Every finding on record at Hospice of Orange & Sullivan Counties, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization had not documented a patient specific assessment required by organizational policy. In the chart for RRNHV#4, the patient had Oxycodone added for pain management upon admission and Lidocaine patches added approximately 3 weeks post admission. There was no follow up regarding pain management needs within 24 hours of a change in the pain management regimen as was required by organizational policy Pain Management. This was discussed with the Administrator and CEO.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4's patient record review it was noted the organization had not ensured staff followed the organization policy Pain Management that included pain would be assessed on character, location, duration, and intensity will be assessed using a pain rating scale of 0-10. For example: review of RR# 4's patient record revealed a Licensed Practical Nurse (LPN) dated approximately 16 days prior to the surveyor review of the record with documentation still struggling with pain management and no documentation of pain duration, character, or intensity. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and the Director of Nursing. Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured staff assessed and reassessed patients per organization policy Comprehensive Assessment that included a comprehensive assessment would be completed as frequently as the patient's conditions requires. For example: review of RR# 2's patient record revealed RR# 2 had a terminal diagnosis of pancreatic cancer with metastasis. Review of RR# 2's start of care (SOC) RN comprehensive assessment revealed RR# 2 was unresponsive, showing signs and symptoms of pain with audible moaning and groaning and was assessed to have a pain intensity of 7 out of 10 on the PAINAD scale. Further review of the start of care RN comprehensive assessment revealed RR# 2 had no shortness of breath during the admission process and the RN advised the wife to administer prescribed Percocet until the comfort pack arrived. Further review of RR# 2's patient record revealed a Family Nurse Practitioner SOC phone call to RR# 2's spouse approximately five hours after the SOC RN comprehensive assessment with documentation of a change in patient condition reported by RR# 2's spouse that now included RR# 2 was agitated, combative, anxious with eyes wide open and has not been taking Percocet and discussed use of morphine and lorazepam - at night to start for anxiety and sleep. Further review of RR# 2's patient record revealed the subsequent nurse visit was the death visit two days after the SOC. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manger and the Director of Nursing.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4's patient record review it was noted the organization had not ensured the RN updated the comprehensive assessment no less than every 15 days. For example: in review of RR#4 patient record revealed RN comprehensive assessment was not performed in the past 30 days prior to the surveyor review of the record. Further review of RR# 4's patient record revealed no subsequent RN comprehensive assessments. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manger and Director of Nursing.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4's patient record review it was noted the organization had not ensured the patient's plan of care was based on the patient's goals and the time frames, settings, and services required to meet those goals. For example: review of RR# 4's patient record revealed the terminal diagnosis of cancer of the mouth secondary of lymph nodes. Review of RR# 4's start of care RN comprehensive assessment revealed documentation that RR# 4 had difficulty swallowing and was able to eat pureed soup and liquids. Review of RR# 4's plan of care revealed no goals related to RR# 4's altered swallowing ability. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and the Director of Nursing.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4's patient record review it was noted the organization had not ensured the plan of care included all services need for the palliation and management of terminal illness and related conditions, including interventions to manage pain and symptoms. For example: review of RR# 4's patient record revealed RR# 4 had a terminal diagnosis of cancer of the mouth secondary of lymph nodes. Review of RR# 4's start of care RN comprehensive assessment revealed documentation that RR# 4 had difficulty swallowing and was able to eat pureed soup and liquids. Review of RR# 4's plan of care revealed no documentation of interventions related to RR# 4's altered swallowing ability or pureed diet. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and Director of Nursing.

Observed in Record Review. In 1 of 1 patient records reviewed with hospice aide, During RR# 5's patient record review it was noted the organization had not ensured the RN supervised the hospice aide during on-site visit to the patient's home no less frequently than every 14 days. For example: review of RR# 5's patient record revealed the hospice aide had been providing services for 27 days prior to the first documented RN Supervisory visit. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and the Director of Nursing.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level Deficiency in the Provision of Care 418.54 and 418.100.

Observed in Record Review. In 1 of 5 patient records reviewed, clinical record did not contain all information. Review of the On call log for 4/30/25 revealed documentation that RR# 2's spouse called approximately one hour before the organization opened with the concern not breathing well during the night. see EMR. Review of RR# 2's patient record/EMR revealed no documentation of the RR# 2's spouse calling the hospice or reporting RR# 2's breathing. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manger and the Director of Nursing.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 5's patient record review it was noted the organization had not ensured entries into the patient record are authenticated. For example: review of RR# 5's nurse visit notes revealed a nurse visit note with the name of the nurse with the title/occupation as SN with no indication if the nurse was a RN or a LPN. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manger and the Director of Nursing.

Observed in Record Review. In 1 of 24 patient records reviewed, the organization had not followed its pain assessment policy. In the chart for RRDC#20, upon admission the patient had been assessed to have a fentanyl patch and prn Morphine ordered for pain control, yet the comprehensive assessment did not include a pain assessment, rather indicated that the patient denied pain. Pain Management policy required that a comprehensive pain assessment/evaluation would be assessed and documented on admission including a minimum set of items including location, severity, frequency, etc. This was discussed with the CNO and CCO.

Observed in Record Review. In 1 of 24 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for RRHV#1, the initial spiritual care assessment was not completed until 11 days post-admission. This was discussed with the CNO and CCO.

Observed in Record Review. In 4 of 24 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#4, one of the patient's most significant issues was pain control. The pain control goal of Patient will verbalize adequate relief of pain with the use of current pain medications did not include a timeframe for completion. In the chart for RRNHV#7, the diabetes goal was not measurable nor time based. Patient will have optimal glucose control through diet; the MSW goal ...husband wishes to hire more private caregivers to provide personal care to (patient name deleted), did not include a time frame for completion. In the chart for RRNHV#10, the goals on the POC were not measurable and/or time based. For example, patient's pain will be controlled, prevention of falls and fall injury the caregiver will demonstrate oxygen management focused on safe use and safe storage with independence. In the chart for RRNHV#14, the time frame for anticipated goal attainment was not appropriate to the problem for this patient with metastatic cancer. Patient will verbalize adequate relief of pain with the use of current pain medications within the cert period. This was discussed with the CNO.

Observed in Record Review. In 2 of 24 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRH#6, the patient has been receiving weekly volunteer visits for more than one year. While these visits are mentioned in the IDT notes for the MSW, when the plan of care is revised at each benefit period, there is no inclusion of the volunteer services on the revised plans of care. In the chart for RRNHV#13, the aide frequency range was written as 1-5 visits per week for 13 weeks, outside the acceptable range of no more than 2 visit range. This was discussed with the DON.

Observed in Record Review. In 1 of 24 patient records reviewed, the plan of care did not include complete and accurate medication orders. In the chart for RRNHV#16, the patient's comfort pack medications are listed as the oral route, however the patient is NPO and feedings/medications must go through the feeding tube. The orders had not been clarified with the physician to change the route to via the feeding tube. This was discussed with the CCO and CNO.

Observed in Record Review. In 3 of 24 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medical supplies and appliances necessary to meet the patient’s needs. In the charts for RRHV#1, RRHV#2 and RRNHV#13, the plans of care did not list the DME needed, it simply stated DME provided by SNF. The patient in RRHV#1 required a wheelchair as well as upper bed rails on the bed for fall precautions/spacial awareness. The patient in RRHV#2 required a wheelchair, low air loss mattress, oxygen prn, etc. In the chart for RRNHV#13, the interventions for falls precautions were not specific to the patient and simply stated Educate patient and family on patients fall risk and risk reduction strategies. The patient's assessment revealed the patient was mostly bed bound, yet was at times able to pivot transfer, however required 2 person assist for transfers. This was discussed with the CNO and CCO.

Observed in Record Review. In 2 of 24 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for RRNHV#10, on multiple visits the LPN documented the oxygen was at either 2lpm or 3lpm, yet the ordered rate is 4lpm. In the chart for RRNHV#11, nursing did not follow the visit frequency required by the hospice plan of care. SN visits were ordered 1-2 times weekly, yet there was no visit, nor documentation of a missed visit in week 5 of care. This was discussed with the CNO.

Observed in Record Review. In 1 of 22 patient records reviewed, in which aide services were ordered, the registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision did not prepare complete written patient care instructions for the hospice aide. In the chart for RRIPU#23, the aide assignment read Assist with bath of choice as requested. This was discussed with the CNO and CCO.

Observed in Record Review. In 1 of 22 patient records reviewed, the RN had not supervised the aide no less frequently than every 14 days. In the chart for RRNHV#8, 28 days lapsed between documented supervisory visits. This was discussed with the DON.

Observed in HR File Review. The organization had not defined the competencies it requires of its staff who provide patient care, treatment, or services. The organization had not defined required competencies for physicians as confirmed with the CEO. Observed in HR File Review. In 1 of 13 HR files reviewed, staff competence was not initially assessed and documented as part of orientation. In the file for HR#7, there was no documentation of initial competencies as discussed with the CCO and HR Director.

Observed in Record Review. In 3 of 24 patient records reviewed, the patient record was not available to review and/or was inaccurately documented. In the chart for RRHV#6, the volunteer is seeing the patient weekly. There are no volunteer notes scanned into the patient record for more than one year. In the chart for RRHV#4, the patient had been on service for more than one month with aide visits 1-2 times weekly. There were only 3 aide visit notes documented in the record at the time of survey. Paper notes had not been scanned into the record, but were available in the organization. In the chart for RRIPU#23 there was incorrect documentation. Another patient's name and gender referenced in the narrative of the admission visit. This was discussed with the CCO.

Based on clinical record review and staff interview, the hospice failed ensure that the IDG were updated including the deterioration of wounds and patient's status. --- The hospice failed to: Ensure updated comprehensive assessment includes the deteriorating of all the wounds for one (1) of three (3) patients with wounds (refer to L533). Ensure hospice nurses and Interdisciplinary Group (IDG) members are performing complete and updated comprehensive assessments or that the hospice nurses are communicating changes in the patient wound care needs and condition to the IDG for one (1) of three (3) patients with wounds (refer to L533). Ensure updated reassessments includes the patients response to wound treatment for one (1) of three (3) patients with wounds (refer to L533). The cumulative effect of the systemic issues identified in the agency's failure to ensure comprehensive assessments are complete, current, and updated has the potential for negative patient outcomes.

Based on clinical record review, policy and procedure review, and staff interviews, the Hospice failed to ensure updated comprehensive assessments, that includes information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care is available to the interdisciplinary team (IDT). This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Specifically, the hospice failed to update the comprehensive assessment of Patient #1 when Patient #1 developed wounds and when Patient #1's wounds deteriorated. Additionally, the hospice failed to complete a comprehensive assessment of all of Patient #1's wounds at least every 15 days. Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient and is available to the IDT, has the potential for negative patient outcomes. --- The findings are: The Palliative Wound Care Protocol dated 02/01/2022 documents: ";Skin integrity is assessed by the RN (Registered Nurse) on admission and at each assessment visit." The protocol documented the initial assessment of the wound included the type of wound, location of wound , stage, measurement, condition of the wound bed, wound edges, peri wound condition, drainage and order. The Nursing Assessment Policy revised 01/2022 documents: ";a nursing assessment will be completed upon admission and as frequently as the patients conditions require. It documented the assessment would include skin integrity and based on the ongoing assessments, the Plan of care, which included problems, interventions, goals and outcomes would be reviewed and revised accordingly, and reassessments for all clinicians should focus on: A. patient's response to care and progress toward desired outcomes. 1. Patient #1 has a Start of Care date of 11/08/2021 with the following diagnoses "Alzheimers Disease, Unspecified Dementia without Behavioral Disturbance, Adult Failure to Thrive" documented in the Hospice Plan of Care dated 07/06/2022 to 09/03/2022. A Licensed Practical Nurse (LPN) Skilled Nurse (SN) Visit Note dated 7/7/2022 documented Patient #1 had a new wound on her left foot about the size of a nickel. Skilled visit notes completed by LPNs and dated 7/19/2022, 7/22/2022, 7/26/2022, 8/3/2022 and 8/9/2022 documented the patient continued to have a wound noted on her left lateral foot. Review of nursing assessments and Interdisciplinary Team (IDT) meetings lacked documentation of a wound assessment of the left lateral foot wound. The SN for RN Telehealth Routine Visit dated 07/22/2022 documents: ";Wound #1 Type: Pressure Ulcer Unstageable, Location: Right Posterior great toe foot, Wound Bed: Eschar – dry tough black/brown 100% / red/ brown/ dry; Wound size Length: 3 cm (centimeter), Width 4.5 cm." There is no documented evidence of the wound assessment after 07/22/2022 for the Right Posterior great toe (foot). The IDT meeting notes dated: 07/27/2022, 08/10/2022, and 08/24/2022 lacked documented evidence of the IDG updating the comprehensive assessment to include right posterior great toe wound (foot). The IDT (Interdisciplinary Team) meeting notes dated: 07/13/2022, 07/27/2022, 08/10/2022, and 08/24/2022 lacks documented evidence of the IDG (Interdisciplinary Group) was aware of left lateral foot wound. A SN telehealth Visit Note dated 8/9/2022 documented the patient had a new stage 2 to her right mid- thigh that was due to pressure of the left leg with contractures. The visit lacked an assessment of the wound that included measurements, condition of the wound bed, wound edges , peri wound condition, drainage , and odor. A LPN skilled nurse Visit Note dated 8/16/2022 documented a wound to the upper right anterior thigh was larger and deeper than the last visit and had bloody drainage. A RN nurse Visit Note dated 8/17/2022, documented a new wound developed to the patient's left ankle. It documented the right and left wound were measured and treated. review of the medical record lacked evidence of an updated comprehensive assessment that included the hospice's interdisciplinary team in collaboration with the individual's attending physician. Additionally, the record lacked an order for wound care. An IGT meeting dated 8/24/2022 documented by a RN that the patient had two stage 2 inside left and right thighs. the RN documented the wounds were dressed with Xeroform and foam dressing daily. Additionally , the RN documented a new stage 2 to the patient's right inner thigh was cleansed with normal saline and triple antibiotic ointment was applied. The RN documented SN visits would be completed once weekly and as needed. The clinical record lacked evidence of a comprehensive assessment completed prior to the 8/24/2022 IDT meeting. A LPN skilled Visit Note dated 8/25/2022 documented the patient's wound on the left ankle had a slight odor, the patient cried out during wound care and the RN was made aware. A RN telehealth routine visit dated 8/25/2022 documented the patient's left wound was unstageable and had copious tan drainage. the RN documented patient had no signs and symptoms of infection and had no pain. The wound to the left lower ankle documented the wound bed was 100% covered with yellow /tan or grey slough and the peri wound area was inflamed. It documented the wound to the right thigh had 75% granulation tissue. A RN visit summary dated 8/29/2022 documented the patient's wound to the right lower extremity had 50 % slough and 50 % eschar - signs of wound deterioration since the previous RN visit. A RN skilled nurse Visit Note dated 8/30/2022 documented the patient's right thigh wound was unstageable and had 25% slough and 75% eschar at the wound bed. There was a moderate amount of pink/tan drainage. The RN documented the patient's left ankle had slight edema, the wound was unstageable , the wound bed was 50% slough and 50% eschar. The patient's son was present for the visit and requested daily visits to assess the patient's wounds. The clinical record lacked evidence of an updated comprehensive assessment that included the hospice's interdisciplinary team in collaboration with the individual's attending physician, following the signs of wound deterioration following the visit on 8/25/2022, 8/29/2022 and 8/30/2022. A LPN SN Visit Note dated 9/1/2022 documented the patient's left ankle wound had a slight odor present. A LPN SN Visit Note dated 9/17/20222 documented the patient had signs and symptoms of cellulitis surrounding the patient's exiting wound and traveling up the foot. it documented during wound care the nurse noted possible cellulitis of the left foot. The NP was notified , and Cephalexin was ordered. A RN SN Visit Note dated 9/19/2022 lacked a complete assessment of the patient's wounds as it did not include type of wound, exact location of wounds, wound measurements, and description of wound. The clinical record lacked evidence of an updated comprehensive assessment that included the hospice's interdisciplinary team in collaboration , with the individual's attending physician , following signs and treatment of a cellulitis to the patient's wounds. On 9/22/2022 at 3:30PM, the Administrator and the Director of Clinicals Services were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview, the hospice failed to ensure that the Interdisciplinary Group (IDG) supervises all patient care and develops plan of care based on the comprehensive assessments for all hospice patients. --- Specifically, the hospice failed to: -Ensure collaboration of all members of the IDG and the attending physician with the update and progress of all the wounds and the development of wound treatments for one (1) of three (3) patients with wounds (refer to L545). -Ensure plan of care was updated to include the need for additional in-home RN (Registered Nurse) visits for one (1) of three (3) patients with wounds (refer to L547). - Ensure that all plans of care include all treatment necessary to meet the needs of the hospice patient for one (1) of three (3) patients with wounds (refer to L549). - Ensure hospice provided the patient with adequate pressure relieving devices to prevent skin breakdown, medication, and treatment supplies for the wounds for one (1) of three (3) patients with wounds (refer to L550). - Ensure IDG review, revise, and document the individualized plan of care as frequently as the patients condition requires for one (1) of three (3) patients with wounds (refer to L552). The cumulative effect of the systemic issues identified in the agency's failure to ensure that individualized plans of care are developed, reviewed and updated to meet the patients wound care needs, failure to address problems with the IDG has the potential for negative patient outcomes.

Based on clinical record review and staff interviews, the Hospice failed to ensure a detailed statement of the scope and frequency of services necessary to meet the specific patient needs. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that a detailed statement of the scope and frequency of services necessary to meet the specific patient needs, has the potential for negative patient outcomes. --- The findings are: 1. Patient #1 has a Start of Care date of 11/08/2021 with the following diagnoses "Alzheimers Disease, Unspecified Dementia without Behavioral Disturbance, Adult Failure to Thrive" documented in the Hospice Plan of Care dated 07/06/2022 to 09/03/2022. The Hospice Plan of Care dated 07/06/2022 to 09/03/2022 documents: Orders for Discipline and Treatments: SN (skilled nurse): Start on 07/07/2022 1x/wk x 1 wk (once a week for one week), 1-2x/wk x 8 wks (one to two times per week for eight weeks), PRN x 15 (as needed times fifteen) s/sx (signs and symptoms) complications. Skilled Observation & Assessment of Cardiovascular Status, Elimination, GI Status, GU Status, Heart Sounds, Integumentary Status, Mental Status, Nutrition/Hydration, Respiratory Status, Safety." The Hospice Interim Orders dated 8/8/2022 documents: "SN: Start on 08/03/2022: 1x/wk x 1 wk, 1-2x/wk x 4 wks." The clinical record documents LPN - PRN visits on the following dates: 07/07/2022, 07/12/2022, 07/22/2022, 07/26/2022, 08/19/2022, 08/23/2022, 08/24/2022, 08/25/2022, 08/31/2022, 09/01/2022, 09/02/2022, and 09/03/2022. The clinical record documents RN - PRN visits on 08/29/2022. The clinical record documents routine RN visits on the following dates: 07/13/2022, 08/04/2022, 08/17/2022, and 08/30/2022. The clinical record documents routine LPN visits on the following dates: 07/19/2022, 08/03/2022, 08/09/2022, 08/16/2022, and 08/28/2022. The clinical record documents RN telehealth visits on the following dates: 07/22/2022, 08/09/2022 and 08/25/2022. There is no documented evidence of ongoing assessments, coordination, and/or discussion by the IDG of the need to increase the frequency of RN services for the deterioration of all wounds and to meet the needs of the hospice patient. There is no documented evidence that the plan of care was updated to patient specific needs: seen three times a week on week: 08/14/2022 to 08/20/2022 and 08/21/2022 to 08/27/2022, seen daily on 08/28/2022 to 09/03/2022, and using 12 PRN visits for the certification period. On 09/22/2022 at 3:30pm, the Administrator and the Director of Clinical Services were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview the hospice failed to ensure all Plans of Care document all wound care treatments to meet the need of the hospice patients. This was evident for two (2) of three (3) clinical records reviewed. (Patient #1, and #2). Specifically, for Patient #2, the hospice failed to ensure the wound site and frequency of wound care to e provided was documented clearly. Additionally, for Patient #1, the hospice failed to update the care plan/obtain orders for treatment of the patient's wounds and the hospice failed to update the care plan/obtain orders that included the frequency of treatments or the specific location the treatments should be provided. Failure to ensure all Plans of Care document all wound care treatments to meet the need of the patient, has the potential for negative patient outcomes.The findings are: --- 1. Patient #1 has a Start of Care date of 11/08/2021 with the following diagnoses "Alzheimer's Disease, Unspecified Dementia without Behavioral Disturbance, Adult Failure to Thrive" documented in the Hospice Plan of Care dated 07/06/2022 to 09/03/2022. The Hospice Plan of Care dated 07/06/2022 to 09/03/2022 documents: "SN (skilled nurse): Start on 07/07/2022: 1x/wk x 1 wk (once a week for one week), 1-2x/wk x 8 wk (one to two times a week for eight weeks), PRNX15 S/SX (as needed times fifteen for signs and symptoms) Complications. Skilled Observation & Assessment of Cardiovascular Status, Elimination, GI Status, Heart Sounds, Integumentary Status." The clinical records documents SN (skilled nurse) Visits on:8/9/2022 "large open abrasion anterior upper right thigh - no drainage, no edema, remaining skin intact, RN (registered nurse) notified and instructed protective dressing left arm Triple Antibiotic Ointment (TAO) and dressing right thigh."8/16/2022 "Large open wound anterior upper right thigh - larger and deeper than last visit - bloody drainage and no odor, new large open area of posterior left leg - clear drainage, no odor, patient with contracted left leg laying across top of right thigh - RN notified and instructed to clean with sterile water, add Xeroform and cover with foam dressing."8/17/2022 "Wound #1 Type: Pressure Ulcer Stage 1; Location: left leg; Wound Bed: Granulation - red/pink 50%; Wound size Length: 6 cm, Width 3 cm. Cleaning/Irrigation Method: NS (normal saline), Packing: Xeroform.""Wound #2 Type: Pressure Ulcer Stage 2; Location: right; Wound Bed: Granulation - red/pink 75%; Wound size Length: 3 cm, Width 3 cm. Cleaning/Irrigation Method: NS (normal saline), Packing: Iodoform gauze."8/19/2022 "Cleansed with NS, Xeroform and foam dressing applied to right anterior thigh and left posterior calf."8/23/2022 "Patient has 2 wounds." "It also appears to have a second wound starting next to it." "Wound care completed per order to both wounds - cleansed with saline, applied Xeroform dressing and placed Allevyn to cover."8/29/2022 Wound #1, Location: Right lower extremities, Care #1 Cleaning/Irrigation Method: NS, Treatment Surrounding Tissue: Skin Prep (preparation), Dressing: MediHoney, calcium Alginate, Allevyn.Wound #2, Location: Left lower extremity, Care #2 Cleaning/Irrigation Method: NS, Treatment Surrounding Tissue: Skin Prep, Dressing: MediHoney, calcium Alginate, Allevyn. 8/30/2022 Wound #1, Location: Right Anterior thigh, Care #1 Cleaning/Irrigation Method: NS, Treatment Surrounding Tissue: Triple Abx (antibiotic), Dressing: Triple Antibiotic Ointment (TAO), calcium Alginate, Non-adherent Allevyn.Wound #2, Location Right anterior thigh adjacent to wound #1 thigh, Care #2 Cleaning/Irrigation Method: NS, Treatment Surrounding Tissue: Calmoseptine, Dressing: Triple Antibiotic Ointment, calcium Alginate, Non-adherent Allevyn.Wound #3, Location: Left Anterior Ankle, Care #3 Cleaning/Irrigation Method: NS, Treatment Surrounding Tissue: Triple Abx, Dressing: Triple Antibiotic Ointment, calcium Alginate, Non-adherent Allevyn.The Interim Order documents: 8/24/2022 "Cleanse wounds to BLE (both lower extremity) with NS, fb (follow by) MediHoney to the wound bed, f/b (followed by) Calcium Alginate cut to size of the wound, f/b DPD (dry protective dressing.) or Allevyn."8/25/2022"Incision/wound care: Cleanse left lower leg/ankle and left thigh with NSS (normal saline solution), apply Calcium Alginate to left lower leg wound and Xeroform to right thigh, cover both wounds with non-adhesive dressing, offload and pad bony prominences."8/29/2022 "LPN (license practical nurse) to perform wound care / dressing change cleanse wounds to BLE with NS, fb MediHoney to wound bed f/b Calcium Alginate cut to size of the wound, f/b DPD or Allevyn."8/31/2022 "Incision/wound care: Cleanse left lower leg/ankle and right thigh with NSS (normal saline solution), apply Triple Antibiotic Ointment and Calcium Alginate, cover both wounds with non-adhesive dressing, offload and pad bony prominences." 9/8/2022 "Incision/wound care: Cleanse left lower leg/ankle and right thigh with NSS (normal saline solution), apply Triple Antibiotic Ointment and Calcium Alginate. Skin prep to surrounding intact tissue, cover both wounds with non-adhesive dressing, offload and pad bony prominences."There is no documented evidence of a medical order for the wound treatment provided on 8/9/2022, 8/16/2022, 8/17/2022, 8/19/2022, 8/23/2022, and 8/29/2022.The interim order on 8/24/2022, 8/25/2022, 8/29/2022, 8/31/2022, and 9/8/2022 lacks documented evidence of the frequency of wound treatment.There is no documented evidence that the interim order on 8/29/2022 was followed by the SN on 8/30/2022 for wound care. There is no documented evidence that the physician was notified of the new development, worsening, and current updates of all the pressure ulcers. On 09/22/2022 at 3:30pm, the Administrator and the Director of Clinical Services were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 05/19/2022 with the diagnosis "Alzheimer Disease" documented in the Hospice Plan of Care dated 08/17/2022 to 11/14/2022. The Hospice Plan of Care dated 08/17/2022 to 11/14/2022 documents: ";SN: 1 x wk x 14wks, PRN 30 Complications/Med Changes. LPN to perform wound care/dressing change LPN to perform one day a week clean with Normal Saline. Apply Silvadene cream. Fill with iodoform and cover with Allyven. RN to perform wound care one day a week clean with Normal Saline. Apply Silvadene cream. Fill with iodoform and cover with Allyven." The Hospice Plan of Care lack documented evidence of clear wound treatment order that includes wound site and clear frequency of treatment. On 09/22/2022 at 04:00PM, the Director of Clinical Services, and President and COO were interviewed, and did not provide an explanation for the findings.

Based on clinical record review and staff interviews, the Hospice failed to ensure that the IDT (Interdisciplinary Team) reviews, revise and document the individualized plan of care as frequently as the patients condition requires. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Specifically , for Patient #1 the hospice failed to review, revise and document the individualized care plan when the patient developed new wounds and when those wounds showed signs of deterioration and infection. Failure to ensure that the IDT reviews, revise and document the individualized plan of care as frequently as the patients condition requires has the potential for negative patient outcomes. --- The findings are: 1. Patient #1 has a Start of Care date of 11/08/2021 with the following diagnoses "Alzheimers Disease, Unspecified Dementia without Behavioral Disturbance, Adult Failure to Thrive" documented in the Hospice Plan of Care dated 07/06/2022 to 09/03/2022. The Hospice Plan of Care dated 07/06/2022 to 09/03/2022 documents: Orders for Discipline and Treatments: SN (skilled nurse): Start on 07/07/2022 1x/wk x 1 wk (once a week for one week), 1-2x/wk x 8 wks (one to two times per week for eight weeks), PRN x 15 (as needed times fifteen) s/sx (signs and symptoms) complications. Skilled Observation & Assessment of Cardiovascular Status, Elimination, GI Status, GU Status, Heart Sounds, Integumentary Status, Mental Status, Nutrition/Hydration, Respiratory Status, Safety." "LPN to observe skin color. LPN to observe if skin is intact." The Hospice Interim Orders dated 08/08/2022 documents: "SN: Start on 8/03/2022: 1x/wk x 1 wk, 1-2x/wk x 4 wks." The clinical record documents SN (skilled nurse) Visit on (left lateral foot): 7/07/2022 ";Patient has new wound on her left foot about the size of a nickel.", 7/19/2022 ";small wound noted left lateral foot", 07/22/2022 ";dark area on left lateral foot", 7/26/2022 ";small wound noted left lateral foot", 8/03/2022 ";red area noted left lateral foot' and 8/09/2022 ";red area noted left lateral foot" The IDT meeting note dated: 07/13/2022, 07/27/2022, 08/10/2022 and 08/24/2022 lacks documented evidence of the discussion, intervention, and goals of the left lateral foot wound. The SN for RN Telehealth Routine Visit dated 07/22/2022 documents: ";Wound #1 Type: Pressure Ulcer Unstageable, Location: Right Posterior great toe foot, Wound Bed: Eschar – dry tough black/brown 100% / red/ brown/ dry; Wound size Length: 3 cm (centimeter), Width 4.5 cm." The IDT meeting note dated: 07/27/2022, 08/10/2022, 08/24/2022, and 09/07/2022 lacks documented evidence of the discussion, intervention, and goals of the right posterior great toe (foot) wound. The clinical record documents SN (skilled nurse) Visit on (left leg): 8/16/2022 ";new large open area of posterior left leg – clear drainage", 8/17/2022 ";Wound #1 Type: Pressure Ulcer Stage 1; Location: left leg; Wound Bed: Granulation – red/pink 50%; Wound size Length: 6 cm, Width 3 cm.", 8/23/2022 ";Patient has 2 wounds. One on her left outer ankle area that is open, about 2 in (inches) x 1 in., has drainage" , 8/24/2022 Patients wound dressings are intact and saturated with drainage, wound continue to have no odor.", 8/25/2022 Patients wound dressings are intact and saturated with drainage, wound on ankle has slight odor and has slough and 8/25/2022 (telehealth) ";Wound #1 Type: Pressure Ulcer Unstageable; Location: left lower leg/ankle" ";Wound Bed: slough – stringy yellow/tan/grey 100%." The IDT meeting note dated 8/24/2022 lacks documented evidence of the discussion, intervention, and goals of the left leg wound. The IDT (Interdisciplinary Team) documents: "8/24/2022 ";Stage 2 skin break down inside of left and right thighs. Dressed with Xeroform and foam dressings." The IDT 08/24/2022 lacks documented evidence of a specific wound sites (on 08/23/2022 assessment with 3 wounds – left outer ankle, top of right thigh, and next to right thigh and on 08/24/2022 IDG - left and right thighs), and discussion of all the current wounds. There is no documented evidence that the attending physician and IDG being notified with the development of new pressure ulcers (left foot, right posterior great toe (foot), right mid-thigh, second wound right next to right mid-thigh, and left leg) in a timely manner. There is no documented evidence of the wound treatment ordered by the physician for right mid-thigh, second wound right next to right mid-thigh, and left leg wounds from 08/09/2022 to 08/23/2022. There is no documented evidence that the IDT being informed of the patient's deterioration of all wounds. There is no documented evidence of the IDT reviewing, revising, and updating the individualized plan of care as frequently as the patients condition requires. On 09/22/2022 at 3:30pm, the Administrator and the Director of Clinical Services were interviewed and did not provide an explanation for the findings.

Based on record review and interview, the hospice failed to ensure that all Licensed Professionals are adequately supervised. --- Specifically, the hospice failed to: -Ensure the Registered Nurses coordinate with the Physician and obtain interim order for all wound care treatments for one (1) of three (3) patients with wounds (refer to L585). -Ensure the Registered Nurses are practicing within their scope of practice, (instructing LPN of wound care without the physician's order) for one (1) of three (3) patients with wounds (refer to L585). -Ensure the Registered Nurses are adequately supervised. -Ensure the Registered Nurses update the comprehensive assessments, communicate development of wounds, and assesses caregivers ability in providing wound care for one (1) of three (3) patients with wounds (refer to L585). The cumulative effect of the systemic issues identified in the agency's failure to ensure supervision of nursing care and services has the likelihood for negative patient outcomes for Patients #1.

Based on clinical care record review and staff interviews, the Hospice failed to ensure all Registered Nurses actively participates in the coordination of all aspects of the hospice patients care, in accordance with current professional standards and practice. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Specifically, for Patient #1 the hospice failed to ensure a Registered Nurse obtained wound care orders from physician prior to instructing an LPN and the patient's family to implement wound treatment. Additionally, the LPN failed to ensure wound care orders were obtained prior to implementing wound treatments. Failure to ensure all Registered Nurses actively participates in the coordination of all aspects of the hospice patients care, in accordance with the current professional standards and practice, has the potential for negative patient outcomes. --- The findings are: New York Codes, Rules and Regulations "Article 139 of the Education Law, Section §6902. Definition of practice of nursing. The practice of the profession of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential health problems through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens prescribed by a licensed physician, dentist or other licensed health care provider legally authorized under this title and in accordance with the commissioner's regulations. 1. Patient #1 has a Start of Care date of 11/08/2021 with the following diagnoses "Alzheimers Disease, Unspecified Dementia without Behavioral Disturbance, Adult Failure to Thrive" documented in the Hospice Plan of Care dated 07/06/2022 to 09/03/2022. The Hospice Plan of Care dated 07/06/2022 to 09/03/2022 documents: Orders for Discipline and Treatments: SN (skilled nurse): Start on 07/07/2022 1x/wk x 1 wk (once a week for one week), 1-2x/wk x 8 wks (one to two times per week for eight weeks), PRN x 15 (as needed times fifteen) s/sx (signs and symptoms) complications. Skilled Observation & Assessment of Cardiovascular Status, Elimination, GI Status, GU Status, Heart Sounds, Integumentary Status, Mental Status, Nutrition/Hydration, Respiratory Status, Safety." ";LPN to observe skin color. LPN to observe if skin is intact." The Hospice Interim Orders dated 08/08/2022 documents: "SN: Start on 08/03/2022: 1x/wk x 1 wk, 1-2x/wk x 4 wks." The clinical record documents SN (skilled nurse) Visits on: 08/09/2022 ";large open abrasion anterior upper right thigh – no drainage, no edema, remaining skin intact, RN (registered nurse) notified and instructed protective dressing left arm Triple Antibiotic Ointment (TAO) and dressing right thigh." 08/16/2022 ";Large open wound anterior upper right thigh – larger and deeper than last visit – bloody drainage and no odor, new large open area of posterior left leg – clear drainage, no odor, patient with contracted left leg laying across top of right thigh – RN notified and instructed to clean with sterile water, add Xeroform and cover with foam dressing." The SN for RN Visit Note dated 8/17/2022 documents: ";Wound #1 Type: Pressure Ulcer Stage 1; Location: left leg; Wound Bed: Granulation – red/pink 50%; Wound size Length: 6 cm, Width 3 cm. Cleaning/Irrigation Method: NS (normal saline), Packing: Xeroform." ";Wound # Type: Pressure Ulcer Stage 2; Location: right; Wound Bed: Granulation – red/pink 75%; Wound size Length: 3 cm, Width 3 cm. Cleaning/Irrigation Method: NS (normal saline), Packing: Iodoform gauze." 08/19/2022 ";Cleansed with NS, Xeroform and foam dressing applied to right anterior thigh and left posterior calf." 08/23/2022 ";Patient has 2 wounds. One on her left outer ankle area that is open, about 2 in (inches) x 1 in., has drainage." ";Second wound in on top of right thigh likely caused by pressure from her left ankle that has been laying on it continuously for over one month per the current aide that is in the home." ";The wound is roughly 5in (inches) x 3in, has drainage, no odor and is fingernail length deep. It also appears to have a second wound starting next to it." ";Wound care completed per order to both wounds – cleansed with saline, applied Xeroform dressing and placed Allevyn to cover." 08/29/2022 Wound #1, Location: Right lower extremities, Care #1 Cleaning/Irrigation Method: NS, Treatment Surrounding Tissue: Skin Prep (preparation), Dressing: Medi Honey, Calcium Alginate, Allevyn. Wound #2, Location: Left lower extremity, Care #2 Cleaning/Irrigation Method: NS, Treatment Surrounding Tissue: Skin Prep, Dressing: Medi Honey, Calcium Alginate, Allevyn. The IDT (Interdisciplinary Team) Note documents: 08/10/2022 ";New: Stage 2 to Right inner thigh – cleansed with NSS, triple antibiotic applied and covered in foam adhesive dressing." 08/24/2022 ";Stage 2 skin break down inside of left and right thighs. Dressed with Xeroform and foam dressings daily." There is no documented evidence of a written order for the treatment/wound care provided by the LPN as instructed by the RN on 08/09/2022, 08/16/2022, 08/17/2022, 08/19/2022, 08/23/2022, and 08/29/2022. There is no documented evidence of the RN practicing within their scope of practice and in accordance with current professional standards and practice, instructing the LPN with wound care without the physicians written order. There is no documented evidence of the coordination to the IDT regarding new development of pressure ulcers, wound treatments, deterioration, and current status of patients wounds condition in a timely manner. On 09/22/2022 at 3:30pm, the Administrator and the Director of Clinical Services were interviewed and did not provide an explanation for the findings.

Based on Agency's Internal Incident Report review, record review and staff interview, the hospice failed to ensure all patients were protected from neglect, mental, or physical abuse; and promote the rights of all patients. The Hospice failed to: Ensure that all patients are protected from neglect, mental, or physical abuse; and promote the Patients Rights. (L 517). The hospice's failure to ensure all patients' rights are respected, has the liklihood to cause serious harm, injury or death to the patients under the care of the hospice.

Based on Agency's Internal Incident Report review, record review, and staff interview the Hospice failed to ensure that all patient's are protected and free from neglect, mental, and physical abuse. This was evident for one (1) of one (1) clinical record review patient #1. Failure to ensure that all patients are protected from neglect, mental, and physical abuse has the likelihood for negative patients outcome. The Findings Are: Patient #1 has start of care date of 3/4/22 and expiration date of 3/9/22, with diagnoses of Malignant Neoplasm of Bronchus or Lung unspecified, Malignant unspecified Kidney, except Renal Pelvis, Localized swelling, Mass and Lump, Bilateral Lower Limb, End Stage Renal Disease, Diabetes Mellitus Type II, Chronic Obstructive Pulmonary Disease unspecified, and Melanoma in situ of unspecified part of face documented on the Hospice Plan of Care for the certification period 3/4/22 to 6/1/22. The Hospice Plan of Care for the certification period 3/4/22 to 6/1/22 documents "DNR (Do Not Resustate) in place, Skilled Nursing (SN) Routine Hospice Care: 2 visits/week x 13 weeks (2 visits per week x 13 weeks), 5 PRN visits (5 visits as needed) for exacerbation of disease process; HCA (Hospice Certified Aide): Routine Hospice Care: 7 visits/week for 13 weeks (7 visits per week x 13 weeks), notify SN for variations of normal BM (bowel movement) or no BM in 2-3 days". The "Incident/Occurrence Report and Assessment" dated 3/8/22 with an occurrence date of 3/7/22 documents, "LPN (Licensed Practical Nurse) reported to (Name of Clinical Nurse Manager) at 8:30 PM that during cares administered on 3/7/22 prior to 7 PM that HHA (Home Health Aide) appeared to be disimpacting patient; on Tuesday morning Human Resources and Director of Quality was notified; investigation initiated". The Internal Investigation dated 3/8/22 documents: "9:35- 9:50 AM received initial phone call from Nurse Practitioner/Director of Patient Services who reported, LPN (Licensed Practical Nurse) had called (Name of Clinical Nurse Manager) at night on 3/7/22 to report an incident that bothered her while working with the Hospice aide; that the aide had stuck his finger in a patient's rectum because the patient was impacted" "9:50 AM - LPN recounted the event of 3/7/22; at approximately 5:00 PM on 3/7/22, LPN and aide walked into room 106 together to perform cares; LPN left the room because other bells were going off and pharmacy was at the front door; at about 5:20 PM - 5:30 PM LPN return to room and noticed the aide was still performing cares; LPN stood on the opposite side of the aide with full view of the patient's face; as the aide was cleaning the patient's backside, the patient yelled Ow Ow; LPN looked at the patient's face and noticed that the patient appeared to be in a great deal of pain; LPN reports that she said stop, stop to the aide; the aide told the LPN the patient was impacted and he was "moving the process along"; LPN believes the aide digitally penetrated the patient's rectum in order to disimpact the patient because she (the LPN) saw the aide's hand motions and then the aide's fingers were covered in feces". The LPN's written statement dated 3/9/22 documents: "I left the facility and had an hour drive home in which I was processing the events of the day. As soon as I got home I called my supervisor (name of supervisor) to let her know what had happened". During the interview on 3/14/22 at 11:25 AM with the Director of Quality, Nurse Practitioner/Director of Patient Services, and Clinical Nurse Manager, they stated that "the aide works the 3:00 PM to 11:00 PM shift and was allowed to work the entire shift on 3/7/22". The report lacks documented evidence that the LPN immediately reported the incident of the aide working out of the scope of practice and causing injury to the patient, to the Registered Nurse (RN) on duty. There is no documented evidence that the Supervisor called the unit to inform the RN on duty of the incident / occurrence. The LPN and the Supervisor neglected to report the incident/occurence to the RN(s) on duty that was responsible for the care of the patient. There is no documented evidence that the Hospice took immediately action to protect the patient from mental and physical abuse. There is no documented evidence the patient was assessed by the RN after the incident. On 3/15/22 at 12:00 PM the Director of Quality was interviewed. The Director of Quality did not provide an explanation for the findings.

Based on record review and interview the hospice failed to ensure that to protect and promote the rights of all patients. The Hospice failed to: Ensure that all patients receive timely and effective pain management and symptom control from medications, and interventions to address all patients' conditions, has the potential for negative patient outcomes. (L 512) Ensure that Patients receive information all services, including financial information, covered under the hospice benefit has the potential for negative patient outcomes. (L 518) ensure that patient/caregivers complaints/concerns are investigated and resolved could result in ongoing quality of care issues and has the potential for negative patient outcomes. (L 505) The hospice's failure to ensure all patients' rights are respected are likely to cause serious harm, injury or death to the patients under the hospice care.

Based on review of the agency's Complaint Log for 2021, Complaint Policy, interviews with the Director of Clinical Services (DCS) Hospice failed to ensure that patient/caregiver complaints are fully investigated and document a resolution and the complainants are informed of the results of the investigation. Failure to ensure that patient/caregivers complaints/concerns are investigated and resolved could result in ongoing quality of care issues and has the potential for negative patient outcomes. The findings are: A request was made on 1/4/22 for the agency's complaint log for 2021. The log documents thirteen (13) complaints were received. The log does not document the actual allegations and whether the complaints were substantiated or not. A request was made for the complaint reports. Six (6) of the thirteen (13) of the complaints lack documented evidence the complaints were fully investigated and/or resolutions to include informing the complainant of the outcome of the investigation. The complaint reports lack documented evidence as to whether the complaints were substantiated or not. During an interview with the Director of Clinical Services (DCS) on 1/12/22 at 12:00 PM, the DCS did not provide an explanation for the above.

Based on record reviews and staff interviews, the Hospice agency failed to ensure the protection of rights of all patients requiring timely and effective pain management, and symptom control from medications, and failed to ensure interventions were put in place to address the patients' conditions. This was evident in one (1) of eighteen (18) Clinical Records reviewed. (Patient #5). Failure to ensure that all patients receive timely and effective pain management and symptom control from medications, and interventions to address all patients' conditions, has the potential for negative patient outcomes. The finding is: Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22. The Hospice Clinical Summary/Plan of Care dated 11/8/21 through 2/5/22 documents: "SN (Skilled Nurse) visits to assess pain; Morphine 20 mg/ml orally every three hours as needed for pain, Oxycodone 30 mg every four hours as needed for pain for pain greater that 7 (on a scale of 0 to 10), Prochlorperazine 10 mg every 6 hours orally as needed for nausea, promethazine suppository 25 mg every 6 hours for mild to moderate nausea. The Registered Nursing notes document: 11/8/21- the Patient "has pain mostly in his abdomen for which he takes Oxycodone 5 mg every 4 hrs (hours) which has been effective so far". 11/18/21- "Patient complaining of pain awful and constant pain in his back, right thoracic region, he states "it is the Lung Cancer"; "physician called who increased his medication to 30 mg of Oxycodone every four hours". 11/24/21 - Patient "states he has pain "most of the time", he is reticent to take his pain meds (medications), he states "nothing works", enouraged him to take his meds as ordered and that if he waits it is much harder to "catch up" to the pain". 12/16/21 - "Patient states the last two days have been better and he is taking Oxycodone 30 mg as ordered with Morphine as break through"; Patient is a little agitated with questions"; Patient's goal of ain will be well controlled is 0% 12/22/21 - Patient "states medication takes the edge offcontinues to take Oxycodone 30 mg with Morphine for break through pain". The notes lack documented evidens=ce of pain ratings and the amount and frequency the pain medications are being taken. The Licensed Practical Nursing (LPN) notes document: 11/23/21 - "Patient vomited several times and he didn't feel well and did not elaborate, when asked if he had pain, he stated "I took my medicine", sat at the table with his head in his arms, Patient is very tired, and when asked if he is sleeping through the night, he stated he is awake until 4 AM most nights and sleeps late into the following day". 12/1/21- "Patient complains of increased severe generalized pain and feeling aggrevated all the time; states he has taken Lorazapam a few times, states pain is abated only fora short time after taking pain medication, he is taking it every 3 hours-6 pills a daymore if he is awake through the night; Patient states he has not eaten in five days because food and drink taste bad to him and he has been feeling intermittent nausea". 12/8/21 - "Patient states he does not get extended sleep 3-4 hours at a time; he complsins "I am always in pain" and does not remember when he last took pain medication:. 12/10/21 - "Patient complains of severe pain to both legs this morning, less so at this time; BLE (bilateral lower extremity) plus 3 edemaand reddened from knees to feet, Patient stated they were more swollen this morning; he reports he is having great difficulty walking due to increased pain ad swelling of the legs and states I feel I won't be able to walk around much any more; he reports lying down with feet elevated causes undue back pain". 12/15/21- "Patient reports he feels awful; nausea and vomited four times today; asked about pain and he shrugged his shoulders and said "it's alright"; Patient reports many new sores to back, arms and axilla, many are dime to quarter size opening in the skin, Patient has scratched at some". 12/29/21 - "Patient complained of increased pain to the lower legs, declines to elaborate". The LPN notes lack documented evidence of the Patient's pain ratings on each visit. The notes dated 11/23/21, 12/8/21, 12/10/21, 12/15/21 and 12/29/21 lack documented evidence of the amount and frequency the Patient is taking 12/8/21 the Patient documents "I am always in pain"; Patient vomited several times this morning 12/10/21, 12/21/21 and 12/29/21 document the Patient has increasing pain to the lower extremities. The LPN notes lack documented evidence of the Patient's rating of the pain and the amount of pain medication being used to alleviate pain. The RN notes lack documented evidence of communication with the LPN regarding the Patient vomiting, whether the Patient is able to keep the medication down, the Patient is "in constant pain: and the frequency and effectiveness of the pain medication. During an interview with the Director of Clinical Services (DCS) on 1/14/21 at 12:00 PM, The DPS did not provide an explanation for the above.

Based on record reviews and staff interviews the agency failed to ensure that Patients receive information of all services, including financial information, covered under the hospice benefit. This was evident for eighteen ( 18) of eighteen ( 18) clinical records reviewed. ( Patients # 1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). Failure to ensure that Patients receive information all services, including financial information, covered under the hospice benefit has the potential for negative patient outcomes. The findings are: 1. A review of the agreement for Hospice Services titled: "Hospice Benefit Election Form" with a revision date of September 2020 for Patients #1, #2, #3,#4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 and #18 documents the following: "Hospice care may involve skilled nursing care, Volunteer companions and caregivers, emotional and spiritual care, social workers". 2. The "Hospice Benefit Election Form" for Patients #1, #2, #3,#4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 and #18 lack documented evidence of all the services, including financial information covered under the hospice benefits, the type of services being provided, the duration and frequency of services at the start of care. On 1/12/21 at 9:28 AM, the Director Of Clinical Services was interviewed and did not provide an explanation.

Based on observations (home visits) HV, record reviews, review of agency Policies/Procedures and staff interviews, the agency failed to ensure that the Interdisciplinary Group supervises patient care and develops plans of care based on comprehensive assessments for hospice patients. The Hospice failed to: Ensure that all members of the Interdisciplinary Group/Team present and actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education has the potential for negative patient outcomes. See L 537. Ensure that plans of care specify the care and services necessary to meet the patient/family needs as identified in the comprehensive assessments. L 538. To develop/revise and follow individualized Plans Of Care and ensure the provision of care in accordance with written Patient Plans of Care to address all Patient needs. L 543. Ensure the Patients Plan Of Care include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. L 547. Ensure all necessary services for the palliation and management of the terminal illness and related conditions, including medical supplies necessary to meet the needs of the patient. L 550. Ensure that the Interdisciplinary Group review/revise individualized Plans of Care as patient condition requires. L 552. Ensure that services are provided in accordance with the written plan of care. L 555. The cumulative effect of the systemic problems resulted in the hospice's failure to ensure that plans of care are developed to meet the needs patients and the Interdisciplinary Group supervises care and services provided as outlined in the Plan of Care and in poor outcomes of patients.

Based on record reviews and staff interviews the hospice failed to ensure that all members of the Interdisciplinary Group/Team actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. This was evident for twelve (12) of eighteen (18) patient care records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, # 10, # 11 and #12). Failure to ensure that all members of the Interdisciplinary Group/Team actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education has the potential for negative patient outcomes. The findings are: . Patient #1 has a start of care date of 12/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 12/17/21 through 3/16/22. The Interdisciplinary Group (IDG) meeting dated 12/21/21 documents that the RN ( Registered Nurse) and MSW (Medical Social Worker) assigned to the Patient were not present during the meeting. The IDG meetings lack documented evidence of the status of the wounds to include the size, and drainage and effectiveness of the wound treatments. 2. Patient #2 has a start of care date of 8/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the Hospice Clinical Summary dated 11/15/21 through 2/12/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 1/11/22, document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The Hospice Clinical Summary/Care Plan dated 11/15/21 through 2/12/21 documents the LPN is to monitor bowel movement and the use of laxatives. The (Licensed Practical Nurse) LPN note dated 11/26/21 documents the Patient's last movement was on 11/22/21 (4 days) and that the Patient complained of stomach pain, nausea and lethargy. There is no documentation as to any interventions taken. There is no documented evidence of discussion of patient's issue with bowel movement and the use of laxatives in the IDG meeting dated 11/30/21. 3. Patient #3 has a start of care date of 2/17/21 with diagnosis of Lung Cancer as documented on the "Hospice Clinical Summary "dated 12/14/21 through 2/11/22. The Interdisciplinary Group (IDG) meetings dated 11/16/21, 12/28/21 and 1/11/22 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary" dated 11/15/21 through 2/12/21 documents LPN visits to observe gastrointestinal status. The LPN note dated 10/21/21 documents the Patient has a low grade fever (no temperature documented) and complains of diarrhea and nausea. The LPN documents the RN was informed. The record lacks documented evidence of follow up and interventions. The IDG meeting dated 11/2/21 does not document these findings. 4. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The Interdisciplinary Group (IDG) meetings dated 12/14/21 and 1/11/22 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary/Care Plan" dated 12/3/21 through 1/31/22 documents (Skilled Nurse) SN visits for assessment; LPN visits for observation and description of measurements of the decubitus wound to right buttock, cleanse with normal saline pat dry and apply Barrier cream and cover with dry sterile dressing; wound to right foot first metatarsal, clean with normal saline, cover with 2 x 2 soaked in Dakins 1/2 strength solution and wrap with Kling. The IDG meetings do not document the status of the wounds to include the size, drainage and effectiveness of the wound treatments. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 12/14/21 and 12/28/21 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 12/14/21 and 12/28/21 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents SN visits for assessment initiate Oxygen flow at 2 liters per minute; LPN visits for observation and treatment; observe nutritional status; LPN to perform wound care to the left jaw, cleanse with normal saline, apply Xeroform, apply foam border dressing every 2 to 3 days, LPN to describe color and amount of wound drainage; Oxygen 2 liters continuous PRN; Oxycodone 30 mg every 4 hours as needed for pain. The initial SN visit dated 11/8/21 documents the RN discussed the use of Oxygen and Patient consents, Patient is still smoking. The SN note dated 12/22/21 documents the Oxygen has not been delivered because the Patient does not answer his phone. The LPN note dated 11/23/21 documents the Patient vomited several times this AM, RN informed. The LPN note dated 12/1/21 documents: the Patient has not eaten in 4 days, has an open flame kerosene heater in home, Oxygen was delivered and is in the basement. The LPN note dated 12/8/21 documents the Patient stated I am always in pain". The LPN note dated 12/15/21 documents the Patient has two wounds, one to the back the size of a nickel and one to the shoulder the size of a quarter. The IDG meetings dated 11/30/21, 12/14/21 and 12/28/21 do not document the above issues/problems. 6. Patient #10 has a start of care date of 10/28/21 with diagnosis of with diagnoses of Alzheimer's Disease as documented on the "Hospice Clinical Summary dated 10/28/21 through 1/25/22. The Interdisciplinary Group (IDG) meetings dated 12/14/21, 12/28/21 and 1/11/22 document that the RN assigned to the Patient was not present during the meetings. The Patient has Alzheimer's Disease and is Bedbound and resides in an assisted living facility that does not allow the hospice team to make visits. All SN visits are via telehealth and do not document the person(s) the telehealth is being conducted with. The IDG meetings do not address this. On 1/13/22 at 1:30 PM, the Director Of Clinical Services was interviewed and stated that a Nursing Supervisor is in attendance but stated the Supervisor does not know the Patients being discussed in the IDG meetings. 7. Patient # 6 has a start of care date of 7/14/21 with diagnosis that include Malignant Neoplasm Of Unspecified Site Of Right Female Breast, Secondary Malignant Neoplasm of Liver, Intrahepatic Bile Duct and Bone, Chronic Ischemic heart Disease as documented on the " Hospice Clinical Summary" for the Certification Period of 11/11/2021 through 1/9/2022. The " Hospice Clinical Summary" for the Certification Period of 11/11/21 through 1/9/22 document: "Orders for Discipline and Treatments: " Skilled Nurse 1x week x one week, 1x week for 9 weeks, As needed (PRN) x 10 exacerbation of disease. MSW (Medical Social Worker ) 1x/ months. PRN x 10 crisis intervention. PRN x 10 MSW phone visit. Clergy 3x month x 3 months. PRN x 5 crisis intervention". A review of the IDG meetings from 11/11/21 to 1/9/22 document the following: 11/23/21: "MSW not present, Chaplain not present". 12/7/21: "MSW not present, Chaplain not present". 12/21/21: "MSW not present, Chaplain not present". 1/4/22: "MSW not present, Chaplain not present." There is no documented evidence of the IDG members discussion and supervision of the care and services provided to the Patient. 8. Patient # 7 has a start of care date 10/27/21 with diagnosis that include Malignant Neoplasm Of Vulva , Unspecified Dementia Without Behavioral Disturbances as documented on the "Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22. The " Hospice Clinical Summary " for the Certification Period of 10/27/21 to 1/24/22 document:" Orders: Skilled Nurse 1x week for one week, 1x week for 7 weeks, 1-2 x week for 6 weeks. PRN x 11 exacerbation of disease. Telehealth 8 PRN visits for symptom management. MSW 1-2 a month for 4 months. Clergy PRN x 6 crisis intervention. A review of the IDG meeting from 10/27/21 to 1/24/22 document the following: 11/2/21 : "MSW not present". 11/2/21 and 11/16/21: "Chaplain not present". 9. Patient # 8 has a start of care date 8/17/21 with diagnosis that include Acute and Chronic Systolic Heart Failure as documented on the " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22. The " Hospice Clinical Summary " for the Certification Period of 11/15/21 to 2/12/22 document:" Orders: Skilled Nurse 1-2 x week for two weeks, , 1x week for 12 weeks. PRN x 10 Complications/ med Changes. Telehealth 8 PRN visits for symptom management. MSW 1-2 a month for 4 months. Clergy 2x month. PRN x 6 crisis intervention". A review of the IDG meeting from 11/15/21 to 2/12/22 document the following: 11/6/21, 12/14/21: "Chaplain not present". 11/30/21: "RN not present". 12/4/21: "MSW not present". There is no documented evidence of the IDG members discussion and supervision of the care and services provided to the Patient. 10. Patient # 9 has a start of care date 9/22/21 with diagnosis that include Alzheimer's Disease, Type II Diabetes with Hperglycemia, Adult Failure to Thrive as documented on the " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21. The " Hospice Clinical Summary " for the Certification Period of 9/22/21 to 12/20/21 document:" Orders: Skilled Nurse once a day for one day, once a week for one week, 1-2 x week for six weeks, 3-5 x week for 8 weeks. PRN x 14 Complications. MSW 2 a month for 4 months. PRN x 6 MSW phone visit, Crisis intervention, PRN x 10 MSW phone visit, PRN x 7 MSW phone visit. Clergy 1- 2x 3 month. PRN x 6 crisis intervention". A review of the IDG meeting from 9/22/21 to 12/20/21 document the following: 9/26/21, RN and MSW not present. 10/12/21, 10/26/21, 11/9/21, 11/23/21, 12/7/21, 12/12/21: Chaplain not present. 12/21/21, MSW, Chaplain not present". 9/26/21, 11/23/21, RN and MSW not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. 11. Patient # 11 has a start of care date 6/8/21 with diagnosis that include as documented on the " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 9/5/21. The " Hospice Clinical Summary " for the Certification Period of 6/8/21 to 9/5/21 document:" Orders: Skilled Nurse once a day for one day, once a week for one week, 1-3 x week for 13 weeks. PRN x 1 Exacerbation of disease, PRN x 15 exacerbation of disease. MSW 3-4 x a month for 4 months. PRN x 6 crisis intervention, PRN x 8 MSW phone visit, Crisis intervention. Clergy 1- 2x month. for 4 months, PRN x 7, spiritual care". A review of the IDG meeting from 9/22/21 to 12/20/21 document the following: 6/15/21, RN and MSW and Chaplain not present. 6/29/21, RN, MSW, Chaplain not present. 7/13/21 post discharge: MSW, RN, Chaplain not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. 12. Patient # 12 has a start of care date 3/30/21 and a discharge date of 6/25/21 with diagnosis that include Alzheimer's Disease without Behavioral Disturbances, Personal History Of Urinary Tract Infections as documented on the " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 6/27/21. The " Hospice Clinical Summary " for the Certification Period of 3/30/21 to 6/27/21 document:" Orders: Skilled Nurse once a week for 14 weeks. PRN x 1 Exacerbation of disease, PRN x 10 exacerbation of disease. MSW 2 x a month for 3 months. PRN x 8 crisis intervention, PRN x 8 MSW phone visit. Clergy 2-3 x month. for 3 months, PRN x 5, spiritual support". A review of the IDG meeting from 3/30/21 to 6/25/21 document the following: 4/6/21 RN MSW and Chaplain not present. 4/20/21 RN, MSW, Chaplain not present. 5/4/21 MSW, RN, Chaplain not present. 5/18/21 MSW, RN, Chaplain not present. 6/1/21 MSW, RN, Chaplain not present. 6/15/21 MSW, RN, Chaplain not present. 6/29/21 MSW, RN, Chaplain not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. On 1/13/22 at 1:30 PM, the Clinical Director was interviewed and stated the Nursing Supervisor is in attendance but the Supervisor does not know the Patients being discussed in the IDG meetings.

Based on record reviews and staff interviews, the hospice failed to specify the care and services necessary to meet the patient and family needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. This was evident for eleven (11) of eighteen (18) patient care records reviewed. (Patients #1, #2, #3, #4, #5, #7, #8, #9, #15, and #17). Failure to specify the care and services necessary to meet the patient and family needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions resulted in serious harm for patient #5 and has the potential for negative patient outcomes for all patients receiving hospice care. Example: 1. Patient #1 has a start of care date of 12/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 12/17/21 through 3/16/22. The "Hospice Clinical Summary/Care Plan" dated 12/17/21 through 3/16/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 2. Patient #2 has a start of care date of 8/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 11/15/21 through 2/12/22. The "Hospice Clinical Summary/Care Plan" dated 11/15/21 through 2/12/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 3. Patient #3 has a start of care date of 2/17/21 with diagnosis of Lung Cancer as documented on the "Hospice Clinical Summary" dated 12/14/21 through 2/11/22. The "Hospice Clinical Summary/Care Plan" dated 12/14/21 through 2/11/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 4. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the" Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The "Hospice Clinical Summary/Care Plan" dated 12/3/21 through 1/31/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22. The hospice failure to meet the specific needs of the patient in the following areas: The Patient's right to pain management and symptoms relief. The Patient's access to oxygen treatment. The Patient's needs for safety in the environment. The Hospice Clinical Summary/Plan of Care dated 11/8/21 through 2/5/22 documents: "SN (Skilled Nurse) visits to assess pain; Morphine 20 mg/ml orally every three hours as needed for pain, Oxycodone 30 mg every four hours as needed for pain greater than 7 (on a scale of 0 to 10), Prochlorperazine 10 mg every 6 hours orally as needed for nausea, promethazine suppository 25 mg every 6 hours for mild to moderate nausea. The Registered Nursing notes document: 11/18/21- "Patient complaining of pain awful and constant pain in his back, right thoracic region, he states "it is the Lung Cancer"; "physician called who increased his medication to 30 mg of Oxycodone every four hours". 11/24/21 - Patient "states he has pain "most of the time", he is reticent to take his pain meds (medications), he states "nothing works", encouraged him to take his meds as ordered and that if he waits it is much harder to "catch up" to the pain". 12/16/21 - "Patient states the last two days have been better and he is taking Oxycodone 30 mg as ordered with Morphine as break through"; Patient is a little agitated with questions"; Patient's goal of pain will be well controlled is 0% 12/22/21 - Patient "states medication takes the edge off continues to take Oxycodone 30 mg with Morphine for break through pain". The notes lack documented evidence of pain ratings and the amount and frequency the pain medications are being taken. The Licensed Practical Nursing (LPN) notes document: 11/23/21 - "Patient vomited several times and he didn't feel well and did not elaborate, when asked if he had pain, he stated "I took my medicine", sat at the table with his head in his arms, Patient is very tired, and when asked if he is sleeping through the night, he stated he is awake until 4 AM most nights and sleeps late into the following day". 12/1/21- "Patient complains of increased severe generalized pain and feeling aggravated all the time; states he has taken Lorazapam a few times, states pain is abated only for a short time after taking pain medication, he is taking it every 3 hours-6 pills a day more if he is awake through the night; Patient states he has not eaten in five days because food and drink taste bad to him and he has been feeling intermittent nausea". 12/8/21 - "Patient states he does not get extended sleep 3-4 hours at a time; he complains "I am always in pain" and does not remember when he last took pain medication:. 12/10/21 - "Patient complains of severe pain to both legs this morning, less so at this time; BLE (bilateral lower extremity) plus 3 edema and reddened from knees to feet, Patient stated they were more swollen this morning; he reports he is having great difficulty walking due to increased pain ad swelling of the legs and states I feel I won't be able to walk around much any more; he reports lying down with feet elevated causes undue back pain". 12/15/21- "Patient reports he feels awful; nausea and vomited four times today; asked about pain and he shrugged his shoulders and said "it's alright"; Patient reports many new sores to back, arms and axilla, many are dime to quarter size opening in the skin, Patient has scratched at some". 12/29/21 - "Patient complained of increased pain to the lower legs, declines to elaborate". The LPN notes lack documented evidence of the Patient's pain ratings on each visit. The notes dated 11/23/21, 12/8/21, 12/10/21, 12/15/21 and 12/29/21 lack documented evidence of the amount and frequency the Patient is taking 12/8/21 the Patient documents "I am always in pain"; Patient vomited several times this morning 12/10/21, 12/21/21 and 12/29/21 document the Patient has increasing pain to the lower extremities. The LPN notes lack documented evidence of the Patient's rating of the pain and the amount of pain medication being used to alleviate pain. The RN notes lack documented evidence of communication with the LPN regarding the Patient vomiting, whether the Patient is able to keep the medication down, the Patient is "in constant pain: and the frequency and effectiveness of the pain medication. 6. Patient # 7 has a start of care of 10/27/21 with diagnosis that include Malignant Neoplasm Of Vulva, Unspecified Dementia Without Behavioral Disturbances, Personal History Of Other Malignant Neoplasm Of the Large Intestine as documented on the " Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22. The " Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22 document: " Orders: Skilled Nurse once a week for one week, once a week for 7 weeks, 1-2/ week for 6 weeks, As needed ( PRN) x 11 Exacerbation of Disease. Licensed Practical Nurse ( LPN) to describe bowel sounds. LPN to perform wound care/ dressing change Pack wound on vulva with calcium alginate once a day. LPN to observe and describe color and amount of wound drainage. LPN to record patient pain 0-10. LPN to administer pain medications ordered. LPN to record patient pain after medication 0-10. LPN to reorder medication. LPN to do colostomy care. Change colostomy appliance weekly and PRN. Change colostomy bag every three days and PRN". On 1/11/21, a review of the patient record indicated there is no documentation of the care and services, wound dressing and colostomy care provided by the LPN. On 1/13/21 at 12: 40 PM, a request was made for the clinical notes pertaining to the patient care provided by the LPN. This information was not provided. There is no documented evidence the Plan Of Care was reviewed/ revise to include the frequency and duration of the LPN order. There is no documented evidence of the scope and frequency of LPN services necessary to meet the patient needs. 7. Patient # 8 has a start of care date of 8/17/21 with diagnosis that include Acute and Chronic Systolic Heart Failure, Chronic Atrial Fibrillation, Pulmonary Hypertension as documented on the " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22. The " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22 document: " Orders: Skilled Nurse 1 -2/week x 2 weeks, 1-2 x week x 12 weeks, PRN x Complications/ Med Changes, Telehealth 8 PRN visits for symptom management. LPN to describe lung sound, LPN to observe and educate on proper use of oxygen via NC @ 2 L/min. LPN to observe for dyspnea, LPN to perform wound care left shin wound, cleanse with normal saline, pat dry, apply Santyl and Mupirocin, cover with calcium alginate,mextra pad and wrap with kling daily. LPN to record patient pain 0-10. LPN to administer pain medication as ordered. LPN to record patient pain after medication 0-10. LPN to reorder medications. LPN special interventions, take vital signs each visit". The record document the following LPN visits: 11/29/21, 12/27/21, 1/11/22. There is no documented evidence of the frequency and duration of the LPN services necessary to meet the patient needs. 8. Patient #9 has a start of care date of 9/22/21 with diagnosis that include Adult failure to Thrive, Alzheimer's Disease, Type II Diabetes Mellitus wit Hyperglycemia as documented on the " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21. The "Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21 document: " Orders: Skilled Nurse once a day for one day, once a week for one week, 2-4 x a week for 6 weeks, 3-5 x a week for 8 weeks. PRN x 14 Signs / Symptoms Complications 8 PRN visits for symptom management. LPN to describe lung sounds. LPN to describe bowel sounds. LPN to observe for dyspnea and cough. LPN to record patient last bowel movement. LPN to observe skin color. LPN to observe and describe color and amount of wound drainage. LPN to record patient appetite. LPN to observe aspiration and fall precautions. LPN . LPN to observe for general weakness. LPN to turn and position patient in bed. LPN document pain status. LPN to observe for agitation". There is no documented evidence of the frequency and duration of the LPN services necessary to meet the patient needs. During an interview with the Director of Clinical Services (DCS) on 1/13/21 at 12:30 PM, the Director Of Clinical Services did not provide an explanation. During an interview with the Director of Clinical Services (DCS) on 1/14/22 at 12:30 PM, the DCS stated she called the DME and the Oxygen was delivered on 11/29/21. No other explanation was provided for the above. 9. Patient #15 has a start of care date of 8/31/21 with diagnosis of Cerebral Infarction due to Thrombosis and Age-Related Physical Debility documented on the "Clinical Summary" for Certification Period 11/29/21 through 2/26/22. The "Clinical Summary" for Certification Period 11/29/21 through 2/26/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x 10 exacerbation of disease; Administer Insulin as Ordered; LPN to observe for dyspnea, LPN to perform wound care/dressing change to suprapubic site every 3-5 days and as needed; Medication: Lantus 12 units SubQ once a day, Novolog 6 units 3 times a day PRN hyperglycemia". The "Clinical Summary" lacks documented evidence of all related diagnosis/condition to include Diabetes Mellitus; the frequency and duration for the LPN to visit the patient. 10. Patient #17 has a start of care date of 8/2/21 with diagnosis of Alzheimer's Disease, and Dementia without Behavioral Disturbance documented on the "Clinical Summary" for Certification Period 10/31/21 through 1/28/22. The "Clinical Summary" for Certification Period 10/31/21 through 1/28/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x 15 exacerbation of disease; LPN to apply dressing to pressure ulcer on bilateral upper buttocks every other day and PRN" The "Clinical Summary" lacks documented evidence of the frequency and duration for the LPN to visit the patient. On 1/13/22 at 1:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation. Patient #16 has a start of care date of 6/28/21 with diagnosis of Creutzfeldt-Jakob Disease, Dementia without Behavioral Disturbance and Malignant Neoplasm of Prostate documented on the "Clinical Summary" for Certification Period 12/25/21 through 2/22/22. The hospice failure to meet the specific needs of the patient in the following areas: The Patient right to pain and symptoms relief; Assessment and observations of the patient's conditions that will require review and /or Revision of the plan of care and communication with the physician; Assessment of wound by an RN and nursing interventions to prevent further deterioration of wound and infection. The "Clinical Summary" for Certification Period 12/25/21 through 2/22/22 documents, "Routine Hospice Care Skilled nursing (SN) 2 visits/ weekly x 13 weeks, PRN x 5 exacerbation of disease; Coccyx Stage II wound; Change dressing daily and PRN". The following "Skilled Nursing Clinical Note" documents: 12/28/21 by LPN "skin is warm/dry. Stage III to coccyx, foam dressing in place"; 12/29/21 by RN, "Increased severity of coccyx wound/ pain. Pain is more severe and harder to get under control; and 1/7/22 by LPN, "No change in pain, FLACC Scale total 6". There is no documented evidence the observations and assessments are integrated into the patient care needs. There is no documented evidence that the care provided is based on all observations and assessments. On 1/13/22 at 1:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation.

Based on record reviews and staff interviews, the hospice failed to develop/revise and follow individualized Plans Of Care and ensure the provision of care in accordance with written Patient Plans of Care to address all Patient needs. This was evident for six (6) of eighteen (18) patient care records reviewed.( Patients #1, #5, #7, #8, #9, and #11). Failure to develop/ revise and follow individualized Plans Of Care to address all Patient needs has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a start of care date of 12/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 12/17/21 through 3/16/22. The "Hospice Clinical Summary/Care Plan" dated 12/17/21 through 3/16/22 documents the Patient is to receive SN (Skilled Nursing) visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse); teach cardiac disease process to include weight monitoring; LPN to perform wound care/dressing change; cleanse wounds to heels with normal saline, skin prep, apply TAO to slit in right heel and apply foam dressing to cover every three days and PRN (as needed); record Patient's pain on a scale of 0 to 10; Acetaminophen suppository 650 mg every 6 hours as needed for pain. The LPN notes dated between 12/22/21 through 12/29/21 lack documented evidence of observations of the wounds to the heels, wound care dressing performed, rating of Patient's pain and whether the Patient is monitoring weights. The SN notes dated between 12/17/21 through 1/8/21 lack documented evidence of assessments of the wounds and whether the Patient's weight is being monitored. The SN documents the Patient has no current pain but does not document whether the Patient has been having pain between visits and if so, the rating of the pain and pain medication being used. There is no documented evidence as to the person(s) that is performing wound care every three days. During an interview with the Director of Clinical Services on 1/13/22 at 12:30 PM, the DPS did not provide an explanation. 2. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents the Patient is to receive SN visits one to two times a week for assessment, assess pain and the use and effectiveness of prescribed medication; LPN (Licensed Practical Nurse for observation; Oxycodone 30 mg every 4 hours as needed for pain, Morphine 20 mg/ml 10 mg orally every 3 hours as needed for pain (administer for breakthrough pain every 3 hours between doses of Oxycodone if pain reaches 8 on a scale of 0 to 10. The RN notes document: 11/18/21- "Patient complaining of pain awful and constant pain in his back, right thoracic region, he states "it is the Lung Cancer"; "physician called who increased his medication to 30 mg of Oxycodone every four hours". 11/24/21- "Patient states he has pain "most of the time", he is reticent to take his pain meds (medications) he states "nothing works", encouraged him to take his meds as ordered and that if he waits too long, it is much harder to catch up to the pain". 12/22/21- "Patient states medication takes the edge off of the pain continues Oxycodone 30 mg with Morphine for breakthrough pain". The RN notes lack complete pain assessments to include the location and rating of the Patient's pain, the amount and frequency for the Oxycodone and Morphine. The notes lack documented evidence of follow up with the Patient's statement that nothing works regarding the pain. The LPN notes document: 11/23/21 - "Patient vomited several times and he didn't feel well and did not elaborate, when asked if he had pain, he stated "I took my medicine", sat at the table with his head in his arms, Patient is very tired, and when asked if he is sleeping through the night, he stated he is awake until 4 AM most nights and sleeps late into the following day". 12/1/21- "Patient complains of increased severe generalized pain and feeling aggrevated all the time; states he has taken Lorazapam a few times, states pain is abated only fora short time after taking pain medication, he is taking it every 3 hours-6 pills a daymore if he is awake through the night; Patient states he has not eaten in five days because food and drink taste bad to him and he has been feeling intermittent nausea; feels cold all the time and sits in front of kerosene heater for warmth, heater is an open flame heater. Patient accepted delivery of Oxygen and placed in basement for storage, not yet in use, RN notified". 12/8/21- Patient states "I am always in pain" and does not remember when he last took his pain medication, RN notified. 12/10/21 - Patient states he has severe pain to both lower extremities, edema plus 3, reddened knees to feet, Patient states they were more swollen this morning, he states he is having great difficulty walking due to increased pain and swelling of legs, he states "I feel I won't be able to walk around much anymore, reports pain to the back when legs are elevated". 12/15/21 - Patient states "I feel awful", vomited 4 times today, reports many new "sores" to back, arms and axilla, many are dime to a quarter sized openings in the skin, applied lotion to the Patient's neck, back and arms". 12/21/21- "Patient has open sores to back and arms which Patient scratches often, two sores noted to be enlarged, Patient noted to have difficulty ambulating due to increased weakness and bilateral edema and holds on to furniture and walls for support". 12/29/21- "Patient having great difficulty ambulating back and forth a few steps, complains of increased pain to his lower legs". The LPN notes lack documented evidence of monitoring the Patient's pain on each visit, a rating for the Patient's pain and the amount of Oxycodone and Morphine is being use. There is no documented evidence the RN assessed the Patient with regards to the LPN's findings of increased pain, vomiting, unsteady gait, increased edema and pain to the legs, the Patient has an open flame kerosene heater in the home, and that the Oxygen was delivered and placed in the basement. During an interview with the Director of Clinical Services on 1/14/22 at 12:30 PM. the Director did not provide an explanation for the above. 3. Patient # 7 has a start of care of 10/27/21 with diagnosis that include Malignant Neoplasm Of Vulva, Unspecified Dementia Without Behavioral Disturbances, Personal History Of Other Malignant . Patient #1 has a start of care date of 12/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 12/17/21 through 3/16/22. The "Hospice Clinical Summary/Care Plan" dated 12/17/21 through 3/16/22 documents the Patient is to receive SN (Skilled Nursing) visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse); teach cardiac disease process to include weight monitoring; LPN to perform wound care/dressing change; cleanse wounds to heels with normal saline, skin prep, apply TAO to slit in right heel and apply foam dressing to cover every three days and PRN (as needed); record Patient's pain on a scale of 0 to 10; Acetaminophen suppository 650 mg every 6 hours as needed for pain. The LPN notes dated between 12/22/21 through 12/29/21 lack documented evidence of observations of the wounds to the heels, wound care dressing performed, rating of Patient's pain and whether the Patient is monitoring weights. The SN notes dated between 12/17/21 through 1/8/21 lack documented evidence of assessments of the wounds and whether the Patient's weight is being monitored. The SN documents the Patient has no current pain but does not document whether the Patient has been having pain between visits and if so, the rating of the pain and pain medication being used. There is no documented evidence as to the person(s) that is performing wound care every three days. During an interview with the Director of Clinical Services on 1/13/22 at 12:30 PM, the DPS did not provide an explanation. 2. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents the Patient is to receive SN visits one to two times a week for assessment, assess pain and the use and effectiveness of prescribed medication; LPN (Licensed Practical Nurse for observation; Oxycodone 30 mg every 4 hours as needed for pain, Morphine 20 mg/ml 10 mg orally every 3 hours as needed for pain (administer for breakthrough pain every 3 hours between doses of Oxycodone if pain reaches 8 on a scale of 0 to 10. The RN notes document: 11/18/21- "Patient complaining of pain awful and constant pain in his back, right thoracic region, he states "it is the Lung Cancer"; "physician called who increased his medication to 30 mg of Oxycodone every four hours". 11/24/21- "Patient states he has pain "most of the time", he is reticent to take his pain meds (medications) he states "nothing works", encouraged him to take his meds as ordered and that if he waits too long, it is much harder to catch up to the pain". 12/22/21- "Patient states medication takes the edge off of the pain continues Oxycodone 30 mg with Morphine for breakthrough pain". The RN notes lack complete pain assessments to include the location and rating of the Patient's pain, the amount and frequency for the Oxycodone and Morphine. The notes lack documented evidence of follow up with the Patient's statement that nothing works regarding the pain. The LPN notes document: 11/23/21 - "Patient vomited several times and he didn't feel well and did not elaborate, when asked if he had pain, he stated "I took my medicine", sat at the table with his head in his arms, Patient is very tired, and when asked if he is sleeping through the night, he stated he is awake until 4 AM most nights and sleeps late into the following day". 12/1/21- "Patient complains of increased severe generalized pain and feeling aggrevated all the time; states he has taken Lorazapam a few times, states pain is abated only fora short time after taking pain medication, he is taking it every 3 hours-6 pills a daymore if he is awake through the night; Patient states he has not eaten in five days because food and drink taste bad to him and he has been feeling intermittent nausea; feels cold all the time and sits in front of kerosene heater for warmth, heater is an open flame heater. Patient accepted delivery of Oxygen and placed in basement for storage, not yet in use, RN notified". 12/8/21- Patient states "I am always in pain" and does not remember when he last took his pain medication, RN notified. 12/10/21 - Patient states he has severe pain to both lower extremities, edema plus 3, reddened knees to feet, Patient states they were more swollen this morning, he states he is having great difficulty walking due to increased pain and swelling of legs, he states "I feel I won't be able to walk around much anymore, reports pain to the back when legs are elevated". 12/15/21 - Patient states "I feel awful", vomited 4 times today, reports many new "sores" to back, arms and axilla, many are dime to a quarter sized openings in the skin, applied lotion to the Patient's neck, back and arms". 12/21/21- "Patient has open sores to back and arms which Patient scratches often, two sores noted to be enlarged, Patient noted to have difficulty ambulating due to increased weakness and bilateral edema and holds on to furniture and walls for support". 12/29/21- "Patient having great difficulty ambulating back and forth a few steps, complains of increased pain to his lower legs". The LPN notes lack documented evidence of monitoring the Patient's pain on each visit, a rating for the Patient's pain and the amount of Oxycodone and Morphine is being use. There is no documented evidence the RN assessed the Patient with regards to the LPN's findings of increased pain, vomiting, unsteady gait, increased edema and pain to the legs, the Patient has an open flame kerosene heater in the home, and that the Oxygen was delivered and placed in the basement. During an interview with the Director of Clinical Services on 1/14/22 at 12:30 PM. the Director did not provide an explanation for the above. 3. Patient # 7 has a start of care of 10/27/21 with diagnosis that include Malignant Neoplasm Of Vulva, Unspecified Dementia Without Behavioral Disturbances, Personal History Of Other Malignant Neoplasm Of the Large Intestine as documented on the " Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22. The " Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22 document: " Orders: Skilled Nurse once a week for one week, once a week for 7 weeks, 1-2/ week for 6 weeks, As needed ( PRN) x 11 Exacerbation of Disease. Licensed Practical Nurse ( LPN) to describe bowel sounds. LPN to perform wound care/ dressing change Pack wound on vulva with calcium alginate once a day. LPN to observe and describe color and amount of wound drainage. LPN to record patient pain 0-10. LPN to administer pain medications ordered. LPN to record patient pain after medication 0-10. LPN to reorder medication. LPN to do colostomy care. Change colostomy appliance weekly and PRN. Change colostomy bag every three days and PRN". On 1/11/21, a review of the patient record indicated there is no documentation of the care and services, wound dressing and colostomy care provided by the LPN. On 1/13/21 at 12: 40 PM, a request was made for the clinical notes pertaining to the patient care provided by the LPN. This information was not provided. There is no documented evidence the Plan Of Care was reviewed/ revise to include the frequency and duration of the LPN order. There is no documented evidence of the scope and frequency of LPN services necessary to meet the patient needs There is no documented evidence the Plan Of Care was followed. Patient # 8 has a start of care date of 8/17/21 with diagnosis that include Acute and Chronic Systolic Heart Failure, Chronic Atrial Fibrillation, Pulmonary Hypertension as documented on the " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22. The " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22 document: " Orders: Skilled Nurse 1 -2/week x 2 weeks, 1-2 x week x 12 weeks, PRN x Complications/ Med Changes, Telehealth 8 PRN visits for symptom management. LPN to describe lung sound, LPN to observe and educate on proper use of oxygen via NC @ 2 L/min. LPN to observe for dyspnea, LPN to perform wound care left shin wound, cleanse with normal saline, pat dry, apply Santyl and Mupirocin, cover with calcium alginate,mextra pad and wrap with kling daily. LPN to record patient pain 0-10. LPN to administer pain medication as ordered. LPN to record patient pain after medication 0-10. LPN to reorder medications. LPN special interventions, take vital signs each visit". The record document the following LPN visits: 11/29/21, 12/27/21, 1/11/22. There is no documented evidence of the frequency and duration of the LPN services necessary to meet the patient needs. Patient #9 has a start of care date of 9/22/21 with diagnosis that include Adult failure to Thrive, Alzheimer's Disease, Type II Diabetes Mellitus wit Hyperglycemia as documented on the " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21. The "Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21 document: " Orders: Skilled Nurse once a day for one day, once a week for one week, 2-4 x a week for 6 weeks, 3-5 x a week for 8 weeks. PRN x 14 Signs / Symptoms Complications 8 PRN visits for symptom management. LPN to describe lung sounds. LPN to describe bowel sounds. LPN to observe for dyspnea and cough. LPN to record patient last bowel movement. LPN to observe skin color. LPN to observe and describe color and amount of wound drainage. LPN to record patient appetite. LPN to observe aspiration and fall precautions. LPN to observe for general weakness. LPN to turn and position patient in bed. LPN document pain status. LPN to observe for agitation". There is no documented evidence of the frequency and duration of the LPN services necessary to meet the patient needs 6. Patient #11 has a start of care date of 6/8/21 with diagnosis that include Malignant Neoplasm Of Rectum, Secondary Neoplasm of Bone as documented on the " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 9/5/21. The " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 9/5/21 document: " Orders: Skilled Nurse once a day for one day, once a week for one week, 1-3 x a week for 13 weeks, PRN x 10 Exacerbation of Symptoms. Skilled Nurse to teach safety measures related to oxygen use. Irrigate nephrostomy tube each visit as needed for sediment. Malignant, fumigating wound on buttocks, remove outer dressing after spraying with dressing removal spray. Flush with normal saline to loosen older dressing packing and irrigate and clean wound, after removal of packing. Sterile dressing absorbent pad cut dressing into packing strips with antiinfective, after spraying with Flagyl and packing with strips, cover with Xeroform, mesh dressing and cover with dry sterile dressing daily. Family does dressing changes when nurse is not scheduled or needed for the day. CADD pump connected via IV tubing to RCW mediport site for continuous dilaudid infusion. Change left nephrostomy tube site dressing via sterile technique 2-3 times weekly". the record document the LPN visits on the following dates: 6/11/21, 6/12/21, 6/13/21, 6/14/21, 6/17/21, 6/23/21, 6/24/21, 6/26/21, 6/28/21, 7/1/21, 7/4/21. There is no documented evidence of the frequency and duration of the LPN services. There is no documented evidence the LPN provided the wound care in accordance the Plan Of Care. There is no documented evidence the Plan Of Care was followed. On 1/13/21 at 12:40 PM, the Director Of Clinical Services was interviewed and did not provide an explanation.

9. Patient #15 has a start of care date of 8/31/21 with diagnosis of Cerebral Infarction due to Thrombosis and Age-Related Physical Debility documented on the "Clinical Summary" for Certification Period 11/29/21 through 2/26/22. The "Clinical Summary" for Certification Period 11/29/21 through 2/26/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x 10 exacerbation of disease; Administer Insulin as Ordered; LPN to observe for dyspnea, LPN to perform wound care/dressing change to suprapubic site every 3-5 days and as needed; Medication: Lantus 12 units SubQ once a day, Novolog 6 units 3 times a day PRN hyperglycemia". The "Clinical Summary" lacks documented evidence of all related diagnosis/condition to include Diabetes Mellitus; the frequency and duration for the LPN to visit the patient. 10. Patient #17 has a start of care date of 8/2/21 with diagnosis of Alzheimer's Disease, and Dementia without Behavioral Disturbance documented on the "Clinical Summary" for Certification Period 10/31/21 through 1/28/22. The "Clinical Summary" for Certification Period 10/31/21 through 1/28/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x 15 exacerbation of disease; LPN to apply dressing to pressure ulcer on bilateral upper buttocks every other day and PRN" The "Clinical Summary" lacks documented evidence of the frequency and duration for the LPN to visit the patient. On 1/13/22 at 1:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation. 6. Patient # 7 has a start of care of 10/27/21 with diagnosis that include Malignant Neoplasm Of Vulva, Unspecified Dementia Without Behavioral Disturbances, Personal History Of Other Malignant Neoplasm Of the Large Intestine as documented on the " Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22. The " Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22 document: " Orders: Skilled Nurse once a week for one week, once a week for 7 weeks, 1-2/ week for 6 weeks, As needed ( PRN) x 11 Exacerbation of Disease. Licensed Practical Nurse ( LPN) to describe bowel sounds. LPN to perform wound care/ dressing change Pack wound on vulva with calcium alginate once a day. LPN to observe and describe color and amount of wound drainage. LPN to record patient pain 0-10. LPN to administer pain medications ordered. LPN to record patient pain after medication 0-10. LPN to reorder medication. LPN to do colostomy care. Change colostomy appliance weekly and PRN. Change colostomy bag every three days and PRN". On 1/11/21, a review of the patient record indicated there is no documentation of the care and services, wound dressing and colostomy care provided by the LPN. On 1/13/21 at 12: 40 PM, a request was made for the clinical notes pertaining to the patient care provided by the LPN. This information was not provided. There is no documented evidence the Plan Of Care was reviewed/ revise to include the frequency and duration of the LPN order. There is no documented evidence of the scope and frequency of LPN services necessary to meet the patient needs. 7. Patient # 8 has a start of care date of 8/17/21 with diagnosis that include Acute and Chronic Systolic Heart Failure, Chronic Atrial Fibrillation, Pulmonary Hypertension as documented on the " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22. The " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22 document: " Orders: Skilled Nurse 1 -2/week x 2 weeks, 1-2 x week x 12 weeks, PRN x Complications/ Med Changes, Telehealth 8 PRN visits for symptom management. LPN to describe lung sound, LPN to observe and educate on proper use of oxygen via NC @ 2 L/min. LPN to observe for dyspnea, LPN to perform wound care left shin wound, cleanse with normal saline, pat dry, apply Santyl and Mupirocin, cover with calcium alginate,mextra pad and wrap with kling daily. LPN to record patient pain 0-10. LPN to administer pain medication as ordered. LPN to record patient pain after medication 0-10. LPN to reorder medications. LPN special interventions, take vital signs each visit". The record document the following LPN visits: 11/29/21, 12/27/21, 1/11/22. There is no documented evidence of the frequency and duration of the LPN services necessary to meet the patient needs. 8. Patient #9 has a start of care date of 9/22/21 with diagnosis that include Adult failure to Thrive, Alzheimer's Disease, Type II Diabetes Mellitus wit Hyperglycemia as documented on the " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21. The "Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21 document: " Orders: Skilled Nurse once a day for one day, once a week for one week, 2-4 x a week for 6 weeks, 3-5 x a week for 8 weeks. PRN x 14 Signs / Symptoms Complications 8 PRN visits for symptom management. LPN to describe lung sounds. LPN to describe bowel sounds. LPN to observe for dyspnea and cough. LPN to record patient last bowel movement. LPN to observe skin color. LPN to observe and describe color and amount of wound drainage. LPN to record patient appetite. LPN to observe aspiration and fall precautions. LPN to observe for general weakness. LPN to turn and position patient in bed. LPN document pain status. LPN to observe for agitation". There is no documented evidence of the frequency and duration of the LPN services necessary to meet the patient needs. During an interview with the Director of Clinical Services (DCS) on 1/13/21 at 12:30 PM, the Director Of Clinical Services did not provide an explanation. Based on record reviews and staff interviews, the hospice failed to ensure the Patients Plan Of Care include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. This was evident for ten (10) of eighteen (18) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #7, #8, #9, #15 and #17 ). Failure to ensure the Patients Plans Of Care include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a start of care date of 12/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 12/17/21 through 3/16/22. The "Hospice Clinical Summary/Care Plan" dated 12/17/21 through 3/16/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 2. Patient #2 has a start of care date of 8/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 11/15/21 through 2/12/22. The "Hospice Clinical Summary/Care Plan" dated 11/15/21 through 2/12/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 3. Patient #3 has a start of care date of 2/17/21 with diagnosis of Lung Cancer as documented on the "Hospice Clinical Summary" dated 12/14/21 through 2/11/22. The "Hospice Clinical Summary/Care Plan" dated 12/14/21 through 2/11/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 4. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the" Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The "Hospice Clinical Summary/Care Plan" dated 12/3/21 through 1/31/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents the Patient is to receive SN visits one to two times a week for assessment. The Clinical Summary/Care Plan documents the Patient is to receive an LPN (Licensed Practical Nurse. The Clinical Summary/Care Plan does not document the frequency the LPN is to go to the Patient's home. During an interview with the Director of Clinical Services (DCS) on 1/13/21 at 12:30 PM, the Director Of Clinical Services did not provide an explanation for the above.

Based on record reviews and staff interviews , the hospice failed to provide all necessary services for the palliation and management of the terminal illness and related conditions, including medical supplies necessary to meet the needs of the patient. This was evident for one (1) of eighteen (18) patient care records reviewed. ( Patient #5). Failure of the hospice to provide medical supplies necessary to meet the patient is likely to cause serious harm and impairment to patient #5 and has the potential for negative patient outcomes to all the patients receiving oxygen treatments under the hospice care. Example: Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the Hospice Clinical Summary dated 11/8/21 through 2/5/22. The Hospice Clinical Summary dated 11/8/21 through 2/5/22 documents Skilled Nursing visits for assessment; Oxygen 2 liters continuous PRN (as needed) for shortness of breath. The initial nursing assessment dated 11/8/21 documents: "Oxygen Saturation 96%, diminished lung sounds, shortness of breath with exertion, Patient reports shortness of breath, he refused Oxygen at first as he is a smoker but eventually agreed that if would be helpful, Oxygen ordered on admission, concentrator and tanks will be stored safely. The hospice failure to provide medical supplies necessary to the patient needs are identified in the following areas: The agency failed to monitor the use of Oxygen during the nursing visits and its effectiveness for the relief of respiratory symptoms. The Agency failed to ensure the patient 's oxygen was delivered promptly, and available for the patient's use at all time as per the MD orders/ Hospice's Plan of Care. The RN failed to communicate with the MD and IDG regarding the delay in the patient's safety, usage, and delivery delays of the oxygen. The agency failed to document the patient's safety instruction for the use of Oxygen to prevent harm to the Patient and the Community. The cumulative effects of the hospice non compliance resulted in the patient's not receiving the appropriate oxygen treatment; and the hospice inability to monitor the use of oxygen in the home while the patient is an active smoker, while using a heater with kerosene is likely to cause serious harm and adverse outcome to the patient and the community. On 1/14/22 at 3:30 PM, the Director Of Clinical Services was interviewed and did not provide an explanation.

Based on observations, record review,and interviews,the hospice agency failed to ensure that the Interdisciplinary Group ( IDG) develops, reviews and revises individualized plans of care which address the needs of patients and families as identified in the comprehensive assessments. This was evident for four (4) of eighteen (18) clinical records reviewed (Patients #4, #5, #15 and #17) Failure to ensure that the Interdisciplinary Group (IDG) develops individualized plans of care that address and meet the physical and psycho/social needs has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The "Hospice Clinical Summary/Care Plan" dated 12/03/21 through 1/31/22 documents the Patient is to receive SN (Skilled Nurse) visits for assessment; LPN (Licensed Practical Nurse) for observation and treatment; LPN to observe and describe size and character of decubitus wound, decubitus wound to right buttock, LPN to perform wound care, cleanse with normal saline, pat dry and apply barrier cream and cover with dry sterile dressing; right foot first Metatarsal, cleanse with normal saline cover with 2 x 2 soaked Dakins 1/2 strength solution and cover with ABD and wrap with Kling. The LPN notes dated 10/18/21 through 1/6/22 lack documented evidence of wound care being performed. There is no documented evidence of communication with the LPN and RN between 10/18/21 through 1/6/22 regarding wound care not being performed. On 1/06/22, the RN documents "wound care performed by nursing home staff". The RN note dated 12/6/21 documents the Patient has a stage two wound to the mid-thoracic and Hydrogel and ABD dressing is being performed. There is no documentation the information regarding the mid-thoracic wound and wound care was discussed in the IDG meetings and revision to the Plan of Care. 2. Patient #5 has a start of care date of 11/8/21 and a discharge date of 1/6/22 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 . The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents: SN (Skilled Nurse) 1 x 1 (11/8/21), 2 x wk for 6 weeks, 3-4 x week x 8 weeks;skilled observation and assessment of Lung sounds; assess respiratory status; assess saftey of care environment and identify ptential hazards; assess pain and use and effectiveness of perscribed medication; instruct patient in wound care; LPN to perform wound care/dressing change to the left jaw, cleanse with normal saline, apply Xeroform, apply foam border dressing every 2 to 3 days, LPN to describe color and amount of wound drainage; Oxygen 2 liters continuous PRN; Oxycodone 30 mg every 4 hours as needed for pain (for pain above 7/10, Morphine 10nmg every three hours as needed for pain or dyspnea (administer for breakthrough pain every three hours in between doses of Oxycodone 30 mg if pain reaches 8/10; Oxygen 2 liters continuos PRN (as needed)". The initial Registered Nurse (RN) note dated 11/8/21 documents the RN "discussed the use of Oxygen and Patient consented, Patient is still smoking; Patient had mandibular reconstruction for Cancer of the lower lip and lost half of his tongue; Patient reports Shortness of Breath with exertion, he refused Oxygen at first as he is a smoker but eventually agreed that it would be helpful". The assessment does not document the wound to the jaw (size, depth, any drainage, pain to the wound) and whether a dressing was on at the time of the visit. The RN note dated 11/18/21 does not document assessment of the wound to the jaw. The RN note dated 11/24/21 documents: "Patient has not answered his phone for the DME to deliver the Oxygen stating "I am not going to stay up late for a delivery"; RN informed Patient "they sually deliver in the morning and that if he would answer his phone,they will come, he denied shortness of breath and continued to smoke through out the visit". The note does not document an assessment of the wound to the jaw. The RN note dated 12/16/21 docements: "Patient has allowed nursing to assist him with wound on his jaw and applying cream to the small open eruptions which are following the vascula system, hopefully it will be less uncomfortable with wound care". There is no assessment of the wound to the jaw or information regarding the Oxygen. The SN note dated 12/22/21 documents Patient's "Oxygen saturation is 90%% on room air, the Oxygen has not been delivered because the Patient does not answer his phone; ". The note does not document an assessment of the wound to the jaw. The LPN note dated 11/23/21 documents the "Patient vomited several times this AM, RN informed". There is no documentation of wound care to the jaw being performed. The LPN note dated 12/1/21 documents: "the Patient has not eaten in 4 days, has an open flame kerosene heater in home, Oxygen was delivered and is in the basement; Patient has increased severe generalized pain and feels aggravated all the time; has not eaten in 5 days as most food and drink now tastes bad; Patient states painis abated only for short time after taking pan medication; he is taking every three hours and reports he takes 6 pills a day, more if he is awake through the night; reports feeling cold all the time and sits directly in front of kerosene heater for warmth, safety discussed; feels intermittent nausea and has taken Haldol for several days with good results". There is no documentation of wound care to the jaw being performed. The LPN note dated 12/8/21 documents "the Patient states he does not get extended sleep, 3 - 4 hours at a time; "I am always in pain" and does not remember when he last took pain medication; wound care performedto left jawper order and tolerated well". The LPN note dated 12/10/21 documents the wound to the jaw measures 5.5 cm by 2.5.cmby 0.1 deep, wound care performed; Patient complained of severe pain the lower legs, plus 3 edema and reddened the the kneew to the feet and reports having great difficulty walking due to increased pain and edema". The LPN note dated 12/15/21 documents the Patient reports many new sores to back, arms and axilla, the wounds are dime to quarter size openings; wound to left jaw no drainage at this time, covered in thin yellow slough, does not appear larger at this time". The record lacks documented evidence of being assessed by the RN, the dressing changed every 2 to 3 days. Ihe IDG meetings dated 11/16/21, 11/30/21, 12/14/21, and 12/28.21 lack documented evidence of review of the wounds to the jaw, arm, back and shoulder; Oxygen is not being used; the amount and effectiveness of the pain medication being used, the Patient's nausea and vomiting and not eating, inability to sleep; the Patient's edema and and pain causing difficulty in ambulating for possible revision to the Plan of Care.. ing and pain not being relieved with the current modalities were discussed in the IDG meetings and revision to the Plan of Care. 3. Patient #15 has a start of care date of 8/31/21 with diagnosis of Cerebral Infarction due to Thrombosis and Age-Related Physical Debility documented on the "Clinical Summary" for Certification Period 11/29/21 through 2/26/22. The "Clinical Summary" for Certification Period 11/29/21 through 2/26/22 documents, "Skilled nursing (SN) 1 x weekly x 13 weeks, PRN x 10 exacerbation of disease; Administer Insulin as Ordered; LPN to observe for dyspnea, LPN to perform wound care/dressing change to suprapubic site every 3-5 days and as needed". There are no documented evidence LPN makes visits to administer Insulin as ordered, and perform wound care/dressing change to suprapubic site every 3-5 days. The IDG meeting Notes for 1/11/22, 12/28/21, and 12/14/21 lack documented evidence the Interdisciplinary Group reviewed and/or revised the patients plan of care to reflect the lack of LPN services On 1/13/22 at 1:44 PM the Director of Quality Assurance, Administrative Manager and Chief Operating Officer were interviewed. They did not provide an explanation for the findings. 4. Patient #16 has a start of care date of 6/28/21 with diagnosis of Creutzfeldt-Jakob Disease, Dementia without Behavioral Disturbance and Malignant Neoplasm of Prostate documented on the "Clinical Summary" for Certification Period 12/25/21 through 2/22/22. The "Clinical Summary" for Certification Period 12/25/21 through 2/22/22 documents, "Routine Hospice Care Skilled nursing (SN) 2 visits/ weekly x 13 weeks, PRN x 5 exacerbation of disease; Coccyx Stage II wound; Change dressing daily and PRN". The following "Skilled Nursing Clinical Note" documents: 12/28/21 by LPN "skin is warm/dry. Stage III to coccyx, foam dressing in place"; 12/29/21 by RN, "Increased severity of coccyx wound/ pain. Pain is more severe and harder to get under control; and 1/7/22 by LPN, "No change in pain, FLACC Scale total 6". The IDG meeting Notes for 12/7/21 and 1/4/22 lack documented evidence the Interdisciplinary Group reviewed and/or revised the patients plan of care to reflect the increased severity of coccyx wound and pain. On 1/14/22 at 10:50 AM the Director of Quality Assurance was interviewed. The Director of Quality Assurance provide an explanation for the findings. 5. Patient #17 has a start of care date of 8/2/21 with diagnosis of Alzheimer's Disease, and Dementia without Behavioral Disturbance documented on the "Clinical Summary" for Certification Period 10/31/21 through 1/28/22. The "Clinical Summary" for Certification Period 10/31/21 through 1/28/22 documents, "Skilled nursing (SN) 1 x weekly x 13 weeks, PRN x 15 exacerbation of disease; LPN to apply dressing to pressure ulcer on bilateral upper buttocks every other day and PRN" There are no documented evidence LPN makes visits. The IDT meeting Notes for 1/11/22, 12/28/21, 12/14/21 and 11/30/21 lack documented evidence the Interdisciplinary Team reviewed and/or revised the patients plan of care to reflect the lack of LPN services On 1/13/22 at 1:44 PM the Director of Quality Assurance, and Chief Operating Officer were interviewed. They did not provide an explanation.

Based on clinical record reviews and staff interview the agency failed to ensure that services are provided in accordance with the written plan of care. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient: #5) Failure to ensure that services are provided in accordance with the written plan of care, has the potential for negative patient outcomes. The finding is: Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung Cancer as documented on the Hospice Clinical Summary dated 11/8/21 through 2/5/22. The Hospice Clinical Summary/Care Plan dated 11/8/21 through 2/5/22 documents the Patient is to receive SN (Skilled Nursing) visits one x one (118/21), two x week x 6 weeks (211/9/21 to 12/11/21), three to four x week for 8 weeks (12/12/21 to 2/5/22). A request was made on 1/13/22 at 1:30 PM for copies of all nursing visits. The record documents: one visit was made between 11/9/21 to 11/13/21; one visit made 11/14/21 to 11/20/21; two visits between 12/12/21 to 12/18/21 (one missed visit). In an interview with the Director Of Clinical Services (DCS) on 1/14/22 at 12:30 PM,no explanation was provided regarding the above.

Based on review of clinical records and interviews the hospice failed to ensure that the care and services provided to patients were based on all assessments of the patient and family needs. This was evident for two (2) of eighteen (18) records reviewed. (Patients #5 and #16) Failure to provide services based on all assessments of the patient and family needs has the potential for unmet patient needs. Findings are: 1. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents the Patient is to receive SN visits one to two times a week for assessment, assess pain and the use and effectiveness of prescribed medication; LPN (Licensed Practical Nurse for observation; Oxycodone 30 mg every 4 hours as needed for pain, Morphine 20 mg/ml 10 mg orally every 3 hours as needed for pain (administer for breakthrough pain every 3 hours between does of Oxycodone if pain reaches 8 on a scale of 0 to 10. The RN notes document: 11/18/21- Patient complaining of "awful and constant" pain to his back, right thoracic region, he states it is the Lung Cancer, physician called to increase pain medication. 11/24/21- Patient states he has pain "most of the time", he is reticent to take his pain meds (medications) he states "nothing works", encouraged him to take his meds as ordered and that if he waits too long, it is much harder to catch up to the pain. 12/22/21- Patient states medication takes the edge off of the pain continues Oxycodone 30 mg with Morphine for breakthrough pain. The RN notes lack complete pain assessments to include the location and rating of the Patient's pain, the amount and frequency for the Oxycodone and Morphine. The notes lack documented evidence of follow up with the Patient's statement that nothing works regarding the pain. The LPN notes dated 11/8/21 through 12/29/21 document: the Patient has been vomiting, has increased pain and edema to the legs causing an unsteady gait, open sores to the back and arms. There is no documented evidence the RN assessed the Patient with regards to the LPN's findings of increased pain, vomiting, unsteady gait, increased edema and pain to the legs, the Patient has an open flame kerosene heater in the home, and that the Oxygen was delivered and placed in the basement. During an interview with the Director of Clinical Services on 1/14/22 at 12:30 PM. the Director did not provide an explanation for the above. 2. Patient #16 has a start of care date of 6/28/21 with diagnosis of Creutzfeldt-Jakob Disease, Dementia without Behavioral Disturbance and Malignant Neoplasm of Prostate documented on the "Clinical Summary" for Certification Period 12/25/21 through 2/22/22. The "Clinical Summary" for Certification Period 12/25/21 through 2/22/22 documents, "Routine Hospice Care Skilled nursing (SN) 2 visits/ weekly x 13 weeks, PRN x 5 exacerbation of disease; Coccyx Stage II wound; Change dressing daily and PRN". The following "Skilled Nursing Clinical Note" documents: 12/28/21 by LPN "skin is warm/dry. Stage III to coccyx, foam dressing in place"; 12/29/21 by RN, "Increased severity of coccyx wound/ pain. Pain is more severe and harder to get under control; and 1/7/22 by LPN, "No change in pain, FLACC Scale total 6". There is no documented evidence the observations and assessments are integrated into the patient care needs. There is no documented evidence that the care provided is based on all observations and assessments. On 1/13/22 at 1:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation.

Based on record reviews and interviews, the agency failed to communicate with professional staff members on patient related issues to ensure that the Interdisciplinary Group ( IDG) is knowledgeable of patient outcomes and the efficacy of the plans of care. This was evident for six (6) of eighteen (18) clinical records reviewed. (Patients #2, #3, #4, #5, #10, #15 and #17) Failure to develop and maintain a communication system to ensure that the IDG (Interdisciplinary Group) reviews comprehensive plans of care has the potential for unmet patient needs to not be identified and addressed. The findings are: 1. Patient #2 has a start of care date of 8/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 11/15/21 through 2/12/22. The "Hospice Clinical Summary/Care Plan" dated 11/15/21 through 2/12/22 documents the Patient is to receive SN (Skilled Nurse) visits for assessment; LPN (Licensed Practical Nurse) for observation and treatment. The LPN note dated 11/26/21 documents: Patient's last bowel movement 11/22/21 (four days); had stomach pain, nausea and lethargy yesterday; family gave Zofran with no effect and will try Haloperidol next time. The note does not document interventions taken to relieve the constipation and communication with the RN and reported in the IDG meetings. 3. Patient #3 has a start of care date of 2/17/21 with diagnosis of Lung Cancer as documented on the "Hospice Clinical Summary" dated 12/14/21 through 2/11/22. The "Hospice Clinical Summary/Care Plan" dated 12/14/21 through 2/11/22 documents the Patient is to receive SN (Skilled Nurse) visits for assessment; LPN (Licensed Practical Nurse) for observation and treatment. The LPN note dated 10/21/21 documents: Patient states she had a low grade fever and complained of diarrhea and nausea; informed the RN at the nursing home. The note does not document whether the LPN took the Patient's temperature and vital signs. There is no documented evidence the LPN communicated these issues to the Hospice RN and reported in the IDG meetings. 3. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The" Hospice Clinical Summary/Care Plan" dated 12/03/21 through 1/31/22 documents the Patient is to receive SN (Skilled Nurse) visits for assessment; LPN (Licensed Practical Nurse) for observation and treatment; LPN to observe and describe size and character of decubitus wound, decubitus wound to right buttock, LPN to perform wound care, cleanse with normal saline, pat dry and apply barrier cream and cover with dry sterile dressing; right foot first Metatarsal, cleanse with normal saline cover with 2 x 2 soaked Dakins 1/2 strength solution and cover with ABD and wrap with Kling. The LPN notes dated 10/18/21 through 1/6/22 lack documented evidence of wound care being performed. There is no documented evidence of communication with the LPN and RN regarding wound care not being performed and the reason(s) and reported in the IDG meetings. 4. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents SN visits for assessment initiate Oxygen flow at 2 liters per minute; LPN visits for observation and treatment; observe nutritional status; LPN to perform wound care to the left jaw, cleanse with normal saline, apply Xeroform, apply foam border dressing every 2 to 3 days, LPN to describe color and amount of wound drainage; Oxygen 2 liters continuous PRN; Oxycodone 30 mg every 4 hours as needed for pain. The initial SN visit dated 11/8/21 documents the RN discussed the use of Oxygen and Patient consents, Patient is still smoking. The SN note dated 12/22/21 documents the Oxygen has not been delivered because the Patient does not answer his phone. The LPN note dated 11/23/21 documents the Patient vomited several times this AM, RN informed. The LPN note dated 12/1/21 documents: the Patient has not eaten in 4 days, has an open flame kerosene heater in home, Oxygen was delivered and is in the basement. The LPN note dated 12/8/21 documents the Patient stated "I am always in pain". The LPN note dated 12/15/21 documents the Patient has two wounds, one to the back the size of a nickle and one to the shoulder the size of a quarter. The record lacks documented evidence of communication between the LPN and the RN and reported in the IDG meetings 6. Patient #10 has a start of care date of 10/28/21 with diagnosis of with diagnoses of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 10/28/21 through 1/25/22. The "Hospice Clinical Summary/Care Plan" dated 10/28/21 through 1/25/22 documents SN visits for assessment. The nursing notes dated between 11/2/21 through 1/04/22 document all of the visits were telehealth visits. The telehealth visits lack documented evidence of comprehensive assessments to include skin assessment and pain with amount, frequency and effectiveness of pain modalities/medications. During an interview with the Director of Clinical Services (DC'S) on 1/14/22 at 12:30 PM, The DC'S stated :the facility does not allow Hospice staff to visit the facility". No other explanation was provided. 6. Patient #15 has a start of care date of 8/31/21 with diagnosis of Cerebral Infarction due to Thrombosis and Age-Related Physical Debility documented on the "Clinical Summary" for Certification Period 11/29/21 through 2/26/22. The "Clinical Summary" for Certification Period 11/29/21 through 2/26/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x 10 exacerbation of disease; Administer Insulin as Ordered; LPN to observe for dyspnea, LPN to perform wound care/dressing change to suprapubic site every 3-5 days and as needed". During the home visit conducted on 1/12/22 at 1:15 PM the privately hired LHCSA aide on duty (aide not hired or contracted through the hospice) states that she administer Insulin as ordered, prepour medications for the other aides covering other shifts, managed patient's pain and other symptoms using the comfort pack; the aides states "I gave Atropine 1/11/22 because the patient had trouble clearing mucus out of his throat; I don't have Aide Plan of Care from the LHCSA or from the Hospice, no RN comes out to supervise us and the Hospice RN does not provide supervision". There are no documented evidence LPN makes visits to administer Insulin as ordered, observer for dyspnea and perform wound care/dressing change to suprapubic site every 3-5 days. There is no documented evidence the care and services are provided directly or under arrangement. On 1/13/22 at 1:44 PM the Director of Clinical Services , and Chief Operating Officer were interviewed. They did not provide an explanation for the findings. 7. Patient #17 has a start of care date of 8/2/21 with diagnosis of Alzheimer's Disease, and Dementia without Behavioral Disturbance documented on the "Clinical Summary" for Certification Period 10/31/21 through 1/28/22. The "Clinical Summary" for Certification Period 10/31/21 through 1/28/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x 15 exacerbation of disease; LPN to apply dressing to pressure ulcer on bilateral upper buttocks every other day and PRN" During the home visit conducted on 1/12/22 at 12:15 PM the RN states "I make 1 visit every other week, the live-in aide privately hired through LHCSA (aide not hired or contracted through the hospice) performs the dressing change when I am not visiting". There are no documented evidence LPN makes visits. There is no documented evidence the care and services are provided directly or under arrangement. On 1/13/22 at 1:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation.

Based on review of the Hospice Quality Assessment and Performance Improvement (QAPI) minutes and interviews with agency staff, the hospice was unable to show that they measured, analyzed, and tracked quality indicators, including adverse patient events and other aspects of performance. Failure to measure, analyze, and track quality indicators to include adverse patient events has the potential for the hospice to be unable to assess processes of care, hospice services, and operations. L 562

Based on review of the Hospice Quality Assessment and Performance Improvement (QAPI) minutes and interviews with agency staff, the hospice was unable to show that they measured, analyzed, and tracked quality indicators, including adverse patient events and other aspects of performance. Failure to measure, analyze, and track quality indicators to include adverse patient events has the potential for the hospice to be unable to assess processes of care, hospice services, and operations. The findings are: A request was made on 1/10/22 for the agency's Quality Assessment and Performance Improvement (QAPI) meeting minutes for 2021 and the agency's policy related to QAPI. Based on review of the Hospice Quality Assessment and Performance Improvement (QAPI) minutes and interviews with agency staff, the hospice was unable to show that they measured, analyzed, and tracked quality indicators, including adverse patient events and other aspects of performance. The lack of measuring, analyzing, and tracking quality indicators has the potential for the hospice to be unable to assess processes of care, hospice services, and operations. The agency's policy titled Quality Assessment Performance Improvement Plan is dated January 2018 and reviewed September 2021 documents: "The Quality Improvement Committee will monitor sentinel and adverse events with referral to appropriate department for development of recommendations or options for systemic changes to prevent recurrence. The agency provided QAPI meeting minutes for 2021. The minutes document the agency is performing QAPI meeting monthly. The meeting minutes lack documented evidence of measuring, tracking and analyzing of patient adverse events. During an interview with the Director of Clinical Services (DCS) on 1/13/21 at 12:30 pm, the DCS stated that the agency is monitoring patient adverse events but did not provide an explanation as to the reason it is not documented in the meeting minutes.

Based on record review and staff interview, the Hospice failed to ensure that all Licensed Professionals are adequatly supervised. The hospice failed to: Ensure that all Licensed professionals actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education has the potential for negative patient outcomes. (L585) Ensure that LPN staff are adequately supervised has the potential to result in the provision of inappropriate and/or incorrect care and negative patient outcomes. (591)

Based on record reviews and staff interviews , the hospice failed to ensure that all licensed professionals actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. This was evident for twelve (12) of eighteen (18) patient care records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, # 10, # 11 and #12). Failure to ensure that all licensed professionals actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a start of care date of 12/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 12/17/21 through 3/16/22. The Interdisciplinary Group (IDG) meeting dated 12/21/21 documents that the RN ( Registered Nurse) and MSW (Medical Social Worker) assigned to the Patient were not present during the meeting. The "Hospice Clinical Summary" dated 12/17/21 through 3/16/22 documents the Patient has wounds to both heels and wound care is to be performed every three days and PRN (as needed). The IDG meetings do not document the status of the wounds to include the size, and drainage and effectiveness of the wound treatments. 2. Patient #2 has a start of care date of 8/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the Hospice Clinical Summary dated 11/15/21 through 2/12/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 1/11/22, document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The Hospice Clinical Summary/Care Plan dated 11/15/21 through 2/12/21 documents the LPN is to monitor bowel movement and the use of laxatives. The (Licensed Practical Nurse) LPN note dated 11/26/21 documents the Patient's last movement was on 11/22/21 (4 days) and that the Patient complained of stomach pain, nausea and lethargy. There is no documentation as to any interventions taken. There is no documented evidence of discussion of patient's issue with bowel movement and the use of laxatives in the IDG meeting dated 11/30/21. 3. Patient #3 has a start of care date of 2/17/21 with diagnosis of Lung Cancer as documented on the "Hospice Clinical Summary "dated 12/14/21 through 2/11/22. The Interdisciplinary Group (IDG) meetings dated 11/16/21, 12/28/21 and 1/11/22 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary" dated 11/15/21 through 2/12/21 documents LPN visits to observe gastrointestinal status. The LPN note dated 10/21/21 documents the Patient has a low grade fever (no temperature documented) and complains of diarrhea and nausea. The LPN documents the RN was informed. The record lacks documented evidence of follow up and interventions. The IDG meeting dated 11/2/21 does not document these findings. 4. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The Interdisciplinary Group (IDG) meetings dated 12/14/21 and 1/11/22 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary/Care Plan" dated 12/3/21 through 1/31/22 documents (Skilled Nurse) SN visits for assessment; LPN visits for observation and description of measurements of the decubitus wound to right buttock, cleanse with normal saline pat dry and apply Barrier cream and cover with dry sterile dressing; wound to right foot first metatarsal, clean with normal saline, cover with 2 x 2 soaked in Dakins 1/2 strength solution and wrap with Kling. The IDG meetings do not document the status of the wounds to include the size, drainage and effectiveness of the wound treatments. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 12/14/21 and 12/28/21 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 12/14/21 and 12/28/21 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents SN visits for assessment initiate Oxygen flow at 2 liters per minute; LPN visits for observation and treatment; observe nutritional status; LPN to perform wound care to the left jaw, cleanse with normal saline, apply Xeroform, apply foam border dressing every 2 to 3 days, LPN to describe color and amount of wound drainage; Oxygen 2 liters continuous PRN; Oxycodone 30 mg every 4 hours as needed for pain. The initial SN visit dated 11/8/21 documents the RN discussed the use of Oxygen and Patient consents, Patient is still smoking. The SN note dated 12/22/21 documents the Oxygen has not been delivered because the Patient does not answer his phone. The LPN note dated 11/23/21 documents the Patient vomited several times this AM, RN informed. The LPN note dated 12/1/21 documents: the Patient has not eaten in 4 days, has an open flame kerosene heater in home, Oxygen was delivered and is in the basement. The LPN note dated 12/8/21 documents the Patient stated I am always in pain". The LPN note dated 12/15/21 documents the Patient has two wounds, one to the back the size of a nickel and one to the shoulder the size of a quarter. The IDG meetings dated 11/30/21, 12/14/21 and 12/28/21 do not document the above issues/problems. 6. Patient #10 has a start of care date of 10/28/21 with diagnosis of with diagnoses of Alzheimer's Disease as documented on the "Hospice Clinical Summary dated 10/28/21 through 1/25/22. The Interdisciplinary Group (IDG) meetings dated 12/14/21, 12/28/21 and 1/11/22 document that the RN assigned to the Patient was not present during the meetings. The Patient has Alzheimer's Disease and is Bedbound and resides in an assisted living facility that does not allow the hospice team to make visits. All SN visits are via telehealth and do not document the person(s) the telehealth is being conducted with. The IDG meetings do not address this. On 1/13/22 at 1:30 PM, the Director Of Clinical Services was interviewed and stated that a Nursing Supervisor is in attendance but stated the Supervisor does not know the Patients being discussed in the IDG meetings. 7. Patient # 6 has a start of care date of 7/14/21 with diagnosis that include Malignant Neoplasm Of Unspecified Site Of Right Female Breast, Secondary Malignant Neoplasm of Liver, Intrahepatic Bile Duct and Bone, Chronic Ischemic heart Disease as documented on the " Hospice Clinical Summary" for the Certification Period of 11/11/2021 through 1/9/2022. The " Hospice Clinical Summary" for the Certification Period of 11/11/21 through 1/9/22 document: "Orders for Discipline and Treatments: " Skilled Nurse 1x week x one week, 1x week for 9 weeks, As needed (PRN) x 10 exacerbation of disease. MSW (Medical Social Worker ) 1x/ months. PRN x 10 crisis intervention. PRN x 10 MSW phone visit. Clergy 3x month x 3 months. PRN x 5 crisis intervention". A review of the IDG meetings from 11/11/21 to 1/9/22 document the following: 11/23/21: "MSW not present, Chaplain not present". 12/7/21: "MSW not present, Chaplain not present". 12/21/21: "MSW not present, Chaplain not present". 1/4/22: "MSW not present, Chaplain not present." There is no documented evidence of the IDG members discussion and supervision of the care and services provided to the Patient. 8. Patient # 7 has a start of care date 10/27/21 with diagnosis that include Malignant Neoplasm Of Vulva , Unspecified Dementia Without Behavioral Disturbances as documented on the "Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22. The " Hospice Clinical Summary " for the Certification Period of 10/27/21 to 1/24/22 document:" Orders: Skilled Nurse 1x week for one week, 1x week for 7 weeks, 1-2 x week for 6 weeks. PRN x 11 exacerbation of disease. Telehealth 8 PRN visits for symptom management. MSW 1-2 a month for 4 months. Clergy PRN x 6 crisis intervention. A review of the IDG meeting from 10/27/21 to 1/24/22 document the following: 11/2/21 : "MSW not present". 11/2/21 and 11/16/21: "Chaplain not present". 9. Patient # 8 has a start of care date 8/17/21 with diagnosis that include Acute and Chronic Systolic Heart Failure as documented on the " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22. The " Hospice Clinical Summary " for the Certification Period of 11/15/21 to 2/12/22 document:" Orders: Skilled Nurse 1-2 x week for two weeks, , 1x week for 12 weeks. PRN x 10 Complications/ med Changes. Telehealth 8 PRN visits for symptom management. MSW 1-2 a month for 4 months. Clergy 2x month. PRN x 6 crisis intervention". A review of the IDG meeting from 11/15/21 to 2/12/22 document the following: 11/6/21, 12/14/21: "Chaplain not present". 11/30/21: "RN not present". 12/4/21: "MSW not present". There is no documented evidence of the IDG members discussion and supervision of the care and services provided to the Patient. 10. Patient # 9 has a start of care date 9/22/21 with diagnosis that include Alzheimer's Disease, Type II Diabetes with Hperglycemia, Adult Failure to Thrive as documented on the " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21. The " Hospice Clinical Summary " for the Certification Period of 9/22/21 to 12/20/21 document:" Orders: Skilled Nurse once a day for one day, once a week for one week, 1-2 x week for six weeks, 3-5 x week for 8 weeks. PRN x 14 Complications. MSW 2 a month for 4 months. PRN x 6 MSW phone visit, Crisis intervention, PRN x 10 MSW phone visit, PRN x 7 MSW phone visit. Clergy 1- 2x 3 month. PRN x 6 crisis intervention". A review of the IDG meeting from 9/22/21 to 12/20/21 document the following: 9/26/21, RN and MSW not present. 10/12/21, 10/26/21, 11/9/21, 11/23/21, 12/7/21, 12/12/21: Chaplain not present. 12/21/21, MSW, Chaplain not present". 9/26/21, 11/23/21, RN and MSW not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. 11. Patient # 11 has a start of care date 6/8/21 with diagnosis that include as documented on the " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 9/5/21. The " Hospice Clinical Summary " for the Certification Period of 6/8/21 to 9/5/21 document:" Orders: Skilled Nurse once a day for one day, once a week for one week, 1-3 x week for 13 weeks. PRN x 1 Exacerbation of disease, PRN x 15 exacerbation of disease. MSW 3-4 x a month for 4 months. PRN x 6 crisis intervention, PRN x 8 MSW phone visit, Crisis intervention. Clergy 1- 2x month. for 4 months, PRN x 7, spiritual care". A review of the IDG meeting from 9/22/21 to 12/20/21 document the following: 6/15/21, RN and MSW and Chaplain not present. 6/29/21, RN, MSW, Chaplain not present. 7/13/21 post discharge: MSW, RN, Chaplain not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. 12. Patient # 12 has a start of care date 3/30/21 and a discharge date of 6/25/21 with diagnosis that include Alzheimer's Disease without Behavioral Disturbances, Personal History Of Urinary Tract Infections as documented on the " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 6/27/21. The " Hospice Clinical Summary " for the Certification Period of 3/30/21 to 6/27/21 document:" Orders: Skilled Nurse once a week for 14 weeks. PRN x 1 Exacerbation of disease, PRN x 10 exacerbation of disease. MSW 2 x a month for 3 months. PRN x 8 crisis intervention, PRN x 8 MSW phone visit. Clergy 2-3 x month. for 3 months, PRN x 5, spiritual support". A review of the IDG meeting from 3/30/21 to 6/25/21 document the following: 4/6/21 RN MSW and Chaplain not present. 4/20/21 RN, MSW, Chaplain not present. 5/4/21 MSW, RN, Chaplain not present. 5/18/21 MSW, RN, Chaplain not present. 6/1/21 MSW, RN, Chaplain not present. 6/15/21 MSW, RN, Chaplain not present. 6/29/21 MSW, RN, Chaplain not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. On 1/13/22 at 1:30 PM, the Clinical Director was interviewed and stated the Nursing Supervisor is in attendance but the Supervisor does not know the Patients being discussed in the IDG meetings. The Director Of Clinical Services did not provide further explanation.

Based on clinical record review and staff interview the hospice failed to ensure adequate supervision of the Licensed Practical Nursing (LPN) staff. This was evident for five (5) of eighteen (18) clinical records reviewed. (Patients #2, #3, #4, #5, #10). Failure to adequately supervise LPN staff has the potential to result in the provision of inappropriate and/or incorrect care and negative patient outcomes. The findings are: 1. Patient #2 has a start of care date of 8/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 11/15/21 through 2/12/22. The "Hospice Clinical Summary/Care Plan" dated 11/15/21 through 2/12/22 documents the Patient is to receive SN (Skilled Nurse) visits for assessment; LPN (Licensed Practical Nurse) for observation and treatment. The LPN note dated 11/26/21 documents: Patient's last bowel movement 11/22/21 (four days); had stomach pain, nausea and lethargy yesterday; family gave Zofran with no effect and will try Haloperidol next time. The note does not document interventions taken to relieve the constipation and communication with the RN and reported in the IDG meetings. 2. Patient #3 has a start of care date of 2/17/21 with diagnosis of Lung Cancer as documented on the "Hospice Clinical Summary" dated 12/14/21 through 2/11/22. The "Hospice Clinical Summary/Care Plan" dated 12/14/21 through 2/11/22 documents the Patient is to receive SN (Skilled Nurse) visits for assessment; LPN (Licensed Practical Nurse) for observation and treatment. The LPN note dated 10/21/21 documents: Patient states she had a low grade fever and complained of diarrhea and nausea; informed the RN at the nursing home. The note does not document whether the LPN took the Patient's temperature and vital signs. There is no documented evidence the LPN communicated these issues to the Hospice RN and reported in the IDG meetings. 3. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The" Hospice Clinical Summary/Care Plan" dated 12/03/21 through 1/31/22 documents the Patient is to receive SN (Skilled Nurse) visits for assessment; LPN (Licensed Practical Nurse) for observation and treatment; LPN to observe and describe size and character of decubitus wound, decubitus wound to right buttock, LPN to perform wound care, cleanse with normal saline, pat dry and apply barrier cream and cover with dry sterile dressing; right foot first Metatarsal, cleanse with normal saline cover with 2 x 2 soaked Dakins 1/2 strength solution and cover with ABD and wrap with Kling. The LPN notes dated 10/18/21 through 1/6/22 lack documented evidence of wound care being performed. There is no documented evidence of communication with the LPN and RN regarding wound care not being performed and the reason(s) and reported in the IDG meetings. 4. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents SN visits for assessment initiate Oxygen flow at 2 liters per minute; LPN visits for observation and treatment; observe nutritional status; LPN to perform wound care to the left jaw, cleanse with normal saline, apply Xeroform, apply foam border dressing every 2 to 3 days, LPN to describe color and amount of wound drainage; Oxygen 2 liters continuous PRN; Oxycodone 30 mg every 4 hours as needed for pain. The initial SN visit dated 11/8/21 documents the RN discussed the use of Oxygen and Patient consents, Patient is still smoking. The SN note dated 12/22/21 documents the Oxygen has not been delivered because the Patient does not answer his phone. The LPN note dated 11/23/21 documents the Patient vomited several times this AM, RN informed. The LPN note dated 12/1/21 documents: the Patient has not eaten in 4 days, has an open flame kerosene heater in home, Oxygen was delivered and is in the basement. The LPN note dated 12/8/21 documents the Patient stated "I am always in pain". The LPN note dated 12/15/21 documents the Patient has two wounds, one to the back the size of a nickle and one to the shoulder the size of a quarter. The LPN notes dated 12/10/21, 12/21/21 and 12/29/21 document the Patient's legs are edematous. have increased pain and the Patient has increased difficulty in ambulating more than a few steps. The record lacks documented evidence of communication between the LPN and the RN and reported in the IDG meetings regarding the Patient's statement "I am always in pain", vomiting, edema to the legs and difficulty ambulating, the Patient's wounds. 5. Patient #10 has a start of care date of 10/28/21 with diagnosis of with diagnoses of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 10/28/21 through 1/25/22. The "Hospice Clinical Summary/Care Plan" dated 10/28/21 through 1/25/22 documents SN visits for assessment. The nursing notes dated between 11/2/21 through 1/04/22 document all of the visits were telehealth visits. The telehealth visits lack documented evidence of comprehensive assessments to include skin assessment and pain with amount, frequency and effectiveness of pain modalities/medications. During an interview with the Director of Clinical Services (DCS) on 1/14/22 at 12:30 PM, the DCS stated :the facility does not allow Hospice staff to visit the facility". No other explanation was provided.

Based on clinical record reviews; policy and procedure reviews and interviews, the governing authority failed to provide adequate oversight of the agency. This was evidenced by failure to: o Ensure the Hospice provides care that optimizes comfort and dignity; and is consistent with patient and family needs and goals, with patient needs and goals as priority. See L 650 o Ensure the Hospice provides care and services consistent with standards of practice. See L 652. o Ensure the Hospice Nursing and Physian services, drugs and biologicals are available 24/7. See L 653. The cumulative effect of these systemic problems resulted in the hospice's failure to ensure the provision of quality health care. The failure to provide oversight resulted in negative outcomes for one (1) patient ( Patients #1) with potential negative outcomes for the agency's entire patient population.

Based on clinical record review and staff interview, the agency failed to ensure Hospice care provided is consistent with the patient and/or family needs and goals to optimize care. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient #5). Failure to ensure Hospice care is consistent with patient and family needs and goals as priority places the patient at risk for negative outcomes. The finding are: Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents, "Skilled nursing (SN) 3-4 x/ week x 8 weeks 12/2/201 to 2/5/2022, PRN X 20 exacerbation of disease progress; telehealth 10 PRN visits for symptom management, skilled observation and assessment of lung sounds, assess need and adequacy of oxygen". The SN notes documents the following: 12/10/201 SN Clinical Note by LPN documents, " patient reports happy with current wound care protocol, however, dressing did not stay in place very long due to difficult area of placement at the jaw line and under chin; patient (Ken) complaint severe pain to bilateral legs this morning; bilateral lower extremities 3+ reddened knees to feet; stated they were more swollen this morning; he (patient) stated, I feel I won't be able to walk around much anymore; RN notified". 12/17/21 by RN- Patient is a little agitated with questions and how weak and dependent he has become; discussed the possibility of inpatient hospice care for his end of life but refused to fill out any paper; patient lives alone with a friend who (the friend) states he is not ready to take care of him; no edema; patient states some increased weakness; pain location : back/ribs, moderate pain, sharp, aggravated by general activity" 12/21 by LPN patient present with open sores to back and arms; 2 sores noted to to be enlarged; patient noted to have difficulty ambulating due to increase weakness and bilateral lower extremities edema; holding onto furniture and walls for stability; RN notified" The RN note dated 12/22/2021 documents "Oxygen ordered on admission. The Oxygen has not been delivered because the Patient does not answer his phone. O2 saturation 90% on Room Air at rest. Encouraged to use oxygen when short of breath, or experiencing difficulty breathing". There is no documented evidence the patient received continuous Oxygen therapy as ordered while on hospice services. The record lacks documented evidence any Continuous Care was provided when the need was identified, the patient had multiple falls and on 1/2/22 the patient fell and was transferred to the hospital. The hospice failed to ensure the provision of care that was necessary to meet the needs of the patient. On 1/13/22 at 1:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation.

Based on record reviews and staff interviews the hospice failed to ensure that all licensed professionals actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. This was evident for twelve (12) of eighteen (18) patient care records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, # 10, # 11 and #12). Failure to ensure that all licensed professionals actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a start of care date of 12/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the "Hospice Clinical Summary" dated 12/17/21 through 3/16/22. The Interdisciplinary Group (IDG) meeting dated 12/21/21 documents that the RN ( Registered Nurse) and MSW (Medical Social Worker) assigned to the Patient were not present during the meeting. The "Hospice Clinical Summary" dated 12/17/21 through 3/16/22 documents the Patient has wounds to both heels and wound care is to be performed every three days and PRN (as needed). The IDG meetings do not document the status of the wounds to include the size, and drainage and effectiveness of the wound treatments. 2. Patient #2 has a start of care date of 8/17/21 with diagnoses of Congestive Heart Failure and Atrial Fibrillation as documented on the Hospice Clinical Summary dated 11/15/21 through 2/12/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 1/11/22, document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The Hospice Clinical Summary/Care Plan dated 11/15/21 through 2/12/21 documents the LPN is to monitor bowel movement and the use of laxatives. The (Licensed Practical Nurse) LPN note dated 11/26/21 documents the Patient's last movement was on 11/22/21 (4 days) and that the Patient complained of stomach pain, nausea and lethargy. There is no documentation as to any interventions taken. There is no documented evidence of discussion of patient's issue with bowel movement and the use of laxatives in the IDG meeting dated 11/30/21. 3. Patient #3 has a start of care date of 2/17/21 with diagnosis of Lung Cancer as documented on the "Hospice Clinical Summary "dated 12/14/21 through 2/11/22. The Interdisciplinary Group (IDG) meetings dated 11/16/21, 12/28/21 and 1/11/22 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary" dated 11/15/21 through 2/12/21 documents LPN visits to observe gastrointestinal status. The LPN note dated 10/21/21 documents the Patient has a low grade fever (no temperature documented) and complains of diarrhea and nausea. The LPN documents the RN was informed. The record lacks documented evidence of follow up and interventions. The IDG meeting dated 11/2/21 does not document these findings. 4. Patient #4 has a start of care date of 8/5/21 with diagnosis of Alzheimer's Disease as documented on the "Hospice Clinical Summary" dated 12/3/21 through 1/31/22. The Interdisciplinary Group (IDG) meetings dated 12/14/21 and 1/11/22 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary/Care Plan" dated 12/3/21 through 1/31/22 documents (Skilled Nurse) SN visits for assessment; LPN visits for observation and description of measurements of the decubitus wound to right buttock, cleanse with normal saline pat dry and apply Barrier cream and cover with dry sterile dressing; wound to right foot first metatarsal, clean with normal saline, cover with 2 x 2 soaked in Dakins 1/2 strength solution and wrap with Kling. The IDG meetings do not document the status of the wounds to include the size, drainage and effectiveness of the wound treatments. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 12/14/21 and 12/28/21 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. 5. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The Interdisciplinary Group (IDG) meetings dated 11/30/21, 12/14/21 and 12/28/21 document that the RN and MSW (Medical Social Worker) assigned to the Patient were not present during the meetings. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents SN visits for assessment initiate Oxygen flow at 2 liters per minute; LPN visits for observation and treatment; observe nutritional status; LPN to perform wound care to the left jaw, cleanse with normal saline, apply Xeroform, apply foam border dressing every 2 to 3 days, LPN to describe color and amount of wound drainage; Oxygen 2 liters continuous PRN; Oxycodone 30 mg every 4 hours as needed for pain. The initial SN visit dated 11/8/21 documents the RN discussed the use of Oxygen and Patient consents, Patient is still smoking. The SN note dated 12/22/21 documents the Oxygen has not been delivered because the Patient does not answer his phone. The LPN note dated 11/23/21 documents the Patient vomited several times this AM, RN informed. The LPN note dated 12/1/21 documents: the Patient has not eaten in 4 days, has an open flame kerosene heater in home, Oxygen was delivered and is in the basement. The LPN note dated 12/8/21 documents the Patient stated I am always in pain". The LPN note dated 12/15/21 documents the Patient has two wounds, one to the back the size of a nickel and one to the shoulder the size of a quarter. The IDG meetings dated 11/30/21, 12/14/21 and 12/28/21 do not document the above issues/problems. 6. Patient #10 has a start of care date of 10/28/21 with diagnosis of with diagnoses of Alzheimer's Disease as documented on the "Hospice Clinical Summary dated 10/28/21 through 1/25/22. The Interdisciplinary Group (IDG) meetings dated 12/14/21, 12/28/21 and 1/11/22 document that the RN assigned to the Patient was not present during the meetings. The Patient has Alzheimer's Disease and is Bedbound and resides in an assisted living facility that does not allow the hospice team to make visits. All SN visits are via telehealth and do not document the person(s) the telehealth is being conducted with. The IDG meetings do not address this. On 1/13/22 at 1:30 PM, the Director Of Clinical Services was interviewed and stated that a Nursing Supervisor is in attendance but stated the Supervisor does not know the Patients being discussed in the IDG meetings. 7. Patient # 6 has a start of care date of 7/14/21 with diagnosis that include Malignant Neoplasm Of Unspecified Site Of Right Female Breast, Secondary Malignant Neoplasm of Liver, Intrahepatic Bile Duct and Bone, Chronic Ischemic heart Disease as documented on the " Hospice Clinical Summary" for the Certification Period of 11/11/2021 through 1/9/2022. The " Hospice Clinical Summary" for the Certification Period of 11/11/21 through 1/9/22 document: "Orders for Discipline and Treatments: " Skilled Nurse 1x week x one week, 1x week for 9 weeks, As needed (PRN) x 10 exacerbation of disease. MSW (Medical Social Worker ) 1x/ months. PRN x 10 crisis intervention. PRN x 10 MSW phone visit. Clergy 3x month x 3 months. PRN x 5 crisis intervention". A review of the IDG meetings from 11/11/21 to 1/9/22 document the following: 11/23/21: "MSW not present, Chaplain not present". 12/7/21: "MSW not present, Chaplain not present". 12/21/21: "MSW not present, Chaplain not present". 1/4/22: "MSW not present, Chaplain not present." There is no documented evidence of the IDG members discussion and supervision of the care and services provided to the Patient. 8. Patient # 7 has a start of care date 10/27/21 with diagnosis that include Malignant Neoplasm Of Vulva , Unspecified Dementia Without Behavioral Disturbances as documented on the "Hospice Clinical Summary" for the Certification Period of 10/27/21 to 1/24/22. The " Hospice Clinical Summary " for the Certification Period of 10/27/21 to 1/24/22 document:" Orders: Skilled Nurse 1x week for one week, 1x week for 7 weeks, 1-2 x week for 6 weeks. PRN x 11 exacerbation of disease. Telehealth 8 PRN visits for symptom management. MSW 1-2 a month for 4 months. Clergy PRN x 6 crisis intervention. A review of the IDG meeting from 10/27/21 to 1/24/22 document the following: 11/2/21 : "MSW not present". 11/2/21 and 11/16/21: "Chaplain not present". 9. Patient # 8 has a start of care date 8/17/21 with diagnosis that include Acute and Chronic Systolic Heart Failure as documented on the " Hospice Clinical Summary" for the Certification Period of 11/15/21 to 2/12/22. The " Hospice Clinical Summary " for the Certification Period of 11/15/21 to 2/12/22 document:" Orders: Skilled Nurse 1-2 x week for two weeks, , 1x week for 12 weeks. PRN x 10 Complications/ med Changes. Telehealth 8 PRN visits for symptom management. MSW 1-2 a month for 4 months. Clergy 2x month. PRN x 6 crisis intervention". A review of the IDG meeting from 11/15/21 to 2/12/22 document the following: 11/6/21, 12/14/21: "Chaplain not present". 11/30/21: "RN not present". 12/4/21: "MSW not present". There is no documented evidence of the IDG members discussion and supervision of the care and services provided to the Patient. 10. Patient # 9 has a start of care date 9/22/21 with diagnosis that include Alzheimer's Disease, Type II Diabetes with Hperglycemia, Adult Failure to Thrive as documented on the " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21. The " Hospice Clinical Summary " for the Certification Period of 9/22/21 to 12/20/21 document:" Orders: Skilled Nurse once a day for one day, once a week for one week, 1-2 x week for six weeks, 3-5 x week for 8 weeks. PRN x 14 Complications. MSW 2 a month for 4 months. PRN x 6 MSW phone visit, Crisis intervention, PRN x 10 MSW phone visit, PRN x 7 MSW phone visit. Clergy 1- 2x 3 month. PRN x 6 crisis intervention". A review of the IDG meeting from 9/22/21 to 12/20/21 document the following: 9/26/21, RN and MSW not present. 10/12/21, 10/26/21, 11/9/21, 11/23/21, 12/7/21, 12/12/21: Chaplain not present. 12/21/21, MSW, Chaplain not present". 9/26/21, 11/23/21, RN and MSW not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. 11. Patient # 11 has a start of care date 6/8/21 with diagnosis that include as documented on the " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 9/5/21. The " Hospice Clinical Summary " for the Certification Period of 6/8/21 to 9/5/21 document:" Orders: Skilled Nurse once a day for one day, once a week for one week, 1-3 x week for 13 weeks. PRN x 1 Exacerbation of disease, PRN x 15 exacerbation of disease. MSW 3-4 x a month for 4 months. PRN x 6 crisis intervention, PRN x 8 MSW phone visit, Crisis intervention. Clergy 1- 2x month. for 4 months, PRN x 7, spiritual care". A review of the IDG meeting from 9/22/21 to 12/20/21 document the following: 6/15/21, RN and MSW and Chaplain not present. 6/29/21, RN, MSW, Chaplain not present. 7/13/21 post discharge: MSW, RN, Chaplain not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. 12. Patient # 12 has a start of care date 3/30/21 and a discharge date of 6/25/21 with diagnosis that include Alzheimer's Disease without Behavioral Disturbances, Personal History Of Urinary Tract Infections as documented on the " Hospice Clinical Summary" for the Certification Period of 6/8/21 to 6/27/21. The " Hospice Clinical Summary " for the Certification Period of 3/30/21 to 6/27/21 document:" Orders: Skilled Nurse once a week for 14 weeks. PRN x 1 Exacerbation of disease, PRN x 10 exacerbation of disease. MSW 2 x a month for 3 months. PRN x 8 crisis intervention, PRN x 8 MSW phone visit. Clergy 2-3 x month. for 3 months, PRN x 5, spiritual support". A review of the IDG meeting from 3/30/21 to 6/25/21 document the following: 4/6/21 RN MSW and Chaplain not present. 4/20/21 RN, MSW, Chaplain not present. 5/4/21 MSW, RN, Chaplain not present. 5/18/21 MSW, RN, Chaplain not present. 6/1/21 MSW, RN, Chaplain not present. 6/15/21 MSW, RN, Chaplain not present. 6/29/21 MSW, RN, Chaplain not present. There is no documented evidence of coordination of services among the designated IDG members. There is no documented evidence of discussion and supervision of the care and services provided to the patient. On 1/13/22 at 1:30 PM, the Clinical Director was interviewed and stated the Nursing Supervisor is in attendance but the Supervisor does not know the Patients being discussed in the IDG meetings. The Director Of Clinical Services did not provide further explanation.

Based on record reviews and interview, the hospice failed to ensure that services and medical equipment are provided in a timely manner to provide symptom management. This was evident for three (3) of eighteen (18) clinical records reviewed (Patients #5, #15 and #17 ). Failure to provide nursing services and medical equipment timely for the patient to manage symptoms appropriately places all patients at risk for sub-standard quality of care. The findings are: 1. Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 2/5/22 documents, "Skilled nursing (SN) 3-4 x/ weekx 8 weeks 12/2/201 to 2/5/2022, PRN X 20 exacerbation of disease progress; telehealth 10 PRN visits for symptom mamangement, skilled oberservation and assessment of lung sounds, assess need and adequacy of oxygen; Medications: Oxygen 2L inhalation continous PRN Shortness of Breath". 12/10/201 SN Clinical Note by LPN documents, " patient reports happy with current wound care protocol, however, dressing did not stay in place very long due to difficult area of placement at the jaw line and under chin; patient (Ken) complaint severe pain to bilateral legs this morning; bilateral lower extremities 3+ reddened knees to feet; stated they were more swollen this morning; he (patient) stated, I feel I won't be able to walk around much anymore; RN notified The RN note dated 12/22/2021 documents "Oxygen ordered on admission. The Oxygen has not been delivered". There is no documented evidence that the Hospice provided timely and adequate nursing care in order to implement interventions for management of the patient's symptoms. On 1/13/22 at 1:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation. 2. Patient #15 has a start of care date of 8/31/21 with diagnosis of Cerebral Infarction due to Thrombosis and Age-Related Physical Debility documented on the "Clinical Summary" for Certification Period 11/29/21 through 2/26/22. The "Clinical Summary" for Certification Period 11/29/21 through 2/26/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x 10 exacerbation of disease; Administer Insulin as Ordered; LPN to observe for dyspnea, LPN to perform wound care/dressing change to suprapubic site every 3-5 days and as needed". During the home visit conducted on 1/12/22 at 1:15 PM the privately hired LHCSA aide on duty (aide not hired or contracted through the hospice) states that she administer Insulin as ordered, prepour medications for the other aides covering other shifts, managed patient's pain and other symptoms using the comfort pack; the aides states "I gave Atropine 1/11/22 because the patient had trouble clearing mucus out of his throat". There is no documented evidence that the Hospice provided timely and adequate nursing care in order to administer medications including Inslins and for management of the patient's symptoms. 3. Patient #17 has a start of care date of 8/2/21 with diagnosis of Alzheimer's Disease, and Dementia without Behavioral Disturbance documented on the "Clinical Summary" for Certification Period 10/31/21 through 1/28/22. The "Clinical Summary" for Certification Period 10/31/21 through 1/28/22 documents, "Skilled nursing (SN) 1x weekly x 13 weeks, PRN x15 exacerbation of disease; LPN to apply dressing to pressure ulcer on bilateral upper buttocks every other day and PRN" There is no documented evidence the LPN services are adequately and frequently enough to provide care for the hospice patient. On 1/13/22 at 2:44 PM the Director of Clinical Services, and Chief Operating Officer were interviewed. They did not provide an explanation.

Based on record reviews and staff interviews, the agency failed to ensure there is a completed hospice discharge summary that include a summary of the patients stay, the current plan of care, the patient's latest physician orders and any documentation that will assist in post discharge continuity of care for all patients discharged from the agency. This was evident for for three ( 3) of three (3) Patients discharged.( Patients #5, # 11, and #12). Failure to ensure there is a completed hospice discharge summary that include a summary of the patients stay, the current plan of care, the patient's latest physician orders and any documentation that will assist in post discharge continuity of care for all patients discharged from the agency has the potential for negative patient outcomes. The findings are: 1. Patient #5 has a start of care date of 11/8/21 and a discharge date of 1/6/22. On 1/14/22, A request was made for the completed discharge summary. The agency provided a document tilted" Hospice Change in Enrollment Form dated 1/6/22. The record document : " Discharge order. Moved out of service area". There is no documented evidence of a completed discharge summary that include the patient's stay including treatment, symptoms and pain management; and any documentation that will assist post discharge continuity of care. 2. Patient #11 has a start of care date of 6/8/21 and a discharge date of 7/7/21. A request was made on 1/14/22 for the completed discharge summary. this information was not provided. There is no documented evidence of a completed discharge summary that include the patient's stay including treatment, symptoms and pain management; and any documentation that will assist post discharge continuity of care. 3. Patient #12 has a start of care date of 3/30/21 and a discharge date of 6/25/21. A request was made on 1/14/22 for the completed discharge summary. This information was not provided. There is no documented evidence of a completed discharge summary that include the patient's stay including treatment, symptoms and pain management; and any documentation that will assist post discharge continuity of care. On 1/13/22 at 12:45 PM, The Director Of Clinical Services was interviewed and did not provide an explanation.

Based on record reviews and staff interviews the hospice failed to ensure that medical supplies and drugs required for the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, were provided by the hospice while the patient was under hospice care. ] Ensure that medical supplies and drugs required for the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, are provided by the hospice while the patient is under hospice care, has the potential for negative patient outcomes. (L 687) Ensure Patient's are instructed in the safe use of durable medical equipment and supplies has the potential for possible harm. (L 702). The hospice's failure to ensure that medical supplies required for the palliation and management of the terminal illness and related conditions for all patients are likely to cause serious harm, injury or death to all the patients under the hospice care.

Based on record reviews and staff interviews the hospice failed to ensure that medical supplies and drugs required for the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, were provided by the hospice while the patient was under hospice care. This was evident for one (1) of six (6) patients receiving Oxygen therapy. (Patient: #5) Failure to ensure that medical supplies and drugs required for the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, are provided by the hospice while the patient is under hospice care, has the potential for negative patient outcomes. The findings are: Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the Hospice Clinical Summary dated 11/8/21 through 2/5/22. The Hospice Clinical Summary dated 11/8/21 through 2/5/22 documents Skilled Nursing visits for assessment; Oxygen 2 liters continuous PRN (as needed) for shortness of breath. The initial nursing assessment dated 11/8/21 documents: "Oxygen Saturation 96%, diminished lung sounds, shortness of breath with exertion, Patient reports shortness of breath, he refused Oxygen at first as he is a smoker but eventually agreed that if would be helpful, Oxygen ordered on admission, concentrator and tanks will be stored safely. The nursing notes between 11/18/21 through 11/29/21 document the Oxygen has not been delivered. The reason it was not documented is that the Patient does not answer the phone when the DME called to schedule delivery. The Patient states "I do not recognize the number", "I do not answer the phone if I do not know the number" and "they call at night, why don't they call in the day". The record lacks documented evidence of interventions the hospice took in order to get the Oxygen delivered. On 12/1/21 (one month after the order) the LPN documents the Patient's "Oxygen was delivered yesterday and placed in the basement, not yet in use, the LPN was concerned because the Patient is still smoking and has an open flame kerosene heater in the home. The Patient was educated on the safety of the Oxygen use. The Patient was admitted to the hospital on 1/2/22. The record lacks documented evidence the Oxygen was set up and utilized by the Patient. The record lacks documented evidence of interventions the hospice took in order to get the Oxygen set up for Patient use. During an interview with the Director of Clinical Services (DCS) on 1/14/22 at 12:30 PM, the DCS stated she called the DME and the Oxygen was delivered on 11/29/21. No other explanation was provided for the above.

Based on record review and interview, the hospice failed to instruct patient in the safe use of and demonstrate durable medical equipment and supplies. This was evident for one (1) of six (6) Patients receiving Oxygen treatment. (Patient #5) Failure to instruct the Patient in the safe use of durable medical equipment and supplies has the potential for possible harm. The finding is: Patient #5 has a start of care date of 11/8/21 with diagnoses of Lung Cancer with Metastases to the Brain and Lung as documented on the "Hospice Clinical Summary" dated 11/8/21 through 2/5/22 and a discharge date of 1/6/22. The "Hospice Clinical Summary/Care Plan" dated 11/8/21 through 1/10/22 documents SN visits for assessment and teaching; Oxygen 2 liters per minute continuous PRN. The SN visit note dated 11/8/21 documents the "Patient gave consent to Oxygen therapy and signed an agreement for Home Oxygen the safe use of Oxygen, Oxygen ordered on admission, concentrator and tanks will be stored safely". On 12/1/21 (one month later) the LPN documents "the Patient's Oxygen was delivered yesterday and placed in the basement, not yet in use, the Patient is still smoking and has an open flame kerosene heater in the home and Patient was educated on the safety of the Oxygen use". The SN note dated 12/22/21 documents the Patient's Oxygen saturation was 90 to 92 on room air and encouraged to use Oxygen when short of breath or has difficulty breathing. The note lacks document evidence the safety concerns of smoking and the open flame kerosene heater being used. The record lacks documented evidence the Oxygen was set up and the Patient was able to demonstrate the appropriate use of durable medical equipment to the satisfaction of the hospice staff. During an interview with the Director of Clinical Services (DCS) on 1/14/22 at 1:00 PM, the DCS stated she called the DME company and was told the Oxygen was delivered on 11/29/21. No other explanation for the above was provided.

Based on record review and interview for patients residing in a skilled nursing facility (SNF) and Adult Care Facility (ACF) receiving hospice care, that the services provided by these facilities are consistent with the hospice plan of care and philosophy. This was one (1) of three (3) patients residing in a facility. (Patient #10) Failure to provide professional management of all patients that reside in these facilities may lead to inadequate symptom management and unmet patient needs. The finding is: Patient #10 has a start of care date of 10/28/21 with diagnosis of with diagnoses of Alzheimer's Disease as documented on the Hospice Clinical Summary dated 10/28/21 through 1/25/22. The "Hospice Clinical Summary/Care Plan" dated 10/28/21 through 1/25/22 documents the Patient is to receive SN visits one time a week for 13 weeks for assessment and 10 PRN (as needed) visits for symptom management; collaborate with facility staff to enhance patient safety; mental status is lethargic. The Plan of Care does not document the care the hospice and the facility is to provide. The record documents the RN made telehealth visits between 10/28/21 through 1/4/22. The notes do not document the name/title of the person conducting the telehealth visit. During a visit with the Director of Clinical Services (DCS) on 1/14/21 at 12:00 PM, the DCS stated "the facility the Patient is in does not allow the hospice staff go in to the home".

Based on record reviews and staff interviews, the hospice failed to ensure that staff are adequately supervised and that personnel are assigned to the care of patients in accordance with their licensure, their training, orientation and demonstrated skills. This was evident for one (1) of eighteen (18) patient care records reviewed. ( Patients # 9). Failure to ensure that staff are adequately supervised and that personnel are assigned to the care of patients in accordance with their licensure, their training, orientation and demonstrated skills have the potential for negative patient outcomes. The findings are: Assessment is not within the scope of practice for an LPN (Licensed Practical Nurse), per Section 6902 of Article 139 of the NY State Education Law. This is clarified in a letter issued by the State Education Department in September 2005, entitled "The Scope of Practice of Licensed Practical Nurses", which clarifies that assessment is not within the privilege of an LPN, and that the roles of RN (Registered Nurse) and LPN are not interchangeable. Patient # 9 has a start of care date of 9/22/21 with diagnosis that include Adult failure to Thrive, Alzheimer's Disease, Type II Diabetes Mellitus wit Hyperglycemia as documented on the " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21. The " Hospice Clinical Summary" for the Certification Period of 9/22/21 to 12/20/21 document: " Orders: Skilled Nurse once a day for one day, once a week for one week, 2-4 x a week for 6 weeks, 3-5 x a week for 8 weeks. PRN x 14 Signs / Symptoms Complications. Telehealth 8 PRN visits for symptom management. LPN to describe lung sounds. LPN to describe bowel sounds. LPN to observe for dyspnea and cough. LPN to record patient last bowel movement. LPN to observe skin color. LPN to observe and describe color and amount of wound drainage. LPN to record patient appetite. LPN to observe aspiration and fall precautions. LPN to observe for general weakness. LPN to turn and position patient in bed. LPN document pain status. LPN to observe for agitation". The document titled: "Visit Notes" Workflow Assess" document the LPN was performing assessments outside of the scope of practice for Licensed Practical Nurses, on the following dates: 10/1/21, 10/8/21, 11/1/21, 11/2/21, 11/9/21,1/5/21. There is no documented evidence of adequate supervision of the LPN while performing assessment of a patient. On 1/14/22 at 1:30 PM, the Director Of Clinical Services was interviewed and did not provide an explanation.

Based on record review and interview, the hospice failed to obtain a criminal background check / Criminal History Record Check ( CHRC) on all hospice employees who have direct patient contact or access to patient records. This was evident for two (2) out of five (5) Home Health Aide records reviewed. (Employees #7 and #8) Failure to obtain a criminal background check / CHRC on all hospice employees who have direct patient contact or access to patient records have the potential for negative patient outcomes. The findings are: 1. The personnel record for Employee #7 has a date of hire of 4/4/11. The record lacks documented evidence of a CHRC clearance letter. 2. The personnel record for Employee #8 has an original date of hire of 8/30/07, left the agency on 2009 and returned in 2012, left and returned on 8/7/20. The record lacks documented evidence of CHRC clearance letters in 2007, 2012 and 2020. There is no documented evidence the hospice obtained the criminal background checks on the employees. During an interview with the Director of Clinical Services (DCS) on 1/14/22 at 2:00 PM, the DCS did not provide an explanation for the above.

Based on record reviews and staff interviews, the Governing Authority failed to ensure compliance with all applicable Federal, State and local laws, rules and regulations related to the health and safety of patients. Failure to ensure compliance with all applicable Federal, State and local laws, rules and regulations related to the health and safety of patients has the potential for negative patient outcomes. This was evident in the following areas: 1. Patients Rights; 2. Nursing Services; 3. Coordination Of Services; 4. Plan Of Care; 5. Discharges Of Patients; 6. Use and maintenance of Equipment; 7. The Home Care Registry and Criminal History Record Check; 8. Emergency Prepareness Plan; 9. Quality Assessment and Performance Improvement; 10. Personnel; 11. Personnel Qualification (Licensed Practical Nurses performing tasks outside the scope of their practice); 12. Complaint procedures; 13. Covid -19 and Infection Control; 14. Licensed Professionas Services. During an interview with the Chief Operating Officer and the Director Of Clinical Services on 1/14/22 at 4: 20 PM, they did not provide an explanation. 1