Every finding on record at Hospice of the Sacred Heart

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting one of one floor. Findings include: 1. Observation on January 30, 2025, at 12:23 p.m., revealed the facility lacked current internal valve and internal pipe inspection data, as well as current sprinkler gauge data (service on internal pipe, internal valve, and sprinkler gauge replacement last performed on 5/3/2018). Exit interview with the Facility Administrator on January 30, 2025, between 1:00 p.m., and 1:10 p.m., confirmed the automatic sprinkler system deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain fire drills in several instances, affecting one of one floor. Findings include: 1. Observation on January 30, 2025, at 12:40 p.m., revealed the previous twelve required fire drills were conducted conducted within a six day period, at the end of each month (between the 25th and 30th of each month). Exit interview with the Facility Administrator on January 30, 2025, between 1:00 p.m., and 1:10 p.m., confirmed the fire drill deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain receptacles in multiple locations, affecting one of one floor. Findings include: 1. Observation on January 30, 2025, at 12:49 a.m., revealed the facility lacked annual receptacle testing data. Exit interview with the Facility Administrator on January 30, 2025, between 1:00 p.m., and 1:10 p.m., confirmed the receptacle testing deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting one of one floor. Findings include: 1. Observation on January 30, 2025, at 12:55 p.m., revealed the facility lacked data to support the required three-year, four hour load test of the generator set. Exit interview with the Facility Administrator on January 30, 2025, between 1:00 p.m., and 1:10 p.m., confirmed the generator set deficiency.

Based on review of hospice policy/procedure and clinical records and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure visit frequencies were established in accordance with hospice admission orders for three (3) of fourteen (14) active patients for whom the initial certification period was reviewed. (Patients #14, #20 and #21) --- Findings include: On January 10, 2025 at approximately 3:12 PM, review of hospice policy HC.V05, titled "Visit Frequencies" revealed the following under "Procedure": 2. Visit frequency or routine orders must be individualized to address the specific patient's needs... Patient #14: On January 9, 2025 at approximately 12:34 PM, review of the clinical record revealed the hospice services were initiated on 12/30/2024 as documented on the hospice election of benefit form dated 12/30/2024. Review of the "Physican Orders for Hospice Patient" dated 12/30/2024 revealed the hospice admission orders included the following physician orders: RN to assess patient and establish plan of care with pt/family/caregiver and attending physician. Establish frequencies within 5 days of patient admission. Review of "Nurse Progress Note Initial Assessment" documentation for the 12/30/2024 start of care (admission) visit revealed that in addition to skilled nursing (SN) services, the patient accepted social work (SW) services. Review of routine visit documentation revealed SN services were provided on 12/30/2024 and 01/02 and 01/07/2025 and that SW services were provided on 01/03/2025. There was no documentation in the clinical record which provided evidence that a SN and SW visit frequency had been established within 5 days of the patient admission. Patient #20: On January 9, 2025 at approximately 3:30 PM, review of the clinical record revealed the hospice services were initiated on 12/20/2024 as documented on the hospice election of benefit form dated 12/20/2024. Review of the "Physican Orders for Hospice Patient" dated 12/20/2024 revealed the hospice admission orders included the following physician orders: RN to assess patient and establish plan of care with pt/family/caregiver and attending physician. Establish frequencies within 5 days of patient admission. Review of "Nurse Progress Note Initial Assessment" documentation for the 12/20/2024 start of care (SOC) visit revealed that in addition to SN services, the patient accepted SW and hospice aide services. Review of routine visit documentation SN services were provided on 12/20, 12/23 and 12/30/2024 and on 01/02 and 01/06/2025, that SW services were provided on 12/23 and 12/31/2024 and that hospice aide services were provided on 12/31/2024 and 01/02 and 01/06/2025. Review of "Physician Order for Hospice Patient" documentation revealed physician orders for SN, SW and hospice aide visit frequencies were obtained on 12/31/2024 which was more than 5 days after the SOC. There was no documentation in the clinical record which provided evidence that SN, SW and hospice aide visit frequencies had been established within five (5) days of the patient admission. Patient #21: On January 9, 2025 at approximately 3:49 PM, review of the clinical record revealed the hospice services were initiated on 12/31/2024 as documented on the hospice election of benefit form dated 12/31/2024. Review of the "Physican Orders for Hospice Patient" dated 12/31/2024 revealed the hospice admission orders included the following physician orders: RN to assess patient and establish plan of care with pt/family/caregiver and attending physician. Establish frequencies within 5 days of patient admission. Review of "Nurse Progress Note Initial Assessment" documentation for the 12/31/2024 SOC visit revealed that in addition to SN services, the patient accepted SW and hospice aide services. Review of routine visit documentation SN services were provided on 12/31/2024 and on 01/02/2025 and that SW services were provided on 01/02/2025. There was no documentation in the printed clinical record which provided evidence hospice aide services had been provided between 12/31/2024 and 01/08/2025. Review of "Physician Order for Hospice Patient" documentation revealed physician orders for SN, SW and hospice aide visit frequencies were obtained on 01/06/2025 which was more than 5 days after the SOC. There was no documentation in the clinical record which provided evidence that SN, SW and hospice aide visit frequencies had been established within five (5) days of the patient admission. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed there was no documentation in the clinical record which provided evidence that the above referenced frequencies had been established within five (5) days of patient admission for the above identified patients.

Based on review of hospice policies/procedures, initial tuberculosis (TB) screening guidance from the Centers for Disease Control (CDC) and personnel files and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure TB screening was conducted in accordance with hospice policies/procedures and CDC recommendations for two (2) of two (2) core hospice employees whose date of hire was after January 13, 2022. (Employees 4 and #6) --- Findings include: On January 10, 2025 at approximately 2:54 PM, review of hospice policy HR.H10, titled "Health/Physical Requirements" revealed the following under "Procedure": 6. All employees and volunteers are required to have documented evidence of a tuberculin screening prior to patient contact. All employees and volunteers are required to complete the two-step PPD (tuberculin purified protein derivative) test if it has been more than one year since their last test was given. The second test must be performed within one to three weeks of the first test. On January 10, 2025 at approximately 3:20 PM, review of hospice policy PC.I60, titled "Infection Control-Tuberculosis Exposure Plan", revealed the following under "Procedure": 1. Testing...(C) Information from the baseline individual TB risk assessment should be used to interpret the results of a TB blood test or TB skin test given on hire. On January 10, 2025 at approximately 3:31 PM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/baseline-testing.html : The TB screening process for health care personnel includes: -A baseline individual TB risk assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step)). On January 10, 2025 at approximately 10:45 AM and January 14, 2025 at approximately 8:09 AM, review of personnel file documentation revealed the following: Employee #4: The date of hire of the registered nurse (RN) was 06/21/2023. Review of TB questionnaire documentation dated 06/21/2023 revealed the RN experienced an allergic reaction to a prior TB skin test and that the RN did not have a past history of a positive PPD result. There was no documentation in the personnel file which provided evidence that a TB blood test had been completed. Employee #6: The date of hire of the RN was 03/06/2023. There was no documentation in the personnel file which provided evidence the RN had completed the second step of the TST. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed TB screening was not conducted in accordance with the above referenced policies/procedures, nor CDC recommendations, for the above identified core hospice staff members.

Based on review of hospice policy/procedure and clinical records, pressure injury (bedsore) guidance from the Cleveland Clinic and the Hospice and Palliative Nurses Association, and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure pressure-type wound assessment was completed in accordance with hospice policy/procedure and professional standards for three (3) of three (3) patients for whom an open wound was assessed by skilled nursing (SN) staff. (Patients #5, #11 and #25) --- Findings include: On January 10, 2025 at approximately 3:15 PM, review of hospice policy PC.A80, titled "Comprehensive Assessment of the Patient" revealed the following under "Procedure": 6. The hospice's assessment and reassessment tool contain data elements that allow for the measurement of outcomes. On January 10, 2025 at approximately 3:13 PM, review of the hospice procedure titled "Protocol for Wound Care" revealed the following: 1. Assessment...A. Once a wound has been identified and staged, the following categories will be part of the ongoing assessment: Size... On January 14, 2025 at approximately 9:00 AM, review of the Cleveland Clinic website revealed the following under the article titled "Bedsores (Pressure Injuries)" https://my.clevelandclinic.org/health/diseases/17823-bedsores-pressure-injuries : Stages of bedsores or pressure ulcers include....Stage 2: A shallow wound with a pink or red base develops. You may see skin loss, abrasions and blisters. On January 14, 2025 at approximately 9:30 AM, review of the Hospice and Palliative Nurses Association article titled "Hospice & Palliative Wound Care" revealed the following: Wound Assessment...perform a wound assessment on admission, weekly, and if the patients condition deteriorates. Key clinical observations include...Size (length, width, and depth)... Patient #5: On January 7, 2025 at approximately 11:01 AM, review of the clinical record revealed hospice problems include skin integrity and that the problem interventions include assessment and monitoring for skin integrity changes as documented on the "Combined Disciplinary Plan of Care" dated 01/02/2025. Review of "Inpatient Nurse Progress Note Routine Visit" documentation dated 01/05/2025 revealed a new open wound was present on the left inner buttocks and that barrier cream was applied to the wound. There was no documentation in the clinical record which provided evidence the inpatient unit SN (Employee #12) assessed the depth of the open left inner buttocks wound on 01/05/2025. Patient #11 (Closed Record): On January 9, 2025 at approximately 9:20 AM, review of the clinical record revealed a new open pressure area was present on the left inner ankle, that a new wound treatment was ordered and that skin integrity interventions included assessment and monitoring wound for changes in healing as documented on the "Nurse Progress Note Routine Visit" dated 08/07/2024. There was no documentation in the clinical record which provided evidence the hospice SN (Employee #13) assessed the depth of the open left ankle wound on 08/07/2024. Patient #25: On January 10, 2025 at approximately 7:39 AM, review of the clinical record revealed a new open pressure blister was present on the right buttock and that goals included for skin integrity to be maintained as feasible as documented on the "Nurse Progress Note Routine Visit" dated 01/06/2025. There was no documentation in the clinical record which provided evidence the hospice SN (Employee #14) assessed the depth of the open right buttock wound on 01/06/2025. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed there was no documentation in the clinical record which provided evidence the depth of the above referenced wounds had been assessed for the above identified patients.

Based on review of hospice policy/procedure and documentation and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure one (1) of two (2) durable medical equipment (DME) companies were accredited as a DME supplier. (DME #1) --- Findings include: On January 10, 2025 at approximately 2:48 PM, review of hospice policy PC.D30, titled "Durable Medical Equpment" revealed the following under "Procedures": 1. The hospice maintains contracts with accredited DME providers for the provision of safe and effective DME for the hospice patients. During interview conducted on January 8, 2025 at approximately 4:02 PM, the Director of Human Services reported DME supplier #1 (DME #1) supplies Broda chairs (tilt-in-space positioning chairs) to hospice patients. On January 8, 2025 at approximately 3:12 PM, review of hospice contract documentation revealed DME #1 became a hospice contracted DME supplier effective 05/29/2024. There was no documentation which provided evidence that DME #1 had obtained accreditation as a DME supplier. On January 10, 2025 at approximately 2:59 PM, review of hospice documentation revealed DME #1 supplied 11 hospice patients with DME equipment between May and December 2024. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed there was no documentation which provided evidence that DME #1 had obtained accreditation as a DME supplier.

Based on review of hospice policy/procedure, documentation and clinical records, and based on interview with skilled nursing facility staff (SNF-social worker (SW)) and the hospice Director of Human Services (Employee #7), the hospice failed to provide a SNF with a copy of the current hospice plan of care for two (2) of two (2) patients. (Patients #6 and #7) --- Findings include: On January 10. 2-25 at approximately 2:50 PM, review of hospice policy PC.H40, titled Hospice Care for Nursing Facility Residents-Coordination of Care" revealed the following under "Procedures": 3. The following information is provided to the facility: (1) The most recent hospice plan of care specific to each patient... On January 8, 2025 at approximately 2:44 PM, review of the hospice contract with SNF #1, which was signed by hospice administrative designee and SNF administrator on 12/13/2021, revealed the following under "Section IV-Cooperation in Professional Management": The Home (SNF) will designate a member of the Home's Interdisciplinary Team to be responsible for working with Hospice representatives to coordinate care by the Home and Hospice staff to the patients. The individual must be responsible for...(4) Obtaining pertinent information from the Hospice including the most recent hospice plan of care specific to each patient... Patient #6: During home visit conducted at SNF #1 on January 8, 2025 at approximately 8:40 AM, review of the SNF hospice folder revealed a hospice form titled "Nursing Facility Plan of Care" was maintained at the SNF which included visit frequencies for skilled nursing (SN), hospice aide (personal care visits-PCV) and the social worker (SW). The "Nursing Facility Plan of Care" form failed to include the hospice diagnosis, a list of hospice problems and affiliated hospice interventions and goals, nor did the form include a list of current medications. On January 9, 2025 at approximately 7:15 AM, review of the hospice clinical record revealed the following was documented on the hospice Combined Disciplinary Plan of Care dated 11/17/2024: -The start of care was 05/15/2024 and the terminal diagnosis is senile degeneration of the brain: -Hospice problems and affiliated interventions and goals include "Neuro/Mental/Emotional-Issues": and -Current medications include Seroquel (medication used to treat bipolar disorder) and Percocet (pain medication). There was no documentation in the hospice SNF folder nor in the hospice clinical record which provided evidence that a copy of the hospice "Combined Disciplinary Plan of Care" for the recertification period of 11/11/2024 through 01/09/2025 had been provided to the SNF. Patient #7: During home visit conducted at SNF #1 on January 8, 2025 at approximately 9:15 AM, review of the SNF hospice folder revealed a hospice form titled "Nursing Facility Plan of Care" was maintained at the SNF which included visit frequencies for SN, PCV, SW and spiritual counseling. The "Nursing Facility Plan of Care" form failed to include the hospice diagnosis, a list of hospice problems and affiliated hospice interventions and goals, nor did the form include a list of current medications. On January 9, 2025 at approximately 7:55 AM, review of the hospice clinical record revealed the following was documented on the hospice Combined Disciplinary Plan of Care dated 12/31/2024: -The start of care was 09/08/2023 and the terminal diagnosis is other frontotemporal neurocognitive disorder (form of dementia), -Hospice problems and affiliated interventions and goals included "Neuro/Mental/Emotional-Issues": and -Current medications include morphine sulfate. There was no documentation in the hospice SNF folder nor in the hospice clinical record which provided evidence that a copy of the hospice "Combined Disciplinary Plan of Care" for the recertification period of 12/31/2024 through 02/28/2025 had been provided to the SNF. During interview conducted on 01/08/2025 at approximately 9:50 AM, the SNF-SW reported SNF #1 does not require that a copy of the hospice plan of care be provided to the SNF. The SNF-SW confirmed there was no evidence that a copy of the current hospice plan of care ("Combined Disciplinary Plan of Care") had been provided to the SNF. During interview conducted on January 10, 2025 at approximately 3:35 PM, the hospice Director of Human Services confirmed there was no documentation which provided evidence that a copy of the current "Combined Disciplinary Plan of Care" had been provided to SNF #1 for the above referenced patients.

Based on review of hospice policies/procedures, documentation and clinical records, based on home visit observations/findings and based on interview with the administrator, the hospice failed to ensure vital signs were assessed during the initial, comprehensive and/or routine skilled nursing (SN) visits for six (6) of fourteen (14) active hospice patients (Patients #4, #6, #9, #11, #12 and #14) Findings include: On January 13, 2022 at approximately 3:10 PM, review of hospice policy PC.A80, titled "Assessment-Comprehensive Assessment of Patient", revealed the following: Policy Statement: The hospice IDT conducts and documents a patient-specific comprehensive assessment that identified the patient's need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care. Procedures...2. The RN (registered nurse) Case Manager coordinates the comprehensive assessment process and ensures that the patient's physical, emotional, psychosocial, spiritual and bereavement needs are addressed. 4. Discipline-specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient's plan of care. On January 13, 2022 at approximately 3:11 PM, review of hospice policy PC.A85, titled "Assessment-Content Comprehensive Assessment of Patient", revealed the following: Procedures...2. Each assessment tool is designed to obtain information related to the patient's history, current status, problems, and needs and contain data elements for the collection of information related to patient outcomes... Patient #4: During home visit conducted on 01/12/2022 at approximately 9:30 AM, the patient was observed utilizing oxygen and the patient reported that she was suffering from increased tracheal (throat) secretions. On January 11, 2022 at approximately 11:39 AM, review of the clinical record revealed the start of care date was 12/16/2021, the primary hospice diagnosis is atherosclerotic (hardening of arteries) heart disease without angina pectoris (chest pain) and that treatment orders included oxygen at 2 to 3 liters per minute via nasal cannula as needed for dyspnea as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/16/2021 through 03/15/2022. Review of SN assessment documentation revealed vital sign assessment (temperature, pulse, respiratory (breathing rate) and blood pressure (BP)) were assessed by the SN on 12/16/2021 (initial SN assessment), 12/21/2021, 12/28/2021 and 01/04/2022. There was no SN documentation which provided evidence that the patient's temperature was assessed during the comprehensive SN visit performed on 12/17/2021. There was no SN documentation which provided evidence that the patient's temperature and blood pressure were assessed during the routine SN visit performed on 01/10/2022. Patient #6: On January 11, 2022 at approximately 1:17 PM, review of the clinical record revealed the start of care date was 10/29/2021, the primary hospice diagnosis is heart failure, a secondary diagnosis is chronic obstructive pulmonary disease (COPD-chronic lung disease) and that treatment orders included oxygen at 2 liters per minute as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 10/29/2021 through 01/26/2022. During home visit conducted on 01/12/2022, observation of the patient revealed oxygen was being administered via nasal cannula. There was no SN documentation which provided evidence that the patient's temperature was assessed during the comprehensive SN visit performed on 10/30/2021. There was no SN documentation which provided evidence that the patient's temperature and blood pressure were assessed during the routine SN visit performed on 11/02/2021. Review of SN documentation dated 11/09/2021 revealed vital sign assessment (temperature, pulse, respiratory rate and BP) was "deferred" (not completed) by the SN because the patient was eating breakfast but there was no documentation which provided evidence that the patient had refused vital sign assessment. Patient #9: On January 13, 2022 at approximately 7:01 AM, review of the clinical record revealed the start of care date was 04/19/2017, the primary hospice diagnosis is non-traumatic intracranial hemorrhage (bleeding in the brain) and that treatment orders included oxygen at 2 liters per minute as needed to maintain a pulse oximetry of greater than 92% as documented on the "Combined Interdisciplinary Plan of Care" for the recertification period of 11/24/2021 through 01/22/2022. Review of SN routine visit documentation dated 01/04/2022 and 01/05/2022 revealed morphine sulfate/Roxanol was utilized/administered for the treatment of dyspnea/pain. There was no SN documentation which provided evidence that the patient's temperature and respiratory rate were assessed during the routine SN visit performed on 01/04/2022. There was no SN documentation which provided evidence that the patient's respiratory rate was assessed during the routine SN visit performed on 01/05/2022. Patient #11: On January 13, 2022 at approximately 8:20 AM, review of the clinical record revealed the start of care date was 06/04/2021, the primary hospice diagnosis is chromosomal abnormality (change in genetic material/DNA which alters a baby's development before birth) and that treatment orders included oxygen at 0.5 to 1.0 liters per minute via blow-by (alternative method to administer oxygen) to maintain a pulse oximetry of 93% as documented on the "Combined Interdisciplinary Plan of Care" for the recertification period of 12/01/2021 through 01/29/2022. Review of SN routine visit documentation dated 12/06/2021 revealed clear phlegm (mucus) was present upon completion of a COVID-19 swab. There was no SN documentation which provided evidence that the patient's temperature and respiratory rate were assessed during the routine SN visit performed on 12/06/2021. Patient #12: On January 13, 2022 at approximately 10:30 AM, review of the clinical record revealed the start of care date was 12/07/2021 and that the primary hospice diagnosis is heart disease, unspecified as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/07/2021 through 03/06/2022. Review of physician order documentation dated 12/17/2021 revealed an antibiotic (Zithromax) was ordered for suspected upper respiratory/strept infection. There was no SN documentation which provided evidence that the patient's blood pressure was assessed during the routine SN visit performed on 01/05/2022. There was no SN documentation which provided evidence that the patient's temperature was assessed during the routine SN visit performed on 01/12/2022. Patient #14: On January 13, 2022 at approximately 1:35 PM, review of the clinical record revealed the start of care date was 12/30/2021 and that the primary hospice diagnosis is COPD as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/30/2021 through 03/29/2022. Review of SN documentation dated 01/12/2022 revealed BP assessment was "deferred" by the SN but there was no documentation which provided evidence that the patient had refused BP assessment. During interview conducted on January 13, 2022 at approximately 3:40 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that vital sign assessment had been completed during routine SN visits performed on the aforementioned dates for the above identified patients.

Based on review of hospice policies/procedures, documentation and clinical records, based home visit observation/findings and based on interview with the administrator, the hospice failed to ensure hospice plan of care problems included goals and discipline-specific assessment guidelines (interventions) for six (6) of twelve (12) active hospice patients for whom hospice services were provided for more than 15 days. (Patients #1, #2, #3, #4, #11 and #12) Findings include: On January 13, 2022 at approximately 3:10 PM, review of hospice policy PC.A80, titled "Assessment-Comprehensive Assessment of Patient", revealed the following: Policy Statement: The hospice IDT conducts and documents a patient-specific comprehensive assessment that identified the patient's need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care. Procedures...2. The RN (registered nurse) Case Manager coordinates the comprehensive assessment process and ensures that the patient's physical, emotional, psychosocial, spiritual and bereavement needs are addressed. 4. Discipline-specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient's plan of care. On January 13, 2022 at approximately 3:11 PM, review of hospice policy PC.A85, titled "Assessment-Content Comprehensive Assessment of Patient", revealed the following: Procedures...3. The IDT (Interdisciplinary Team) uses the information from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/caregiver. On January 13, 2022 at approximately 3:12 PM, review of hospice policy PC.P40, titled "Plan of Care", revealed the following: Procedures...1. The patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver identified in the initial, comprehensive and updated comprehensive assessments of the patient... On January 13, 2022 at approximately 3:13 PM, review of hospice policy PC.P45, titled "Plan of Care-Content", revealed the following: Policy Statement: The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. Patient #1: Between January 10, 2022 at approximately 3:16 PM and January 11, 2022 at approximately 8:20 AM, review of the clinical record revealed the start of care date was 12/21/2021, the primary hospice diagnosis is non-rheumatic aortic (heart) valve insufficiency and that treatment orders included oxygen at 2.5 liters per minute via nasal cannula (oxygen tubing inserted into the nose) as needed for dyspnea (difficulty breathing) or hypoxemia (low levels of oxygen in the blood) as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/21/2021 through 03/20/2022. Review of the "Interdisciplinary Note" dated 01/08/2022 revealed the patient's family member placed a telephone call to the hospice to provide notification that the patient's pulse oximetry (oxygen level in the blood) was low (82%) and that the patient's heart rate was 140. Review of the "Combined Interdisciplinary Plan of Care" forms dated 12/22/2021 and 01/06/2022 revealed the cardiopulmonary problem issue and goal status was listed as "current" but there was no documentation which provided evidence that goals and discipline-specific assessment guidelines (interventions) had been established for the hospice cardiopulmonary problem included on the "Combined Interdisciplinary Plan of Care" forms. Patient #2: On January 11, 2022 at approximately 8:56 AM, review of the clinical record revealed the start of care date was 09/25/2021, the primary hospice diagnosis was malignant neoplasm (cancer) of unspecified part of bronchus (airway) or lung and that treatment orders included oxygen at 2 liters per minute via nasal cannula as needed for dyspnea or hypoxemia as documented on the "Combined Interdisciplinary Plan of Care" for the recertification period of 11/24/2021 through 01/22/2022. Review of documentation included on the "Medical Director Certification of Terminal Illness" form for the recertification period of 11/24/2021 through 01/22/2022 revealed the medical director documented that the patient experienced dyspnea with exertion. Review of the "Combined Interdisciplinary Plan of Care" forms dated 11/24/2021 and 12/08/2021 revealed the patient was documented as experiencing slight dyspnea when ambulating (walking). Review of the "Combined Interdisciplinary Plan of Care" forms dated 11/24/2021, 12/08/2021 12/22/2021 and 01/05/2022 revealed the cardiopulmonary problem issue and goal status was listed as "current" but there was no documentation which provided evidence that goals and discipline-specific assessment guidelines (interventions) had been established for the hospice cardiopulmonary problem included on the "Combined Interdisciplinary Plan of Care" forms. Patient #3: On January 11, 2022 at approximately 10:00 AM, review of the clinical record revealed the start of care date was 12/24/2021, the primary hospice diagnosis is malignant neoplasm of upper lobe bronchus or lung and that treatment/medication orders included portable oxygen and morphine sulfate for pain/dyspnea as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/24/2021 through 03/23/2022. Review of the "Interdisciplinary Note" dated 01/05/2022 revealed the patient's family member placed a telephone call to the hospice to provide notification that Roxanol (morphine sulfate) was ineffective for symptom management. Review of the "Combined Interdisciplinary Plan of Care" forms dated 01/04/2022 revealed the cardiopulmonary problem issue and goal status was listed as "current" but there was no documentation which provided evidence that goals and discipline-specific assessment guidelines (interventions) had been established for the hospice cardiopulmonary problem included on the "Combined Interdisciplinary Plan of Care" forms. Patient #4: During home visit conducted on 01/12/2022 at approximately 9:30 AM, the patient was observed utilizing oxygen and the patient reported that she was suffering from increased tracheal (throat) secretions. On January 11, 2022 at approximately 11:39 AM, review of the clinical record revealed the start of care date was 12/16/2021, the primary hospice diagnosis is atherosclerotic (hardening of arteries) heart disease without angina pectoris (chest pain) and that treatment orders included oxygen at 2 to 3 liters per minute via nasal cannula as needed for dyspnea as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/16/2021 through 03/15/2022. Review of documentation included on the "Medical Director Certification of Terminal Illness" form for the initial certification period of 12/16/2021 through 03/15/2022 revealed the medical director documented that the patient experienced shortness of breath with exertion. Review of the "Combined Interdisciplinary Plan of Care" forms dated 12/22/2021 and 01/06/2022 revealed the cardiopulmonary problem issue/goals had been established for cardiac symptoms but there was no documentation which provided evidence that goals and discipline-specific assessment guidelines (interventions) had been established for the hospice pulmonary problem included on the "Combined Interdisciplinary Plan of Care" forms. Patient #11: On January 13, 2022 at approximately 8:20 AM, review of the clinical record revealed the start of care date was 06/04/2021, the primary hospice diagnosis is chromosomal abnormality (change in genetic material/DNA which alters a baby's development before birth) and that treatment orders included oxygen at 0.5 to 1.0 liters per minute via blow-by (alternative method to administer oxygen) to maintain a pulse oximetry of 93% as documented on the "Combined Interdisciplinary Plan of Care" for the recertification period of 12/01/2021 through 01/29/2022. Review of the "Interdisciplinary Note" dated 12/08/2021 revealed the hospice was notified that during the prior evening, the patient's pulse oximetry reading dropped to 85%, that the patient became cyanotic (bluish skin color due to low oxygen level in the blood) and that a nurse from another agency administered oxygen via nasal cannula which resulted in the pulse oximetry improving to 98%. Review of the "Combined Interdisciplinary Plan of Care" forms dated 11/21/2021, 12/09/2021, 12/23/2021 and 01/06/2022 revealed the cardiopulmonary problem issue and goal status was listed as "current" but there was no documentation which provided evidence that goals and discipline-specific assessment guidelines (interventions) had been established for the hospice cardiopulmonary problem included on the "Combined Interdisciplinary Plan of Care" forms. Patient #12: On January 13, 2022 at approximately 10:30 AM, review of the clinical record revealed the start of care date was 12/07/2021 and that the primary hospice diagnosis is heart disease, unspecified as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/07/2021 through 03/06/2022. Review of documentation included on the "Medical Director Certification of Terminal Illness" form for the initial certification period of 12/16/2021 through 03/15/2022 revealed the medical director documented that the patient experiences shortness of breath while at rest. Review of skilled nursing documentation dated 12/07/2021, 12/09/2021, 12/15/2021, 12/22/2021, 12/29/2021 and 01/05/2022 revealed the patient suffered from edema (swelling caused by accumulation of excess fluid trapped in the body's tissues). Review of the "Combined Interdisciplinary Plan of Care" forms dated 12/09/2021, 12/20/2021 and 01/04/2022 revealed the cardiopulmonary problem issue/goals had been established for cardiac symptoms but there was no documentation which provided evidence that goals and discipline-specific assessment guidelines (interventions) had been established for the hospice pulmonary problem included on the "Combined Interdisciplinary Plan of Care" forms. During interview conducted on January 13, 2022 at approximately 3:40 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that goals and discipline-specific assessment guidelines (interventions) had been included for hospice cardiac and/or pulmonary problems included on the "Combined Interdisciplinary Plan of Care" for the above identified patients.

Based on review of hospice policies/procedures, documentation and clinical records, and based on interview with the administrator, the hospice failed to ensure a physician order was obtained to modify visit frequencies included on the hospice plan of care for five (5) of six (6) active hospice patients for whom a visit frequency had been reduced. (Patients #4, #6, #8, #9 and #11) Findings include: On January 13, 2022 at approximately 3:13 PM, review of hospice policy PC.P45, titled "Plan of Care-Content", revealed the following: Policy Statement: The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. Procedures...2. The plan of care includes, but is not limited to... b. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs... On January 13, 2022 at approximately 3:12 PM, review of hospice policy PC.P40, titled "Plan of Care", revealed the following: Procedures...5. The plan of care is reviewed and updated by the IDT (Interdisciplinary Team) every 15 days or more frequently if needed...7. Reviews of and changes to the plan of care will be documented and communicated to members of the IDT. Patient #4: On January 11, 2022 at approximately 11:39 AM, review of the clinical record revealed the start of care date was 12/16/2021, the primary hospice diagnosis was atherosclerotic (hardening of arteries) heart disease without angina pectoris (chest pain) and that hospice aide services are to be provided two (2) times a week and as needed as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 12/16/2021 through 03/15/2022. Review of hospice aide documentation revealed one (1) of two (2) hospice aide visits were provided during the hospice treatment week beginning 12/26/2021 and 01/02/2022. There was documentation in the clinical record which provided evidence that a "Physician Orders for Hospice Patient' had been obtained prior to the reduction the hospice aide visit frequency nor was documentation present on the "Combined Interdisciplinary Plan of Care" form dated 01/06/2022 which provided evidence that the hospice plan of care had been updated to reflect the reduction in hospice aide visit frequency during the aforementioned treatment weeks. Patient #6: On January 11, 2022 at approximately 1:17 PM, review of the clinical record revealed the start of care date was 10/29/2021, the primary hospice diagnosis is heart failure, a secondary diagnosis is chronic obstructive pulmonary disease (COPD-chronic lung disease) and that hospice aide services are to be provided two (2) times a week and as needed as documented on the "Combined Interdisciplinary Plan of Care" for the initial certification period of 10/29/2021 through 01/26/2022. Review of hospice aide documentation revealed one (1) of two (2) hospice aide visits were provided during the hospice treatment weeks beginning 11/21/2021, 12/19/2021, 12/26/2021 and 01/02/2022. There was documentation in the clinical record which provided evidence that a "Physician Orders for Hospice Patient' had been obtained prior to the reduction the hospice aide visit frequency nor was documentation present on the "Combined Interdisciplinary Plan of Care" forms dated 11/24/2021, 12/09/2021, 12/23/2021 nor 01/06/2022 which provided evidence that the hospice plan of care had been updated to reflect the reduction in hospice aide visit frequency during the aforementioned treatment weeks. Patient #8: On January 12, 2022 at approximately 7:03 AM, review of the clinical record revealed the start of care date was 11/12/2019, the primary hospice diagnosis is degenerative disease of the nervous system and that hospice aide services are to be provided two (2) times a week and as needed as documented on the "Combined Interdisciplinary Plan of Care" for the recertification period of 12/31/2021 through 02/28/2022. Review of hospice aide documentation revealed one (1) of two (2) hospice aide visits were provided during the hospice treatment week beginning 01/02/2022. There was documentation in the clinical record which provided evidence that a "Physician Orders for Hospice Patient' had been obtained prior to the reduction the hospice aide visit frequency nor was documentation present on the "Combined Interdisciplinary Plan of Care" form dated 01/06/2022 which provided evidence that the hospice plan of care had been updated to reflect the reduction in hospice aide visit frequency during the aforementioned treatment week. Patient #9: On January 13, 2022 at approximately 7:01 AM, review of the clinical record revealed the start of care date was 04/19/2017, the primary hospice diagnosis is non-traumatic intracranial hemorrhage (bleeding in the brain) and that hospice aide services are to be provided three (3) times a week and as needed as documented on the "Combined Interdisciplinary Plan of Care" for the recertification period of 11/24/2021 through 01/22/2022. Review of hospice aide documentation revealed two (2) of three (3) hospice aide visits were provided during the hospice treatment weeks beginning 12/19/2021 and 01/02/2022 and that one (1) of three (3) hospice aide visits were provided during the hospice treatment week of 12/26/2021. There was documentation in the clinical record which provided evidence that a "Physician Orders for Hospice Patient' had been obtained prior to the reduction the hospice aide visit frequency nor was documentation present on the "Combined Interdisciplinary Plan of Care" forms dated 12/23/2021 nor 01/06/2022 which provided evidence that the hospice plan of care had been updated to reflect the reduction in hospice aide visit frequency during the aforementioned treatment weeks. Patient #11: On January 13, 2022 at approximately 8:20 AM, review of the clinical record revealed the start of care date was 06/04/2021, the primary hospice diagnosis is chromosomal abnormality (change in genetic material/DNA which alters a baby's development before birth) and that skilled nursing (SN) services are to be provided one (1) time a week and as needed as documented on the "Combined Interdisciplinary Plan of Care" for the recertification period of 12/01/2021 through 01/29/2022. There was no documentation in the clinical record which provided evidence that SN services were provided during the hospice treatment weeks beginning 12/26/2021 and 01/02/2022. There was documentation in the clinical record which provided evidence that a "Physician Orders for Hospice Patient' had been obtained prior to the reduction the SN visit frequency nor was documentation present on the "Combined Interdisciplinary Plan of Care" form dated 01/06/2022 which provided evidence that the hospice plan of care had been updated to reflect the reduction in hospice aide visit frequency during the aforementioned treatment weeks. During interview conducted on January 13, 2022 at approximately 3:40 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence a "Physician Orders for Hospice Patient' had been obtained prior to the reduction the hospice aide or SN visit frequency nor was documentation present on the "Combined Interdisciplinary Plan of Care" forms which provided evidence that the hospice plan of care had been updated to reflect the reduction in hospice aide or SN visit frequency during the aforementioned treatment weeks for the above identified patients.