Every finding on record at Hospice of Muskegon County, Inc.

Observed in Document Review. In review of the patient handbook as part of the admission packet it was noted that the organization did not inform the patient of and provide the patient with written information about its policies on advance directives, including a description of any state law concerning advance directives. This was noted in review of the admission handbook provided to the surveyor as well as in review of documents in home visits #1, 2 and 3. This was discussed with and confirmed by the Quality Director.

Observed in Record Review. In 2 of 3 patient records reviewed, it was noted that stated goals were not measurable or specific. For example, in IPU record review #1 a goal was stated as follows: Pain to be managed to satisfaction through end of life. Anxiety will be managed to patient satisfaction. In IPU record review #2 a goal was stated as follows: Pt will achieve and maintain optimal physical comfort. This was discussed with the IPU director. Observed in Record Review. In 7 of 20 patient records reviewed, it was noted that the stated goals on the plan of care were not specific or measurable. For example, in record review for home visit #6 the goals were stated as follows: Pt will report satisfaction with pain control and verbalize satisfaction with pain level. In record review #1 there was a goal stated as , Pt will have optimal breathing pattern through end of life and will be free of complications related to aspiration. In record review #3 goals were stated as Pt will have optimal breathing pattern and optimal urinary pattern. In record review #3 there were goals stated as Pt will have adequate cardiac function and verbalize acceptable comfort of respiratory status. In record review #5 the goals were stated as Pt will have optimal skin integrity maintained and Pain issues will be met to patient satisfaction. In record review #7 a goal was stated as pt will verbalize satisfaction of treatment for nausea and pt will verbalize satisfaction with nutrition and hydration and control of blood sugars through end of life. In record review #9 a goal was stated as pt will have optimal sleep. This was confirmed by the Director of Clinical Services.

Observed in Record Review. In 2 of 2 patient records reviewed, for patients who were discharged it was noted that there were no discharge orders. This was noted in discharge record review #1 who revoked care and for discharge record #2 who elected to transfer to another hospice. This was confirmed by the Director of Clinical Services. Observed in Record Review. In 2 of 20 patient records reviewed, it was noted that in review of record for home visit #3 there were no wound care orders on the plan of care for a patient with three wounds. Review of five skilled nurse visit notes indicated that the nurse was cleansing the wound with wound cleanser and applying xeroform gauze twice weekly. There was only an order to cleanse wound #1 with wound cleanser and the dressing was To be determined based on wound healing with no frequency for changing the dressing. In another example for record review #2 there were no orders for wound care in which the nurse documented providing wound care with xeroform dressing. This was confirmed by the Director of Clinical Services.

Observed in Record Review. In 3 of 20 patient records reviewed, It was noted that in review of record for home visit #3 there was no documentation during the IDT meetings for the last two months that included revisions in the plan of care for a patient with three wounds which deteriorated to include purulent drainage and foul odor. In another example, it was noted in review of record for home visit #5 the plan of care was not updated to include a new development of cellulitis in bilateral lower legs for which an antibiotic was prescribed. In another example, in record review for home visit #6 it was noted that the plan of care was not updated to include sleeping issues for which sleep medication was increased. This was confirmed by the Director of Clinical Services.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that in review of record for home visit #2 the aide did not communicate with the RN regarding the fact that the patient declined personal care tasks for more than two months. This was discussed with the Director of Patient Care.

Observed in Document Review. During review of patient education materials in the admission packet and patient handbook it was noted that there was no education provided for respiratory hygiene practices. This was confirmed by the Quality Director.

Observed in Record Review. In 1 of 12 patient records reviewed, where hospice aide services were provided it was noted in review of record for home visit # 3 the aide plan of care/task sheet did not include any direction regarding the fact that the patient had dressings on both lower extremities. This was discussed with the Director of Patient Care who was present on the visit.

Observed in Record Review. In 2 of 12 patient records reviewed, for those patients that had hospice aide services provided it was noted that in record review #1 there had been no supervisory in 40 days. In another example for record review #11 it was noted that there had been no supervisory visit documented for a period of 15 days and a period of 23 days. This was confirmed by the Director of Quality assisting with record review.

Observed in Record Review. In 1 of 12 patient records reviewed, where hospice aide services were provided it was noted that the supervising nurse did not assess if assigned tasks were being completed. For example, in review of record for home visit #2 and in discussion with the patient it was noted that none of the hands on care activities had been completed in review of notes for the past two months. For example, bathing, skin care, peri-care were assigned tasks however the aide documented that the patient refused these care tasks on every visit. This was discussed with the Director of Quality and Director of Patient Care.

Observed in Record Review. In 4 of 20 patient records reviewed, it was noted that in record review for home visit #4, record review #2, record review #4 and record review #5 the hospice aide documented in multiple visit notes that all of the bath types were completed to include bed bath, partial bath, shower, etc. This was confirmed by the Director of Clinical Services. Observed in Record Review. In 1 of 20 patient records reviewed, It was noted that in review of record for home visit #3 there had been no documentation of wound measurements since the start of care two months ago for a patient with three wounds, with one that was documented as having tunneling. Agency policy is to document wound measurements monthly and as needed. This was confirmed by the Director of Clinical Services.

Observed in Record Review. In 2 of 2 patient records reviewed, who had been discharged from hospice care it was noted that there was no documentation of a discharge summary. This was noted in discharge record #1 for a patient who revoked hospice care and in discharge record #2 for a patient who was elected to be transferred to another hospice. This was confirmed by the Director of Clinical Services.

Observed in Patient Home. In 2 of 6 home visits conducted, it was noted that in home visit #2 an oxygen tank was leaning against a grandfather clock unsecured in the living room. In another example, in home visit #6 there were two small oxygen tanks standing upright and unsecured in the living room. This was confirmed by the Director of Patient Care present on the visit.

Observed in HR File Review. In 5 of 10 HR files reviewed, it was noted that primary source verification had not been obtained. For example, in review of one Medical Director file, 2 hospice aide files and 2 RN files there had been no verification from primary source since the last renewal in 2023. The record contained only copies of the physical license sent to the staff member. This was confirmed by the HR staff member assisting with the review.

Observed in Document Review. The organization did NOT have a written interim life safety measures (ILSM) policy or assessment. This was verified by the Residence Manager and Quality Director. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Document Review. The Annual Fire Alarm Inspection and Test documentation from April 2025 and May 2024 did NOT include an INVENTORY of notification appliances (speakers, horns, chimes, and strobes). The report only included a statement that all horn/strobes passed. This was verified by the Residence Manager and Quality Director. Observed in Document Review. The Quarterly test of the dry fire sprinkler low-air supervisory was NOT completed the 2nd and 3rd Quarter of 2024, or the 1st Quarter of 2025. This was verified by the Residence Manager and Quality Director.

Observed in Individual Tracer. In 2 of 6 patient records reviewed, the plan of care did not reflect goals based on the problems identified on the initial and comprehensive assessments. In RR#4 nutrition, dysphagia, urinary incontinence and wound care did not have written goals. In RR#5 urinary incontinence managed with a Foley catheter did not have a written goal. This was verified by the Quality Manager.

Observed in Individual Tracer. In 1 of 6 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In RR#4 the care plan did not address the patient's nutrition and dysphagia. This was verified by the Quality Manager.

Observed in Individual Tracer. In 2 of 6 patient records reviewed, the plans of care did not include the treatments necessary to meet the needs of the patient. In RR# 4 the plan of care did not address wound care of the first wound identified 8/29. The second wound identified 9/7 was not care planned until 9/27. In RR#5 the plan of care did not include the Foley catheter care. This was verified by the Quality Manager.

Observed in Individual Tracer. In 1 of 6 patient records reviewed, the organization did not provide services in accordance with the plan and organization policy to measure wounds initially and monthly. In RR#4 the first wound documented 8/29 and a second wound documented 9/7 did not have complete comprehensive assessment of wounds, ie measurements. This was verified by the Quality Manager.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, where the patient received aide services the written patient instructions did not include all information related to the patient's care. In RR #8 the aide assignment did not include the patient's safety measures, i.e., fall risk and oxygen safety. This was verified by the Quality Manager.

Observed in Building Tour. During the building tour, the surveyor noted the remote shut off was on the generator itself and was not located outside of the emergency power system location. This was confirmed with the Facilities Manager.

Observed in HR File Review. In 1 of 11 HR files reviewed, the organization did not provide emergency preparedness training to staff annually as required by organization policy. In HR #11, the surveyor noted the IPU hospice aide did not have annual emergency management training in 2021 as required by organization's policy. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 2 of 16 patient records reviewed, the organization did not assess the patient's pain.In HV #1, the surveyor noted the comprehensive pain assessment on admission did not include quality, what makes it worse and what makes it better as required by the organization's comprehensive assessment policy. This was confirmed with the Quality and Compliance Manager.In RR #3, the surveyor noted the skilled nursing pain assessment did not include quality, what makes it worse, and what makes it better. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 16 of 16 patient records reviewed, the hospice did not conduct and document in writing a patient-specific comprehensive assessment. In all records reviewed, the surveyor noted the skilled nursing comprehensive assessments did not include imminence of death. This was confirmed with the Quality and Compliance Manager. In HV #4, the surveyor noted the nurse did not perform a complete assessment of the foley catheter to include size of catheter, balloon and insertion date at the time of admission. This was confirmed with the Quality and Compliance Manager. In RR #3, the surveyor noted the skilled nurse at the recertification visit did not assess the patient for edema; however, the patient had a secondary diagnosis of heart failure. This was confirmed with the Quality and Compliance Manager. In RR #5, the surveyor noted the skilled nurse did not assess the patient's bowel sounds or the last bowel movement as part of the admission comprehensive assessment; however, the comprehensive assessment policy required this assessment. In addition, the nurse documented that SNF BM list indicated patient had no bowel movement for 7 days. Staff at SNF believe that was inaccurate; however, the nurse failed to perform an abdominal assessment and bowel sounds at the visit. This was confirmed with the Quality and Compliance Manager. In RR #9, the surveyor noted the patient had a secondary diagnosis of dysphagia; however, there was no assessment of dysphagia on the skilled nursing admission comprehensive assessment. This was confirmed with the Quality and Compliance Manager. In RR #10, the surveyor noted the patient had a terminal diagnosis of heart failure; however, the skilled nurse did not assess edema on admission comprehensive assessment. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 8 of 16 patient records reviewed, an initial bereavement risk assessment was not performed as part of the initial comprehensive assessment.In RR #3, RR #6, RR #8, RR #10, RR #11, RR #12, HV #1 and HV #2, the surveyor noted the initial comprehensive assessment did not include a bereavement assessment. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 9 of 16 patient records reviewed, the written plan of care was not based on the patient's goals and the time fames, settings and services required to meet those goals. In IPU #1, the surveyor noted the plan of care included the following non-measurable goal: have comfort goals maintained during dying process. In addition, the plan of care included wound care for a stage 1 pressure ulcer to the coccyx; however, there was no goal for this intervention. This was confirmed with the Quality and Compliance Manager. In IPU #2, the surveyor noted the plan of care goal times frames were from previous certification periods. In addition, the plan of care included the following non-measurable goal: Patient will express satisfaction with art therapy. This was confirmed with the Quality and Compliance Manager. In HV #1, the surveyor noted the plan of care included the following non-measurable goals: Verbalizes acceptable level of symptom control and self monitoring. Have comfort goals maintained during dying process. In addition, the except for the pain goal, the goals did not include time frames. This was confirmed with the Quality and Compliance Manager. In HV 2, the surveyor noted the plan of care included the following non-measurable goal: PT/CG to express spiritual peace with the dying process. This was confirmed with the Quality and Compliance Manager. In RR #3, the surveyor noted the goals were not updated in the second certification period were dated to be achieved by the end of the first certification period; however, the were not updated or resolved on the plan of care prior to the second certification period. In addition, the plan of care included the following non-measurable goals:: PCG wants patient last days to be what patient wants with pain management. Pt/cg will be supported by HH to form educated goals and interventions. Demonstrates anticoagulation therapy. Goal verbalizes agreement with DC plan. Spiritual goal to report satisfaction with spiritual support through IDG biweekly. This was confirmed with the Quality and Compliance Manager. In RR #5, the surveyor noted the plan of care included the following non-measurable goal: Verbalizes acceptable level of symptom control and self monitoring, increased mood stability. In addition, the goals did not include time frames. This was confirmed with the Quality and Compliance Manager. In RR #8 and RR #9, the surveyor noted the patient had an intervention for wound care; however, the plan of care did not include a wound care goal. This was confirmed with the Quality and Compliance Manager. In RR #11, the surveyor noted the plan of care goals did not include time frames except for one risk goal. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 11 of 16 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms.In IPU #1, the surveyor noted the patient was identified as having pain and at fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In HV #1, the surveyor noted the patient was identified as having dysphagia and at fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In HV #2, the surveyor noted the patient was identified as having edema and at fall risk; however, the plan of care did not include interventions to address these identified needs. In addition, the patient developed thrush in the fourth month of service and nausea in the fifth month of service; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In HV #3, the surveyor noted the patient was identified as having itching, fall risk and pain; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In RR #4, the surveyor noted the patient was identified as having dysphagia and at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In RR #6, the surveyor noted the patient was identified as having pain and aphasia; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In RR #7, the surveyor noted the patient was identified as having dysphagia, UTI and at fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager. In RR #8, the surveyor noted the patient was identified as having seizures and at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In RR #9, the surveyor noted the patient was identified at fall risk and had dysphagia; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Quality and Compliance Manager.In RR #10 and RR #12, the surveyor noted the patient was identified at fall risk; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 10 of 16 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In HV #1, the surveyor noted the plan of care skilled nursing visit frequency included 20 prn visits. In addition, the patient was receiving aide services; however, the plan of care did not include a visit frequency for the aide. This was confirmed with the Quality and Compliance Manager. In HV #2 and RR #3, the surveyor noted the plan of care skilled nursing visit frequency and the aide visit frequency included 20 prn visits. This was confirmed with the Quality and Compliance Manager. In HV #3, the surveyor noted the skilled nurse stated to surveyor that the patient's stage 4 pressure ulcer to the coccyx has been declining, the patient's family has not participated in the changing of the dressing. The wound care was an ABD dressing applied to the wound daily; however, nursing visits were not increased to meet this identified need when the family were not providing this care. This was confirmed with the Quality and Compliance Manager. In RR #4, RR #10 and RR #12, the surveyor noted the plan of care skilled nurse visit frequency included 30 prn visits. This was confirmed with the Quality and Compliance Manager. In RR #5, RR #9 and RR #12, the surveyor noted the plan of care aide visit frequency included 20 prn visits. This was confirmed with the Quality and Compliance Manager. In RR #8, the surveyor noted the aide visit frequency included 10 prn visits and the skilled nursing visit frequency included 20 prn visits. This was confirmed with the Quality and Compliance Manager. In IPU #2, the surveyor noted the patient was receiving art therapy; however, the plan of care did not include a visit frequency and services to be provided. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 11 of 16 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In IPU #1, the surveyor noted the plan of care included may use standing orders. For example, the plan of care standing order included foley catheter 16 French balloon inflated with 10 ml normal saline, may straight or external cath to gravity drainage prn; however, there was no indication given and the patient upon admission was not identified as having urinary difficulties. Also included may irrigate/flush catheter with 60 ml normal saline as indicated; however, there was no indication given. Second example, the plan of care standing order included the following medications for itching prn: Benadryl, atarax, calamine lotion, 1% hydrocortisone cream; however, the orders did not specify when to give which medication. This was confirmed with the Quality and Compliance Manager. In HV #1, the surveyor noted the on the admission patient comprehensive assessment the patient was identified as having dysphagia and on a soft diet with thickened liquids; however, the plan of care did not include the patient's diet type and the need for thickened liquids. This was confirmed with the Quality and Compliance Manager. In HV #3, the surveyor noted the patient was identified as having a foley catheter on admission; however, the plan of care did not include the foley catheter change frequency. This was confirmed with the Quality and Compliance Manager. In RR#3, the surveyor noted the patient was identified as having a foley catheter and oxygen at 6 liters per nasal cannula, increasing to 7 liters with activity; however, these interventions were not on the plan of care. In addition, the plan of care included a medication order for Ativan which indicated 0.5 - 2 mg and morphine 5 - 15 mg; however, the orders did not specify when to give which dose. This was confirmed with the Quality and Compliance Manager. In RR #4, the surveyor noted the patient was identified as having a skin tear; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Quality and Compliance Manager. In RR #5, the surveyor noted the plan of care did not specify the patient's ordered diet; however, the patient had a secondary diagnosis of dysphagia. In addition, the plan of care indicated admin wound care as ordered; however, the plan of care did not include specific wound care interventions. This was confirmed with the Quality and Compliance Manager. In RR #6, the surveyor noted the plan of care did not specify the type of diet; however, patient had dysphagia and was on a pureed diet per comprehensive assessment. In addition, the plan of care medication order for Biofreeze did not include the location of application. Also, the patient was taking Eliquis; however, the plan of care did not include interventions to address this identified risk. This was confirmed with the Quality and Compliance Manager. In RR #7, the surveyor noted the patient had dysphagia and was on a pureed diet with honey thickened liquids; however, the diet was not included on the plan of care. In addition, the patient was identified as taking insulin and on coumadin; however, the plan of care did not include interventions to address these identified needs such as INR monitoring and blood sugar monitoring. This was confirmed with the Quality and Compliance Manager. In RR #8, the surveyor noted the plan of care did not specify the type of diet. This was confirmed with the Quality and Compliance Manager. In RR #9 and IPU #2, the surveyor noted the plan of care included a medication order for Ativan which indicated 0.5 - 2 mg and morphine 5 - 15 mg; however, the orders did not specify when to give which dose. This was confirmed with the Quality and Compliance Manager. In IPU #2, the surveyor noted the plan of care indicated obtain COVID test four times from previous certification periods, however, these were not dated for when to obtain and were not discontinued. This was confirmed with the Quality and Compliance Manager. In RR #11, the surveyor noted the plan of care included a range order for Benadryl 25 - 50 mg; however, did not specify when to take 25 mg versus 50 mg. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 6 of 16 patient records reviewed, the organization did not ensure that the care and services were provided in accordance with the plan of care. In HV #1, the surveyor noted the plan of care visit frequency for spiritual services was one time per month with 5 prn visits. The first week of service a prn visit was made; however, there was no indication given for the prn visit. The visit note indicated joint visit with MSW, listening and supportive presence. This was confirmed with the This was confirmed with the Quality and Compliance Manager. In HV #2, the surveyor noted the plan of care indicated assess skin integrity; however, the nurse did not assess the patient's skin at the time of the home visit to include all pressure points. In addition, there was a missed nursing visit the 11th week of the second certification period. This was confirmed with the Quality and Compliance Manager. In HV #3, the surveyor noted the plan of care medication order was for dilaudid concentration 1mg/1ml, 0.2 mg/hr via CADD pump; however, the CADD pump was programmed with a concentration of 0.1 mg/ml for four days. This was confirmed with the Director of Clinical Services. In RR #3, the surveyor noted the plan of care included an order to assess the lungs; however, the skilled nurse at the recertification visit did not assess the lung sounds, although the wife reported increased coughing. In addition, the aide visit frequency was twice per week; however, there was a missed visit in the second certification period. This was confirmed with the This was confirmed with the Quality and Compliance Manager. In RR #7, the surveyor noted the plan of care included assess edema; however, the assessment was not performed on a skilled nursing visit last month. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 1 of 16 patient records reviewed, all disciplines did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In RR #5, the surveyor noted the aide documented last week that reddened area noted to elbow and nurse was off so will contact her with next visit. This was confirmed with the Quality and Compliance Manager.

Observed in Individual Tracer. In 1 of 4 home visits conducted, the organization did not use standard precautions to reduce the risk of infection.In HV #3, the surveyor noted the nurse performed hand hygiene and then touched their phone and then donned gloves prior to performing wound care. In addition, the nurse removed the patient's soiled diaper and then with same gloved hands touched the patient's bed controls. This was confirmed with the Director of Clinical Services.

Observed in Record Review. In 10 of 14 patient records reviewed where the patient received aide services, the registered nurse did not prepare written patient care instructions for the hospice aide. In HV #1, the surveyor noted the aide plan of care did not include fall precautions, aspiration precautions or oxygen precautions/instructions. This was confirmed with the Quality and Compliance Manager. In HV #3, the surveyor noted the aide plan of care included wound care to right heel pressure ulcer cleanse with normal saline/wound cleanser, apply hydrocellular dressing and cover with ABD, wrap with kerlix. In addition, the aide plan of care included wound care to a stage 4 wound which consisted of cleansing the wound and then applying ABD dressing. This wound care was completed by the aide at a home visit without the nurse present. This was confirmed with the Quality and Compliance Manager. In HV #4, RR #5, RR #6 and RR #9, the surveyor noted the aide plan of care did not include fall precautions. This was confirmed with the Quality and Compliance Manager. In RR #3, the surveyor noted the aide plan of care did not include bleeding precautions, fall precautions, and oxygen precautions/instructions This was confirmed with the Quality and Compliance Manager. In RR #7, the surveyor noted the aide plan of care included feeding patient; however, the aide plan of care did not specify the diet type of pureed with honey thickened liquids. In addition, the aide plan of care did not include bleeding precautions, fall precautions, and aspiration precautions. This was confirmed with the Quality and Compliance Manager. In RR #8, the surveyor noted the aide plan of care did not include seizure and fall precautions. This was confirmed with the Quality and Compliance Manager. In RR #12, the surveyor noted the aide plan of care included feeding the patient, however, the aide plan of care did not specify the type of diet. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 3 of 15 patient records reviewed where the patient received aide services, the registered nurse did not supervise the hospice aide during an on-site visit no less frequently than every 14 days. In HV #4, the surveyor noted the aide supervisory visit was completed 16 days apart. This was confirmed with the Quality and Compliance Manager. In RR #3, the surveyor noted the aide supervisory visit was completed 21 days apart. This was confirmed with the Quality and Compliance Manager. In RR #8, the surveyor noted the aide supervisory visit was 23 days apart. This was confirmed with the Quality and Compliance Manager.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 and 418.56, 418.76.

Observed in HR File Review. In 1 of 11 HR files reviewed, staff competence was not assessed and documented annually as required by the organization's competence plan. In HR #6, the surveyor noted the registered nurse's competence was not assessed in 2021 as required by the organization's competence plan for CADD pump and wound care. This was confirmed with the Quality and Compliance Manager. Observed in HR File Review. In 1 of 11 HR files reviewed, staff competence was not initially assessed and documented as part of orientation. In HR #3, the surveyor noted the organization did not assess competence of the volunteer coordinator as part of orientation. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 2 of 16 patient records reviewed, the patient record was not accurately documented. In HV #1, the surveyor noted the aide visit documentation from this week indicated the total bath was completed and also the total bath was refused. This was confirmed with the Quality and Compliance Manager. In RR #6, the surveyor noted the plan of care indicated the patient was taking lisinopril was for diarrhea and escitalopram was for diabetes. This was confirmed with the Quality and Compliance Manager.

Observed in Record Review. In 2 of 2 bereavement records reviewed, all entries were not appropriately authenticated and dated. In BRV #1 and BRV #2, the surveyor noted the bereavement summary was entered into the clinical record by the volunteer coordinator; however, the medical social worker who performed bereavement assessment was not authenticating the documentation. In addition, the bereavement contact note entries were not authenticated and dated as to when entered into the clinical record. This was confirmed with the Director of Social Work and Counseling Services.

Observed in Record Review. In 1 of 1 patient's transferred to Medicare facility, the hospice did not provide a copy of the discharge summary to the hospital. In RR #10, the patient revoked hospice services due to transfer to hospital due to fall; however, the organization did not provide a copy of the discharge summary to the hospital. This was confirmed with the Quality and Compliance Manager.

Observed in Individual Tracer. In 3 of 4 home visits conducted, the hospice did not provide education on an individualized emergency management plan.In HV #1, HV #2, and HV #3, the surveyor noted the organization did not develop an individualized emergency plan for the patient/family and did not provide a copy of this plan to the patient/family. In discussion with the Hospice Director, the organization did not have a process in place at the time of survey to develop an individualized emergency plan. This was confirmed with the Director of Clinical Services.

Observed in Building Tour. During the building tour, the surveyor noted the bottom rack of the cart in the kitchen was stored a colander and bowl used in the preparation of food; however, the bottom rack was not protected from splash. In addition, in the freezer in the kitchen there was smoked sausage and hamburger meat that was labeled but did not contain a beyond use date. This was confirmed with the Director of Clinical Services.

Observed in Record Review. In 2 of 6 patient records reviewed where the patient resided in a nursing facility, the hospice plan of care did not identify which provider was responsible for performing the functions in the plan of care.In RR #5, the surveyor noted the patient resided in the skilled nursing facility and the plan of care included an intervention admin wound care as ordered; however, the plan of care did not specify which provider was responsible for the wound care. This was confirmed with the Quality and Compliance Manager.In RR #8, the surveyor noted the patient resided in the skilled nursing facility; however, the plan of care did not specify which provider was responsible for the wound care. This was confirmed with the Quality and Compliance Manager.