Every finding on record at Heartland Healthcare, Inc

Based on clinical record review, hospice policy review, nursing home record review, patient interview, patient representative interview, nursing home staff interview and hospice staff interview, the agency failed to: 1) ensure hospice staff placed the patient's advance directives in a prominent place in the patient's record for all hospice staff and non-hospice staff providing care to the patient to see (see L0503); 2) ensure the hospice staff honored the right of the patient to receive timely and effective pain, dyspnea and anxiety treatment related to the terminal and related illnesses (see L0512); and, 3) ensure hospice staff documented the patient/patient's representative's choice on whether or not they wanted information in writing about the care and services covered under the hospice benefit (see L0518). Findings include: --- The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the hospice promoted and supported the coordination of safe and effective delivery of care according to patient's advance directives to the hospice's patients.

Based on hospice clinical record review, hospice policy review, nursing home record review, patient and patient representative interview and hospice staff interview, the hospice failed to ensure the the documentation and correct identification, in a prominent part of the patient's record, any advance directives executed by the patient or patient's representative for 7 of 14 sampled patients (Patients #1, #2, #3, #4, #6, #11 and #13). Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: --- 2. Patient #1 had a hospice admission date of 7/21/22 and received routine home care hospice services while residing in a nursing facility (nursing home). Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by a registered nurse (RN), dated 7/21/22, included documentation the patient had chosen to not be resuscitated (DNR) in the event the patient stopped breathing or the patient's heart stopped. b. The initial evaluation completed by a social worker (SW), dated 7/25/22, included documentation the patient had a living will and durable power of attorney (DPOA) for healthcare. c. The clinical record lacked a copy of any of the advance directives enacted by the patient or patient's representative. d. The initial Plan of Care (POC), dated 7/21/22 to 10/18/22, included a place on the document for the hospice Interdisciplinary Group (IDG) to identify any advance directives the patient had in place. The POC identified the patient did not have any advance directives. e. The subsequent POC recertification periods, dated 10/19/22 to 1/16/23, 1/17/23 to 3/17/23 and 3/18/23 to 5/16/23, did not identify if the patient had any advance directives. f. The IDG meetings, dated 2/1, 2/15, 3/1, 3/8, 3/22 and 3/29/23, all identified the patient did not have any advance directives in place. On 3/29/23 at 9:00 AM, during an interview and record review with nursing facility staff, the nursing facility staff showed the surveyor a physician signed copy of the patient's DNR status. 3. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by a RN, dated 3/22/23, included documentation the patient/patient representative had chosen DNR status. b. The initial evaluation completed by a social worker (SW), dated 3/27/23, included documentation the patient had a living will and durable power of attorney (DPOA) for healthcare. c. The POC, dated 3/22/23 to 6/19/23, identified the patient had a diagnosis of Alzheimer's and only identified DNR as the patient's advance directive. On 4/5/23 at 9:52 AM, during an interview, the patient's DPOA confirmed their status as the active DPOA for healthcare decisions. The hospice POC failed to identify all of the patient's advance directives. 4. Patient #4 had a hospice admission date of 3/23/23, received routine home care hospice services while residing in a nursing home, and died on 3/29/23 after the start of the survey. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by a RN, dated 3/23/23, identified the patient had a dementia due to Alzheimer's disease and oriented to person only. The assessment included documentation the patient/patient representative had chosen DNR status. b. The hospice clinical record included a scanned copy of the patient's DPOA for healthcare effective since 2011. c. The POC, dated 3/23/23 to 6/20/23, identified for advance directives that the patient was DNR. The POC did not identify the patient had a DPOA. d. The IDG meeting, dated 3/29/23, identified the patient's only advance directive was DNR status. 5. Patient #6 had a hospice admission date of 4/6/22, received hospice services while residing in a nursing home, and revoked hospice services on 6/21/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by a RN, dated 4/6/22, identified the patient was alert, but oriented to person only, confused, difficulty understanding and lethargic. The assessment included documentation the patient/patient representative had chosen DNR status. b. The hospice clinical record included a scanned copy of the patient's DPOA for healthcare effective since 2011. c. The POC, dated 4/6/22 to 7/4/22, identified for advance directives that the patient was DNR. The POC did not identify the patient had a DPOA. d. The IDG meetings, dated 4/13, 4/27, 5/11, 5/24, 6/8 and 6/21/22, only identified the patient was DNR status. 6. Patient #11 had a hospice admission date of 7/28/22, received routine home care hospice services while residing in a private residence and died on 8/5/22. Review of the clinical record revealed the following: a. The POC, dated 7/28/22 to 10/25/22, identified the patient had chosen DNR status and had a living will. b. The hospice clinical record included a scanned copy of the patient's DPOA for healthcare dated 6/1/2016. The POC failed to identify the patient had a DPOA. 7. Patient #13 had a hospice admission date of 4/22/22, received routine home care services while residing in a private residence and respite services in a nursing home (4/29 to 5/3/22), and died on 5/9/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by a RN, dated 4/22/22, identified the patient had a primary diagnosis of Parkinson's disease, had impaired cognition, memory or consciousness. The assessment included documentation the patient/patient representative had chosen DNR status. b. The initial social worker visit, dated 4/25/22, included documentation the patient had a DPOA for healthcare and finances and had a living will. c. The POC, dated 4/22/22 to 7/20/22, identified the patient had a DPOA, but failed to identify the patient had a living will and was DNR status. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. According to the undated hospice policy titled Patient and Family Rights and Responsibilities, each hospice client has the right to receive information regarding advance directives including a living will and healthcare surrogate and will be able to voice concerns and not be discriminated against for doing so. 1. Patient #3 had a hospice admission date of 2/27/23 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The signed consent, dated 2/27/23, included in the patient wished to be a do not resuscitate (DNR). b. The initial assessment completed by the skilled nurse, dated 2/27/23, included documentation the patient's preferences regarding life-sustaining treatments and hospitalization included DNR preference confirmed with the patient. c. The initial Plan of Care (POC), dated 2/27/23 to 5/27/23, included a place on the document for the hospice Interdisciplinary Group (IDG) to identify any advance directives the patient had in place. The POC identified the patient had wishes for DNR. d. The IDG meetings, dated 3/8 and 3/22/23, identified the patient had initially signed a DNR but after admission decided he/she wanted to be full code status. The hospice physician identified with staff since the patient signed a DNR, he/she had to sign another form to revoke that before hospice going to declare them a full code. e. During an observational home visit on 4/4/23 at 9:00 AM, with Staff B, Clinical Manager, the patient stated they changed their wishes to be a full code and not a DNR. During an interview on 4/6/23 at 12:10 PM, the Administrator provided a copy of the patients advance directives for do not resuscitate status. He stated the advanced directive had not been returned signed by the physician. The hospice refaxed a copy of the advanced directives to the physician. Review of the clinical record lacked documentation of na new form to include the patient's wishes to be changed to a full code.

Based on clinical record review and hospice policy review, the hospice failed to ensure hospice staff offered effective and timely pain, dyspnea and anxiety management for conditions related to the patient's terminal illness and related conditions for 1 of 14 sampled patients (Patient #13). Failure to ensure hospice staff effectively manage the patient pain and other related symptoms in a timely manner placed hospice patients at risk to suffer pain and other symptoms unnecessarily. Findings include: --- Review of the the hospice's admission packet provided to patients and their families revealed the packet included information, titled Patient and Family Rights and and Responsibilities. The information identified the patient had the right to receive effective pain management and symptom control for conditions related to the terminal illness. Patient #13 had a hospice admission date of 4/22/22, received routine home care services while residing in a private residence and respite services in a nursing home (4/29 to 5/3/22), and died on 5/9/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a registered nurse (RN) at the start of care, dated 4/22/22, included documentation the patient reported zero pain on admission, but had a pain level intensity of 3 of 10 (with 10 the worst pain) in the last 24 hours. The patient described the pain as generalized, aching, daily, but not constant, weight bearing and certain position changes increased the patient's pain. The nurse assessed the patient had 3 plus pitting (applied pressure to the area leaves a 5 to 6 millimeter indentation for 30 seconds) edema (fluid retention) in the lower extremities. The patient had abnormal, diminished lung sounds and no respiratory treatment in place. The patient reported dyspnea (difficulty breathing) at a 2 of 10 (10 being the worst) in the last 24 hours, but zero at the time of the assessment. The nurse documented the patient declined treatment at the time of the assessment for shortness of breath. The patient reported anxiety was a zero at the time of the assessment, but had been a 2 in the last 24 hours. The patient wanted pain to be a zero intensity level. b. The Plan of Care (POC), dated 4/22/22 to 7/20/22, identified the patient had a primary diagnosis of Parkinson's disease and related diagnoses of hypertensive heart disease without heart failure and osteoarthritis. The POC included Interdisciplinary Group (IDG) orders for skilled nursing services 2 times per week, social work, chaplain and hospice aide services. The POC included one order for a medication to treat pain, Acetaminophen 325 milligrams, 2 tablets every 4 hours as needed. The POC included an order for Lasix 40 mg 1 to 2 tablets, take one tablet daily and may take an extra tablet for increased edema (fluid retention). The POC lacked any orders treatment of dyspnea (difficulty breathing) and lacked any orders for treatment of anxiety and depression. c. The skilled nursing visit, dated 4/23/22, included documentation the patient had no pain, but pain daily. The visit note lacked a pain intensity rating for last 24 hours. The nurse documented the treatment for pain was for the patient to reposition. The nurse documented the patient had 4 plus pitting edema in the lower extremities, abnormal, diminished breath sounds. The patient rated dyspnea at a 3, but up to 5 intensity level in last 24 hours. The nursed documented the initiation of rest and repositioning for dyspnea. The patient wanted the dyspnea level to be zero. The patient did not report any anxiety. d. The social worker evaluation, dated 4/25/22, and Chaplain evaluation, dated 4/25/22, both documented the patient did not have any pain. e. The skilled nursing visit, dated 4/26/22, included documentation the patient rated the pain level at the time of the visit at a 6, and the patient's pain had been a 6 in the last 24 hours. The patient described pain in the neck, shoulders and upper back as daily, but not constant. The nurse documented the pain was related to the patient's diagnosis of Parkinson's and osteoarthritis. The nurse documented methods used to alleviate pain included ice/hot pack, massage, over the counter pain medication, rest and to reposition. The patient again reported they wanted the pain level to be zero. The nurse documented the patient's skin was cyanotic (indicating an insufficient oxygen supply) and pale. The patient had extreme 4 plus pitting edema in the lower extremities, abnormal breath sounds with very little air flow in the lower lobes of the right and left lungs. The patient reported that dyspnea significantly affected the patient and rated the dyspnea level at a 3. The patient again reported they wanted the dyspnea level to be zero. The nurse documented no initiation of treatment for dyspnea. The nurse documented the patient was alert and oriented to person, place and time. The documented anxiety was not significantly affecting the patient. The patient had rated an overall sense of psychological well-being in the last 24 hours at a 4 of 10 (10 being the worst). f. The IDG meeting, dated 4/27/23, included documentation the nurse reported the patient had lower back pain and pain in the patient's buttocks. The nurse documented the patient had a small open wound on the left inner buttocks. The documented the patient took Acetaminophen as needed for pain. The nurse documented the patient was not seeking curative treatment for Parkinson's of lung cancer. The hospice diagnosis list on the POC and IDG meeting note did not include a diagnosis for lung cancer. The IDG meeting note lacked documentation of the patient's reports of pain in the neck, shoulders and upper back on 4/26/22 with a pain intensity rating of 6. The IDG meeting note lacked documentation the nurse reported the patient's dyspnea and 4 plus pitting edema. g. The skilled nursing visit, dated 4/29/23, included documentation the hospice was providing respite care to the patient at a nursing home. The patient reported having pain daily, but not constant at a 3 during the time of the visit, and pain at a 3 during the last 24 hours. The patient rated their anxiety level at a 3 and depression at a 5. The nurse assessed the patient had 4 plus pitting edema. The patient's lungs had wheezes with abnormal breath sounds and a cough. The nurse documented the patient's dyspnea was currently under treatment. The nurse did not document the patient's dyspnea level of intensity. The clinical record lacked documentation of any treatment for the patient's dyspnea. h. The skilled nursing visit, dated 5/3/22, included documentation the hospice was providing respite care to the patient at a nursing home. The nurse documented the patient rated their pain intensity at a 3 at the time of the visit. The patient reported pain had been at an 8 in the last 24 hours and felt their pain had not been brought back into an acceptable level within the last 24 to 48 hours. The nurse assessed the patient had dizziness, fainting, 4 plus pitting edema, leg cramps, discomfort with breathing while laying down flat, deteriorating respiratory condition with abnormal, diminished breath sounds. The nurse documented dyspnea did not significantly affect the patient. The patient rated their anxiety level at a 3 at the time of the visit and reported their anxiety level had been a 4 in the last 24 hours. The nurse documented anxiety significantly affected the patient and the patient had a deteriorating emotional status with a sense of psychological well-being in the last 24 hours at a 7. The nurse documented that they had not initiated treatment for anxiety. i. The skilled nursing visit, dated 5/4/23, included documentation the patient had returned home from respite. The nurse documented the patient rated pain at 6 during the visit, with pain being daily, but not constant. The patient had rated pain at a 7 in the last 24 hours. The patient continued to have edema in the lower extremities, abnormal and diminished breath sounds. The nurse documented dyspnea was not significantly affecting the patient. The patient rated anxiety and depression at a 3. j. The skilled nursing visit, dated 5/6/23, included documentation the patient rated pain at a 7 at the time of the visit. The patient continued to report the pain was daily, but not constant. The patient reported a pain level of 8 in the last 24 hours and felt their pain had not been brought back into an acceptable level within the last 24 to 48 hours. The nurse documented the patient reported severe pain with activity and moderate pain with rest. The nurse assessed the patient had 4 plus pitting edema in the lower extremities, abnormal and diminished breath sounds. The nurse documented the patient's dyspnea was currently under treatment. The patient reported an anxiety level of 4, with an intensity of 7 within the last 24 hours. The nurse documented the patient had a flat affect and rated their emotional well-being at a 7 in the last 24 hours. The nurse documented the implementation of Lorazepam and Morphine. The nurse documented the patient "was started on Gabapentin". k. Review of the hospice medication profile revealed a nurse added Gabapentin 100 milligrams three times per day for foot pain and a start date of 5/2/22. The hospice clinical record lacked documentation of the actual order for this medication. The hospice staff failed to ensure the patient's right to adequately receive timely and effective treatment for pain, anxiety and dyspnea. The patient reported a pain of 6 and dyspnea at a 4 on 4/26/22 and anxiety at a 3 an depression at a 5 on 4/29/22. The clinical record lacked documentation of any new interventions for pain until 5/2/22 with the start of Gabapentin. The patient continued to report pain with no relief on 5/3 and 5/4/22. The patient did not receive treatment for adequate pain, anxiety and dyspnea treatment until 5/6/22 with the start of Morphine (pain and dyspnea) and Lorazepam (anxiety and dyspnea). The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, family/patient representative interview and hospice staff interview, the hospice failed to ensure hospice staff documented whether or not the patient, or patient's representative chose to receive an election benefit addendum in writing, which identified the items (care, services, medications, treatments) specific to the patient not covered under the hospice benefit for 14 of 14 sampled patients ( Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14). Failure of hospice staff to ensure they included documentation in the clinical record which identified they honored the patient or patient representative right to receive written information which identified the items not covered under the hospice benefit resulted in patient not receiving necessary non-coverage information and placed patients at risk for being billed unexpectedly for treatment, medications or services. Findings include: --- 8. Patient #3 had a hospice admission date of 2/27/23 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: a. Review of the patient's Medicare Benefit Election Form, dated 2/27/23, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient and hospice staff. During an observational home visit on 4/4/23 at 9:00 AM the patient identified many forms were explained and signed at the start of care. The hospice home folder lacked any copies of of the signed Medicare Benefit Election Form. They stated some of the ordered medications were not covered under the hospice benefit and was surprised the medications would not be covered. During an interview during the same observational home visit, the spouse stated there has been confusion what hospice covers and what it doesn't cover. 9. Patient #5 had a hospice admission date of 5/2/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 5/2/22, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's durable power of attorney (DPOA) and hospice staff. 10. Patient 7 had a hospice admission date of 8/21/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 3/22/23, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient and hospice staff. 11. Patient #9 had a hospice admission date of 2/14/23 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 2/14/23, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient and hospice staff. 12. Patient #10 had a hospice admission date of 1/20/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 1/20/23, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient and hospice staff. 13. Patient #12 had a hospice admission date of 2/24/22 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 3/22/23, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's durable power of attorney (DPOA) and hospice staff. 14. Patient #14 had a hospice admission date of 5/31/22 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 5/31/22, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's durable power of attorney (DPOA) and hospice staff. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. 1. Patient #1 had a hospice admission date of 7/21/22 and received routine home care hospice services while residing in a nursing facility (nursing home). Review of the clinical record revealed the following: a. Review of the patient's Medicare Benefit Election Form, dated 7/21/22, included a section on the form which notified the patient, or patient's representative, that they had the right to request written notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The hospice must furnish this notification within 5 days, if request the notification on the start of care date. The hospice must furnish the notification within 72 hours or 3 days if requested during the course of hospice care. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient and hospice staff. b. The Plan of Care (POC), dated 7/21/22 to 10/18/22, identified the patient did not have any advance directives, and subsequent recertification periods to the POC, dated 10/19/22 to 1/16/23, 1/17/23 to 3/17/23 and 3/18/23 to 5/16/23, did not identify if the patient had any advance directives or a patient representative. On 3/29/23 at 7:59 AM, during a home visit observation with the Clinical Manager at the patient's nursing home, the surveyor observed the patient answered the Clinical Manager's questions appropriately with the exception of not knowing the day of the week. In an interview, during the same home visit observation, the patient was unable to answer the question on whether the patient had requested information on non-covered hospice items related to care and services or whether the patient had any out of pocket medical expenses since the start of hospice. On 3/29/23 at 8:47 AM, during an interview, the patient's primary nursing facility's nurse reported the patient was still able to sign and represent the patient's self. On 4/6/23 at 8:45 AM, during an interview, the Clinical Manager reported they had not given a copy of the signed patient rights and Medicare Benefit Election form to patients or their representatives ";for a while". 2. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 3/22/23, identified the form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's durable power of attorney (DPOA) and hospice staff. On 4/5/23 at 9:52 AM, during an interview, the DPOA for healthcare confirmed their active status as DPOA and reported being unsure if the hospice staff had given them a copy of the Medicare Benefit Election form, or if the hospice offered to give them specific information on what the hospice did not cover. The DPOA explained they signed a lot of forms and got a booklet with information in it. The DPOA denied having any out of pocket expenses for the patient. 3. Patient #4 had a hospice admission date of 3/23/23, received routine home care hospice services while residing in a nursing home, and died on 3/29/23 after the start of the survey. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 3/23/23, identified the form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's DPOA and hospice staff. 4. Patient #6 had a hospice admission date of 4/6/22, received hospice services while residing in a nursing home, and revoked hospice services on 6/21/22. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 4/6/22, identified the form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's DPOA and hospice staff. 5. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 12/20/22, identified the form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient and hospice staff. On 4/5/23 at 9:01 AM, during an interview, the patients spouse reported being unsure and unable to remember if the hospice discussed what services and medications would be covered under the hospice Medicare Benefit, or if they requested this information. The patients spouse explained it was such a whirlwind and there was too much going on. The patients spouse reported not having any out of pocket medical expenses; the hospice covered everything. 6. Patient #11 had a hospice admission date of 7/28/22, received routine home care hospice services while residing in a private residence and died on 8/5/22. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 7/28/22, identified the form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient and hospice staff. 7. Patient #13 had a hospice admission date of 4/22/22, received routine home care services while residing in a private residence and respite services in a nursing home (4/29 to 5/3/22), and died on 5/9/22. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 4/22/22, identified the form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's DPOA and hospice staff.

Based on clinical record review, hospice policy review, nursing home record review, nursing home staff interview and hospice staff interview, the hospice failed to: 1) ensure the hospice interdisciplinary group must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care (see L0523); 2) ensure the hospice nurse member of the interdisciplinary group completed a comprehensive assessment which included a complete assessment of the patient's physical condition including alterations in skin integrity (wounds) (see L0524); 3) ensure the hospice interdisciplinary group completed a drug regimen review that included the required components with each comprehensive and update to the comprehensive assessment (see L0530); and 4) ensure the hospice nurse member of the interdisciplinary group updated the comprehensive assessment with changes to the patient condition and included wound assessment and measurements per hospice policy (see L0533). --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and treatment needs to their hospice patients.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure all members of the patient's hospice interdisciplinary group completed the comprehensive assessment no later than 5 calendar days after the election of hospice care benefit for 3 of 14 sampled patients (Patient #2, #8 and #14). Failure of all of the patient's Interdisciplinary Group members to complete the comprehensive assessment within 5 calendar days after the election of hospice care increased the risk the patients assessed needs would not be treated appropriately and timely. --- 2. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by a registered nurse (RN), dated 3/22/23, identified the patient's religious faith and included documentation the RN had referred the patient for spiritual counseling by the hospice chaplain. b. The Plan of Care (POC), dated 3/22/23 to 6/19/23, included an IDG order for chaplain services 1 time the first month and interventions for the chaplain to evaluate the patient and develop a POC. c. The initial spiritual evaluation completed by the hospice chaplain, dated 3/28/23, included documentation the patient was alert and engaged with the chaplain. The chaplain determined the patient would benefit from spiritual care services 2 times per month and included documentation of interventions and goals related to this service. The chaplain failed to complete their portion of the initial comprehensive assessment as part of the patient's identified Interdisciplinary Group (IDG) within 5 days from the election of the hospice benefit (dated 3/22/23). On 4/5/23 at 5:10 PM, during an interview, the Chaplain reported trying to get out to see patients within the first 5 days after the patient elects to receive hospice services, but the Chaplain reported working another job and sometimes they go over the 5 days. 3. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN at the start of care, dated 12/20/22, included documentation the nurse had collaborated with the social worker and medical director regarding the patient's POC. b. The POC, dated 12/20/22 to 3/19/22, included IDG orders for social work (SW) services complete an evaluation and develop a POC. The POC included orders for SW 1 time the first month. c. The clinical record lacked documentation of a SW visit or attempt to visit prior to the patient's death on 12/27/22. The SW failed to complete their portion of the initial comprehensive assessment as part of the patient's identified IDG within 5 days from the election of the hospice benefit (dated 12/20/22). On 4/5/23 at 9:01 AM, during an interview, the patients spouse reported the social worker did not make it out prior to the patients death, but did meet with them and call them one time after the death of the patient. On 4/5/23 at 1:28 PM, during an interview, the SW reported the hospice staff notified them timely of new hospice admissions. The SW explained they were able to flex their time to accommodate seeing patients and their had only been a few times when the SW had not been able to get out to evaluate patients within 5 days after the patient elected to receive hospice services. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. During an interview on focus on 4/4/23 at 2:56 PM, the Clinical Manager stated during comprehensive assessments, staff focus on patient's pain, shortness of breath, constipation, ability, such as struggling with ADLs will put hospice aide services in place. If the patient is in a facility, staff will ask if they want hospice aide services. Staff address signs and symptoms to keep the patient comfortable and have a good bowel program if using pain medications. 1. Patient #14 had a hospice admission date of 5/31/22 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The plan of care (POC), dated 5/31/22 to 7/29/22, included orders for social work and spiritual care services. b. The initial comprehensive assessment at start of care, completed by the social worker, included a signature date of 6/6/22, 7 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 2 days. c. The initial comprehensive assessment at start of care, completed by the chaplain, included a signature date of 6/6/22, 7 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 2 days. Hospice staff failed to complete the initial comprehensive assessment 5 days following the election of hospice care. Findings include: Review of the hospice policy, titled Comprehensive Assessment, dated April 2018, identified a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician.

Based on clinical record review, hospice policy review, nursing facility record review and staff interview, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements within 5 days after the patient's election of the hospice care for 3 of 4 sampled patients (Patient #2, #8 and #14) with a wound at the time of admission to hospice services. Failure to complete an initial wound assessment increased the risk that patient's needs would not be identified and/ or addressed appropriately and the hospice would have an incomplete baseline assessment for comparison in order to determine effectiveness of wound treatments and interventions. --- 2. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a registered nurse (RN) at the start of care, dated 3/22/23, included documentation of a skin assessment, but lacked any documentation which identified the patient had a wound. b. The Plan of Care (POC), dated 3/22/23 to 6/19/23, included Interdisciplinary Group (IDG) orders for skilled nursing services. The POC did not identify the patient had a wound or had any wound care orders. c. A skilled nursing visit, dated 3/23/23, identified the patient had a right posterior lower leg wound covered with a dressing and no other wound assessment information. d. The IDG meeting, dated 3/29/23, lacked any information regarding a wound on the patient. On 4/3/23 at 1:28 PM, during an observation at the patients nursing home, the Clinical Manager performed an assessment of the patient while the patient was laying in bed. As part of the assessment, the Clinical Manager pulled back the patient's covers, partially unfastened the Velcro on the bilateral lower leg protectors and viewed the patient's front side of the lower legs. The Clinical Manager then refastened the Velcro and covered the patient. The Clinical Manager did not mention that the patient had a wound or perform any type of wound assessment during the visit. Review of the patient's nursing home Treatment Administration Record (TAR) for April 2023 revealed the following: An order for posterior left leg wound, cleanse with wound cleanser, cover abrasion with island dressing, change daily and as needed with an order date of 3/21/23 and a start date of 3/22/23. On 4/4/23 at 12:24 PM, during an interview, the nursing facility Minimum Data Set (MDS) Assessment Coordinator reported the facility staff do weekly wound assessment and agreed to send a copy of the wound assessments on the patient. Review of the nursing home skin assessment form included documentation of an assessment of a wound on the left posterior ankle area with a start date of 3/11/23 and the following wound assessments: on 3/11/23, the wound measured 5.1 centimeters (cm) in length, 4.0 cm in width, and 0.1 cm in depth with a small amount of blood tinged drainage; on 3/21/23, the wound measured 6 cm in length, 3 cm in width and less than 0.1 cm in depth; the patient had a patient reduction mattress on the bed per the wound documentation; on 3/28/23, the wound measured 0.6 cm in length, 0.6 cm in width and less than 0.1 cm in depth; on 4/4/23, the wound measured 0.5 cm in length, 0.2 cm in width and less than 0.1 cm in depth with serous drainage. The comprehensive assessment completed by the RN lacked complete assessment information of the patient's current physical condition. 3. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN at the start of care, dated 12/20/22, included documentation which identified the patient had 4 plus pitting edema (a measure which indicates the patient had an extreme amount of fluid retention) in the right and left lower legs and had bilateral blisters on the lower legs. The assessment lacked an assessment on number of blisters, exact location and measurements of the wounds. b. The POC, dated 12/20/22 to 3/19/23, lacked any identification of the patient's extreme edema or lower leg blisters. c. The skilled nursing visit, dated 12/26/22, included documentation which identified the patient's blisters were "weeping", implying the blisters had opened. The visit note lacked an assessment on number of blisters, exact location and measurements of the wounds. The comprehensive assessment completed by the RN lacked complete assessment information of the patient's current physical condition. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. 1. Patient #14 had a hospice admission date of 5/31/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The plan of care (POC), dated 5/31/22 to 7/29/22, identified the patient had a stage 2 (partial thickness) pressure wound to the ischium area and included orders for skilled nursing services. b. The comprehensive assessment at start of care, completed by the Registered Nurse (RN), dated 5/31/22, included documentation the patient had a stage 2 pressure wound to the ischium area. The note included wound measurements of 1.5 centimeters (cm) (length) by 0.5 cm (width) and 0 cm wound depth. The wound identified to have 75 to 100 % epithelialization (wound healing). The comprehensive assessment failed to include complete measurements of the wound (depth). Findings include: Review of the hospice policy, titled Wound Care, dated 5/14/2020, identified the need for registered nurse will assess wound(s) as part of the initial comprehensive assessment and will document each wound status including, location and etiology, measurement of length, width and depth. At least every week, the wound assessment and documentation will include measurement of length, width, and depth. During an interview on 4/4/23 at 2:46 PM, Clinical Manager reported the nurse is to measure wounds once a week, this includes length by width by depth.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the drug regimen review identified need for laboratory monitoring associated with all medications taken by the patient for 7 of 14 sampled patients (Patients #2, #3, #4, #5, #6, #8 and #14). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. Findings include: --- 4. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 3/22/23 to 6/19/23, included an order for Metformin, a medication used to treat diabetes and associated with blood sugar level testing. b. The comprehensive assessment completed at the start of care by a RN, dated 3/22/23, included documentation they completed a DRR. The DRR identified the patient did not currently take any medications associated with laboratory monitoring. c. An IDG meeting, dated 3/29/23, identified the patient did not currently take any medications associated with laboratory monitoring, but continued to include an order for Metformin. Review of the patient's nursing home Treatment Administration Record (TAR) for April 2023 revealed the following: 1) An order for hemoglobin A1C (blood test used to determine blood sugar levels over a period of time) blood testing every 12 months with a 3/31/22 start date and the next draw date on 4/4/23. 2) An order for weekly blood sugar level testing with a start date of 9/14/22. The DRR failed to accurately identify the patient was taking a medications associated with laboratory monitoring. 5. Patient #4 had a hospice admission date of 3/23/23, received routine home care hospice services while residing in a nursing home, and died on 3/29/23 after the start of the survey. Review of the clinical record revealed the following: a. The POC, dated 3/23/23 to 6/20/23, included an order for Levothyroxine, a medication used to treat hypothyroidism and associated with periodic laboratory testing for thyroid hormone levels. b. The comprehensive assessment completed at the start of care by a RN, dated 3/23/23, included documentation they completed a DRR. The DRR identified the patient did not currently take any medications associated with laboratory monitoring. c. An IDG meeting, dated 3/29/23, identified the patient had not taken any medications associated with laboratory monitoring. The DRR failed to accurately identify the patient was taking a medications associated with laboratory monitoring. 6. Patient #6 had a hospice admission date of 4/6/22, received hospice services while residing in a nursing home, and revoked hospice services on 6/21/22. Review of the clinical record revealed the following: a. The POC, dated 4/6/22 to 7/4/22, included an orders for Insulin Glargine and Novolog, both injectable medications used to treat diabetes and associated with blood sugar level testing. The POC included an order for as needed Novolog 10 units for blood sugar readings over 400. b. The comprehensive assessment completed at the start of care by a RN, dated 4/6/22, included documentation they completed a DRR. The DRR identified the patient did not currently take any medications associated with laboratory monitoring. c. An IDG meeting, dated 4/13/22, identified the patient did not currently take any medications associated with laboratory monitoring, but continued to include orders for Insulin Glargine and Novolog. Review of the patient's nursing home Treatment Administration Record (TAR) for June 2022 revealed an order for blood sugar testing 4 times per day and finger sticks as needed with a start date of 4/7/22. The DRR failed to accurately identify the patient was taking a medications associated with laboratory monitoring. 7. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: a. The POC, dated 12/20/22 to 3/19/23, included orders for Jardiance, Novolog and Ozempic, medications used to treat diabetes and associated with blood sugar level testing. b. The comprehensive assessment completed at the start of care by a RN, dated 12/20/22, included documentation they completed a DRR. The DRR identified the patient did not currently take any medications associated with laboratory monitoring. The DRR failed to accurately identify the patient was taking a medications associated with laboratory monitoring. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. According to the hospice policy, titled Comprehensive Assessment, dated April, 2018, during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record. Review of current and related past medications, including prescription and over-the-counter medications, allergy history and other medication information, including but not limited to identification of the following: effectiveness drug therapy, unwanted side and tosic effects, drug interactions, duplicate drug therapy, drug therapy currently associated with laboratory monitoring. According to the hospice policy titled, Interdisciplinary Group Meeting (IDG), dated April 2018, an interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include pharmacotherapeutic effectiveness of symptom management outcomes. During an interview on 4/4/23 at 2:13 PM, the Clinical Manager stated a drug regimen review is completed at least once a week, if setting up meds could be every visit 1. Patient #3 had a hospice admission date of 2/27/23, received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/27/23 to 5/27/23, included physician orders for Warfarin (blood thinner). b. The IDG meeting notes, dated 3/8/23, included a DRR reviewed for drug therapy currently associated with laboratory monitoring. The DRR lacked documentation of outcomes of the review. The DRRs failed to identify the patient required routine laboratory testing associated with taking Warfarin. 2. Patient #5 had a hospice admission date of 5/2/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/2/22 to 7/30/22, 7/31/22 to 9/28/22 and 9/29/22 to 10/31/22 included physician orders for synthroid (thyroid medication). b. The IDG meeting notes, dated 9/14/22, 9/28/22, 10/12/22 and 10/26/22, included a DRR reviewed for drug therapy currently associated with laboratory monitoring. The DRR lacked documentation of outcomes of the review. The DRRs failed to identify the patient required routine laboratory testing associated with taking Synthroid. 3. Patient #14 had a hospice admission date of 5/31/22, received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/31/22 to 7/29/22, included physician orders for Levothyroxine (thyroid medication). b. The Skilled nurse note, dated 5/31/22, included a DRR reviewed for drug therapy currently associated with laboratory monitoring. The DRR lacked documentation of outcomes of the review. The DRR failed to identify the patient required routine laboratory testing associated with taking Levothyroxine.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound description and measurements for 1 of 7 sampled patients with an open wound (Patients #3). The hospice reported a current census of 43 patients. Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. Findings include: --- According to undated hospice policy, titled Wound Care, dated 5/14/2020, at least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present. During an interview on 4/4/23 at 2:46 PM, the Clinical Manager stated staff are expected to look at and assess the wound every visit, measure once a week, and include length by width by depth, monitoring drainage and redness. Staff can do the assessment more frequently if needed. 1. Patient #3 had a hospice admission date of 2/27/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/27/23 to 5/27/23, included physician orders for skilled nursing services 3 times per week. b. The skilled nurse visit notes, dated 3/31/23 and 4/4/23, included an integumentary assessment but lacked wound measurements or any further information or description of the lesion. c. During an observations home visit on 4/4/23 at 9:00 AM with Staff B, Clinical Manager, the patient observed to have a blister on the left mid shin. Staff failed to measure the lesion. d. During an interview during the same observational home visit, Staff B stated she first became aware of the wound on 3/31/23 during a skilled nurse visit. Hospice staff failed to provide complete assessment of the patient's wound. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on hospice clinical record review, hospice policy review, nursing home staff interview, home visit observation, patient interview, patient representative interview and hospice staff interview, the hospice failed to: 1) ensure all hospice care and services furnished to patients and families must follow an individualized written plan of care (L0543); 2) ensure standing orders are individualized to meet the patient's needs (see L0547); 3) ensure all treatments necessary to meet the needs of the patient are on the plan of care (L0549); 4) ensure the medical supplies and appliances necessary to meet the needs of the patient are provided as directed by the Interdisciplinary Group in collaboration with the attending physician (L0550); 5) ensure the hospice Interdisciplinary Group developed and maintained a system of communication to direct, coordinate and supervise the care and services provided (L0554); and, 6) ensure that the care and services provided are based on all assessments of the patient and family needs (L0556). --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.

Based on hospice clinical record review, hospice policy review, nursing home record review, patient representative interview and hospice staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 2 of 14 sampled patients (Patients #6 and #8). Failure to follow the patient's Plan of Care (POC) as directed by the Interdisciplinary Group (IDG) puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: --- Review of the policy, titled The Plan of Care, dated April 2018, revealed each patient will have an individualized, written Plan of Care (POC). Hospice staff will provide care and services based on the POC. 1. Patient #6 had a hospice admission date of 4/6/22, received hospice services while residing in a nursing home and revoked hospice services on 6/21/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a registered nurse (RN) at the start of care, dated 4/6/22, included documentation which identified the patient was oxygen dependent and used oxygen at 2.5 liters (per minute). b. The POC, dated 4/6/22 to 7/4/22, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease. The POC identified the patient used oxygen supplies, but lacked an order for the use of oxygen. c. The IDG meeting, dated 4/13/22, included documentation in the skilled nurse's narrative which identified the patient was oxygen dependent and used oxygen at "2 liters". The narrative did not identify a route. The meeting note included documentation which identified the patient used oxygen at 2.5 liters on 4/6/22 and 2 liters on 4/7 and 4/11/22. The meeting note lacked any documentation which identified if the IDG addressed the patient's use of oxygen at 2.5 liters per minute on 4/6/22. d. The skilled nursing visit, dated 4/25/22, identified the patient was on room air. The visit note included documentation the nurse assessed the patient had abnormal breath sounds with crackles in the lungs and a cough. The nurse documented the patient's respiration rate was "22" and was not short of breath. The visit note lacked documentation of contact with the physician for not using oxygen at a rate of 2 liters per minute e. The IDG meeting, dated 4/27/22, included documentation the patient used oxygen at 2 liters on 4/14, 4/18 and 4/22/22, and was on room air on 4/25/22. The meeting note lacked any discussion on the patient's lack of oxygen use on a patient previously reported to IDG as oxygen dependent. f. The IDG meeting, dated 5/11/22, included documentation the patient used oxygen at 2 liters on 4/28, 5/3, 5/8 and 5/9/22. g. The IDG meeting, dated 5/24/22, included documentation the patient used oxygen at 2 liters on 5/13, 5/16, 5/19 and 5/22/22. h. The skilled nursing visit, dated 5/25/22, identified the patient used oxygen at 3 liters. The visit note included documentation the patient had abnormal breath sounds and rhythm, had rapid breathing and dyspnea affected the patient. The nurse documented the initiation of oxygen at 3 liters on 5/1/22. The visit note lacked any documentation the nurse contacted the physician about the patient's oxygen use at 3 liters. The clinical record lacked documentation of an order for the use of oxygen at 3 liters per minute. i. The skilled nursing visit, dated 5/29/22, identified the patient used oxygen at 1 liter. The visit note lacked documentation the nurse contacted the physician or discussed with the patient and facility staff the patient's use of oxygen at 1 liter. j. The skilled nursing visit, dated 6/1/22, identified the patient used oxygen at 3 liters. The visit note included documentation the patient had abnormal breath sounds and rhythm, had rapid breathing and dyspnea affected the patient. The visit note lacked any documentation the nurse contacted the physician about the patient's oxygen use at 3 liters. The clinical record lacked documentation of an order for the use of oxygen at 3 liters per minute. k. The skilled nursing visit, dated 6/6/22, identified the patient used oxygen at 2.5 liters. The visit note included documentation the patient had abnormal breath sounds with diminished air flow in the lung bases. The nurse documented the initiation of oxygen at 2.5 liters on 6/1/22. The visit note lacked any documentation the nurse contacted the physician about the patient's oxygen use at 2.5 liters. The clinical record lacked documentation of an order for the use of oxygen at 2.5 liters per minute. l. The IDG meeting, dated 6/8/22, included documentation the patient used oxygen at 3 liters on 5/25 and 6/1/22, used oxygen at 1 liter on 5/29/22 and oxygen at 2.5 liters on 6/6/22. The IDG meeting note lacked documentation of any discussion or order changes related to the patient's use of oxygen at varying rates. Review of the patient's nursing home Treatment Administration Record (TAR) for June 2022 revealed the TAR included an order for oxygen 2 liters per nasal cannula as needed during the day and constant at night, may remove oxygen during the day as desired with a 5/4/22 start date and 6/24/22 end date. On 4/4/23 at 2:50 PM, during an interview, the Clinical Manager reported oxygen orders should be with the medication orders. If the hospice nurse goes into the home and or facility and assesses the patient is using oxygen at a different flow rate than what the physician ordered, the hospice nurse will assess the patients need, collaborate with the facility staff to see if there has been an order change and collaborate with the patients physician to adjust orders if necessary. On 4/6/23 at 8:45 AM, during an interview, the Clinical Manager reported being aware that the agency had a problem with remembering to get orders for oxygen use. The hospice nurse failed to ensure the patient received oxygen at a rate ordered by a physician, or collaborated with the facility staff, ordering physician and hospice medical director to ensure the patient's oxygen orders reflected the patient's need. 2. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN at the start of care, dated 12/20/22, identified the patient used oxygen at 3 liters (per minute). 1) The POC, dated 12/20/22 to 3/19/23, included a diagnosis of dependence on supplemental oxygen and that the patient had an oxygen concentrator, but lacked an order for oxygen use. 2) The skilled nursing visit, dated 12/27/22, identified the patient was using oxygen at a rate of 5 liters. 3) The clinical record lacked an order for oxygen use. The hospice nurse failed to ensure the patient received oxygen at a rate ordered by a physician, or collaborated with the patient's attending physician, or hospice medical director to ensure the patient's oxygen orders reflected the patient's need. b. The skilled nursing visit, dated 12/21/22, included documentation the nurse assessed the patient was experiencing anxiety and shortness of breath. The nurse documented the patient requested an order for Lorazepam (medication used to treat anxiety and difficulty breathing). The nurse documented they were going to add Lorazepam and Morphine to the patient's medication regimen. The visit note lacked documentation the nurse had contacted the patient's physician or the hospice's medical director for orders. 1) The POC, dated 12/20/22 to 3/19/23, included an order for Morphine concentrate 100 milligrams(mg)/5 milliliters (ml) 0.25 ml by mouth every 1 to 2 hours for dyspnea, air hunger or pain. The POC did not include an order for Lorazepam. 2) The clinical record included an order for Lorazepam 2 mg/ml 0.25 ml every hour as needed by mouth for dyspnea and restlessness with a verbal order date of 12/27/22. The clinical record lacked documentation of a physician order for Lorazepam prior to 12/27/22. On 4/5/23 at 9:01 AM, during an interview, the patients spouse reported the patient did have anxiety, and they had talked about taking Lorazepam with one of the nurses. The nurse was going to get an order for the Lorazepam liquid, but the patient had some Lorazepam tablets already. They told the nurse the patient would just take the patients own Lorazepam tablets. The patients spouse was unsure if the patient ever received the Lorazepam in liquid form prior to the patients death. The hospice nurse failed to ensure the patient took medication per the hospice POC and ensure the Lorazepam in the patient's home was congruent with the patient's current needs and approved by the attending physician and/or the hospice medical director. c. The POC, dated 12/20/22 to 3/19/23, included an order for Soaanz (a diuretic used to help reduce fluid retention) 40 mg tablet 2 tablets by mouth daily for congestive heart failure. 1) The skilled nursing visit completed by the Clinical Manager, dated 12/26/22, included documentation the patient had 4 plus pitting edema (a measure used to describe extensive fluid retention) from the lower extremities up into the pelvis areas causing pain and irritation in the perineal area. The nurse documented she instructed the patient to take an extra Torsemide (Soaanz) yesterday and today and planned to contact the patient's primary physician for additional orders. 2) The clinical record lacked documentation of a physician order for the patient to take an extra Torsemide beyond what the physician ordered on the POC. The clinical record lacked documentation of any additional orders to treat the patient's excessive fluid retention. On 4/6/23 at 8:45 AM, during an interview, the Clinical Manager reported the discharge orders from the patient's last hospital stay (prior to hospice) included instructions that the patient could take an extra Torsemide if needed. The Clinical Manager explained the agency should have included this part of the order on the POC. d. The skilled nursing visit, dated 12/27/22, included documentation the nurse inserted an 18 French urinary catheter. The POC, dated 12/20/22 to 3/19/23, and clinical record lacked documentation of an order for a urinary catheter. The nurse inserted a catheter without obtaining a physician order. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of hospice standing orders and staff interview, the hospice failed to ensure the ensure hospice staff used standing orders specific and individualized to the patient's assessed needs for 2 of 14 sampled patients (Patients #10 and #13). Failure to establish the use of individualized standing orders rather than generalized, non-specific standing orders placed patients for potential risk of receiving medications, treatments and services that did not adequately meet the individualized needs of hospice patients. Findings include: --- 2. Patient #13 had a hospice admission date of 4/22/22, received routine home care services while residing in a private residence and respite services in a nursing home (4/29 to 5/3/22), and died on 5/9/22. Review of the clinical record revealed the following: a. The clinical record included documentation of an interim order written by a RN, dated 5/9/22. The order included the following: Per hospice standing orders initiate Atropine drops 1 percent, give 2 drops by mouth every hour as needed for excessive secretions. The order identified the nurse did not verbally contact a physician to obtain the order, but sent notification to let the physician know the nurse had enacted a standing order. b. Review of the clinical record revealed a lack of physician signed standing orders for the Patient. On 4/5/23 at 12:05 PM, during an interview, the Clinical Manager reported standing orders were not approved prior to use by the patients physician, but they did send the patients physician an order if they used a medication on the standing order list. The Clinical Manager explained no one told them they needed to get the standing orders individualized for each patient, get an order from the physician to use the standing orders and maintain a copy of the approved standing orders in the patients medical record. Review of the hospice's standing orders, signed and not dated by the hospice Medical Director, identified revealed the following orders: a. Lorazepam 0.5 mg give 1 tablet by mouth every 4 hours as needed for anxiety. b. Lorazepam 2 mg/ml give 0.5 mg (o,25 ml ) sublingual or by mouth every hour as needed for agitation or anxiety c. Morphine sulfate (Roxanol) 20 mg/ml give 5 mg (0.25 ml) sublingual or by mouth every hour as needed for pain or dyspnea. d. Fentanyl patch 12 mcg, 1 path topically change every 72 hours for chronic pain. e. Atropine 1% give 2 drops sublingual every hour as needed for excessive secretions. f. Fever: Acetaminophen 650 milligrams (mg) by mouth every 4 hours as needed for fever or pain. g. Acetaminophen 650 mg suppository every 6 hours as needed for fever or pain. h. Bisacodyl with senna 1 tablet by mouth 2 times a day as needed for nausea. i. Bisacodyl suppository 10 mg daily as needed for constipation. j. Ondansetron 4 mg 1 tablet by mouth every 4 hours as needed for nausea. k. Phenergan 25 mg by mouth or suppository every 4 hours as needed for nausea. Review of the medical record for sample patients (Patients #1 through #14) revealed a lack of signed, patient-specific, standing orders in any of the records and a lack of an order signed by the attending physician or hospice medical director to use hospice standing orders for any of the patients. During an interview on 4/4/23 at 2:46 PM, the Clinical Manager stated the hospice uses standing orders. The date and initial orders to initiate is sent to pharmacy or the facility to initiate. The medication only initially utilized specific to patient. Standing orders on paper, order is entered in electronic medical record after it is initiated, an interim physicians order is placed in the electronic record, then is sent out to the attending physician. 1. Patient #10 had a hospice admission date of 1/20/23 and discharge date of 2/17/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/20/23 to 2/17/23, included orders for skilled nursing services and lacked orders for narcotic medication. b. The standing orders for a narcotic medications did not include orders individualized to the patient's specific need. c. A communication note, dated 2/13/23, included documentation new orders for comfort medications were put in place. d. The medication report, dated 2/13/23, included the following new medications: Lorazepam (antianxiety) 2 milligrams (mg)/milliliter (ml) give 0.25 ml by mouth every hour as needed for restlessness, air hunger and Morphine (analgesic) concentrate 100 mg/5 ml give 0.25 ml by mouth every hour as needed for pain, restlessness or air hunger. The plan of care updated, signed by the physician 2/15/23, included orders for Lorazepam and Morphine. The document identified no verbal order received. The clinical record lacked documentation of contact with the a physician regarding the new orders for Lorazepam and Morphine prior to 2/15/23.

Based on hospice clinical record review, hospice policy review, nursing home record review, patient interview, nursing home staff interview and hospice staff interview, the hospice failed to ensure the hospice plan of care included a complete order for all medications and treatments to meet the needs of the patient for 5 of 14 sampled patients (Patients #1, #2, #3, #6 and #8). Failure to ensure the plan of care included physician orders for all necessary medications and treatments placed patients at risk to not receive needed or appropriate treatment of symptoms. Findings include: --- 2. Patient #1 had a hospice admission date of 7/21/22 and received routine home care hospice services while residing in a nursing facility (nursing home). On 3/29/23 at 7:54 AM, during a home visit observation at the patient's nursing home, the patient's primary nursing facility nurse for the day reported the patient had a left hand-splint treatment for a left hand contracture and only wore the left hand splint on occasion. The nursing facility nurse asked for clarification on whether to discontinue the treatment or have the nursing home staff reinforce the treatment as ordered. The Clinical Manager reported being unaware of the patient's left hand-splint treatment, but reported they would check with the patient's physician. On 3/29/23, review of the patients nursing home treatment administration record (TAR) for March 2023 revealed an order for a hand splint to the left hand to be 4 hours during the day and while sleeping at night, two times per day to prevent contractures with a 1/11/21 start date. Review of the clinical record revealed the following: a. The initial Plan of Care (POC), dated 7/21/22 to 10/18/22, and the subsequent POC recertification periods, dated 10/19/22 to 1/16/23, 1/17/23 to 3/17/23 and 3/18/23 to 5/16/23, did not identify the patient's left hand contracture, or the splint treatment for the patient's contracture. b. The IDG meetings, dated 2/1, 2/15, 3/1, 3/8, 3/22 and 3/29/23, did not identify the patient had a left hand contracture, the patient's left hand splint treatment for the patient's contracture, or any discontinuation orders for this treatment. 3. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. See L0524. The hospice POC failed to include wound care treatment orders for a left posterior leg wound. b. Review of the patient's nursing home Treatment Administration Record (TAR) for April 2023 revealed the following: 1) An order for hemoglobin A1C (blood test used to determine blood sugar levels over a period of time), complete blood count with differential, Vitamin B 12 blood draw and basic metabolic panel with Calcium blood testing every 12 months with a 3/31/22 start date and the next draw date on 4/4/23. 2) An order for weekly blood sugar level testing with a start date of 9/14/22. The hospice POC failed to included orders for these treatments or an order to discontinue the treatment/labs if the patient no longer needed them. 4. Patient #6 had a hospice admission date of 4/6/22, received hospice services while residing in a nursing home, and revoked hospice services on 6/21/22. Review of the clinical record revealed the following: a. The POC, dated 4/6/22 to 7/4/22, included an orders for Insulin Glargine and Novolog, both injectable medications used to treat diabetes and associated with blood sugar level testing. The POC included an order for as needed Novolog 10 units for blood sugar readings over 400. Review of the patient's nursing home Treatment Administration Record (TAR) for June 2022 revealed an order for blood sugar testing 4 times per day and finger sticks as needed with a start date of 4/7/22. The POC failed to include an order for the blood sugar testing 4 times per day and as needed. b. The comprehensive assessment completed by a registered nurse (RN) at the start of care, dated 4/6/22, included documentation which identified the patient was oxygen dependent and used oxygen at 2.5 liters (per minute). 1) The POC, dated 4/6/22 to 7/4/22, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease. The POC identified the patient used oxygen supplies, but lacked an order for the use of oxygen. 2) The IDG meeting, dated 4/13/22, included documentation in the skilled nurse's narrative which identified the patient was oxygen dependent and used oxygen at "2 liters". The narrative did not identify a route. c. The skilled nursing visits, dated 6/9 and 6/13/22, included documentation the patient had edema on the lower extremities and wore ready wraps on the lower legs. The POC, dated 4/6/22 to 7/4/22, and subsequent IDG meetings, dated 4/13, 4/27, 5/11, 5/24, 6/8 and 6/21/22, lacked any documentation of an order for the ready wrap treatment. The clinical record lacked documentation of an order for this treatment. 5. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN at the start of care, dated 12/20/22, identified the patient used oxygen at 3 liters (per minute). b. The POC, dated 12/20/22 to 3/19/23, included a diagnosis of dependence on supplemental oxygen and that the patient had an oxygen concentrator, but lacked an order for oxygen use. On 4/6/23 at 8:45 AM, during an interview, the Clinical Manager reported being aware that they had a problem with remembering to get orders for oxygen use. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. According to the hospice policy titled The Plan of Care, dated April 2018, the written plan of care will contain, but will not be limited to the following: drugs and treatments (including allergies) to meet patient needs. 1.Patient #3 had a hospice admission date of 2/27/23 and received routine home care hospice services while residing in a private home residence. The plan of care (POC), dated 2/27/23 to 5/27/23, identified durable medical equipment including oxygen and oxygen supplies. The POC failed to include a physician's order for dose and route of oxygen. The Interdisciplinary Group (IDG) notes, dated 3/8/23 and 3/22/23, failed to include orders for oxygen dose or route. On 4/4/23 at 9:00 AM, during a home visit observation at the patient's home, the patient reported using oxygen. He/she stated they had the oxygen since hospitalization and used 3 liters at that time via nasal cannula. He/she reported to be weaning themself off of oxygen at times during the day and is now down to 2 1/2 liters. The hospice failed to have orders for the patient's oxygen dose and route.

Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview, patient interview and hospice staff interview, the hospice failed to ensure the Plans of Care for 5 of 14 sampled patients (Patients #1, #2, #3, #6 and #8) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: --- 2. Patient #1 had a hospice admission date of 7/21/22 and received routine home care hospice services while residing in a nursing facility (nursing home). On 3/29/23 at 7:54 AM, during a home visit observation at the patient's nursing home with the Clinical Manager, the patient's primary nursing facility nurse for the day reported the patient had a left hand-splint treatment for a left hand contracture and only wore the left hand splint on occasion. The nursing facility nurse asked for clarification on whether to discontinue the treatment or have the nursing home staff reinforce the treatment as ordered. The Clinical Manager reported being unaware of the patient's left hand-splint treatment, but reported they would check with the patient's physician. On 3/29/23 at 7:59 AM, during an observation with the patient and the Clinical Manager, the surveyor observed the patient had a soft, padded foot cradle for prevention of pressure ulcers on the back of the heels. In an interview, during the same home visit observation, the Clinical Manager reported they had been providing services to the patient since November 2022, and the patient had been using the foot cradle since they had started working with the patient. On 3/29/23, review of the patients nursing home treatment administration record (TAR) for March 2023 revealed an order for a hand splint to the left hand to be 4 hours during the day and while sleeping at night, two times per day to prevent contractures with a 1/11/21 start date. Review of the hospice clinical record revealed the following: a. The initial Plan of Care (POC), dated 7/21/22 to 10/18/22, and the subsequent POC recertification periods, dated 10/19/22 to 1/16/23, 1/17/23 to 3/17/23 and 3/18/23 to 5/16/23, did not identify the patient's left hand splint or foot cradle. b. The IDG meetings, dated 2/1, 2/15, 3/1, 3/8, 3/22 and 3/29/23, did not identify the patient's left hand splint or foot cradle. 3. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. On 4/3/23 at 1:28 PM, during an observation at the patients nursing home, the Clinical Manager completed an assessment of the patient while the patient was laying in bed. The surveyor observed the use of a fall safety mat on the floor in front of the patient's bed, a quarter bed rail and bilateral soft lower leg and foot protection boots. On 4/3/23 at 2:00 PM, during an interview, the patient's nursing facility nurse reported the patient had been using the above mentioned medical equipment/supplies prior to the start of hospice services. Review of the patient's nursing home Treatment Administration Record (TAR) for April 2023 revealed the following: An order for posterior left leg wound, cleanse with wound cleanser, cover abrasion with island dressing, change daily and as needed with an order date of 3/21/23 and a start date of 3/22/23. Review of the hospice clinical record revealed the following: The POC, dated 3/22/23 to 6/19/23, and IDG meeting, dated 3/29/23, failed to identify the patient's use of wound care supplies, a fall safety mat on the floor in front of the patient's bed, a quarter bed rail and bilateral soft lower leg and foot protection boots. 4. Patient #6 had a hospice admission date of 4/6/22, received hospice services while residing in a nursing home, and revoked hospice services on 6/21/22. Review of the clinical record revealed the following: a. The POC, dated 4/6/22 to 7/4/22, identified the patient used the following medical equipment and supplies: incontinence briefs, elevated toilet seat, diabetic supplies, oxygen supplies, over the bed table, nebulizer, grab bars, shower chair, hand held shower, walker and wheelchair. 1) A skilled nursing visit, dated 4/18/22, identified the patient utilized a 2-handled cup to drink beverages. 2) The IDG meetings, dated 4/13, 4/27, 5/11, 5/24, 6/8 and 6/21/22, lacked any documentation the patient used a 2-handled cup. b. The skilled nursing visits, dated 6/9 and 6/13/22, included documentation the patient had edema on the lower extremities and wore ready wraps on the lower legs. The POC, dated 4/6/22 to 7/4/22, and subsequent IDG meetings, dated 4/13, 4/27, 5/11, 5/24, 6/8 and 6/21/22, lacked any documentation used ready wraps. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. According to the hospice policy titled The Plan of Care, dated April 2018, the written plan of care will contain, but will not be limited to the following: durable medical equipment and supplies to meet patient needs. 1. Patient #3 had a hospice admission date of 2/27/23 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/27/23 to 5/27/23, identified the patient had the following medical equipment and supplies: briefs/bladder control pads, oxygen concentrator, oxygen supplies, walker. b. The IDG meeting, dated 3/8/22, identified no additional medical equipment and supplies used by the patient. c. The IDG meeting, dated 3/22/22, identified no additional medical equipment and supplies used by the patient. d. On 4/4/23 at 9:00 AM, during a home visit observation with Staff B, Clinical Manager, the surveyor identified the patient also utilized a reacher, grab bars, hand held shower, shower chair and spirometer. e. In an interview, during the same nursing home visit observation, the patient stated he/she has used the equipment prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient.

Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview, patient representative interview and hospice staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members and patients attending physician to ensure hospice staff provided treatment and services to the patients according to team decisions. The survey identified this concern with 5 of 14 sampled patients (#1, #2, #6, #8 and #13). Failure of the hospice IDG members to communicate and collaborate with each other to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients. Findings include: --- Review of the policy, titled The Plan of Care, dated April 2018, revealed each patient will have an individualized, written Plan of Care (POC). Hospice staff will provide care and services based on the POC. The POC will identify the needs and services to meet those needs. The members of the IDG perform the initial and ongoing comprehensive assessments which are the basis of the POC The IDG will update the POC at least once every 15 days. 1. Patient #1 had a hospice admission date of 7/21/22 and received routine home care hospice services while residing in a nursing facility (nursing home). a. See L0503 for concerns related to advance directives. b. See L0549 for concerns related to an unidentified treatment. c. See L0550 for concerns related to unidentified medical equipment and supplies. d. Review of the hospices medication orders, as of 3/29/23, compared to the patients Medication Administration Record (MAR) for March 2023 at the nursing home revealed the following medication discrepancies: 1) The hospice medication orders included an order for Ondansetron 4 milligrams (mg) by mouth every 12 hours as needed (prn) for nausea with a start date of 7/23/22. The nursing home MAR lacked an order for this medication. 2) The hospice medication orders included an order for Lorazepam 0.5 mg tablet, give 1 tablet every 4 hours as needed for anxiety with a start date of 7/29/22. The nursing home MAR did not have an order for the oral tablet, but had an order for Lorazepam oral concentrate 2 mg/milliliter (ml), give 0.25 ml every 4 hours as needed for restlessness and anxiety with a start date of 2/23/23. The hospice did not have an order for the oral concentrate form of Lorazepam. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to advance directives, treatments, medications and medical equipment and supplies. 2. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. a. See L0503 for concerns related to advance directives. b. See L0523 for concerns related to IDG member involvement in the development of the POC. c. See L0524 for wound care assessment concerns. d. See L0530 for concerns related to drug regimen review. e. See L0549 for concerns related to an unidentified treatment. f. See L0550 for concerns related to unidentified medical equipment and supplies. g. Review of the hospices medication orders, as of 4/3/23, compared to the patients nursing home MAR for March and April 2023 revealed the following medication discrepancies: 1) The nursing home MAR included an order for Cranberry tablet 450 mg one tablet by mouth daily with a start date of 9/15/21. The hospice medication orders lacked an order for this medication. 2) The hospice medication orders included an order for Lisinopril 2.5 mg 1 tablet daily by mouth with a start date of 3/24/23. The nursing home MAR for March 2023 included an order to discontinue the medication on 3/23/23. 3) The hospice medication orders included an order for Metformin 500 mg 1 tablet two times per day by mouth with a 3/24/23 start date. The nursing home MAR for April 2023 lacked an order for this medication. 4) The hospice medication orders included an order for Cholecalciferol (Vitamin D 3) 25 micrograms (mcg) two tablets daily by mouth with a start date of 3/24/23. The nursing home MAR for March 2023 included an order to discontinue the medication on 3/23/23. 5) The hospice medication orders included an order for Multivitamin 1 tablet daily by mouth with a start date of 3/24/23. The nursing home MAR for April 2023 lacked an order for this medication. 6) The nursing home MAR for April 2023 included an order for Nystatin powder 100,00 units/gram, apply to affected area topically every 8 hours as needed for contact dermatitis with a start date of 6/14/21. The hospice medication orders lacked an order for this medication. 7) The nursing home MAR for April 2023 included an order for Nystatin powder 100,00 units/gram, apply to perineal skin rash topically every 12 hours as needed with a start date of 4/29/22. The hospice medication orders lacked an order for this medication. On 4/4/23 at 12:24 PM, during an interview, the nursing facility Minimum Data Set (MDS) Assessment Coordinator reported the patients physician discontinued the patients Metformin on 3/23/23. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to advance directives, IDG member involvement in the development of the POC, identification and assessment of wounds, drug regimen review, treatments, medications and medical equipment and supplies. 3. Patient #6 had a hospice admission date of 4/6/22, received hospice services while residing in a nursing home, and revoked hospice services on 6/21/22. a. See L0503 for concerns related to advance directives. b. See L0530 for concerns related to drug regimen review. c. See L0543 for concerns related to following the POC. d. See L0549 for concerns related to an unidentified treatment. e. See L0550 for concerns related to unidentified medical equipment and supplies. f. Review of the clinical record revealed the following: 1)The POC, dated 4/6/22 to 7/4/22, included IDG orders for skilled nursing services 2 times per week for 13 weeks. 2) The IDG meeting, dated 6/8/22, continued to include an order for skilled nursing services two times per week. 3) The week of 5/29/22 included documentation of one skilled nursing visit, dated 6/1/22. The clinical record lacked documentation of a reason why the patient only received one visit the week of 5/29/22. 4) The subsequent IDG meeting, dated 6/8/22, continued to include an order for skilled nursing services two times per week and lacked any documentation of IDG awareness of the missed nursing visit the week of 5/29/22. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to advance directives, following the POC, drug regimen review, treatments, medical equipment and supplies and services. 4. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. a. See L0523 for concerns related to all IDG members being involved in the comprehensive assessment in order to develop a POC to meet the needs of the patient. b. See L0524 for concerns related to wound identification and assessment. c. See L0530 for concerns related to drug regimen review. d. See L0543 for concerns related to following the POC. e. See L0549 for concerns related to unidentified treatment. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to IDG member involvement in the development of the POC, wound assessment and identification, the drug regimen review, following the POC in relation to medications and treatments, and identifying treatments used by the patient. 5. Patient #13 had a hospice admission date of 4/22/22, received routine home care services while residing in a private residence and respite services in a nursing home (4/29 to 5/3/22), and died on 5/9/22. a. See L0503 for concerns related to advance directives. b. See L0512 for concerns related to the right of the patient to receive timely and effective pain and symptoms control. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to advance directives and pain and symptom management control for conditions related to the terminal illness. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, hospice admit packet review, patient interview, patient representative interview and hospice staff interview, the hospice failed to develop and maintain a system of communication and integration, in accordance with hospice's own policies and procedures when it did not ensure the patient received hospice aide and homemaker services as identified in the comprehensive assessment for 2 of 14 sampled patients (Patient #2 and #3). Failure to ensure hospice staff provide care and services in accordance with the Plan of Care developed by the interdisciplinary Group (IDG) placed the patient at risk for not receiving necessary care and services to meet the needs of the patient. Findings include: --- 2. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed by the Clinical Manager at the start of care, dated 3/22/23, identified the following: the lived at a skilled nursing facility, had dementia due to Alzheimer's disease, oriented to person only, forgetful, confused, lethargic, could not sit up without assistance, had physical limitations and cognitive deficits, incontinent of bowel and bladder, needed assistance with activities of daily living (ADL) including bathing, feeding, dressing, grooming and toileting. b. The Plan of Care (POC), dated 3/22/23 to 6/19/23, included a orders for the hospice nurse to coordinate the POC with facility staff. The POC included IDG orders for skilled nursing services 2 times per week and social work and chaplain services one time per month. The POC did not address the patient's need for assistance with ADLs and what entity or entities would be responsible for meeting this need. On 3/29/23 at 12:00 PM, during an interview, the Administrator reported the hospice had only one nurse, the Clinical Manager. On 3/30/23 at 7:59 AM, in an interview during a home visit observation, the Clinical Manager reported the hospice did not have a hospice aide hired. The Clinical Manager was responsible for providing hospice aide services. On 4/5/23 at 9:52 AM, during an interview, the Durable Power of Attorney (DPOA) for healthcare confirmed active status as DPOA. When asked if the hospice had offered hospice aide services, the DPOA reported the hospice had offered the service and the DPOA requested the hospice provide this service along with any other services the hospice could provide. The DPOA wanted to make sure the patient was being taken care of. The DPOA reported the nursing home had changed staff and they had concerns with the care the patient received. The DPOA reported being glad the patient was getting hospice aide services. The DPOA explained the hospice nurse was very responsive to any questions and gave updates on the patient after each visit. On 4/6/23 at 8:45 AM, during an interview, the Clinical Manager reported being unaware the DPOA had requested this service. The hospice clinical record lacked documentation the hospice IDG addressed the patient's assessed ADL needs and the needs identified by the patient's DPOA. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. According to the undated admission form (provided to patients at start of care) titled, "Welcome to Hospice, Providing life changing services, when the choice is comfort", Interdisciplinary Team Member Visits include the home care aide provides assistance with personal cares, changing the bed, light housekeeping and comfort measures planned through the team. According to the hospice policy titled Scope Of Services, dated April, 2018, an interdisciplinary group (IDG) of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which will include, as appropriate, the following services, hospice aide and homemaker services. On 4/6/23 at 8:04 AM, during an interview, the Administrator provided the completed CMS 417 form which identified the hospice did not have any homemaker services. The Administrator reported being unaware of the requirement for the hospice to provide homemaker services. 1. Patient #3 was admitted to hospice on 2/27/23. a. The plan of care (POC), dated 2/27/23 to 5/27/23, included physician orders for skilled nursing and social worker services. b. The comprehensive skilled nursing note on admission, dated 2/27/23, indicated the patient required assistance with housekeeping, shopping and meal prep. c. The IDG, dated 3/8/23 and 3/22/23, failed to include orders for homemaking services. d. During an observational home visit on 4/4/23 at 9:00 AM, with Staff B, Clinical Manager, the patient stated they would like to have homemaker services provided. e. During the same home visit, Staff B, Clinical Manager stated Medicare did not really allow for that type of service. The hospice failed to develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures when it did not ensure the patient received homemaker services as identified in the comprehensive assessment.

Based on clinical record review, hospice admission packet review and staff interview, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved. The survey identified this concern with 2 of 2 sampled bereavement records (Patient #13 and #14). Failure to provide bereavement counseling according to identified needs, placed the bereaved at increased risk for worsening severe grief and increased the potential for self harm. Findings include: --- 2. Patient #13 had a hospice admission date of 4/22/22, received routine home care services while residing in a private residence and respite services in a nursing home (4/29 to 5/3/22), and died on 5/9/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a registered nurse (RN) at the start of care, dated 4/22/22, identified there were no bereavement risks. The assessment identified the patient had a spouse. b. The initial social worker visit, dated 4/25/22, identified the patient had substantial family involvement. c. The clinical record lacked documentation of a bereavement risk assessment of the patient's spouse after the patient's death. d. The clinical record lacked documentation of a bereavement plan of care. d. The clinical record included documentation of one bereavement care visit completed via phone call, dated 5/31/22. The visit note included documentation the hospice Chaplain completed the phone call and documented the spouse of the patient was doing "fine", had accepted the passing of the "well" and had excellent support. The note did not indicate if the bereaved would be receiving any further phone calls, visits or mailings. On 4/6/23 at 8:45 AM, during an interview, the Administrator reported they thought the bereaved persons had not wanted to accept bereavement services and the hospice staff doing the bereavement services had just not documented this. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. According to the hospice document titled the hospice team includes a bereavement counselor to provide support and education to help families understand their grief journey after the death of a loved one. The bereavement program provides follow-up for 13 months after your loved one's passing which includes the following: periodic mailings to provide information, support and inspiration, annual special events, contact with a bereavement counselor for those seeking additional support and grief groups. During an interview on 4/5/23 at 1:34 PM The Bereavement Coordinator stated staff look at risk factors identified such as substance abuse, if average or low risk, staff will call 1-2 times and then send the booklet out. If a higher risk is identified will contact sooner and more frequently. Services provided are documented in the electronic medical record under the bereaved activity section. The patient assessment has to be completed for bereaved to be promoted and bereaved record activated. This can be tricky over weekends. Once promoted to bereaved status, a care plan is developed and all contact is documented in this section. The contacts include assessments, narratives and phone calls. During an interview on 4/6/23 at 1:30 PM the Administrator stated he and the social worker reviewed the clinical record and were not able to locate documentation of bereavement services completed for the patients. 1. Patient #14 had a hospice admission date of 5/31/22 and died on 6/7/22. Review of the hospices' clinical record for hospice services provided to the identified bereaved individual revealed the following: a. The Plan of Care (POC), dated 5/31/22 to 7/29/22, included IDG orders for social worker 1 visit a month times 1 month. b. The initial skilled nurse assessment, dated 5/31/22, included documentation there were no bereavement risks identified. c. The clinical record failed to include documentation of a bereavement plan of care or any phone calls, visits or mailings completed. The hospice failed to provide bereavement services for the patient's bereaved individuals.

Based on clinical record review, review of the hospice's admission packet information and hospice staff interview, the hospice failed to ensure hospice staff facilitated spiritual counseling visits through the patient's and family's clergy of choice for 1 of 14 patients sampled (Patient #11). Failure of hospice staff to ensure they facilitate spiritual counseling visits in accordance with the patient/family's desires placed patients and their families at risk for not meeting their spiritual needs before the patient dies. Findings include: --- Review of the hospice's admission packet revealed under Patient and Family Rights and Responsibilities, the patient has the right to expect hospice staff to be available to meet the patient's physical, spiritual, emotional and social needs. Patient #11 had a hospice admission date of 7/28/22, received routine home care hospice services while residing in a private residence and died on 8/5/22. On 4/5/23 at 5:10 PM, during an interview, the hospice Chaplain reported hospice staff would contact the patient's clergy of choice if requested. Review of the clinical record revealed the following: a. The comprehensive assessment completed by the registered nurse (RN) at the start of care, dated 7/28/22, identified the patient's disease process disrupted the patient's spiritual activities and identified the patient's religious faith. The nurse indicated the patient did not want hospice chaplain services, as identified as "NA" (not applicable). b. The skilled nursing visit, dated 7/29/22, included documentation the patient had a strong spiritual well-being and derived hope, comfort and strength from the patient's beliefs. The patient/family gave permission for the hospice nurse to contact the patient's pastor and provided the name of the pastor. c. The clinical record lacked documentation the hospice staff contacted the patient's pastor.

Based on clinical record review, review of employee personnel files and hospice policy review, the hospice failed to ensure 1 of 1 sampled hospice aide (Staff F) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 1 of 1 sampled patients who required an extra skill task to be performed (Patient #1). The hospice reported 4 current patients at the time of the survey. The hospice employed a total of 0 aides at the time of the survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. --- Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. According to the hospice policy titled Hospice Aide Training, dated April 2018, the hospice will schedule training/competency testing time, competencies and skills will be assessed prior to delivery of services and updated every 12 months. Competency evaluations will be signed and date by the registered nurse and will be maintained in the personnel file. During an interview on 4/6/23 at 10:23 AM, Staff C, Human Resource Manager, reported no other skills competency form available for Staff F, Hospice Aide, she will recheck file and get back to surveyor. During an interview on 4/6/23 at 10:40 AM, Staff C, reported she was unable to locate additional competency forms that identified shave as an extra skill. Patient #1 had a hospice admission date of 7/21/22, and received hospice services while residing in a nursing home. The aide care plan included Registered Nurse (RN) instructions to the aide to shave the patient. Review of the clinical record showed Staff F, Hospice Aide, provided aide services independently for Patient #1. Staff F, Hospice Aide, had a hire date of 1/3/23 and a termed date of 3/7/23. Staff F's personnel file lacked documentation RN had observed Staff F competently perform the task of shave for patient or observed competently perform the task shave for a patient. The above findings were reviewed with the Administrator and Staff C, Human Resource Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) ensure the hospice primarily engaged in provided required hospice services included hospice aide and homemaker services (L0652) 2) ensure the hospice provided orientation about hospice philosophy to all employees and contracted staff who have patient and family contact (L0661). --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure employees and contracted staff provided services in accordance with hospice philosophy.

Based on clinical record review, admit packet review, patient and patient representative interview and hospice staff interview, the hospice failed to ensure the hospice primarily engaged in providing all required hospice services including hospice aide and homemaker services for 2 of 14 sampled patients (Patients #2 and #3). Failure to ensure the hospice provided all required hospice services to patients in need of the services placed the patient's at risk for unmet health and safety needs. Findings include: --- 2. Patient #3 had a hospice admission date of 2/27/23 and received routine home care hospice services while residing in a private home setting. See L0556 The hospice failed to offer hospice aide services to a patient with an assessed need for assistance with activities of daily living and per the patient's request. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice's admission packet revealed the hospice provided the following services: nursing, social work, chaplain, hospice aide, medical director and bereavement counseling. The hospice aide services included personal care and changing the patient's bed linens. The admission packet failed to identify the hospice requirement of providing homemaker services. 1. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. See L0556 The hospice failed to offer hospice aide services to a patient with an assessed need for assistance with activities of daily living and per the patient's durable power of attorney's request.

Based on review of employee personnel files and staff interview, the hospice failed to ensure the hospice provided orientation on the hospice's philosophy for 2 of 4 sampled staff (Staff B and D). The hospice reported hiring 18 employees since the last survey. Failure to provide orientation on hospice's philosophy increased the potential for provision of services in a manner contradictory to the hospice's philosophy. --- Findings include: 1. Staff B, Clinical Manager, had a hire date of 10/26/22. Staff Bs personnel file included documentation of orientation on the hospices philosophy, dated 8/21/20, greater than 2 years prior to the hire date. 2. Staff D, Social Worker, had a hire date of 10/7/2020. Staff Ds personnel file lacked documentation of orientation on the hospices philosophy. On 4/5/23 at 9:10 AM, during an interview, Staff C, Human Resource Manager, provided surveyor with orientation forms for hospice. The forms are new and have not been used. Staff C will look for hospice orientation documentation for staff. 4/5/23 at 9:35 AM, during an interview, Staff C, reported unable to find hospice orientation for Staff D, was able to find hospice orientation for Staff B from 8/21/2020 but nothing from when she was rehired 10/26/22. The above findings were reviewed with the Hospice Administrator and Human Resource Manager. The hospice provided no further information prior to the end of the survey.

Based on clinical record review, policy review, family and staff interview, the hospice failed to ensure patient clinical records included a physician order for all medications and treatments for 3 of 14 sampled patients (Patients #8, #11 and #13). Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings include: --- Review of the policy, titled The Plan of Care, dated April 2018, revealed each patient will have an individualized, written Plan of Care (POC). Hospice staff will provide care in accordance with the POC. 1. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: a. The skilled nursing visit, dated 12/21/22, included documentation the nurse assessed the patient was experiencing anxiety and shortness of breath. The nurse documented the patient requested an order for Lorazepam (medication used to treat anxiety and difficulty breathing). The nurse documented they were going to add Lorazepam and Morphine to the patient's medication regimen. The visit note lacked documentation the nurse had contacted the patient's physician or the hospice's medical director for orders. 1) The POC, dated 12/20/22 to 3/19/23, included an order for Morphine concentrate 100 milligrams(mg)/5 milliliters (ml) 0.25 ml by mouth every 1 to 2 hours for dyspnea, air hunger or pain. The POC did not include an order for Lorazepam. 2) The clinical record included an order for Lorazepam 2 mg/ml 0.25 ml every hour as needed by mouth for dyspnea and restlessness with a verbal order date of 12/27/22. The clinical record lacked documentation of a physician order for Lorazepam prior to 12/27/22. On 4/5/23 at 9:01 AM, during an interview, the patients spouse reported the patient did have anxiety, and they had talked about taking Lorazepam liquid with one of the nurses. The nurse was going to get an order for the Lorazepam, but the patient had some Lorazepam tablets already. The patients spouse was unsure if the patient ever got the Lorazepam in liquid form prior to the patients death. The clinical record lacked documentation of an order for Lorazepam tablets. b. The POC, dated 12/20/22 to 3/19/23, included an order for Soaanz (a diuretic used to help reduce fluid retention) 40 mg tablet 2 tablets by mouth daily for congestive heart failure. 1) The skilled nursing visit completed by the Clinical Manager, dated 12/26/22, included documentation the patient had 4 plus pitting edema (a measure used to describe extensive fluid retention) from the lower extremities up into the pelvis areas causing pain and irritation in the perineal area. The nurse documented they instructed the patient to take an extra Torsemide (Soaanz) yesterday and today and planned to contact the patient's primary physician for additional orders. 2) The clinical record lacked documentation of a physician order for the patient to take an extra Torsemide beyond what the physician ordered on the POC. The clinical record lacked documentation of any additional orders to treat the patient's excessive fluid retention. On 4/6/23 at 8:45 AM, during an interview, the Clinical Manager reported the discharge orders from the patient's last hospital stay (prior to hospice) included instructions that the patient could take an extra Torsemide if needed. The Clinical Manager explained the agency should have included this part of the order on the POC. c. The comprehensive assessment completed by a RN at the start of care, dated 12/20/22, identified the patient used oxygen at 3 liters (per minute). 1) The POC, dated 12/20/22 to 3/19/23, included a diagnosis of dependence on supplemental oxygen and that the patient had an oxygen concentrator, but lacked an order for oxygen use. 2) The skilled nursing visit, dated 12/27/22, identified the patient was using oxygen at a rate of 5 liters. 3) The clinical record lacked an order for oxygen use. 2. Patient #11 had a hospice admission date of 7/28/22, received routine home care hospice services while residing in a private residence and died on 8/5/22. Review of the clinical record revealed the following: a. The skilled nursing visit, dated 8/4/22, included documentation the nurse inserted a 16 French urinary catheter with a 10 milliliter (ml) bulb inflation (balloon like device inserted into the bladder and filled with fluid) amount. b. The clinical record included documentation of an interim physician order, dated 8/4/22, for the nurse to place a urinary catheter for comfort. The order failed to include the urinary catheter size and bulb inflation amount. 3. Patient #13 had a hospice admission date of 4/22/22, received routine home care and respite hospice services and died on 5/9/22. Review of the clinical record revealed the following: a. The skilled nursing visit, dated 5/6/22, included the following documentation: "(the patient) was started on Gabapentin". b. Review of the hospice's medication profile revealed the patient started on Gabapentin 100 milligrams (mg) three time per day with a start date of 5/2/22. c. The clinical record lacked documentation of an interim physician order for Gabapentin. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, family interview and staff interview, the hospice failed to ensure the hospice nurse obtained a physician order for a medication change prior to instructing the patient on the medication change for 1 of 14 sampled patients (Patient #8). Failure to ensure the hospice nurse obtained a physician order for a medication or treatment change prior to instructing the patient on the medication or implementing the treatment change placed the patient at potential risk to receive incorrect or ineffective treatment to meet the assessed needs of the patient. Findings include: --- Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 14 sampled patients (Patient #8). Failure of the hospice Interdisciplinary Group (IDG) members to maintain a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the policy, titled The Plan of Care, dated April 2018, revealed each patient will have an individualized, written Plan of Care (POC). Hospice staff will provide care and services based on the POC. Patient #8 had a hospice admission date of 12/20/22, received routine home care hospice services while residing in a private residence and died on 12/27/22. Review of the clinical record revealed the following: a. The skilled nursing visit, dated 12/21/22, included documentation the nurse assessed the patient was experiencing anxiety and shortness of breath. The nurse documented the patient requested an order for Lorazepam (medication used to treat anxiety and difficulty breathing). The nurse documented they were going to add Lorazepam and Morphine to the patient's medication regimen. The visit note lacked documentation the nurse had contacted the patient's physician or the hospice's medical director for orders. 1) The POC, dated 12/20/22 to 3/19/23, included an order for Morphine concentrate 100 milligrams(mg)/5 milliliters (ml) 0.25 ml by mouth every 1 to 2 hours for dyspnea, air hunger or pain. The POC did not include an order for Lorazepam. 2) The clinical record included an order for Lorazepam 2 mg/ml 0.25 ml every hour as needed by mouth for dyspnea and restlessness with a verbal order date of 12/27/22. The clinical record lacked documentation of a physician order for Lorazepam prior to 12/27/22. On 4/5/23 at 9:01 AM, during an interview, the patients spouse reported the patient did have anxiety, and they had talked about taking Lorazepam with one of the nurses. The nurse was going to get an order for the Lorazepam, but the patient had some Lorazepam already. They told the nurse the patient would just take the patients own Lorazepam tablets. The patients spouse was unsure if the patient ever got the Lorazepam in liquid form prior to the patients death. The hospice nurse failed to ensure the Lorazepam in the patient's home was congruent with the patient's current needs and approved by the attending physician and/or the hospice medical director. b. The POC, dated 12/20/22 to 3/19/23, included an order for Soaanz (a diuretic used to help reduce fluid retention) 40 mg tablet 2 tablets by mouth daily for congestive heart failure. 1) The skilled nursing visit completed by the Clinical Manager, dated 12/26/22, included documentation the patient had 4 plus pitting edema (a measure used to describe extensive fluid retention) from the lower extremities up into the pelvis areas causing pain and irritation in the perineal area. The nurse documented they instructed the patient to take an extra Torsemide (Soaanz) yesterday and today and planned to contact the patient's primary physician for additional orders. 2) The clinical record lacked documentation of a physician order for the patient to take an extra Torsemide beyond what the physician ordered on the POC. The clinical record lacked documentation of any additional orders to treat the patient's excessive fluid retention. On 4/6/23 at 8:45 AM, during an interview, the Clinical Manager reported the discharge orders from the patient's last hospital stay (prior to hospice) included instructions that the patient could take an extra Torsemide if needed. The Clinical Manager explained they should have included this part of the order on the POC. The hospice nurse instructed the patient to take medications without consulting a physician. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to maintain documentation in the patient clinical records as evidence that patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 1 sampled patients (Patients #10) who received routine home care while living in a private home residence and had a physician ordered controlled medication after the start of hospice services. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: --- According to the undated hospice policy titled Patient and Family Rights and Responsibilities, receipt of education from hospice staff included safe medication disposal-instruction sheet and policy and procedure. 1. Patient #10 had a hospice admission date of 1/20/23 and discharge date of 2/17/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/20/23 to 2/17/23, included orders for skilled nursing services and lacked orders for narcotic medication. b. A communication note, dated 2/13/23, included documentation new orders for comfort medications were put in place. c. The medication report, dated 2/13/23, included the following new medications: Lorazepam (antianxiety) 2 mg/ml give 0.25 ml by mouth every hour as needed for restlessness, air hunger and Morphine (narcotic analgesic) concentrate 100 mg/5 ml give 0.25 ml by mouth every hour as needed for pain, restlessness or air hunger. The plan of care updated, signed by the physician 2/15/23, included orders for Lorazepam and Morphine. The document identified no verbal order received. The clinical record lacked documentation of hospice staff providing a discussion of policy for disposal of controlled drugs at the time of ordering the controlled drug. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on review of hospice policy review, nursing home and hospice staff interview, nursing home record review and hospice clinical record review, the hospice failed to: 1) ensure hospice staff coordinates with nursing home staff in development of the plan of care (see L0778) and providing treatment; and 2) ensure the hospice provides the nursing home with patient's POC, hospice election form, CTI, names and contact information, instructions to access the hospice 24 hours on call system, medication information and hospice physician and attending physician (see L0781). --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure nursing homes provided patient care in a manner to meet the individualized needs of all patients effectively and safely.

Based on clinical record review, onsite visit observation, nursing home medication and treatment administration records, nursing home staff interview, patient representative interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 2 of 2 sampled patients (Patients #1 and #2) residing in a nursing home and receiving an onsite visit observation. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: --- Findings include: 1. Patient #1 had a hospice admission date of 7/21/22 and received routine home care hospice services while residing in a nursing facility (nursing home). See L0503, L0549, L0550 and L0554. The hospice IDG failed to ensure they maintained the overall coordination of the patient's care with the nursing home in relation to advance directives, treatments, medications and medical equipment and supplies. 2. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. See L0503, L0524, L0549, L0550, L0554 and L0556. The hospice IDG failed to ensure they maintained the overall coordination of the patient's care with the nursing home in relation to advance directives, wound identification and assessment, treatments, medications, services and medical equipment and supplies. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, nursing home clinical record review, nursing home staff interview and hospice staff interview, the hospice failed to ensure the nursing home received copies of all required documents including physician certification of terminal illness specific to the patient and hospice benefit election form for 2 of 2 sampled patients (Patients #1 and #2) with home observation visits in nursing homes. Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: --- 1. Patient #1 had a hospice admission date of 7/21/22 and received routine home care hospice services while residing in a nursing facility (nursing home). Review of the hospice clinical record revealed the following documents: a. An initial CTI, dated 7/21/22 to 10/18/22, and subsequent CTIs, dated 10/19/22 to 1/16/23, 1/17/23 to 3/17/23 and 3/18/23 to 5/16/23. b. A Medicare Benefit Election form, dated 7/21/22. On 3/29/23 at 9:00 AM, during an interview and record review with nursing facility staff, the nursing facility staff showed the surveyor the documents the hospice provided to the nursing home. The nursing facility staff confirmed the hospice chart at the facility had the initial Certificate of Terminal Illness (CTI), but could not find the subsequent CTIs, dated 10/19/22 to 1/16/23, 1/17/23 to 3/17/23 and 3/18/23 to 5/16/23. The chart included a Medicaid election benefit form, but lacked a Medicare benefit election form. On 3/29/23 at 3:24 PM, during an interview, the Administrator and Human Resources both confirmed the hospice billed Medicare for the patient's hospice services. The hospice staff failed to provide a copy of the patient's subsequent CTIs and Medicare Benefit Election form to the nursing home. 2. Patient #2 had a hospice admission date of 3/22/23 and received routine home care hospice services while residing in a nursing home. Review of the hospice clinical record revealed the following documents: a. An initial CTI, dated 3/22/23 to 6/19/23. b. A Medicare Benefit Election form, dated 3/22/23. On 4/3/23 at 2:00 PM, during an interview, the patient's nursing facility nurse reported the documents provided by the hospice were located in a binder in the back nursing station closest to the patient. On 4/3/23 at 2:15 PM, a nursing facility aide and the hospice Clinical Manager searched for a binder with information the hospice provided to the nursing home. The facility aide and Clinical Manager were unable to find any provided information. The Clinical Manager had a folder with them that they identified as the exact same information the Clinical Manager had faxed to the facility on Friday, 3/30/23. Review of the folder the Clinical Manager identified as faxed information to the nursing home identified a lack of a CTI and Medicare Benefit Election form. The Clinical Manager reported they could get this information sent to the facility. The hospice staff failed to provide a copy of the patient's initial CTI and Medicare Benefit Election form to the nursing home. The Administrator and Clinical Manager received the above information and hospice staff provided no further information prior to the end of the survey. Findings include:

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal background check for 2 of 4 sampled employees (Staff A and D) who began serving hospice patients since their last survey, dated 8/19/2020. The hospice reported hiring 18 employees since the last survey. Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice employees who had direct patient contact. --- Findings include: On 4/5/23 at 8:20 AM, during an interview, Staff C, Human Resource Manager explained the hospice uses DCI for the criminal background check and Accurate for other background check. The SING has not been used since Staff C started in this position approximately 6-8 months ago. Staff C confirmed a SING report had not been completed for staff recently hired. On 4/5/23 at 9:00 AM, during an interview, the Administrator reported he had reached out to someone at the corporate level and requested information on how to access the SING repository and was waiting for a response back. 1. Staff D, Social Worker, had a hire date of 10/7/2020. A SING criminal background check was completed but lacked a date of completion to identify when the criminal background check was performed. 2. Staff A, Administrator, had a hire date of 7/11/22. A criminal background check was completed using DCI and dated 7/20/22, 9 days after the hire date. The hospice failed to complete a criminal background check within 30 days prior to the date of hire. Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients. The above findings were reviewed with the Hospice Administrator and Human Resource Manager. Hospice staff provided no further information prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 4 of 4 sampled employees (Staff A, B, D and E) who began serving hospice patients since their last survey, dated 8/19/2020. The hospice reported hiring 18 employees since the last survey. Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from staff who had direct patient contact. --- Findings include: On 4/5/23 at 8:20 AM, during an interview, Staff C, Human Resource Manager explained the hospice uses DCI for the criminal background check and Accurate for other background check. The SING has not been used since Staff C started in this position approximately 6-8 months ago. Staff C confirmed a SING report had not been completed for staff recently hired. On 4/5/23 at 9:00 AM, during an interview, the Administrator reported he had reached out to someone at the corporate level and requested information on how to access the SING repository and was waiting for a response back. 1. Staff A, Administrator, had a start date of 7/11/22. Staff A's personnel file lacked documentation of completed dependent adult and child abuse record checks. 2. Staff E, Chaplain, had a start date of 1/5/23. Staff E's personnel file lacked documentation of completed dependent adult and child abuse record checks. 3. Staff B, Clinical Manager, had a start date of 10/26/22. Staff B's personnel file included documentation of completed criminal history, dependent adult and child abuse record checks, dated 7/14/2020, greater than 2 years prior to Staff B's start date. 4. Staff D, Social Worker, had a start date of 10/7/2020. Staff D's personnel file included documentation of completed criminal history, dependent adult and child abuse record checks, but were undated. Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring. The above findings were reviewed with the Hospice Administrator and Human Resource Manager. Hospice staff provided no further information prior to the end of the survey.