO FOR THE APPEALS PROCESS TO INCLUDE THE NUMER FOR KEPPRO (the name of the agency contacted to initiate a discharge appeal). I MADE A FOLLOW UP CALL TODAY, HE DID NOT ANSWER AND I LEFT THE SAME INFORMATION AGAIN." There was no evidence in the clinical record of discharge coordination with the patient or caregiver prior to 09/15/21. There was no evidence of referrals for other services at the time of discharge. In an interview on 11/01/21 at approximately 4:00 PM, Employee #1 confirmed that there was not evidence of discharge coordination with the patient or caregiver in the clinical record prior to 09/15/21 Employee #1 agreed that discharge coordination should have taken place and stated that live-discharge patients would typically be referred for palliative care services to ensure that the patient is being monitored for changes or a decline that may make him/her eligible for hospice services again.