Every finding on record at Hca Acquisition Holdings Inc.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 01/10/2025 with a diagnosis of Parkinson's disease with dyskinesia, without mention of fluctuations. The initial nursing assessment dated 01/10/2025, the narrative documented, "The patient eats bites of mechanical soft diet with honey thickened liquids....He has significant dysphagia and requires feeding". The interdisciplinary group (IDG) POC dated 01/10/2025 did not document a goal(s) and an intervention(s) for dysphagia. Clinical Record 5: The patient elected hospice care on 08/21/2023 with a diagnosis of chronic diastolic congestive heart failure. The initial "Massage Therapy Hospice Add-On Evaluation" dated 08/28/2023, ordered one (1) time weekly for massage. This document provided evidence of massage goals and interventions. The IDG POC dated 08/28/2023 documented the problem: "Massage therapy evaluation for hospice patient." The IDG POC dated 08/28/2023 did not document goal(s) and intervention(s) for massage therapy. The Corporate Manager of Accreditation and the Manager of Clinical Services stated during an interview and a joint record review on 04/11/2025, that the Massage Therapist was documenting goals and interventions within the visit note, but the goals and interventions were not flowing over to the IDG POC like the other disciplines. They stated, "It appears there might be a 'Click' that was missed." The Administrator, Manager of Accreditation, and Manager of Clinical Services confirmed during an interview on 04/11/2025 that the IDG POC did not reflect patient and family goals and interventions based on problems identified in the comprehensive assessments.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the plan of care (POC) included all treatments to meet the patient's needs. Clinical Record 4: The patient elected hospice care on 06/23/2023 with a diagnosis of Ischemic cardiomyopathy. The skilled nursing (SN) assessment dated 12/20/2024 documented that the SN received wound care orders from the physician: "Hospice nurse to cleanse with wound wash, pat dry with gauze, apply small amount of medihoney, and cover with dressing once weekly. Family to perform wound care once weekly or as needed if soiled or dislodged." The IDG POC dated 12/20/2024 documented the patient goal "Need for wound care - Hospice." The IDG POC documented the interventions, "Provided wound care per physician orders...Instructed in performing wound care." A clinical record review revealed no evidence of the IDG POC documenting interventions for the specific wound care to be provided by the SN, and the specific wound care to be taught to the patient's caregivers. The Administrator, Manager of Accreditation, and Manager of Clinical Services stated in an interview on 04/11/2025 that the IDG POC did not include all interventions with specifics.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.. This standard was not met as evidenced by document review and interview. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the "Volunteer Hours Compared to Direct Patient Care Employee Hours Report" revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency's 2024 "Volunteer Hours Compared to Direct Patient Care Employee Hours Report" revealed that the volunteer percentage of hours worked for the year 2024 was 1.48%. There was evidence of a performance improvement plan (PIP) initiated in January 2025. However, the agency has not reached the 5% usage since the implementation of the PIP. The percentage of volunteer hours for January 2025 = 0.4%; February 2025 = 0.2%; and March 2025 = 0.1%. The Regional Volunteer Coordinator stated in an interview on 04/11/2025 that three (3) new volunteers are onboarding at the agency. During an interview on 04/11/2025, the Administrator, Manager of Accreditation, and Manager of clinical services confirmed that volunteers had not provided at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the "Volunteer Hours Compared to Direct Patient Care Employee Hours Report" revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

Based on a review of clinical records, policies and staff interview, it was determined the Hospice failed to ensure care and services were furnished according to the Patients individualized POC. This was found in 3 of 4 (Pt. #1, 2 and 4) clinical records reviewed. --- Findings include: 1. Pt. #1. SOC: 4/28/21. Diagnosis: Alzheimers Disease. The clinical record was reviewed on 5/22/23 at 12:30 PM. The record contained a physician order for 3/3/23 requiring a Hospice Aide frequency of 3 times a week for 6 weeks. The record lacked documentation of 1 Hospice Aide visit for the weeks of 3/19/23 to 3/25/23 and 4/9/23 to 4/15/23. ";Caregiver Provided Care" was documented on the record as description on how patients needs were met but there was no documentation for the reason of the missed visits. 2. Pt. #2. SOC: 11/22/22. Diagnosis: Parkinsons Disease. The clinical record was reviewed on 5/22/23 at 1:30 PM. The record contained a plan of care update dated 4/12/23 which required the Hospice to continue the Hospice Aide frequency of 2 times a week for 12 weeks. The record lacked documentation of 1 Hospice Aide visit for the following weeks: 2/12/23 to 2/18/23, 2/19/23 to 2/25/23, 2/26/23 to 3/4/23, 3/12/23 to 3/18/23, 3/19/23 to 3/23/23 and 4/2/23 to 4/8/23. ";Caregiver Provided Care" was documented on the record as description on how patients needs were met but there was no documentation for the reason of the missed visits. 3. Pt. #4. SOC: 4/1/23. Diagnosis: Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 5/22/23 at 2:30 PM. The record contained a plan of care dated 4/1/23 which required Hospice Aide frequency of 2 times a week for 12 weeks, then 1 time a week for 1 week. The record lacked documentation of 1 Hospice Aide visit for the weeks of 4/2/23 to 4/8/23, 4/9/23 to 4/15/23 and 4/30/23 to 5/6/23. ";Caregiver Provided Care" was documented on the record as description on how patients needs were met but there was no documentation for the reason of the missed visits. 4. The Agency Policy titled, ";The Plan of Care" which was reviewed on 5/22/23 includes, ";The care provided to the patient must be in accordance with the plan of care." 5. The Agency Policy titled, ";Missed Visits" which was reviewed on 5/22/23, requires: ";1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled, the clinician will: A. Notify the Interdisciplinary Team, Manager of Clinical Services of the missed visit and the reason of the missed visit... B. Document in the patients clinical record the following information: 3. Reason for the missed visit... 5. Any other follow-up needed." 6. An interview was conducted at 3:00 PM with Manager of Clinical Services/RN Coordinator (E#1) related to missed visits for Pts. #1, #2 and #4. During the same interview, E#1 reviewed and confirmed all of the above-mentioned missed visits. E#1 also confirmed that documentation for the reason of missed visits was not specified. E#1 stated that the phrase ";...Caregiver Provided Care..." is a default phrase in the software that is allowed to be entered in the system, but staff can enter specific reasons for the missed visit. E#1 stated, ";Im not sure why the aide visits were missed."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records, document review and interview. Policy #9-020, "Hospice Aide Services", states in part, "Hospice aide will document care provided in accordance with the hospice aide assignment." 2 of 5 (40%) clinical records reviewed of patients who received hospice aide services revealed the aide failed to provide services ordered by the interdisciplinary group (IDG) and included in the aide plans of care (POC). Clinical Record 2: The patient was admitted on 9/23/22 with a diagnosis of Alzheimer's Disease. The aide POC dated 12/23/22 assigned the aide to perform a "shower" for the bathing task. The aide visit note dated 2/12/23 documented the aide completed a "partial sponge bath". The aide failed to provide the bathing task assigned on the aide POC. Clinical Record 1: The patient was admitted on 6/11/22 with a diagnosis of Alzheimer's Disease. The aide POC dated 9/22/22 assigned a "shower" for the bathing task. The aide visit note dated 2/8/23 documented the aide completed a "bed bath". The aide failed to provide the bathing task assigned on the aide POC. Upon interview on 2/21/23, the Manager of Clinical Services and the Manager of Accreditation reviewed the records and agreed with the findings. THIS FORMER REQUIRED ACTION CONTINUES at a lower rate of non-compliance than previously (64%)

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records, document review and interviews. Policy #9-020, "Hospice Aide Services", states in part, "Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities." 2 of 5 (40%) clinical records reviewed of patients who received hospice aide services revealed the aides failed to report changes in the patients' medical needs to a registered nurse (RN). Clinical Record 2: The patient was admitted on 9/23/22 with a diagnosis of Alzheimer's Disease. The aide POC was dated 12/23/22. The aide visit note dated 2/13/23 documented, "No" for "completed patient shower", and documented in the comments box that a partial sponge bath was completed. The record lacked evidence that the aide notified the RN regarding the patient's request to change the bath-type assignment from "shower" to "partial sponge bath" on the aide POC. Clinical Record 1: The patient was admitted on 6/11/22 with a diagnosis of Alzheimer's Disease. The aide POC was dated 9/22/22. The aide visit note dated 2/8/23 documented, "No" for "completed patient shower", and documented in the comments box that a bed bath was completed. The record lacked evidence that the aide notified the RN regarding the patient's request to change the bath-type assignment from "shower" to "bed bath" on the aide POC. Upon interview on 2/21/23, the Manager of Clinical Services and the Manager of Accreditation reviewed the records and agreed with the above findings. THIS FORMER REQUIRED ACTION CONTINUES at a lower rate of non-compliance than previously cited (64%)

It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 2 (50%) live discharge records, the patient and family were not provided the information for hospice coverage of benefits with the opportunity to have time to appeal the discharge. Record #57611: The patient was discharged on 05/02/2022. A Physician Order on 04/28/2022 stated, "OK to discharge from hospice." Interdisciplinary Team meeting update from nursing on 04/28/2022 documented that, "Patient will be signing off of hospice at the end of his cert period 05/02/2022. Coordination Note was documented from social work on 05/02/2022 that "He understands he will be discharged "Graduated" on 05/02/2022 due to his improved and stabilized condition." Revocation signed 05/02/2022 was documented with the reason - "no longer eligible." Coordination note was documented 05/05/2022 that, "received discharge signed form since the patient is no longer on hospice services." Agency Policy, 9-002 Financial Responsibility and Medicare Written, Notices stated, "The ABN (Advance Beneficiary Notice) will be given if ineligibility because the beneficiary is not "terminally ill" as defined in 1879(g) (2) of the Act." Agency Policy, 1-025 Discharge from Hospice Program, stated, "Provide written notice as appropriate …If the patient is discharged to the community, the organization will inform the family both verbally and in writing, including a timeline for discontinuation of services." An interview with the Administrator and Director of Clinical Services on 06/07/2022 stated that the discharge was planned.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review, and interview. In 6 of 11 (55%) records reviewed, the agency failed to complete a timely comprehensive bereavement assessment within five (5) calendar days. Record #52922: The start of hospice care on 8/3/2021 had documented the first initial bereavement assessment on 8/23/2021. (this is day 20 and is 15 days late). Record #60657: The start of hospice care on 5/7/2021 had documented the first initial bereavement assessment on 5/26/2022. (this is day 19 and is 14 days late) Record #40860: The start of hospice care on 12/16/2021 had documented the first initial bereavement assessment on 1/17/2022. (this is day 30 and is 25 days late) Record #44482: The start of hospice care on 8/3/2021 had documented the first initial bereavement assessment on 8/23/2021. (this is day 20 and is 15 days late) Record #64048: The start of care on 1/10/2022 lacked documentation of an initial bereavement assessment as of 6/7/2022. (this is day 178 and 173 days late). Agency policy no. 1-014 Comprehensive Assessment stated, "a comprehensive patient assessment will be performed by the interdisciplinary group no later than five calendar days after the election of hospice care in consultation with attending physician...included...a bereavement assessment of the needs of the patient's family and other individual focusing on the nature of the relationship to the patient, circumstances surrounding the illness/prognosis, behaviors prior to and after the illness/prognosis, survivor needs and potential for pathological grief reactions." The interview with the Administrator revealed the bereavement assessments of the reviewed records were not completed timely within the five (5) calendar days requirement and noted the missing bereavement assessment of record #64048 had been completed as of 6/8/2022.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by review of clinical records, document review and interview. In 1 of 11 (09%) records reviewed revealed the agency failed to document an initial bereavement assessment. Record #64048: The start of care on 1/10/2022 lacked documentation of an initial bereavement assessment as of 6/7/2022. (this is day 178 and 173 days late). Agency Policy: 1-014 Comprehensive Assessment stated in part, "A bereavement assessment of the needs of the patients family and other individuals focusing on the nature of the relationship to the patient, circumstances surrounding the illness, behaviors prior to and after the illness, survivor needs, and potential for pathological grief. Agency Policy: 9-023 Bereavement Services stated in part, "A bereavement risk assessment will be completed by the hospice social worker or registered nurse at the time of the comprehensive assessment." Interview with the Administrator on 06/07/2022 stated that the bereavement assessment was not documented.

It is required that the hospice designates a Registered Nurse member of the IDG to: provide coordination of care and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by review of clinical records and interview. In 1 of 11 (09%) records reviewed, the RN failed to document coordination of care and oversight of care for the implementation of the physician ordered interdisciplinary plan of care. Record #57462: The hospice benefit of the election was signed on 05/10/2022. The patient was admitted following hospitalization for sepsis and co-morbidities not limited to three-stage four pressure areas, a tube feeding, and a Foley catheter which was being cared for at home with family in attendance. The initial plan of care for the patient failed to include the details for the tube feeding that should have included the tube type, rate, and flushes. The documentation as of review 06/07/2022 failed to document a complete assessment of the wounds that would consist of measurements, description of wound and wound edges as well as drainage, and ordered wound care. The record documented a physician order on 05/11/2022, "to assess sacral wound each visit, family to dress the wound daily and the Registered Nurse will change if the family has not done the dressing change." The record failed to document assessment of the sacral wound on nursing visits 05/10/2022, 05/11/2022, 05/17/2022, 05/20/2022, 05/24/2022, 05/27/2022, 05/31/2022, and 06/03/2022. The sacral wound was assessed and documented on 05/13/2022. Interview with the Director of Clinical Services on 06/08/2022 stated that the family is very concerned about the patient and told the nurse on 06/07/2022 that the wounds were starting to improve and that they wanted to continue to do the wound care. Interview with the RN Case Manager on 06/07/2022 reported that attempts had been made to schedule visits during wound care to evaluate the wounds but that the family always changed prior to these arranged visits. There is no documented wound deterioration, signs or symptoms of infection, or patient decline since admission to services.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records and interview. In 1 of 11 (09%) records reviewed the agency failed to document complete interventions for problems identified in the initial comprehensive assessment. Record #57462: An initial comprehensive assessment completed on 05/10/2022 identified a tube feeding through a PEG [percutaneous endoscopic gastrostomy ] tube and three-stage four decubitus ulcers. The initial plan of care and all updated plans of care as of review 06/07/2022 failed to document interventions for the tube feeding and complete interventions for the wound care. A physician's order was for Osmolite 1.5 calories 1000cc bag 55 milliliters per hour with a 40 milliliter flush (water) per hour. Still, these interventions were not documented on any of the plans of care. Additionally, an intervention for wound care of the sacral wound was documented, but no interventions for the two-stage four wound on each hip were not reported. Interview with the Administrator and Director of Clinical Services stated that the family provided most of the care but agreed that the interventions should have been on the plan of care.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group and written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by review of clinical records, document review, and interview. In 1 of 11 (9%) records reviewed the RN failed to document clear and specific instructions to the hospice aide assignment, thus leaving the aide to perform outside of their scope of practice. Record #57462: The hospice aide plan developed by the RN on 05/10/2022 failed to include an assigned task for peg tube care or how to manage large wound dressing during the assigned task of bed bath. The documented peg tube provided nutrition feeding during the day, and no task for the aide to wash around the tube or that the tube was present. The patient also had three large dressings for stage IV wounds that were not identified on the aide plan for what to do if the dressing were saturated or fell off. Agency policy no. 9-020 Hospice Aide Services (last review date 11/30/2021) stated, "hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record." The interview with the Administrator stated that the hospice aide care plan lacked detail and instructions on the peg tube care and reporting changes of the multiple wound dressing.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 7 of 11 (64%) records of patients that accepted hospice aides, the aide failed to provide the services in accordance with the documented plan of care. Record #52922: The hospice aide's written instruction documented on 5/19/2022 assigned the tasks of skin care, oral care, providing incontinence care, and transfer assistance at every visit. Aide visit note 5/18/2022 documented the oral care, incontinence care, and transfer assist as not completed with the reason of not applicable, and the task of skin care documented as not completed with the reason "RN order is for another scheduled visit this week." (the schedule was for the first visit of the week and that would be 5/18/2022). Aide visit note on 5/23/2022 documented the skin care, oral care, provide incontinence care as not completed with the reason of not applicable. Aide visit note on 5/26/2022 documented skin care, oral care, incontinence care, and transfer assistance as not completed with the reason of not applicable. Record #40860: The hospice aide's written instruction documented on 12/16/2021 assigned the tasks of oral care, skin care, perineal care, providing incontinence care, and transfer assistance at every visit. Aide visit note on 3/7/2022 documented the skin care, perineal care, oral care, provide incontinence care, and transfer assist as not completed with the reason of not applicable. Record #64048: The hospice aide's written instruction documented on 4/10/2022 assigned the tasks of turning and positioning in bed, dressing, bathing, shower, oral care, providing incontinence care, and changing linens at every visit. Aide visit note on 5/5/2022 documented the tasks of turn and position in bed, dressing, bathing shower, providing incontinence care and changing linens as not completed without reason of not applicable. Aide visit note on 5/9/22 documented the tasks of turn and position in bed, oral care, dressing, providing incontinence care, changing linens as not completed with the reason of not applicable and bathing shower as not completed with reason "RN order is for another scheduled visit this week." Aide visit note on 5/24/2022 documented turn and position in bed, oral care, change linens not completed with a reason as not applicable. Record #68773: The hospice aide's written instruction documented on 5/13/2022 assigned tasks of turn and position in bed, skin care, routine catheter care, oral care, dressing, provided incontinence care at every visit, and the tasks of the bathing shower at the last visit of the week and the task of transfer assist as needed. Aide visit note on 5/16/2022 documented turn and position as not completed with a reason not applicable. Aide visit note on 5/19/2022 documented turn and position in bed, oral care, provide incontinence care as not completed with the reason of not applicable. Aide visit note on 5/23/2022 documented turn and position in bed, oral care, and provide incontinence care as not completed with the reason of not applicable. Aide visit note on 5/26/2022 documented turn and position in bed and oral care as not completed with the reason of not applicable Record #57462: The hospice aide's written instruction documented on 5/10/2022 assigned tasks of bathing bed, routine catheter care, oral care, providing incontinence care, transfer assist, and empty urinary drainage bag at every visit. Aide visit note on 5/11/2022 documented bathing bed, routine catheter care, provide incontinence care, empty urinary drainage bag as not completed with the reason of not applicable. Aide visit on 5/16/2022 documented oral care and provided incontinence care as not completed with the reason of not applicable. Aide visit on 5/18/2022 documented bathing bed, providing incontinence care, transfer assist, and empty urinary drainage bag as not completed and reason of not applicable. Record #34408: The hospice aide's written instruction documented on 6/18/2021 assigned tasks of skin care, oral care, dressing, providing incontinence care and transfer assistance at every visit, and the tasks of the bathing shower and shampoo for the first visit of the week. Aide visit note on 6/25/2021 documented oral care and provided incontinence care as not completed with the reason of not applicable. Aide visit note on 6/28/2021 documented bath shower as not completed with the reason "RN order is for another scheduled visit this week" despite 6/28/2021 was the first visit of the week on a Monday and incontinence care documented as not completed with the reason of not applicable. Aide visit note on 6/30/2021 performed by LPN documented shampoo and bathing shower as not completed with the reason of "not day." Record #29432: The hospice aide's written instruction documented on 3/10/2022 assigned tasks of assisting to the toilet, assist feeding, oral care, providing incontinence care and transfer help at every visit, and the tasks of skin care, dressing, bathing, shower at the last visit of the week. Aide visit note on 4/25/2022 documented assistance with feeding, oral care, dressing, provide incontinence care as not completed with the reason of not applicable. Aide visit note on 4/27/2022 documented oral care as not completed with the reason of not applicable. Aide visit note on 5/2/2022 documented assist with feeding, oral care, and dressing as not completed with the reason of not applicable. Agency policy no. 9-020 Hospice Aide Services stated, "hospice aide will document care provided in accordance with the hospice aide assignment." Interview with Administrator that reviewed the aide records and agreed the tasks on the aide plan of care were not followed.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. In 7 of 11 (64%) records the Hospice aide failed to provide care tasks assigned at every visit and failed to document notification of the nurse. Record #52922: The aide visit note on 05/23/2022 documented skin care, oral care, and incontinence care as not completed with the reason of not applicable and lacked documentation of the nurse notified. Aide visit note on 5/26/2022 documented tasks of skin care, oral care, provide incontinence care, and transfer assistance documented as not completed with the reason of not applicable and lacked documentation of report to the nurse. Record #40860: The aide visit note on 3/7/2022 documented skin care, perineal care, oral care, provide incontinence care, and transfer assistance as not completed with a reason as not applicable and lacked documentation of report to the nurse. Record #64048: The aide visit note on 5/5/2022 documented turn and position in bed, dressing, bathing shower, provided incontinence care, change linens as not completed with a reason as not applicable and lacked documentation of report to the nurse. Aide visit note on 5/9/2022 documented turn and position in bed, oral care, dressing, provided incontinence care, change linens as not completed and reason note as not applicable with lacked documentation of report to the nurse. Aide visit note on 5/24/2022 documented turn and position in bed, oral care, change linens as not completed with reason note as not applicable and lacked documentation of report to the nurse. Record #68773: The aide visit note on 5/16/2022 documented turn and position as not completed, reason as not applicable, and lacked documentation of report to the nurse. Aide visit note on 5/19/2022 documented turn and position in bed, oral care, provide incontinence care as not completed with a reason as not applicable and lacked documentation of report to the nurse. Aide visit note on 5/23/2022 documented turn and position in bed, oral care, and provide incontinence care as not completed with a reason as not applicable and lacked documentation of report to the nurse. Aide visit note on 5/26/2022 documented turn and position in bed and oral care as not completed, reason as not applicable, and lacked documentation of report to the nurse. Record #57462: The aide visit note on 5/11/2022 documented bathing bed, routine catheter care, incontinence care, empty urinary drainage bag documented as not completed and reason as not applicable and lacked documentation of report to the nurse. Aide visit note on 5/16/2022 documented oral care and provided incontinence care as not completed, reason as not applicable, and lacked documentation of report to the nurse. Aide visit note on 5/18/2022 documented bathing bed, providing incontinence care, transfer assist, and empty urinary drainage bag as not completed with a reason as not applicable and lacked documentation of report to the nurse. Record #34408: The aide visit note on 6/25/2021 documented oral care and provided incontinence care as not completed, reason as not applicable, and lacked documentation of reporting to the nurse. Record #29432: The aide visit note on 4/25/2022 documented assistance with feeding, oral care, dressing, provide incontinence care as not completed and reason as not applicable and lacked documentation of report to the nurse. Aide visit note on 4/27/2022 documented oral care as not completed with the reason of not applicable and lacked documentation of report to the nurse. Aide visit note on 5/2/2022 documented assist with feeding, oral care, and dressing as not completed with a reason as not applicable and lacked documentation of report to the nurse. Agency policy no. 9-020 Hospice Aide Services stated, "hospice aides must report changes in the patient's medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities." Interview with Administrator stated that reviewed records had no evidence of nurse notification.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Responses to medications, symptom management, treatments, and services. This standard was not met as evidenced by review of clinical records, document review, and interview. In 1 of 11 (09%) records reviewed the RN failed to document a complete medication list or reconciliation of medication on the plan of care and complete nutrition treatment the patient received. Record #57463: The patient was admitted on 05/10/2022 following discharge from the hospital for sepsis, four large stage 4 wounds, a peg tube feeding, Foley catheter, and diabetes, managed at home with the family. The face-to-face documented on 05/05/2022 by the nurse practitioner and signed by the physician on 05/20/2022 documented the patient's tube feeding and sliding scale insulin. The hospital discharge paperwork on 05/04/2022 documented the patient using Humalog insulin [fast-acting insulin] 1-5 units every 6 hours. The hospital discharge paperwork on 05/04/2022 documented that a protein supplement was used in the feeding tube daily. The initial nursing assessment on 05/10/2022 documented the patient had a feeding of 1500 calories via PEG [ percutaneous endoscopic gastrostomy ] per pump. The initial plan of care on 05/10/2022 was documented in the section for Nutrition and tube feeding. No documentation on the plan of care as of review 06/08/2022 documents the type of tube feeding, the quantity of tube feeding, the rate of flow for the tube feeding, or if the protein additive continues. Additionally, no insulin is documented on the plan of care as of review 06/07/2022. The initial nursing assessment on 05/10/2022 documented that medications were reviewed and reconciled, but there is no documentation of the insulin or resolution with the interdisciplinary team. Agency Policy: #9-017 The Plan of Care stated in part, "The plan of care will identify the patient's needs and services to meet those needs, including the detail, the scope, and the frequency..... The written plan of care will contain, but will not be limited to, the following: nutritional requirements." Interview with the Director of Clinical Services and RN Case Manager stated that the patient is receiving the tube feeding and a written physician order, 05/11/2022 for the tube feeding of Osmolite 1.5 calories 1000cc bag 55 milliliters per hour with a 40 milliliter flush (water) per hour. The order does not document via a pump. This is not on the plan of care as of 06/08/2022. An interview with the RN Case manager on 06/08/2022 stated that the family decided they did not want to continue the sliding scale insulin but agreed that this decision was not documented in the record.