Every finding on record at Hospice Buffalo Inc

Based on review of clinical records and staff interview, one (1) of twenty-seven (27) patients (Patient #'s: 14), lack a comprehensive assessment performed by the hospice interdisciplinary group within five (5) days after the election of hospice care. Failure of the IDG members to participate in completing the comprehensive assessment has the potential to place the patient/family at risk for the development of incomplete and/or inaccurate Plans of Care.The agency failed to ensure a comprehensive assessment conducted by the interdisciplinary group within five days as evidenced by the following: --- Patient #14 – This 78-year-old patient with a terminal diagnosis of end-stage high-grade serous carcinoma of the ovary involving pleura with a malignant pleural effusion and abdominal carcinomas was admitted to the hospice on 4/18/2025.A. Review of the Hospice Certification and Plan of Care from 4/18/2025 to 7/16/2025 revealed the following order: Chaplain (CH) effective 4/20/2025 1 week 1.Review of the Chaplain Hospice Add-on Evaluation note dated 04/29/2025 revealed the first Chaplain visit was completed on 04/29/2025, eight (8) days after the start of care.During interview on 05/15/2025 at 9:10 AM, the Chief of Clinical Operations stated that the Chaplain did not see the patient within five (5) days of the start of care. A voicemail was left by the Chaplain on 4/21/2025, however, no further attempt to initiate services was completed until the following week. B. Review of the clinical record lacked documented evidence that the interdisciplinary group collaborated on an initial comprehensive plan of care within five (5) days of the start of care. During interview on 5/14/2025 at 11:32 AM, the Chief of Clinical Operations confirmed that there was no initial interdisciplinary group plan of care collaboration note in the patient’s record and there should have been.

Based on review of clinical records and interviews with agency staff, the hospice failed to ensure in three (3) of twenty- seven (27) clinical records (Patient #'s: 3, 19, and 20), the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. The agency failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process as evidenced by: --- Patient #3 – This 92-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/19/2025. Review of the clinical record from 04/19/2025 to 05/05/2025 lacked documented evidence the patient’s immunization status was assessed. During an interview on 05/14/2025 at 12:38 PM, the Vice President of Quality Improvement stated no, there is no documentation to show that the patient’s immunization status was assessed and that there should be a note in the clinical record to clarify the patient’s immunization status.   Patient #19- This 64-year-old patient with a terminal diagnosis of senile degeneration of the brain, not elsewhere classified was admitted to the hospice on 04/18/2025. Review of the Registered Nurse Start of Care Visit Note dated 10/11/2024 lacks documented evidence the Registered Nurse assessed the patient’s immunization status. During interview on 05/14/2025 at 01:24 PM, the Vice President of Quality Improvement stated that there are no vaccinations documented in this patient’s record.  Patient #20- This 83-year-old patient with a terminal diagnosis of cerebral vascular disease, unspecified was admitted to the hospice on 04/15/2025. Review of the agency's policy entitled "Alterations in Skin Integrity - Assessment, Early Intervention and General Treatment" dated 04/20/2010 revealed the following:1.    “Assessment of skin integrity; A.   All patients should have an integumentary assessment completed at the time of admission and with each comprehensive assessment.B.   The documentation of altered skin integrity will occur at the time of detection and will be completed weekly thereafter for all skin integrity issues.ii.              Documentation of malignant wounds, sutured surgical incisions, skin tears, rashes, fistulas, cancerous tumors and all other wounds or skin issues is to be done in the "integumentary" section of the RN assessment."iii.            The wound care documentation will include the wound care provided, description of the wound, and the patient response to care.” Review of the Registered Nurse Admission Visit Note dated 04/15/2025 revealed the Registered Nurse documented the patient has a skin tear to the right wrist. The visit note lacks documented evidence of an assessment of the skin tear. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During interview on 05/14/2025 at 10:07 AM, the Chief of Clinical Operations stated that the Registered Nurse did not clearly assess the area, no wound care orders were documented, so the wound was likely left open to air, but the Chief of Clinical Operations could not confirm that. Additionally, the Chief of Clinical Operations stated that there should be some documentation on the Plan of Care for wound care and monitoring.

Based on review of clinical records, agency policy and procedure, and interviews with staff, for one (1) of twenty-seven (27) clinical records (Patient #16), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug profile review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group to act on inaccurate information. --- Review of the agency policy and procedure entitled “Drug Profile Review, Management of Drugs and Biologicals, & Monitoring for Optimal Pharmaceutical Outcomes dated 04/20/2010 revealed the following:"a. The admission nurse will review all prescription medications, OTC (over the counter) medications, vitamin/mineral supplements, herbal/alternative remedies, and illicit drugs that could affect drug therapy.i. Medication information will be obtained from all sources possible including but limited to mediation bottles, devices, or vials, discharge instructions/ orders, physician office notes, and patient/family reports of administration use.ii. The patient’s physician will be contacted to review all pre-admission medications and obtain admission medication orders.1.      The admission nurse will identify pre-admission medications not continued or changed, and new medication orders obtained.iii.   If the patient is taking medications prescribed by more than one physician, orders will be obtained at time of admission from the patient’s primary physician to verify all medications.iv. The nurse will collaborate with the attending/ordering physician and the hospice medical director/hospice physician or nurse practitioner/hospice pharmacist as appropriate, to correlate current therapy with each patient problem/disease. The following concepts will be incorporated; therapeutic objectives related to palliation and management of the terminal illness and related conditions, selection of the best therapy inclusive of the least obtrusive and most cost effective, and consideration of the patient variables that would affect medication pharmacokinetic and pharmacodynamics.v. The physician’s admission orders will be entered into the patient’s record." Patient #16 – This 99-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/18/2025.   A. Review of the Encounter for Annual Wellness Visit dated 04/14/2025 revealed the following medication order:- Brinzolamide (Azopt) 1% ophthalmic suspension – administer 1 drop into both eyes in the morning and 1 drop before bedtime. Review of the Hospice Certification and Plan of Care from 04/18/2025 to 07/16/2025 revealed the following order:- Brinzolamide 1% eye drops, suspension – 1 drop daily, reason: glaucoma, instructions: right eye. Review of RN (Registered Nurse) Hospice Admission Visit dated 04/18/2025 revealed the Registered Nurse documented the following:Medication ReconciliationPre-admission medication list reviewed with hospice medical director, patient, and primary caregiver.Indicate information reviewed: Physician Office EMR (Electronic Medical Record) MED (Medication) List, pill bottles, scripts, and OTC (over the counter) medications in the home.Pre-admission medications discontinued: artificial tears, vitamin D2, furosemide, and lidocaine solution.Pre-admission medications changed: Tylenol, tramadol, iron, and metoprolol succ (succinate) ER (extended Release).New medications added to the plan of care: Colace, Dulcolax tablet, comfort pack, lidocaine patch, Synthroid, and Claritin.Status of Medication Reconciliation: medication list, PRN (as needed) log and pill bottles reviewed and reconcile, no follow up needed.There is a lack documented evidence that the Registered Nurse discussed the discrepancy with the physician.Review of the IDG Summary Report dated 04/22/2025 lacked documented evidence the medication discrepancy was discussed during the meeting. During an interview on 05/14/2025 at 03:38 PM, the Admissions Registered Nurse stated that the Admissions Registered Nurse does not recall if the patient was to be using the brinzolamide 1% eye drops in the right eye or in both eyes. B. Review of the Encounter for Annual Wellness Visit dated 04/14/12025 revealed the following medication order:- dorzolamide (Trusopt) 2% ophthalmic solution – administer into affected eye(s). Review of the Hospice Certification and Plan of Care from 04/18/2025 to 07/16/2025 lacked an order for the medication. Review of RN (Registered Nurse) Hospice Admission Visit dated 04/18/2025 revealed the Registered Nurse documented the following:Medication ReconciliationPre-admission medication list reviewed with hospice medical director, patient, and primary caregiver.Indicate information reviewed: Physician Office EMR (Electronic Medical Record) MED (Medication) List, pill bottles, scripts, and OTC (over the counter) medications in the home.Pre-admission medications discontinued: artificial tears, vitamin D2, furosemide, and lidocaine solution.Pre-admission medications changed: Tylenol, tramadol, iron, and metoprolol succ (succinate) ER (extended Release).New medications added to the plan of care: Colace, Dulcolax tablet, comfort pack, lidocaine patch, Synthroid, and Claritin.Status of Medication Reconciliation: medication list, PRN (as needed) log and pill bottles reviewed and reconcile, no follow up needed.There is a lack of documented evidence that the Registered Nurse discussed the discrepancy with the physician. Review of the Initial IDT (Interdisciplinary Team) POC (Plan of Care) Collaboration dated 04/22/2025 lacked documented evidence the medication discrepancy was discussed during the meeting. During an interview on 05/14/2025 at 03:39 PM, the Admissions Registered Nurse stated that the Admissions Registered Nurse does not recall if the patient was to be using the dorzolamide 2% ophthalmic solution.

Based on review of clinical records and interviews with staff for three (3) of twenty- seven (27) clinical records (Patient #s: 1, 4, and 9), the hospice failed to provide services according to the Plan of Care. Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs. The hospice failed to provide services according to the Plan of Care as evidenced by the following: --- Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025.Review of the Plan of Care Update Order dated 04/11/2025 revealed an order for a Home Health Aide (HHA) effective 04/13/2025 at the following frequency: two (2) visits per week for eleven (11) weeks, and one (1) time a week for one (1) week.Review of the clinical record for the week of 04/13/2025 through 04/19/2025 revealed the HHA provided services one day during that week, on 04/17/2025. Review of the clinical record lacks documented evidence that the patient and/or physician requested a change in the Home Health Aide visit frequency.During interview on 05/15/2025 at 09:03 AM, the Chief of Clinical Operations stated that visits are scheduled Monday through Friday and the visit was done on Thursday and another visit was not scheduled for that week.During interview on 05/15/2025 at 09:04 AM, the Vice President of Quality Improvement stated that the nurse obtains the order frequency and then the scheduler puts in the frequency to populate on the schedule. Additionally, the scheduler then contacts the family to schedule the visits and would remove any frequencies that cannot be met and should have put in a note if any are missed. Review of the Massage Therapy Hospice Add-on Evaluation visit dated 4/25/2025 revealed the Licensed Massage Therapist documented the following: “Frequency is set at one (1) to four (4) times per month and as needed to address discomfort and provide ongoing support.”Review of the Hospice Add-On order dated 4/25/2025 revealed the following: “Massage Therapy Effective 4/20/2025 3 every 2 weeks for 2 weeks, 1 week 10.”Review of the clinical record for the weeks of 4/20/2025 through 05/3/2025 revealed two (2) Licensed Massage Therapy visits occurred on 04/25/2025 and 05/2/2025.Review of the clinical record lacked documented evidence that the Massage Therapy frequency was implemented as ordered by the physician.During interview on 5/14/2025 at 11:25 AM the Chief of Clinical Operations stated that a frequency order should not be a range as documented in the Massage Therapist’s note. The agency was going to look at their visit documentation calendar to identify if more visits were made.During interview on 5/15/2025 at 8:55 AM, the Vice President of Quality Improvement stated that there were no further Massage Therapy appointments and that the order should have been updated to reflect the following frequency “1 week 2, 12 as needed for change of condition.” Patient #4- This 87-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 02/03/2025. Review of the Hospice Certification and Plan of Care from 02/03/2025 revealed the following order: Frequency/ Duration of Visits: Skilled Nurse- three (3) visits per week for one (1) week, two (2) visits per week for three (3) weeks, one (1) visit per week for one (1) week, and twenty- six (26) As Needed Visits  for Changes in Condition. Review of the clinical record for the week of 02/23/2025 through 03/01/2025 revealed only one Skilled Nurse visit occurred on 02/26/2025, instead of the two visits ordered. Review of the clinical record lacks documented evidence that the patient and/ or physician requested a change in the Skilled Nurse visit frequency. During an interview on 05/15/2025 at 09:28 AM, the Vice President of Quality Improvements stated that the agency was not able to find any missed visit notifications for the week of 0/23/2025 through 03/01/2025.

Based on a review of clinical records and interview with agency staff for one (1) of twenty-seven (27) patients (Patient #: 1) the agency failed to ensure the patient and/or caregiver received education and training identified in the Plan of Care. Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. The hospice failed to provide education and training as evidenced by the following: --- Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025. Review of the Hospice Certification and Plan of Care dated 04/04/2025 to 07/02/2025 revealed an order for skilled nurse/caregiver/facility staff to apply A&D ointment or nursing cream every four (4) hours as needed. Cover with non-adherent dressing to promote comfort and wound healing to wound location on coccyx. Review of the Hospice Registered Nurse Subsequent Visit Note dated 04/07/2025 revealed the Registered Nurse documented the following:#1 Mid- coccyx, pressure ulcer I Change in status: none…Wound Care provided: skilled nurse/caregiver/facility staff to apply A&D ointment or nursing cream every four (4) hours as needed. Cover with non-adherent dressing to promote comfort and wound healing to wound located on the coccyx. Patient tolerated well.-          Indicate teaching performed:o   Infection control and prevention;o   Covid-19 precautions and prevention;o   Medication or treatment changes;o   Falls prevention;o   Oxygen use and safety including no smoking or open flames;o   Future planning; ando   Encouraged to call with any change in condition or symptom concerns.-          Who was teaching provided to:o   Patient-          Was a demo/redemo completed today?o   No During interview on 05/15/2025 at 09:18 AM, the Home Care Registered Nurse stated wound care education was discussed with the caregiver and should have been documented, including the demonstration and redemonstration of the wound care.

Based on review of clinical records and interviews with staff, for six (6) of twenty-seven  (27) patients (Patient #'s: 7, 12, 15, 16, 17, and 18) the hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. The agency failed to develop complete and individualized plans of care as evidenced by the following: --- Patient #12 – This 100-year-old patient with a terminal diagnosis of sensile degeneration of brain, not elsewhere classified was admitted to the hospice on 04/16/2025.Review of the Hospice RN (Registered Nurse) Subsequent Visit dated 05/02/2025 revealed the Registered Nurse documented the following:IntegumentaryIndicate Integumentary Assessment Findings: Erythema, Pale, Poor Turgor, and Other (Specify).Indicate Location of Erythema: bilateral buttocks, blanchable, no open wounds. Staff applying vitamin A and D ointment.Review of the clinical record lacked documented evidence of an order for the use of vitamin A and D ointment.During an interview on 05/14/2025 at 12:58 PM, the Facility Based Services Team 7 Manager stated that it "looks like we don’t have an order for the vitamin A and D ointment." Patient #16 – This 99-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/18/2025.  Review of the Hospice Certification and Plan of Care for certification period 04/18/2025 to 07/16/2025 revealed the following order: hospice nurse/caregiver to clean area around cholecystectomy insertion site with alcohol pad, flush tubing with 10 ml and drain the collection bag twice daily and change connection tube and bag every three weeks. There is a lack of documented evidence of what the cholecystectomy tube should be flushed with.During an interview on 05/14/2025 at 01:04 PM, the Chief of Clinical Operations stated that the order should have what to flush the cholecystectomy tube with and the order would have to be clarified with the Registered Nurse.During an interview on 05/14/2025 at 03:35 PM, the Admissions Registered Nurse stated, "I feel like the family had all the supplies in the home and were managing the cholecystectomy tube" and that "I don’t recall what they were using to flush the cholecystectomy tube with."  Patient #15 – This 75-year-old patient with the terminal diagnosis of unspecified combined systolic and diastolic (Congestive) heart failure was admitted to the hospice on 04/19/2025.A.     Review of the Hospice Certification and Plan of Care dated 04/19/2025 to 07/17/2025 revealed an order for Systane Preservative Free (PF) 0.4%-0.3% eye drops in a dropperette, one (1) dropperette single-use drop dispenser daily. The medication order for Systane Preservative Free (PF) 0.4%-0.3% eye drops lacked instructions for which eye to apply the medication.During interview on 05/14/2025 at 02:28 PM, the Chief of Clinical Operations stated the instructions should include which eye the medication is to be applied to and does not.B.     Review of the Hospice Certification and Plan of Care dated 04/19/2025 to 07/17/2025 revealed an order for Hospice nurse to instruct and monitor use of oxygen. Patient, primary caregiver, skilled nurse to apply two (2) – four (4) liters via nasal cannula as needed for comfort and shortness of breath.The Hospice Certification and Plan of Care lacks an order for oxygen tubing and supplies.During interview on 05/14/2025 at 02:30 PM, the Chief of Clinical Operations stated the oxygen tubing and supplies should be included in the orders. Patient #7 – This 89-year-old patient with the terminal diagnosis of cerebrovascular disease, unspecified was admitted to the hospice on 04/14/2025.Review of the Hospice Certification and Plan of Care dated 04/14/2025 to 07/12/2025 revealed an order for Brimonidine 0.2% eye drops one (1) drop two (2) times daily.The order for the Brimonidine 0.2% eye drops lacks instructions on whether the eye drops are to be applied to the left, right or both eyes.During interview on 05/14/2025 at 02:15 PM, the Chief of Clinical Operations stated that it is not clear and would be expected that the instructions would include which eye or both eyes medication is to be applied. Patient #17 – This 91-year-old patient with the terminal diagnosis of unspecified combined systolic and diastolic (Congestive) heart failure was admitted to the hospice on 04/19/2025.Review of the Hospice Certification and Plan of Care dated 04/19/2025 to 07/17/2025 revealed orders for the following:-          Brimonidine 0.2% - Timolol 0.5% eye drops one (1) drop daily;-          Dorzolamide 2% eye drops one (1) drop daily; and -          Rocklatan 0.02%-0.005% eye drops one (1) drop at bedtime.     The orders for Brimonidine, Dorzolamide, and Rocklatan lacks instructions on whether the eye drops are to be applied to the left, right or both eyes.During interview on 05/14/2025 at 02:35 PM, the Chief of Clinical Operations stated it is not clear what eye(s) the medication is to be applied and is expected to be included in the instructions for the medications. Patient #18 – This 99-year-old patient with the terminal diagnosis of malignant neoplasm of the prostate was admitted to the hospice on 04/04/2025.Review of the Hospice Certification and Plan of Care dated 04/18/2025 to 07/16/2025 revealed an order for miralax 17 gram oral powder packet, 17 gram daily as needed for constipation. The order lacks instructions that include how to take the Miralax powder.During interview on 05/14/2025 at 02:41 PM, the Chief of Clinical Operations stated that it is not clear how the powder should be taken and the instructions should have included to mix in water.

Based on clinical record review and interview with agency staff, for seven (7) of twenty-seven (27) patient records (Patient #: 1, 9, 12, 13, 14, 23, and 24), the hospice failed to ensure records are complete and contain all pertinent information related to the care and delivery of service to the patient. Failure to ensure clinical records are complete and contain all pertinent information related to patient care and services has the potential to result in inadequate and inappropriate care. The Hospice failed to ensure records are complete and contain all pertinent patient information as evidenced by the following: --- Patient #23 – This 78-year-old patient with a terminal diagnosis of cerebrovascular disease with recent cerebrovascular accident (CVA) was admitted to the hospice on 10/1/2024.A. Review of the Registered Nurse Hospice PRN Visit – As Needed dated 10/05/2024 revealed the Registered Nurse documented the following:“Indicate problems/concern reported: patient’s daughter questions if "menuca" honey should be used on the stage 2 coccyx wound.”“Visit overview/plan for visit: on-call visit to assess coccyx wound for possible wound change to include "minooka" honey.“Collaborated with doctor written for new orders for wound care to coccyx to include "minocha" honey.”“New orders or treatments this visit: Skilled Nurse/Wife to cleanse coccyx wound with normal saline, pat dry, apply a thin layer of "minooka" honey, place allevyn every 3 to 5 days or as needed if loose or soiled to promote healing and prevention of infection”“Indicate supplies left in the home this visit: Manuka honey, 5x5 allevyn, 4x4 gauze, normal saline.”During interview on 5/14/2025 at 11:02 AM, the Chief of Clinical Operations stated that the discrepancies in the treatment with manuka honey was a typographical error likely caused by the Registered Nurse using talk to text while documenting.B. Review of the skilled nursing facility form titled ‘Medical Patient Instructions for Continuity of Care’ dated 10/01/2024 revealed the following medication order: “Esomeprazole Magnesium 40 delayed release capsule.”Review of the Registered Nurse Hospice Admission Visit dated 10/01/2024 revealed the following documentation “pre-admission medications discontinued or changed: discontinued this visit omeprazole.”During interview on 5/14/2025 at 10:58 AM, the Chief of Clinical Operations stated that the Registered Nurse most likely made a transcription error and the medication that was discontinued at start of care was Esomeprazole Magnesium. Patient #9 – This 88-year-old patient with a terminal diagnosis of end-stage Chronic Obstructive Pulmonary Disease (COPD) with hypoxic respiratory failure was admitted to the hospice on 4/19/2025.Review of the Skilled Nurse Hospice Revisit note dated 05/01/2025 revealed the following documentation regarding the patient’s pain assessment:“Alleviating factors: repositioning, rest, morphine”“Is this patient receiving opioid medication: No”During interview on 5/14/2025 at 9:41 AM, the Registered Nurse stated “no” must have accidentally been pressed instead of “yes” while documenting on the tablet. The patient was receiving opioids for pain management. Patient #14 – This 78-year-old patient with a terminal diagnosis of end-stage high-grade serous carcinoma of the ovary involving pleura with a malignant pleural effusion and abdominal carcinomas was admitted to the hospice on 4/18/2025.Review of the Aide Hospice Visit note dated 05/02/2025 revealed the following:“Service: observe and report. Completed: Yes Note: Nothing to report”Review of the Skilled Nurse Hospice Revisit note dated 05/02/2025 revealed the following:“Home Health Aide contact this reporter informing of no void since last night, fourteen (14) hours.”During interview on 5/14/2025 at 11:37 AM, the Home Health Aide stated that documentation was completed during visit in real time and once the aide went to leave the patient disclosed that they had not voided. The nurse was then notified after the visit, but the home health aide had forgotten to update charting to reflect reporting of information. Patient #24 – This 53-year-old patient with a terminal diagnosis of colorectal cancer metastatic to lung and liver with a large fungating rectal mass was admitted to the hospice on 9/26/2023.Review of the Hospice Registered Nurse Subsequent Visit note dated 10/11/2023 revealed the following: “medication: nature’s bounty acidophilus probiotic 100 million colony forming units."  The visit note lacked complete documentation for the indication of initiating the probiotic at this visit.During interview on 5/14/2025 at 10:19 AM the clinician was unavailable for interview. The Chief of Clinical Operations stated that care was planned around gastrointestinal symptoms and assumes the medication was ordered to manage excessive bowel movements. The Chief of Clinical Operations further confirmed that agency expectation would be to indicate why the medication was initiated in the clinical record, and it is likely that the clinician forgot to include this information while documenting. Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025.Review of the Registered Nurse Hospice Admission Visit dated 04/04/2025 revealed the Registered Nurse documented the patient has a stage 1 pressure ulcer on the mid-coccyx, identified as wound #1. Review of the Registered Nurse PRN (as needed) Visit Note dated 04/13/2025 revealed the Registered Nurse documented the patient’s wound #1, mid-coccyx pressure ulcer as a Stage I. Review of the Hospice Registered Nurse Subsequent Visit Note dated 04/14/2025 revealed the Registered Nurse documented wound #1, mid- coccyx was a stage III pressure ulcer.The documentation regarding the stage of the wound is inconsistent.During interview on 05/15/2025 at 09:37 AM, the Registered Nurse stated that the stage of the pressure ulcer (stage III) was documented in error on 04/14/2025.  Patient #12: This 100-year-old patient with a terminal diagnosis of sensile degeneration of brain, not elsewhere classified was admitted to the hospice on 04/16/2025. Review of the RN (Registered Nurse) Hospice Admission Visit dated 04/16/2025 revealed the Registered Nurse documented the following mid upper arm circumference (MUAC): “MUAC 18.5 cm today.”  There is no documentation to state which arm was measured.  During an interview on 05/14/2025 at 12:55 PM, the Registered Nurse stated that MUAC is mid upper arm circumference. The Registered Nurse continued to state, "I don’t recall which arm that I took the patient’s mid upper arm circumference." Patient #13: – This 83-year-old patient residing in a skilled nursing facility (SNF) with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 04/15/2025. Review of the RN (Registered Nurse) Admission Visit dated 04/15/2025 revealed the Registered Nurse documented the following:Medication ReconciliationPre-admission medication list reviewed with the hospice medical director.Indicate information reviewed: Facility MAR (Mediation Administration Record).Pre-admission medications discontinued: meds (medications) discontinued at this time. No medications are listed. During an interview on 05/14/2025 at 12:25 PM, the Chief of Clinical Operations stated that the registered nurse reconciled the medications with the facility MAR (medication administration record) and that the documentation regarding medications that were discontinued was a typographical error as there were no medications discontinued.

Based on review of clinical records and interviews with agency staff, the agency failed for sixteen (16) of twenty-seven (27) (Patient #'s: 1, 3, 4, 6, 9, 10, 13, 14, 15, 16, 19, 20, 23, 24, 26, and 27) to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice.  Failure to authenticate documentation with professional credentials has the potential for patients to receive care from unlicensed staff. The hospice failed to ensure that all documentation by professional staff is appropriately authenticated as evidenced by the following: --- Patient #3 – This 92-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/19/2025.Review of the Aide Hospice Visit dated 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, and 05/05/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 12:24 PM, the Chief of Clinical Operations stated that the lack of credentials is a system problem and that the problem will be fixed.During an interview on 05/14/2025 at 02:04 PM, the Vice President of Clinical Education and Patient Advocacy stated the employee is a Home Health Aide. Patient #13 – This 83-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 04/15/2025. A. Review of the RN (Registered Nurse) Hospice Admission Visit dated 04/15/2025 lacked documented evidence of the professional’s credentials. During an interview on 05/14/2025 at 12:24 PM, the Chief of Clinical Operations stated that the employee is a Registered Nurse and that the lack of credentials is a system problem and that the problem will be fixed.B. Review of the Aide Hospice Visit dated 04/18/2025, 04/21/2025, 04/23/2025, 04/25/2025, 04/28/2025, and 04/30/2025 lacked documented evidence of the paraprofessional’s credentials.   During an interview on 05/14/2025 at 12:24 PM, the Chief of Clinical Operations stated that the employee is a Home Health Aide and that the lack of credentials is a system problem and that the problem will be fixed. Patient #16 – This 99-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/18/2025.  A. Review of the Aide Hospice Visit dated 04/25/2025, 04/28/2025, 04/30/2025, 05/02/2025, and 05/05/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 01:00PM, the Chief of Clinical Operations stated that the employee is a Home Health Aide and that there are no credentials next to the employee’s electronic signature on the employee’s documentation.B. Review of the LPN (Licensed Practical Nurse) Visit dated 04/25/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 01:00 PM, the Chief of Clinical Operations stated that the employee is a Licensed Practical Nurse and that there are no credentials next to the employee’s electronic signature on the employee’s documentation.Patient #26 – This 80-year-old patient with a terminal diagnosis of cerebrovascular disease, unspecified was admitted to the hospice on 05/29/2024.A. Review of the LPN (Licensed Practical Nurse) Visit dated 05/31/2024, 06/04/2024, 06/05/2024, 06/06/2024, 06/07/2024, 06/10/2024, and 06/11/2024 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 12:46 PM, the Chief of Clinical Operations stated that the employee is a Licensed Practical Nurse and there are no credentials next to the employee’s electronic signature.B. Review of the Aide Hospice Visit dated 06/03/2024, 06/05/2024, 06/07/2024, 06/10/2024, 06/12/2024, and 06/14/2024 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 12:47 PM, the Chief of Clinical Operations stated that the employee is a Home Health Aide and there are no credentials next to the employee’s electronic signature on the employee’s documentation.    Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025.A.     Review of the Inpatient Unit Licensed Practical Nurse Subsequent Visit Note dated 05/03/2025 at 12:28 AM lacked the credentials for the employee.During interview on 05/14/2025 at 02:09 PM, the Chief of Clinical Operations stated the employee is a licensed practical nurse. Additionally, there is a system error that did not include the credentials with the signature of the employee. B.     Review of the Aide Hospice Inpatient Visit Note dated 05/05/2025 at 02:24 PM revealed the note for the aide contains the credentials for a Registered Nurse, not an aide. During interview on 05/14/2025 at 02:07 PM, the Chief of Clinical Operations stated the employee is not a Registered Nurse but is employed as a Home Health Aide. Additionally, the Registered Nurse credentials were included in error and should have been documented as Home Health Aide. C.    Review of the Aide Hospice Inpatient Visit Note dated 04/30/2025 at 06:22 AM lacked the credentials for the employee.D.     Review of the Aide Hospice Inpatient Visit Note dated 04/30/2025 at 10:30 PM lacked the credentials for the employee.E.      Review of the Aide Hospice Inpatient Visit Note dated 05/01/2025 at 05:56 AM lacked the credentials for the employee.F.      Review of the Aide Hospice Inpatient Visit Note dated 05/01/2025 at 10:30 PM lacked the credentials for the employee.G.    Review of the Aide Hospice Inpatient Visit Note dated 05/03/2025 at 10:37 PM lacked the credentials for the employee.H.    Review of the Aide Hospice Inpatient Visit Note dated 05/04/2025 at 02:03 PM lacked the credentials for the employee.I.        Review of the Aide Hospice Inpatient Visit Note dated 05/05/2025 at 09:45 PM lacked the credentials for the employee.During interview on 05/14/2025 at 02:06 PM, the Chief of Clinical Operations stated employees are Home Health Aides. Additionally, there are no credentials next to the employee’s electronic signature on the employee’s documentation. Patient #15 – This 76-year-old patient with the terminal diagnosis of unspecified combined systolic and diastolic (congestive) heart failure was admitted to the hospice on 04/19/2025.Review of the Chaplain Hospice Add-On Evaluation Visit dated 04/22/2025 lacked documented evidence of employee HH’s professional credentials.During interview on 05/14/2025 at 02:31 PM, the Chief of Clinical Operations stated there is a system error and the chaplain credentials should have been included with the signature. Patient #9 – This 88-year-old patient with a terminal diagnosis of end-stage Chronic Obstructive Pulmonary Disease (COPD) with hypoxic respiratory failure was admitted to the hospice on 4/19/2025.A. Review of the Aide Hospice Visits dated 4/23/2025, 4/25/2025, 4/28/2025, 4/30/2025, 5/2/2025, and 5/5/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee BBB is a Home Health Aide.B. Review of the On Call note dated 5/2/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee CCC is a Licensed Practical Nurse.C. Review of the On Call note dated 4/27/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee LL is a Licensed Practical Nurse.D. Review of the Home Health Aide Schedule Update note dated 4/22/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee OO is a Team Scheduler.E. Review of the Medication Recommendations note dated 4/21/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee AA is the Pharmacy Director.F. Review of the Volunteer Care Plan note dated 4/24/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee NN is a Coordinator Volunteer Services. Patient #24 – This 53-year-old patient with a terminal diagnosis of colorectal cancer metastatic to lung and liver with a large fungating rectal mass was admitted to the hospice on 9/26/2023.A. Review of the Aide Hospice Visits dated 11/14/2023 and 11/15/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee QQ is a Home Health Aide. B. Review of the Aide Hospice Visit dated 11/14/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee PP is a Home Health Aide. C. Review of the Aide Hospice Visit dated 11/14/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee RR is a Home Health Aide.D. Review of the Aide Hospice Visit dated 11/13/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee SS is a Home Health Aide. Patient #6 – This 87-year-old patient with a terminal diagnosis of stage IV (four) squamous cell carcinoma of the larynx involving esophagus and lung was admitted to the hospice on 4/19/2025. A. Review of the Aide Hospice Visits dated 11/14/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee PP is a Home Health Aide. B. Review of the Chaplain Add-on Evaluation Visit dated 4/23/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:20 AM, the Chief of Clinical Operations verified that employee HH is a Chaplain. Patient #14 – This 78-year-old patient with a terminal diagnosis of end-stage high-grade serous carcinoma of the ovary involving pleura with a malignant pleural effusion and abdominal carcinomas was admitted to the hospice on 4/18/2025.A. Review of the Aide Hospice Visits dated 4/24/2025, 4/25/2025, 4/28/2025, 4/29/2025, 4/30/2025, 5/1/2025, 5/2/2025, 5/5/2025, and 5/6/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee JJ is a Home Health Aide.B. Review of the Phone Call Check notes dated 5/4/2025, 5/4/2025, and 5/5/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee LL is a Licensed Practical Nurse.C. Review of the Master of Social Work Add-on Evaluation visit dated 4/18/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee KK is a Social Worker.D. Review of the Home Health Aide Schedule Update note dated 4/23/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee MM is a Coordinator Home Health Aide Services. Patient #23 – This 78-year-old patient with a terminal diagnosis of cerebrovascular disease with recent cerebrovascular accident (CVA) was admitted to the hospice on 10/1/2024.A. Review of the Medication Recommendations note dated 10/2/2024 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:57 AM, the Chief of Clinical Operations verified that employee AA is the Pharmacy Director.B. Review of the Tuck In Call note dated 10/1/2024 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:57 AM, the Chief of Clinical Operations verified that employee CCC is a Licensed Practical Nurse. Patient #27- This 87-year-old patient with a terminal diagnosis of alzhiemer’s disease, unspecified was admitted to the hospice on 05/16/2024. A.   Review of the Registered Nurse Hospice Admissions Visit Note dated 05/16/2024 lacks documented evidence of Employee BB’s professional credentials.B.   Review of the Licensed Practical Nurse Visits dated 05/27/2025 lacks documented evidence of Employee EE’s professional credentials.C.   Review of the Licensed Practical Nurse Visits dated 05/29/2025, 05/30/2025 and 05/31/2025 lacks documented evidence of Employee FF’s professional credentials.D.   Review of the Licensed Practical Nurse Visits dated 06/04/2025 lacks documented evidence of Employee YY’s professional credentials.E.    Review of the Licensed Practical Nurse Visits dated 06/05/2025 lacks documented evidence of Employee ZZ’s professional credentials. Patient #20- This 83-year-old patient with a terminal diagnosis of cerebral vascular disease, unspecified was admitted to the hospice on 04/15/2025. A.   Review of the Registered Nurse Hospice Admissions Visit Note dated 04/15/2025 lacks documented evidence of Employee BB’s professional credentials.B.   Review of the Home Health Aide Visits dated 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, and 05/01/2025 lacks documented evidence of Employee EEE’s professional credentials.C.   Review of the Medical Social Worker Visits dated 04/16/2025, and 04/21/2025 lacks documented evidence of Employee KK’s professional credentials. Patient #4- This 87-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 02/03/2025. A.   Review of the Licensed Practical Nurse Visits dated 02/26/2025 and 04/28/2025 lacks documented evidence of Employee EE’s professional credentials.B.   Review of the Licensed Practical Nurse Visits dated 05/05/2025 lacks documented evidence of Employee YY’s professional credentials. Patient #10- This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the brain, unspecified was admitted to the hospice on 04/15/2025.Review of the Medical Social Worker Visit dated 04/15/2025 lacks documented evidence of Employee DDD’s professional credentials. Patient #19- This 64-year-old patient with a terminal diagnosis of senile degeneration of the brain, not elsewhere classified was admitted to the hospice on 04/18/2025.Review of the Home Health Aide Visits dated 04/25/2025, 04/28/2025, 04/30/2025, 05/02/2025, and 05/05/2025 lacks documented evidence of Employee CC’s professional credentials. During interview on 05/14/2025 at 09:30 AM, the Chief of Clinical Operations stated that this is an issue with the system when the employee electronic signatures are developed. Additionally, the Chief of Clinical Operations stated that all staff should have titles included in the signatures.

Based on clinical record review and staff interview for one (one) of three (3) live discharged patients (Patient #23). the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components. Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice.The hospice failed to prepare a comprehensive discharge summary as evidenced by the following: --- Patient #23 – This 78-year-old patient with a terminal diagnosis of cerebrovascular disease with recent cerebrovascular accident (CVA) was admitted to the hospice on 10/1/2024.Review of the Hospice Revocation and Clinical Note dated 10/17/2024 revealed the patient was revoking the hospice benefit to pursue restorative therapies.Review of the clinical record lacked documented evidence that a comprehensive discharge summary was prepared at the time of discharge.During interview on 05/14/2025 at 10:56 AM, the Home Care Services Team 4 Manager stated the agency expectation is for all live discharges to have discharge summaries. The Home Care Services Team 4 Manager confirmed that this patient did not have a discharge summary prepared, that the agency is aware, and they are implementing internal changes to ensure compliance.

Based on review of clinical records and interviews with agency staff, the hospice failed to ensure in one (1) of five (5) clinical records (Patient #5), the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. --- Patient #5 - This 82-year-old patient with a terminal diagnosis of senile degeneration of the brain, residing in a skilled nursing facility, was admitted to the hospice on 02/06/2023. Review of the Initial Registered Nurse (RN) Hospice Admission Visit Note dated 02/06/2023 revealed the RN documented the following:-Is the patient taking an anticoagulant: No. Review of the Hospice Certification and Plan of Care for 02/06/2023 to 05/06/2023 revealed the patient had cerebral infarction and takes Aspirin (antithrombotic) for cardiac prophylaxis daily. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During interview on 02/22/2023 at 11:38 AM, the Director of Quality stated that the clinician answered the question incorrectly, as aspirin is considered to be an anticoagulant. The Director of Quality added that going forward they will change the way the question is being asked.

Based on review of clinical records and interview with staff, for one (1) of five (5) patients (Patient #4), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group (IDG) to act on inaccurate information. --- Patient #4 – This 75-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease was admitted to the hospice on 02/07/2023. Review of the referral to the agency dated 12/09/2022 revealed the following medications:- escitalopram oxalate 10 mg (milligram) tablet take 1 tablet by mouth once a day. Review of the Hospice Certification and Plan of Care for 02/07/2023 to 05/06/2023 lacks orders for the identified medication. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancies with the physician or the IDG. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 02/22/2023 at 11:15 AM, the RN stated she did call the patients physician but did not specifically document that the medication was discontinued.

Based on clinical record review and staff interviews for one (1) of five (5) clinical records (Patient #1) lacks documented evidence the hospice nurses and Interdisciplinary Group (IDG) members are performing complete updated comprehensive assessments or that the hospice nurses are communicating changes in the patient's condition or treatment to the IDG. Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient has the potential for the patient's health status to be compromised and result in the provision of poor quality of care. --- Patient #1 – This 70-year-old patient with a terminal diagnosis of end stage cerebrovascular disease, residing in a skilled nursing facility, was admitted to the hospice on 02/06/2023. A.) Review of the Plan of Care Update dated 02/08/2023 revealed an order to discontinue the daily intravenous Heparin Lock Flush to the patients central line. Review of the Hospice RN (Registered Nurse) Subsequent Visit dated 02/17/2023 revealed the RN documented the patient had a central line in place that was last flushed on 02/16/2023. Review of the clinical record lacks documented evidence of the intravenous central line flushes being reinstated after 02/08/2023. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/22/2023 at 10:15 AM, the RN stated the assessment documentation was incorrect as the central line flushes had been discontinued. B.) Review of the SN (Skilled Nurse) Hospice Revisit dated 02/08/2023 revealed the following integumentary assessment: - Number of pressure ulcers- stage 1: Four or more; - Number of pressure ulcers- stage 2: Two; and - Indicate other integumentary issues: Two abrasions to left scapula, one abrasion to left elbow and one abrasion to left lower back. Review of the Hospice RN Subsequent Visit dated 02/17/2023 revealed the RN documented on the following wounds: a stage II pressure ulcer to the left heel and an unstageable deep tissue injury to the mid sacrum. The documentation lacks an assessment of the four (4) stage I pressure ulcers to the left scapula, left elbow and left lower back identified on 02/08/2023. Review of the clinical record between 02/08/2023 and 02/17/2023 lacks documented evidence of the identified stage I pressure ulcers being resolved. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 02/22/2023 at 10:17 AM, the RN stated she failed to document on the identified stage I pressure ulcers on the 02/17/2023 assessment.

Based on review of clinical records and interviews with staff for one (1) of five (5) clinical records (Patient #2), the hospice failed to provide services according to the Plan of Care (POC). Failure to provide services in accordance with the POC has the potential for unmet patient needs. --- Patient #2 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of pancreas was admitted to the hospice on 02/07/2023. Review of the Home Health Certification and Plan of Care for certification period 02/07/2023 to 05/07/2023 revealed the following order for the patients mediport access site: ";Dressing and Huber needle to be changed every 7 (seven) days and PRN (as needed) soiled or loose." Review of the RN (Registered Nurse) Hospice Admission Visit dated 02/07/2023 revealed the RN documented the following assessment: - Does the patient have an access device? Yes - Type of access device(s): Port - Location of access device: right chest - Condition of access device site: site dry, clean and intact - Was site accessed? No - Date of last access/flush: 01/25/2023 - Is a medication pump being utilized? No Review of the RN Hospice Admission Visit dated 02/07/2023 revealed the RN documented ";Pt (patient) has decided to stop chemo (chemotherapy) as quality of life was poor from side effects." Review of the clinical record from 02/07/2023 to 02/21/2023 (date of survey) lacks documented evidence of a dressing change or change of Huber needle. The hospice failed to provide services according to the POC. During interview on 02/22/2023 at 11:06 AM, the RN stated the site has not been accessed since the patients start of care. He is no longer receiving chemotherapy. The order to change the dressing and Huber needle is an error.

Based on review of clinical records and interviews with staff, for one (1) of five (5) patients (Patient #1) the hospice failed to develop an individualized written plan of care (POC) that reflects patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. --- Review of agency policy entitled ";Plan of Care" dated 09/13/2022 revealed ";The plan of care must include all services necessary for palliation and management of the terminal illness and related conditions, including the following:...d. Drugs and treatment necessary to meet the needs of the patient....5aii. Treatment orders are inclusive of pulse ox measurement, anti- embolic stockings, VAD (vascular access device) maintenance and site care, application of braces, enteral feedings and site care." Patient #1 – This 70-year-old patient with a terminal diagnosis of end stage cerebrovascular disease, residing in a skilled nursing facility, was admitted to the hospice on 02/06/2023. Review of the RN (Registered Nurse) Hospice Admission Visit revealed following regarding the patients central line access device: - Location of access device: Right chest; - Condition of access device site: Patent per Skilled Nursing Facility (SNF) staff, no issues noted, site dry, clean and intact; - Type of site dressing: Gauze and tape; - Date of last site dressing change: 02/05/2023; - Date cap changed: 02/05/2023; and - Last flush: 02/05/2023. Review of the Hospice Certification and Plan of Care for 02/06/2023 to 05/06/2023 revealed the following order: Per SNF MAR (medication administration record): Heparin Sodium port lock flush IV (intravenous) solution 10 u (unit)/ml (milliliter) use 5 ml IV one time a day for central line maintenance. The POC fails to include dressing change orders for the central line catheter. The hospice failed to develop a complete and individualized POC. During interview on 02/22/2023 at 11:27 AM, the RN stated she failed to specify the central line dressing change orders on the POC.

Based on review of clinical records and staff interview, for one (1) of two (2) patients receiving Home Health Aide (HHA) services (Patient #1), the agency failed to ensure the Interdisciplinary Group (IDG), in collaboration with the patient's physician, reviewed and revised the individualized plan of care (POC) as changes occurred, but no less frequently than every fifteen (15) days. Failure of the IDG to develop, review and revise the POC has the potential for unmet patient needs and inadequate care. --- Patient #1 – This 70-year-old patient with a terminal diagnosis of end stage cerebrovascular disease, residing in a skilled nursing facility, was admitted to the hospice on 02/06/2023. Review of the Aide Care Plan Report dated 02/09/2023 revealed the HHA is assigned the following tasks: - Turn and position in bed every visit; - Bathing every visit; - Catheter care every visit; - Oral care every visit; - Incontinent care every visit; - Mouth care (swab mouth) every visit; - Dressing total care every visit; - Activity, bedbound every visit, Details: hoyer lift with 2 (two) assist as tolerated, patient remains in bed at all times for comfort; - Date of last bowel movement every visit; - Diet- total feed every visit, Details: continuous feeds via peg (percutaneous endoscopic gastrostomy) tube (feeding tube located in stomach), patient does not tolerate PO (by mouth) intake due to severe risk of aspiration; - Indicate how patient was left at end of visit every visit; - Observe and report every visit, Details: call hospice nurse or nursing home team office with any new concerns or change in status; - Empty foley catheter drainage bag every visit; and - Oxygen- check flow rate (note liters/ minute) every visit, Details: 4 liters/ minute via nasal cannula continuous. A.) Review of the Plan of Care Update dated 02/08/2023 revealed a new order for Oxygen 2 liters/ minute continuous by nasal cannula and Oxygen at 4 liters/ minute continuous was discontinued. Review of the clinical record lacks documented evidence the Aide Care Plan was updated to include the new Oxygen orders. B.) Review of the Plan of Care Update dated 02/09/2023 revealed the patients continuous tube feed is discontinued and the patient is ordered to take by mouth intake for oral gratification only. Review of the clinical record lacks documented evidence the Aide Care Plan was updated to include the new diet orders. The aide POC failed to be updated as changes occurred. During interview on 02/22/2023 at 10:20 AM, the Registered Nurse (RN) stated she failed to update the Aide Care Plan with the identified changes.

Based on review of clinical records, agency policies and procedures, and interviews with agency staff, the hospice failed to ensure in three (3) of sixteen (16) clinical records (Patient #'s: 5, 8 and 10) the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. Findings are: Review of the agency's policy entitled "Alterations in Skin Integrity - Assessment, Early Intervention and General Treatment" dated 04/20/2010 revealed "All patients should have an integumentary assessment completed at the time of admission and with each comprehensive assessment. If there is a new wound noted, documentation should occur in the Integumentary Command Center (ICC) section of the RN (Registered Nurse) assessment. Documentation of pressure ulcers, stasis ulcers, diabetic, arterial, burns and open surgical wounds are to be done in the ICC section of the RN assessment. Documentation of malignant wounds, sutured surgical incisions, skin tears, rashes, fistulas, cancerous tumors and all other wounds or skin issues is to be done in the "integumentary" section of the RN assessment." Patient #5 - This 98-year-old patient with a terminal diagnosis of combined systolic and diastolic heart failure was admitted to the hospice on 07/25/2022. Review of the RN Hospice Admission Visit Note dated 07/25/2022 revealed the RN documented the patient has a skin tear to the right forearm. The visit note lacks documented evidence of an assessment of the skin tear. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During interview on 08/12/2022 at 12:04 PM, the Admission RN stated she assessed the skin tear but it was an oversight that the assessment was not documented. Patient #8 - This 79 -year-old patient with a terminal diagnosis of neoplasm of the bladder, unspecified was admitted to the hospice on 07/24/2022. Review of the discharge summary dated 06/17/2022 revealed the patient had a left sided nephrostomy tube. Review of the Hospice Certification and Plan of Care for 07/22/2022 to 10/21/2022 revealed the order for SN (Skilled Nurse) to perform dressing change every 5-7 (five to seven) days and PRN (as needed) dressing soiling/loosening to maintain skin integrity. Review of the clinical record lacks documented evidence to state when the initial dressing change is due. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During interview on 08/12/2022 at 12:50 PM, the Admission Manager stated the RN did not document an assessment that included the date of the last dressing change or when it is due. Patient #10 - This 68-year-old patient with a terminal diagnosis of malignant neoplasm of left kidney, except renal pelvis was admitted to the hospice on 07/24/2022. Review of the RN Hospice Admission Visit Note dated 07/24/2022 revealed the RN documented the patient has a diabetic ulcer on the right foot, third toe. Review of the ICC section of the RN assessment dated 07/24/2022 revealed the following: - Diabetic ulcer, 3rd (third) toe, right foot onset date: 07/24/2022 - Measurements taken: no - Reason measurements not taken: unable The hospice failed to ensure the content of the comprehensive is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During interview on 08/12/2022 at 09:30 AM, the Admission RN stated she cannot remember why she didn' t measure the wound. The Chief Clinical Officer stated the expectation is that the wound is measured at the start of care.

Based on review of clinical records, agency policies and procedures, and interview with staff, for seven (7) of sixteen (16) patients (Patient #'s: 1, 3, 6, 10, 11, 12, and 15), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects,and/or the Interdisciplinary Group (IDG) to act on inaccurate information. Findings are: Review of the agency's policy entitled "Drug Profile Review, Management of Drugs and Biologicals, and Monitoring for Optimal Pharmaceutical Outcomes" dated 04/20/2010 revealed "All medication bottles, devices, or vials, etc. will be reviewed and medications will be reconciled with discharge instructions/ orders in cases where a patient was transferred from a facility. The nurse will clarify with the physician and patient any discrepancies found in the medication therapy. Any new or discontinued medications, OTC (over the counter) medications, vitamins, herbals, etc. (Et Cetera) will be entered as a modified physician order and placed in the patient's active medication profile. The modified order will be signed by the physician." Patient #11 - This 85-year-old patient with a terminal diagnosis of malignant neoplasm of breast with brain metastasis was admitted to the hospice on 07/24/2022. A.) Review of the facility referral dated 07/12/2022 revealed the following medication orders: - Aspirin low dose 81 mg oral delayed release tablet, 81 mg tab (tablet) oral daily; and - Duloxetine 30 mg oral delayed release capsule, 30 mg oral daily. Review of the Hospice Certification and Plan of Care from 07/24/2022 to 10/21/2022 lacks orders for the identified medications. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician. Review of the IDG Summary Report dated 07/26/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 09:42 AM, the Admissions Manager stated the RN that completed the drug profile review was unavailable for interview. The Admissions Manager stated there is no documentation to clarify the identified medication discrepancies in the clinical record. B.) Review of the facility referral dated 07/12/2022 revealed the patient has allergies to Meperidine and Sulfa drugs. Review of the Hospice Certification and Plan of Care from 07/24/2022 to 10/21/2022 revealed Allergies: NKA (no known allergies). Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician. Review of the IDG Summary Report dated 07/26/2022 lacks documented evidence the allergy discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 09:46 AM, the Director of Quality stated the RN that completed the drug profile review was unavailable for interview. The Director of Quality stated there was no documentation in the clinical record to clarify the allergy discrepancies. Patient #15 - This 69-year-old patient with a terminal diagnosis of malignant neoplasm of bronchus or lung was admitted to the hospice on 07/13/2021. A.) Review of the Hospice Certification and Plan of Care from 07/13/2021 to 10/10/2021 revealed the following orders: - Ipratropium 0.5 mg - Albuterol 3 mg (2.5 base)/ 3 ml inhalation every 4 (four) hours PRN for dyspnea; and - Loratadine 10 mg tablet oral daily. Review of the discharge summary dated 07/06/2021 lacks orders for the medications listed above. Review of the clinical record lacks documentation the RN discussed the discrepancy with the physician. Review of the IDG Summary Report dated 07/15/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 11:33 AM, the Admissions Manager stated discussion of the discrepancies with the physician were not documented in the clinical record. B.) Review of the discharge summary dated 07/06/2021 revealed the patient has an allergy to Benadryl (category: intolerance). Review of the Hospice Certification and Plan of Care from 07/13/2021 to 10/10/2021 revealed the RN documented the patient has no known allergies. Review of the clinical record lacks documentation the RN discussed the discrepancy with the physician. Review of the IDG Summary Report dated 07/15/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 11:31 AM, the Admissions Manager stated the discrepancy is not clarified in the clinical record. Patient #1 - This 91-year-old patient with a terminal diagnosis of encephalopathy was admitted to the hospice on 07/22/2022. Review of the Hospice Certification and Plan of Care for 07/22/2022 to 09/19/2022 revealed the following orders: - Acetaminophen 325 mg tablet every 6 (six) hours PRN for pain or temperature greater than 101. Maximum daily dose of 3,000 mg per 24 (twenty-four) hours; and - Tylenol (Acetaminophen) Extra Strength 500 mg tablet twice a day. Review of the medication orders revealed that if the patient takes every PRN dose and the scheduled dose, the total dose will equal 3,600 mg in 24 (twenty-four) hours exceeding the ordered maximum daily dose of 3,000 mg by 600 mg. Review of the clinical record lacks documentation the RN discussed the discrepancy with the physician. Review of the IDG Summary Report dated 08/02/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 09:58 AM, the RN Case Manager stated the patient lives in a Skilled Nursing Facility and the nurses ensure the patient does not exceed the maximum daily dose as ordered; however, the order should be clarified to state the maximum daily dose from all sources and added to the order for Tylenol Extra Strength 500 mg tablet twice a day so that it is not overlooked and flags that there is more than one source of Acetaminophen. Patient #3 - This 67-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 07/25/2022. A.) Review of the facility Discharge Summary dated 07/22/2022 revealed the following medication orders: - Famotidine (Pepcid) 20 mg (milligram) tablet (no frequency ordered); - Amoxicillin (Amoxil) 500 mg capsule (no frequency and duration ordered); - Ascorbic Acid (Vitamin C) 500 mg tablet every other day; - Atorvastatin (Lipitor) 80 mg tablet- 40 mg daily; - Ferrous Sulfate 325 mg (65 mg Iron) tablet- 1 (one) tablet every other day; - Hydrocortisone- Iodoquinol 1-1 % (percent) cream (no frequency and location ordered); - Magnesium Oxide 400 mg tablet (no frequency ordered); - Nitroglycerin (Nitrostat) 0.4 mg SL (sublingual) - 0.4 mg every 5 (five) min (minutes) PRN (as needed); - Potassium Chloride (Klor- Con) 20 mEq (milliequivalent) packet- 20 mEq daily; - Pyridostigmine (Mestinon) 60 mg tablet- 60 mg 3 (three) times daily; and - Sertraline (Zoloft) 100 mg tablet- 2 (two) tablet(s) daily. Review of the Hospice Certification and Plan of Care from 07/25/2022 to 10/22/2022 lacks orders for the identified medications. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancies with the physician. Review of the IDG Summary Report dated 08/02/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 01:32 PM, the Admissions Clinical Manager stated the RN that completed the drug profile review was unavailable for interview. The Admissions Clinical Manager stated there is no documentation to clarify the identified medication discrepancies in the clinical record. Patient #6 - This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 07/25/2022. Review of the discharge summary dated 07/22/2022 revealed the following orders: - Lidocaine 5% (five percent) topical film apply topically to affected area once a day; - Olanzapine 5 mg oral tablet 1 tab orally once a day; - Lamivudine 100 mg tablet 1 tab orally once a day; - Vitamin D3 125 mcg (micrograms) oral tab 1 tab orally once a day; and - Zinc 140 mg oral tablet 1 tab orally once a day. Review of the Hospice Certification and Plan of Care from 07/25/2022 to 10/22/2022 lacks orders for the medications listed above. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician. Review of the IDG Summary Report dated 08/03/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 11:08 AM, the Admission RN stated she did discuss discrepancies with the physician and did clarify some of them in the documentation but did not specifically list all discrepancies that were identified. Patient #10 - This 68-year-old patient with a terminal diagnosis of malignant neoplasm of left kidney, except renal pelvis was admitted to the hospice on 07/24/2022. Review of the Hospice Certification and Plan of Care from 07/24/2022 to 10/21/2022 revealed the order for Colace 100 mg capsule oral 2 (two) times daily. Review of the discharge summary dated 07/17/2022 lacks an order for Colace. Review of the clinical record lacks documentation the RN discussed the discrepancy with the physician. Review of the IDG Summary Report dated 07/27/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 09:22 AM, the Admission RN stated she does not recall speaking to the physician about adding this medication. Patient #12 - This 61-year-old patient with a terminal diagnosis of right heart failure was admitted to the hospice on 07/25/2022. Review of the facility Discharge Summary dated 06/09/2022 revealed the following medication orders: - Lidocaine (Lidoderm) 5 % patch- 2 (two) patch daily; - Pantoprazole (Protonix) 40 mg EC (enteric coated) tablet- 40 mg daily; - Ammonium Lactate (Amlactin) 12% cream- 1 (one) application 2 (two) times daily PRN (order lacks location to apply); - Cyclosporine (Restasis) 0.05% ophthalmic emulsion- 1 (one) drop 3 (three) times daily (order lacks location to apply); and - Rosuvastatin (Crestor) 5 mg tablet- 5 mg every evening. Review of the Hospice Certification and Plan of Care from 07/25/2022 to 09/22/2022 lacks orders for the identified medications. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician. Review of the IDG Summary Report dated 08/04/2022 lacks documented evidence the medication discrepancies were discussed during the meeting. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 08/12/2022 at 01:50 PM, the Admissions Clinical Manager stated the clinician that complete the drug profile review was unavailable for interview. The Admissions Clinical Manager provided the Admission Medication Record Form signed and dated by the patient on 07/25/2022 as clarification of the identified medication discrepancies. This form specifies which medications are covered by the hospice benefit. The handwritten form provided failed to clarify the identified medication discrepancies were discussed with the physician.

Based on clinical record reviews, agency policy and procedures, and staff interviews, two (2) of sixteen (16) clinical records (Patient #'s: 12 and 14) lack documented evidence the hospice nurses and Interdisciplinary Group (IDG) members are performing complete updated comprehensive assessments or that the hospice nurses are communicating changes in the patient's condition or treatment to the IDG. Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient has the potential for the patient's health status to be compromised and result in the provision of poor quality of care. Findings are: Review of the agency's policy entitled "Alterations in Skin Integrity - Assessment, Early Intervention and General Treatment" dated 04/20/2010 revealed "All patients should have an integumentary assessment completed at the time of admission and with each comprehensive assessment. If there is a new wound noted, documentation should occur in the Integumentary Command Center (ICC) section of the RN (Registered Nurse) assessment. Documentation of pressure ulcers, stasis ulcers, diabetic, arterial, burns and open surgical wounds are to be done in the ICC section of the RN assessment. Documentation of malignant wounds, sutured surgical incisions, skin tears, rashes, fistulas, cancerous tumors and all other wounds or skin issues is to be done in the "integumentary" section of the RN assessment." Patient #12 - This 61-year-old patient with a terminal diagnosis of right heart failure was admitted to the hospice on 07/25/2022. A.) Review of the Hospice RN Subsequent Visit Note date 07/26/2022 revealed the RN documented the patient had a new skin tear to the right forearm, orders were obtained for wound care for the skin tear and a dressing was applied to the area. The visit note lacks an assessment of the skin tear or an indication as to why an assessment was not performed. B.) Review of the clinical record revealed the next comprehensive nursing visit after the 07/26/2022 visit occurred on 08/02/2022. Review of the Hospice RN Subsequent Visit Note dated 08/02/2022 lacks an assessment of the right arm skin tear or an indication as to why an assessment was not performed. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 08/12/2022 at 02:07 PM, the Team Manager stated the RN was not available for interview. The Team Manager stated there was not an assessment of the skin tear during the identified visits and one should have been completed. Patient #14 - This 81-year-old patient with a terminal diagnosis of malignant neoplasm, unspecified was admitted to the hospice on 07/24/2021. Review of the Hospice RN Subsequent Visit Note dated 08/09/2021 revealed the RN documented the patient has two (2) new stage II ulcers. Review of the ICC section of the RN assessment dated 08/09/2021 revealed the following: Right upper back, stage II onsite date: 08/09/2021 - Measurements taken: unable - Reason measurements not taken: unable Left upper buttock, stage II onset date: 08/09/2021 - Measurements taken: unable - Reason measurements not taken: unable Review of the clinical record lacks documented evidence stating why the measurements were not obtained. The hospice nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 08/12/2022 at 09:31 AM, the Team Manager stated the expectation is that new wounds are measured but there is no measurement documented during this visit for either wound.

Based on review of clinical records and interviews with staff for eight (8) of sixteen (16) clinical records (Patient #'s: 3, 5, 6, 8, 9, 12, 13 and 15), the hospice failed to provide services according to the Plan of Care (POC). Failure to provide services in accordance with the POC has the potential for unmet patient needs. Findings are: Patient #6 - This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 07/25/2022. A.) Review of the supplemental order dated 08/01/2022 revealed the order for HHA (Home Health Aide) effective 07/31/2022 2 wk 12 (twice weekly for twelve weeks). Review of the Aide Care Plan Report dated 08/04/2022 revealed the HHA is instructed to document the date of the patient's last BM (bowel movement) at every visit. Review of the Aide Hospice Visit Notes dated 08/04/2022 and 08/09/2022 revealed the HHA documented the following: - Service: date of last BM - Completed: Y (yes) The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 11:36 AM, the Chief Clinical Officer stated the expectation is that the HHA documents the date of the last BM. B.) Review of the supplemental order dated 07/27/2022 revealed the order for MA (Massage Therapy) effective 07/25/2022 1 wk 1 (one visit for the first week). Review of the clinical record from 07/25/2022 to 07/30/22 lacks documented evidence the Massage Therapist attempted to contact the patient or made a visit. Review of the clinical record revealed the Massage Therapist documented the initial phone call to the patient on 08/01/2022 (during second week of service). The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 11:10 AM, the Massage Therapist stated she did not receive the referral until 08/01/2021. The Chief Clinical Officer stated she would look into why the referral was received late. No further information was provided. Patient #13 - This 72-year-old patient with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 05/09/2022. This is a patient that resides in a Skilled Nursing Facility. A.) Review of the Hospice Add-On Supplemental Order dated 05/31/2022 revealed the following order: SN (Skilled Nurse) effective 05/29/2022- 2 WK 1 (two times per week for one week), 1 WK 9 (one time per week for nine weeks), and 20 (twenty) PRN. Review of the clinical record for the week of 05/29/2022 through 06/04/2022 revealed one (1) SN visit occurred on 06/02/2022. Review of the clinical record lacks documentation that the patient and/ or physician requested a change in the SN visit frequency. The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 10:40 AM, the Chief Clinical Officer stated the SN visit frequency was ordered incorrectly on the supplemental order. B.) Review of the Hospice Certification and Plan of Care from 05/09/2022 to 08/06/2022 revealed orders for the Hospice Nurse to coordinate with facility staff for the patient to be weighed once a week and to notify the RN if weight decreases. Review of the clinical record from 05/15/2022 through 07/16/2022 revealed weekly SN visits occurred on: 05/18/2022, 05/25/2022, 06/02/2022, 06/08/2022, 06/15/2022, 06/23/2022, 06/30/2022 and 07/11/2022. Review of the Hospice RN Subsequent Visit Notes occurring on 05/18/2022, 05/25/2022, 06/02/2022, 06/23/2022, 06/30/2022 and 07/11/2022 lack documented evidence of a weight being obtained or recorded from the facility. The hospice failed to ensure weekly weights were obtained and documented. During interview on 08/12/2022 at 10:15 AM, the RN Case Manager stated it was an oversight that weekly weights were not obtained on the identified visits. Patient #3 - This 67-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 07/25/2022. Review of the Hospice Add- On Supplemental Order dated 07/25/2022 revealed an order for MSW (Medical Social Worker) Effective 07/24/2022- 3 WK 1 (three visits a week for one week), 1 WK 11 (one visit a week for eleven weeks). Review of the clinical record for the week of 07/24/2022 through 07/30/2022 revealed the MSW made two (2) visits for the week, on 07/25/2022 and 07/26/2022 (order is for three MSW visits for this week). Review of the clinical record for the week of 07/31/2022 through 08/06/2022 lacks documented evidence the MSW made a visit (order is for one MSW visit this week). Review of the clinical record lacks documentation that the patient and/ or physician requested a change in the MSW visit frequency. The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 01:27 PM, the Chief Clinical Officer stated she would look for additional documentation to clarify the discrepancy. The agency provided no further documentation. Patient #5 - This 98-year-old patient with a terminal diagnosis of combined systolic and diastolic heart failure was admitted to the hospice on 07/25/2022. Review of the Hospice Certification and Plan of Care from 07/25/2022 to 09/22/2022 revealed the following orders: - Skilled Nurse/ Caregiver/ Facility Staff to cleanse wound with NS (Normal Saline), apply DCD (dry clean dressing) every daily (day) and PRN for soiling/ loosening to wound located on right arm for patient comfort and to promote healing. Review of the Hospice Revisit Note dated 07/29/2022 revealed the RN documented the following regarding wound care: "Right upper arm skin tear: cleansed (with) NS, pat dry, TAO (Triple Antibiotic Ointment) applied, sterile NS gauze, Kerlix." Review of the clinical record lacks documented evidence of an updated wound care order to the right arm. The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 12:27 PM, the RN Case Manager stated she made an error and documented the wrong wound care to the right arm in the identified visit. Patient # 8 -This 79-year -old patient with a terminal diagnosis of malignant neoplasm of the bladder, unspecified was admitted to the hospice on 07/24/2022. Review of the Hospice Certification and Plan of Care for 07/22/2022 to 10/21/2022 revealed the order for SN to perform nephrostomy site dressing change every 5-7 (five to seven) days and PRN dressing soiling/loosening to maintain skin integrity. Review of the clinical record from 07/24/22 to 08/09/2022 lacks documented evidence the dressing change to the nephrostomy site was completed. The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 12:50 PM, the Admission Manager stated the nurses did not document performing the dressing change as ordered. Patient #9 - This 101-year-old patient with a terminal diagnosis of dementia with lewy bodies was admitted to the hospice on 07/24/2022. Review of the Hospice Physician Order dated 07/25/2022 revealed an order for HHA effective 07/24/2022- 2 WK 13 (two times per week for thirteen weeks). Review of the Coordination Note dated 08/02/2022 revealed the initial service visit for the HHA was scheduled for 08/02/2022 but was cancelled at the caregiver's request due to the patient not feeling well. Review of the clinical record revealed the first service visit for the HHA occurred on 08/04/2022. Review of the clinical record lacks documentation of any HHA visits occurring or request to delay for the week of 07/24/2022 through 07/30/2022 (order is for two HHA visits this week). The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 01:15 PM, the Chief Clinical Officer stated she would look for additional documentation to explain the discrepancy. No further documentation was provided by the agency. Patient #12 - This 61-year-old patient with a terminal diagnosis of right heart failure was admitted to the hospice on 07/25/2022. Review of the Plan of Care Update dated 07/26/2022 revealed the SN frequency was ordered effective 07/25/2022 as: 3 WK 1 (three times per week for one week), 2 WK 1 (two times per week for one week), 1 WK 6 (one time per week for six weeks), 2 PRN WK 7 (two as needed visits for seven weeks). Review of the clinical record for the week of 07/24/2022 through 07/30/2022 revealed two (2) SN visits occurred on: 07/25/2022 and 07/26/2022 (order is for three SN visits this week). Review of the clinical record lacks documentation that the patient and/ or physician requested a change in the SN visit frequency. The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 01:47 PM, the Admissions Clinical Manager stated the SN visit frequency was ordered incorrectly on the Plan of Care Update. Patient #15 - This 69-year-old patient with a terminal diagnosis of malignant neoplasm of bronchus or lung was admitted to the hospice on 07/13/2021. Review of the supplemental order dated 07/27/2021 revealed the order for HHA services effective 07/25/2021 2 wk 1 (twice a week for one week), 3 wk 10 (three times a week for ten weeks). Review of the clinical record from 07/25/2021 to 07/31/2021 revealed the patient received HHA services on 07/30/2021, one visit less than what was ordered. The hospice failed to provide services according to the POC. During interview on 08/12/2022 at 11:33 AM, the Chief Clinical Officer stated she would look for documentation to support the missed visit. No further information was provided.

Based on a review of patient care records and interview with agency staff for two (2) of sixteen (16) patients (Patient #'s: 8 and 12), the agency failed to ensure the patient and/or caregiver received education and training identified in the plan of care (POC). Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. Findings are: Patient #8 - This an 80-year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 07/24/2022. Review of the Hospice Certification and Plan of Care for 07/24/2022 to 10/21/2022 revealed the following orders: "Skilled Nurse (SN) to provide patient and family education: Cleanse skin around nephrostomy tube with soap and water, pat dry and cover with transparent dressing every 5-7 (five to seven) days and PRN (as needed) soiling/loosening to maintain skin integrity." Review of clinical record from 07/24/2022 to 08/09/2022 (date of survey) lacks documented evidence the caregiver was instructed in performing the nephrostomy tube care. The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 08/12/2022 at 12:50 PM, the Admissions Manager stated the teaching was not documented in the record. The Registered Nurse (RN) was unavailable for interview. Patient #12 - This 61-year-old patient with a terminal diagnosis of right heart failure was admitted to the hospice on 07/25/2022. Review of the Plan of Care Update dated 07/26/2022 revealed an order for the SN/ Caregiver to apply an Allevyn Foam dressing (absorbent wound dressing) to the right forearm skin tear and change dressing every seven (7) days or PRN for soilage. Review of the Hospice RN Subsequent Visit Note dated 07/26/2022 revealed the RN documented the patient had a new skin tear to the right forearm, orders for wound care were obtained and an "Allevyn" was applied. (The visit note lacks documentation regarding instructing the caregiver in the wound care). Review of the clinical record revealed after the 07/26/2022 visit, the subsequent SN visit occurred on 08/02/2022. Review of the Hospice RN Subsequent Visit dated 08/02/2022 lacks documented evidence of the following: - The RN performing the right forearm wound care; and - The RN instructing/ demonstrating the right forearm wound care with the caregiver. The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 08/12/2022 at 02:11 PM, the Team Manager stated the RN was unavailable for interview. The Team Manager stated the clinical record lacks documentation regarding caregiver instruction of the right forearm dressing.

Based on review of clinical records and interviews with staff, for sixteen (16) of sixteen (16) patients (Patient #'s: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) the hospice failed to develop an individualized written Plan of Care (POC) that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. Findings are: Review of the agency policy entitled "Physician Orders" dated 04/20/2010 revealed "The individual patient plan of care shall be comprised of discipline problems, goals and interventions, Hospice Aide Care Plan when indicated, in conjunction with physician orders and DME (durable medical equipment) List which specifies hospice services necessary to meet the patient/ family specific needs identified in the comprehensive assessment and as it relates to the terminal illness and related conditions. The Physician Orders are individualized and a detailed statement of the scope of services necessary to meet the needs of the patient will be specifically defined in the care plan." Patient #10 - This 68-year-old patient with a terminal diagnosis of malignant neoplasm of left kidney, except renal pelvis was admitted to the hospice on 07/24/2022. A.) Review of the Hospice Certification and Plan of Care for 07/24/2022 to 10/21/2022 revealed the order for SN (Skilled Nurse) 4wk1 (four times a week for first week), 3wk2 (three times a week for two weeks), 1wk10 (once a week for ten weeks, and 2PRNwk12 (two as needed for twelve weeks). Review of the supplemental order dated 07/28/2022 revealed the order for MSW (Medical Social Worker) effective 07/24/2022 1month4 (once a month for four months) and 12PRN (twelve as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. B.) Review of the Hospice Certification and Plan of Care for 07/24/2022 to 10/21/2022 revealed the following order: "Skilled Nurse/patient/caregiver to perform blood sugar analysis fasting in the AM (morning), call Hospice if less than 80 (eighty) or greater than 400 (four hundred)." Review of the Hospice Certification and Plan of Care for 07/24/2022 to 10/21/2022 lacks an order for blood glucose testing supplies. C.) Review of the Aide Care Plan Report dated 08/01/2022 revealed the patient uses a cane. Review of the Hospice Certification and Plan of Care for 07/24/2022 to 10/21/2022 lacks an order for a cane. The POC lacks orders for DME and supplies. During interview on 08/12/2022 at 09:22 AM, the Admission RN stated she doesn't typically include DME on the POC but will do so going forward. Patient #15 - This 69-year-old patient with a terminal diagnosis of malignant neoplasm of bronchus or lung was admitted to the hospice on 07/13/2021. A.) Review of the Hospice Certification and Plan of Care for 07/13/2021 to 10/10/2021 revealed the order for SN 3wk1 (three times a week for first week), 2wk3 (twice a week for three weeks), and 2PRNwk13 (two as needed for thirteen weeks). Review of the supplemental order dated 07/14/2021 revealed the order for MSW effective 07/25/2021 1month3 (once a month for three months), 11PRN (eleven as needed). Review of the supplemental order dated 07/16/2021 revealed the order for CH (Chaplain) effective 07/13/2021 1month3 (once a month for three months), 13PRN (thirteen as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. B.) Review of the RN Hospice Admission Note dated 07/13/2021 revealed the patient uses a walker. Review of the Hospice Certification and Plan of Care for 07/13/2021 to 10/10/2021 lacks an order for a walker. C.) Review of the Hospice Certification and Plan of Care for 07/13/2021 to 10/10/2021 revealed the following order: Ipratropium 0.5 mg (milligrams) - Albuterol 3 mg (2.5 base)/ 3 mL (milliliters) inhalation every 4 (four) hours PRN for dyspnea. Review of the Hospice Certification and Plan of Care for 07/13/2021 to 10/10/2021 lacks an order for the patient's nebulizer. The POC lacks an order for the patient's DME and supplies. During interview on 08/12/2022 at 11:36 AM, the Admissions Manager stated DME/supplies is not typically included on the POC. Patient #3 - This 67-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 07/25/2022. A.) Review of the Hospice Certification and Plan of Care from 07/25/2022 to 10/22/2022 revealed orders for SN3wk1 (three visits for first week), 1wk12 (one visit a week for twelve weeks), 2PRNwk13 (two as needed for thirteen weeks). Review of the Hospice Add-On Order dated 07/27/2022 revealed an order for CH effective 07/25/2022 1month1 (one visit for first month), 5month1 (five visits a month for one month), 4month1 (four visits a month for one month), 3month1 (three visits a month for one month) and 13 PRN (thirteen as needed). Review of the Hospice Physician Order dated 08/03/2022 revealed an order for SN effective 07/31/2022 3wk1 (three visits for first week), 1wk11 (one visit a week for eleven weeks), 2PRNwk12 (two as needed for twelve weeks). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. B.) Review of the RN Hospice Admission Visit Note dated 07/25/2022 revealed the patient has a urostomy (surgical stoma that re-directs urine from the bladder) in place. Review of the Hospice Certification and Plan of Care from 07/25/2022 to 10/22/2022 lacks orders for the supplies the patient uses to manage the urostomy. The POC lacks orders for DME and supplies. During interview on 08/12/2022 at 01:35 PM, the Chief Clinical Officer stated the RN was unavailable for interview and the POC does not specify the urostomy supplies being used. Patient #4- This 80-year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 07/13/2022. A.) Review of the Hospice Certification and Plan of Care for 07/13/2022 to 10/10/2022 revealed the following order: "Skilled Nurse/patient/caregiver to perform finger stick blood sugar analysis fasting one hour post prandial, call Hospice if less than 60 (sixty) or greater than 400 (four hundred)." Review of the Hospice Certification and Plan of Care for 07/13/2022 to 10/10/2022 lacks an order for blood glucose testing supplies. B.) Review of the Aide Care Plan for 08/08/2022 revealed the patient uses a walker. Review of the Hospice Certification and Plan of Care for 07/13/2022 to 10/10/2022 lacks an order for a walker. The POC lacks orders for DME and supplies. During interview on 08/12/2022 at 11:23 AM, the Admission RN stated she doesn't typically include DME/supplies on the POC but will do so going forward. Patient #12 - This 61-year-old patient with a terminal diagnosis of right heart failure was admitted to the hospice on 07/25/2022. A.) Review of the Hospice Certification and Plan of Care from 07/25/2022 to 09/22/2022 revealed the order for SN 3wk1 (three visits first week), 2wk2 (two visits a week for two weeks), 1wk5 (one visit a week for five weeks), 2PRNwk8 (two as needed for eight weeks). Review of the Hospice Add-On Order dated 07/26/2022 revealed an order for MSW effective 07/25/2022 1month3 (one visit a month for three months), 8PRN (eight as needed). Review of the Hospice Add-On Order dated 08/02/2022 revealed an order for CH effective 07/31/2022 2month1 (two visits a month for one month), 1month1 (one visit a month for one month) and 7PRN (seven as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. B.) Review of the Hospice Certification and Plan of Care from 07/25/2022 to 09/22/2022 revealed the following order: Ipratropium 0.5 mg - Albuterol 3 mg (2.5 base)/ 3 mL inhalation every 6 (six) hours PRN for wheezing or SOB (shortness of breath). Review of the Hospice Certification and Plan of Care for 07/25/2022 to 09/22/2022 lacks an order for the patient's nebulizer machine. The POC lacks an order for the patient's DME and supplies. During interview on 08/12/2022 at 01:52 PM, the Chief Clinical Officer stated the nebulizer was not included on the POC. Patient #13 - This 72-year-old patient with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 05/09/2022. A.) Review of the Hospice Certification and Plan of Care from 05/09/2022 to 08/06/2022 revealed the order SN 2wk1 (two visits first week), 1wk12 (one visit a week for twelve weeks), 2PRNwk13 (two as needed for thirteen weeks). Review of the Hospice Add-On Order dated 05/11/2022 revealed an order for MSW effective 05/09/2022 1month4 (one visit a month for four months), 13PRN (thirteen as needed). Review of the Hospice Add-On Order dated 05/11/2022 revealed an order for CH effective 05/09/2022 1wk1 (one visit first week), 1every3wk12 (one visit every three weeks for twelve weeks), 13PRN (thirteen as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. B.) Review of the RN Hospice Admission Visit Note dated 05/09/2022 revealed the RN documented the patient uses a chest vest in the wheelchair to keep from falling forward. Review of the Hospice Certification and Plan of Care from 05/09/2022 to 08/06/2022 lacks orders for the chest vest and wheelchair. The POC lacks orders for DME and supplies. During interview on 08/12/2022 at 10:56 AM, the Chief Clinical Officer stated the patient's chest vest is equipped to the wheelchair, but there was not an order for the wheelchair on the POC. Patient #1 - This 91-year-old patient with a terminal diagnosis of encephalopathy was admitted to the hospice on 07/22/2022. Review of the Hospice Certification and Plan of Care for 07/22/2022 to 09/19/2022 revealed the order for SN 1wk10 (once a week for ten weeks), 2PRNwk9 (two as needed for nine weeks). Review of the supplemental order dated 07/25/2022 revealed the order for MSW effective 07/24/2022 1month3 (once a month for three months), 8PRN (eight as needed). Review of the supplemental order dated 07/25/2022 revealed the order for CH effective 07/24/2022 1month2 (once a month for two months), 8PRN (eight as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. Patient #2- This 78-year-old patient with a terminal diagnosis of acute on chronic diastolic congestive heart failure, was admitted to the hospice on 07/25/2022. Review of the supplemental order dated 08/08/2022 revealed the order for MSW effective 08/07/2022 2month1 (twice a month for one month) and 11PRN (eleven as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 1:05 PM, the Chief Clinical Officer stated indicators for PRN clinical visits will be added to the POCs. Patient #5 - This 98-year-old patient with a terminal diagnosis of combined systolic and diastolic heart failure was admitted to the hospice on 07/25/2022. Review of the Hospice Certification and Plan of Care from 07/25/2022 to 09/22/2022 revealed the following orders: - SN 3wk1 (three visits for first week), 2wk2 (two visits a week for two weeks), 1wk5 (one visit a week for five weeks), 2PRNwk8 (two as needed for eight weeks); and - MSW 1wk1 (one visit for first week), 1month1 (one visit a month for one month), 1PRNwk8 (one as needed for eight weeks). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. Patient #6 - This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 07/25/2022. Review of the Hospice Certification and Plan of Care for 07/25/2022 to 10/22/2022 revealed the order for SN 2wk1 (twice a week for one week), 1wk12 (once a week for twelve weeks), 2 PRNwk13 (two as needed for thirteen weeks). Review of the supplemental order dated 07/28/2022 revealed the order for MSW effective 08/21/2022 1month3 (once a month for three months), 9PRN (nine as needed). Review of the supplemental order dated 07/29/2022 revealed the order for CH effective 07/24/2022 1month2 (once a month for two months), 2month1 (twice a month for one month), 1month1 (once a month for one month), 13PRN (thirteen as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. Patient #7- This 85-year-old patient with a terminal diagnosis of senile degeneration of brain, not elsewhere classified, was admitted to the hospice on 07/25/2022. Review of the Hospice Certification and Plan of Care for 07/25/2022 to 10/22/2022 revealed the order for SN 2wk1(twice a week for first week), 1wk12 (once a week for twelve weeks), and 2PRNwk13(two as needed for thirteen weeks). Review of the supplemental order dated 07/29/2022 revealed the order for the CH effective 07/25/2022 1month4 (once a month for four months), 13PRN (thirteen as needed). Review of the supplemental order dated 08/02/2022 revealed the order for MSW effective 09/04/2022 1month3 (once a month for three months), 7PRN (seven as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 11;47 AM, the Chief Clinical Officer stated indicators for PRN clinical visits will be added to the POCs. Patient #8 - This 79 -year-old patient with a terminal diagnosis of neoplasm of the bladder, unspecified was admitted to the homecare agency on 07/24/2022. Review of the Hospice Certification and Plan of Care for 07/24/2022 to 10/21/22 revealed the order SN2wk1(twice a week for first week), 1wk12 (once a week for twelve weeks), 2PRNwk12 (two as needed for twelve weeks). Review of the supplemental order dated 07/27/2022 revealed the order for CH effective 07/24/2022 1month4 (once a month for four months), 13PRN (thirteen as needed). Review of the supplemental order dated 07/27/2022 revealed the order for MSW effective 07/24/2022 1month4 (once a month for four months), 12PRN (twelve as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 12:55 PM, the Chief Clinical Officer stated indications for PRN Clinical visits will be added to the POCs. Patient #9 - This 101-year-old patient with a terminal diagnosis of dementia with lewy bodies was admitted to the hospice on 07/24/2022. Review of the Hospice Certification and Plan of Care from 07/24/2022 to 10/21/2022 revealed the order for SN 2wk1 (two visits first week), 1wk12 (one visit a week for twelve weeks), 2PRNwk12 (two as needed for twelve weeks). Review of the Hospice Add-On Order dated 07/26/2022 revealed the order for MSW effective 07/24/2022 1month4 (one visit a month for four months) and 12PRN (twelve as needed). Review of the Hospice Add-On Order dated 07/27/2022 revealed the order for CH effective 07/24/2022 1month4 (one visit a month for four months), 13PRN (thirteen as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. Patient #11 - This 85-year-old patient with a terminal diagnosis of malignant neoplasm of breast with brain metastasis was admitted to the hospice on 07/24/2022. Review of the Hospice Certification and Plan of Care from 07/24/2022 to 10/21/2022 revealed the order for SN 2wk1 (two visits first week), 1wk12 (one visit a week for twelve weeks), 2PRNwk12 (two as needed for twelve weeks). Review of the Hospice Add-On Order dated 07/25/2022 revealed an order for MSW effective 07/24/2022 1month4 (one visit a month for four months) and 12PRN (twelve as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. Patient #14 - This 81-year-old patient with a terminal diagnosis of malignant neoplasm, unspecified was admitted to the hospice on 07/24/2021. Review of the Hospice Certification and Plan of Care for 07/24/2021 to 10/21/2021 revealed the order for SN1wk14 (once a week for fourteen weeks), 2PRNwk13 (two as needed for thirteen weeks). Review of the supplemental order dated 07/28/2021 revealed the order for MSW effective 07/25/2021 1month1 (once a month for one month), 2month2 (twice a month for two months), 1month2 (once a month for two months), 12PRN (twelve as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. Patient #16 - This 96-year-old patient with a terminal diagnosis of cerebrovascular disease was admitted to the hospice on 07/23/2021. Review of the Hospice Certification and Plan of Care for 07/23/2021 to 10/20/2021 revealed the order for SN 1wk14 (once a week for fourteen weeks), 2PRNwk13 (two as needed for thirteen weeks). Review of the supplemental order dated 08/05/2021 revealed the order for MSW effective 08/08/2021 2month1 (twice a month for one month), 1month2 (once a month for two months), and 10PRN (ten as needed). Review of the supplemental order dated 07/25/2021 revealed the order for CH effective 07/25/2021 1month4 (once a month for four months), 12PRN (twelve as needed). The POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs.

Based on review of clinical records, agency policy and procedure and staff interview, for one (1) of one (1) recertified patients (Patient #13), the agency failed to ensure the Interdisciplinary Group (IDG), in collaboration with the patient's physician, reviewed and revised the individualized plan of care (POC) as changes occurred, but no less frequently than every fifteen (15) days. Failure of the IDG to develop, review and revise the POC has the potential for unmet patient needs and inadequate care. Findings are: Review of the Hospice's policy entitled "Physicians Orders" dated 04/20/2010 revealed the following: "Review and/or revision of the POC will occur at the time of recertification; however, it should occur as often as there is a change which would warrant obtaining new physician's orders. This would include changes in: a. the patient's health status or condition. 2j. The detailed statement of the scope of services necessary to meet the needs of the patient will be specifically defined in the care plan." Patient #13 - This 72-year-old patient with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 05/09/2022. A.) Review of the Hospice Recertification Orders dated 07/23/2022 revealed the following orders: - SN (Skilled Nurse) effective 08/07/2022 1wk13 (one visit a week for thirteen weeks), 24PRN (twenty-four as needed); - MSW (Medical Social Worker) effective 08/07/2022 1wk5 (one visit a week for five weeks), 1month2 (one visit a month for two months), 7PRN (seven as needed); and - CH (Chaplain) effective 08/07/2022 1PRNwk4 (one as needed visit for four weeks), 1month2 (one visit a month for two months), 8PRN (eight as needed). The updated POC lacked a qualifier for the PRN visit frequencies. During interview on 08/12/2022 at 08:45 AM, the Chief Clinical Officer stated indications for PRN clinical visits will be added to the POCs. B.) Review of the RN (Registered Nurse) Hospice Recert Assessment dated 07/22/2022 revealed the RN documented the patient has poor trunk control and utilizes a chest vest at all times when out of bed in the wheelchair. Review of the Hospice Recertification Orders dated 07/23/2022 lack an order for the wheel chair the patient uses when out of bed. The updated POC lacks orders for Durable Medical Equipment (DME) used by the patient. During interview on 08/12/2022 at 10:28 AM, the RN Case Manager stated the chest vest is part of the patient's wheelchair. She stated the Recertification Orders do not include the wheelchair used by the patient.

Based on review of clinical records and interviews with staff, for seven (7) of eight (8) patients (Patient #s: 5, 6, 7, 9, 10, 15, and 16) receiving Home Health Aide (HHA) services, the hospice failed to ensure the Aide Plan of Care (POC) is complete. Failure to ensure the Aide POC is complete and accurate has the potential for the patient to receive inappropriate care. Findings are: Patient #4- This 80-year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 07/13/2022. Review of the supplemental order dated 08/14/2022 revealed the order for HHA effective 07/17/2022 3wk6 (three visits weekly for six weeks) and 2wk1 (two visits weekly for one week). Review of the Aide Care Plan Report dated 08/08/2022 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the aide POC is complete. During interview on 08/12/2022 at 02:00 PM, the RN Case Manager stated that specific instructions regarding when to call the RN will be added to each Aide POC. Patient #5 - This 98-year-old patient with a terminal diagnosis of combined systolic and diastolic heart failure was admitted to the hospice on 07/25/2022. Review of the Plan of Care Update Order dated 07/26/2022 revealed the order for HHA effective 07/25/2022 2wk9 (two visits weekly for nine weeks). Review of the Aide Care Plan Report dated 07/29/2022 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the Aide POC is complete. During interview on 08/12/2022 at 12:16 PM, the RN Case Manager stated it is not her practice to include this on Aide Care Plans. During interview on 08/12/2022 at 12:18 PM, the Chief Clinical Officer stated going forward, Aide Plans of Care will include observations to report to the RN. Patient #6 - This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 07/25/2022. Review of the supplemental order dated 08/01/2022 revealed the order for HHA effective 07/31/2022 2wk12 (two visits weekly for twelve weeks). Review of the Aide Care Plan Report dated 08/03/2022 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the Aide POC is complete. During interview on 08/12/2022 at 08:45 AM, the RN Case Manager stated that specific instructions regarding when to call the RN will be added to each Aide POC. Patient #7- This 85-year-old patient with a terminal diagnosis of senile degeneration of brain, not elsewhere classified, was admitted to the hospice on 07/25/2022. Review of the supplemental order dated 07/28/2022 revealed the order for HHA effective 07/25/2022 1wk1 (one visit for one week), and 3wk12 (three visits weekly for twelve weeks). Review of the Aide Care Plan Report dated 08/01/2022 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the Aide POC is complete. During interview on 08/12/2022 at 12:44 PM, the Admission RN stated that the specific instructions regarding when to call the RN will be added to each Aide POC. Patient #9 - This 101-year-old patient with a terminal diagnosis of dementia with lewy bodies was admitted to the hospice on 07/24/2022. Review of the Hospice Physician Order dated 07/25/2022 revealed the order for HHA effective 07/24/2022 2wk13 (two visits weekly for thirteen weeks). Review of the Aide Care Plan Report dated 08/01/2022 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the Aide POC is complete. During interview on 08/12/2022 at 09:07 AM, the RN Case Manager stated being unaware that instructions for Aide observations to report to the RN are to be included on Aide Care Plans. Patient #10 - This 68-year-old patient with a terminal diagnosis of malignant neoplasm of left kidney, except renal pelvis was admitted to the hospice on 07/24/2022. Review of the supplemental order dated 08/01/2022 revealed the order for HHA effective 07/31/2022 2wk12 (two visits weekly for twelve weeks). Review of the Aide Care Plan Report dated 08/01/2022 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the Aide POC is complete. During interview on 08/12/2022 at 08:45 AM, the RN Case Manager stated that specific instructions regarding when to call the RN will be added to each Aide POC. Patient #15 - This 69-year-old patient with a terminal diagnosis of malignant neoplasm of bronchus or lung was admitted to the hospice on 07/13/2021. Review of the supplemental order dated 07/27/2021 revealed the order for HHA effective 07/25/2021 2wk1(two visits for one week), 3wk10 (three visits weekly for ten weeks). Review of the Aide Care Plan Report dated 08/09/2021 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the Aide POC is complete. During interview on 08/12/2022 at 08:45 AM, the RN Case Manager stated that specific instructions regarding when to call the RN will be added to each Aide POC. Patient #16 - This 96-year-old patient with a terminal diagnosis of cerebrovascular disease was admitted to the hospice on 07/23/2021. Review of the supplemental order dated 07/27/2021 revealed the order for HHA effective 07/25/2021 2wk1 (two visits for first week), 5wk11 (five visits weekly for eleven weeks), and 3wk1 (three visits weekly for one week). Review of the Aide Care Plan Report dated 08/05/2021 lacks instructions for the HHA to observe the patient for diagnosis related changes and report the changes to the Registered Nurse (RN). The hospice failed to ensure the aide POC is complete. During interview on 08/12/2022 at 08:45 AM, the RN Case Manager stated that specific instructions regarding when to call the RN will be added to each Aide POC.

Based on review of clinical records and interview with agency staff, for one (1) of sixteen (16) patients (Patient #9) the hospice failed to ensure the clinical record contains correct clinical information. Failure to ensure that clinical records are complete and accurate has the potential for agency staff to act on inaccurate information and may place the patient's health and welfare at risk. Findings are: Patient #9 - This 101-year-old patient with a terminal diagnosis of dementia with lewy bodies was admitted to the hospice on 07/24/2022. Review of the Hospice Certification and Plan of Care from 07/24/2022 to 10/21/2022 revealed an order for Dulcolax (Bisacodyl) 10 mg (milligram) rectal suppository, 1 (one) suppository rectal daily PRN (as needed) for constipation. Review of the Hospice Revisit Note dated 08/05/2022 revealed the RN documented the following regarding bowel habit characteristics: "Orders received to D/C (discontinue) Senna S, suppositories (Dulcolax) to be administered BID (twice daily) PRN if necessary." Review of the clinical record lacks documented evidence of an order for Dulcolax to be administered BID PRN. The documentation is inconsistent regarding the Dulcolax order. During interview on 08/12/2022 at 09:10 AM, the RN Case Manager stated the Dulcolax was ordered to be administered daily PRN for constipation and she documented incorrectly.

Based on observation the facility does not maintain all sef-closing doors in corridors. Findings include: During the facility tour, on 08/10/2022 at 10:00 am, it was observed that the double doors to the C-wing, one door leaf had a wood chock block holding it open. When the chock was removed the door didn't fully close. The upper part of the door hit the door frame. The door had a fire rating tag of 1.5 hours. This finding was verified with Employee BB, Facilities Manager on 08/10/2022 at 10:00 am.

Based on observation the facility does not maintain two of four electrical panel indexes. Findings include: During the facility tour, on 08/10/2022 at 11:00 am, it was observed that two of four electrical panels in electric room B156 had indexes that didn't correspond to the breakers. There were spaces in the indexes that didn't have anything identifying what the breaker was energizing. This finding was indentified with Employee BB, Facility Manager on 08/18/2022 at 11:00 am.