Every finding on record at Diversified Hospice Care, Inc.

Based on record review and interview, it was determined that the hospice agency failed to maintain documentation of emergency preparedness training, which resulted in the potential for inappropriate, unprepared responses to emergencies and an interruption in the provision of needed patient care and services. Findings include: --- During a review of the hospice emergency preparedness program, it was discovered that no sign-in sheets were available to document the 88 employees' participation in the emergency preparedness drills. The agency failed to document employee participation-including that of all new, existing, and contract employees-in the drills. During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings.

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by all disciplines no later than 5 calendar days after the election of hospice care (see L523); failed to ensure the initial comprehensive assessment included wound measurements (see L524); failed to ensure the physician was notified of potential medication interactions and failed to perform an appropriate review concerning listed medication allergies (see L530); failed to ensure the comprehensive assessment included an initial bereavement assessment of the patient's family to determine factors that may impact the family's ability to cope with the patient's impending death (see L531); and failed to ensure the comprehensive assessment was updated by the social worker every 15 days (see L533), resulting in the potential for unmet care needs and poor patient outcomes. --- .

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by all disciplines no later than 5 calendar days after the election of hospice care in 2 (P-1 and P-5) of 19 records reviewed, resulting in the potential for unmet care needs. Findings include: --- Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was determined social work did not complete an assessment until 9/22/24 – 8 days after care was started. There were no orders or documentation regarding the delay in care.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was determined no assessment had been completed by social work - 16 days after care was started. Additionally, there were no orders or documentation by the social worker regarding missed visits or the reason for no assessment.A review of agency policy titled “III.8 PATIENT ASSESSMENT & REASSESSMENT” (not dated) revealed, “A comprehensive assessment will be conducted within 5 days of the patient’s election of hospice services and shall include all disciplines needed.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the agency failed to ensure the initial comprehensive assessment included wound measurements in 4 (P-1, P-2, P4, and P-5) of 19 records reviewed, resulting in the potential for unmet care needs. Findings include: --- Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted the initial comprehensive assessment indicated P-1 had, “a dime sized ‘black’ area noted to coccyx, no odor or discharge noted,” however, there were no objective measurements of the wound.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the initial comprehensive assessment indicated P-2 had, “Wound / Drain (dime size st 2 on r hip), SkinLesions/Wounds Current: ["Pressure Ulcer(s)/Injuries"], Skin and Ulcer/Injury” [sic], however, there were no objective measurements of the wound or any further assessment.During a joint home visit with P-2 and a skilled nurse (RN #3) on 10/16/25 at 11:00 AM, RN #3 was asked about the expectation for wound assessment during the initial comprehensive assessment. RN #3 admitted she hasn’t measured the wounds because she wasn’t sure what she was supposed to do, however, she agreed the wounds should be assessed and documented to establish a baseline and establish a plan of care.Upon return to the agency on 10/16/25 at 12:33 PM, the administrator (Adm #1) was asked to provide an agency policy regarding the agency expectation for wound care and assessment. Adm #1 stated there is no agency policy regarding wound care, but stated wounds should be measured and assessed at the initial comprehensive assessment or upon discovery of new wounds.Patient #4 (P-4) was admitted to this hospice agency on 8/25/25 with the terminal diagnosis of cerebrovascular disease and hypertension. During record review on 10/17/25, it was noted the comprehensive assessment indicated P-4 “…has some healing skin tears to her left forearm along with bruises.” Additionally, a face-to-face note by the physician dated 8/25/25 indicated P-4 had a recent fall with a “laceration to the L UE (arm)” and a skilled nursing note dated 8/26/25 indicated P-4 had “stitches noted to left forearm.” Upon further review of the record, it was determined the initial comprehensive assessment failed to include objective measurements or further assessment of P-4’s wounds.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was noted a skilled nursing note dated 10/3/25 stated, “…Has dressing on right chest wall. Will remove today to shower.” Upon review of the initial comprehensive assessment, it was noted there were no measurements or assessments made of this wound.The agency failed to identify and assess wounds at the initial comprehensive assessment to establish a baseline and to establish a plan of care.Adm #1 again reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM. The director of clinical services (DCS #1) was also present at this time and acknowledged the findings.

Based on record review and interview, the agency failed to ensure the physician was notified of potential medication interactions and took them into consideration when creating the patients' plan of care in 5 (P-3, P-9, P-15, P-16, P-18) of 5 patients with identified major drug interactions, from a total of 19 sampled records reviewed; and failed to perform an appropriate review concerning listed medication allergies in 1 (P-15) of 19 records reviewed for medication allergies, from a total of 19 sampled records, resulting in the potential for harm from adverse medication interactions to all 139 patients currently receiving hospice services. Findings include: --- Patient #15 (P-15) was admitted to hospice on 7/11/25 with terminal diagnoses that included chronic obstructive pulmonary disease and diabetes-type 2. On 10/15/25 at 3:50 PM, a review of the agency's "Drug Interactions" report was reviewed. This report noted a major drug to drug interaction, but additional review found no evidence that the physician had been notified. This was verified by the administrator on 10/16/25 at 09:17 AM that the hospice agency does not have a procedural pathway yet to notify the physician.Further, when comparing the listed patient allergies found in the attached hospital records dated 4/5/25, the following allergies were listed: Codeine (for pain) “Acts crazy”, Diazepam (for anxiety) “hallucinates”, and Hydrocodone-Acetaminophen (for pain) “hallucinates”. However, the hospice’s listed medication allergies for P-15 failed to include Diazepam. This is significant as P-15’s history is positive for anxiety and this was noted by the skilled nurse who documented on the initial comprehensive assessment (dated 7/11/25) under “Social Assessment” the following: “Sleep Disturbances: Yes, Anxiety/Panic: Yes.”Patient #16 (P-16) was admitted to hospice on 9/16/25 with terminal diagnoses of cerebral infarction (brain stroke).  On 10/16/25 at 8:45 AM, a review of the agency's "Drug Interactions" report was reviewed. This report noted a major drug to drug interaction, but additional review found no evidence that the physician had been notified. This was verified by the administrator on 10/16/25 at 09:17 AM that the hospice agency does not have a procedural pathway yet to notify the physician.Patient #18 (P-18) was admitted to hospice on 8/30/25 with terminal diagnoses of hypertensive heart disease with heart failure. On 10/17/25 at 10:10 AM, a review of the agency's "Drug Interactions" report was reviewed. This report noted a major drug to drug interaction, but additional review found no evidence that the physician had been notified. This was verified by the administrator on 10/16/25 at 09:18 AM that the hospice agency does not have a procedural pathway yet to notify the physician.The Administrator and Director of Clinical Services reviewed and acknowledged the above findings during an interview on 10/21/25 at 11:40 AM. Both further acknowledged this did not meet agency expectations or its policy noted above for P-9. Policy: III.20 Medication Management & Administration, undated, stated, "All medications will be reviewed for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy and for patient non-compliance with drug therapy. The admitting nurse will contact the patient's physician immediately if there are any questions or concerns regarding the medications a patient is taking." Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia.  On 10/16/25 at 1:35 p.m., a review of the agency's "Drug Interactions" report was reviewed.  The report revealed that major drug to drug interactions had been identified.  Upon further review, there was no documented evidence that the Physician had been notified.The Administrator reviewed and acknowledged these findings during an interview on 10/21/25 at 8:55 a.m. Patient #3 (P-3) was admitted to this hospice on 9/20/25 with the terminal diagnosis of cerebrovascular disease. During record review on 10/17/25, it was noted the drug interaction report in the agency’s electronic medical record system identified 1 major drug to drug interaction. Upon further review of the record, it was determined there was no evidence the physician was notified of the interaction.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the hospice failed to ensure the comprehensive assessment included an initial bereavement assessment of the patient's family to determine factors that may impact the family's ability to cope with the patient's impending death for 3 (P-3, P-15 and P-18) of 19 total sampled records reviewed, resulting in the potential to negatively affect the loss/grief issues for all 139 patients current receiving hospice services. Findings include: --- P-15: The start of care date to hospice was on 7/11/25, with terminal diagnoses that included chronic obstructive pulmonary disease and diabetes-type 2. On 10/15/25, a review of P-15's bereavement assessment (BA) noted on three occasions a BA was performed: 7/11/25 by the RN; 7/14/25 by the Chaplin, and 7/16/25 by the Social Worker. All (3 of 3) documented a BA which listed only the patient's nephew. However, on 10/15/25 during a joint home visit with aide services, P-15 during an interview was asked, "Who do you feel would significantly grieve and mourn upon your passing?" P-15 who is alert and oriented with no documented confusion replied, "George (nephew), Barb (niece), Sharon (P-15's sister), and Claudia (best friend of 40 years)." P-15 was then queried again if anyone from the hospice team inquired about any of the listed loved ones you just mentioned? P-15 responded, "No, not that I can remember at least."P-18 was admitted to hospice on 8/30/25 with terminal diagnoses of hypertensive heart disease with heart failure. On 10/17/25, a review of P-18's BA noted on three occasions a BA was performed: 8/30/25 by the RN; 9/2/25 by the Chaplin, and 9/4/25 by the Social Worker. All (3 of 3) documented a BA which listed only the patient's one daughter. However, further record review found documentation within the Social Worker's initial assessment on 9/4/25 which documented the following, "She (P-18) later moved to Bay City where she raised her two daughters (twins) who live in town and are very supportive.”    The findings above were reviewed and acknowledged by the Administrator and Director of Clinical Services during an interview on 10/21/25 at 11:44 AM. A quick audit review during the time of the interview above, noted that a vast majority of hospice patients had only one individual listed on the BA. Both noted this is an area that will be addressed to align with the agency's policy referenced below.Agency Policy: "III.39 Bereavement Program" (undated) stated, "The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The program shall involve out-of-town family members as well, referring them to support resources in their geographical area if requested."   Patient #3 (P-3) was admitted to this hospice on 9/20/25 with the terminal diagnosis of cerebrovascular disease. During record review on 10/17/25, it was determined P-3’s daughter (who is her primary caregiver) was listed as the only individual on the initial bereavement assessment. However, upon review of the social work evaluation dated 9/24/25, it was documented that, “Caregiver is mainly her daughter, but she does have her other children, and also grandchildren who help each other out.” [sic] The social work note also stated that in addition to her daughter, a son and grandson were also present during the assessment. The agency failed to identify and assess all individuals that may be affected by P-3’s death.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated by the social worker every 15 days for 1 (P-2) of 19 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, 4 of 11 interdisciplinary group (IDG) notes (dated 5/22/25, 6/19/25, 9/11/25, and 10/9/25) failed to include an update of the patient by a social worker. There was no evidence a social worker participated in the IDG meetings listed above to update the comprehensive assessment.A review of agency policy titled “III.16 IDG CASE CONFERENCE/UPDATE OF COMPREHENSIVE ASSESSMENT” (not dated) revealed, “All professional disciplines participating in the patient’s care, including contractual staff, should have input at this conference. For personnel participating in the patient’s care but unable to attend the conference, a telephone conference should be established. Documentation of the conference shall be the responsibility of the primary nurse or supervisor, or other professional as instructed by the supervisor. The documentation shall include a summary of progress, assessment of the needs for continuing care, medication effectiveness for pain management and relief, and patient status.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the agency failed to  develop an individualized plan of care that included safety precautions and failed to incorporate wound care interventions and treatment (see L545); failed to develop a patient specific plan of care that included specific interventions for pain and symptom management (see L546); and failed to ensure the plan of care included patient specific measurable goals (see L548). --- .

Based on record review, and interview, it was determined the hospice failed to develop an individualized plan of care (POC) that included safety precautions in 3 (P-1, P-12, and P-14) of 19 records reviewed, out of a total sample of 19 records reviewed; and failed to incorporate wound care interventions and treatment in 5 (P-1, P-2, P-4, P-5, and P-17) of 7 records reviewed with wound care, out of a total of 19 records reviewed, resulting in the potential for patient harm and unmet clinical needs. Findings include: --- Patient #17 (P-17) was admitted to hospice on 9/20/25, with a terminal diagnosis vascular dementia with agitation, diabetes-type 2, hypertension and repeated falls. On 10/16/25, a review of the referral for hospice from the rehabilitation and skilled nursing center where P-17 resides noted the following documentation (dated 9/12/25): "Sacral/bilateral buttocks continue with Stage 3 Pressure Ulcer, current measurements are 2.2 cm length x 5.5 cm width x 0.4 depth. 25% yellow slough, 50% pink granulation, small amount of serosanguinous drainage... resident needs reminders/cues and assistance with repositioning and offloading frequently. Continue with low air loss mattress, bilateral heel lift boots AAT (at all times)."Further review of the initial comprehensive assessment (ICA) performed by skilled nursing (SN) on 9/20/25 documented the following in the ICA: "Pt. (patient) current weight is 160 pounds down from 210 pounds in Jan. 2025. In June (2025) pt. was able to have mobility via wheelchair. Now in September pt. is bedbound, with an unstageable decubitus pressure injury." The hospice's EMR (electronic medical record) noted an individual order on 9/20/25 under "Wound Type" a pressure ulcer to the sacrum and to "remove prior dressing, cleanse wound with wound wash, pat dry with gauze. Apply Medi-Honey (wound care ointment), cover with clean dressing, change daily and prn (as needed) if soiling occurs."However, review of the submitted POC (effective 9/24/25) failed to have any documentation directing SN to perform wound assessments, interventions or treatments concerning P-17's pressure ulcer. Subsequently, additional review of the SN visit notes performed after 9/20/25 found 7 (9/23/25, 9/25/25, 9/27/25, 9/30/25, 10/1/25, 10/2/25, and 10/3/25) of 7 SN notes failed to acknowledge P-17's wound in any manner. Additionally, the hospice POC failed to direct staff on coordinating wound care needs and preventative comfort measures (air mattress, bridging both heels) with the facility where P-17 resided. P-17 passed away on 10/3/25 and the hospice agency failed to provide documentation if P-17's wound care needs were ever met. The findings above were reviewed and acknowledged by the Administrator and Director of Clinical Services during an interview on 10/21/25 at 11:37 AM. Both noted this did not meet agency expectations or its policy referenced below.Agency Policy: "III.10 Provision of Care to Residents of a Facility" (undated) stated, "The Hospice will have written agreements that meet State and Federal regulations with a skilled nursing facility (SNF), nursing facility (NF), or inpatient care facility (ICF) to provide hospice care to residents. It is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the resident were in his or her own home."   Patient #12 (P-12): The Start of Care (SOC) was dated 11/1/24. The Plan of Care (POC) dated 11/1/24 identified diagnoses of breast cancer and hypertension. Upon review of the POC, it was noted that no oxygen precautions were documented for a patient receiving supplemental oxygen.Patient #14 (P-14): The Start of Care (SOC) was dated 9/22/25. The Plan of Care (POC) dated 9/22/25 identified diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus. Upon review of the POC, it was noted that no oxygen precautions were documented for a patient that smokes/vapes and is receiving supplemental oxygen. During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings.  Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted the initial comprehensive assessment indicated P-1 had, “a dime sized ‘black’ area noted to coccyx, no odor or discharge noted.” The next skilled nursing note dated 9/18/24 also indicated P-1 had a “Wound to right ankle posterior.” [sic] Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.Additionally, it was noted the initial comprehensive assessment dated 9/14/24 indicated P-1 was “strict npo” -meaning he was not allowed to eat or drink anything by mouth. Upon further review of the plan of care, it was determined the there were no safety precautions listed regrading P-1’s NPO status.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the initial comprehensive assessment indicated P-2 had, “Wound / Drain (dime size st 2 on r hip), SkinLesions/Wounds Current: ["Pressure Ulcer(s)/Injuries"], Skin and Ulcer/Injury.” [sic] Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.Patient #4 (P-4) was admitted to this hospice agency on 8/25/25 with the terminal diagnosis of cerebrovascular disease and hypertension. During record review on 10/17/25, it was noted the initial comprehensive assessment indicated P-4 had “she has some healing skin tears to her left forearm along with bruises.” Additionally, a face-to-face note by the physician dated 8/25/26 indicated P-4 had a recent fall with a “laceration to the L UE” and a skilled nursing note dated 8/26/25 indicated P-4 had “stitches noted to left forearm.” A licensed practical note dated 9/3/25 noted, “Wound rewrapped with dry dressing to protect area.” Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was noted the initial comprehensive assessment indicated P-5 had a “diabetic foot wound” that measured 1x1x0.4 (no unit of measurement given). Additionally, a skilled nursing note dated 10/3/25 indicated P-5 “…has dressing on right chest wall. Will remove today to shower.” Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.A review of agency policy titled “III.7 HOSPICE PLAN OF CARE” (not dated) revealed, “The plan of care shall include all hospice care and services necessary to meet the patient and family needs identified in the comprehensive assessment, as such needs relate to the terminal illness and related conditions. If needs are identified that are not related to the terminal illness and conditions, the IDG shall document that they are aware of the needs and note who is addressing them.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM

Based on record review and interview, the hospice agency failed to develop a patient specific plan of care that included specific interventions for pain and symptom management for 3 (P-9, P-10, P-19) of 3 records reviewed for appropriate pain and symptom management, from a total of 19 sampled records reviewed, resulting in the potential for unrelieved pain and poor symptom management.  Findings include: --- Policy: III.7 Hospice Plan of Care, undated, stated, "The plan of treatment shall include but not limited to: Interventions to manage pain & symptoms." Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. The Plan of Care (POC) ordered Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided.  During the record review on 10/16/25 at 1:35 p.m., it was noted that the POC was void of interventions to monitor, assess and treat pain, that included alternative interventions to manage pain and symptomology during the end of life. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 10/21/25 at 8:55 a.m.P-10 was admitted to hospice on 9/26/25 with a terminal diagnosis of Senile Degeneration of the Brain. The POC ordered SN, HHa and MSW services to be provided.  On 10/17/25 at 10:00 a.m., during the clinical record review, it was noted that the POC was void of interventions to monitor, assess and treat pain, with alternative interventions to manage pain and symptomology during the end of life. Adm #1 reviewed and acknowledged these findings during an interview on 10/21/25 at 9:08 a.m.P-19 was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant Neoplasm of Lower right Lobe (Lung Cancer). The POC ordered SN, HHa and MSW services to be provided.  During the record review on 10/21/25 at 10:40 a.m., it was noted that the POC was void of interventions to monitor, assess and treat pain, and alternative interventions to manage pain and symptomology during the end of life. Adm #1 reviewed and acknowledged these findings during an interview on 10/21/25 at 1:32 p.m.

Based on record review and interview, it was determined that the hospice failed to ensure the plan of care (POC) included patient specific measurable goals in 8 of 19 records reviewed (P-11, P-12, P-13, P-14, P-15, P-16, P-17, P-18) out of a total sample of 19 records reviewed, which resulted in the potential for unmet patient needs. Findings include: --- Patient #15 (P-15) was admitted to hospice on 7/11/25 with terminal diagnoses that included chronic obstructive pulmonary disease and diabetes-type 2. On 10/15/25 at 3:50 PM, a review of the Plan of Care (POC) effective 7/11/25, it was noted 4 of 4 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Patient/Caregiver will verbalize understanding of oxygen use related to uses and safety.” Another example documented, "Patient will maintain optimal cardiac function within constraints of disease process." Patient #16 (P-16) was admitted to hospice on 9/16/25 with terminal diagnoses of cerebral infarction (brain stroke).  On 10/16/25 at 8:45 AM, a review of the POC effective 7/11/25, it was noted 8 of 8 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Patient/Caregiver will verbalize understanding of oxygen use related to uses and safety.” Another example documented, "Patient will maintain optimal cardiac function within constraints of disease process." Patient #17 (P-17) was admitted to hospice on 9/20/25 with a terminal diagnosis vascular dementia with agitation. On 10/16/25 at 3:45 PM, a review of the POC effective 9/20/25, it was noted 2 of 2 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Call advisacare 24/7 if needs or concerns aris.” (sic) Another example documented, "Patient/Caregiver will understand pain scale, how to manage pain and report changes to Hospice. Patient’s pain level will be at their acceptable level as evidence by nonverbal cues." Patient #18 (P-18) was admitted to hospice on 8/30/25 with terminal diagnoses of hypertensive heart disease with heart failure. On 10/17/25 at 10:10 AM, a review of the POC effective 7/11/25, it was noted 9 of 9 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Patient/Caregiver will verbalize understanding of oxygen use related to uses and safety.” Another example documented, "Patient will maintain optimal cardiac function within constraints of disease process." The Administrator and Director of Clinical Services reviewed and acknowledged the above findings during an interview on 10/21/25 at 11:37 AM. Patient #11 (P-11): The Start of Care (SOC) was dated 2/28/25. The Plan of Care (POC) dated 2/28/25 identified a diagnosis of Post Polio Syndrome. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, "Patient/caregiver will understand pain scale, how to manage pain and report changes to hospice." Another goal stated, "Patient will maintain optimal cardiac function." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.Patient #12 (P-12): The Start of Care (SOC) was dated 11/1/24. The Plan of Care (POC) dated 11/1/24 identified diagnoses of breast cancer and hypertension. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, "Patient/Caregiver able [sic] to verbalize measures to promote comfort related to respiratory system in the terminal patient as evidenced by having decrease in SOB." Another stated, "Patient verbalize [sic] understanding of pain medication administration and side effects, patient's pain will be at a tolerable level, patient will exhibit abilities to implement alternate pain/symptom management with nonpharmacological interventions." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.Patient #13 (P-13): The Start of Care (SOC) was dated 8/22/25. The Plan of Care (POC) dated 8/22/25 identified a diagnosis of Parkinsonism. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, "Patient will receive personal care and hygiene including activities of daily living to his optimallevel." Another goal stated, "Patient will demonstrate O2 sat to his optimal level as established by physician." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.Patient #14 (P-14): The Start of Care (SOC) was dated 9/22/25. The Plan of Care (POC) dated 9/22/25 identified diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, "Close to Home facility staff willverbalize/demonstrate adequate knowledge of endocrine status as evidenced by verbal teach back." Another goal stated, "Close to home facility staff will understand thepain scale, how to manage pain and report changes to Hospice. Patient's pain level will be at their acceptable level as evidence [sic] by patient report." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings.

Based on record review and interview, it was determined that the hospice agency failed to collect any data which could be measured, analyzed, and tracked to evaluate the hospice's processes of care for all of 2024, and failed to acknowledge and track any adverse patient events as required since 2024, resulting in the potential for unrecognized negative patient outcomes for all 139 patients currently receiving hospice services. Findings include: --- On 10/16/25, a request was made to review the hospice agency's QAPI program. Review of the QAPI (Quality Assurance Performance Improvement) binder and Governing Body meeting minutes were reviewed since 2023 and found no evidence of data collection for 2024. In addition, no evidence was found that the hospice agency acknowledged and tracked adverse patient events from 2024 through 10/16/25 as required.These findings were reviewed with and confirmed by the agency's Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 11:55 AM. Both further acknowledged this did not meet agency's QAPI expectations or its policy referenced below.Agency Policy: “VI.3 Evaluation of Services and Scope of Care” (undated) stated, “The Hospice will identify important processes and functions that affect health care outcomes… The focus will be on high-risk, high volume and/or problem-prone activities, choosing at least one process to be analyzed per year to review, based on results of data collection…”

Based on record review and interview, it was determined that the hospice agency failed to collect data which could be utilized to monitor the safety, effectiveness and quality of patient care services for all of 2024, resulting in the potential for unrecognized negative patient outcomes for all 139 patients currently receiving hospice services. Findings include: --- On 10/16/25, a request was made to review the hospice agency's QAPI (Quality Assurance Performance Improvement) program. Review of the QAPI binder found no evidence of data collection for 2024 as required. This finding was reviewed with and confirmed by the agency's Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 11:58 AM. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “VI.3 Evaluation of Services and Scope of Care” (undated) stated, “The Hospice will identify important processes and functions that affect health care outcomes… The focus will be on high-risk, high volume and/or problem-prone activities, choosing at least one process to be analyzed per year to review, based on results of data collection…”

Based on record review and interview, the hospice agency failed to ensure its Governing Body (GB) approved the frequency and detail of the data collection for the QAPI (Quality Assurance Performance Improvement) program, which had the potential to negatively affect all 385 patients admitted during the past 12 months. Findings included: --- On 10/16/25, a request was made to review the hospice agency's QAPI (Quality Assurance Performance Improvement) program. Review of the QAPI binder for the last 3 years found no evidence that the frequency and detail of the hospice's data collection was presented to or approved by agency’s GB for the years 2023 and 2024. This finding was reviewed with and confirmed by the agency's Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 12:01 PM. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “VI.2 QAPI Monitoring and Responsibility” (undated) stated, “Responsibility for the QAPI program ultimately rests with the Governing Body. At least annually, receives reports on all QAPI activities, including the assessment of the effectiveness of QAPI activities in identifying the quality of care, opportunities to improve patient care …” No specific language was found in 3 of 3 submitted QAPI policy and procedures concerning the GB’s approval of the frequency and detail of data collection for the QAPI program.

Based on record review and interview, the Hospice's Governing Body (GB) failed to perform an evaluation of the implementation and maintenance of its QAPI (Quality Assurance and Performance Improvement) program annually for the period of January 2023 through October 16th, 2025. Findings include: --- On 10/16/25, a request was made to review the hospice agency's QAPI program and GB meeting minutes since 2023. Subsequent review of QAPI program documentation and GB meeting minutes found no evidence that the agency’s GB had evaluated the implementation and maintenance of its QAPI activities since January 2023. The findings above were reviewed with and confirmed by the agency's Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 12:06 PM. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “VI.2 QAPI Monitoring and Responsibility” (undated) stated, “Responsibility for the QAPI program ultimately rests with the Governing Body. At least annually, receives reports on all QAPI activities, including the assessment of the effectiveness of QAPI activities in identifying the quality of care, opportunities to improve patient care …”

Based on record review and interview, it was determined the hospice agency failed to implement and maintain a coordinated agency-wide program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases that was a required portion of the agency’s Quality Assurance and Performance Improvement program (See L 580); failed to incorporate a method of identifying infectious and communicable diseases problems and implement appropriate actions that would improve disease prevention (See L 581); and failed to provide documentation of any infection control education instructed to employees, contracted providers, patients, and family members and other caregivers (See L 582). --- .

Based on document review and interview, the hospice failed to have an infection control program that is an integral part of their Quality Assessment and Improvement Program which includes surveillance, identification, prevention, control, and investigation of infectious diseases, resulting in the potential for poor palliative outcomes and services for the 139 current hospice patients. Findings include: --- On 10/16/25, review of the hospice's QAPI (Quality Assurance and Performance Improvement) program concerning infection control revealed it was void of any information except for the following: An undated document of an influenza “Outbreak at Park Place” and an undated “Covid outbreak at Lasher” which had no data or other information. An infection control log regarding 5 staff members symptom of infection (date of year is unknown) were found with no follow-up or other information found.  Otherwise, no documented evidence was found that indicated the agency had conducted any infection control activities/monitoring over the last 3 years. The above findings were reviewed with and confirmed by the agency’s Administrator and Director of Clinical Services during an interview on 10/21/25 at 12:10 PM. Both further acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “X.3 Infection Control Program (undated) stated, “The goal of the surveillance, prevention and control of the infection control program is to improve patient health outcomes through identification and risk reduction… and to reduce the risk of transmission of infectious agents among patient’s staff and other care givers… Educating staff in the prevention and control of infections initially and at least annually… Observing and evaluating all staff at least annually in an effort to identify sources or causative factors of infection and track patterns and trends of infection.”

Based on record review and interview, the hospice agency failed to develop a method that identified infectious diseases with responding actions that would have an anticipated outcome in improvement of disease prevention and infection control, resulting in the potential to negatively affect care for all 139 patients currently receiving hospice services. Findings included: --- On 10/16/25, review of the hospice's QAPI (Quality Assurance and Performance Improvement) program concerning infection control since 2023, noted a failure of any methodology that identified infectious and communicable diseases. In addition, no actions or interventions were found that were geared towards intended improvement/containment in disease prevention and infection control during the last 3 years. Further, no documentation was evidenced concerning when and to what level an infectious issue would warrant the activation of further infection control measures as stipulated by the agency's policy referenced below. The above findings were reviewed with and confirmed by the agency's Administrator and Director of Clinical Services during an interview on 10/21/25 at 12:13 PM. Both acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: "X.3 Infection Control Program (undated) stated, "The best course of action to prevent the spread of infection and interventions will be applied to protect staff and patients. The risk for and trends of infections are used to study ways to improve both prevention and control activities and to reduce the risk of occurrence of infections to the lowest possible levels."

Based on record review and interview, it was determined the hospice agency failed to ensure all hospice employees received education on infection control outside of orientation of new hires since 2023, resulting in the potential for the development and spread of infectious diseases to all 139 patients currently serviced by this agency. Findings include: --- On 10/16/25, review of the hospice's QAPI (Quality Assurance and Performance Improvement) program concerning infection control education to staff and patients since 2023 was performed. No evidence (outside the agency’s orientation of new hires) was found regarding the provision of education that was specific towards infection prevention and control for the last 3 years.  These findings were acknowledged by the agency’s Administrator (Adm #1) during an interview conducted on 10/17/25 at 11:40 AM. Adm #1 stated that education was performed to staff but failed to retain any of the documentation of the content or in-services conducted in 2025. Further, agency efforts to retrieve documentation for 2023 and 2024 found no evidence of infection control education being performed to staff or patients. Adm #1 further acknowledged on 10/21/25 at 12:15 this did not meet agency expectations or its policy referenced below.  Agency Policy: "X.3 Infection Control Program (undated) stated, "Educating staff in the prevention and control of infections initially and at least annually thereafter, or as needed per change in policies. Patients, family members and/ or caregivers will receive education regarding basic infection control measures on admission and as needed during the delivery of services.”

Based on record review and interview the agency failed to ensure nursing needs of the patient were identified and met and failed to ensure the Registered Nurse provided oversight and supervision of its Licensed Practical Nurses (See L591); failed to ensure medical social work services provided ongoing assessment of patients (See L594); failed to make bereavement services available to all of the bereaved family members who would be affected by the patient's death and failed to complete a bereavement plan of care that reflected the needs of each bereaved family member, the kind of bereavement services to be offered, and the frequency of service delivery (See L596). --- .

Based on record review and interview, the agency failed to ensure the Registered Nurse provided oversight and supervision of its Licensed Practical Nurses in 4 (P-2, P-3, P-4, and P-9) of 10 records of patients who received care from Licensed Practical Nurses, from a total of 19 sampled records reviewed; and failed to ensure nursing needs of the patient were identified and met in 1 (P-2) of 19 records reviewed, resulting in the potential for substandard care and unmet patient care needs.  Findings include: --- Policy: II.5 Supervision and Evaluation of Staff, undated, stated, "Each case receiving care provided by an LPN or therapy/social work assistant will be assessed by the appropriate registered nurse, therapist or social worker no less often than monthly."Patient #9 (P-9) was admitted to hospice on 6/12/25 with diagnoses that include Chronic Obstructive Pulmonary Disease and Vascular Dementia.  The Plan of Care ordered Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided.  During a review of the clinical record on 10/16/25 at 1:35 p.m., it was noted that the Licensed Practical Nurse (LPN) provided care of P-9 on the following dates:  8/15/25, 8/22/25, 8/29/25, 9/5/25, 9/12/25, 9/19/25, 9/26/25 and10/3/25. Upon further review, there was no documented evidence that the Registered Nurse provided oversight and supervision of the LPN, no less often than monthly, as per this requirement and in accordance with the agency's policy. The Administrator reviewed and acknowledged these findings during an interview on 10/21/25 at 8:55 a.m. Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted skilled nursing notes dated 3/28/25, 4/9/25, and 6/30/25 all documented new or changing wounds noted on P-2’s skin. However, it was also noted there were no objective measurements or assessments made of these wounds. The note dated 4/9/25 indicated wound care was provided by the skilled nurse. Upon review of the orders and plan of care, it was determined there were no orders written for wound care for who would take care of the wounds going forward and how.Additionally, during a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:00 AM, it was noted P-2 had square adhesive bandages on her right hip, right knee, and left heel. A staff member from the skilled nursing facility (SNF) was present to assist in positioning P-2 stated the bandages were “for protection”, however, upon removing them, it was noted there were open areas on each location. During the visit, RN #3 was asked what the procedure was for new wounds. RN #3 stated she “sucks at wounds” and wasn’t sure what to do. RN #3 also acknowledged she hadn't made any wound measurements “from the beginning” and that a wound care nurse “takes care of it.” RN #3 stated she can contact the SNF wound care nurse to look at them, but the night shift nurses often do the dressing changes. RN #3 was also asked how she would know how to care for the wounds if she had to provide the wound care (as done during the joint home visit). RN #3 stated there should be wound care orders to follow, however, she was unable to provide evidence of wound care orders in P-2’s record for any current or previous wounds.The agency failed to provide care to ensure ongoing nursing needs were met as identified in the patient assessments.The records for P-2, Patient #3 (P-3), and Patient #4 (P-4) were reviewed from 10/15/25 through 10/21/25. During review of the records to assess licenses practical nurse (LPN) supervision, it was noted skilled nursing notes included a section under "Supervisory Visit" titled "LPN/LVN Information” that was filled out at least every 30 days. However, the only information under this section was the name of the LPN being supervised and the word “indirect” under “Type of Supervision” for all notes. There was no other documentation regarding how the LPN was supervised, therefore, there was no evidence of LPN supervision.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, it was determined the hospice agency failed to provide ongoing psychosocial assessments to identify issues that may impede or facilitate care in 1 (P-2) of 19 records reviewed; and failed to provide the core service of medical social worker (MSW) as ordered in the Plan of Care (POC) to meet the needs of the patient and family in 2 (P-5 and P-17) of 19 total sampled records reviewed, resulting in the potential for unaddressed social care needs and lack of community resources. Findings include: --- P-17: The hospice start of care date (SOC) was 9/20/25, with diagnoses that included vascular dementia with agitation, diabetes-type 2, hypertension and repeated falls. On 10/17/25, review of P-17’s plan of care (POC), effective 9/20/25, noted an order to provide Master of Social Work (MSW) services at a frequency of once monthly with 2 as needed visits every 30 days. Further record review revealed that no MSW services had been provided as of 10/17/25 (28 days after SOC). No evidence was found in the medical record of the patient/family refusing services or an order to discontinue MSW services. No evidence was found in the medical record that the physician was notified of this.During an interview on 10/21/25 at 12:35 PM, the findings above were reviewed and acknowledged by the Administrator and Director of Clinical Services. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “III.8 Patient Assessment & Reassessment” (undated) stated, “A comprehensive assessment will be conducted within 5 days of the patient’s election of hospice services and shall include all disciplines needed. The social worker shall perform a thorough psychosocial assessment of the patient at the time of admission and shall reassess the patient throughout the course of care.”  Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the electronic medical record system had an alert that indicated no information should be shared with who was initially listed as P-2's significant other. Additionally, the alert indicated that P-2’s daughter was now her guardian.During a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:00 AM, RN #3 was asked about the situation. RN #3 stated P-2 lived with her significant other when she was admitted to hospice. RN #3 stated P-2 and her significant other had been evicted from their apartment and had issues finding somewhere for her live. RN #3 stated P-2 was hospitalized at one point and eventually moved the skilled nursing facility (SNF) where she currently resided. RN #3 stated that sometime after P-2 moved to the facility, there were concerns P-2’s significant other was abusing her and was stealing money. RN #3 also indicated adult protective services was called. Eventually, it was decided P-2’s significant other could no longer come to the facility and P-2’s daughter would be her guardian.Upon return to the agency to further review the record, it was noted the social worker performed the initial assessment on 4/1/25 with P-2’s significant other and a family friend because the patient was sleeping. It was also noted P-2 requested assistance with getting a wheelchair ramp. There was no documentation this was ever followed up on. The next social work notes on 5/21/25 and 5/28/25 indicated phone calls were made, but no physical visit. On 5/28/25, P-2’s significant other called back and reported they had been evicted, P-2 was in the hospital, and the social worker at the hospital was working on a facility for P-2 to move to. The next social work note was not dated until 6/27/25 and did not mention the move the SNF. The following social work notes dated 7/3/25, 7/26/25, 7/30/25, 8/7/25, 8/14/25, 8/23/25, 8/29/25, 9/6/25, 9/9/25, 9/19/25, 9/27/25, 10/4/25, and 10/7/25 were also reviewed. Upon review of the visit notes, it was determined there was no mention of P-2’s move to the SNF, of P-2’s significant other no longer being allowed to visit her, or of P-2’s daughter now being her guardian. Additionally, there was no signed documentation of guardianship to confirm this.A review of agency policy titled “III.8 PATIENT ASSESSMENT & REASSESSMENT” (not dated) revealed, “Ongoing counseling will be provided to address areas in which the patient or family unit of care require assistance.”A review of agency policy titled “III.1 TERMINALLY ILL PATIENTS/LEVELS OF CARE & SERVICES AVAILABLE” (not dated) revealed under the “Medical Social Workers” section that the social worker, “Assesses and reassesses social and emotional factors in order to help  the patient and family to cope with problems in daily living and to help them follow medical recommendations to maximize the patient’s health condition.”The agency failed to provide ongoing psychosocial assessments to identify issues that may impede or facilitate patient care, including a significant move and major changes in family dynamics.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was noted the plan of care ordered social work for 1 time per month with 3 PRN (as needed visits). Additionally, skilled nursing notes dated 10/6/25, 10/8/25, and 10/15/25 indicated coordination of care was done between the skilled nurse and social worker. Upon further review of the record, it was determined social work never saw this patient. There was no documentation from the social worker regarding missed visits or the patient declining care. There was also no documentation of the physician being notified.The agency failed to provide social work services as ordered.A review of agency policy titled “III.8 PATIENT ASSESSMENT & REASSESSMENT” (not dated) revealed, “The social worker shall perform a thorough psychosocial assessment on the patient at the time of admission and shall reassess the patient throughout the course of care.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the hospice failed to make bereavement services available to all of the bereaved family members who would be affected by the patient's death, and failed to complete a bereavement plan of care that reflected the needs of each bereaved family member, the kind of bereavement services to be offered and the frequency of service delivery in 1 (BRV #3) of 3 bereavement records reviewed, resulting in the potential for ineffective coping/grieving and unmet bereavement needs.  Findings include: --- Bereavement Record #3 (BRV #3):  This patient was admitted to hospice on 2/11/25 with a terminal diagnosis of Parkinson's Disease. A review of the clinical record on 10/15/25 at 3:35 p.m., revealed the patient expired on 3/11/25.  The Initial Bereavement Assessment dated 2/11/25, conducted by the Registered Nurse, revealed that BRV #3 was survived by his wife, "daughters and families."  The Bereavement Care Plan dated 3/31/25 only identified the patient's wife.  The Bereavement Care Plan made no mention of the patient's daughters and families as identified in the initial assessment. The hospice failed to ensure a Bereavement Plan of Care was developed for BRV #3's daughters and families, that reflected and addressed their individualized bereavement needs.The Administrator reviewed and acknowledged the above findings during an interview on 0/21/25 at 8:40 a.m.

Based on record review and interview, the registered nurse failed to ensure the written plan of care for the assigned hospice aide provided specific guidance and care instructions on the needs of the patient and failed to ensure safety precautions were included on the hospice aide plan of care (See L625); failed to ensure the hospice aide provided care and services as ordered in the plan of care (See L0626); failed to ensure its hospice aides reported changes in patient's care and documented tasks upon completion (See L628); and failed to ensure the Registered Nurse made on-site visits to the patient's home no less than every 14 days to assess the adequacy of aide services (See L629). --- .

Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned hospice aide provided specific guidance and care instructions on the needs of the patient for 4 (P-1, P-2, P-9, and P-19) of 15 records with hospice aide services ordered, and failed to ensure safety precautions were included on the hospice aide plan of care for 3(P-1, P-12, and P-14) of 15 records with hospice aide services provided, from a total of 19 records reviewed resulting in the potential for unmet patient care needs and patient injury. Findings include: --- Patient #12 (P-12): The Start of Care (SOC) was dated 11/1/24. Upon review of the hospice aide Plan of Care (POC) dated 11/1/24, it was noted that no oxygen precautions were documented for a patient receiving supplemental oxygen.Patient #14 (P-14): The SOC was dated 9/22/25. Upon review of the hospice aide POC dated 9/22/25, it was noted that no oxygen precautions were documented for a patient that smokes/vapes and is receiving supplemental oxygen. During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings. Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia.  The clinical record was reviewed on 10/16/25 at 1:35 p.m. and revealed that Hospice Aide (HHa) services were ordered at a frequency of 2x/wk. effective 6/12/25. Upon review of the aide care plan, last reviewed on 6/16/25, it was noted that the Registered Nurse (RN) checked off every task listed on the plan such as, TPR and BP (temperature, pulse, respiration and blood pressure), bathroom assistance, patient independent, urinary catheter, draw sheet, complete bed bath every visit, partial bed bath, shower and shave.  The aide care plan indicated that these tasks were to be completed every visit.   On 10/17/25 at 9:10 a.m., the Administrator (Adm #1) reviewed the above documentation and reported, "The nurse checked off on every one of the tasks.  There is an issue."  Additionally, Adm #1 reported that none of the hospice aides are allowed to check patient's vital signs as ordered by the nurse in the aide care plan. The Registered Nurse failed to provide clear written patient care instructions and guidance for the hospice aide. Adm #1 reviewed and acknowledged the above findings at the time of discovery during the above review.   Patient #19 (P-19) was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant Neoplasm of Lower right Lobe.  During the record review on 10/21/25 at 10:40 a.m., it was noted that Hospice Aide services was ordered at a frequency of 2x/wk. with 3 prn (as needed) visits. Further review revealed that the patient was admitted with an unstageable pressure sore on his buttock that measured 3 by 5 (unit of measurement used unknown) to be covered with absorbent foam dressing. Upon review of the aide care plan, there was no instruction or guidance for the aide on measures to take if the dressing should become dislodged or soiled. The Administrator reviewed and acknowledged these findings during an interview on 10/21/25 at 10:40 a.m.  No response was offered.  Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted a skilled nursing note dated 9/18/24 indicated that P-2 had a “small wound to coccyx, wound to wound to right ankle posterior” [sic] and “Some skin issues small wound to coccyx treated with triad. Wound to right ankle, outer cleaned with wound cleaner and covered with boarder foam.” [sic] The start of care assessment dated 9/14/24 (as well as subsequent skilled nursing notes) also indicated P-1 had a PEG (percutaneous endoscopic gastrostomy) tube (a thin tube inserted through the stomach through a small incision in the abdominal wall used to deliver nutrition and medication to patients who cannot eat or drink orally). Additionally, it was also noted the patient was “strict NPO” – meaning “nothing by mouth.” It was documented P-1 was bed bound and unable to get out of bed without assistance of a mechanical lift. P-1 was receiving hospice aide services 2 times per week.During review of the aide care plan, it was determined there were no written instructions for the aide regarding care for the uncovered coccyx wound during/following bathing or what to do if the dressing on the right ankle was soiled or dislodged.Upon further review of the aide care plan, it was also noted it included interventions to “Assist with Feeding” and to “Encourage Fluids Offer Hydration during every visit, and have next to Patient within reach (Ensure, Juice, Bottled Water).” [sic] However, the aide care plan failed to include safety precautions regarding P-1 not being allowed to eat or drink.Additionally, the aide care plan indicated P-1 could ambulate “with 1 person assist with rolling walker” and transfer with “1 person assist with rolling walker.”The information in the aide care plan is conflicting, inaccurate, and potentially unsafe for the aide to follow.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:00 AM, it was observed that P-2 had severe contractures (permanent tightening of muscles that causes joints to be stiff) of her knees, hips, and elbows. It was observed P-2 was only able to lay with her knees, hips, and elbows fully flexed (bent) and was unable to straighten any of her joints. Additionally, any movement caused P-2 extreme pain and crying. During the joint visit, it was also observed 2 people were needed to assist in changing P-2’s brief.During review of the record for P-2 on 10/16/25, it was noted the aide care plan failed to include information regarding P-2’s contracted status and the need for assistance during care.The aide care plan failed to provide specific guidance for safe care of this patient.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the agency failed to ensure the hospice aide provided care and services as ordered in the plan of care, and in accordance with the specified visit frequency in 3 (P-2, P-3, and P-9) of 15 records of patients ordered to receive hospice aide services, from a total of 19 records reviewed, resulting in patients not receiving services in accordance with their identified needs.  Findings include: --- Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia.  The clinical record was reviewed on 10/16/25 at 1:35 p.m. and revealed that Hospice Aide (HHa) services were ordered at a frequency of 2x/wk. effective 6/12/25.During the review, it was noted that the Hospice Aide (HHa #1) had a total of 10 missed visits with associated missed visit notes. Upon further review, HHa #1 made no visits to the patient's home on the following dates:No aide visits made during the first week of service.Only 1 visit made the week of 6/15/25.Missed visits the week of 6/22/25 and 6/29/25.No aide visits made during the weeks of 6/29/25 or 7/6/25.Only 1 aide visit made the week of 7/20/25.No aide visits made during the weeks of 7/27/25, 8/3/25 or 8/10/25.Two documented missed visits the week of 8/17/25.No aide visits made the week of 8/24/25.No aide visits made the week of 8/31/25 (1 of the 2 scheduled visits was a documented missed visit).Only 1 visit made the week of 9/7/25.Only 1 aide visit made the week of 9/14/25. (1 of the 2 scheduled visits was a documented missed visit).No aide visits made the week of 9/21/25.Only 1 of the 2 scheduled visits was made the week of 9/28/25. (one was a documented missed visit).Only 1 of the 2 scheduled visits was made the week of 10/5/25 (one was a documented missed visit).Only 1 visit made the week of 10/12/25.There was no documented rationale as to why HHa #1 failed to follow the ordered visit frequency.  Further, there was no documentation of patient refusal or that the nurse or Physician had been notified accordingly. Additionally, upon review of the aide visit notes dated 6/17/25 to 10/14/25, the hospice aide placed a check mark in the box titled "acknowledged," next to each assigned task, however, the box titled "completed" was left blank. There was no way to ascertain whether all assigned tasks had been completed. This pattern of documentation was the same in all 9 visit notes documented by the aide. The Administrator reviewed and acknowledged the above findings during an interview on 10/21/25 at 8:55 a.m. Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted hospice aide services were ordered 2 times per week. Upon further review of the record, it was determined P-2 received 1 hospice aide visit the week of 4/6/25 due to P-2’s sister performing bathing for P-2 another day. It was also noted P-2 received no hospice aide visits the week of 4/13/25 due to P-2’s significant other canceling them. There was no documentation of attempts to reschedule the canceled visits to meet the ordered frequency. Additionally, another missed visit due to a cancelation was documented the week of 4/21/25 and it was noted P-2 did not receive any other hospice aide visits that week. After 4/21/25, it was noted the next documentation from a hospice aide was for a visit completed on 6/17/25 – 57 days since the last aide documentation (missed visit) and 71 days after the last aide visit was made. There were no orders to cancel hospice aide services and no documentation as to why there were no aide visits between the last cancellation note on 4/21/25 and the next visit note on 6/17/25.Upon further review of the aide care plan, it was noted there was an intervention to “Document Last BM” (bowel movement) every visit. During review of the hospice aide visits dated 3/31/25, 4/2/25, and 4/7/25, it was determined the date of the last bowel movement was not documented.Patient #3 (P-3) was admitted to this hospice on 9/20/25 with the terminal diagnosis of cerebrovascular disease. During record review on 10/17/25, it was noted hospice aide services were ordered 2 times per week. Upon further review of the record, it was determined P-3 only received 1 hospice visit during the weeks of 9/21/25 and 9/28/25. There was no documentation of missed visits or orders to change the hospice aide frequency.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the hospice failed to ensure its hospice aides reported changes in patient's care and documented tasks upon completion for 3 (P-1, P-2, and P-9) of 15 patients who received hospice aide services, from a total of 19 records reviewed, resulting in patients not receiving care based on their identified needs and lack of continuity of care.  Findings include: --- Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia.  The clinical record was reviewed on 10/16/25 at 1:35 p.m. and revealed that Hospice Aide (HHa) services were ordered at a frequency of 2x/wk. effective 6/12/25. During the review, it was noted that the patient resided in an Assisted Living Facility.  An aide missed visit note dated Tuesday 6/24/25 documented, "Pt (patient) refused care for the day. Stated facility staff said told her (patient) she has showers on Wednesday and Sunday only." [sic] There was no documented evidence that the aide reported this information to the nurse in order to adjust the visit dates and update the aide care plan.  Further, the hospice aide made all but one future visits on Tuesdays and Thursdays.  These are the days the shower would not have been available to the patient, per facility staff. Additionally, upon review of the aide visit notes dated 6/17/25 to 10/14/25, the hospice aide placed a check mark in the box titled "acknowledged," next to each assigned task, however, the box titled "completed" was left blank. There was no way to ascertain whether all assigned tasks had been completed. This pattern of documentation was the same in all 9 visit notes documented by the aide.  The Administrator reviewed and acknowledged the above findings during an interview on 10/21/25 at 8:55 a.m.  Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted the aide visits included a check box for each task with the words “acknowledged” and “completed.” During review of the 17 aide visit notes dated between 9/20/24 and 11/12/24, it was determined “acknowledged” was checked for all listed tasks, however, the box next to “completed” was left blank for several tasks during each visit. There was no indication of why a task was not completed or that the nurse was notified the care had not been completed as ordered.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the aide visits included a check box for each task with the words “acknowledged” and “completed.” During review of the 3 aide visits dated 3/31/25, 4/2/25, and 4/7/25, it was determined “acknowledged” was checked for all listed tasks, however, the box next to “completed” was left blank for all tasks during these visits. There was no indication of why a task was not completed or that the nurse was notified the care had not been completed as ordered.During an interview with the administrator (Adm #1) on 10/16/25 at 4:03 PM, Adm #1 was asked what it meant if the box next to “completed” was not marked. Adm #1 stated if “completed” wasn’t marked, the task was not completed, and it should be documented as to why and who was contacted about it.The administrator (Adm #1) again reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM. The director of clinical services (DCS #1) was also present during the interview and acknowledged the findings.

Based on record review and interview, the Hospice failed to ensure the Registered Nurse made on-site visits to the patient's home no less than every 14 days to assess the adequacy of aide services for 4 (P-2, P-3, P-4, and P-9) of 15 records in which Hospice Aide services were provided, from a total of 19 records reviewed, resulting in the potential for the rendering of unauthorized substandard care and the potential for unmet patient care needs.  Findings include: --- Policy: II.5 Supervision and Evaluation of Staff, undated, stated, "A registered nurse will make a supervisory visit to all patients receiving hospice aide services at least every 2 weeks. The visits will be made either when the aide is present to observe the aide in the performance of their duties or when the aide is absent to determine the relationship of the aide and the patient." Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. The Plan of Care (POC) ordered Skilled Nursing, Hospice Aide, Spiritual Care and medical Social Work services to be provided.  During the clinical record review on 10/16/25 at 1:35 p.m., it was noted that the Hospice Aide made a total of 9 visits between 6/17/25 to 10/14/25. On 10/17/25 at 11:38 a.m., the Administrator (Adm #1) was asked for assistance in locating the Aide supervisory visits within the Electronic Medical Record (EMR) system.  Upon retrieval and review, it was noted that none of the supervisory visits had been completed.  The section of the Nurse visit notes titled "Supervision" merely documented, "indirect."  There was no other documentation related to supervision of the Hospice Aide.  Adm #1 reported, "The nurses are probably not checking all the appropriate boxes and that's why it's not showing up in the supervisory notes."  There was no documented evidence that the Registered Nurse made supervisory visits at least every 2 weeks as per this requirement, and in accordance with the agency's policy.  These findings were reviewed with and acknowledged by Adm #1 at the time of discovery during the above review.   The records for Patient #2 (P-2), Patient #3 (P-3), and Patient #4 (P-4) were reviewed from 10/15/25 through 10/21/25. During review of the records to assess hospice aide supervision, it was noted skilled nursing notes included a section under "Supervisory Visit" titled “Hospice Aide Care” that was filled out at least every 14 days. However, the only information under this section was the name of the hospice aide being supervised and the word “indirect” under “Type of Supervision” for all notes except 1 for P-4. There was no other documentation regarding how the aide was supervised.During an interview with the administrator (Adm #1) on 10/17/25 at 11:37 AM, Adm #1 was asked to provide documentation of how the aides were supervised. When shown the above records with the missing information, Adm #1 stated he was made aware of the additional boxed the nurses should be checking about 2 weeks ago and was working on making those mandatory to fill out.Adm #1 acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to provide evidence of volunteer orientation for 1 (Vol #1) of 1 active volunteers, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- During an interview with the volunteer coordinator (VC #1) on 10/15/25 at 1:35 PM, VC #1 was asked to provide evidence of volunteer orientation and training. VC #1 stated the agency currently has 1 active volunteer (Vol #1) who has completed all the required training, however, VC #1 stated he started before she was the volunteer coordinator and was unable to provide evidence of his orientation. VC #1 stated she has 7 volunteers in the process of training, and she has a system to keep track of orientation going forward.A review of agency policy titled “IV.10 ORIENTATION FOR HOSPICE STAFF & VOLUNTEERS” (not dated) revealed, “All Hospice volunteers shall receive orientation and training prior to providing patient, family, and caregiver care…”.VC #1 acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to ensure volunteers provided a minimum of 5% of the total patient care hours of all paid hospice employees and contract staff. Findings include: --- During an interview with the volunteer coordinator (VC #1) on 10/15/25 at 1:35 PM, VC #1 was asked to provide documentation of volunteer hours. VC #1 provided information from a Quality Assurance Performance Improvement (QAPI) meeting dated 7/29/25. According to the information in the meeting minutes, volunteers only provided 16.75 hours out of a total of 25,672 hours for a total of 0.00065%. VC #1 stated she started her position as the volunteer coordinator recently and has already taken steps to improve this number.VC #1 acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to ensure clinical record entries were clear and complete in 1 (P-2) of 19 records reviewed, resulting in the potential for an inaccurate and incomplete medical record. Findings include: --- Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted social work notes dated 8/23/25, 8/29/25, and 9/6/25 all stated under “General Visit Note Information”:“MSW MET WITH PT IN HER ROOM.   PT IS A/OX4. PT REC'D LAYING IN HER HOSPITAL BED. PT PAIN  IS 10/10 ON AN A.D SCALE. . PT WAS DRESSED IN APPEARANCE.  PT APPETITE HAS DECREASED AND DIFFICULTY SLEEPING DUE TO PAIN LEVEL.  MSW PROVIDED SUPPORTIVE PRESENCE, ACTIVE LISTENING, ENCOURAGEMENT, AND CARE AND TOUCH.” [sic]Additionally, it was noted social work notes dated 9/9/25, 9/19/25, 9/27/25, 10/4/25, and 10/7/25 all stated under “General Visit Note Information”:“MSW MET WITH PT IN HER ROOM. PT REC;D  LAYING IN HER HOSPITAL BED .  PT DRESSED IN APPEARANCE. PT IS VERBAL AND A FALL-RISK. PT IS DEPRESSED. PAIN LEVEL ON AN A.D SCALE IS 10/10. PT  APPETITE IS FINE SLEEPING HAS INCREASED. MSW PROVIDED CARE AND TOUCH, ENCOURAGEMENT, AND ACTIVE LISTENING. MSW COLLABORATED WITH RN  CONCERNING HER CARE.” [sic]The information was copied and pasted word for word from previous notes, therefore, cannot be an accurate assessment of treatment or response to treatment.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on interview and record review, the Hospice failed to identify the care and services that were needed and identify each provider's responsibility for performing the needed functions that had been agreed upon and included in the hospice plan of care in 3 (P-1, P-2, and P-19) of 4 records of patients who resided in a Skilled Nursing Facility, from a total of 19 sampled records reviewed, resulting in the potential for needed care and services to be overlooked and unmet patient care needs. Findings include: --- Patient #19 (P-19) was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant Neoplasm of Lower Right Lobe (Lung Cancer).  The Plan of Care (POC) ordered Skilled Nursing, Hospice Aide and Medical Social Work services to be provided.  During the clinical record review on 10/21/25 at 10:40 a.m., it was noted that P-19 resided in a Skilled Nursing Facility (SNF).The POC stated, "Need for Facility Staff Care Coordination."  There was no indication of which services would be provided by the Hospice or the SNF. The Hospice agency failed to establish clear delineation of duties. On 10/17/25 at 1:32 p.m., the Administrator reviewed and acknowledged the above findings and responded, "Theres just a generic plan of care. It doesn't specify each role."  Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was determined that P-1 lived in a skilled nursing facility (SNF). Upon further review of the record, it was determined the plan of care failed to indicate which interventions and services would be provided by the hospice and which would be provided by the SNF.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/15/25, it was determined that P-2 lived in a SNF. Upon further review of the record, it was determined the plan of care failed to indicate which interventions and services would be provided by the hospice and which would be provided by the SNF.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the Hospice failed to ensure the plan of care reflected the collaborative participation of the Hospice, Skilled Nursing Facility and the patient/family in 1 (P-19) of 2 records reviewed in which the patients resided in a skilled nursing facility, from a total of 19 sampled records reviewed, resulting in the potential for ineffective coordination of care and unmet care needs.  Findings include: --- Patient #19 (P-19) was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant neoplasm of the Right Lower Lobe/Lung Cancer.  The Plan of Care (POC) ordered Skilled Nursing, Hospice Aide and Medical Social Work services to be provided.  The patient resided in a Skilled Nursing Facility (SNF).During a review of the Hospice POC on 10/21/25 at 10:40 a.m., it was noted that participation by the SNF staff, patient and family was not reflected in the problems, interventions and documentation of outcomes. The Administrator reviewed and acknowledged the above findings during an interview on 10/21/25 at 1:32 p.m. No response was offered.

Based on observation, record review, and interview, the agency failed to provide the skilled nursing facility (SNF) with the most recent hospice plan of care for 1 (P-2) of 1 patients with home visits that resided in a SNF, resulting in the potential for unmet care needs and poor patient outcomes due to a lack of coordination. Findings include: --- Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. Following a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:28 AM, RN #3 was asked to locate the plan of care provided to the skilled nursing facility. RN #3 located a binder at the nurse’s station and stated it should be in there under the “Plan of Care” tab. Upon review of the binder, it was noted there were blank forms titled “Community and Hospice Coordination of Care Form” located under the “Plan of Care” tab, however, there was no information filled out for the skilled nursing facility. Additionally, there was no plan of care from the hospice agency. RN #3 stated it should be there and didn’t know why it wasn’t. RN #3 acknowledged the findings at the time of interview.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.

Based on record review and interview, the Hospice failed to ensure that staff at 23 of 23 Skilled Nursing Facilities that currently house its hospice residents, received orientation and training regarding the needs of the Hospice patient and the Hospice philosophy, resulting in the potential for the rendering of substandard care and unmet patient care needs at the end of life.  Findings include: --- On 10/21/25 at 2:30 p.m., the Administrator (Adm #1) was asked to provide documented evidence to show that the Skilled Nursing Facility (SNF) staff had received in-service training, orientation and education on the Hospice philosophy, however, was unable to provide the requested information and reported, "There is no formal evidence of training to SNF staff regarding hospice care."The Hospice failed to ensure SNF staff received the required training on the Hospice philosophy, as per this requirement.Adm #1 acknowledged the above findings at the time of discovery during the above request.

Based on record review and interview, the agency failed to develop an Emergency Preparedness plan that included a communication plan, training, and testing, and must be reviewed every two years. These practices could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: 1. The agency failed to develop an emergency preparedness plan that must be reviewed and updated at least annually. (See E0004) 2. The agency failed to develop Emergency Preparedness policies and procedures that aligned with the emergency plan, risk assessment and communication plan. (See E0013) 3. The hospice failed to develop and implement emergency preparedness policies and procedures to follow up with on duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency. (See 0016) 4. The agency failed to develop a system to track patients and staff during an emergency. (See 0018) 5. The agency failed to develop policies and procedures for the safe evacuation from the facility, and a communication plan. (See 0020) 6. The agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least every two years. (See E0029) 7. The agency failed to develop and maintain an emergency preparedness communication plan that included an alternate means for communicating with agency staff, Federal, State, tribal, regional, and local emergency preparedness officials. (See E0032) 8. The agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. The training and testing program must be reviewed and updated at least annually. (See 0036) 9. The agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training. (See 0037) 10. The agency failed to conduct exercises every two years to test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the clinic's response to and maintain documentation of all drills, tabletop exercises, emergency events and revise the emergency plan as needed. (See 0039) --- The cumulative effect of these systemic problems resulted in the agency's inability to ensure patient safety during an emergency which could result in the agency not providing quality health care.

Based on record review and interview, the agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every two years. Resulting in no directions for agency actions in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all agency patients in the event of a facility emergency or disaster. Findings include: --- On 03/31/23, the agency's emergency preparedness documentation was reviewed. There was no documentation the agency had developed and maintained a comprehensive emergency preparedness plan. The agency had not reviewed and updated the emergency preparedness plan since 2020. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, the agency failed to develop Emergency Preparedness policies and procedures that aligned with the emergency plan, risk assessment and communication plan. The policies and procedures must be reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of natural, man-made, or facility-based emergencies. Findings include: --- On 3/31/23, the agency's emergency preparedness program was reviewed. There was no evidence emergency preparedness policies and procedures were reviewed and updated every two years. The policies and procedures the agency had were undated. There was no further documentation in the emergency preparedness program that showed a review of policies and procedures. All agency patients could be impacted by the agency's failure to review and update emergency preparedness policies and procedures. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, the agency failed to implement the procedures in place to follow up with staff and patients to determine services that are needed in the event that there is an interruption in services due to an emergency. This has the potential to negatively affect the health and safety of the agency's 17 current patients. Findings include: --- **Agency policy "3.D Planning - Patient Care" in the Emergency Preparedness binder states that, "On admission, the admitting nurse assigns each patient a priority code, dictating that patient's emergency rating." It also distinguishes the priority code levels as Level 1, Level 2 and Level 3 with instructions on how to proceed in each case. MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the patient was given a disaster acuity rating of "CLASS 4" on the Start of Care (SOC) dated 12/20/22. There are no instructions in the policy as to what to do in an emergency with a patient of that classification. MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's disease. During record review on 3/30/23, it was noted that the patient was given a disaster acuity rating of "NA - Not yet defined" on the SOC dated 1/10/23. There are no instructions in the policy as to what to do in an emergency with a patient who has not been assigned a level. The agency failed to follow its own policy regarding assigning appropriate disaster codes to patients. Findings were reviewed with and acknowledged by the administrator (Adm #1) and the director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m.

Based on record review and interview, it was determined the agency failed to develop a system to track patients and staff during and emergency, resulting in the potential for harm to all agency patients and staff. Findings include: --- On 03/31/23, the agency's emergency preparedness documentation was reviewed. There was no documentation the agency had developed a system to track patients and staff during an emergency event. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview the agency failed to develop policies and procedures for the safe evacuation from the facility, and a communication plan with external sources for assistance, resulting in the potential for injury to agency patients. Findings include: --- On 03/31/23, the agency's emergency preparedness documentation was reviewed. There was no documentation the agency had developed policies and procedures for the safe evacuation of patients from the facility, or a communication plan with external sources for assistance in evacuating patients. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: --- The agency's emergency preparedness program was reviewed on 3/31/23. There was no documented evidence the agency had developed an Emergency Preparedness communication plan and that the communication plan was reviewed and updated at least annually. All agency patients could be impacted by the agency's failure to develop an emergency preparedness communication plan. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan that included an alternate means for communicating with agency staff, Federal, State, tribal, regional, and local emergency preparedness officials, resulting in the lack of essential information in the event of an actual emergency. Findings include: --- During a review of the clinic's Emergency Preparedness Program on 3/31/23, it was noted there was no identification of an alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency preparedness officials. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. The training and testing program must be reviewed and updated at least every two years. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: --- The agency's emergency preparedness program was reviewed on 3/31/23. There was no documented evidence the agency had developed a training and testing program to guide personnel and agency actions during an emergent situation. All agency patients could be impacted by the agency's failure to develop and maintain an emergency preparedness training and testing program. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, it was determined the agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: --- On 3/31/23, the administrator (Adm#1) was asked to provide evidence of initial training for all staff employed by the clinic yet was unable to do so. There was no indication that initial Emergency Preparedness training had been provided to all staff as required, and no staff attendance sheet was available. The clinic failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, the agency failed to conduct exercises every two years to test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the clinic's response to and maintain documentation of all drills, tabletop exercises, emergency events and revise the emergency plan as needed. This deficient practice could affect the health and safety of all clinic patients in the event of a facility emergency or disaster. Findings include: --- On 3/31/23, the clinic's emergency preparedness documentation was reviewed. Record review indicated there was no documentation of a full-scale exercise or a table-top exercise since 2020. There was no documentation of the following: an actual event that would qualify as a test of the emergency plan, an additional full-scale exercise or a table-top exercise, and an analysis of the clinic's response to all drills, tabletop exercises, emergency events and revisions to the emergency plan as needed. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings.

Based on record review and interview, the Hospice failed to ensure the comprehensive assessment included an initial bereavement assessment and bereavement care plan that identified all who would be affected by the patient's death in 4 (MR #1, #14, #2, #11) records, from a total of 14 records reviewed resulting in the potential for unmet bereavement care needs. Findings included: **Agency Policy #III.39: "AdvisaCare Hospice Bereavement Program", no date. The policy states, "A bereavement risk assessment will be completed by the hospice social worker, bereavement coordinator, or spiritual counselor within 5 days of the patient's admission to hospice. The program will provide bereavement services to the family units of care of hospice patients both before and after the patient's death in accordance with the Plan of Care." --- MR #1: The patient was admitted to Hospice services on 6/20/22 with a terminal diagnosis of Ischemic Heart Disease. The clinical record review was conducted on 3/29/23 at 11:25 a.m. and revealed the patient had 2 sons and a daughter-in-law that assisted in the provision of care. The Initial Bereavement Assessment, dated 6/24/22, completed by the Social Worker failed to include all parties (Son #2) who would be affected by the patient's death. These findings were reviewed with and acknowledged by the Administrator and Clinical manager during an interview on 3/31/23 at 9:16 a.m. MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that there was no bereavement assessment done in the comprehensive assessment dated 12/20/22. Upon further record review, it was noted that the social worker (Staff #9) attempted to visit the patient on 12/23/22. It was documented in this note (as well as in the comprehensive assessment) that, "Pt was sleeping upon MSW's arrival. MSW tried reaching out to the POA twice and received no answer. MSW will revisit the patient and contact POA to complete assessment." The next documented visit by a social worker was on 1/9/23 as a follow-up visit with no further evaluation data collected. MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's disease. During record review on 3/30/23, it was noted that the initial bereavement assessment was incomplete in the social work evaluation dated 1/13/23. The evaluation included some information but did not include a bereavement risk assessment and did not identify the individuals that would be affected by the patient's death. Findings were reviewed with and acknowledged by the administrator (Adm #1) and the director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m. They were unsure as to why these documents were incomplete. MR #14: This Patient was admitted to Hospice on 5/6/2022 with diagnoses of Acute Kidney Injury, Cerebral Infarction, Dysphasia, Muscle weakness, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Gun Shot Wound, Hepatitis C, History of Heroin Abuse, and Prediabetes. Upon review of the electronic record on 3/28/2023 at 11:00 a.m., it was noted that there was no Bereavement Assessment or Bereavement Care Plan found in the record for this patient. The patient shared a home with a brother and had several other siblings whose names and information were not documented within the record. The electronic record was reviewed again on 3/30/2023 at 2:30 p.m., however during this electronic record review under the category of "Dashboard Alerts/Activity", the following information dated 3/30/2023 at 1:52 p.m. was noted as follows: "Bereavement Coordinator (CH#2) created a Bereavement Care Plan 2 days ago." This date, 3/28/23, occurred on the date of arrival of the State Surveyors to conduct a survey of the agency. The Bereavement Care Plan was developed by the Bereavement Coordinator approximately 11 months after the patient's date of death on May 12, 2022. It was unclear how this delay in creating a Bereavement Care Plan would benefit the remaining family of this patient as the agency's bereavement program lasts for only 12 months. These findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 1:15 p.m.

Based on record review and interview, the Hospice Agency failed to ensure that all care and services followed an individualized plan of care for 2 (MR #10, and #14) of 2 records to whom an individualized plan of care had not been developed, from a total of 14 sampled records reviewed, resulting in the potential for the provision of unauthorized, unsafe care and services and poor patient outcomes. Findings include: **Agency Policy III.7: "Hospice Plan of Care", no date. The Policy States, "The hospice plan of care is an individualized plan for care and treatment prepared by the IDG in collaboration with the patient's attending physician, based upon the assessment of the patient. The plan of treatment shall include but not be limited to: Date plan was established, diagnosis-primary and secondary, specific disciplines and frequency of services, functional limitations, safety precautions, mental status, including patient or representative's level of understanding, involvement, and agreement with the plan of care, prognosis, medications, allergies, diet, medical supplies and equipment, activities permitted and restricted, interventions to manage pain and symptoms, goals/outcomes anticipated, discharge plans, including rehabilitation potential and anticipated length of service delivery." --- MR #1: The patient was admitted to Hospice on 6/20/22 with a terminal diagnosis of Ischemic Heart Disease. During the clinical record review on 3/29/23 at 11:25 a.m., it was noted that a Plan of Care, that reflected the needs of the patient, had not been established. Further review revealed a "Problem list" which identified the patient's problems on admission to the Hospital, however, the Interdisciplinary Group failed to develop a formal plan of care which integrated all the required services, medications and treatments in accordance with the patient's identified needs. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Director of Clinical Services during an interview on 3/31/23 at 9:16 a.m. MR 14: The patient was admitted to Hospice on 11/6/2022 with terminal diagnoses of Cerebral Infarction, dysphasia following cerebral infarction, muscle weakness, chronic obstructive pulmonary disease, and hypertension. Upon review of the record, there was no Care Plan found in the record. The record contained a "Care Plan Problem Details List," however, there was no evidence of a "Care Plan" that included ordered interventions, services to be provided, medications, and treatments that were related to the patient's identified needs. These findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 1:15 p.m.

Based on record review and interview, the agency failed to reflect patient and family goals based on problems identified in the initial, comprehensive, and updated comprehensive assessment that were measurable to determine the family and patient's progress toward achieving the goals in 3 (MR#s 12, 13, and 14) of 14 records reviewed, resulting in goals that fail to measure the family/patient's progress or decline during the course of hospice care. Findings included: --- MR#12: This patient was admitted to the hospice on 12/18/2022. The Plan of Care for the certification period 12/18/2022 to 2/15/2023 Identified diagnoses of alcoholic cirrhosis of liver with ascites, portal hypertension, anemia, thrombocytopenia, protein-calorie malnutrition, hemiplegia following cerebral infarction affecting left nondominant side, depression, anxiety disorder, alcohol abuse, dependance on wheelchair, nicotine dependence, and absence of left breast due to malignant neoplasm of breast. The patient had 2 daughters, one living locally and one residing in Illinois. The patient was living with the daughter and son-in-law who resided locally. Upon review of the goals on the Plan of Care, it was noted that the goals pertained to the interventions ordered to specifically assess the patient's symptoms and disease process. There were no individualized goals that included family centered goals, or inclusion of how the family was involved in the interventions and specifically what goals the family wished to achieve during the patient's hospice care. Examples included: "Patient will have diagnosis specific interventions/monitoring throughout the Home Care Admission; Patient depression and anxiety to be managed; Patient will verbalize understanding of Liver Cirrhosis; Prevent bed sores and skin breakdown by promoting bed mobility; Joint protection and prevent any contractures; Follow Home Exercise Program." These goals are not objectively measurable to determine the patient's progress toward achieving the goals. MR#13: The patient was admitted to Hospice on 3/3/2021 with a primary diagnosis of Malignant neoplasm of left bronchus of lung with metastatic disease to bone in right lower leg, and secondary diagnosis of failure to thrive. The Care Plan was valid from 3/3/2021and ended on 3/12/21, upon the hospice patient's death. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress toward achieving the goals. Examples included: 1) To the problem of physical comfort due to increased edema of bilateral lower legs and lung cancer the written goal was "to manage pain and discomfort through use of medication, symptom management and education by May 1, 2021." 2) To the Problem of deficit related to airway and breathing, the written goal was, "Patient will achieve optimal breathing patterns, airway patency, and comfort for as long as possible due to current disease progression." 3) For the problem of Deficit related to skin/membrane integrity, the goal was, "Patient will achieve and maintain optimal skin integrity as disease progresses. Heal current wounds by 4/1/21." For the Problem of Initial Plan of Care prior to Service Provision, the goal was, "Facilitate compliance with CMS regulation regarding new admissions to Hospice Services to be completed by 3/3/2021. These goals are not patient specific, nor are they objectively measurable to determine the patient's progress towards goals. MR #14: This Patient was admitted to Hospice on 5/6/2022 with diagnoses of Acute Kidney Injury, Cerebral Infarction, Dysphasia, Muscle weakness, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Gun Shot Wound, Hepatitis C, History of Heroin Abuse, and Prediabetes. Upon review of the Goals as documented in the patient's Care Plan on 3/29/2023 at 11:00 a.m. it was noted the goals did not directly pertain to the patient, nor were they objectively measurable to determine the patient's progress towards achieving the goals. Examples include: The only goal found in the record was to "Facilitate compliance with CMS regulation regarding new admissions to Hospice Services." This was a goal for the facility, and not directly related to the needs or issues to address the patient's health needs. These findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 1:15 p.m.

Based on record review and interview, the Hospice interdisciplinary group failed to ensure the plans of care had been reviewed, revised, and document individualized plans of care at least every14 days for 7 (MR's #6, 3, 9, 10, 2, 11, 12) records, resulting in the potential for overlooked, untreated health concerns and poor patient outcomes. Findings include: **Agency Policy: "Clinical Record Contents and Maintenance", no date. The policy states, "The clinical record will be maintained in such a manner that all information is assembled and filed in a timely manner and in accordance with law and regulations including Comprehensive assessment and reassessment at the specified time frames." --- MR#6: This 100-year-old patient was admitted to hospice on 2/25/23 with terminal diagnosis of chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the plan of care was last reviewed on 3/1/23. There was no additional documentation for review to indicate the plan of care for this patient was reviewed or revised by the interdisciplinary group (IDG) for the past 28 days. The findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 10:25 a.m. Adm#1 acknowledged the findings and explained that the IDG meetings were documented on paper and those papers did not get put into the medical record. MR #12: This patient was admitted to hospice on 2/1/22 with terminal diagnoses of Alcoholic Cirrhosis of the liver with ascites, Encephalopathy, muscle weakness, moderate protein-calorie malnutrition, and dysphagia. During record review on 3/28/23, it was noted there were only 2 documented notes from the Interdisciplinary Group (IDG) team meetings since the start of care. These were dated 2/2/23 and 2/16/23. There was no evidence of any IDG team meeting occurring after 2/16/23. There is no evidence that the patient's plan of care had been reviewed or updated during the last 41 days. These findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 1:15 p.m. MR#9: This patient was admitted to hospice on 3/1/23 with terminal diagnosis of encephalopathy. During record review on 3/29/23, it was noted that there was no additional documentation to indicate the plan of care for this patient was reviewed or revised by the interdisciplinary group (IDG) since admission. MR#10: This patient was admitted to hospice on 2/20/23, with terminal diagnosis of senile degeneration of the brain. During record review on 3/29/23, it was noted that there was no additional documentation to indicate the plan of care for this patient was reviewed or revised by the interdisciplinary group (IDG) since admission. The findings were reviewed with and acknowledged by the administrator (Adm#1) and the director of clinical services (Staff#3) during an interview on 3/31/23 at 12:50 p.m. Adm#1 acknowledged the findings and explained that the IDG meetings were documented on paper and those papers did not get put into the medical record. MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted there were only 2 documented notes from the Interdisciplinary Group (IDG) team meetings since the start of care. These were dated 2/2/23 and 2/16/23. There was no evidence of any IDG team meeting occurring before 2/2/23 or after 2/16/23. There is no evidence that the patient's plan of care had been reviewed by the team during the last 41 days. MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's disease. During record review on 3/30/23, it was noted there was only one documented IDG meeting since the start of care on 1/10/23. This was dated 2/16/23. There was no further evidence of any IDG meeting occurring before or after this date and no evidence that this patient's plan of care had been reviewed during the last 41 days. Findings were reviewed with and acknowledged by the administrator (Adm #1) and the director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m. Adm #1 explained that other meetings had taken place, however these were on paper and had not been put into the electronic record. Adm #1 was not able to provide the paper documentation for review. MR #3: This patient was admitted to Hospice on 2/10/23 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. During a review of the clinical record on 3/29/23 at 2:00 p.m., it was noted that the Interdisciplinary Group (IDG) assembled to discuss the status and needs of the patient. It was documented that, "Next IDG meeting due 3/2/23." Upon review, there were no IDG meeting notes available for review. Additionally, the next IDG meeting would be due on 3/16/23. There was no documentation for the 3/16/23 meeting available for review. There was no documented evidence that the IDG met to discuss, review and update the patient's plan of care in accordance with this requirement. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Director of Clinical Operations during an interview on 3/31/23 at 10:00 a.m. The Clinical Manager reported that she had taken minutes/notes from the meetings on her personal paper. The Clinical Manager then retrieved sheets of paper from her desk drawer which revealed illegible handwriting and stated, "These are the notes from the meeting. We just haven't entered them yet."

Based on record review and interview, the agency failed to ensure that the care and services were provided in accordance with the plan of care in 2 of 14 records reviewed (MR #2, 11), resulting in the potential for unmet care needs. Findings include: --- MR #2. This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the plan of care (dated 12/20/22 to current) ordered aide services 2 times per week. During further review of the aide schedule and documentation, it was noted that there were no aide visits provided during the week of 1/30/23. There was no documentation of any missed visits or reason for no visits done by the aide that week. MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's disease. During record review on 3/30/23, it was noted that skilled nursing services were ordered for 1-3 times per week (+ 8 as needed) from 1/20/23 to 4/9/23. Upon further review of the schedule and documentation, it was noted that there were no skilled nursing visits provided during the weeks of 1/16/23 and 1/23/23, leaving the patient without a visit from a skilled nurse from 1/12/23 to 2/1/23 (19 days). There was no further documentation as to why these visits had not occurred. It was also noted that aide services were ordered for 3 times per week (+5 as needed) during this time period. There were only 2 aide visits recorded during the weeks of 1/16/23, 1/23/23 and 2/27/23, 1 aide visit during the week of 1/30/23 and no aide visits during the week of 2/13/23. Findings were reviewed with and acknowledged by the administrator (Adm #1) and director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m. They did not know why services has not been provided as ordered during those weeks.

Based on record review and interview, the Hospice failed to maintain an effective system of communication and an ongoing sharing of information between its disciplines in 5 (MR's #1, 3, 4, 2, 11) records, from a total of 14 sampled patients reviewed, resulting in lack of coordinated care, the potential for the rendering of unsafe care and services and unmet patient care needs. Findings include: --- MR#4: This patient was admitted to hospice care on 10/25/22 with a terminal diagnosis of senile degeneration of the brain. The patient received skilled nursing, aide, spiritual care, and social work services. During record review on 3/29/23, it was noted that the aide care plan reviewed by the nurse on 10/29/22 directed the aide to provide a bedside bath. The patient resided in an assisted living facility. The patient received eight aide visits from 10/31/22 through 11/15/22. Two of eight aide visit notes indicate that the patient declined bathing because the facility had already bathed the patient. There was no documentation to indicate the aide shared this information with the nurse. The hospice also failed to communicate and coordinate patient care with the facility regarding bathing the patient. MR #1: The patient was admitted to Hospice on 6/20/22 with a terminal diagnosis of Ischemic Heart Disease. The plan of care (POC) ordered Skilled Nursing (SN), Spiritual Care (SC), Medical Social Work (MSW) and Hospice Aide services to be provided. During the clinical record review on 3/29/23 at 11:25 at a.m., it was noted that the Hospice Aide documented, "Arrived to get (patient's name) a bath before bed did not know she was still in hospital. Upon further review, there was no information in the patient's clinical record regarding hospitalization. The Agency failed to ensure that the sharing of patient information was ongoing and consistent among its disciplines. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Director of Clinical Operations on 3/31/23 at 9:16 a.m. at which time the Clinical Manager reported, "I wasn't aware of this." MR #3: The patient was admitted to Hospice on 2/10/23 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. The patient received SN, SC, MSW and Aide services during the course of care. During the clinical record review on 3/29/23 at 2:00 p.m., it was noted that Aide services had been provided prior to the SN conducting the Initial Comprehensive Assessment. There was no Aide Care plan that instructed Aide services to be provided prior to development of the POC. The Hospice failed to maintain the ongoing sharing of information. These Findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Director of Clinical Operations on 3/29/23 at 3:38 p.m. MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the aide (Staff #10) documented that the patient had been having trouble with his oxygen on 1/11/23. It was documented that she changed the nasal cannula but there was no adapter to attach the longer cord. There was no documentation to show that this information was relayed to anyone else involved in the patient's care to get it resolved. On 2/13/23, the chaplain (Staff #4) documented that the patient reported difficulty sleeping. There was no documentation that this information was relayed to the nurse or anyone else providing care to this patient to determine if he could benefit from something to help him sleep. MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's disease. During record review on 3/30/23, it was noted that the aide visit note dated 2/6/23 reported that there was no answer at the door when she arrived to see the patient. It was also noted that she informed the front desk at the facility who stated that they had not seen the patient since the aide was there last Wednesday (5 days prior). There was no further documentation that anything was done to ensure that the patient was in her room and safe. Findings were reviewed with and acknowledged by the administrator (Adm #1) and director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m.

Based on record review and interview, it was determined that the Hospice failed to ensure that the frequency and detail of data collection for the QAPI program was reviewed and approved by the governing body. Findings Included: --- On 3/31/23 at 10:24 a.m. during a review of the Quality Assessment Performance Improvement (QAPI) data for the 2021 and 2022 calendar years, it was noted that there was no language in the Governing Board meeting minutes that declared that the frequency/detail of data collection had been approved by the Governing Body. These findings were reviewed with and acknowledged by the Clinical Manger at the time of discovery.

Based on record review and interview, it was determined that the Hospice failed to ensure the Quality Assessment Performance Improvement (QAPI) performance improvement activities focused on high risk, high volume, or problem-prone areas. Findings include: --- During an interview with the Clinical Manager on 3/31/23 at 10:24 a.m., a request was made to review the 2021 and 2022 QAPI data that included the chosen Performance Improvement Projects (PIP). Upon review of the requested data, it was noted that the Agency had identified infections (Urinary Track Infections) and falls in their data collection, however, for each year, the Hospice selected "EMR (Electronic Medical Record) and documentation" as the areas of improvement. During the review, the Clinical Manager reported, "I'm new to this role. I'm not sure why this area (EMR documentation) was chosen as a PIP because there were at least 5 falls and some infections to improve on." There was no documented evidence that the 2021 and 2022 QAPI data included Performance Improvement activities that focused on high risk, high volume, or problem-prone areas. These findings were reviewed with and acknowledged by the Clinical Manager at the time of discovery.

Based on record review and interview, the Hospice failed to ensure its Performance Improvement Activities/Projects tracked adverse patient events, analyzed the causative factors and implemented preventative measures. Findings include: --- On 3/31/23 at 10:24 a.m., during a review of the Agency's Quality Assessment Performance Improvement (QAPI) data, with the Clinical Manager, it was noted that the identified Performance Improvement Projects for calendar years 2021 and 2022 focused on EMR (Electronic Medical Record) documentation and did not include a focus on any adverse patient events. These findings were reviewed with and acknowledged by the Clinical Manager at the time of discovery.

Based on record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of Covid-19 that included a method of pre-screening all staff employed by this agency, prior to the provision of care, including contracted staff, resulting in the potential for the development and spread of a contagious viral infection between agency staff and patients. Findings include: --- On 3/31/23 at 10:24 a.m., the Clinical Manager was asked for permission to review the Agency's Infection Control data for calendar years 2021 and 2022. During the review, with the clinical Manager present, it was noted that there was no Infection Control data (surveillance, screening, minutes) available for review for the 2021 calendar year. The clinical Manager responded, "I don't usually oversee the Infection Control Program. I can try to look for it, but this is all I could find." These findings were reviewed with and acknowledged by the Clinical Manager at the time of discovery.

Based on record review and interview, the Hospice agency failed to provide Infection Control in-services and education to all staff employed by this agency, including contracted staff resulting in the potential for the development and spread of infection. Findings include: --- On 3/31/23 at 10:24 a.m., the agency's Infection Control documents for 2021 and 2022 were reviewed with the Clinical Manager. During the review, there was no documented evidence that all staff employed by this agency, including contracted staff had received in-services and education in Infection Control for the 2021/2022 calendar years. The Clinical Manager produced an in-service on "Hand Hygiene" that was dated 2/2023. It was unclear if all staff, including contracted staff, received this in-service. These findings were reviewed with and acknowledged by the Clinical Manager at the time of discovery.

Based on record review and interview, the agency failed to provide Medical Social Work services that were based on the patient's psychosocial assessment and the patient and family needs in 2 of 14 records (MR#14, 2) reviewed, resulting in lack of support for identified needs for Hospice patients and family. Findings included: --- MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the patient did not receive an evaluation by the social worker (Staff #9), therefore appropriate services were not able to be provided as the needs for this patient were never identified. According to the documentation, an evaluation was attempted by Staff #9 on 12/23/22, but was not completed due to the patient sleeping. The next documented visits by social work were dated 1/9/23, 2/9/23 and 3/10/23 and were all documented as follow-up/treatment visits with no evidence of an evaluation being completed. The administrator (Adm #1) was questioned regarding the completion of a social work evaluation and he was unable to produce any record of this. He was unsure as to why it was never completed and acknowledged the findings along with the director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m. MR #14: This Patient was admitted to Hospice on 5/6/2022 with diagnoses of Acute Kidney Injury, Cerebral Infarction, Dysphasia, Muscle weakness, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Gun Shot Wound, Hepatitis C, History of Heroin Abuse, and Prediabetes. This patient died on 5/12/2022. Upon review of the record on 3/28/2023 at 10:00 a.m., a review of the Medical Social Work (MSW9) initial assessment dated 5/11/22 at 3:40 p.m. documented under Financial Concerns, "Just prior to patient's death, the brother indicated that there were no funds at present to pay for final arrangements for patient." Further review of the record failed to contain documentation that the Medical Social Worker (MSW9) had provided any resources for the brother to pay for final arrangements for the patient. These findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 1:15 p.m.

Based on record review and interview, the hospice failed to ensure the registered nurse prepared written patient specific care instructions that included the frequency and duration of visits for the aide for 9 of 12 (MR# 4, 5, 1, 3, 7, 9, 10, 2, 11) records reviewed in which aide services were provided, resulting in a lack of direction regarding weekly visits pertinent to the needs of these patients. Findings include: --- MR#4: This patient was admitted to hospice care on 10/25/22 with a terminal diagnosis of senile degeneration of the brain. The patient received skilled nursing, aide, spiritual care, and social work services. During record review on 3/29/23, it was noted that the aide care plan reviewed by the nurse on 10/29/22 failed to indicate a visit frequency and duration for the aide. The patient resided in an assisted living facility. The patient received eight aide visits from 10/31/22 through 11/15/22. Two of eight aide visit notes indicate that the patient declined bathing because the facility had already bathed the patient. There was no indication on the aide care plan which days the hospice aide was to provide a bath. The aide care plan failed to be specific to the needs of this patient. MR#5: This patient was admitted to hospice care on 10/10/22 with a terminal diagnosis of hypertensive heart disease with heart failure. The patient received skilled nursing, aide, spiritual care, and social work services. During record review on 3/29/23, it was noted that the aide care plan reviewed by the nurse on 10/16/22 failed to indicate a visit frequency and duration for the aide. The patient resided in an assisted living facility. The patient received eight aide visits from 10/13/22 through 11/4/22. Eight of eight aide visit notes indicate that the patient declined bathing. There was no indication on the aide care plan which days the hospice aide was to provide a bath. The aide care plan failed to be specific to the needs of this patient. The findings for MR#4 and MR#5 were reviewed with the administrator (Adm#1) and the director of clinical services (Staff#3) during an interview on 3/31/23 at 10:25 a.m. Adm#1 explained that the electronic medical record system utilized by the hospice does not have a place for them to note the aide frequency and duration of services. MR #1: The patient was admitted to Hospice on 6/20/22 with a terminal diagnosis of Ischemic Heart Disease. During the record review on 3/29/23 at 11:25 a.m., it was noted that the patient had been receiving Hospice Aide services. The "Aide Tasks" document revealed that the aide plan of care was generated on 6/28/22. This was one week after the beginning of services. Upon review of the Aide Tasks list, there was no frequency indicating when the aide was to provide services and no guidance on the frequency of tasks to be performed. The Registered Nurse failed to establish written guidelines that instructed on the provision of care and services. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Director of Clinical Operations. MR #3: The patient was admitted to Hospice on 2/10/23 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. During the clinical record review on 3/29/23 at 2:00 p.m., it was noted that the patient had been receiving Hospice Aide services beginning on 2/10/23. Upon further review, it was noted that the Aide care plan "Aide Tasks" had not been updated since the prior episodes of care in August of 2022. Additionally, the patient discharged from the previous episode of care on 11/18/22. No new Aide care plan had been developed directing the care that would be provided by the Aide. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/29/23 at 3:38 p.m. and a subsequent interview on 3/31/23 at 10:00 a.m. that included the Clinical Manager and Director of Clinical Operations. MR #7: The patient was admitted to Hospice on 3/15/23 with a terminal diagnosis of Acute diastolic congestive Heart Failure. During the clinical record review on 3/30/23 at 11:40 a.m., it was noted that the patient had been receiving Hospice aide services. Upon further review, it was noted that the Aide Tasks assignment had not been created until 3/27/23. This was 12 days after the Aide had been providing care. The document dated 3/27/23 was void of the frequency in which aide visits were to take place, safety precautions and the frequency in which tasks were to be conducted. The Aide assignment provided unreasonable directives for the aide to reposition the patient every 2 hours as the aide does not provide 24-hour in-patient care and would not be available to complete this task. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 3/31/23 at 8:46 a.m. During the interview, the above administrative staff was queried as to the whereabouts of the Aide visit notes/documentation, to which the Director of Clinical Operations replied, "I know what the problem is. You won't see the Aide notes because there was no Aide plan of care prior to 3/27/23." MR#9: This patient was admitted to hospice care on 3/1/23, with a terminal diagnosis of encephalopathy. The patient received skilled nursing, aide and spiritual care. During record review on 3/29/23, it was noted that the aide care plan reviewed by skilled nursing, failed to indicate a visit frequency and duration for the aide. The patient resided in an assisted living facility. The patient received 11 aide visits from 3/3/23 through 3/27/23. There was no indication on the aide care plan which days the hospice aide was to provide a bath. The aide care plan failed to be specific to the needs of this patient. MR#10: This patient was admitted to hospice care on 2/20/23, with a terminal diagnosis of senile degeneration of the brain. The patient received skilled nursing, aide, spiritual care, and social work services. During record review on 3/29/23, it was noted that the aide care plan reviewed by skilled nursing, failed to indicate a visit frequency and duration for the aide. The patient resided in an assisted living facility. The patient received 13 aide visits from 2/20/23 through 3/28/23. There was no indication on the aide care plan which days the hospice aide was to provide a bath. The aide care plan failed to be specific to the needs of this patient. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings. MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the aide care plan did not specify a frequency or duration for the aide to provide care for this patient. The aide care plan also included the task of, "Bedbound, turn every 2 hours and prn." The administrator (Adm #1) was questioned regarding this task being included in the aide care plan and he reported that it should have been removed as it is not an appropriate order for an aide who is not present with the patient at all times. He reported that it was an oversight and should be a task for the facility staff or caretakers. MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's disease. During record review on 3/30/23, it was noted that there was no aide care plan in the record to assign tasks to the aide. According to the record, the aide had been providing services to this patient since 1/16/23. The administrator (Adm #1) was questioned as to where this document was located in the record, and he reported that it is not there because it had not been done for this patient. The findings were reviewed with and acknowledged by Adm #1 and the director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m.

Based on record review and interview, the hospice failed to ensure the aide provided care in accordance with the plan of care for 7 of 12 (MR# 4, 5, 1, 7, 8, 9, 2) records reviewed in which aide services were provided, resulting in the potential for negative patient outcomes due to a lack of care and services. Findings include: --- MR#4: This 83-year-old patient was admitted to hospice care on 10/25/22 with a terminal diagnosis of senile degeneration of the brain. During record review on 3/29/23, it was noted that the aide care plan reviewed by the nurse on 10/29/22, assigned the aide to provide 11 personal care tasks for this patient. The aide (Staff#10) documented that 8 visits were provided from 10/31/22 through 11/14/22. For 8 of 8 visits the aide failed to document whether the following care was provided or declined: document last bowel movement each visit, notify the nurse/office if no bowel movement in 3 days, and shampoo and rinse hair. For 7 of 8 visits the aide failed to document whether the following care was provided or declined: skin-care-lotion, oral care, and perineal care-wash area well. Dry well, apply Calmoseptine (moisture barrier) to reddened areas. On 11/2/22 the aide documented that she took the patient's blood pressure (95/57) and temperature (98.7). The aide care plan did not assign the aide to take the patient's blood pressure and temperature. There was no documented evidence the aide reported the vital signs to the nurse for evaluation. Staff#10 failed to provide the care ordered in the aide care plan and provided additional services that were not assigned in the aide care plan. MR#5: This 84-year-old patient was admitted to hospice care on 10/10/22 with a terminal diagnosis of hypertensive heart disease with heart failure. During record review on 3/29/23, it was noted that the aide care plan reviewed by the nurse on 10/16/22, assigned the aide to notify the registered nurse if the patient refuses or is unable to tolerate a shower. On 10/13/22, Staff#10 documented the patient declined her shower because she was coughing a lot from Covid. The patient continued to decline every shower for 8 of 8 aide visits from 10/13/22 through 11/4/22. There was no documentation to indicate Staff#10 informed the nurse that the patient declined showers and was coughing a lot from Covid. The findings for MR#4 and MR#5 were reviewed with and acknowledged by the administrator (Adm#1) and the director of clinical services (Staff#3) during an interview on 3/31/23 at 10:25 a.m. MR #1: The patient was admitted to Hospice on 6/20/22 with a terminal diagnosis of Ischemic Heart Disease. The plan of care (POC) ordered Skilled Nursing (SN), Spiritual Care (SC), Medical Social Work (MSW) and Hospice Aide services to be provided. During the record review on 3/29/23 at 11:25 a.m., it was noted that the "Aide Tasks," (aide plan of care) instructed, "Call RN if patient refuses or is unable to tolerate shower, document last BM (bowel movement) each visit..." Further review of the record revealed the aide failed to document the patient's last bowel movement for all 8 visits conducted and failed to notify the nurse of the patient's refusal to shower for 4 of 8 visits conducted by the Aide. There was no documented evidence that the Aide documented the patient's bowel movements and notified the nurse of refusal of care as indicated in the Aide plan of care. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Clinical Director of Operations during an interview on 3/31/23 at 9:16 a.m. MR #7: The patient was admitted to Hospice on 3/15/23 with a terminal diagnosis of Acute Diastolic congestive Heart Failure. The POC ordered SN, MSW, SC and Aide services to be provided. During the record review on 3/30/23 at 11:40 a.m., it was noted that the Aide Tasks assignment sheet instructed, "Document last BM (bowel movement) each visit..." Review of the clinical record on 3/30/23 at 11:40 a.m., revealed no evidence that the Aide documented the patient bowel movements in accordance with the Aide Tasks. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 3/31/23 at 8:46 a.m. MR#8: This patient was admitted to hospice care on 2/16/23 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). During record review on 3/30/23, it was noted that the aide care plan reviewed by the nurse, assigned the aide to provide 14 personal care tasks for this patient. The aide documented that 12 visits were provided from 2/20/23 through 3/27/23. For 14 visits the aide failed to document whether the following care was provided or declined: document last bowel movement each visit, notify the nurse/office if no bowel movement in 3 days. The aide failed to provide the care ordered in the aide care plan. MR#9: This patient was admitted to hospice care on 3/1/23 with a terminal diagnosis of encephalopathy. During record review on 3/29/23, it was noted that the aide care plan reviewed by the nurse, assigned the aide to provide 14 personal care tasks for this patient. The aide documented 11 visits were provided from 3/6/23 through 3/27/23. For 14 visits the aide failed to document whether the following care was provided or declined: document last bowel movement each visit, notify the nurse/office if no bowel movement in 3 days, oral care completed, or shampoo and rinse completed. The aide failed to provide the care ordered in the aide care plan. During an interview on 3/31/23 at 12:50 p.m., the administrator (Adm #1) and the director of clinical operations (Staff#3) acknowledged the above findings. MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the aide care plan included the tasks, "Document Last BM each visit" and "Notify RN / office if no BM in 3 days." Upon further record review, there was no documentation of bowel movement status in 27 aide notes reviewed from 12/22/22 to 3/8/23 and there was no notification of the registered nurse (RN) regarding bowel movement status. The aide failed to provide the care ordered in the aide care plan. Findings were reviewed with and acknowledged by the administrator (Adm #1) and director of clinical operations (Staff #3) during an interview on 3/31/23 at 12:00 p.m.

Based on record review and interview, the Hospice failed to ensure the Hospice Aide promptly notified the Registered Nurse of a change in patient condition for 1 (MR #7) patient discovered to have an alteration in skin integrity, from a total of 14 sampled records reviewed, resulting in the patient not receiving care and services in accordance with the identified needs. Findings include: --- MR #7: The patient was admitted to Hospice on 3/15/23 with a terminal diagnosis of Acute Diastolic Congestive Heart Failure. The plan of care ordered Hospice Aide services to be provided at a frequency of 3x/wk. The Aide Tasks list instructed, "Assess skin for red areas (pressure areas or bruising) and notify SN (Skilled Nurse) of any changes." On 3/30/23 at 11:40 a.m., during the clinical record review, it was noted that on 3/28/23, the Aide documented, "Starting to form a pressure also (ulcer) on ankle on the left side." Upon further review, there was no documented evidence that the Aide informed the nurse of these new findings. Additionally, the Aide still had not informed the nurse of the newly identified skin changes by the end of the survey. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 3/31/23 at 8:46 a.m. to which the Clinical Manager responded, "I don't see any documentation that she (Aide) informed the nurse."

Based on record review and interview, the hospice failed to ensure to provide orientation about the hospice philosophy for 5 of 9 (Adm#1, Staff#5, Staff#6, Staff#8, and Staff#9) personnel files reviewed, resulting in a lack of training in the hospice philosophy of care for these 5 employees. Findings include: --- The following personnel files were reviewed on 3/30/23 and it was noted that each of the files failed to contain documentation of training in the hospice philosophy of care. Adm#1 (administrator) date of hire 11/28/22. Staff#5 (chaplain) date of hire 7/24/22 Staff#6 (registered nurse) date of hire 10/03/22. Staff#8 (registered nurse) date of hire 3/8/22. Staff#9 (social worker) date of hire 5/26/22. The findings were reviewed with and acknowledged by Adm#1 and Staff#3 (director of clinical services) during an interview on 3/31/23 at 10:25 a.m. No additional documentation was provided for review by the time of the exit on 3/31/23 at 1:30 p.m.

Based on record review and interview, the Hospice failed to ensure that all clinical records were complete and contained visit notes and all updated information pertinent to the care of the patient for 3 (MR's 1, 3, 2) records, from a total of 14 sampled records reviewed, resulting in incomplete information in determining the needs of the patient and the potential for poor patient outcomes. Findings include: --- MR #1: The patient was admitted to Hospice on 6/20/22 with a terminal diagnosis of Ischemic Heart Disease. The patient was ordered to receive Skilled Nursing (SN), Spiritual Care (SC), Medical Social Work (MSW) and Hospice Aide services. During the clinical record review on 3/29/23 at 11:25 a.m., a Hospice Aide note documented, "Arrive to get (patient's name) a bath before bed did not know she (patient) was still in hospital." Upon further review, there was no documentation in the clinical record of the patient's hospitalization. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Director of Clinical Operations during an interview on 3/31/23 at 9:16 a.m. MR #3: The patient was admitted to Hospice on 2/10/23 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. The plan of care ordered SN, SC, MSW and Hospice Aide services to be provided. SN had a visit frequency of 2x/Month and 3 prn (as needed) visits. During the clinical record review on 3/29/23 at 2:00 p.m., it was noted that there were no documented SN visit notes for the first 3 weeks of February. Only one SN visit note was entered for the month of February (2/28/23). The Agency failed to ensure the clinical record was complete. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Director of Clinical Services during an interview on 3/29/23 at 3:38 p.m. MR #2: This 90-year-old patient was admitted to hospice on 12/20/22 with the terminal diagnoses of congestive heart failure, syncope and collapse, and chronic respiratory failure with hypoxia. During record review on 3/29/23, it was noted that the aide visits dated 1/22/23 and 2/13/23 did not contain any documentation as to what treatments were or were not performed on that day. It was noted and signed by the aide that they did complete the visit, but there was no further information documented on those visits. Findings were reviewed with and acknowledged by the administrator (Adm #1) and the director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m.

Based on record review and interview, the agency failed to ensure that the clinical record contained signed copies of the election statement in 1 of 14 records reviewed (MR #11), resulting in an incomplete medical record. Findings include: --- MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's disease. During record review on 3/30/23, it was noted that there was no signed election of benefits form in this patient's record. During an interview with the administrator (Adm #1) on 3/31/23 at 12:00 p.m., he reported that some of the charts have documents on paper as well and it might be in there. He looked through the paper chart and was unable to provide this document for review. He states he does not know where it is. Findings were reviewed with and acknowledged by Adm #1 and the director of clinical services (Staff #3) at this time.

Based on record review and interview, the agency failed to ensure all visits in the patient's electronic medical record (EMR) were clear and dated timely in 2 of 14 records reviewed (MR#14, 11) resulting in patient records that do not include current and timely information. Findings included: --- MR#14: During a review of the record on 3/28/2023, it was noted that the Initial Assessment conducted by the Medical Social Worker (Staff#9) occurred on 5/11/2022 at 3:40 p.m. However, upon further review, it was noted the date and signature of the MSW were dated 5/24/2022 at 13:21:43 (1:21 p.m.). The patient died on 5/12/2022. The Medical Social Worker visit note was submitted 13 days after the patient's death. The Social Worker failed to submit visit notes timely to ensure all information documented in the EMR included current information. In addition, the Hospice Aide was to perform visits 2x week with 4 prn visits within 30 days. Upon review of the Hospice Aide visit notes, it was noted that the aide conducted a visit on 5/9/2022, however the note was not signed by the Aid until 05/22/2022@ 21:56:57 (9:56 pm), 13 days after the visit. The Hospice Aide failed to submit visit notes timely in the medical record. These findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 1:15 p.m. MR #11: This 87-year-old patient was admitted to hospice on 1/10/23 with the terminal diagnoses of senile degeneration of the brain and dementia due to Alzheimer's. During record review on 3/30/23, it was noted that the information in the aide notes dated 2/8/23 and 2/20/23 was unclear, making it difficult to understand what had occurred with the patient. The note dated 2/8/23 reported, "....She was sitting in her wheelchair her breath of soil and smelt like urine. Her bed was wet. What you were in a feces and some clothes she had on side of the wall...". The noted dated 2/13/23 reported, ".....She said she can Beaver on cell and I told her that I needed to see her get into the shower so I can assist she said Ill let you tomorrow I picked up underwear that happy shes in it....". Findings were reviewed with and acknowledged by the administrator (Adm #1) and director of clinical services (Staff #3) during an interview on 3/31/23 at 12:00 p.m. Adm #1 states he could "probably guess" what she meant to say in those notes but agreed that they were not clear as to what had occurred during those visits.

Based on record review and interview, the Hospice failed to ensure a Discharge Summary was completed that detailed the course of care provided, including symptom and pain management, responses to treatment, Physician's orders and the patient's health status at the time of discharge for 4 of 4 (MR's #1, 3, 5, and 12) patients who were discharged to the community or revoked Hospice services, from a total of 14 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: --- MR #1: The patient was admitted to Hospice on 6/20/22 with a terminal diagnosis of Ischemic Heart Disease. During the clinical record review on 3/29/23 at 11:25 a.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN), Spiritual Care (SC), Medical social Work (MSW) and Hospice Aide services to be provided. The record revealed the patient revoked hospice services on 7/18/22. The Auto-Generated Discharge Summary (undated and unsigned) failed to include a summary that detailed the course of care provided, including symptom and pain management, and the patient's health status at the time of discharge/revocation. Further, there was no indication that the Physician was provided a copy of a detailed discharge summary. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Clinical Manager (CM #1) and Director of Clinical Operations (Staff #3) during an interview on 3/31/23 at 9:16 a.m. MR #3: The patient was admitted to Hospice on 2/10/23 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. During the record review on 3/29/23 at 2:00 p.m., it was noted that patient was ordered to receive SN, Hospice Aide, MSW and SC care services. The record revealed the patient was discharged from Hospice services on 11/18/22. The Auto-Generated Discharge Summary, undated and unsigned, failed to include a summary of care which detailed the course of care provided, pain and symptom management and the patient's health status at the time of discharge. Additionally, there was no indication the Physician had been provided with a copy of a detailed discharge summary. These findings were reviewed with and acknowledged by Adm #1, CM #1 and Staff #3 during an interview on 3/31/23 at 10:00 a.m. MR#5: This patient was admitted to hospice care on 10/10/22 with a terminal diagnosis of hypertensive heart disease with heart failure. During record review on 3/29/23, it was noted that the plan of care ordered SN, aide, SC, and MSW services to be provided. The patient revoked hospice services on 11/10/22. There was no documented evidence of a discharge summary. The findings were reviewed with Adm#1 and Staff#3 during an interview on 3/31/23 at 10:25 a.m. Staff#3 reviewed the clinical record and explained that a discharge summary should be found under "Change in Care" information however, there was no discharge summary for review. There was no evidence the patient's attending physician was provided a copy of the discharge summary. MR 12: This 79-year-old patient was admitted to Hospice on 2/1/2023 with end-state cirrhosis of the liver with ascites due to alcohol abuse, encephalopathy due to a Urinary Tract Infection and high ammonia. The patient is receiving paracentesis once a month for comfort measures. The patient also has comorbidities of portal hypertension, hemiplegia due to intracerebral bleed, and history of left breast cancer with mastectomy. Patient is dependent, has weakness, and is bedbound with dysphagia. The patient was discharged from hospice on 1/6/2023 due to "goals met/maximum potential reached" and "Improved knowledge of self-care management." There was no documentation in the record that indicated whether the patient or physician had requested this discharge from hospice. The discharge summary stated, the physician was notified of discharge summary availability, however there was no documentation found in the record that the discharge summary had been sent or provided to the physician. Upon review of the record, it was unclear why the patient was discharged, who had requested the discharge, and whether there were any unmet needs at the time of discharge. These findings were reviewed with and acknowledged by Adm#1 (administrator) and Staff#3 (director of clinical services) during an interview on 3/31/23 at 1:15 p.m.

Based on record review and interview, the hospice failed to obtain a criminal background check on an employee that has direct patient contact and access to patient records for 1 of 9 (Staff#9) personnel files reviewed, resulting in a lack of protection for all hospice patients that received social work services in the past 10 months. Findings include: --- Staff#9 (social worker) date of hire 5/26/22. The personnel file was reviewed on 3/30/23 at 3:15 p.m. The file failed to contain documentation of a fingerprint criminal background check. The findings were reviewed with the administrator (Adm#1) during an interview on 3/31/23 at 10:25 a.m. Adm#1 acknowledged the finding and replied that they were trying to locate a copy of the criminal background check for Staff#9. No additional documentation was provided for review by the time of the exit on 3/31/23 at 1:30 p.m.

Based on record review and interview, the hospice failed to ensure to track and document the COVID-19 vaccination status of 1 of 15 staff (Adm#1), resulting in the potential to spread the COVID-19 virus to all hospice patients and staff who had contact with Adm#1 in the past 4 months. Findings include: --- The hospice's COVID-19 vaccination information was reviewed on 3/30/23. Review of the documentation indicates that the administrator (Adm#1) hired on 11/28/22, had no documentation to indicate his vaccine status and no documentation to indicate Adm#1 had been granted a religious or medical exemption. During an interview on 3/30/23 at 12:30 p.m., Adm#1 was queried regarding documentation of his vaccine status. Adm#1 explained that he had left his vaccine card at home, and he would bring it in tomorrow. On 3/31/23 at 8:30 a.m., Adm#1 was queried regarding documentation of his vaccine status. Adm#1 explained that he had forgot to bring in his vaccine card. No additional documentation was provided for review by the time of the exit on 3/31/23 at 1:30 p.m.

Based on record review and interview, it was determined the hospice agency failed to ensure the rights of the patient to receive effective pain management from the hospice as related to the terminal illness in a timely manner for 1 of 3 records reviewed, (MR #1), resulting in delayed pain management for the patient. Findings included: --- MR #1: This 94-year-old patient was admitted to the agency on 11/4/22 with terminal diagnosis of end stage chronic obstructive pulmonary disease (disease of the airways). On 1/13/23 the clinical record for MR #1 was reviewed. The start of care (SOC) was completed on 11/4/22 with chronic pain noted to be an ";active problem". The admitting nurse (Staff D) recorded the pain medication orders in the SOC to include Morphine 5mg every 4 hours as needed. On 1/13/23 at 1:57 p.m., and interview was conducted with Family #1 who stated that during the nights of 11/4 and 11/5, MR #1 had experienced ";extreme pain" and that Tylenol was the only medication available, which was ineffective for managing the pain. On 1/13/23, the hospice agency phone triage record was reviewed. An incoming call was recorded on 11/5/22 for MR #1 and noted that it was relating to medications (no time of call or specific medication details were listed). On a Nursing Summary Note entered by Staff D dated 11/5/22 at 3:00 p.m., Staff D documented a phone call with the daughter of MR #1 and stated it was related to ";issues with patient medications" and told the daughter that the doctor had ";put a rush on the patients medications to be delivered". At the time of the complaint investigation, Staff D was not available for interview. On 1/13/23 at 12:25 p.m., interview was conducted with the agency Administrator, (Staff A) and the Executive Director (Staff B, over phone). Staff B explained the process for admitting patients who have been discharged from a hospital, specifically on the weekend, and how they obtain needed medications. Staff B stated the hospice agency (either assigned nurse or clinical manager) would normally reach out to the discharging hospital and request that prescriptions for needed medications be sent with the patient at discharge. Staff B also stated that the agency has a clearing house pharmacy which supplies medications ordered by the hospice agencys Medical Director within 24-48 hours and she was not sure what occurred with MR #1 but would reach out to the pharmacy for order and delivery details for surveyor review. The pharmacy order and delivery record for MR #1s pain medication was received and reviewed on 1/13/23. During review, it was noted that the discharging physician from the hospital did write a prescription for Morphine on 11/4/22 and the pharmacy did not receive that prescription for Morphine until 11/7/23 at 11:57 a.m. (as indicated by fax stamp of the prescription document). The Delivery Sheet for the Morphine was signed and received at the facility in which MR #1 resided on 11/7/22 (no time noted) which was 3 days after MR #1 was admitted to the agency. The above findings were reviewed and acknowledged by Staff A and Staff B on 1/13/23 at 3:30 p.m.