Every finding on record at Good Shepherd Hospice

Based on patient record review and staff interview, the Hospice did not ensure the prompt delivery of medications/Comfort pack provided by the Hospice as needed to meet the patient's needs.  This was evident in one (1) of three (3) records reviewed (Patient #1).   Failure to ensure that the medications/Comfort pack were promptly delivered has the potential for negative patient outcomes. --- 1) Patient #1 has a referral and encounter note dated 05/14/2026, the Registered Nurse documents that the patient and partner/primary caregiver are agreeable to Hospice.  Discussed Hospice services and Hospice levels of care as per Medicare guidelines. Medication review will be done by Hospice Nurse upon admission. Tentative discharge date of 05/14/2026 from the hospital.The clinical record lacks documented evidence of Hospice admission on 05/14/2026 as scheduled.  The telephone encounter notes of 05/14/2026 documents that the primary caregiver was informed that a nurse is not available for 05/16/2026, a nurse would be sent on 05/18/2026.  The primary caregiver agrees.    The "On-Call" log dated 05/17/2026 at 07: 25PM documents that the patient/partner/caregiver called reporting that the patient had a "seizure".  The patient is scheduled for admission on Monday 05/18/2026. Primary caregiver states they need someone now and it is agreeable for a 12:30 AM admission visit on 05/18/2026. Discussed possible Inpatient Unit admission and hospitalization with primary caregiver who declined.  The Plan of Care for certification period 05/18/26 to 08/08/26 document orders for "Skilled Nurse 1 visit every day for one day, 1 - 4 (one to four) visits every week for 12 (twelve weeks), 1 - 5 (one to five) visits as needed".  Hospice diagnoses including "Secondary Malignant Neoplasm of Liver, Malignant Neoplasm of Female Breast, Hepatic Cirrhosis, and Ascites".  The Hospice Benefit Election is dated 05/18/2026.   The clinical record documents Registered Nurse visits conducted on 05/18/2026:05/18/26 at 01:00 AM – abbreviated Nursing admission.  The Registered Nurse documents the patient’s “pain level of 4/10 (4 out of 10 pain scale), after pain medications, frequent and relieving factors Hydromorphone”.   The Care Plan problem list indicates the patient was assessed for pain and family educated on analgesic regimen.  The clinical note lacks documented evidence of the name, dosage, and route of the medication that the family was educated on.  The medication profile dated 05/18/2026 generated by the Registered Nurse documents the patient’s medications include Haldol 1 milligram sublingual every 4 hours as needed for - agitation, Atropine sulfate 1 milligram sublingual every 4 hours as needed for – secretions, dyspnea, Tylenol 650 milligram per rectal every 6 hours as needed for – mild pain and elevated temperature, Lorazepam/Ativan 1 milligram oral every 8 hours as needed for – anxiety/sleep, Compazine 10 milligram oral every 6 hours as needed for – nausea/vomiting. The medication profile does not include Hydromorphone.  The encounter notes dated 05/18/2026 at 12:30PM documents telephone call made to primary caregiver and family regarding Codeine allergy.  The continued Nursing admission assessment visit dated 05/18/2026 at 12:45 PM – 02:15 PM, the Registered Nurse documents the patient’s pain as 0/10 (0 out of 10 pain scale), no pain. Caregivers have been administering Xanax 0.5 milligrams/Dilaudid 2 milligrams crushed in slurpy as per MD’s instructions.  They are awaiting delivery of Comfort kit.  The Care Plan problem list indicates the patient was assessed for pain and family educated on analgesic regimen.  The clinical note lacks documented evidence of the name, dosage, and route of the medication that the family was educated on.     There is no documented evidence that the Hospice ensures that the Comfort pack medications were promptly delivered to the patient on 05/18/2026  prior to time of death.  Immediate pain management medications were given as per order of the patient’s private/primary Medical Doctor. The Hospice did not ensure that the Hospice pain management medications/Comfort pack was delivered to the patient promptly in a timely manner to ensure the effective pain management of the Hospice patient. The survey findings were reviewed on 06/15/2026 at 01:44 PM with the Director of Patient Services and Performance Improvement Director.

Based on record reviews and staff interviews, the Hospice failed to ensure a comprehensive assessment is conducted to identify all patient's needs to provide the appropriate treatments and services, this was evident for -- (-) of twenty-seven (27) clinical records reviewed. (Patients #8). Failure to ensure assessments are comprehensive has the potential for unmet patient needs. --- 1) Patient #8 has start of care date 10/31/2024 with diagnoses of Acute respiratory failure, spastic quadriplegic cerebral palsy, intellectual disability, and S/P percutaneous endoscopic gastrostomy (PEG) tube placement as documented on ";The Hospice Plan of Care" for certification period 10/31/2024 to 1/28/2025. The Hospice Plan of Care for certification period 10/31/2024 to 1/28/2025 documented orders for Skilled Nurse (SN) visits 1 to 2 visits every week for 13 weeks; Problem: Hospice Diet and Nutrition – Jevity 1.5 infusing @ 50ml/hour (hr.) via PEG tube with Kangaroo pump with 55ml water flush every 1 hr. for 20 hrs. Staff to manage. The initial Skilled Nurse Hospice visit notes dated 10/31/2024 lacked documented evidence related to the scrotal edema. 1. Skilled Nurse Hospice visit notes dated 11/3/2024, 11/04/2024, 11/12/2024, 11/20/2024, 11/25/2024, 12/10/2024, and 12/17/2025 lacked documented evidence related to the scrotal edema. Skilled Nurse Hospice visit notes documented the following: 12/28/2024 – ";Pt (patient) has small skin irritation around his scrotum, scrotum swollen, barrier cream to apply daily reviewed with facility staff." No documented evidence the Medical Doctor was notified regarding edema. 01/07/2025 – ";Scrotal swelling persists which is patient baseline per staff." No documented evidence the Medical Doctor was notified regarding edema. Hospice Plan of Care IDG (Interdisciplinary Group) dated 12/27/2024 documented, ";Scrotal swelling persists which is pt (patient) baseline as per staff." 1. Skilled Nurse Hospice visit notes dated 11/03/2024, 11/04/2024, 11/26/2024 lacked documented evidence related to the assessment of PEG tube insertion site. Skilled Nurse Hospice visit notes reviewed from 11/03/2024 to 01/07/2025 lacked consistent documentation regarding assessment of the PEG tube insertion site. Skilled Nurse Hospice visit notes documented the following: 11/12/2024 – G-tube insertion site with no redness. 11/20/2024 – G-tube feeds as ordered. Skin warm, dry and intact. 12/04/2024 – G-tube site clean and dry split gauze in place. 12/10/2024 – G-tube site with no signs and symptoms of infection. 12/17/2024 – G-tube site with no signs and symptoms of infection. 12/28/2024 – Feed tube in place site intact. 01/07/2025 - G-tube site with no signs and symptoms of infection. On 1/10/2025 the Director of Patient Services was interviewed and stated a head-to-toe assessment should be completed on admission and the PEG tube insertion site and scrotal edema should be assessed at each visit and documented in the nurses note. No further information was provided.

Based on review of clinical records and interviews, the hospice failed to develop an individualized Plan of Care that that reflects all patients pertinent diagnoses, services, and treatments. This was evident in three (3) of twenty -seven (27) clinical records (Patient #1, # 12 and # 18). Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs and negative patient outcomes. --- 2) Patient #1 has a start of care date of 03/15/24 with diagnosis of Alzheimer's Dementia, Transplant wound granuloma, and Malignant Neoplasm of prostate as documented on the "Hospice Plan of Care" for certification period 11/10/2024 to 01/08/2025. The "Hospice Plan of Care" for certification period 11/10/2024 to 01/08/2025 documents orders for "Skilled Nurse 1 to 2 visits every week for 9 weeks. Wound location: mid lower abdomen. Skilled clinician as needed: remove old dressing and discard as per policy, cleanse with wound cleanser, dry with sponge or gauze pad, apply to wound bed Mupirocin 2%, cover with (cdd) clean dry dressing, change dressing daily- caregiver independent, measure wound length, depth, width weekly". The "Skilled Nurse Hospice visit" notes dated 11/14/24, 11/22/24, 11/27/24, 11/29/24, 12/6/24, 12/11/24, 12/20/24, 12/26/24, and 1/2/25 lack documented evidence that the Skilled Nurse performed wound measurement. A Home Visit was conducted with the Skilled Nurse on 01/07/2025 with the Skilled Nurse. The Skilled was observed performing wound care measurement to the mid-lower abdominal area. There was no observable cleansing of the wound with wound cleanser as ordered in the Plan of Care. The Hospice "Wound Assessment" policy dated 09-2024 documents "Reassessment and documentation of wound should include 1) wound measurement weekly, 2) wound bed description, 3) clinical evaluation of wound progress". The Hospice did not ensure that Skilled Nurse services and wound care treatments are provided in accordance with the individualized Plan of Care and Hospice policy. Survey findings and Interview were conducted on 01/07/2025 at 03:30 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 3) Patient #12 has a start of care date of 07 04/2024 with diagnoses of "Alzheimer's Dementia, and Urinary Incontinence" as documented on the ";Hospice Plan of Care" for certification period 10/02/2024 to 12/30/2024. The "Hospice Plan of Care" for certification period 10/02/2024 to 12/30/2024 documents an order for "Medical Social Work 1 to 2 visits every month for three months, 6 as needed visits for social support and crisis" The Medical Social Work visits are dated 10/29/2024 and 12/16/2024. The clinical record lacks documented evidence of a Medical Social Work visit conducted during the month of 11/2024 to ensure the continued need for social support of the Hospice recipient and primary caregivers. The survey findings and interview were conducted on 01/09/2024 at 04:10 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 1) Patient # 18 has a start of care date of 10/02 2024 with diagnoses of Lewy Body Dementia, Parkinsons, Type 2 Diabetes, Hyperlipidemia, Prostate Cancer as documented on the "Hospice Plan of Care" for certification period of 01/01/2025 to 03/30/2025. The "Hospice Plan of Care" for certification period of 01/01/2025 to 03/30/2025 documents orders for: "Skilled Nurse visits 1 to 3 visits every week for fourteen weeks, 1 to 6 visits as needed for symptoms management. Medical Social Worker 1 to 2 visits every month for four months and 1 to 6 visits as needed for psychosocial crisis." The Hospice Plan of Care Interdisciplinary Group (IDG) dated 10/02/2024 documented the following Problem: "Risk for skin breakdown related to immobility. Goal: Patient verbalizes understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Caregiver will verbalize understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Intervention: Prevention of Pressure Injuries: Instruct caregiver in the causes and prevention of pressure injuries including positioning strategies and using pressure relieving devices/strategies. Instruct in dietary/nutritional needs to optimize skin health and healing." Master of Social Work (MSW) Hospice Visit note dated 10/29/2024 documents: ";SW (social worker) spoke to Licensed Practical Nurse (LPN) who states Pt (patient) has a wound on his buttocks that they are treating." The note lacked documented evidence the hospice RN was notified regarding wound. Skilled Nurse Hospice Visit note dated 10/31/2024 lacked documented evidence related to wound. Skilled Nurse Hospice Visit note dated 11/04/2024 documents: "Integumentary: Pressure Injury developed to sacrum (0.5 cm x 0.5 cm) Stage II. Encounter Notes: Charge Nurse present and reports patient has developed pressure injury to sacrum (small) otherwise no new concerns. The Wound Assessment: Sacrum Medial Stage 2. Measurements: 0.5 cm x 0.5 cm x 0.1 cm. Treatment: Wound Cleanser water and soap and treatment/intervention barrier cream." The Skilled Nurse Hospice Visit note dated 11/04/2024 lacked documented evidence that the Risk for Skin Breakdown problem area had been updated to reflect the patients current stage 2 pressure ulcer. The Hospice "Wound Assessment" policy dated 09-2024 documents "Reassessment and documentation of wound should include 1) wound measurement weekly, 2) wound bed description, 3) clinical evaluation of wound progress." The record lacked documented evidence the wound was re-assessed weekly after 11/04/2024 per the agencies Wound Assessment Policy dated 09/2024. The Skilled Nurse Hospice Visit notes dated 11/07/2024, 12/02/2024, and 12/05/2024 lacked documented evidence related to wound. The Skilled Nurse Hospice Visit note dated 11/21/2024 documents: ";Facility staff reports skin intact." The Skilled Nurse Hospice Visit note dated 12/11/2024 documented, ";Wound to sacrum improving and educated facility staff on off-loading patient to prevent skin injury. Wound Assessment: Sacrum Medial Stage 2. Measurements: 0.5 cm x 0.5 cm x 0.1 cm. Treatment: Wound Cleanser water and soap and treatment/intervention barrier cream." The Wound Assessment dated 12/18/2024 documented the pressure injury was removed (discontinued 12/18/2024) due to ";wound healed." Survey findings and interviews were conducted on 1/13/2024 at 10:16 am and 1:34 pm with the Director of Patient Services. An email provided to the surveyor documented her interview with MSW, ";The MSW stated her usual practice was to notify the RN or Team Manager of findings. Does not recall if this occurred." Interview with the RN related to visit on 10/31/2024, ";patient was seen at the nurses station and didnt mention any changes with skin, due to the patients history of agitation she left the patient in his current area to not disrupt him too much." No additional information or explanation was provided.

Based on clinical record review and staff interview, the Hospice failed to develop an individualized Plan of Care that that reflects all patients pertinent diagnoses, Skill Nursing interventions and dietary requirements for three (3) of twenty-seven (27) records reviewed (Patients #4, #6 and #8). Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs and negative patient outcomes. --- 2) Patient # 4 has a start of care date of 11/22/2024 with one diagnosis of "Alzheimer's Dementia" as documented on the "Hospice Plan of Care" for certification period 11/22/2024 to 02/19/2025. The "Hospice Plan of Care" for certification period 11/22/2024 to 02/19/2025 documents orders for "Skilled Nurse 1 to 2 visits every week for 14 weeks. Skilled Nurse intervention - Drain site care, cleanse with alcohol, apply drain sponge, gauze dressing and cover transparent dressing weekly and as needed. Drain method - self suctioning. Instruct caregiver to empty cholecystostomy drain bulb when half full and record output. Flush drain with 5 milliliter Normal Saline daily. Primary care giver independent". The initial and comprehensive assessment dated 11/22/2024, the Skilled Nurse/Registered Nurse documents patient has right upper quadrant "Cholecystostomy drain to be flush drain with 5 milliliter Normal Saline daily. Primary care giver independent". The Hospice Plan of Care lacks documented evidence of pertinent diagnoses related to the Cholecystostomy tube and Dietary/Nutritional requirement. The survey findings and interview were conducted on 01/09/2025 at 04:00 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 3) Patient #6 has a start of care date of 05/07/2024 with diagnoses of "Severe Alzheimer's Dementia, Hypernatremia, Acute Renal Failure, Hypermagnesemia, and Dysphagia" as documented on the "Hospice Plan of Care" for certification period 01/02/2025 to 03/02/2025. The "Hospice Plan of Care" for certification period 01/02/2025 to 03/02/2025 documents orders for "Skilled Nurse 1 to 2 visits every week for 10 weeks. Medications include: Starch Thickening Liquid 1000 milliliters add thick it liquid to food and drinks as directed. Tick-It starch -malt Dextrin 1020 gram take one scoop by mouth as needed for nectar thick liquids, follow packaging instructions. Route -oral, indications - difficulty swallowing". The Plan of Care lacks an order for modified Dietary restrictions and Skilled Nurse interventions to address the patient's dietary restrictions. The survey findings and interview were conducted on 01/09/2025 at 04:18 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 1) Patient #8 has start of care date 10/31/2024 with diagnoses of acute respiratory failure, spastic quadriplegic cerebral palsy, intellectual disability, and S/P percutaneous endoscopic gastrostomy (PEG) tube placement as per the "Hospice Plan of Care" for certification period 10/31/2024 to 1/28/2025. The "Hospice Plan of Care" for certification period 10/31/2024 to 1/28/2025 documented orders for "Skilled Nurse (SN) visits 1 to 2 visits every week for 13 weeks; Problem: Hospice Diet and Nutrition: Jevity 1.5 infusing @ 50ml/hour (hr.) via PEG tube with Kangaroo pump with 55ml water flush every 1 hr. for 20 hrs. Staff to manage." Skilled Nurse Hospice visit notes dated 10/31/2024, 11/03/2024, 11/04/2024, 11/26/2024 lacked documented evidence related to the assessment of PEG tube insertion site. The Hospice Plan of Care lacked documented evidence related to the skin assessment of the PEG tube insertion site. On 1/10/2025 the Director of Patient Services was interviewed and stated a head-to-toe assessment should be completed on admission and the PEG tube insertion site should be assessed at each visit and documented in the nurses note. No further information was provided.

Based on clinical record review and staff interview, the Hospice failed to ensure pain and symptom management is accurately reflected in the clinical record. This was evident in one (1) of twenty-seven (27) clinical records reviewed. (Patient #11). Failure to ensure the effective pain and symptom management, has the potential for negative patient outcome. --- Patient #11 has a start of care date of 11/22/2024 with diagnoses of Malignant Neoplasm of Right Female Breast, Secondary Malignant Neoplasm of Bone, Neoplasm related pain, Pathological Fracture of Rib of Left side as documented on the "Hospice Plan of Care" for certification period 11/22/2024 to 02/20/2025. The "Hospice Plan of Care" for certification period 11/22/2024 to 02/20/2025 documents orders for "Skilled Nurse 1 to 2 visits every week for 13 weeks. Skilled Nurse intervention - assess pain each visit. The "Skilled Nurse Hospice visit" note dated 11/27/2024 documents inconsistent pain level. The "Pain Assessment" section documents "no pain". The "Edmonton symptom assessment system" documents the patient's pain level of "8" (on scale of 0 - 10). The "Encounter note" lacks documentation of pain intervention. There is no documented evidence of intervention to address the patient's high pain level of 8. The "Skilled Nurse Hospice visit" note dated 12/10/2024 documents inconsistent pain level. The "Pain Assessment" section documents pain level "8/10" (on scale of 0 - 10). The "Edmonton symptom assessment system" documents the patient's pain level of "1". ). The "Encounter notes", the Skilled Nurse documents "reports pain has very much improved after increase of Fentanyl patch to 100 microgram every 3 days, 2 days ago". There is no documented evident of interventions to address the patient's current high pain level of 8. The ";Skilled Nurse Hospice visit" note dated 12/23/24, documents inconsistent pain level. The "Pain Assessment" section documents patient's pain level of "5/10" (on scale of 0 - 10). The "Encounter notes", the Skilled Nurse documents the patient reports "verbal pain 8/10". Patient stated she should be taking pain medication now. Medication reconciliation completed with new order for Morphine 20 milligram per oral". Patient stated it has been effective with conflicting pain level". The clinical record lacks documentation of accurate pain assessment, intervention and resolution to the patient's pain level. The survey findings and interview were conducted on 01/09/2025 at 03:45 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided.

Based on clinical record review and interview, the Hospice failed to ensure communication and an ongoing sharing of information with the interdisciplinary Group. This was evident in one (1) of twenty-seven (27) records reviewed (Patient #18). Failure to ensure effective communication with the Interdisciplinary Group has the potential for the unmet patient needs and negative patient outcomes. --- Patient # 18 has a start of care date of 10/02/2024 with diagnoses of Lewy Body Dementia, Parkinsons, Type 2 Diabetes, Hyperlipidemia, Prostate Cancer as documented on the Hospice Plan of Care for certification period of 01/01/2025 to 03/30/2025. The Hospice Plan of Care for certification period of 01/01/2025 to 03/30/2025 documents orders for "Skilled Nurse visits 1 to 3 visits every week for fourteen weeks, 1 to 6 visits as needed for symptoms management. Medical Social worker 1 to 2 visits every month for four months and 1 to 6 visits as needed for psychosocial crisis." The Hospice "Wound Assessment" policy dated 09-2024 documents "Reassessment and documentation of wound should include 1) wound measurement weekly, 2) wound bed description, 3) clinical evaluation of wound progress." The Hospice Plan of Care Interdisciplinary Group (IDG) dated 10/02/2004 documented the following: "Problem: Risk for skin breakdown related to immobility. Goal: Patient verbalizes understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Caregiver will verbalize understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Intervention: Prevention of Pressure Injuries: Instruct caregiver in the causes and prevention of pressure injuries including positioning strategies and using pressure relieving devices/strategies. Instruct in dietary/nutritional needs to optimize skin health and healing." The Master of Social Work (MSW) Hospice Visit note dated 10/29/2024 documented, ";SW (social worker) spoke to Licensed Practical Nurse (LPN) who states Pt (patient) has a wound on his buttocks that they are treating." The Skilled Nurse Hospice Visit note dated 10/31/2024 lacked documented evidence related to wound. The IDG notes dated 10/02/2024, 10/04/2024, and 10/11/2024 documented skin intact. The IDG note dated 10/25/2024 lacked documented evidence related to skin assessment. Survey findings and interviews were conducted on 1/13/2024 at 10:16 am and 1:34 pm with the Director of Patient Services. An email provided to the surveyor documented her interview with MSW, ";The MSW stated her usual practice was to notify the RN or Team Manager of findings. Does not recall if this occurred." Interview with the RN related to visit on 10/31/2024, ";patient was seen at the nurses station and didnt mention any changes with skin, due to the patients history of agitation she left the patient in his current area to not disrupt him too much." No additional information or explanation was provided.

Based on clinical record review and staff interview, the Hospice failed to provide nursing care and services by or under the supervision of a registered nurse. This is evident in one (1) of the twenty-seven (27) clinical records reviewed. (Patient #10) Failure to provide nursing care services under the supervision of a registered nurse has the potential for negative patient outcomes. The findings are: --- Patient #10 has a start of care date 06/07/2024 with diagnoses that include Alzheimer's, dementia and depression documented on the "Hospice Plan of Care" for the certification period 12/04/2024-02/01/2025. The "Hospice Plan of Care" for the certification period 12/04/2024-02/01/2025 documents orders for "Skilled Nurse one (1) to two (2) visits every week for nine (9) weeks. Five (5) visits are needed. Comments: symptom management" The "Encounter Notes" dated 01/07/2025 documents a Licensed Practical Nurse (LPN) visit. "2:00pm LPN (Licensed Practical Nurse) visit at The Bristal in Bethpage. Received pt (patient) sitting in common area in wheel chair. Pt (patient) alert with confusion. Unable to make needs known. RSP even on R/A (room air). ABD (abdomen) soft and non-tender. +BS (bowel sounds). No S/S (signs/symptoms) pain or discomfort. Supplies ordered. Called pt (patient) daughter to update on visit with no answer. Message left. ALF (assisted living facility) made aware to call GSH (Good Shepherd Hospice) with any questions or concerns." There is no documented evidence the Licensed Practical Nurse reported their assessment to a Registered Nurse. The survey findings and interview were conducted on 01/09/2025 at 3:30pm with the Director of Performance Improvement, Director of Patient Services and Administration staff. No explanation was provided.

Based on home visit observation, clinical record review and staff interview, the Hospice failed ensure dietary counselling and intervention necessary are provided to patients as condition progresses. This was evident in the one (1) of six (6) home visits conducted (Patient # 3). Failure to ensure patients nutritional changes are assessed by a qualified individual can result in negative patient outcomes. --- Patient #3 has a start of care date of 12/26/2024 with diagnoses of late onset Alzheimer's Dementia, Hypertension, Stroke , and Transient Ischemic Attack as documented on the "Hospice Plan of Care" for certification period of 02/26/2024 to 02/23/2025. The "Hospice Plan of Care" for certification period of 12/26/2024 to 02/23/2025 documents order for Skilled Nursing, 1 to 2 visits every week for 10 weeks; 1 to 6 visits as needed for 10 weeks for pain and symptoms management. The skilled nursing plan of care note dated 12/27/2024 documented patient had a 12 lb. weight loss with recent vomiting when trying to eat. A home visit was conducted on 01/07/2025 at the Skilled Nursing Facility where patient resides. Patient's family member was present and informed surveyors patient has problem swallowing, tends to pocket food and appetite has declined. The record lacked documented evidence that the Hospice referred the patient for swallowing and dietary evaluation. Survey findings and interview were conducted on 01/07/2025 at 2:15.PM with the Hospice Nurse and Supervisor. No explanation was provided. The survey findings were reviewed with Hospice Administrator, and Director of Patient Services at the exit conference on 01/13/2025.

Based on home visit observation, clinical record review and staff interview, the Hospice failed to ensure coordination and evaluation of services between the Hospice and the skilled nursing facility. This was evident in the one (1) of six (6) home visits conducted (Patient #3). Failure to ensure coordination of services has the potential for negative patient outcomes. --- Patient #3 has a start of care date of 12/26/2024 with diagnoses of late onset Alzheimer's Dementia, Hypertension, Stroke, and Transient Ischemic Attack as documented on the "Hospice Plan of Care" for certification period of 12/26/2024 to 02/23/2025. The "Hospice Plan of Care" for certification period of 12/26/2024 to 02/23/2025 documents order for "Skilled Nursing, 1 to 2 visits every week for 10 weeks; 1 to 6 visits as needed for 10 weeks for pain and symptoms management". The clinical record lacked documented evidence of communication between the IDG (Interdisciplinary Group) and the skilled nursing facility. A home visit was conducted on 01/07/2025 between 2:00PM and 2:45PM at the Skilled Nursing Facility where patient resides. The Skilled Nursing Facility staff were interviewed during the visit. The staff at the facility denied having received training in Hospice Care Philosophy, the Hospice's Policy and Procedure, and written instructions for hospice-related interventions. Survey findings and interview were conducted on 01/07/2025 at 3:55.PM with the Hospice Nurse and Supervisor. No explanation was provided. The survey findings were reviewed with Hospice Administrator, and Director of Patient Services at the exit conference on 01/13/2025.

Based on clinical record review and staff interview, the Agency failed to ensure the Interdisciplinary Group coordinate and communicate pertinent changes in patient conditions at all Interdisciplinary Group meetings. This was evident in one (1) of three (3) clinical records reviewed. Patient #1. Failure to ensure that the Interdisciplinary Group coordinate and communicate pertinent changes in patient conditions, has the potential for negative patient outcome. The findings include: --- Patient #1 has a start of care date of 07/20/2023 with diagnoses of Diffuse large B-Cell Lymphoma, Secondary Malignant Neoplasm of Retro perineum and Peritoneum, Malignant Ascites, Encounter for change or removal of drains, and Pleural Effusion as documented on the ";Physicians Order and Plan of Care" dated 07/20/2023 – 10/17/2023. The ";Physicians Order and Plan of Care" dated 07/20/2023 – 10/17/2023 and 10/18/2023 to 01/17/2024 documents: Skilled Nurse 1x day x1 one visits a week for one week), 6 PRN (six visits as needed), 1x day x2 (one visit a week for two weeks), 1 -2 x week x 12 weeks (one to two visits a week for twelve weeks). A" Supplemental Order" dated 07/20/23 documents: Oxygen 2 – 4 liters per minute intermittent via Nasal Cannula". The Skilled Nurse visit note dated 08/02/2023, the Licensed Practical Nurse documents the ";patient ";daughter c/o (complaint of) that patient had a cough. No cough noted during visit and patient denies cough". The visit record note dated 08/06/2023, the Skilled Nurse documents the patents ";left eyes appears blood shot due to possible persistent coughing. TC (telephone call) to Medical Doctor and Diflucan 100 mg (milligram) ordered for six (6) days and Tussin DM Q 6-hour PRN (every six hours as needed). The visit record note dated 08/07/203, the Registered Nurse documents ";Oxygen at 3 Liters/minute. Respiration labored upon exertion. Crackles noted on auscultation. The visit record note dated 08/09/2023, the Licensed Practical Nurse documents ";cough has decreased". The visit record note dated 08/14/2023, the Registered Nurse documents ";cough better, stopped Tussin. Respiration even and unlabored". The Interdisciplinary Team meeting dated 08/17/2023 lacks documentation of the patients cough and pertinent medication changes for respiratory symptom management. The visit record note dated 08/21/2023, the Registered Nurse documents ";Respiration even and unlabored on Oxygen at 3 Liters per minute via Nasal Cannula. Breath Sounds diminished bilaterally". The visit record note dated 08/28/2023 and 09/05/2023, the Registered Nurse documents ";Respiration even and unlabored on Oxygen 3 Liters per minute via Nasal Cannula. Breath sounds decreased on right side". The Interdisciplinary Team meeting dated 08/31/2023 lacks documentation of the changes in the patients condition and diminished breath sounds. The Interdisciplinary Group did not maintain coordination, communication, discussion, and documentation of changes in patient conditions at all Interdisciplinary Group meetings. The survey findings and interview were conducted on 12/11/2023 at 2:50 PM with the Director of Patient Services and President of Quality Improvement. No explation was provided.

2010 NFPA 13 8.5.6* Clearance to Storage. 8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. 8.5.6.2 Where other standards specify greater clearance to storage minimums, they shall be followed. 8.5.6.3 A minimum clearance to storage of 36 in. (914 mm) shall be permitted for special sprinklers. 8.5.6.4 A minimum clearance to storage of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful largescale fire tests for the particular hazard. 8.5.6.5 The clearance from the top of storage to sprinkler deflectors shall be not less than 36 in. (914 mm) where rubber tires are stored. Based on observation and staff interview during the life safety code survey, the facility did not ensure that all components of the automatic sprinkler system were installed per 2010 NFPA 13. The findings include: During the life safety survey of 2/2/2022 at approximately 10:40 am, it was noted that in the IT closet located near room 102, a sprinkler head was located less than 18" above an equipment rack. This configuration would disrupt the spray pattern of the sprinkler head in the event of a fire emergency in this room. At the time of this finding, the facility's life safety compliance representative stated that this issue would be corrected.

2012 NFPA 101 19.3.6.4 Transfer Grilles. 19.3.6.4.1 Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors. 19.3.6.4.2 Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall be permitted to have ventilating louvers or to be undercut. Based on observation and interview during the life safety code survey, the facility did not ensure that all corridor doors were constructed to resist the passage of smoke. The findings include: During the life safety survey of 2/2/2022 at approximately 10:50 am, it was noted that the doors to the janitor's closet and the soiled utility room (located near room 108) were equipped with transfer grilles at the bottom of each door. These grilles would allow for the passage of smoke into the corridor in the event of a fire. At the time of this finding, the facility's life safety compliance representative stated that the openings in the doors would be covered.

Based on review of the hospice's admission packet given to the patient at the start of care, clinical record review, and staff interview, the Governing Authority (GA) failed to ensure that patients were fully informed of all components of the procedure for submitting a complaint. This was evident in the Hospice's Admission Packet and twenty-one (21) of twenty-one (21) Clinical Records reviewed (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21). Failure to ensure the patient is informed of all components of the procedures for submitting a complaint/grievance inhibits the patient's ability to exercise their rights with the potential to result in negative patient outcomes. The Hospice's "Admission Packet", reviewed on 01/10/2022, lacks documented evidence of the patient right to be fully informed of the procedures for submitting patient complaints. The "Admission Packet" includes the "Patient Rights and Responsibilities". Item #10 informs the patient how to "express complaints" and fails to advise the patient of the right to appeal the outcome of the agency's complaint investigation and the appeals process with review by a member or committee of the governing authority within 30 days of receipt of the appeal. The Clinical Records of all patient's reviewed during survey (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) lack documented evidence of being advised of the complaint appeals process. The Hospice's Director of Patient Services and Director of Performance Improvement on 01/10/2022 at 2:15 PM were interviewed. The findings were acknowledged on 01/18/2022 at 11:00 AM by the Director of Performance Improvement.

Based on Clinical Record review and staff interview, the Hospice failed to develop plans of care that are individualized based on a comprehensive assessment of the patient's needs; and in collaboration with the interdisciplinary group. This was evident in four (4) out of twenty-one (21) records reviewed (Patient's #2, #5, #14, and #19). Failure to develop a comprehensive plan of care that addresses the patient's needs has the potential for negative patient outcomes. The findings are: 1) Patient #2 has a start of care date of 08/03/2021 with diagnoses of Alzheimer's Disease with late onset, Dementia in other diseases classified, Unspecified Urinary Incontinence, and Chronic Obstructive Pulmonary Disease as documented on the "Physician's Orders/Plan of Care" from 11/01/2021 to 01/29/2022. The "Physician's Orders/Plan of Care" from 11/01/2021 to 01/29/2022 documents "SN: 1-2xweek x 12 weeks, 5 PRN: symptoms management. The "Physician's Order/Plan of Care" from 08/03/2021 to 10/31/2021 documents "SN: 1 x day x 1 day, 2 x week x 1 week, 1-2 x week 12 weeks, 6 PRN: symptoms management". The Clinical Record includes evidence of nursing visits on 09/23/2021 then 10/06/2021. During this time nursing visit frequency is 1-2 x week as documented on the "Physician's Orders/Plan of Care". The Clinical Record lacks documented evidence of a nursing visit for the week of 09/26/2021. The Clinical Record includes evidence of nursing visits on 11/16/2021 then 12/05/2021. During this time nursing visit frequency is 1-2 x week as documented on the "Physician's Orders/Plan of Care". The Clinical Record lacks documented evidence of a nursing visit for the weeks of 11/21/2021 and 11/28/2021. The "Physician's Orders/Plan of Care" from 08/03/2021 to 10/31/2021 documents "SN: 1 x day x 1 day, 2 x week x 1 week, 1-2 x week 12 weeks, 6 PRN: symptoms management. Wound care as ordered Left heel area. NS (normal saline). Betadine. Border gauze. 2 x day. Family independent. The Comprehensive Nursing Assessment conducted on 08/03/2021, start of care, fails to document the left heel wound measurements. The initial measurement of the left heel wound is documented on the 09/02/2021 nursing visit note. Nursing visits were conducted on 08/03/2021, 08/05/2021, 08/11/2021, 08/19/2021, and 08/26/2021. That is, five (5) nursing visits were conducted before the initial measurement assessment of the left heel wound. The Assistant Vice President (AVP) and Director of Quality Assurance were interviewed on 01/18/2022 and the AVP states: "wounds should be measured weekly". Findings were reviewed with the Assistant Vice President and Director of Quality Assurance on 01/18/2022 at 11:05 AM. Findings were acknowledged on 01/18/2022 at 2:25 PM. 2) Patient #19 has a start of care date of 04/13/2021 with diagnoses of End stage heart failure, Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease as documented on the "Physician's Orders/Plan of Care from 04/13/2021 to 07/11/2021". The "Physician's Orders/Plan of Care from 04/13/2021 to 07/11/2021" document SN 1 x day x 1 day, 1-2 x week x 1 week, 1-2 x week x 12 weeks, 6 PRN: pain and symptom management and wound care as ordered. Wash sacral area extending to buttocks with wound cleanser, pat dry apply triad cream daily, cover with DPD and PRN (as needed) when soiled, Pressure injury. The Clinical Record documents a sacral/buttock wound measurement on 04/13/2021 at the start of care nursing assessment visit. Nursing visits were conducted on 04/15/2021, 04/23/2021, 04/27/2021, 04/29/2021, and 04/30/2021. The Clinical Record lacks documented evidence the wound to the sacral/buttocks area was measured after 04/13/2021. Findings were reviewed with the Assistant Vice President and Director of Quality Assurance on 01/18/2022 at 11:05 AM. Findings were acknowledged on 01/18/2022 at 1:00 PM. 3) Patient #5 has a start of care date of 10/14/2021 with diagnoses Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease and Unspecified systolic (congestive) heart failure as documented on the "Physician's Orders/Plan of Care from 01/12/2022 to 04/11/2022". The "Physician's Orders/Plan of Care from 10/14/2021 to 01/11/2022" documents PC (Pastoral Care): 1-2 x month x 3 months, 6 PRN: spiritual support". The Clinical Record documents a "Charts/Clinical Notes", dated 10/19/2021 at "9:40 am chaplain initial phone call to pcg (primary care giver), introduce self and offer to visit patient. PCG said would ask father if he open to chaplain visit and a Priest to come, give him Sacrament of the sick." The Clinical Record documents a "Charts/Clinical Notes" dated 12/30/2021 at "12:50 pm Chaplain phone call to PCG. PCG said patient decline chaplain services at present time. Updated POC to reflect decline". The Clinical Record lacks documented evidence of a Pastoral Care visit for the month of November as frequency is 1-2 x month. Findings were reviewed with the Assistant Vice President and Director of Quality Assurance on 01/18/2022 at 11:05 AM. Findings were acknowledged on 01/18/2022 at 1:52 PM. 4) Patient #14 has a start of care date of 07/16/2021 with diagnoses of Alzheimer's Disease, unspecified, Dementia in other diseases classified elsewhere without behavioral disturbance and pure Hypercholesterolemia, unspecified as documented on the "Physician's Orders/Plan of Care from 10/14/2021 to 1/11/2021", the date of discharge from the Hospice. The "Physician's Orders/Plan of Care from 10/14/2021 to 1/11/2021" documents "SN: 1-2 x week x 12 weeks, 5 PRN: symptoms management". The Clinical Record documents nursing visits on 10/20/2021 then 11/03/2021 and fails to document a visit the week of 10/24/2021 when the SN frequency is 1-2 x week. Findings were reviewed with the Assistant Vice President and Director of Quality Assurance on 01/18/2022 at 11:05 AM. Findings were acknowledged on 01/18/2022 at 2:25 PM.

Based on Clinical Record reviews and staff interviews, the hospice failed to ensure the Plans of Care were complete and failed to reflect all of the patient's needs. This was evident in two (2) out of twenty-one (21) records reviewed (Patient's #12 and #16) Failure to develop a patient specific individualized and complete plan of care has the potential to result in unmet patient needs and negative patient outcomes. The Findings are: 1) Patient #12 has an Admission date of 10/24/2021 with the following diagnoses: Idiopathic Pulmonary Fibrosis, Personal history of other Malignant Neoplasm of Large Intestine, and Pressure Ulcer of Sacral region, stage 2 as documented on the "Physician's Orders/Plan Of Care" dated 10/24/21 to 01/21/22. The "Physician's Orders/Plan Of Care" dated 10/24/21 to 01/21/22 documents: "Wound Care as ordered: clean with wound cleanser, apply triad cream and cover with biatain 4x4 cm bandage". The wound care orders fails to include frequency of wound care to Sacral Region. The Skilled Nursing Visit Notes documents wound care provided by the SN once a week on the following weeks: 10/24/21, 11/02/21, 11/09/21, 11/16/21, 11/18/21, 11/23/21, 11/30/21, 12/07/21, 12/14/21, 12/20/21, 12/30/21, 01/06/22, and 01/14/22. There is no documented evidence of Interim Orders for frequency of wound care treatment to Sacral region. On 01/18/2022 at 2:25 PM, the Assistant Vice President, and Director of Quality Assurance were interviewed. The Assistant Vice President states: "there is no frequency documented for the wound care orders, it should have been 3 x week. The family was taught on the 1st visit with return demonstration. Family was independent other 2 days when the nurse was not in the home. 2) Patient #16 has a start of care date of 06/29/2021 with diagnoses Nonrheumatic Aortic (Valve) Stenosis, Dementia with Lewy bodies, Personal history COVID-19, Unsteadiness on feet as documented on the "Physician's Orders/Plan of Care from 09-27-21 to 12-25-21" and "12-26-21 to 02-23-22". The "Physician's Orders/Plan of Care from 09-27-21 to 12-25-21", the order is incomplete as it lacks Volunteer services. The Volunteer visit notes are dated 09/29/21, 10/01, 10/03, 10/05, 10/07/21 to 10/09/21, 10/11, 10/15, 10/18, 10/20, 10/23, 10/25, 10/27, 10/29/21, 11/01, 11/03, 11/05, 11/10/21 to 11/13/21, 11/15/21, and 11/17/21. On 01/19/22 at 10:00 AM, the Assistant Vice President and Director of Quality Assurance were interviewed and informed of the survey findings. At 3:25 PM, the Assistant Vice President states: "it's a system issue, on 07/21/21, the IDG (Interdisciplinary Group) reviewed in the team and has been on every Team Care Plan reflecting: "VC (Volunteer Care) 1-2 x month x 3 month; 6 PRN (as needed): companionship and socialization". The findings were confirmed; no additional evidence was provided.

Based on Clinical Records review and staff interview, the hospice failed to ensure that Interdisciplinary Group (IDG) reviewing and revising the plan of care at least every 21 days. This was evident for one (1) out of twenty-one (21) Clinical Records reviewed (Patient #14). Failure to ensure that IDG reviewing and revising the plan of care at least every 21 days, has the potential for negative patient outcomes. The finding is: Patient #14 has a start of care date of 07/16/2021 with diagnoses Alzheimer's Disease, unspecified, Dementia in other diseases classified elsewhere without behavioral disturbance and pure Hypercholesterolemia, unspecified as documented on the "Physician's Orders/Plan of Care from 10/14/2021 to 1/11/2021", the date of discharge from the Hospice. The Clinical Record documents the Hospice Interdisciplinary Group (IDG) reviewed the patient's individualized team care plan on 11/24/2021 then on 12/29/2021. The Hospice failed to ensure the IDG reviewed the patient's team care plan at a minimum of every twenty-one (21) days( Per CMS current waiver). Findings were reviewed with the Assistant Vice President and Director of Quality Assurance on 01/18/2022 at 11:05 AM. Findings were acknowledged on 01/18/2022 at 2:25 PM.

Based on Clinical Record reviews, Home Visit (HV) observations, and interviews with hospice staff, the hospice nurse failed to develop a coordinated plan of care with the Skilled Nursing Facility (SNF) to meet the needs of the hospice patient. This was evident in one (1) of one (1) visits conducted in SNF (Patient #4). Failure to communicate, coordinate, and provide professional management of hospice patients that reside in a SNF has the potential for provision of inadequate patient care and unmet patient needs. The Findings are: Patient #4 (HV), a SNF patient, was admitted to the Hospice on 06/24/21 with diagnoses Ischemic Cardiomyopathy, Anemia unspecified, Gastrointestinal hemorrhage, unspecified, and Nausea and Vomiting as documented on the "Physician's Orders/Plan of Care from 09-22-21 to 12-20-21" and "12-21-21 to 02-18-22". A Home Visit to this patient residing in a SNF, was conducted on 01/11/22 at 11:40 AM with the Hospice Skilled Nurse (SN) and the Director of Patient Services. The SNF MAR (Medication Administration Record) printed on 01/11/22 at 11:57 AM was compared to the Hospice Clinical Record Physician's Orders/Plan of Care printed on 01/10/22 which was provided to the surveyor prior to visit documents that the SNF Nurses were no longer administering the following medications, which were still included on the hospice "Physician's Orders/Plan of Care" dated 12/21/21 to 02/18/22. For example: Pantoprazole Sodium by mouth tablet delayed release 40 mg 1 tablet daily by mouth; and Sennosides-Docusate Sodium by mouth tablet, 2 tablet bedtime by mouth. The original ordered date is documented as "06/24/2021". The hospice RN visits the patient on 11/10/21, 11/18/21, 11/23/21, 11/29/21, 12/01/21, 12/07/21, 12/09/21, 12/17/21, 12/24/21, 12/28/21, and 01/06/22 and documents "patient is managed on current poc (plan of care)" per SNF staff. The Hospice Assistant Vice President were interviewed on 01/18/22 at 10:15 AM, and informed of the survey findings. The Assistant Vice President states: the medication "Pantoprazole and Sennosides-Docusate Sodium were discontinued in December 2021". The hospice Electronic Medical Record documents: "Pantoprazole" was discontinued on 12/01/21 and "Sennosides-Docusate Sodium" was discontinued as of "7/7/21" after the findings were reviewed with the hospice. The Assistant Vice President states, the nurses are suppose to reconcile the medication on a weekly visits and coordinates care with the SNF Nurses.