Every finding on record at Echo Hospice of Indiana, LLC

Based on record review and interview, the hospice failed to ensure the emergency preparedness policy and procedures included notifying state and local emergency preparedness officials of on-duty staff and patients the agency was unable to contact in the event of an emergency for 1 of 1 hospice. The findings include: --- The emergency preparedness plan provided, was reviewed and failed to evidence the procedures for contacting state and local emergency preparedness officials of on-duty staff and patients the agency is unable to contact in the event of an emergency. During an interview, on 11/22/2023 at 11:45 AM, the Regional Quality Director indicated he/she was not able to find the procedures for notifying state and local emergency preparedness officials of on-duty staff and patients the hospice was unable to contact during an emergency.

Based on record review and interview, the hospice failed to ensure there were procedures in place for notifying state and local emergency preparedness officials of patients in need of evacuation from their residences in the event of an emergency for 1 of 1 hospice. The findings include: --- The hospices' Emergency Preparedness plan, provided for review on 11/22/2023, failed to evidence the procedures for notifying state and local emergency preparedness officials of patients needing evacuation from their place of residence in the event of an emergency. During an interview on 11/22/2023, at 11:47 AM, the Regional Quality Director indicated he/she could not locate within the emergency preparedness plan the procedures for notifying state and local emergency preparedness officials of patients in need of evacuation.

Based on observation, record review, and interview, the agency failed to ensure the comprehensive assessment was complete to include a complete wound assessment in 3 of 6 active clinical records reviewed with wounds (Patient #3, 8, 9), 1 of 1 active clinical record reviewed with a feeding tube (Patient #4), and 1 of 1 clinical record reviewed with a colostomy (a surgically created hole in the stomach to allow stool to be removed from the body). (Patient #6) The findings include: --- A clinical record review for Patient 4 included a comprehensive assessment (CA) dated 11/16/23, completed by a registered nurse that identified Patients diet of Jevity 1.2(a type of formula administered through gastrostomy tube) [needs explained to the general reader] bolus, 8 cans daily. The CA failed to evidence the characteristics related to the assessment of his gastrostomy tube, stoma site, frequency of feeding or tolerance of feeding. During a telephone interview on 11/22/23 at 1:11 PM with the nurse manager of the Alzheimers Care Unit at the skilled nursing facility in which Patient resided indicated for Jevity 1.5 bolus feedings of 2 cans (474 ml) at 6:00 AM, 1 can (237 ml) at 11:00 AM, 2 cans (474 ml) at 2:00 PM, and 2 cans (474 ml) at 10:00 PM with 175 ml of water prior to and after each bolus feeding. Within the Comprehensive Assessment (CA) dated 10/26/23, the registered nurse documented they assessed Patient #4 to be alert to self and with noted confusion. The CA included documentation that Patient 4 stayed up at night, going in and out of other patients rooms, looking for food although Patient 4 was aware they were NPO. The clinical record for Patient 6 included a comprehensive assessment dated 11/2/23, completed by a registered nurse which indicated Patient 6 had an ostomy, per facility nursing staff report. The comprehensive assessment failed to reveal characteristics related to an assessment of stoma, including moisture, level of stoma or color nor documentation as to why the comprehensive assessment did not include an assessment of the stoma. The clinical record for Patient 8 included a comprehensive assessment dated 11/15/23, completed by a registered nurse which indicated the presence of wounds. Documentation failed to include assessment of the wounds or measurements. During an interview on 11/21/23 at 1:45 PM with the Patient Family Care Coordinator (PFCC) , when queried how often the agency is measuring the wounds for patient 8 the PFCC indicated they ask for weekly measurements from the skilled nursing facility (SNF) at which Patient 8 resides. When queried if wound measurements would be included in a comprehensive assessment, the PFCC indicated they should be and there are no measurements for that visit nor that week. 1. During an observation on 11/15/2023, at 9:52 AM, at the home of Patient #3, Licensed Practical Nurse (LPN) 1 was observed removing a dressing from the patients left arm with a red wound base and the size of a dime. A clinical record review of an agency document identified as a physician order dated 8/23/2023, indicated the patient had a left arm skin tear and was to receive wound care 3 times a week. Review of an agency document identified as a recertification comprehensive assessment completed by the registered nurse and dated 11/6/2023, indicated the patient had a skin tear to the left arm and failed to evidence a complete assessment to include the size, appearance, and any signs and symptoms of infection. 2. A clinical record review of an agency document identified as a comprehensive assessment completed by the registered nurse and dated 11/9/2023, indicated the patient had a skin tear to the right arm. Review failed to evidence the assessment included the size, appearance, any signs and symptoms of infection, and wound treatment. 3. During an interview on 11/17/2023, at 11:59 AM, the Patient Family Care Coordinator indicated the comprehensive assessment should include the type, location, size, appearance, any signs and symptoms of infection, and treatment for all wounds.

Based on observation, record review, and interview, the hospice failed to ensure the plan of care included measurable outcomes in 1 of 1 active clinical record reviewed, discussed during IDG with food seeking behavior (See L0539); failed to develop an individualized written plan of care to reflect interventions based on problems identified in the comprehensive assessment and services necessary for management of the terminal illness (See L0545); failed to ensure the plan of care included interventions to manage pain and symptoms (See L0546); failed to ensure the plan of care included measurable outcomes (See L0548); failed to ensure the interdisciplinary group reviewed and revised the plan of care as frequently as the patients condition required but no less than every 15 days and failed to follow their policy for documentation of the review of changes in the plan of care (See L0552); hospice care and services were provided as directed by the plan of care (See L0555); failed to ensure care was coordinated between all disciplines involved in the patients care reported extreme pain (See L0557); and failed to ensure coordination of care with non-hospice healthcare providers for patients that resided in an assisted living facility (See L0558). The cumulative effect of these systemic problems has resulted in the hospice agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services. Based on record review and interview, the agency failed to ensure the plan of care specified the hospice care and services necessary to meet the patient's needs identified in the comprehensive assessment as it relates to the terminal illness in 1 of 5 active clinical records reviewed with a fall while the patient resided in an assisted living facility (ALF). (Patient #15) The findings include: --- The clinical record for Patient #15 evidenced a document identified as the initial comprehensive assessment, dated 11/16/2023, which indicated Patients terminal illness was symptomatic bradycardia (low heart rate increasing the risk of dizziness, fainting, weakness, confusion, and easy to tire) and resided in an assisted living facility [ALF]. The assessment indicated Patient had a history of falls, was a high fall risk, dependent for activities of daily living, unsteady and required extensive assistance with ambulation, safety was a concern due to cognitive impairment and Patient unable to recognize limitations. Patient needed one-on-one care which the ALF did not provide and the familys plan was to hire private caregiver services. The document titled ";Plan of Care" effective 11/16/2023, failed to evidence the hospice specified the need for one-on-one care as assessed and by whom the one-on-one care would be provided. The record included a visit note, identified as a PRN (as needed) fall visit and dated 11/19/2023; the visit note indicated Patient fell from their wheelchair on 11/18/2023. During an interview on 11/20/2023 at 4:14 PM, Person 7 at Entity 6 (ALF where patient resided) indicated they were unaware of a private caregiver, they relayed Patient was alone at the time of the fall. During an interview, on 11/20/2023 at 3:18 PM, the Patient Family Care Coordinator indicated the plan of care did not include the need for one-on-one care and did not have Patient specific interventions. They indicated the safety interventions on the plan of care were standard interventions used for a safety goal, and indicated he/she was unsure if the one-on-one caregiver had been secured and put into place yet.

Based on observation and interview, the hospice failed to ensure the plan of care included measurable outcomes in 1 of 1 active clinical record reviewed, discussed during IDG with food seeking behavior (Patient #4). The findings include: --- During an observation of an IDG meeting, on 11/15/23, a registered nurse brought to IDG, Patient #4's food seeking behavior. During the IDG, the IDG did not discuss interventions nor goals related to this behavior. During an interview, on 11/20/2023 at 2:10 PM, the Patient Family Care Coordinator indicated IDG should discuss patient changes/concerns and interventions by all disciplines to meet patient needs.

Based on observation, record review, and interview, the hospice failed to develop an individualized written plan of care to reflect interventions based on problems identified in the comprehensive assessment and services necessary for management of the terminal illness in 14 of 15 active clinical records reviewed. (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15). The findings include: --- 12. The comprehensive assessment for Patient 4, dated 11/16/23, included documentation that Patients diet was Jevity 1.2, 8 cans daily via g-tube. The Plan of Care for benefit period 9/25/23 – 11/23/23 effective 11/15/23, failed to evidence interventions and goals related to their g-tube, enteral feeding orders, durable medical equipment associated with enteral feeding, interventions and goals related to the care associated with the presence of a g-tube or how the hospice would measure anticipated outcomes as a result of the implementation of the plan of care. Clinical record notes dated 11/9/23, 11/2/23, 10/16/23, 10/24/23 indicated Patient 4 to be food seeking. The clinical record to failed to evidence interventions for the food seeking behaviors. In an interview on 11/17/23 at 11:20 AM the Assistant Director of Clinical Services (ADCS) when queried about Patient 4 non-compliance with a diet order; the ADCS indicated a conversation with the guardian and physician should be had. When queried if this had occurred for Patient 4, the ADCS stated they would need to search Patient 4s chart. The ADCS further states they would order pleasure feeding with physician approval. A follow up interview conducted on 11/21/23 at 10:05 AM with the ADCS, when queried if they were able to find documentation of the guardian response to pleasure feeding for Patient 4; the ADCS revealed they did not. 13. A clinical record review on 11/16/23 for Patient 6 evidenced a comprehensive assessment dated 11/2/23 completed by the registered nurse which indicated the presence of an ostomy. Review of the Plan of Care effective 11/8/23 failed to evidence the ostomy, durable medical equipment associated with the presence of an ostomy, interventions related to the care associated with an ostomy or how the agency would measure anticipated outcomes ass a result of the implementation of the plan of care. During an interview on 11/21/23 at 2:20 PM with the Patient Family Care Coordinator (PFCC), when queried what the individualized goals and interventions are for Patient 6 ostomy the PFCC indicated that if there is not a care plan for the ostomy it should be added to the plan of care. The PFCC indicated that they do not see a care plan for the ostomy. A clinical record review on 11/1623 for Patient 6 evidenced a comprehensive assessment dated 11/2/23 completed by the registered nurse which failed to evidence the presence of impaired skin integrity. Review of the Plan of Care effective 11/8/23 indicated the presence of a coccyx wound with goals and interventions. During an interview on 11/21/23 at 2:20 PM with the Patient Family Care Coordinator (PFCC), when queried if Patient 6 currently has a coccyx wound the PFCC indicated Patient 6 has no wounds. When queried when interventions should be removed from the Plan of Care, the PFCC indicated those interventions should be removed immediately. 14. A clinical record review on 11/20/23 for Patient 8 included a comprehensive assessment dated 10/14/23 which revealed Patient 8 to have wounds located on the right knee, left knee, right lateral foot, right lateral malleolus, left heel, right medial distal foot, right medial great toe, right hip and coccyx. Review of the plan of care dated 11/1/23 included a goal of optimal skin integrity as disease progresses as evidenced by reduction in current wounds. The interventions failed to include wound treatment orders or how progression of healing/ reduction of wound would be monitored. During an interview on 11/21/23 at 1:45 PM with the Patient Family Care Coordinator (PFCC), when queried what entity is managing the wounds for Patient 8; the PFCC indicated the skilled nursing facility is managing the wounds. 1. A clinical record review for Patient #1 evidenced an agency document titled ";Plan of Care" effective 9/27/2023, which indicated the agency was to intervene to bring the patient to a level of comfort. Review failed to evidence the plan of care was individualized to include the patient-specific level of comfort. During an interview on 11/20/2023, at 2:27 PM, the Regional Quality Director indicated the plan of care should be individualized to include the patients acceptable level of pain. 2. During an observation of care at the home of Patient #2, on 11/16/2023, at 9:58 AM, CNA 1 and CNA 2 were observed providing the patient a bed bath. No open areas or wound dressings were observed. Patient #2 was observed to be non ambulatory and required the use of a hoyer lift (a mechanical device to lift the patient) to transfer from the bed into the wheelchair. A clinical record review evidenced an agency document identified as a comprehensive assessment completed by the registered nurse and dated 11/7/2023, which indicated the patient was a total assist for transfers, wheelchair bound, and incontinent of bowel and bladder. Review indicated the patients skin was intact. A review of an agency document titled ";Plan of Care" effective 11/8/2023, indicated the interventions included, but were not limited to, assess wound dimensions weekly, consult with physician to obtain wound consultation, monitor and treat for pain associated with dressing change, and educated patient/caregiver on wound care. Review indicated the plan of care included toileting the patient per facility policy and reporting any wandering behavior. During an interview on 11/20/2023, at 2:54 PM, the Patient Family Care Coordinator indicated the patient did not have a wound and the wound interventions should have been removed from the plan of care. During an interview on 11/20/2023, at 2:56 PM, the Regional Quality Director indicated Patient #2 used to be ambulatory, would wander and would toilet, they declined and was no longer ambulatory, wandering, and toileting. The Regional Quality Director indicated the interventions related to toileting and wandering were no longer applicable to Patient and should be removed from the plan of care. 3. During an observation on 11/15/2023, at 9:52 AM, at the home of Patient #3, Licensed Practical Nurse (LPN) 1 was observed removing a dressing from the patients left arm. Patient #1 was observed to have an open area on the left arm, and LPN 1 was observed cleansing the wound and applying an ointment and dry dressing to the open area. During an interview on 11/15/2023, at 9:52 AM, LPN 1 indicated Patient 3 had a skin tear to the left arm and received wound care 3 times a week to include cleansing the wound with normal saline (wound cleanser), applying bacitracin (antibiotic), and a dry dressing. A clinical record review for Patient #3 evidenced an agency document titled ";Plan of Care" with an effective date of 11/15/2023, which failed to include individualized wound treatment orders and goals. During an interview on 11/17/2023, at 11:27 AM, the Patient Family Care Coordinator indicated the wound and treatment orders for the skin tear to the left arm should have been added to the plan of care. 4. A clinical record review for Patient #5 evidenced an agency document identified as the admission assessment by the registered nurse dated 11/14/2023, which indicated the patient had a foley catheter (an indwelling tube placed into the bladder to drain urine from the body). A review of an agency document titled ";Plan of Care" effective 11/15/2023, indicated the skilled nurse was to change and irrigate the foley catheter as ordered and failed to include patient-specific orders for the change and irrigation of the foley catheter. During an interview on 11/20/2023, at 3:40 PM, the Regional Quality Director indicated the foley catheter and irrigation intervention on the plan of care was a standard template and not patient specific. The Regional Quality Director indicated there were no orders for irrigation of the foley catheter. 5. A clinical record review for Patient #7 evidenced an agency document identified as the admission assessment by the registered nurse dated 11/6/2023, which indicated the patient a Stage III pressure ulcer (a wound caused by pressure against the skin resulting in damage to the fatty tissue underneath the layers of skin) to the coccyx (lower back above the buttocks). Review of an agency document titled ";Plan of Care" effective 11/15/2023, failed to evidence the plan of care included the location of the wound and wound care treatment orders. During an interview on 11/20/2023, at 3:14 PM, the Patient Family Care Coordinator indicated the plan of care should include the wound location and wound treatment orders. 6. A clinical record review for Patient #9 evidenced an agency document identified as the admission assessment by the registered nurse dated 11/4/2023, which indicated the patient had a skin tear to the left upper extremity. Review of an agency document titled ";Plan of Care" effective 11/8/2023, failed to evidence the plan of care included the location of the wound and wound care treatment orders. During an interview on 11/20/2023, at 3:16 PM, the Regional Quality Director indicated the treatment order for the skin tear was bacitracin ointment and a dry dressing 1 time daily and indicated the wound and wound care order should be included in the plan of care. 7. A clinical record review for Patient #10 evidenced an agency document titled ";Plan of Care" effective 10/25/2023, which evidenced tasks assigned to a hospice aide for personal care to include assist with shower, shampoo, shave, nail care, oral care, and dressing. Review failed to evidence the frequency of hospice aide visits to be provided by the agency and failed to evidence the agency provided hospice aide services during the benefit period beginning 9/21/2023. Review evidenced the terminal diagnosis was Alzheimers Disease and indicated the patients history included aggression and agitation. Review failed to evidence the plan of care was individualized to include interventions related to the terminal diagnosis and behaviors. Review indicated the skilled nurse was to assess wound dimensions weekly, consult with physician to obtain wound consultation, instruct patient/caregiver on wound care, and assess for pain associated with dressing change. Review failed to evidence the patient had a wound or was receiving wound care. During an interview on 11/20/2023, at 2:08 PM, the Assistant Director of Clinical Services indicated hospice aide services were discontinued on 8/7/2023 and should have been removed from the plan of care. At 2:13 PM, the Assistant Director of Clinical Services indicated the patient had a skin tear that healed on 8/11/2023. During an interview on 11/20/2023, at 2:13 PM, the Patient Family Care Coordinator indicated the patient did not have a wound and the plan of care should be tailored to the patient and to delete what was not appropriate for the patient. At 2:19 PM, the Patient Family Care Coordinator indicated the only goal and intervention on the plan of care was related to skin integrity. 8. Clinical record review for Patient #11 evidenced an agency document titled ";Plan of Care" effective 11/1/2023, which indicated the agency would provide hospice aide services 3 times a week but failed to evidence the interventions and goals related to the hospice aide services. During an interview on 11/21/2023, on 2:44 PM, the Regional Quality Director indicated the interventions of the hospice aide needed to be clicked in the electronic medical record in order for them to be added to the plan of care and they should have been added. 9. Clinical record review for Patient #13 evidenced an agency document identified as the initial comprehensive assessment completed by the registered nurse and dated 11/10/2023, indicated the patient received nystatin (a medication used to treat fungal infections) daily to the groin. Review of an agency document titled ";Plan of Care" effective 11/10/2023, failed to evidence the nystatin was to be applied to the groin but indicated nystatin was to be applied to the abdominal folds. During an interview on 11/21/2023, at 2:59 PM, the Regional Quality Director indicated the plan of care should be based on the comprehensive assessment and would need to clarify the plan of care. No additional documentation or information was provided. 10. Clinical record review for Patient #14 evidenced an agency document identified as the admission assessment by the registered nurse dated 10/24/2023, which indicated the patient had a 16 French (the size of the catheter) foley catheter. A review of an agency document titled ";Plan of Care" effective 11/15/2023, indicated the skilled nurse was to change and irrigate the foley catheter as ordered and failed to include patient-specific orders for the change and irrigation of the foley catheter. During an interview on 11/21/2023, at 3:50 PM, the Regional Quality Director indicated the agency needed to add the patient-specific orders to the plan of care regarding the foley change and the foley catheter irrigation intervention needed to be removed as there were no orders to irrigate the foley catheter. 11. A clinical record review for Patient #15 evidenced an agency document identified as the initial comprehensive assessment completed by the registered nurse and dated 11/16/2023, indicated the patient was on a pureed diet. Review of an agency document titled ";Plan of Care" effective 11/16/2023, indicated the agency was to assist with transfers and specify the type of transfer which was left blank. Review indicated the agency was to use restraints per physicians order and to specify the type of restraints which was left blank. Review failed to evidence physician orders for restraints. Review indicated the agency was to educate the patient and caregiver to the use of safety equipment and to specify what safety equipment was in use which none was specified. Review indicated the hospice aide interventions included, but were not limited to, encouraging a regular diet. Review indicated the agency was to intervene as necessary to bring the patient to a level of comfort and failed to individualize the plan of care to what was the patients level of comfort. During an interview on 11/21/2023, at 3:29 PM, the Patient Family Care Coordinator indicated the hospice agency did not use restraints and should not be included on the plan of care. At 3:31 PM, the Patient and Family Care Coordinator indicated the plan of care should specify what was the patients individual level of comfort. During an interview on 11/21/2023, at 3:25 PM, the Regional Quality Director indicated the diet order on the plan of care should be the same as what was assessed to be the need.

Based on record review and interview, the hospice failed to ensure the plan of care included interventions to manage pain and symptoms in 8 of 15 active clinical records reviewed (Patient #2, 3, 4, 8, 10, 11, 12, 14). The findings include: --- A clinical record review for Patient #4 evidenced an agency document titled ";Plan of Care" effective 11/15/23, failed to evidence pain interventions or how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. A clinical record review for Patient #8 included a document titled ";RN Admission" dated 10/14/23, the registered nurse assessed pain to the right hip while turning/repositioning secondary to wound on right hip. The plan of care failed to evidence pain interventions or how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. During an interview with on 11/21/23 at 1:45 PM when queried as to the plan for managing Patient 8s pain the Patient Family Care Coordinator indicated patient 8 did not have an active care plan to manage pain. During an interview on 11/21/2023, at 3:11 PM, the Patient Family Care Coordinator indicated the patient-specific acceptable level of pain should be included in the plan of care to measure the outcome of the interventions provided. 1. A clinical record review for Patient #2 evidenced an agency document titled ";Plan of Care" effective 11/8/2023, which indicated the patients medications included, but were not limited to, morphine (medication for severe pain) as needed for pain. Review failed to evidence the plan of care included interventions to assess pain and pain management. 2. A clinical record review for Patient #3 evidenced an agency document titled ";Plan of Care" effective 11/15/2023, which indicated the patients diagnoses included, but were not limited to, anxiety disorder and arthritis. Review failed to evidence the plan of care included interventions to manage pain and anxiety symptoms. During an interview on 11/17/2023, at 11:55 AM, the Patient and Family Care Coordinator indicated the interventions to address pain should be included in the plan of care. 3. A clinical record review for Patient #10 evidenced an agency document titled ";Plan of Care" effective 10/25/2023, which evidenced the terminal diagnosis was Alzheimers Disease and indicated the patients history included anxiety. Review indicated the patients medications included morphine and lorazepam (medication for anxiety) but failed to evidence the plan of care included interventions to assess for pain and pain management. 4. A clinical record review for Patient #11 evidenced an agency document titled ";Plan of Care" effective 11/1/2023, which indicated the patients medications included, but not limited to, morphine. Review failed to evidence the plan of care included interventions to assess for pain and management. During an interview on 11/21/2023, at 2:46 PM, the Patient Family Care Coordinator indicated the plan of care should have patient-specific interventions for pain management. 5. A clinical record review for Patient #12 evidenced an agency document identified as a comprehensive assessment completed by the registered nurse and dated 11/15/2023, indicated the patient reported pain rated 10 on a scale of 0-10 (0 being no pain and 10 being extreme pain). Review of an agency document titled ";Plan of Care" effective 11/10/2023, which indicated the patients medications included, but not limited to, morphine. Review failed to evidence the plan of care included interventions to assess for pain and management. 6. A clinical record review for Patient #14 evidenced an agency document titled ";Plan of Care" effective 10/25/2023, which indicated the patients medications included, but were not limited to, acetaminophen (medication used to treat pain) and Voltaren (a medicated ointment to treat pain). Review failed to evidence the plan of care included interventions to assess for pain and management. 7. During an interview on 11/20/2023, at 2:18 PM, the Patient Family Care Coordinator indicated the plan of care should include the assessment of pain and pain management at every visit.

Based on record review and interview, the agency failed to ensure the plan of care included measurable outcomes in 9 of 15 active clinical records reviewed. (Patient #1, 2, 3, 6, 7, 11, 12, 14, 15) The findings include: --- A clinical record review for Patient 6 evidenced an agency document titled ";Plan of Care" (POC) effective 11/8/23, which indicated the patient will experience management of his/her symptoms related to cardiac/circulatory dysfunction and fluid volume overload. The POC failed to evidence how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. During an interview on 11/17/2023, at 11:57 AM, the Patient and Family Care Coordinator indicated the goals on the plan of care should be measurable by adding ";as evidenced by" and including patient specific ways to measure the goals. 1. A clinical record review for Patient #1 evidenced an agency document titled ";Plan of Care" effective 9/27/2023, which indicated the patient would experience management of his/her symptoms related to cardiac/circulatory dysfunction and fluid overload and failed to evidence how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. 2. A clinical record review for Patient #2 evidenced an agency document titled ";Plan of Care" effective 11/8/2023, which indicated the agency would promote optimal patient safety and prevention of injury by implementing effective strategies to increase safety awareness and failed to evidence how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. 3. A clinical record review for Patient #3 evidenced an agency document titled ";Plan of Care" effective 11/15/2023, which indicated the patient would have modifications to his/her environment to compensate for deficits and help maintain optimal patient orientation. Review failed to evidence how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. 4. A clinical record review for Patient #7 evidenced an agency document titled ";Plan of Care" effective 11/15/2023, which indicated the agency would promote optimal patient safety and prevention of injury by implementing effective strategies to increase safety awareness and indicated the chaplain would address the patients problem through ritual support, spiritual presence, and encouragement and failed to evidence how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. 5. A clinical record review for Patient #11 evidenced an agency document titled ";Plan of Care" effective 11/1/2023, which indicated the agency would promote optimal patient safety and prevention of injury by implementing effective strategies to increase safety awareness and failed to evidence how the agency would measure the anticipated outcome as a result of the implementation of the plan of care. 6. A clinical record review for Patient #12 evidenced an agency document titled ";Plan of Care" effective 10/25/2023, which included goals which indicated the patient would achieve optimal physical comfort by reporting an acceptable level of pain and the patient would have a decreased risk of harm with physical and functional decline. Review failed to evidence the outcome was measurable. During an interview on 11/21/2023, at 3:11 PM, the Patient Family Care Coordinator indicated the patient-specific acceptable level of pain should be included in the plan of care to measure the outcome of the interventions provided. 7. A clinical record review for Patient #14 evidenced an agency document titled ";Plan of Care" effective 11/15/2023, which indicated the agency would promote optimal patient safety and prevention of injury by implementing effective strategies to increase safety awareness and failed to evidence how the agency would measure the anticipated outcome after the implementation of the plan of care. 8. A clinical record review for Patient #15 evidenced an agency document titled ";Plan of Care" effective 11/16/2023, which indicated the agency would promote optimal patient safety and prevention of injury by implementing effective strategies to increase safety awareness and failed to evidence how the agency would measure the anticipated outcome after the implementation of the plan of care. 9. During an interview on 11/17/2023, at 11:57 AM, the Patient and Family Care Coordinator indicated the goals on the plan of care should be measurable by adding ";as evidenced by" and including patient specific ways to measure the goals.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group (IDG) reviewed and revised the plan of care as frequently as the patients condition required but no less than every 15 days and failed to follow their policy for documentation of the review of changes in the plan of care in 4 of 10 active clinical records reviewed with falls (Patients #3, 10, 11, 12). The findings include: --- During a clinical record review on 11/17/23 for Patient 4 a fall was identified on 8/3/23. In an interview with the Assistant Director of Clinical Services when queried if they were able to identify where the fall on 8/3/23 was discussed in IDG the ADCS indicated she was not able to. Clinical record review on 11/17/23 failed to evidence an IDG meeting between the dates of 7/12/23 through 8/9/23 and again on 9/13/23 through 10/25/23. Clinical record review on 11/16/23 indicated IDG meetings for Patient 6 were due to have been conducted on 9/6/23, 9/13/23, 9/20/23, 10/4/23, 10/18/23, 10/25/23, 11/8/23. In an interview on 11/16/23 at 1:55 PM with the Patient Family Care Coordinator (PFCC) when queried if there was documentation related to the meeting dates; the PFCC indicated she keeps a book. Review of the book revealed a ledger with names for review including Patient 6 for the dates of 9/6/23, 9/13/23, 9/20/23, 10/4/23, 10/18/23, 10/25/23 and 11/8/23. The PFCC was unable to evidence the documentation of what was discussed during the IDG meeting. A clinical record review on 11/20/23 for Patient 8 reveals IDG meeting would have been held on 10/18/23 and 10/25/23. An incomplete note included wound measurements unchanged between meetings. During an interview with the Patient Family Care Coordinator (PFCC) on 11/21/23 at 1:45 PM, when queried as to the wound measurements; the PFCC indicated the measurements may be in documents faxed from the facility and not in the record. 1. A review of an agency policy titled ";Interdisciplinary Group Meeting" revised December 2022, stated ";... The plan of care will be updated no less frequently than every 15 days or more frequently if the patients condition requires ... An interdisciplinary group meeting plan of care update form will be used for update of the patient ... It will note changes, response to treatment and progress toward targeted outcomes, which may include: ... an increase or decrease in symptoms or acuity ... Plan for changes in treatment or procedures ...." 2. A clinical record review for Patient #3 evidenced an untitled agency document dated 8/23/2023, which indicated the physician ordered skilled nursing to provide wound care to the left arm skin tear 3 times a week. A review of an agency visit note completed by the registered nurse and dated 11/8/2023, indicated the patient fell out of the chair. A review of agency documents titled ";IDG Comprehensive Assessment Details" dated 8/23/2023 and 9/6/2023, failed to evidence the IDG reviewed and revised the plan of care to include the ordered wound care to the patients left arm and documented the changes per agency policy. Review of document dated 11/15/2023, failed to evidence the IDG reviewed and revised the plan of care related to the patients fall. During an interview on 11/17/2023, at 11:35 AM, the Patient and Family Care Coordinator indicated the IDG notes did not include documentation of the review of the patients plan of care to include the wound treatment to the left arm. At 11:39 AM, the Patient and Family Care Coordinator indicated the IDG meeting documentation should have included review of the patients fall and implemented interventions for safety. 3. A clinical record review for Patient #10 evidenced an agency document identified as a nurse visit completed by the skilled nurse on 10/16/2023, which indicated the patient had a fall the day prior to the visit. Review of an agency document titled ";IDG Comprehensive Assessment Details" dated 10/25/2023, indicated the patient had no falls. Review failed to evidence the IDG reviewed and revised the plan of care related to the patients fall. 4. A clinical record review for Patient #11 evidenced an agency document identified as a nurse visit completed by the registered nurse and dated 10/12/2023, which indicated the patient fell resulting in a skin tear to the right arm and bruising to the right eye area. Review of an agency document titled ";IDG Comprehensive Assessment Details" dated 10/25/2023, failed to evidence the IDG reviewed and revised the plan of care related to the patients fall. During an interview on 11/21/2023, at 2:42 PM, the Regional Quality Director indicated there was nothing specific about the fall and sustained injuries as reported on 10/12/2023 reported to the IDG. 5. A clinical record review for Patient #12 evidenced an agency document identified as a comprehensive assessment completed by the registered nurse and dated 8/30/2023, which indicated the patient reported a fall from the wheelchair. Review of an agency document titled ";IDG Comprehensive Assessment Details" dated 9/6/2023, indicated the patient had no falls. Review failed to evidence the IDG reviewed and revised the plan of care related to the patients fall. During an interview on 11/21/2023, at 3:10 PM, the Patient and Family Care Coordinator indicated there was no documentation the IDG had been informed of and reviewed the plan of care related to the patients fall. 6. During an interview on 11/20/2023, at 2:10 PM, the Patient Family Care Coordinator indicated IDG should discuss patient concerns and changes with all disciplines and discuss interventions needed to meet the patient needs.

Based on record review and interview, the agency failed to ensure hospice care and services were provided as directed by the plan of care in 8 of 15 active clinical records reviewed. (Patient #1, 2, 3, 7, 9, 12, 13, 14) The findings include: --- 1. A clinical record review for Patient #1 evidenced an agency document titled ";Plan of Care" effective 9/27/2023, indicated the agency was to provide skilled nursing services 2 times a week. Review failed to evidence the agency provided 2 skilled nursing visits during the weeks of 10/1/2023, 10/22/2023, 10/29/2023, and 11/5/2023. During an interview on 11/20/2023, at 2:32 PM, the Patient and Family Care Coordinator indicated he/she did not see an order to decrease skilled nursing services and there was no update to the plan of care to reduce skilled nursing services to 1 time per week. 2. A clinical record review for Patient #2 evidenced agency documents titled ";Plan of Care" effective 9/27/2023 and 11/8/2023, which indicated the agency was to provide hospice aide services 2 times a week. Review indicated the agency provided hospice aide services 3 times a week during the weeks of 10/15/2023, 10/22/2023, 10/29/2023, 11/5/2023, and 11/12/2023. During an interview on 11/20/2023, at 2:45 PM, the Regional Quality Director indicated the corporate office wanted hospice aide visits to be conducted 3 times a week but indicated it probably was not changed on the plan of care. 3. A clinical record review for Patient #3 evidenced an agency document titled ";Plan of Care" for benefit period 9/15/2023-11/15/2023, indicated the agency was to provide hospice aide services 2 times a week. Review indicated the agency provided hospice aide services 3 times a week and not per the plan of care during the weeks of 10/1/2023 and 10/15/2023. During an interview on 11/17/2023, at 11:52 AM, the Regional Quality Director indicated per corporate, the agency was to increase hospice aide frequency to 3 times per week and indicated there was not an increase of hospice aide frequency to the plan of care. A review of an agency document titled ";Visit Summary" dated 11/6/2023, at the home of the patient on 11/15/2023, at 10:04 AM, indicated the registered nurse performed digital disimpaction (the removal of stool from the rectum by use of a finger) of the patient resulting in a large amount of stool. Review failed to evidence the plan of care included digital disimpaction. A review of an untitled agency document of a registered nurse visit note on 11/6/2023, indicated Patient #3 was constipated and required disimpaction. During an interview on 11/17/2023, at 11:50 AM, the Regional Quality Director indicated the plan of care did not include digital disimpaction as an individualized intervention. 4. A clinical record review for Patient #7 evidenced an agency document titled ";Physicians Verbal/Telephone Orders/Addendum to POC [plan of care]" dated 11/7/2023, which indicated the wound to the sacrum (lower back) was to be cleansed with normal saline (wound cleanser) and apply a foam dressing 3 times per week. Review of an agency document identified as a nurse visit completed by the registered nurse and dated 11/13/2023, indicated the nurse applied medi-honey (a wound ointment) and a foam dressing to the coccyx wound (lower back above the buttocks). Review failed to evidence the nurse provided care as directed by the plan of care. During an interview on 11/20/2023, at 3:13 PM, the Patient Family Care Coordinator indicated there was not an order for medi-honey for the wound treatment. 5. A clinical record review for Patient #9 evidenced an agency document titled ";Plan of Care" effective 11/8/2023, which indicated the agency was to provide hospice aide visits 3 times a week. Review failed to evidence the agency provided services per the plan of care and provided hospice aide services 3 times a week during the week of 11/12/2023. During an interview on 11/20/2023, at 3:28 PM, the Patient Family Care Coordinator indicated there was not a 3rd hospice aide provided during the week of 11/12/2023. 6. A clinical record review for Patient #12 evidenced agency documents titled ";Plan of Care" effective 8/30/2023 and 10/25/2023, which indicated the agency was to provide hospice aide services 2 times a week. Review failed to evidence the agency provided 2 hospice aide visits per the plan of care during the weeks of 9/10/2023, 9/17/2023, 10/1/2023, and 10/15/2023. Review failed to evidence the agency provided services as directed in the plan of care by providing 3 hospice aide visits during the weeks of 9/24/2023, 10/8/2023, 10/22/2023, and 10/29/2023. During an interview on 11/21/2023, at 3:17 PM, the Patient Family Care Coordinator indicated the plan of care frequencies should be followed and indicated he/she would check for an order on the increase of hospice aide services to 3 times a week but no additional documentation or information was provided. 7. A clinical record review for Patient #13 evidenced an agency document titled ";Plan of Care" effective 11/10/2023, which indicated the agency was to provide hospice aide services 3 times a week. Review failed to evidence the agency provided hospice aide services 3 times a week during the week of 11/12/2023. During an interview on 11/21/2023, at 2:57 PM, the Patient Family Care Coordinator indicated there was not a 3rd visit documented and would check the schedule for a missed visit. No additional documentation or information was provided. 8. A clinical record review for Patient #14 evidenced an agency document titled ";Physicians Verbal/Telephone Orders/Addendum to POC" dated 11/7/2023, indicated the agency should provide skilled nursing services 3 times a week. Review failed to evidence the agency provided 3 skilled nursing visits as directed in the plan of care during the week of 11/12/2023. Review of an agency document titled ";Plan of Care" effective 10/25/2023, indicated the agency should provide hospice aide services 1 time weekly. Review indicated the agency provided hospice aide services 3 times a week during the weeks of 10/29/2023 and 11/5/2023. During an interview on 11/21/2023, at 3:56 PM, the Regional Quality Director indicated the agency should provide the services as directed by the plan of care.

Based on record review and interview, the hospice failed to ensure care was coordinated between all disciplines involved in the patients care in 1 of 1 clinical record reviewed with extreme pain reported. (Patient #13) The findings include: --- A clinical record review for Patient #12 evidenced a comprehensive assessment, dated 11/15/2023, which indicated Patient reported constant severe pain to the right leg which worsened with movement. The record indicated Patient required total assistance for ambulation, bathing, toileting, and transfers. Review of the Plan of Care, effective 11/10/2023, indicated the hospice provided hospice aide services 3 times a week for personal care to include bathing and dressing. Review failed to evidence the hospice coordinated care with the hospice aide regarding Patients report of severe pain worsened with movement. During an interview on 11/21/2023, at 3:02 PM, the Regional Quality Director indicated there should have been care coordination completed with the hospice aide in regards to Patients pain.

Based on observation, record review, and interview, the hospice failed to ensure coordination of care with non-hospice healthcare providers in 3 of 8 active clinical records reviewed who resided in an assisted living facility (ALF) (Patient #2, 3, 10). The findings include: --- 1. During an observation of care on 11/16/2023, at 9:58 AM, at Entity 4, the home of Patient #2, the patient was observed to by lying in bed quietly. At 10:15 AM, Certified Nurse Aide (CNA) 1 and CNA 2 remove the patients socks and Patient #2 was heard moaning. As CNA 1 and CNA 2 were observed removing the patients shirt, the patient was heard shouting, ";Woah," and was observed pushing CNA 2s hands away. Patient #2 was heard repetitively mumbling and stating, ";Go away." Throughout the bed bath, Patient #2 was observed demonstrating signs of agitation by repetitively shouting and pushing staffs hands away. During an interview on 11/16/2023, at 10:29 AM, both CNA 1 and CNA 2 indicated Patient 2s agitation during bathing was typical for the patient. CNA 2 indicated Patient #2s behavior could get worse than this sometimes. A clinical record review for Patient #1 evidenced an untitled agency document of a visit provided by the registered nurse on 10/31/2023, which indicated the patient could be agitated especially during bathing. Review of an agency document titled ";Plan of Care" effective 9/27/2023, indicated the medications included Ativan (medication for anxiety) every 8 hours as needed for anxiety/agitation. Review failed to evidence coordination of care related to agitation during bathing with the ALF. Review of the plan of care effective 11/8/2023, indicated the medications included atropine (a medication used to dry secretions), morphine (a medication for extreme pain/shortness of breath), and ondansetron (medication for nausea), bisacodyl (a medication used to treat constipation). Review of a document from Entity 4 titled ";Order Summary Report" dated 11/16/2023, failed to evidence the medications for Patient #2 included atropine, morphine, ondansetron, and bisacodyl. During an interview on 11/16/2023, at 10:52 AM Person 5, nurse at Entity 4 (ALF), where patient resided, indicated Patient #2 had not received Ativan as needed since 10/20/2023. During an interview on 11/20/2023, at 2:42 PM, the Regional Quality Director indicated the agency should have talked to the ALF about administering Ativan prior to bathing for the agitation. The Regional Quality Director indicated there was not any documentation of care coordination with the ALF regarding agitation. At 3:00 PM, the Regional Quality Director indicated the hospice nurses should be reviewing the medications listed at the ALF because the medication lists should match between the hospice and the ALF. 2. A clinical record review for Patient #3 evidenced a document from Entity 3 (ALF), where patient resided, titled ";Resident Face Sheet" dated 11/15/2023, which indicated the patients medications included bacitracin (antibiotic ointment), calmoseptine ointment (medicated skin protectant ointment), ciprofloxacin (antibiotic) eye drops, and megestrol (an appetite stimulant). A review of an agency document titled" Plan of Care" dated 11/15/2023, failed to evidence bacitracin, calmoseptine, ciprofloxacin, and megestrol. Review indicated the plan of care included the medication, Milk of Magnesia (for treatment of constipation) daily as needed. A review of an untitled agency document of a registered nurse visit note on 11/6/2023, indicated Patient #3 was constipated and required disimpaction. Review failed to evidence the registered nurse coordinated care with the ALF regarding the patients constipation and on the use of the as needed medication, Milk of Magnesia, for constipation. During an interview on 11/17/2023, at 11:30 AM, the Patient and Family Care Coordinator indicated the hospice nurses should review medications with the ALF staff at every visit. During an interview on 11/17/2023, at 11:33 AM, the Regional Quality Director indicated all medications should have been reviewed with the ALF and indicated megestrol should have been discontinued. At 11:51 AM, the Regional Quality Director indicated the nurse should have coordinated care with the ALF regarding the patients constipation, use of medications for constipation, and the disimpaction. 3. A clinical record review for Patient #10 evidenced an agency document identified as the comprehensive assessment completed by the registered nurse and dated 11/8/2023, which indicated the terminal diagnosis was senile degeneration of the brain (dementia) and lived in an ALF. Review indicated Patient #10 required total assistance for toileting, bathing, and dressing. Review evidenced an agency document titled ";Plan of Care" effective 10/25/2023, which evidenced tasks assigned to a hospice aide for personal care to include assist with shower, shampoo, shave, nail care, oral care, and dressing. Review failed to evidence the agency provided hospice aide services during the benefit period beginning 9/21/2023. Review failed to evidence documentation regarding the failure to provide hospice aide services and care coordination with the ALF regarding meeting the patient needs for personal care. During an interview on 11/20/2023, at 2:08 PM, the Assistant Director of Clinical Services indicated hospice aide services were discontinued on 8/7/2023, because the patient was combative and would not allow hospice staff to bathe the patient. The Assistant Director of Clinical Services indicated the agency did attempt to intervene with the ALF regarding the patients behavior at bathing and would look for documentation. No additional documentation or information was provided.

Based on record review and interview, the agency failed to report falls per agency policy and track falls to enable to the hospice to assess processes of care, hospice services, and operations in 6 of 7 clinical records reviewed with falls. (Patient #2, 3, 10, 11, 12, 15) The findings include: --- 1. A review of an agency policy titled ";Incident Reporting" revised 7/20/2022, stated, ";... All events or occurrences ... must be reported ... The incident reporting system will be part of the organizations overall performance improvement and risk management plan ... When an incident occurs, the individual discovering the incident will: ... Complete an incident report form within 24 hours of the incident ... The Program Director or designee will review and sign the incident report form, request any necessary follow-up from appropriate personnel, and initiate incident report follow-up form, as required. ... The QAPI [quality assessment performance improvement] Coordinator will review the incident reports and conduct follow-up as indicated...." 2. During an interview on 11/16/2023, at 10:52 AM, Person 5 at Entity 4, where Patient #2 resided, indicated Patient #2 had a fall on 10/2/2023. A clinical record review for Patient #2, election date of 4/11/2023, evidenced an agency document of a visit provided by the registered nurse dated 10/3/2023, which indicated the patient was found on the floor in front of the wheelchair on 10/2/2023. Review failed to evidence an incident report for the fall on 10/2/2023. During an interview on 11/17/2023, at 11:03 AM, the Regional Quality Director indicated the agency did not have any incident reports related to falls for Patient #2 because the nurse did not complete the fall report in the electronic medical record. 3. A clinical record review for Patient #3 evidenced an agency document of a registered nurse visit dated 11/6/2023, which indicated the patient slid out of the chair on 10/22/2023. Review failed to evidence the agency completed an incident report for the fall on 10/22/2023 per policy. During an interview on 11/17/2023, at 11:48 AM, the Regional Quality Director indicated there was not a fall report completed for 10/22/2023. 4. A clinical record review for Patient #10 evidenced an agency document identified as a nurse visit completed by the skilled nurse on 10/16/2023, which indicated the patient had a fall the day prior to the visit. Review failed to evidence the agency completed an incident report for the fall as reported on 10/16/2023. 5. A clinical record review for Patient #11 evidenced an agency document identified as a nurse visit completed by the registered nurse and dated 10/12/2023, which indicated the patient fell resulting in a skin tear to the right arm and bruising to the right eye area. Review failed to evidence the agency completed an incident report for the fall as documented on 10/12/2023. 6. A clinical record review for Patient #12 evidenced an agency document identified as a comprehensive assessment completed by the registered nurse and dated 8/30/2023, which indicated the patient reported a fall from the wheelchair. Review failed to evidence the agency completed an incident report for the fall as reported on 8/30/2023 per policy. 7. A clinical record review for Patient #15 evidenced an agency document identified as a PRN (as needed) fall visit completed by the registered nurse and dated 11/19/2023, which indicated the patient fell from the wheelchair on 11/18/2023. Review failed to evidence the agency completed an incident report for the fall on 11/18/2023 per policy. 8. During an interview on 11/17/2023, at 11:48 AM, the Regional Quality Director indicated the QAPI cannot analyze and track falls that were not documented on a fall report.

Based on observation, record review, and interview, the agency failed to ensure agency personnel followed standard precautions to prevent the transmission of infections and communicable diseases in 1 of 1 home visit with a hospice aide (Patient #2) and 1 of 2 home visits with a licensed practical nurse (Patient #3). The findings include: --- 1. A review of an agency policy titled ";Hand Hygiene" revised July 2022, stated, ";... Hand decontamination using an alcohol-based hand rub should be performed: ... After contact with ... wound dressings... when moving from a contaminated body site to a clean body site during patient care ... After removing gloves...." 2. During an observation of care on 11/16/2023, at 10:20 AM, at the home of Patient #2, Certified Nurse Aid (CNA) 1 was observed with gloved hands wiping a brown, soft substance from in between the patients buttocks with a disposable wipe while the patient was lying on his/her right side in bed. CNA 1 was observed with gloved hands picking up the washcloth from the soapy water basin and washed the patients buttocks and in between the patients buttocks with the soapy washcloth. At 10:23 AM, CNA 1 was observed with gloved hands applying lotion to the patients shoulders, chest, and arms and then was observed dressing the patients lower body. CNA 1 was not observed removing the gloves and performing hand hygiene after wiping away a brown, soft substance from in between the patients buttocks and before applying lotion to the patients skin and dressing the patient. 3. During an observation of care on 11/15/2023, at 10:01 AM, at the home of Patient #3, Licensed Practical Nurse (LPN) 1 was observed with gloved hands removing a dressing on Patient #3s left arm revealing an open area. LPN 1 was observed with gloved hands cleansing the open area with clear liquid applied to a dry gauze and then applying a clear ointment to a dry gauze and applying the gauze to the open area on the left arm. LPN 1 was not observed removing the gloves and performing hand hygiene after removing the dressing and cleansing the open area and before applying the clean dressing. 4. During an interview on 11/16/2023, at 3:50 PM, the Patient and Family Care Coordinator indicated gloves should be removed and hand sanitizer should be applied after removing a wound dressing and cleansing the wound and before applying a new dressing and should remove gloves and wash hands after cleaning a bowel movement and before doing anything else.

Based on record review and interview, the agency failed to ensure a bereavement plan of care was developed and bereavement counseling services were provided per the plan of care in 2 of 2 closed records reviewed receiving bereavement services. (Patient #16, 17) The findings include: --- 1. Review of an agency policy revised December 2022, titled ";Bereavement Services" stated, ";... Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. ... Within three (3) weeks, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. ... Within three (3) to five (5) weeks after the patients death, a bereavement assessment... will be completed by the bereavement counselor following the family/caregiver. ... A bereavement file will be maintained on each family/caregiver until of care. Each file will contain the following information: ... A bereavement plan of care that includes needs and goals for ongoing support ... All bereavement clinical notes that have been written and/or letters sent to the bereaved ... Bereavement assessment and clinical notes will be submitted to the patients permanent clinical record." 2. A clinical record review for Patient #16, date of death of 8/4/2023, evidenced an agency document titled ";Bereavement Care Plan Details" effective 8/7/2023. Review indicated the patients caregiver was receiving bereavement services and failed to indicate what the needs and goals were for ongoing support per agency policy. Review indicated the caregiver was due to receive a sympathy card on 8/18/2023 and a letter on 9/3/2023 and was due to be invited to a support group on 11/2/2023, which failed to evidence were completed. Review failed to evidence any bereavement clinical notes. 3. A clinical record review for Patient #17, date of death 8/21/2023, evidenced an agency document titled ";Bereavement Care Plan Details" effective 8/21/2023. Review indicated the patients caregiver was receiving bereavement services and failed to indicate what the needs and goals were for ongoing support per agency policy. Review indicated the caregiver was due to be invited to a support group on 11/19/2023, which failed to evidence was completed. Review failed to evidence any bereavement clinical notes. 4. During an interview on 11/21/2023, at 9:46 AM, the Bereavement Coordinator indicated the bereavement plan of care and assessments were in the electronic clinical record. The Bereavement Coordinator indicated the interventions included phone calls and cards sent to the decedent and invitations to the support group as indicated on the plan of care. 5. During an interview on 11/21/2023, at 4:02 PM, the Regional Quality Director indicated there were no bereavement clinical notes in the clinical record and the bereavement plan of care did not include the needs and goals for ongoing support. 6. During an interview on 11/21/2023, at 4:03 PM, the Administrator indicated he/she was unsure where the bereavement clinical notes were and suggested that the notes possibly were with the Bereavement Coordinator. At 4:08 PM, the Administrator indicated the Bereavement Coordinator should be documenting communication with the patients decedent to determine if outcomes were being reached per the goals.

Based on observation, record review, and interview, the agency failed to ensure the hospice aide provided services as directed in the plan of care in 1 of 1 home visit with a hospice aide. (Patient #2) The findings include: --- A clinical record review for Patient #2 evidenced an agency document titled ";Plan of Care" effective 11/8/2023, which indicated the hospice aide was to provide oral care at every visit and shave every Tuesday and Thursday. During an observation of care on 11/16/2023 (Thursday), between 9:58 AM and 10:42 AM, at the home of Patient #2, Certified Nurse Aide (CNA) 1 and CNA 2 were observed providing personal care to Patient #2. At the conclusion of the hospice aide visit, CNA 1 and CNA 2 were not observed to have provided oral care and shave the patient as directed in the plan of care. During an interview on 11/20/2023, at 2:50 PM, the Regional Quality Director indicated the hospice aide should provide all of the care as directed in the plan of care.

Based on observation, record review, and interview, the agency failed to ensure the hospice aide appropriately authenticated clinical documentation in the clinical record in 1 of 1 home visit with a hospice aide. (Patient #2) The findings include: --- During an observation of care on 11/16/2023 (Thursday), between 9:58 AM and 10:42 AM, at the home of Patient #2, Certified Nurse Aide (CNA) 1 and CNA 2 were observed providing personal care to Patient #2. At the conclusion of the hospice aide visit, CNA 1 and CNA 2 were not observed to have provided oral care, nail care, and shave the patient. Review of an untitled agency document of a hospice aide visit dated 11/16/2023, and completed by CNA 1, indicated CNA 1 completed oral care, nail care, and shaved the patient. During an interview on 11/20/2023, at 2:50 PM, the Regional Quality Director indicated only care that was performed should be documented.

Based on record review and interview, the agency failed to ensure all professional licenses for personnel were kept current in 1 of 1 personnel record reviewed for a medical social worker (MSW 1) and failed to evidence a license in the state of Indiana for 1 of 3 personnel records reviewed for a registered nurse (RN, Patient Family Care Coordinator). The findings include: --- 1. Review of an agency policy titled ";Licensure/Certification/Registration" revised December 2022, stated, ";... Personnel must maintain and show proof of licensure ... Personnel will show proof of updated license ... and a copy will be kept in personnel record...." 2. A personnel record review for MSW 1 evidenced the social worker license expired on 4/1/2022 and failed to evidence proof of current licensure. During an interview on 11/15/2023, at 3:20 PM, the Business Office Manager indicated the personnel file did not contain proof of a current social worker license. 3. A personnel record review for the Patient Family Care Coordinator failed to evidence a registered nurse license in the state of Indiana. During an interview on 11/15/2023, 3:20 PM, the Business Office Manager indicated the Patient Family Care Coordinator was not yet licensed in the state of Indiana.

Upon client record review, 1 of 11 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: During a Surveyor attended home visit, the RN performed wound care to a wound located on the right leg. There was no Physician order for the wound care provided.