Every finding on record at Hospice of Orleans , Inc

Based on review of clinical records and interviews with staff, the hospice failed to ensure in three (3) of fourteen (14) clinical records (Patient #s: 2, 8, and 12) the content of the comprehensive assessment is of sufficient scope to identify all of the patient's needs in order to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm.The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all of the patient's needs in order to promote the patient's well-being and comfort throughout the dying process as evidenced by the following: --- Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.Review of the Initial Visit dated 02/03/2025 and Oncall/Unscheduled Visit dated 02/04/2025 and 02/05/2025 revealed the Registered Nurse documented the patient has a traumatic wound to their left forehead, that is not healing, and wound measurements were not obtained.  The agency failed to measure wounds, to include a length, width, and depth.During interview on 06/09/2025 at 02:51 PM, the Home Care Registered Nurse stated wound measurements were not done.    Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.Review of the Initial Visit dated 05/20/2025 and Routine Visits dated 05/22/2025 and 05/27/2025 revealed the Registered Nurse documented the following:- Pressure ulcer - coccyx, stage 1, length - 4.2 centimeters, and width – 3.5 centimeters, and- Pressure ulcer – right heel, suspected deep tissue injury, length 2.3 centimeters, and width 2.3 centimeters. Review of the Routine Visit dated 06/02/2025 and the Oncall/Unscheduled visit dated 06/06/2025 revealed the Registered Nurse documented the following:- Pressure ulcer – gluteal cleft, stage 1, length - 4.4 centimeters, and width – 3.7 centimeters;- Pressure ulcer – right heel, suspected deep tissue injury, length 3.4 centimeters, and width 3.7 centimeters;- Pressure ulcer – mid-back, stage 1, length – 0.4 centimeters, and width – 0.2 centimeters; and- Pressure ulcer – left upper coccyx, stage 1, length 1.2 centimeters, and width 0.8 centimeters. The agency failed to measure wounds, to include a length, width, and depth.During interview on 06/09/2025 at 11:51 AM, the Clinical Services Director stated that including a depth measurement has not historically been done but moving forward they will ensure a depth is included in all wound assessments.  Patient #12 - This 76-year-old patient with a terminal diagnosis of malignant melanoma of overlapping sites of skin was admitted to the hospice on 02/21/2025.Review of the Initial Visit dated 02/21/2025 revealed the Registered Nurse documented the patient is a non-insulin dependent Type 2 diabetic who is prescribed Metformin.Review of the Physician Orders/Plan of Care for 02/21/2025 to 05/21/2025, revealed orders for the following:-       Fingerstick blood sugar: Daily – contact Hospice if blood glucose more than 300; -       Educate: signs and symptoms of hyper and hypoglycemia; and-       Metformin HCL 500 mg every day by mouth; one (1) tablet daily as needed for elevated blood glucoseReview of the Routine Visits dated 02/27/2025 and 03/07/2025 lacked documented evidence of the following: an assessment of the patient’s endocrine status, a fingerstick blood glucose, and education for signs and symptoms of hyper and hypoglycemia.During interview on 06/09/2025 at 02:28 PM, the Clinical Services Director stated the agency does not perform fingerstick blood glucose checks for diabetic assessments and that the family of the patient typically monitors diabetic symptoms.  The Clinical Services Director also stated the families are educated to report to the Registered Nurse if there is a concern.  During interview on 06/09/2025 at 02:29 PM, the Home Care Coordinator stated the patient was reluctant to have daily finger sticks completed by his family for blood glucose checks.

Based on review of clinical records and interviews with staff, the hospice failed to ensure for one (1) of fourteen (14) clinical records (Patient #5), that the nursing staff completed an accurate and comprehensive drug review.  Specifically, the hospice failed to ensure dosages are consistent with recommended guidelines.  Failure to complete an accurate and comprehensive drug review has the potential for patients to experience drug interactions/side effects and may result in the Interdisciplinary Group (IDG) acting in inaccurate information. --- Patient #5 - This 78-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation was admitted to the hospice on 05/09/2025.Review of the Physician’s Orders/Plan of Care from 05/09/2025 to 08/06/2025 revealed the following orders:- Tylenol Extra Strength 500 milligram tablet, take one (1) tablet by mouth every six (6) hours as needed for pain/fever, and - Acetaminophen Rectal Suppository 650 milligram rectal suppository, take one (1) rectal suppository every six (6) hours as needed for pain/fever.  Review of the Acetaminophen (Tylenol) manufacturers guidelines revealed the maximum daily dose of Acetaminophen (Tylenol) is 3,000 mg to 4,000 mg in twenty-four (24) hours. Based on the prescribed dosage, if the patient was administered the Acetaminophen (Tylenol) as ordered, the patient could receive 4,600 milligrams in twenty- four (24) hours. (600 milligrams to 2,600 milligrams above the maximum daily dose). Review of the clinical record from 05/09/2025 to 06/09/2025 lacked documented evidence of a comprehensive drug review to ensure dosages are consistent with recommended guidelines.During interview on 06/09/2025 at 10:50 AM, the Home Care Coordinator stated, the rectal Tylenol is in place for when the patient can no longer swallow.  The Home Care Coordinator stated the patient would never use the oral and rectal Tylenol at the same time.  The Home Care Coordinator stated that they would make the order more specific in the future.

Based on review of clinical records and interviews with staff, for ten (10) of fourteen (14) patients (Patient #'s: 1, 2, 4, 5, 6, 7, 8,10, 11 and 12) the hospice failed to develop individualized written plans of care that reflect patient and family goals and that are based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care.The hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals, and is based on the problems identified in the initial and updated comprehensive assessments as evidenced by the following: --- Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.A. Review of the Physician’s Orders/Plan of Care from 05/20/2025 to 08/17/2025 revealed an order for an as tolerated diet.  The Plan of Care lacked an order for a therapeutic diet.During interview on 06/09/2025 at 11:37 AM, the Home Care Registered Nurse stated the patient was eating a regular diet with thin liquids, as tolerated.  The Home Care Registered Nurse stated the patient’s diet was poor and that is why they wrote an order for an as tolerated diet.B. Review of Supplemental Order dated 05/28/2025 revealed the order MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and four (4) PRN (as needed) visits.During interview on 06/09/2025 at 11:45 AM, the Social Worker stated the as needed visits are for any additional psychosocial needs, but that this is not included in the order they wrote on 05/28/2025.    Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.Review of Supplemental Order dated 02/03/2025 revealed the order MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and four (4) PRN (as needed) visits.During interview on 06/09/2025 at 03:07 PM, the Social Worker stated that the order does not contain an indication for the as needed visits, but the as needed visits are for any additional psychosocial needs.   Patient #5 - This 78-year-old patient with a terminal diagnosis chronic obstructive pulmonary disease with (acute) exacerbation was admitted to the hospice on 05/09/2025.Review of Supplemental Order dated 05/09/2025 revealed the order MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and four (4) PRN (as needed) visits.During interview on 06/09/2025 at 03:07 PM, the Social Worker stated that the order does not contain an indication for the as needed visits, but the as needed visits are for any additional psychosocial needs.   Patient #12 - This 76-year-old patient with a terminal diagnosis of malignant melanoma of overlapping sites of skin was admitted to the hospice on 02/21/2025.Review of the Initial Visit dated 02/21/2025 reveals the Registered Nurse documented the patient is a non-insulin dependent Type 2 diabetic who is prescribed Metformin.Review of the Physician Orders/Plan of Care for 02/21/2025 to 05/21/2025, revealed orders for the following:-       Fingerstick blood sugar: Daily – contact hospice if blood glucose more than 300; -       Educate: signs and symptoms of hyper and hypoglycemia; and-       Metformin HCL 500 mg every day by mouth; one (1) tablet daily as needed for elevated blood glucoseReview of the Physician's Orders/Plan of Care for 02/21/2025 to 05/21/2025, lacked an order for blood glucose monitoring supplies to include glucometer, lancets, and blood glucose test strips.During interview on 06/09/2025 at 02:31 PM, the Clinical Services Director stated there is no physician order for blood glucose monitoring supplies. Patient #7 – This 74-year-old patient with a terminal diagnosis of metastatic ovarian cancer was admitted to the Hospice on 05/05/2025.A. Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following orders:“Fingerstick blood sugar as ordered: Blood sugars are checked three times (3x) per day (before meals) and as needed for signs and symptoms of hypo/hyperglycemia.Novolin 70/30 flexpen subcutaneous suspension pen-injector 100 units/milliliter. 10 units before meals subcutaneously.Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following durable medical equipment/supplies: “ordered through respiratory services hospital bed four (4) half rails, alternating pressure (APP) mattress, bedside table, commode 22 inches, wheelchair – exchanged for transport chair on 5/6.”The plan of care lacked durable medical equipment and supplies orders for the following: a glucometer and diabetic supplies (lancets, testing strips, insulin pen needles) necessary to monitor blood glucose levels and administer insulin.During interview on 6/9/2025 at 2:08 PM, the Clinical Services Director confirmed that the glucometer, lancets, testing strips, and insulin pen needles are not listed on the plan of care. B. Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following orders:“Fingerstick blood sugar as ordered: Blood sugars are checked 3x per day (before meals) and as needed for signs and symptoms of hypo/hyperglycemia.Novolin 70/30 flexpen subcutaneous suspension pen-injector 100 units/milliliter. 10 units before meals subcutaneously.”The plan of care lacked blood glucose parameters for the administration of insulin.During interview on 6/9/2025 at 2:06 PM, the Clinical Services Director stated that the agency’s policy does not state that parameters must be included but believes it should be included as best practice. C. Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following order:“Ipratropium-albuterol inhaler solution 0.5-2.5 3 milligrams per 3 milliliters four times a day as needed. Inhale 3 milliliters via nebulizer 4 times daily as needed for wheezing/shortness of breath.”Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following durable medical equipment/supplies: “ordered through respiratory services hospital bed four (4) half rails, alternating pressure (APP) mattress, bedside table, commode 22 inches, wheelchair – exchanged for transport chair on 5/6.”The plan of care lacked durable medical equipment and supplies orders for medical equipment (nebulizer) necessary to administer inhalation treatments.During interview on 6/9/2025 at 2:08 PM, the Clinical Services Director confirmed that the nebulizer is not listed on the plan of care. D. Review of Supplemental Order dated 5/5/2025 revealed the following: “Master of Social Service (MSS) 4 as needed (PRN): additional Social Work (SW) visits as needed.”The as needed (PRN) frequency order for Social Work (SW) lacked a qualifier for the as needed additional visits.During interview on 6/9/2025 at 2:09 PM, the Clinical Services Director stated that the Social Worker was unaware of the requirement to include a qualifier for as needed orders and will add to orders moving forward. In addition, the Social Worker stated that the order should state “as needed for additional psychosocial issues.” Patient #1 – This 60-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of bladder was admitted to the Hospice on 05/09/2025.A. Review of the Initial visit comprehensive assessment on 5/9/2025 revealed the Registered Nurse documented the following:“Genitourinary – voiding method: urinary diversion. Urinary symptoms: none. Genitourinary observation: urine clear, direct observation.Urinary Diversion – type: ileal conduit. Site: date performed: 5/9/2025. Pouch type: two (2) piece. Frequency of pouch change in days: two to three (2-3) days and as needed. Date of last pouch change: 05/09/2025. Assess stoma: yes. Stoma details: pink, round shape. Stoma appearance: moist, edematous, protruding. Peristomal skin: intact.”Review of the Physician Orders/Plan of Care from 5/9/2025 to 8/6/2025 revealed the following durable medical equipment/supplies: “at home cane, commode, wheelchair ramp, ordered at start of care hospital bed four (4) half rails, alternating pressure (APP) mattress, bedside table, wheelchair.”The durable medical equipment/supplies lacked the supplies necessary to manage the patient’s urostomy site.During interview on 6/9/2025 at 09:58 AM, the Clinical Services Director stated that the urostomy supplies should have been included in the plan of care but were missed. B. Review of Supplemental Order dated 5/9/2025 revealed the following: “Master of Social Service (MSS) four (4) as needed (PRN): additional Social Work (SW) visits as needed.”The as needed (PRN) frequency order for Social Work lacked a qualifier for use of additional visits.During interview on 6/9/2025 at 10:02 AM, the Clinical Services Director stated that the Social Worker was unaware of requirement of qualifier for as needed orders and will add to orders moving forward. Patient #11 – This 90-year-old patient with a terminal diagnosis of End Stage Alzheimer’s Disease was admitted to the Hospice on 03/13/2025.A. Review of Supplemental Order dated 3/13/2025 revealed the following order: “Master of Social Service (MSS) four (4) as needed (PRN): additional visits as needed.”The as needed (PRN) frequency order for Social Work lacked a qualifier for use of additional visits.During interview on 6/9/2025 at 10:24 AM, the Social Worker stated she did not know that was a requirement. Patient #4 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 05/16/2025. Review of the Supplemental Order dated 05/16/2025 revealed an order for MSS (Medical Social Services) one (1) to three (3) times a month for three (3) and four (4) PRN (as needed): additional SW (Social Work) visits PRN (as needed). There is a lack of documented evidence of the reason for the PRN (as needed) visits. During an interview on 06/09/2025 at 09:47 AM, the Social Worker stated that the PRN (as needed) visits would be if a need arises. The Director of Clinical Services stated that adding a reason to the PRN (as needed) frequency would be an easy fix. Patient #6 – This 97-year-old patient with a terminal diagnosis of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 04/09/2025. Review of the Supplemental Order dated 04/09/2025 revealed an order for MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and three PRN (as needed): additional SW (Social Work) visits PRN (as needed). There is a lack of documented evidence of the reason for the PRN (as needed) visits. During an interview on 06/09/2025 at 10:35 AM, the Social Worker stated that the PRN (as needed) visits would be for additional psychosocial needs and that the reason for the PRN (as needed) visits would need to be included. Patient #10 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/23/2025. Review of the Supplemental Order dated 01/23/2025 revealed an order for MSS (Medical Social Services) two (2) to four (4) times a month for three (3) months and four (4) PRN (as needed): additional SW (Social Work) visits PRN (as needed). There is a lack of documented evidence of the reason for the PRN (as needed) visits. During an interview on 06/09/2025 at 11:16 AM, the Social Worker stated that the PRN (as needed) visits would be for additional psychosocial needs and that the reason for the PRN (as needed) visits would need to be included.

Based on review of clinical records and interviews with staff, the Hospice failed to ensure in two (2) of fourteen (14) patients (Patient #s: 2 and 10) that care and services are provided in accordance with the Plan of Care (POC). Specifically, the Registered Nurse failed to obtain an order for arthritis compression and an order for an antibiotic. Failure to provide care in accordance with the patient’s established plan of care has the potential to result in inappropriate care, unmet patient needs, and negative patient outcomes. --- Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.Review of the Case Conference Summary report dated 05/29/2025 revealed the Registered Nurse documented the patient had a general decline last week and was treated for a suspected aspiration pneumonia with a z-pack (an antibiotic used to treat various bacterial infections).Review of the clinical record from 05/29/2025 to 06/09/2025 lacked documented evidence of an order for a z-pack.During interview on 06/09/2025 at 03:16 PM, the Clinical Services Director stated they would ask the responsible Registered Nurse about the missing order.  The Clinical Services Director later stated that there was never an order placed for the z-pack discussed in the 05/29/2025 interdisciplinary meeting.  Patient #10 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/23/2025. Review of the Charts/Clinical Notes dated 05/06/2025 revealed the Registered Nurse documented the following: the patient is wearing an arthritis compression glove to the patient’s right hand and states that it helps provide some relief when the patient is using their hand. Review of the clinical record from 01/23/2025 to 06/09/2025 lacked documentation of an order for the arthritis compression glove.    During an interview on 06/09/025 at 11:30 AM, the Registered Nurse state that the arthritis compression glove should be on the plan of care but that the arthritis compression glove is not.

Based on review of clinical records and interviews with staff for one (1) of fourteen (14) clinical records (Patient #6), the hospice failed to ensure ongoing sharing of information between all members of the Interdisciplinary Group. Failure to ensure ongoing sharing of information can result has the potential unmet patient needs. The Registered Nurse failed to update the Interdisciplinary Group as evidence by: --- Patient #6 – This 97-year-old patient with a terminal diagnosis of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 04/09/2025. Review of the clinical record revealed the Registered Nurse completed a Hospice v25.1 (Comprehensive Update 25) Routine Visit on 04/30/2025 and 05/07/2025.   Review of the Case Conference Summary Report (Interdisciplinary Group Meeting) dated 05/08/2025 lacked documented evidence of a discussion/outcomes regarding the patient since the last IDG review by the Registered Nurse (Case Manager) on 04/24/2025. During an interview on 06/09/2025 at 10:40 AM, the Director of Clinical Services stated that I don’t know why there is not an update on the patient’s status/progress by the Registered Nurse and all I can do is show you that the Registered Nurse was at the Interdisciplinary Group meeting.

Based on review of clinical records and interview with agency staff, for nine (9) of fourteen (14) patients (Patient #s: 1, 2, 5, 6, 7, 8, 10, 11, and 14) the hospice failed to ensure the clinical record is complete and contains all pertinent information, is consistent, and accurately reflects the care and delivery of service to the patient. Failure to ensure clinical records are complete and contain all pertinent and accurate information related to patient care and services has the potential to result in inadequate and inappropriate care.The agency failed to ensure clinical records are complete, contain all pertinent information, and consistently and accurately reflects the care and delivery of service to the patient as evidenced by: --- Patient #1 – This 60-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of bladder was admitted to the Hospice on 05/09/2025.A. Review of the medication list provided on 06/03/2025 revealed the following“Methadone Hydrochloride by mouth tablet 10 milligrams. Start date: 05/27/2025. Covered by Hospice: No”During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medication is covered by the agency, and that there was a clerical error while entering the medication into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications.B. Review of the Case Conferences Summary report revealed the following: “5/15/2025 Interdisciplinary Group 5 day, Team B”Review of the Interdisciplinary Team Attendance Sheet revealed the following date: “5/14/2025”During an interview on 06/10/2025 at 12:07 PM, the Clinical Services Director stated that the date on the sign in sheet was a clerical error and confirmed the Interdisciplinary group occurred on 5/15/2025.The agency failed to ensure the clinical record accurately and consistently captured the date of the Interdisciplinary Group meeting. Patient #7 – This 74-year-old patient with a terminal diagnosis of metastatic ovarian cancer was admitted to the Hospice on 05/05/2025.A. Review of the medication list provided on 06/04/2025 revealed the following:“Lorazepam by mouth tablet 0.5 milligrams. Start date: 05/16/2025. End date:05/18/2025 Covered by Hospice: NoXanax by mouth tablet 0.5 milligrams. Start date: 05/18/2025. Covered by Hospice: NoLevaquin by mouth tablet 250 milligrams. Start date 5/16/2025. Covered by Hospice: NoBuspirone Hydrochloride by mouth tablet 15 milligrams. Start date 05/15/2025. Covered by Hospice: No.”During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medications are covered by the agency, and that there was a clerical error while entering the medications into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications. Patient #11 – This 90-year-old patient with a terminal diagnosis of End Stage Alzheimer’s Disease was admitted to the Hospice on 03/13/2025.A. Review of the medication list provided on 06/04/2025 revealed the following:“Gabapentin by mouth 100 milligrams. Start date: 03/13/2025. Covered by Hospice: NoSeroquel by mouth tablet 50 milligrams. Start date: 4/09/2025. Covered by Hospice: No”During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medications are covered by the agency, and that there was a clerical error while entering the medications into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications. Patient #14 – This 70-year-old patient with a terminal diagnosis of End Stage Heart Failure was admitted to the Hospice on 04/17/2024.A. Review of the medication list provided on 06/05/2025 revealed the following:“Morphine Sulfate (Concentrate) by mouth solution 100 milligrams per 5 milliliters. Start Date: 4/20/2024. End Date 04/22/2024. Covered by Hospice: NoOndansetron Hydrochloride by mouth tablet 4 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: NoLorazepam by mouth tablet 1 milligram. Start date: 5/28/2024. End Date 6/1/2024. Covered by Hospice: NoLorazepam by mouth tablet 0.5 milligram. Start date: 4/22/2024. End date 4/23/2024. Covered by Hospice: No.Bumetanide by mouth tablet 2 milligrams. Start date: 4/17/2024. End date 6/1/2024. Covered by Hospice: No.Midodrine Hydrochloride by mouth tablet 5 milligrams. Start date: 4/17/2024. End date 6/1/2024. Covered by Hospice: No.Spironolactone by mouth tablet 50 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: No.Tamsulosin Hydrochloride by mouth capsule 0.4 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: No.Allergy relief (loratadine) by mouth 10 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: No.Morphine Sulfate (concentrate) by mouth solution 100 milligrams per 5 milliliters. Start date: 4/22/2024. End date: 6/1/2024. Covered by hospice: No.Lorazepam by mouth tablet 0.5 milligrams. Start date: 4/17/2024. End date: 4/22/2024. Covered by Hospice: No.Senna S by mouth tablet 8.6 milligrams – 50 milligrams. Start date: 4/22/2024. End date: 6/1/2024. Covered by Hospice: No.Morphine sulfate (concentrate) by mouth solution 100 milligrams per 5 milliliters. Start date: 4/17/2024. End date: 4/20/2024. Covered by Hospice: No.Lorazepam by mouth tablet 1 milligram. Start date: 4/23/2024. End date: 5/28/2024. Covered by Hospice: No.Ipratropium-albuterol inhaler solution 0.5-2.5 3 milligrams per 3 milliliters. Start date: 5/18/2024. End date: 6/1/2024. Covered by Hospice: No.Atropine sulfate ophthalmic solution 1%. Start date: 5/29/2024. End date: 6/1/2024. Covered by Hospice: No.” During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medications are covered by the agency, and that there was a clerical error while entering the medications into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications.  Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.A. Review of the Case Conferences Summary Report dated 05/15/2025 revealed the Interdisciplinary Group meeting was held on 05/15/2025.Review of the IDT (Interdisciplinary Team) Attendance Sheet dated 05/14/2025 revealed the Interdisciplinary Team meeting was held on 05/14/2025 from 12:00 PM to 01:00 PM.There is inconsistent documentation regarding the date that the Interdisciplinary Group met.During interview on 06/10/2025 at 12:07 PM, the Director of Clinical Services stated that the date of the sign in sheet is a clerical issue and confirmed the date of the Interdisciplinary meeting was 05/15/2025.   B. Review of the Initial Visit dated 02/03/2025 revealed the Registered Nurse documented the following:- Patient is oriented to person and place, has intermittent confusion, is cooperative, lethargic and withdrawn;- Patient manages medications appropriately;- Patient caregiver manages medications appropriately; and- All medications reviewed with daughter and son.Review of the Team Care Plan developed on 02/03/2025 revealed the following:- Problem: Unique Nursing Visit Needs;- Interventions: Pill box fill done by daughter; and- Medications to be administered by family/private hire staffReview of the Routine Visits dated 04/30/2025, 05/06/2025, 05/12/2025, and 05/19/2025 revealed the Registered Nurse documented the following:-  Alert to person, place and situation, has intermittent confusion, is cooperative, and forgetful; - Patient unable to manage medications- Patient caregiver manages medications appropriately; and - All medications reviewed with daughter.There is inconsistent documentation regarding the patient’s ability to manage medications.During interview on 06/09/2025 at 03:03 PM, the Home Care Registered Nurse stated they may have clicked on more than one option.  The Home Care Registered stated that per the care plan developed on 02/03/2025 the daughter prepares the medications and the daughter and the private hire administer the medications.    Patient #5 - This 78-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation was admitted to the hospice on 05/09/2025.Review of the Case Conferences Summary Report dated 05/15/2025 revealed the Interdisciplinary Group meeting was held on 05/15/2025.Review of the IDT (Interdisciplinary Team) Attendance Sheet dated 05/14/2025 revealed the Interdisciplinary Team meeting was held on 05/14/2025 from 12:00 PM to 01:00 PM.There is inconsistent documentation regarding the date that the Interdisciplinary Group met.During interview on 06/10/2025 at 12:07 PM, the Director of Clinical Services stated that the date of the sign in sheet is a clerical issue and confirmed the date of the Interdisciplinary meeting was 05/15/2025.     Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.Review of the Routine Visit dated 05/22/2025 at 09:18 AM revealed the Registered Nurse documented the patient has pain…changes necessary, primary care physician contacted for pain medication orders, patient having increased difficulty swallowing Tylenol, and morphine concentrate requested from the primary care doctor.  Review of the 05/22/2025 Case Conferences Summary Report dated 05/22/2025 at 12:30 PM revealed the Registered Nurse documented the patient denies pain but grimaces when their legs are moved and the family manages the pain with as needed Tylenol with good effect reported.  The clinical record lacks documentation of complete and pertinent information related to the patient’s pain management.During interview on 06/10/2025 at 12:05 PM, the Clinical Services Director stated that the note that pulled into the 05/22/2025 Case Conference Summary report was from the nurse visit that took place on 05/20/2025.  The Clinical Services Director stated that because the documentation was not updated the addition of the Morphine did not get discussed at the 05/22/2025 interdisciplinary meeting.    Patient #6 – This 97-year-old patient with a terminal diagnosis of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 04/09/2025.Review of the Supplemental Order dated 04/09/2025 revealed an order for aide services, one (1) to two (2) times a week for thirteen (13) weeks.  Review of the Hospice v25.1 (Comprehensive Update 25) Routine Visit dated 04/14/2025 revealed the Registered Nurse documented the following:Aide Supervision: Yes, hospice aide present.Aide Employment: Employed by this company.Is the Hospice Aide following the Care Plan? Yes, care plan reviewed.Are the patient/family satisfied with care? Yes.Has there been a change in service? Yes: HHA (Home Health Aide) placed for 2x (two times) weekly.Did the clinician observe the Aide performing any duties? No.Review of the clinical record from 04/09/2025 to 06/09/2025 revealed a home health aide provided care on 04/18/2025, 04/22/2025, 04/25/2025, 04/29/2025, 05/02/2025, 05/06/2025, 05/09/2025, 05/13/2025, 05/16/2025, 05/20/2025, 05/27/2025, 05/30/2025, 06/04/2025, 06/06/2025, and 06/09/2025. There is a lack of documented evidence that the Home Health Aide provided care on 04/14/2025.During an interview on 06/09/2025 at 10:43 AM, the Registered Nurse stated that no, the aide was not present for the supervision and that the error was in the documentation. Patient #10 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/23/2025.A. Review of Physician Orders/Plan of Care from 01/23/2025 to 04/22/2025 revealed a diagnosis of Type II Diabetes Mellitus with hyperglycemia.Review of the Hospice v24.1 (Comprehensive Update 23) Initial Visit dated 01/23/2025 revealed the Registered Nurse documented the following:Metabolic Symptoms: No - Symptoms.Diabetes Detail: Not Diabetic.Review of the Physician Orders/Plan of Care from 04/23/2025 to 07/21/2025 lacked documented evidence of a diagnosis of Type II Diabetes Mellitus with hyperglycemia.Review of the Supplemental Orders as of 05/02/2025 revealed the order "patient does not check fasting blood sugar."Review of the Hospice v25.1 (Comprehensive Update 25) Routine Visits dated 04/29/2025, 05/06/2025, 05/13/1025, 05/20/2025, 05/27/2025, and 06/03/2025 revealed the Registered Nurse documented the following:Metabolic Symptoms: No -Symptoms.Diabetes Detail: Not Diabetic.   Review of the Supplemental Orders as of 05/02/2025 revealed the order "patient does not check fasting blood sugar."There is inconsistent documentation regarding whether the patient has a diagnosis of Type II Diabetes Mellitus with hyperglycemia.During an interview on 06/09/025 at 11:25 AM, the Registered Nurse was observed shaking her head no, when asked if the patient has Type II Diabetes Mellitus. The Director of Clinical Services stated not having a clue as to how the diagnosis of Type II Diabetes Mellitus got on the Physician Orders/Plan of Care from 01/23/2025 to 04/22/2025.   B. Review of the Case Conferences Summary Report dated 05/15/2025 revealed the Interdisciplinary Group meeting was held on 05/15/2025.Review of the IDT (Interdisciplinary Team) Attendance Sheet dated 05/14/2025 revealed the Interdisciplinary Team meeting was held on 05/14/2025 from 12:00 PM to 01:00 PM.There is inconsistent documentation regarding the date that the Interdisciplinary Group met on.During an interview on 06/10/2025 at 12:07 PM, the Director of Clinical Services stated that the date on the sign in sheet is a clerical issue and confirmed the Interdisciplinary meeting was held on 05/15/2025.

Based on review of clinical records and interviews with staff, the hospice failed to ensure for one (1) of fourteen (14) patients (Patient #8), that the content of the clinical records include each individual patient’s formulated Advance Directives.  Failure to ensure the patient's advanced directives are obtained and included in the clinical record places the patient at risk for not having his/her choices about medical treatment followed. --- Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.Review of the forms entitled Admission Packet Contents, HIPAA Compliant Authorization for Release of Medical Information, HIPAA/Confidential Communication Information, Hospice Election Form, and Notice of Financial Responsibility all dated 05/2025 revealed they were all signed by the patient’s daughter who identifies as the patient’s Health Care Proxy.Review of the Initial Visit dated 05/20/2025 revealed the Registered Nurse documented the patient is oriented to person, place and situation and the MOLST is in place.Review of the Social Work Initial Visit dated 05/20/2025 revealed the Social Worker documented MOLST/DNR/DNI is in place.  Review of the Chart/Clinical Note dated 05/20/2025 revealed the Social Worker documented the patient is alert and oriented times three, disoriented to time, calm, minimally participatory, tired but able to make decisions related to her care, and the MOLST/DNR/DNI are in place and they have been scanned into the medical record.Review of the clinical record from 05/20/2025 to 06/09/2025 lacked documented evidence of MOLST/DNR/DNI form and/or a Health Care Proxy.The hospice failed to ensure that the content of the clinical records include each individual patient’s formulated Advance Directives.  During interview on 06/09/2025 at 11:34 AM, the Home Care Registered Nurse stated they do not see one in the record.During interview on 06/09/2025 at 11:40 AM, the Clinical Services Director stated that if the patient was alert and oriented the patient could have requested her daughter to sign the paperwork and the nurse could have stated as such in their documentation.  The Clinical Services Director stated that this is not in the record either.

Based on review of clinical records and interviews with agency staff, the agency failed for one (1) of fourteen (14) patients (Patient #1) to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice.  Failure to authenticate documentation with professional credentials has the potential for patients to receive care from unlicensed staff.The hospice failed to ensure that all documentation by professional staff is appropriately authenticated as evidenced by the following: --- Patient #1 – This 60-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of bladder was admitted to the Hospice on 05/09/2025.Review of the Supplemental Orders dated 05/09/2025, 05/10/2025 and 05/12/2025 revealed an illegible signature with a date of 06/03/2025. The signature lacked any legible identifier.Review of the Supplemental Orders dated 05/09/2025, 05/10/2025 and 05/12/2025 lacked documented evidence of the attending physician's professional credentials. During an interview on 06/09/2025 at 09:56 AM, the Clinical Services Director stated the signature was that of the patient's attending physician. She confirmed legibility was an issue and that there should be written or stamped name with credentials. The Clinical Services Director further stated there may be a signature log containing the physician’s signature to provide. As of time of exit conference on 6/10/2025 at 1:00 PM, the Clinical Services Director stated, “I must have just not have written that physician down to be honest with you” and was unable to provide any documented evidence of a signature log.

Based on review of clinical records, agency policy and procedure and interviews with staff, the hospice failed to ensure in two (2) of five (5) clinical records (Patient #'s: 1 and 3), the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. --- Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. A.) Review of the Registered Nurse (RN) Initial Patient Assessment dated 02/14/2023 revealed the patient was experiencing shortness of breath, intermittent coughing, labored breathing, was not ordered Oxygen and had a room air Oxygen saturation of 97 % (percent). (The documentation lacks an assessment for initiating Oxygen). The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patients needs to promote the patients well-being and comfort throughout the dying process. During interview on 03/31/2023 at 09:49 AM, the Clinical Manager stated the need for Oxygen therapy had been evaluated and the patient refused Oxygen being placed in the home at that time. The Clinical Manager stated she failed to document this in her initial assessment. B.) Review of the RN Initial Patient Assessment dated 02/14/2023 revealed the patient reports having a fall at home the previous week when standing up quickly, causing lightheadedness and denies injury. The patient was assessed to have a palliative performance scale (PPS) of 70 % and was experiencing diminished strength and weakness. (The assessment lacks evaluation of assistive devices/ durable medical equipment being used by the patient or needing to be ordered). The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patients needs to promote the patients well-being and comfort throughout the dying process. During interview on 03/31/2023 at 10:05 AM, the Clinical Manager stated the patient was assessed and offered durable medical equipment but she failed to document this. C.) Review of the RN Initial Patient Assessment dated 02/14/2023 revealed the following: - The patient lives with his son who works, leaving the patient alone for periods of time; - The patient is experiencing diminished strength and weakness; - The patient gets very short of breath with walking and exertion, having to stop and take breaks to catch his breath; and - A fall was reported occurring the previous week due to the patient standing up quickly. (The assessment lacks evaluation for a hospice Aide and/ or Volunteer services). The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patients needs to promote the patients well-being and comfort throughout the dying process. During interview on 03/31/2023 at 10:06 AM, the Clinical Manager stated both hospice Aide and Volunteer services were offered and the patient declined, but she failed to document this. Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the agency policy entitled ";Wound Assessment and Treatment" dated 02/2020 revealed ";All patients regardless of location of care must have an integumentary assessment completed when seen for an initial visit and every comprehensive visit, if there is a new wound noted, documentation should occur in the integumentary section of the comprehensive assessment section of the EMR (electronic medical record)." Review of the RN Initial Patient Assessment dated 03/07/2023 revealed the following regarding the patients right heel wound: - Wound Type: Right foot/ heel ulcer, osteomyelitis; - Size: Unable to measure; - Tracking: (left blank); - Undermining: (left blank); - Exudate level: (left blank); - Stage: (left blank); - Consistency: (left blank); - Drainage type: (left blank); - Pain Tool: (left blank); - Score: (left blank); and - Wound Care Treatment: Clean with Normal Saline, pat dry and apply wet to dry dressing daily and PRN (as needed). The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During interview on 03/30/2023 at 03:59 PM, the Clinical Manager stated the wound was not assessed because the dressing had been changed earlier in the day but this was not documented. Patient #3 - This 72-year-old patient with a terminal diagnosis of lung cancer was admitted to the hospice on 02/22/2023. Review of the Registered Nurse (RN) Initial Patient Assessment dated 02/22/2023 lacks documented evidence that the patient's immunization status was assessed. Review of the clinical record lacks documented evidence that the patient's immunization status was assessed. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. During an interview on 03/31/2023 at 09:32 AM, the Clinical Manager stated that the patient's immunization status should be part of the admission visit assessment, but staff failed to document during the initial assessment.

Based on review of clinical records and interview with staff, for three (3) of five (5) patients (Patient #'s: 1, 2 and 4), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group (IDG) to act on inaccurate information. --- Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the facility referral to the agency dated 03/06/2023 revealed the following medication orders: - Sulfamethoxazole- Trimethoprim 800- 160 milligram (mg) tablet; - Eliquis 10 mg tablet; - Atorvastatin tablet; - Carvedilol 3.125 mg tablet; - Furosemide 40 mg tablet; - Spironolactone 25 mg tablet; - Nystatin powder; - Docusate Sodium 100 mg capsule; - Amlodipine 10 mg tablet; - Cholecalciferot 1000 unit capsule; and - Pyridoxine 100 mg tablet. Review of the IDG Meeting Notes dated 03/08/2023 lack orders for the identified medications and documentation of the medication discrepancies being discussed during the 03/08/2023 meeting. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancies with the physician. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 03/09/2023 at 03:50 PM, the Clinical Manager stated there was no documentation to clarify the identified discrepancies. Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. A.) Review of the facility referral dated 02/07/2023 revealed the following medication orders: - Potassium Chloride 10 milliequivalents (meq) oral tablet, 1 (one) tab (tablet) orally once a day; - Mirtazapine 7.5 mg oral tablet, 1 (one) tab orally once a day; - Levofloxacin 500 mg oral tablet, 1 (one) tab orally once a day; - Prednisone 20 mg oral tablet, 2 (two) tabs orally once a day; - Senna leaf extract oral tablet, 2 (two) tabs orally once a day as needed for constipation; - Hydroxyzine Hydrochloride 10 mg oral tablet, 1 (one) tab orally 4 (four) times a day as needed for itching; - Advair Diskus 250 mcg (microgram)- 50 mcg inhalation powder, 1 (one) inhalation 2 (two) times a day; - Triamcinolone 0.1 % (percent) topical ointment, apply topically to affected area 2 (two) times a day as needed for itching; - Prochlorperazine 10 mg oral tablet, take 1 (one) tab as needed every 6 (six) hours for nausea/ vomiting; - Folic Acid 1 mg oral tablet, 1 (one) tab orally once a day; and - Albuterol 90 mcg/inhalation aerosol, 2 (two) puffs inhaled every 4 (four) hours as needed. Review of the IDG Meeting Notes dated 02/15/2023 lack orders for the identified medications and documentation of the medication discrepancies being discussed during the 02/15/2023 meeting. Review of the clinical record lacks documentation the RN discussed the discrepancies with the physician. B.) Review of the facility referral dated 02/07/2023 revealed the medication order for Dextromethorphan 15 mg/5 ml (milliliter), 10 ml orally every 8 (eight) hours as needed for cough. Review of the Comprehensive Plan of Care dated 02/14/2023 revealed an order for Dextromethorphan Polistirex extended release oral suspension 30 mg/5 ml, take 10 ml (60 mg) by mouth every 12 (twelve) hours as needed. Review of the IDG Meeting Notes dated 02/15/2023 lack orders for the identified medications and documentation of the medication discrepancies being discussed during the 02/15/2023 meeting. Review of the clinical record lacks documentation the RN discussed the discrepancy with the physician. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 03/31/2023 at 09:50 AM, the Clinical Manager stated there was no documentation to clarify the identified discrepancies. Patient #4 - This 81-year-old patient with a terminal diagnosis of cerebral infarction, residing in the in-patient residence, was admitted to the hospice on 02/14/2023. Review of the referral to the agency dated 02/14/2023 revealed the order for Melatonin 3 mg (milligram) tablet take by mouth at bedtime as needed. Review of the IDG (Interdisciplinary) Meeting Notes dated 02/15/2023 and the Plan of Care (POC) dated 02/14/2023 lacks an order for the identified medications and documentation of the medication discrepancy being discussed during the 02/15/2023 IDG meeting. Review of the clinical record lacks documentation the Registered Nurse (RN) discussed the discrepancy with the physician. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. During interview on 03/31/2023 at 10:30 AM, the Clinical Manager stated there was no documentation to clarify the identified discrepancy.

Based on a review of clinical records and staff interviews for two (2) of five (5) patients (Patient #'s: 1 and 2), lack evidence that the hospice nurses and Interdisciplinary Group (IDG) members are performing complete updated comprehensive assessments. Failure to ensure that comprehensive assessments are updated and reflect the patient's current status of the patient has a potential for the patients health to be compromised and can result in poor quality of care. --- Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the agency policy entitled ";Wound Assessment and Treatment" dated 02/2020 revealed ";All patients regardless of location of care must have an integumentary assessment completed when seen for an initial visit and every comprehensive visit, if there is a new wound noted, documentation should occur in the integumentary section of the comprehensive assessment section of the EMR (electronic medical record)." A.) Review of the Patient Encounter Note dated 03/10/2023 revealed the Registered Nurse (RN) documented the following: ";Approximately 2 cm (centimeter) diameter stage II pressure injury noted on sacrum, barrier cream applied." Review of the clinical record lacks documented evidence of a comprehensive assessment of the newly identified sacral wound. Review of the IDG Meeting Notes dated 03/22/2022 (first IDG meeting after sacral wound was identified) lacks documentation of discussion and follow-up regarding the patients new sacral wound. The hospice Nurse failed to ensure that comprehensive assessments are updated and reflect changes in the status of the patient. During interview on 03/30/2023 at 04:16 PM, the Clinical Manager stated the RN who identified the wound failed to notify the Clinical Manager of the new wound and it was not discussed in the identified IDG as neither the RN or Clinical Manager were present at the IDG meeting. B.) Review of the RN Comprehensive Assessment Patient Assessment Report dated 03/22/2023 revealed the following documentation regarding the patients right heel wound: - Wound Type: Right foot/ heel ulcer, osteomyelitis; - Size: Unable to measure; - Tracking: (left blank); - Undermining: (left blank); - Exudate level: (left blank); - Stage: (left blank); - Consistency: (left blank); - Drainage type: (left blank); - Pain Tool: (left blank); - Score: (left blank); and - Wound Care Treatment: Clean with normal saline, pat dry and apply wet to dry dressing daily and PRN. The hospice Nurse failed to perform an updated comprehensive assessment of the patients heel wound. During interview on 03/30/2023 at 04:15 PM, the Clinical Manager stated the wound was not assessed because the dressing had been changed earlier in the day by the in-patient staff, but this was not documented. Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. A.) Review of the RN Comprehensive Assessment Patient Assessment Report dated 02/24/2023 revealed the RN documented the following respiratory assessment: - Patient is experiencing shortness of breath; - Patient is experiencing a dry intermittent cough; - Other respiratory issues- ";Air-hunger", labored breathing; - Respiratory rate- 20 breaths per minute; - Oxygen saturation- 98 % (percent); - Patient is not on oxygen; - Patient with diminished strength and weakness; and - Palliative performance scale (PPS)- 60 (was 70 on 02/14/2023). There is a lack of documentation addressing whether the current respiratory status is distressing to the patient. Review of the IDG Meeting Minutes dated 03/01/2023 revealed the RN reported the following: - Patient gets very short of breath with walking and exertion, having to stop and take breaks to catch his breath. Patient does not have home oxygen in place. - Patient reports that he sleeps in 3 (three) hour blocks at night, waking up frequently to use the bathroom and from coughing. - Patient states that he has Morphine Oral Concentrate in home for shortness of breath but has not tried using it yet. There is a lack of documentation addressing whether the patients respiratory status and labored breathing are distressing to the patient, and whether the RN and IDG re-evaluated the effectiveness of the current plan of care to determine whether additional interventions should be put in place, i.e. the addition of oxygen. The hospice Nurse and IDG failed to address the patient's symptoms and put interventions in place to alleviate the symptoms. During interview on 03/31/2023 at 10:15 AM, the Clinical Manager stated interventions to ease the shortness of breath had been discussed with the patient and with the IDG, but failed to be documented. The Clinical Manager stated the patient was refusing to have oxygen placed in the home but failed to document this. B.) Review of RN Comprehensive Assessment Patient Assessment Report dated 03/25/2023 revealed the patient has intermittent periods of shortness of breath and treatment for shortness of breath was declined by the patient. The patient reports not using the nebulizer therapy, has not tried taking the Miralax to help with bowel movements despite reports of constipation and is avoiding taking the Morphine to ease the shortness of breath. There is a lack of documentation of why the patient is not taking the Miralax, Morphine or nebulizer therapy. Review of the IDG Meeting Notes dated 03/29/2023 revealed the RN reported that the patient is not using the nebulizer therapy, has not tried taking the Miralax to help with bowel movements despite reports of constipation and is avoiding taking the Morphine to ease the shortness of breath. The IDG Physician documented ";appreciate IDG review- continue current RX (prescription) plan." The IDG meeting minutes lack discussion and follow-up regarding the patients non-compliance with the medication regime and alternatives to the current prescribed regimen. The hospice RN and IDG failed to address the patient's symptoms and put interventions in place to alleviate the symptoms. During interview on 03/31/2023 at 10:25 AM, the Director of Patient Services acknowledged the identified documentation lacks discussion and follow-up regarding the patients non-compliance with the prescribed medications and alternatives being discussed.

Based on review of clinical records and interviews with staff for three (3) of five (5) clinical records (Patient #'s: 1, 2 and 5), the hospice failed to provide services according to the Plan of Care (POC). Failure to provide services in accordance with the POC has the potential for unmet patient needs. --- Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the Comprehensive Plan of Care dated 03/09/2023 revealed the following wound care orders to the right heel: Use Metronidazole crushed on wound to help with odor and cleanse with NS (Normal Saline) and Povidone- Iodine Solution daily. Review of the Registered Nurse (RN) Comprehensive Assessment Patient Assessment Report dated 03/22/2023 revealed the RN documented the following wound care treatment to the right heel: Clean with Normal Saline, pat dry and apply wet to dry dressing daily and PRN (as needed). The RN failed to provide wound care as ordered. During interview on 03/30/2023 at 04:12 PM, the Clinical Manager stated she documented the old wound care and failed to document the correct wound care in the identified assessment. Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. Review of the IDG Meeting Note dated 03/01/2023 revealed an order for the patient to receive the RN one time a week and PRN . Review of the clinical record for the week of 03/12/2023 to 03/18/2023 lacks documented evidence the RN made a visit for the week. Review of the clinical record lacks documentation that the patient and/ or physician requested a change in the RN visit frequency. The hospice failed to provide services according to the POC. During interview on 03/31/2023 at 10:15 AM, the Clinical Manager stated the patient refused a RN visit on 03/18/2023 but this was not documented. Patient #5 – This 86-year-old patient with a terminal diagnosis of diastolic heart failure was admitted to the hospice on 10/12/2022. Review of the IDG Meeting Notes dated 01/11/2023 revealed an order for the patient to receive a hospice Aide two times a week and 3 PRN visits. Review of the clinical record for the week of 01/08/2023 to 01/14/2023 revealed the patient received (1) one hospice Aide visit for the week on 01/12/2023. Review of the clinical record from 01/15/2023 to 01/21/2023 revealed the patient received (1) one hospice Aide visit for the week on 01/19/2023. Review of the clinical record from 01/22/2023 to 01/28/2023 revealed the patient received (1) one hospice Aide visit for the week on 01/26/2023. Review of the clinical record lacks documentation that the patient and/ or physician requested a change to the hospice Aide frequency. The hospice failed to provide services according to the POC. During interview on 03/30/2023 at 03:11 PM, the Director of Nursing stated she would look for additional documentation for why the aide made weekly visits for the identified weeks. No additional documentation was provided.

Based on a review of clinical records and interview with agency staff for two (2) of five (5) patients (Patient #'s: 2 and 5), the hospice failed to ensure the patient and/or caregiver received education and training identified in the plan of care (POC). Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. --- Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. Review of the Comprehensive Plan of Care dated 02/14/2023 revealed the patient was ordered to take the following medications: Dextromethorphan Polistirex, Dexamethasone, Morphine Sulfate, Seroquel and Lorazepam. A.) Review of the Registered Nurse (RN) Initial Patient Assessment dated 02/14/2023 revealed the following medication teaching: - Was teaching performed on safe medication administration? Yes; and - Safe medication administration taught to: Patient. (The documentation lacks instruction and the patients understanding of the prescribed medications). The agency failed to ensure the patient received education and training identified in the POC. During interview on 03/31/2023 at 09:48 AM, the Director of Patient Services (DPS) acknowledged the documentation lacks instruction on the medications the patient is ordered to take. B.) Review of the Comprehensive Plan of Care dated 02/28/2023 revealed the following new orders: - Nebulizer machine - Ipratropium- Albuterol Sulfate 0.5-2.5 (3) mg (milligram) /3 ml (milliliter), inhale 3 ml by mouth via nebulizer every 6 (six) hours; and - Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (percent), inhale 3 (three) ml (2.5 mg) by mouth via nebulizer every 3 (three) hours as needed. Review of the clinical record from 02/28/2023 to 03/18/2023 lacks documented evidence the patient and/or caregiver was instructed in using the nebulizer and administering medications through the nebulizer. Review of the RN Comprehensive Assessment Patient Assessment Report dated 03/19/2023 revealed ";Education completed on using nebulizer to help with SOB (shortness of breath) and cough." (The documentation fails to specify the patient/ caregiver response to the teaching and re-demonstration on the use of the nebulizer to administer medications). The agency failed to ensure the patient and/or caregiver received education and training identified in the POC. During interview on 03/31/2023 at 10:22 AM, the Clinical Manager stated the patient demonstrated using the nebulizer to administer the identified medications but failed to document this. Patient #5 - This 83-year-old patient with a terminal diagnosis of diastolic congestive heart failure was admitted to the hospice on 10/12/2022. Review of the Comprehensive Plan of Care dated 10/12/2022 revealed an order for oxygen two (2) liters nasal canula (NC) administer PRN (as needed). Review of the Initial Assessment Patient Assessment Report dated 10/12/2022 revealed the Registered Nurse (RN) documented the following:-Does the patient experience shortness of breath; yes; - was treatment for shortness of breath initiated? yes; - Is the patient on Oxygen; yes continuous;- Delivery source: Nasal cannula. Review of the clinical record lacks documented evidence the patient and/or caregiver was instructed on Oxygen safety. The agency failed to ensure the patient and/or PCG received education and training identified in the POC. During interview on 03/30/2023 at 03:30 PM, the Clinical Manager acknowledged the clinical record lacks the identified education and training and stated it should have been completed.

Based on review of clinical records and interviews with staff, for two (2) of five (5) patients (Patient #'s 2 and 3), the hospice failed to develop an individualized written Plan of Care (POC) that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. --- Patient #3 - This 72-year-old patient with a terminal diagnosis of lung cancer was admitted to the hospice on 02/22/2023. A.) Review of the Comprehensive Plan of Care for the certification period beginning 02/22/2023 revealed the following orders:- Lorazepam oral tablet 0.5 mg (milligram) take 1(one) tablet (0.5 mg) by mouth every 4 hours as needed; - Bisacodyl rectal suppository 10 mg, insert 1 (one) suppository (10 mg) rectally daily as needed;- Haloperidol oral tablet 0.5mg, take 1(one) tablet by mouth every 6 hours as needed; and - Morphine sulfate(concentrate), oral solution 20 mg/ml, take 10 mg by mouth every 4 hours as needed. The as needed (PRN) medications lack indications for use. During interview on 03/31/2023 at 10:52 AM, the Director of Patient Services stated the identified medication orders should include indications for use. B.) Review of the Registered Nurse (RN) Initial Patient Assessment Patient Assessment Report dated 02/22/2023 revealed the RN documented the patient has a history of malignant neoplasm of lower lobe of lung and is using Oxygen. Review of the Comprehensive Plan of Care for the certification period beginning 02/22/2023 lacks an order for Oxygen.Review of the IDG Meeting Notes dated 02/24/2023 lack an order for Oxygen.The POC failed to include an order for the Oxygen use.During interview on 03/31/2023 at 09:25 AM, the Clinical Manager stated it was an oversight that there were no orders for Oxygen on the POC. C.) Review of the RN Initial Patient Assessment Report dated 02/22/2023 revealed the patient uses a Hoyer lift, and that extensive education was given to the family on safe use of the Hoyer in the home. Review of the Comprehensive Plan of Care for the certification period beginning 02/22/2023 lacks an order for the Hoyer lift. Review of the IDG Meeting Notes dated 02/24/2023 lacks an order for the Hoyer lift.The POC failed to include an order for the patient's Hoyer lift.During interview on 03/31/2023 at 09:25 AM, the Clinical Manager stated she was not aware the order should have been included on the POC. Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. A.) Review of the RN Initial Patient Assessment dated 02/14/2023 revealed the patient was experiencing shortness of breath, intermittent coughing, labored breathing, was not ordered Oxygen and had a room air Oxygen saturation of 97 % (percent). Review of the IDG (Interdisciplinary Group) Meeting Notes dated 02/15/2023 revealed the following: - The Registered Nurse (RN) reported the patient gets very short of breath with exertion, is not using Oxygen at this time, has to stop and take breaks to catch his breath and reports constant dry cough while sitting that lessons when lays down. - The hospice Physician reported to continue current RX (prescription) plan. There is a lack of documentation addressing whether the patients respiratory status and labored breathing are distressing to the patient, and if a discussion regarding interventions to manage symptoms occurred. Review of the Comprehensive Plan of Care for the certification period beginning 02/14/2023 lacks interventions to manage the patients respiratory symptoms. The hospice failed to develop an individualized POC. During interview on 03/31/2023 at 09:49 AM, the Clinical Manager stated having had a discussion with the patient regarding Oxygen being placed in the home but the patient was refusing Oxygen. The Clinical Manager stated she failed to document this. B.) Review of the RN Initial Patient Assessment dated 02/14/2023 revealed the patient reports having a fall at home the previous week when standing up too quickly, causing lightheadedness and denies injury. The patient was assessed to have a palliative performance scale (PPS) of 70 % and was experiencing diminished strength and weakness. Review of the IDG Meeting Notes dated 02/15/2023 revealed the following: - The RN reported the patient had a fall at home the previous week when standing up quickly, causing lightheadedness and denies injury; and - The hospice Physician reported to continue current RX plan. The meeting lacks a discussion of interventions and/ or equipment that would be beneficial to prevent patient falls. Review of the Comprehensive Plan of Care for the certification period beginning 02/14/2023 revealed the following: - The patient is ordered to be activity as tolerated; - Patient Goal: To be free from harm; and - Patient Intervention: Patient will be encouraged to use MDEs (DME, durable medical equipment) appropriately. The orders to not include DME and/ or interventions for fall prevention. The hospice failed to develop an individualized POC. During interview on 03/31/2023 at 10:05 AM, the Clinical Manager stated the patient was assessed, offered and declined the use of DME to be used in the home which she failed to document.

Based on review of clinical records, agency policy and procedure, and interview with staff, for one (1) of five (5) patients (Patient #2) , the hospice failed to ensure the Plan of Care (POC) included effective interventions to manage patient pain and symptoms. Failure to ensure effective interventions to address the patient's needs for pain and symptom management has the potential to result in unmet patient needs, may diminish quality of life for the patient, and may result in negative patient outcomes. --- Review of agency policy entitled ";Plan of Care- Establishment, Content and IDG (Interdisciplinary Group) Review" revised 04/13/2022 revealed ";The Comprehensive Plan of Care is designed to address needs related to the terminal illness and for each problem or need identified, the Care Plan will include goal(s), plan(s), and outcomes." Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. Review of the RN Initial Patient Assessment dated 02/14/2023 revealed the patient was experiencing shortness of breath, intermittent coughing, labored breathing, was not ordered Oxygen and had a room air Oxygen saturation of 97 % (percent). Review of the Comprehensive Plan of Care for the certification period beginning 02/14/2023 revealed the following: - Issue: Safety Risk; - Goal: Patient will remain free from harm; - Intervention: Patient will be encouraged to use MDEs (durable medical equipment) appropriately. The POC lacks effective interventions regarding the patients difficulty breathing identified in the comprehensive assessment. Review of the clinical record lacks documented evidence of the POC being updated with additional individualized interventions. The hospice failed to ensure the POC includes effective interventions to manage patient pain and symptoms. During interview on 03/31/2023 at 09:43 AM, the Clinical Manager stated the POC lacks interventions to manage the patients primary symptoms.

Based on review of clinical records, agency policy and procedure and staff interview, for two (2) of five (5) patients (Patient #'s: 4 and 5), the agency failed to ensure the Interdisciplinary Group (IDG), in collaboration with the patient's physician, reviewed and revised the individualized plan of care (POC) as changes occurred, but no less frequently than every fifteen (15) days. Failure of the IDG to develop, review and revise the POC has the potential for unmet patient needs and inadequate care. --- Patient #5 – This 86-year-old patient with a terminal diagnosis of diastolic heart failure was admitted to the hospice on 10/12/2022. Review of the agency policy entitled ";Plan of Care- Establishment, Content and IDG Review" revised 04/13/2022 revealed ";Efforts to involve the patients attending physician (if there is one) in the development and updating of the hospice plan of care and the results of those efforts are documented in the patients clinical record." Review of the Hospice Election Statement dated 10/12/2022 revealed the patient chose her private physician as her attending physician to work in collaboration with the hospice to oversee her care. Review of the IDG Meeting Notes dated 03/08/2023 revealed the following Registered Nurse (RN) documentation: "Daughter reports patient has foul odor to urine, urine appears cloudy with foul odor upon assessment. Hospice Medical Director notified and new order for Cipro 250 mg (milligrams) BID (twice daily) X 5 (times five) days for UTI (urinary tract infection)." Review of the IDG Meeting Notes dated 03/08/2023 lack documented evidence the patients attending physician participated in the IDG meeting. Review of the clinical record lacks documented evidence the patients attending physician was notified of the identified update to the POC. The hospice failed to collaborate with the attending physician regarding updates to the POC. During interview on 03/30/2023 at 02:43 PM, the Chief Executive Officer stated the agency failed to update the attending physician of the identified changes. Review of the Hospice's policy entitled "Plan of Care -Established Content and IDG Review" dated 04/13/2022 revealed the following: "Efforts to involve the patients attending physician (if there is one) in the development and updating of the hospice plan of care and the results of those efforts are documented in the patients record. 12. Review of, and changes to the plan of care are documented and communicated to members of the IDG." Patient #4 - This 81-year-old patient with a terminal diagnosis of cerebral infarction, residing in the in-patient residence, was admitted to the hospice on 02/14/2023. Review of the RN (Registered Nurse) Comprehensive Assessment Patient Assessment dated 03/17/2023 revealed the RN documented the patient has some excoriation under both breasts being treated with Clotrimazole-Betamethasone External Cream 1-0.05 % and is now improving since discontinuing Nystatin powder. Review of the Comprehensive Plan of Care dated 03/23/2023 reveals the following orders: - Clotrimazole-Betamethasone External Cream 1-0.5%, Apply 1(one) application topically to affected area 2 (two) times per day; and -Nystatin Powder 1 (one) application in the morning and in the evening. Review of the IDG Meeting notes dated 03/29/2023 revealed an order for Nystatin Powder, 1 (one) application in the morning and in the evening. Review of the IDG Meeting Notes dated 03/29/2023 failed to reflect the patient was no longer using the Nystatin Power. The RN failed to update the POC and IDG Meeting Notes to reflect that the patient was no longer using the Nystatin powder. During interview on 03/31/2023 at 10:37 AM, the Clinical Manager stated the identified medication was discontinued and should not have been removed from the POC.

Based on review of clinical records and interview with staff, for one (1) of five (5) patients (Patient #1), the hospice failed to ensure ongoing sharing of information between all disciplines providing care. Failure to ensure the ongoing sharing of information has the potential for unmet patient needs. --- Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the Patient Encounter Note dated 03/21/2023 revealed the Registered Nurse (RN) documented the following: - Patient ate 50% (percent) of dinner (had been eating 100% of previous meals); - Patients daughter came in for a visit and requested to know if the patient could restart taking Prozac, as had been previously prescribed. Additionally, the daughter reported the patient is no longer interested of spiritual or bereavement care. The RN left a message for the physician of the request for the following day. Review of the IDG Meeting Notes dated 03/22/2023 revealed the following documentation: - The RN reported patients Palliative Performance Scale (PPS) rating has declined to 30 (was 70 on 02/14/2023) and has no urgent needs at this time; - The Social Worker reported patient verbalized feeling confused at this time as he has exceeded the prognosis given by the hospital physician; - The Bereavement Coordinator reported the patient does not want to receive spiritual care or bereavement services anymore; and - The hospice Medical Director ordered to continue current RX (prescription) plan except to have labs rechecked regarding prognosis. The IDG lacks discussion and follow-up regarding the daughters request for the patient to restart taking Prozac, an antidepressant. Review of the clinical record lacks documentation of follow-up regarding the family request of the patient restarting Prozac. The hospice staff failed to follow-up with patient/ patients family regarding the identified request. During interview on 03/30/2023 at 04:18 PM, the Clinical Manager stated she would look for additional documentation regarding follow-up of the identified issue. No further documentation was provided.

Based on review of clinical records and interviews with agency staff for two (2) of five (5) patients receiving Social Work Services (Patient #s 1 and 5), the Licensed Medical Social Worker (LMSW) failed to adequately supervise the unlicensed Social Worker to ensure the hospice plan of care was followed and all patients needs were met. Failure to adequately supervise the unlicensed Social Worker may lead to unmet needs and adverse patient outcomes. --- Review of the agency policy entitled ";Social Work" revised 07/14/2021 revealed ";SW (Social Worker) with a bachelors in social work will be supervised by an MSW (Master Social Worker) and receive regular onsite supervision during a patient visit." Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the Social Worker Initial/ Comprehensive Assessment Patient Assessment Report dated 03/06/2023 revealed the unlicensed Social Worker completed the admission assessment. Review of the IDG (Interdisciplinary Group) Meeting Notes dated 03/08/2023 revealed orders for Social Worker 2x (two times) per month with 2 PRN (as needed) visits. Review of the Clinical Record lacks documented evidence the LMSW provided supervision and oversight of the unlicensed Social Worker. The hospice failed to supervise unlicensed staff. During interview on 03/30/2023 at 04:02 PM, the Director of Patient Services acknowledged the unlicensed Social Worker was not supervised. Patient #5 – This 86-year-old patient with a terminal diagnosis of diastolic heart failure was admitted to the hospice on 10/12/2022. Review of the IDG Meeting Notes dated 01/11/2023 revealed an order for Social Worker 2x month and 2 PRN visits. Review of the clinical record for the second certification period beginning 01/10/2023 revealed the unlicensed Social Worker made home visits on 01/27/2023 and 03/09/2023. Review of the Clinical Record lacks documented evidence the LMSW provided supervision and oversight of the unlicensed Social Worker. The hospice failed to supervise unlicensed staff. During interview on 03/30/2023 at 02:57 PM, the Chief Executive Officer acknowledged the LMSW failed to supervise the unlicensed Social Worker.

Based on review of clinical records and interviews with staff, for one (1) of three (3) patients receiving Aide services (Patient #5), the hospice failed to ensure the Aide Plan of Care (POC) is complete. Failure to ensure the Aide POC is complete and accurate has the potential for the patient to receive inappropriate care. --- Patient #5 – This 86-year-old patient with a terminal diagnosis of diastolic heart failure was admitted to the hospice on 10/12/2022. Review of the Comprehensive Plan of Care dated 10/20/2022 revealed an order for Oxygen 2 L (liters) NC (nasal cannula), PRN (as needed). Review of the Comprehensive Plan of Care dated 10/27/2022 revealed the following orders: - Hospice Aide 1x (one time) weekly and 3 PRN visits; - The hospice Aide is assigned the following tasks: - Feed patient as needed every visit; - Comb/ brush hair as desired by patient every visit; - Shampoo as desired by patient every visit; - File nails as needed and tolerated by patient every visit; - Oral care assist as desired by patient every visit; - Assist with dressing as desired by patient every visit; - Change bed linens every visit; - Apply lotion as desired by patient every visit; - Shower or bed bath every visit; and - Toileting, bed pan/ bed side assist every visit. The Aide Care Plan lacks instructions for 2L PRN Oxygen use and Oxygen precautions to be followed. The hospice failed to ensure the Aide POC is complete. During interview on 03/30/2023 at 03:05 PM, the Director of Patient Services acknowledged the Oxygen instructions were lacking from the Aide POC and stated they should have been included.

Based on clinical record review and staff interview, five (5) of five (5) patient records (Patient #s: 1, 2, 3, 4 and 5) lack documented evidence of clinical information necessary for certification of the terminal illness, and evidence of an initial certification of terminal illness being completed by the Medical Director and Attending Physician within 2 (two) calendar days of the patient electing hospice services (Patient #5). Failure to ensure the information used to establish the patient's eligibility for hospice services and certify the terminal illness is in the clinical record, and to ensure the hospice Medical Director and Attending Physician certifies the terminal illness, has the potential for ineligible persons to be admitted to hospice services. --- Patient #5 - This 83-year-old patient with a terminal diagnosis of diastolic congestive heart failure was admitted to the hospice on 10/12/2022. Review of the patients Hospice Election Statement revealed the patient elected to receive hospice services on 10/12/2022. A.) Review of the Hospice Initial Certification (of terminal illness) provided on 03/30/2023 revealed the following: - the hospice Medical Director electronically signed but failed to date the document; and - The Attending Physician had not signed or dated the document. During interview on 03/29 2023 at 03:29 PM, the Chief Executive Officer acknowledged the identified document was incomplete and stated she would look for additional documentation. Review of the Hospice Initial Certification provided by the Chief Executive Officer on 03/31/2023 at 03: 35 PM, revealed the Attending Physician signed and dated the document on 12/16/2022 (sixty-five days after the election of the hospice benefit). Additionally, the hospice Medical Director signed and dated the document on 12/21/2022 (seventy days after the election of the hospice benefit). The hospice failed obtain an initial verbal or written certification of terminal illness within the required timeframe. During interview on 03/31/23 at 03: 40 PM, the Social Worker stated the identified document was mailed to the Attending Physician upon election to the hospice, but they did not receive the document back via regular mail until 12/16/2022. The Social Worker stated being unable to locate any documentation showing the agency obtained a verbal certification order from the Attending Physician. During interview on 03/31/2023 at 03:45 PM, the Chief Executive Officer stated being able to locate another copy of the certification of terminal illness and acknowledged the hospice Medical Director failed to complete the initial certification document within the required time frame and had no explanation of why this occurred. B.) Review of the Certification of Terminal Illness for the certification period from 10/12/2022 to 01/09/2023 revealed the hospice Medical Director documented the patients terminal diagnosis is end-stage chronic diastolic heart failure and based on known natural disease progression, survival is anticipated to be less than 6 (six) months of life. The certification lacks related diagnoses, current subjective and objective medical findings, current medication and treatment orders and information about the medical management of any of the patients conditions unrelated to the terminal illness. Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the Hospice Election Statement revealed the patient elected to receive hospice services on 03/06/2023. Review of the Certification of Terminal Illness for the certification period from 03/06/2023 to 06/03/2023 revealed the hospice Medical Director documented the patients terminal diagnosis is underlying sepsis and based on known natural disease progression, survival is anticipated to be less than six (6) months of life. The certification lacks a primary terminal condition, related diagnoses, current subjective and objective medical findings, current medication and treatment orders and information about the medical management of any of the patients conditions unrelated to the terminal illness. Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. Review of the Hospice Election Statement revealed the patient elected to receive hospice services on 02/14/2023. Review of the Certification of Terminal Illness for the certification period from 02/14/2023 to 05/14/2023 revealed the hospice Medical Director documented the patients terminal diagnosis is metastatic malignant lung carcinoma and based on known natural disease progression, survival is anticipated to be less than six (6) months of life. The certification lacks related diagnoses, current subjective and objective medical findings, current medication and treatment orders and information about the medical management of any of the patients conditions unrelated to the terminal illness. Patient #3 - This 72-year-old patient with a terminal diagnosis of lung cancer was admitted to the hospice on 02/22/2023. Review of the Hospice Election Statement revealed the patient elected to received hospice services on 02/22/2023. Review of the Certificate of Terminal Illness for the certification period 02/22/2023 to 05/23/2023 revealed the hospice Medical Director documented the patient is terminally ill with a life expectancy of six (6) months or less if the terminal illness runs its normal course. The certification lacks the primary terminal condition, related diagnoses, current subjective and objective medical findings, current medication and treatment orders and information about the medical management of any of the patients conditions unrelated to the terminal illness. Patient #4 - This 81-year-old patient with a terminal diagnosis of cerebral infarction, residing in the in-patient residence, was admitted to the hospice on 02/14/2023. Review of the Hospice Election Statement revealed the patient elected to received hospice services on 02/14/2023. Review of the Certification of Terminal Illness for the certification period from 02/014/2023 to 05/14/2023 revealed the hospice Medical Director documented the patients terminal diagnosis is underlying cerebrovascular accident (CVA) and based on known natural disease progression, survival is anticipated to be less than six (6) months of life. The certification lacks related diagnoses, current subjective and objective medical findings, current medication and treatment orders and information about the medical management of any of the patients conditions unrelated to the terminal illness. The hospice failed to ensure the Certification of Terminal Illness was comprehensive to determine eligibility for hospice services. During interview on 03/31/2023 at 10:56 AM, the Chief Executive Officer acknowledged the identified Certifications lack the required documentation to assess hospice eligibility and was unable to provide an explanation for this.

This tag is no longer active in the hospice 5.01 regulation set and will be cited in L- 0672. --- There are no findings for this citation and will be cited in L- 0672.

Based on review of clinical records and interview with agency staff, for three (3) of five (5) patients (Patient #s 1, 2 and 5), the hospice failed to ensure the clinical record contains accurate and complete information regarding the patient's current status. Failure to ensure that clinical records are complete and accurate has the potential for agency staff to act on inaccurate information and may place the patient's health and welfare at risk. --- Patient #1 – This 84-year- old patient with a terminal diagnosis of streptococcal sepsis, residing in the in-patient residence, was admitted to the hospice on 03/06/2023. Review of the Comprehensive Plan of Care for the certification period beginning 03/06/2023 revealed an order for Miralax Oral Powder 17 gm (gram)/scoop, take 17 gm by mouth daily, PRN (as needed) for constipation. Review of the Registered Nurse (RN) Initial Patient Assessment revealed the following documentation: - Does the patient have a bowel regimen? Yes; and - Treatment: Enema, Prescriptive Medication, Suppositories. Review of the RN Comprehensive Assessment Patient Assessment Report dated 03/22/2023 revealed the following documentation: - Does the patient have a bowel regimen? Yes; - Date order was initiated or continued: 03/06/2023; and - Treatment: Enema, Prescriptive Medication, Suppositories. Review of the clinical record lacks documented evidence of an order for Enemas or Suppositories to be administered to the patient. The documentation is inconsistent regarding the Enema and Suppositories being used for the patients bowel regimen. During interview on 03/30/2023 at 04:08 PM, the Clinical Manager stated the RN documented incorrectly in each identified visit as the patient did not have Enemas or Suppositories ordered. Patient #2 – This 65-year-old patient with a terminal diagnosis of metastatic malignant lung carcinoma was admitted to the hospice on 02/14/2023. A.) Review of the clinical record revealed the unlicensed Social Worker made an initial patient assessment visit on 02/14/2023. Review of the indirect Social Worker Supervisory Visit Patient Assessment Report dated 02/22/2023 revealed the following: ";LMSW (Licensed Master Social Worker) reviewed BSWs (bachelor degree Social Worker) patients EMR (electronic medical record) 02/09/23. LMSW agrees with plan of care with no further recommendations. Patient/ family satisfied with care." The documentation is inconsistent regarding the referenced date of 02/09/2023 as the patient had not been admitted to the hospice until 02/14/2023. During interview on 03/31/2023 at 10:13 AM, the Director of Patient Services stated the LMSW documented the incorrect date. The visit should have been documented as 02/14/2023. B.) Review of the Comprehensive Plan of Care dated 02/28/2023 revealed the following orders: - Ipratropium- Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligram)/ 3 ml (milliliter), inhale 3 ml by mouth via nebulizer every 6 (six) hours; and - Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (percent), inhale 3 ml (2.5 mg) by mouth via nebulizer every 3 (three) hours as needed. Review of the Registered Nurse (RN) Routine Patient Assessment Report dated 03/01/2023 revealed the following documentation: - Does the patient require breathing treatment/ handheld Nebulizer? Yes; - Type: Nebulizer; - Medication: Duoneb (Ipratropium- Albuterol Inhalation Solution) and Albuterol; and - Frequency: TID (three times daily) and every 3 (three) hours PRN (as needed). Review of the clinical record lacks documented evidence of an order for Duoneb (Ipratropium- Albuterol Inhalation Solution) being administered TID. The documentation is inconsistent regarding if the Duoneb (Ipratropium- Albuterol Inhalation Solution) is being administered TID or every 6 (six) hours. During interview on 03/31/2023 at 10:18 AM, the Clinical Manager stated she documented incorrectly as the patient received the medication every 6 (six) hours. Patient #5 – This 86-year-old patient with a terminal diagnosis of diastolic heart failure was admitted to the hospice on 10/12/2022. Review of the Comprehensive Plan of Care dated 10/20/2022 revealed an order for Oxygen 2 L (liters) via NC (nasal cannula), PRN. Review or the RN Comprehensive Assessment Patient Assessment Report dated 01/06/2023 revealed the following: - Is Oxygen present? No. Review of the clinical record lacks an order to discontinue the Oxygen therapy. The documentation is inconsistent regarding weather the patient has Oxygen in place at the home. During interview on 03/30/2023 at 3:00 PM, the Clinical Manager stated she answered the question interpreting it to mean if the patient was wearing the Oxygen at the time of the assessment. During interview on 03/30/2023 at 3:03 PM, the Director of Patient Services stated the question was asking if the patient had Oxygen in place in the home, which the patient had, and should have been answered ";yes".

Based on clinical record review, agency policy and procedure and staff interview, for one (1) of one (1) discharged records (Patient #5), the hospice failed to ensure a discharge summary was prepared and submitted to the Attending Physician. Failure to prepare a discharge summary and notify the physician of the patient's discharge places all patients at risk for poor coordination of patient services and unmet patient needs upon discharge from the hospice. --- Patient #5 – This 86-year-old patient with a terminal diagnosis of diastolic heart failure was admitted to the hospice on 10/12/2022. Review of the agency policy and procedure entitled ";Discharge From Hospice Care" revised 03/09/2022 revealed: ";Prior to discharge, the hospice obtains a written physicians discharge order from the hospice physician and consults with the patients attending physician, documenting his/ her review of the discharge decision in the discharge note or summary. The hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patients attending physician." Review of the IDG (interdisciplinary Group) Meeting Notes dated 03/22/2023 revealed the patient/ caregiver had revoked hospice services upon transfer to a long term care facility that did not have a contract with the hospice. Review of the clinical record lacks documented evidence of the Attending Physician being notified of the patients discharge. During interview on 03/30/2023 at 02:39 PM, the Director of Patient Services acknowledged the hospice failed to follow the discharge policy and procedure and did not notify the Attending Physician of the patients revocation of hospice.

Based on clinical record review, agency policy and procedure and staff interview the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components for one (1) of one (1) patients discharged (Patient #5). Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice. --- Review of the agency policy and procedure entitled ";Discharge From Hospice Care" revised 03/09/2022 revealed: ";Prior to discharge, the hospice obtains a written physicians discharge order from the hospice physician and consults with the patients attending physician, documenting his/ her review of the discharge decision in the discharge note or summary. The hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patients attending physician. This discharge summary is filed in the clinical record and includes: a. the date of discharge, b. the reason for the discharge, c. a summary of the patients stay including treatments, and symptom and pain management, e. the patients latest physician orders, and f. any other documentation that will assist in post- discharge continuity of care." Patient #5 – This 86-year-old patient with a terminal diagnosis of diastolic heart failure was admitted to the hospice on 10/12/2022 and discharged on 03/17/2023. Review of the IDG (interdisciplinary Group) Meeting Notes dated 03/22/2023 revealed the patient/ caregiver had revoked hospice services upon transfer to a long term care facility that did not have a contract with the hospice. Review of the clinical record lacks documented evidence of a discharge summary being completed. The hospice failed to complete a discharge summary upon the revocation of hospice services. During interview on 03/30/2023 at 02:37 PM, the Director of Patient Services acknowledged the hospice failed to follow the discharge policy and procedure and there is no discharge summary.

Based on observation the facility did not maintain one of four delayed-egress locking devices on exit doors. Findings include: During the facility tour, on 08/25/2022 at 10:10 am, in the dining area the exit door on the right, the door did not release within 15 seconds. The audible alarm, for the delayed-egress locking device, was intermittent. The alarms on other doors tested had an audible alarm tone that was consistent until the door released. The magnetic hold did not release for two of three times tested. This finding was verified with staff S, Maintenance, on 08/29/2022 at 10:10 am.

Based on observation the facility did not ensure that the generator is mainatined. Findings include: During the facility tour, on 08/29/2022 at 10:45 am, it was observed that there was a small amount of antifreeze on the top of the radiator. There was white salt build up near the radiator hose at th etop of the radiator. When the small amount of radiator fluid was wiped away a droplet did reform. This finding was veriefed with staff S, Maintenance on 08/29/2022 at 11:30 am.