Every finding on record at Integrity Home Care, Inc

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect the hospice provider's ability to ensure safe and effective use of medications for all the patients served by the provider.  Findings included:Review of the policy titled, “Medication Management and Administration,” dated revised 01/05/2026, showed in part:- “Named provider” has established procedures to ensure safe medication administration and management in the home;- Medication reconciliation should be completed on assessment and reassessment; see Client Assessment- Hospice policy;- Medication reconciliation includes:  * Obtain information about medications currently being taken, in addition to those prescribed: over the counter medication, herbal preparations and dietary supplements;   * Medication prescribed by another healthcare provider;   * Use of illegal drugs;   * Discuss any unresolved, significant concerns about the medication with the client’s physician/health care practitioner;- Reconcile all medications the client takes in the home against the medication list provided by the discharging facility or primary care provider; and- Verify that there are acceptable, written physician/healthcare practitioner’s orders for all medications that client is taking. Review of the policy titled, “Client Assessment- Hospice,” dated revised 06/03/2024, showed in part:- “Named provider” Interdisciplinary Group (IDG) conducts and documents a client- specific comprehensive assessment that identifies the client's needs from their hospice care and services;- A start of care assessment is completed in the electronic medical record by a hospice registered nurse within 48 hours of election of Hospice care, unless the physician, client, or client representative request the initial assessment be completed in less than 48 hours. The assessment includes medication;- Drug profile (medication reconciliation) includes prescriptions, over the counter medications, supplements, herbal remedies, and other alternative treatments that could affect drug therapy which includes: identification of effectiveness of drug therapy, drug side effects, actual/potential drug interactions, duplicate drug therapy, and drug therapy related to laboratory monitoring. --- RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/26/2026 with a terminal diagnosis of unspecified severe protein-calorie malnutrition (a critical condition defined by extreme deficiencies in protein and caloric intake, leading to significant muscle wasting, fat loss, and potential edema). The patient resided at home with family caregivers.Observation and interview on 04/14/2026 at 8:30 AM, showed the following medication discrepancies with the provider’s medication profile:-The medication profile showed an order for acetaminophen (used to treat mild pain) 325 milligram (mg) tablets, take two tablets every four hours. The patient’s caregiver (cg) stated that the patient no longer took this medication;-The medication profile showed an order for acetaminophen 500 mg tablets, take two tablets every six hours. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for Advanced Eye Health (used to support retinal health, filter blue light, and reduce eye strain) 250 mg-2.5 mg- 0.5 mg capsules, take one capsule daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for bisacodyl (a stimulant laxative used for short-term relief of occasional constipation and to clear the bowels) 10 mg rectal suppository, use one suppository daily as needed. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for cyanocobalamin (a synthetic form of vitamin B12 used to treat and prevent deficiencies) 500 micrograms (mcg) tablets, take two tablets daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for dextrose 5% in water (a fluid used to treat dehydration, low blood sugar (hypoglycemia), and as a vehicle for medication administration - D5W) intravenously as needed for drugs incompatible with normal saline. The patient’s caregiver stated the patient no longer used this medication;-The medication profile showed an order for fenofibrate (a medication used to treat high cholesterol and high triglycerides by reducing fat production in the liver and boosting good cholesterol) 160 mg. The patient’s caregiver stated that the patient no longer took this medication;-The medication profile showed an order for hydrocodone 5 mg – acetaminophen 325 mg (a prescription combination of 5 mg hydrocodone (opioid) and 325 mg acetaminophen (non-opioid) used to manage moderate to severe pain) take one tablet every six hours. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for hyoscyamine (an anticholinergic/antispasmodic medication used to treat stomach/intestinal cramps, irritable bowel syndrome, ulcers, and bladder spasms by relaxing smooth muscles) 0.125 mg sublingual (under the tongue) tablets, take one tablet every four hours as needed. The patient’s cg stated that the patient no longer took the medication;-The medication profile showed an order for laxative stool softener with senna (an over the counter medication containing a stimulant laxative and a stool softener) 8.6 mg – 50 mg tablets, take one tablet two times daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for levothyroxine (a synthetic hormone used to treat low thyroid hormone) 25 mcg tablets, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for melatonin (used to treat insomnia) 3 mg tablets, take one tablet at bedtime. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for miralax (used to treat constipation) 17 gram/dose oral powder, use 17 grams daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for naloxone 0.4 mg/milliliter (mL) injection solution, inject 0.1-0.4 mg per physician instructions. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for ondansetron hydrochloride (used to nausea and vomiting) 4mg/2mL injection solution, take four mg intravenously every six hours as needed. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for pantoprazole (a proton-pump inhibitor used to treat heartburn and stomach ulcers by reducing stomach acid production) 20 mg tablets, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for promethazine (a prescription strength antihistamine used to treat allergy symptoms, motion sickness, nausea, and to provide sedation) 25 mg tablets, take one tablet every six hours. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for simvastatin (a prescription statin medication used to lower high cholesterol and triglycerides) 20 mg tablets, take one tablet at bedtime. The patient’s cg stated that the patient no longer took this medication;-The medication profile showed an order for sodium chloride 0.9 % flush (normal saline) injection syringe, use 10 mL every 12 hours for line patency. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for sodium chloride 0.9% flush injection syringe, use 10 mL before and after medication administration. The patient’s cg stated that the patient no longer used this medication;-The medication profile showed an order for sucralfate (a mucosal protectant used to treat and prevent duodenal ulcers) 1-gram tablets, take one tablet two times daily. The patient’s cg stated that the patient no longer took this medication; and-The medication profile showed an order for Tums Ultra (use to treat heartburn and acid indigestion) 400 mg chewable tablet, take one tablet every six hours. The patient’s cg stated that the patient no longer took this medication.During an interview on 04/14/2026 at 12:00 PM, the administrator stated that the case manager saw the patient on 04/13/2026 and reconciled the medications and provided this surveyor with a new medication profile. The administrator also stated that the patient had a tuck-in visit on 04/10/2026 after returning home from respite and the medications should have been reconciled during that visit. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/26/2025 with a terminal diagnosis of combined systolic and diastolic heart failure (a severe condition where the heart muscle is both weak and stiff. This combination causes significantly reduced cardiac output often leading to pulmonary congestion (a dangerous accumulation of fluid in the lungs air sacs causing severe breathing difficulty, shortness of breath, and reduced oxygen intake). The patient currently resided in a long-term care facility (LTCF).Observation on 04/14/2026 at 8:58 AM, showed the following medication discrepancies between the hospice provider’s medication profile and the LTCF medication record: - The LTCF medication profile showed docusate sodium 100 mg (milligrams), two capsules every 12 hours as needed for constipation. The hospice provider’s medication profile showed docusate sodium 100 mg , one capsule twice daily as needed;- The LTCF medication profile showed loperamide HCL (hydrochloride) two mg, one tablet every four hours as needed for loose stools. The hospice medication profile showed loperamide 2 mg, two capsules at onset of diarrhea followed by one capsule as needed after each loose stool. Maximum of 16mg/day.- The LTCF medication profile showed Calcium 600/Vitamin D3 600-20 MG-MCG (microgram) give one tablet one time daily for supplement.  The hospice medication profile failed to show calcium documented. During an interview on 04/16/2026 at 12:55 PM the administrator stated that the provider’s medication list should match the facility’s medication list. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/13/2026 with a terminal diagnosis of malignant neoplasm of overlapping sites of pancreas (pancreatic cancer).  The patient resided at home with their spouse.Observation and interview on 04/14/2026 at 12:20 PM, showed the following medication discrepancies between the hospice provider’s medication profile and the patient’s home medication bottles.- The patient’s medication bottle showed clonidine 0.1 mg one tablet twice daily. The hospice provider’s medication profile showed clonidine 0.2 mg, one tablet two times daily. The patient stated that they took one of the clonidine 0.1 mg tablets twice daily;- The hospice medication profile showed Flintstone’s with iron 18 mg iron chewable one tablet and vitamin C 1,000 mg one tablet daily.  The patient stated that they no longer took the Flintstone’s vitamins or the vitamin C and hadn’t for a couple months; and- There failed to be a bottle of apixaban.  The patient stated that they were not taking it anymore and hadn’t for a couple months.- The referral information dated 02/03/2026 showed apixaban (a medication used thin blood to prevent blood clots) 5 mg take two tablets twice daily for six days, then take one tablet twice daily starting on 02/10/2026. The hospice medication profile failed to show apixaban documented. During an interview on 04/16/2026 at 12:55 PM the administrator stated that:- The patient had stopped taking the apixaban before admission because the patient had been falling at home and there failed to be any documentation of communication with the physician to clarify this;- The medication reconciliation had not been done correctly because the Flinstone’s vitamins and the vitamin C both should have been caught and not listed; and- He/she was unsure how the clonidine was listed as 0.2mg in the chart on the provider’s list.

Based on policy review, job description review, record review, and interview, the hospice provider failed to ensure clinicians followed their policies and procedures (P&P) in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider.  Findings included:Review of the provider’s policy titled, “Communicating with Physicians,” dated revised 10/01/2024, showed in part:- There is ongoing communication with the client's physician/health care provider when indicated, including written summaries throughout service delivery and at discharge;- Throughout the duration of service, whenever a change in client status occurs that requires the physician/healthcare provider to be notified, the communication will be documented; and- The method of communication should include communication of the situation, background information, assessment, and recommendations. Review of the “Job Description and Performance Evaluation: Registered Nurse- Hospice Services,” dated revised 05/11, showed in part:- Main function: A member of the hospice interdisciplinary group (IDG) who assures the delivery of quality care through responsible management of cases assigned, and coordination of services provided by all hospice IDG members;- Clinical responsibilities: initial and ongoing assessment of the impact of the terminal diagnosis on the client's physical, functional, psychosocial, and environmental needs and activities of daily living;- Implementing the individualized plan of care (POC) and recommending revisions to the plan as necessary;- Informing the physician and other personnel of changes in the client’s needs and outcomes of intervention; and- Communicating information using current process and technology available to the organization --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/13/2026 with a terminal diagnosis of malignant neoplasm of overlapping sites of pancreas (pancreatic cancer).  The patient resided at home with their spouse.Review of a skilled nurse visit note dated 04/01/2026, signed by a hospice registered nurse (RN) showed the patient reported a fall the prior Friday night getting up to go to the bathroom. He/she hit their head. A small scratch was noted on their head. No other injuries were noted at that time.  The note failed to show documentation of notification to a physician, including the primary care physician listed on the patient’s POC. Review of a client occurrence report dated 04/01/2026 showed physician notified was marked, although it failed to identify what physician had been notified.  During an interview on 04/16/2026 at 12:55 PM the administrator stated that he/she was unable to tell which physician was notified. During an interview on 04/16/2026 at 1:10 PM the administrator stated that he/she would expect the patient’s physician to be notified of a fall.

Based on policy review, record review, and interview, the hospice provider failed to ensure that physician’s orders were obtained prior to providing wound care in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Chart Data Requirements & Format – Hospice,” dated 06/02/2025, showed "The CMS (Centers for Medicare and Medicaid Services) home health certification and plan of care (POC) is (includes) the physician’s orders and documentation of the hospice care plan process for the care and services to be provided".Review of the provider’s policy titled, “Job Description and Performance Evaluation Registered Nurse – Hospice Services,” dated 05/2011 showed the clinician’s responsibilities include implementing the individualized POC and recommending revisions to the plan as necessary.RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 07/10/2025 with a terminal diagnosis of achondroplasia (an abnormal development of cells that hinders bone growth). The patient expired on 07/19/2025. The patient resided at home with a family caregiver.Review of the skilled nursing (SN) initial assessment, dated 07/10/2025, showed the patient had an unstageable wound to the left upper buttock. The SN cleansed the wound with wound cleanser and covered it with adhesive dressing. The note included instructions to change the dressing daily and PRN (as needed).Review of the POC dated 07/10/2025 – 09/07/2025, showed the POC failed to include wound care orders.Review of the SN visit note, dated 07/11/2025, showed the caregiver changed the dressing on the patient’s left buttock. The wound was still covered (with slough/eschar-dead tissue in a wound bed/dead tissue that is dry, tough, leather and black, tightly attached to the bound bed) and unstageable. There was a small amount of drainage on the dressing, and the wound had an odor.Review of the SN visit note, dated 07/14/2025, showed the caregiver had completed wound care and a dressing change.Review of the SN visit note, dated 07/15/2025, showed the caregiver had completed wound care and a dressing change.Review of the SN visit note, dated 07/16/2025, showed the SN cleansed the wound with wound cleanser and covered the wound with an adhesive dressing.Review of the SN visit note, dated 07/17/2025, showed the caregiver had completed wound care and a dressing change.Review of the SN visit note, dated 07/18/2025, showed the SN cleansed the wound with wound cleanser and covered the wound with an adhesive dressing.During an interview on 04/15/2025 at 3:30 PM, the administrator stated that he/she would expect there to be orders for any treatment that the patient was receiving and he/she could not locate the wound care order.

Based on policy review, record review, and interview, the hospice provider failed to ensure that volunteer services equal a minimum of five (5) percent of the total patient care hours of all paid hospice employees and contract staff. This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider's policy titled, “Volunteer Services- Hospice,” last revised 06/04/2024, showed in part, that the hospice provider would document and maintain volunteer staff sufficient to provide administrative or direct client care in an amount that, at a minimum, equals 5% of the total client care hours of all paid hospice employees and contract staff.Review of the hospice volunteer requirement report showed that the total percentage of volunteer hours was 3.40%.During an interview on 04/16/2026 at 1:00 PM, the administrator stated that, in February, a mandatory teams meeting was held to address the volunteer hours being less than 5%. Corrective action plans were discussed and a performance improvement plan was initiated to address the issue.

Based on state statute review, policy review, record review, and interview, the hospice provider failed to ensure a patient was free from neglect (L0517).The cumulative effect of this deficient practice has the potential to affect all the patients served by the provider.

Based on state statute review, policy review, clinical record review and interview, the hospice provider failed to immediately report to the state agency a concern of neglect when an eligible adult was bedbound, lived home alone, and was unable to adequately perform or obtain services which were necessary to meet his/her essential human needs, in one of four records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patient's receiving hospice services. --- Findings included: 192.2400 RSMo.  Definitions. — As used in sections 192.2400 to 192.2505, the following terms mean: (4) “Department”, the department of health and senior services;  (6) “Eligible adult”, a person sixty years of age or older who is unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs or an adult with a disability, as defined in section 192.2005, between the ages of eighteen and fifty-nine who is unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs; (10) “In-home services client”, an eligible adult who is receiving services in his or her private residence through any in-home services provider agency; (12) “ In-home services provider agency”, a business entity under contract with the department or with a Medicaid participation agreement, which employs persons to deliver any kind of services provided for eligible adults in their private home; (14) “Likelihood of serious physical harm”, one or more of the following:      (a) a substantial risk that physical harm to an eligible adult will occur because of his or her failure or inability to provide for his or her essential human needs as evidenced by acts or behavior which has caused such harm or which gives another person probable cause to believe that the eligible adult will sustain such harm;    (b) a substantial risk that physical harm will be inflicted by an eligible adult upon himself or herself, as evidenced by recent credible threats, acts, or behavior which has caused such harm or which places another person in reasonable fear that the eligible adult will sustain such harm;    (c) a substantial risk that physical harm will be inflicted by another upon an eligible adult as evidenced by recent acts or behavior which has caused such harm or which gives another person probable cause to believe the eligible adult will sustain such harm;   (d) a substantial risk that further physical harm will occur to an eligible adult who has suffered physical injury, neglect, sexual or emotional abuse, or other maltreatment or wasting of his or her financial resources by another person; and(15) “Neglect”, the failure to provide services to an eligible adult by any person, firm or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious physical harm would result.  192.2405 RSMo.  Mandatory reporters--penalty for failure to report. — 1.  The following persons shall be required to immediately report or cause a report to be made to the department under sections 192.2400 to 192.2470:  (1)  Any person having reasonable cause to suspect that an eligible adult presents a likelihood of suffering serious physical harm, or bullying as defined in subdivision (2) of section 192.2400, and is in need of protective services; and  (2)  Any adult day care worker, chiropractor, Christian Science practitioner, coroner, dentist, embalmer, employee of the departments of social services, mental health, or health and senior services, employee of a local area agency on aging or an organized area agency on aging program, emergency medical technician, firefighter, first responder, funeral director, home health agency, home health agency employee, hospital and clinic personnel engaged in the care or treatment of others, in-home services owner or provider, in-home services operator or employee, law enforcement officer, long-term care facility administrator or employee, medical examiner, medical resident or intern, mental health professional, minister, nurse, nurse practitioner, optometrist, other health practitioner, peace officer, pharmacist, physical therapist, physician, physician's assistant, podiatrist, probation or parole officer, psychologist, social worker, or other person with the responsibility for the care of an eligible adult who has reasonable cause to suspect that the eligible adult has been subjected to abuse or neglect or observes the eligible adult being subjected to conditions or circumstances which would reasonably result in abuse or neglect.  Notwithstanding any other provision of this section, a duly ordained minister, clergy, religious worker, or Christian Science practitioner while functioning in his or her ministerial capacity shall not be required to report concerning a privileged communication made to him or her in his or her professional capacity.  2.  Any other person who becomes aware of circumstances that may reasonably be expected to be the result of, or result in, abuse or neglect of an eligible adult may report to the department.  3.  The penalty for failing to report as required under subdivision (2) of subsection 1 of this section is provided under section 565.188. Review of the provider's policy titled, "Abuse & Neglect Screening & Reporting," last revised September 26, 2022, showed in part, the following:- All employees and contractors in the normal course of providing services to clients, who identify, notice, or recognize incidences, allegations or circumstances of mistreatment, neglect, verbal, mental, sexual and/or physical abuse, including injuries of unknown sources, or misappropriation of client property have a legal and professional obligation to report these findings according to the following timeline:* Medicare certified offices, immediately to state authorities and the Hospice provider* Non-Medicare certified offices, immediately to the Hospice provider and the appropriate authorities within the time frame required by state law and or payer requirements- Immediately means reporting without delay. The interim time between discovery and reporting an incident may be influenced by the individual situation. However, the reporting must be accomplished as soon as possible following the discovery; - If needed, an employee may contact their supervisor to access state-specific reporting procedures, including telephone hotline numbers and required documentation; and- Neglect indicators, included in part: * Failure to provide the medical, dental or psychiatric care needed to prevent or treat physical or emotional illness * Consistent hunger, poor hygiene, poor growth patterns, inappropriate dress * Consistent lack of supervision for long periods or for dangerous activities * Unattended physical problems or medical needs * Abandonment. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/05/2025 with a terminal diagnosis of gangrene (a condition where tissue dies due to a lack of blood supply) and resided at home alone. Review of the hospital discharge records, showed in part:- The patient was admitted to the hospital on 08/26/2025 for further evaluation of generalized weakness and gangrene of his/her right foot and lower leg;- On arrival to the emergency room (ER) it was noted that the patient had gangrene to the right foot with a completely black toe and the foot was cold with areas of cellulitis (a common and potentially serious bacterial skin infection);- The patient had a wound on the back of his/her right thigh; - The patient had a necrotic (tissue that is dead or dying) sacral (lower back, base of the spine) wound with gangrene;- The patient declined surgery on multiple occasions and was aware of the risks and benefits of not having surgery including worsening infection and death;- The patient was informed that it was a terminal condition, and it was inevitable that he/she would get sepsis (a life-threatening infection in the blood stream);- The patient was converted to comfort care on 09/02/2025 during the hospitalization;- The patient lived at home alone;- The patient had two sisters that lived out of state; and- “Going home on hospice without caregivers wound (would) not be a good choice. Case management trying to find options.”  Review of the hospice referral record from the hospital, dated 09/03/2025, showed in part:- “Please review this patient to see if the patient can be admitted for hospice;”- The patient lived alone and had no family close to assist him/her;- The patient was going to get a life alert to use in case of emergencies;- “Please let me (the hospital case manager) know if (he/she) is appropriate for admission to agency (hospice);” and-The patient did not have payor source for facility placement. Review of the hospice initial comprehensive assessment (completed by registered nurse (RN) -A), dated 09/05/2025 at 11:21 PM, showed:- The patient lived alone in unsanitary living conditions;- The type of safety and sanitary issues included; * Loose/unsafe flooring * Unclean/cluttered living area * Poorly controlled pets/animals * Structural problems (floor/roof/windows)- The patient’s mental status included alert, oriented to person, oriented to place, oriented to time, forgetful and confused;- Signs and symptoms that showed decline included uncontrolled pain, change in heart rate from baseline, and weakness;- The patient self reported pain 5/10 (zero being no pain and 10 being the worst pain) on a numeric pain scale, the nurse administered PRN (as needed) pain medication and the patient’s pain improved to 2/10;- The patient was unable to ambulate;- The patient was incontinent of bowel and bladder; - The patient was unable to transfer independently;- The patient required assistance with dressing;- The patient required total assistance with bathing;- The patient required assistance with food preparation and meals; - The patient had unstageable pressure ulcers (a type of pressure injury where the depth of the wound cannot be determined because it covered by slough (yellow, gray, or green dead tissue) or eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed) to the buttocks and right thigh;- The pressure sore risk assessment showed: * Physical condition- very bad * Mental condition- alert * Activity- bedridden * Mobility- immobile * Incontinence- urinary and fecal * Risk assessment score of eight (8) indicated the patient was very high risk for pressure ulcers- With the patient being in the hospital for 10 days, it was unlikely that he/she would be able to walk or transfer to the wheelchair; - The patient had an unstageable necrotic wound to the right mid dorsum (the middle part of the top surface of the foot) measuring 40 centimeters (cm) in length and 20 cm in width with 0 cm in depth;- The patient had an unstageable necrotic wound to the coccyx that measured 9 cm in length by 15 cm in width with 0 cm in depth;- The patient had an unstageable wound to the right mid-thigh (the middle part of the right thigh) measuring 10 cm in length and 5 cm in width with 0 cm in depth; and- The narrative note showed, in part:  * The nurse assisted emergency medical service (EMS) with transferring the patient into his/her hospital bed * The patient was alert and oriented x4 (times four; person, place, time, and situation) * The patient lived alone and refused to live in a nursing facility despite it being beneficial for him/her to have 24-hour care * As the visit went on the patient got more tired and had some intermittent confusion which was to be expected with gangrene infection * The nurse entered the 24-hour hospice number in the patient’s contacts of his/her cell phone * The nurse placed the fully charged cell phone, a glass of water, and some snacks on the bedside table for the patient to have access to until the patient’s sisters could get there the next morning * The patient was placed on daily visits through the weekend until the registered nurse case manager (RNCM) could reevaluate for nurse visit frequency needs on Monday  * The nurse sent an email to the medical social worker (MSW) regarding the patient's need for a life alert necklace.  Review of an email sent from the admission nurse (RN-A) to all staff, dated 09/06/2025 at 8:08 PM, showed: - The patient (pt) lived alone;  - The pt stated that he/she could get up, but the nurse had yet to see it happen;- House very unsanitary; - “MSW- pt needs life alert necklace ASAP (as soon as possible)! Plus sisters are needing your help with Medicaid application;” and - “Nurse- placing on daily nurse visits throughout weekend until RNCM can re-evaluate.”  Review of the skilled nurse (SN) visit note, dated 09/07/2025 at 4:11 PM, showed:- The patient’s sisters were present when the nurse arrived; - The patient’s bedding and clothes were saturated in urine;- The patient’s wounds to the buttocks and thigh were wet with urine;- The nurse discussed Foley catheter placement for skin integrity and comfort due to bladder incontinence and the patient agreed to have the Foley catheter (a sterile tube placed in the bladder to drain urine);- The patient refused wound care after the Foley catheter was placed and bed linens were changed;- The nurse informed the patient’s sisters that the MSW was notified of their needs for a life alert necklace and help with the Medicaid paperwork (The documentation failed to show the patient’s orientation status during this visit); and - An email was sent to all staff notifying them of the daily nurse visit status.  Review of an email dated 09/07/2025 at 8:07 PM, showed:- RN-A sent an email to all staff that provided updates from the SN visits with the patient over the weekend;  - The patient needed to remain on daily visits;- The patient’s wounds required daily dressing changes;- The patient was no longer eating;- RN-A believed that the patient would “take a nose dive” after the sister’s left; - Upon RN-A’s arrival to the home the patient was found saturated with urine from his/her shoulder blades to the backs of his/her knees; and - RN-A sent another email to the MSW that stated “we need to get (the patient) a life alert necklace ASAP” and that the MSW also needed to help the sisters with (the patient’s) Medicaid application.  Review of the SN visit note, dated 09/08/2025 at 3:33 PM, showed in part:- The patient reported pain at a six (6)/10 upon SN arrival but had just taken PRN pain medication;- The patient reported pain at a two (2)/10 by the end of the visit; - Education was provided to the pt and patient caregivers (pcg’s) regarding the need for frequent repositioning and pericare (washing the genitals and anal area); - The sisters (pcg’s) did not appear interested in the pericare of the pt; - The pcg’s would require continued education with personal care of the pt; and- The documentation failed to show the patient’s orientation status this visit. Review of the initial MSW visit note (completed by MSW-A), dated 09/09/2025 at 9:04 AM, showed in part:- Referrals for long-term care (LTC) were submitted;- The patient lived alone; - The patient’s memory and cognitive status showed: * Normal * Forgetful- short term- Safety hazards included inadequate heating and pets;- Sanitary issues included cluttered/soiled living area;- The patient was assessed for an emergency alert button; - The patient did not need emergency alert services (The clinical record failed to show documentation explaining why the patient no longer needed an emergency alert necklace);- Family/social support findings showed limited family members/friends available or supportive; and- The narrative note showed, in part: * The patient was alert and oriented x3 (times three) * The patient’s two sisters lived out of state and were in town to assist the patient * The patient reported pain at a 6 (zero indicating no pain and 10 indicated the worse pain)  * The patient’s sister gave the patient pain medication during the visit * The patient was bedbound  * The patient was having a hard time coming to terms with needing 24-hour care that could only be provided in a nursing home * The patient stated that he/she did not want to go to a nursing home but knew it was best * The MSW sent referrals to two (named) facilities for placement  * One facility declined the referral and the second facility requested the last three months of bank statements * The patient’s sisters were to take the bank statements to the facility the following day * The MSW discussed visit frequency with pt and family and they were agreeable with the plan of care (POC) and the MSW visiting 1x (one time) weekly for the first month and then 1x monthly and as needed (PRN) after; and  * The MSW collaborated with interdisciplinary group (IDG) through documentation.  Review of the SN (RN-C) visit note, dated 09/10/2025 at 11:47 AM, showed in part:- The patient was alert and oriented, answered questions appropriately, dozed off when not in direct communication with the nurse; - The sisters were present during the visit and reported that they stayed with the patient during the day but left the patient alone at night (The documentation failed to show a plan that explained how symptoms would be managed and care provided while the bedbound patient was alone at night); - They were seeking placement for the patient; - The pain assessment showed pain was reported by the caregiver, the pain intensity scale that was used showed, “patient visual”, and the visual rating was a zero;- The nurse noted that the patient had no sheets on his/her bed and only had an incontinence pad underneath him/her that was soiled with bowel movement (BM); - The nurse cleaned the patient up from the BM, provided pericare, and wound care to the coccyx wound;- Extensive education was provided to the sisters regarding the importance of repositioning the patient and ensuring the patient was clean and checked frequently for bowel movements in order to help prevent further skin breakdown;- The sisters asked the nurse to empty the urine in the catheter bag, stating they were shown how but wanted the nurse to do it;- The nurse demonstrated and reinforced education on how to empty the urinary drainage bag; and- The patient remained on daily nurse visits. Review of the SN (RN-B) visit note, dated 09/11/2025 at 9:58 AM, showed in part:- Neurological findings showed the patient was unable to communicate and there was no caregiver present (The plan of care failed to show interventions for communication deficit); - Communication issues identified showed the patient was unable to make needs known;- The patient moaned when his/her head was turned (The plan of care failed to show patient-specific pain assessment scale and interventions);- The pain assessment section showed pain was reported by the patient (This contradicts the patients neurological findings and communication issues);- The pain intensity scale used showed patient visual with a score of zero (This contradicts the patient moaning when head was turned and the need for an “extra dose” of morphine);- The nurse looked through the house for the patient’s family, and there was no family present, but shortly thereafter, they arrived;- The patient was minimally responsive;- The patient was given “an extra dose” of morphine during the visit to help get the patient settled;- The MSW was contacted regarding status update on facility placement and the nurse was informed the patient was accepted; - The sisters were informed that the patient was accepted for facility placement; and- The sisters did not want the patient touched or moved to worry about wound care due to the patient being comfortable (This contradicts the interviews and the reason for the PRN visit that was made six hours and 37 minutes later).  Review of the PRN MSW visit note, dated 09/11/2025 at 10:38 AM, showed in part:- The MSW arrived at the home to notarize a last will and testament;- The MSW informed the family that he/she was unable to notarize it due the patient being lethargic and unable to answer questions appropriately; - The MSW reached out to the nursing facility and spoke to the administrator to inquire if hospice needed to be revoked before the patient could be admitted to the nursing facility and find out about transportation arrangements;- The MSW was informed by the nursing facility administrator that the patient had to be discharged from their hospice before the nursing facility would take the patient because the facility refused to take a hospice patient that was on service with the hospice provider (the patient was going to use a different hospice provider);- The patient’s sister completed the revocation (a patient’s or their representatives’ voluntary decision to stop receiving hospice benefits) paperwork; - The MSW informed the sister that someone with the new hospice provider would reach out and follow-up with them regarding the transfer;- The bath aide arrived during the MSW visit to assist with a bath;- The MSW was in his/her car to leave, and the bath aide went out to the car and informed the MSW that someone from the other hospice company had called the patient’s sister;- The other hospice company could not accept the patient until the following day and the patient needed to be a transfer and not a revocation; - The MSW voided the revocation document and reached out to the RN identified by the provider as a "clinical manager" (CM);- The CM informed the MSW that the new hospice company had called the office regarding the transfer and would be sending their transfer document; - The new hospice company made transportation arrangements for the patient to be transported at 1:00 PM on 09/12/2025 and they (the new hospice provider’s staff) would be at the home at noon (on 09/12/2025) to sign the patient onto their services prior to the transport; and- The documentation failed to show a plan in place for how symptoms were going to be managed until the transfer took place. Review of the PRN SN (licensed practical nurse (LPN)-A) visit note, dated 09/11/2025, beginning at 4:35 PM (six hours and 37 minutes after the routine SN visit with RN-B), showed in part:- A PRN nurse visit was made due to the patient needing wound care performed;- The patient was alert to person; - Wound care provided to thigh and coccyx but was refused to right foot wound (This contradicts the patient’s orientation status and the interviews that stated the reason wound care was not provided was due to not having swabs in the home that were needed); - Upon arrival the patient was found alone;- The patient was alert to person;- The nurse contacted the sister and the sister requested that the nurse administer morphine prior to performing wound care (The patient was left alone, alert to self only, in pain, unable to self-administer pain medication, and left alone without symptom management the entire night following this SN visit);- The patient reported pain was a 4/10 (The patient was alert to person only and unable to make needs known by this time);- Apnea (temporary pauses in breathing that occur as a person approaches death) noted up to 25 seconds at times with respirations 8 breaths per minute (bpm);- Heart rate irregular and tachycardic (fast heart rate); and - The patient was transferring to the facility the following day (The patient arrived at the nursing facility at 1:15 PM on 09/12/2025, 20 hours and 40 minutes after this last visit. The patient was left in the home alone all night without pain management and arrived at the facility in severe pain).  Review of the receiving hospice provider’s admission note, dated 09/12/2025, showed the following:- The patient arrived to the nursing facility via gurney by (named company) from his/her home (arrival time was 1:15 PM);- The patient was unable to move self, moaning, and in obvious pain;- The patient was awake, moaning, screaming in pain, FLACC (a pain assessment tool used when the patient is unable to express their pain verbally) score 10/10;- The patient was totally dependent and required x4 (4 people) assist to transfer from the gurney to the bed after arrival to the facility;- The patient was in severe pain and combative at times during the transfer;- The patient noted to be severely emaciated;- The patient was experiencing 10/10 pain with tactile stimuli, responding with hollering, moaning, and yelling;- Pupils were sluggish to light, lips dry and cracked, mucus membranes reddened/inflamed and dry;- Oral mucosa with erythematous lesions/sores noted to hard palate; - Tongue was markedly swollen with significant asymmetry, distorted with irregular contour, giving appearance of partial tissue loss;- Nutritional status is profoundly compromised;- Lung sounds diminished throughout lobes, respiration slightly labored at 24 breaths per minute;- Heart rate and rhythm irregular, tachycardia at 115 beats per minute;- Abdomen emaciated, flat, tender to touch, bowel sounds hypoactive in all four quadrants, noted black tarry stool with foul odor of possible gastrointestinal (GI) bleed, oozing incontinent of bowel, peri-care was provided; - Foley catheter was patent with dark amber foul-smelling urine in the tubing;- The patient was covered in open sores, possibly Kennedy ulcers (a dark sore that develops rapidly during the final stages of a person’s life) and gangrene;- The patient arrived with dry dressings to right foot and right posterior thigh;- The facility nurse saturated dressings with distilled water so as not to debride skin with dry dressing;- Wounds were noted to have multiple white long hairs that appeared to be animal hair and the sister reported the patient had a dog in the home until this week; - Wounds were noted to the right posterior thigh, right lower leg, right foot, left hip, left leg, left heel, left ankle, and coccyx;- The patient had a low-grade fever with tachycardia that was suggestive of severe sepsis;-The patient exhibited severe uncontrolled pain with any tactile stimuli, hollering/moaning with movement or care when the patient was first assessed;- The pain was consistent with advanced tissue necrosis and systemic illness; and-The patient also demonstrated signs of systemic infection/sepsis including altered responsiveness, elevated low-grade temperature, tachycardia, foul odor from wounds, and overall rapid decline. Review of a client coordination note (completed by RN-E), dated 09/15/2025 (three days after the patient was transferred to another hospice provider), showed:- Note type: missed visit notification; - Date of missed visit: 09/12/2025; and- Reason for missed visit: Discharged (patient transferred to another hospice). Review of the clinical record showed the patient was discharged (transferred to another hospice) without a visit and/or assessment on the day the patient was transferred to the nursing facility and new hospice provider. During an interview on 09/16/2025 at 12:35 PM, the patient's sisters stated that:- They lived out of state and came to assist the patient with nursing home placement; - They had to stay in a hotel room because there was no place for them to sleep at the patient’s home;- The home was extremely unsanitary and had dog feces and urine all over the floor; - One sister was 78 years old, and the other was 73 years old; - They were physically unable to provide care to the patient due to not having the physical strength; - They asked the hospice staff about respite placement and were informed that the patient did not qualify for respite; - The hospice was aware that the patient was home alone at night;- The MSW did not get the life alert necklace because he/she informed them that it was not needed since the patient would be going to a nursing home; - There was no safety plan for the patient in the event of an emergency;- The patient was in excruciating pain until the other hospice company took over and were able to get the pain under control;- They (sister’s) spoke to a hospice staff member and complained about the poor care provided by the nurse case manager (RN-B) because he/she was always rough and never provided wound care during any of his/her visits;- Hospice sent a nurse (LPN-A) back out to the house but that nurse was unable to perform wound care to the patient’s right leg and foot because he/she did not have the supplies that was needed and was not aware that he/she would need to take any supplies; and- A nurse was supposed to make a visit the morning of 09/12/2025 to help get the patient cleaned up and ready for the transfer to the nursing facility but the nurse never showed up and never called. During an interview on 09/16/2025 at 3:15 PM, the administrator stated that:- Continuous care would be offered for symptom management when eight hours of skilled care is needed; - The patient needed custodial care and that is not offered by hospice;- Respite would have been for caregiver fatigue and the sister’s just were not fatigued, they just were not willing to provide care; - “It is not encouraged to go from respite to permanent placement”; - They were physically able to meet the needs of the patient, they just did not want to; and- He/she was unaware of the sister’s filing a complaint regarding the nurse case manager providing poor care. During an interview on 09/16/2025 at 4:20 PM, the clinical manager stated that:- He/she did receive a call from the patient’s sister regarding the RN case manager (RN-B) not providing wound care;- He/she sent another nurse to the home to do the wound care (LPN-A); and- He/she was informed by LPN-A that he/she was only able to provide wound care to two out of the three wounds because there were not any swabs in the home and they were needed for the third wound (right lower extremity, RLE). During an interview on 09/17/2025 at 11:14 AM, RN-A stated that:- He/she was the admitting nurse and the nurse that completed daily visits over the weekend; - When he/she arrived at the home for the admission the house was extremely unsanitary with dog feces and urine all over the floors;- The patient informed RN-A that he/she could transfer to the wheelchair, but RN-A never witnessed it and did not believe that the patient could transfer; - He/she never even saw the patient sit up in the bed;- The patient’s sisters were not at the home during the admission but were at the home the next day;- The sisters left the patient alone at night because they were staying at a hotel;- The house was unsanitary and there was nowhere for the sisters to stay at the patient’s home;- There was no food in the patient’s refrigerator;- RN-A went to his/her car and got snacks for the patient to have something to eat until the sisters could get there the next day;- He/she called the sisters and informed them that the patient needed food and bottled water;- He/she educated the sisters that they needed to bring food that could be left at bedside and within reach because the patient was bedbound;- He/she was very concerned about the patient’s living environment and physical condition (RN-A began crying during the interview while explaining the horrible conditions of the home and the patient);- He/she did not want to leave the patient but he/she did not know what else could have been done; - He/she called his/her administrator on-call (AOC) and explained how bad the home was and the condition the patient was in; - He/she expressed to the AOC that he/she felt the patient needed hotlined (state abuse and neglect hotline) and the AOC agreed; - He/she thought that the AOC was going to hotline and he/she was not aware that a hotline report was not made; and- He/she did not know that he/she could be the one to hotline the patient and he/she asked what that hotline number was for future reference. During an interview on 09/17/2025 at 12:24 PM, the MSW stated that:- He/she received the emails regarding the patient on Monday (09/08/2025) morning but did not do the initial visit until Tuesday (09/09/2025); - He/she did not proceed with the life alert necklace due to working on permanent placement for the patient; and - He/she was not aware that the patient was home alone at night. During an interview on 09/17/2025 at 1:00 PM, the AOC stated that:- RN-A did contact him/her about the horrible living conditions; - He/she was aware the patient was bedbound;- RN-A did discuss the patient being hotlined; - He/she agreed that the patient needed hotlined, but he/she never informed RN-A that he/she would be the one doing it; and- He/she would have expected RN-A to hotline the patient as RN-A was the one that witnessed the conditions.  During an interview on 09/17/2025 at 1:29 PM, RN-B (the RN case manager) stated that:- He/she had only seen the patient twice and did not perform wound care either time due to the patient having too much pain with wound care; - The patient was incontinent of bowels and had bowel movement up his/her back upon arrival;- The patient had black, tarry bowel movements (This was not documented); - He/she did not notify the physician about the pain, wound care not being provided, and the black tarry stools because the patient was receiving daily nursing visits to monitor his/her status; and - He/she did not request emergency respite placement because the MSW was working on finding permanent nursing home placement for the patient.   During an interview on 09/17/2025 at 2:00 PM, the AOC stated that:- The admitting nurse would be the one that was expected to hotline the patient; - He/she would expect the nurse that witnessed the conditions to be the one filing the hotline report; and- He/she agreed that RN-A should have hotlined the patient.   During an interview on 09/18/2025 at 1:02 PM, the hospice medical director stated that:- He/she had not met the patient personally; - He/she thought that they (interdisciplinary group, IDG) discussed emergency respite placement during the meeting on 09/10/2025; and - He/she would have expected emergency respite or hospitalization to meet the patient’s needs.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure:- The interdisciplinary group (IDG) met the needs of the patient and family (L0539);- An individualized POC was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments (L0545); and- The IDG maintains responsibility for directing, coordinating, and supervising the care and services provided (L0554).The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) provided care and services offered by the hospice, in its entirety, to meet the needs of the patient, in one of four full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's policy titled, "Admission Criteria & Procedure- Hospice," last revised March 29, 2023, showed in part, the following:- The hospice admits clients based on the reasonable expectation that their physical, social, psychological, and spiritual needs can adequately be met throughout the continuum of hospice services, and provides these services in accordance with the Medicare conditions of participation. All hospice clients must meet the admission criteria and Medicare Hospice conditions of participation eligibility requirements;- Additional admission criteria, included in part:* There is a capable primary caregiver living in the home or, if no caregiver is available, the client agrees to assist the Hospice in developing a plan of care to meet their future needs* The hospice has adequate resources and staffing to meet the needs of the client; and- A registered nurse (RN) must conduct the initial hospice assessment visit to determine the immediate care and support needs of the patient.  Review of the provider's policy titled, "Provisions of Hospice Services," last revised June 3, 2024, showed in part, the following:- Volunteer services - volunteers are recruited and retained with efforts that are sufficient to ensure that the Hospice has enough volunteers to meet the needs of the patients and the requirements of the federal regulations- Volunteers provide services that include administrative duties and or direct client care;- Availability of services- as needed to meet the needs of the patients and their caregivers, care and services provided by hospice are available 24 hours a day, seven (7) days a week; and- The Hospice ensures there is adequate staffing to meet the needs of the patients. Review of the provider's policy titled, "Interdisciplinary Group-Hospice," last revised January 1, 2024, showed in part, the following:- The governing body designates an IDG composed of qualified individuals who assess, plan, coordinate, provide, and evaluate the care and services provided to hospice clients/caregivers;- The IDG works together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient family facing terminal illness and bereavement by:* Establishing, implementing, reviewing, and revising the client's plan of care* Directing, coordinating, and supervising hospice care and services - The focus of the IDG conference is to plan and coordinate the care and services provided to hospice clients and their caregivers; - The IDG conferences include: * Identify obstacles to and solutions for access of care issues * Determine appropriate level of services required, evaluate current level of service effectiveness- A RN member of the IDG is there designated to manage care for each client/caregiver; and- The RN under physician orders and in coordination with all members of IDG is responsible for coordinating the care and services provided and implementing the interdisciplinary plan of care. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/05/2025 with a terminal diagnosis of gangrene (a condition where tissue dies due to a lack of blood supply) and resided at home alone. Review of the initial comprehensive assessment (completed by RN-A), dated 09/05/2025, showed:- The patient (pt) was appropriate for volunteer services and would have benefited from the following: * Patient support * Household support * Companionship- The support services needed and referrals required included: * Home maintenance/repairs/handyman services * Homemaker services * Relocation to different care setting- Care coordination included the following disciplines: * Social worker * Spiritual Counselor * Hospice aide * Clinical manager (a term used by the hospice provider to describe certain RNs) * Registered nurse/skilled nurse (SN) * Pharmacist- Activities of daily living (ADL’s) that the patient required assistance with included: * Housekeeping * Shopping * Meal preparation- The patient was dependent on assistance with the following ADL’s:  * Ambulation * Continents * Transfers * Dressing * Feeding * Bathing- The patient was bedbound and lived home alone; and - The patient needed a life alert necklace for emergencies.   Review of an email from RN-A to all staff, dated 09/06/2025, showed: - Pt living alone;  - The pt stated that he/she could get up, but the nurse had yet to see it happen;- T house was very unsanitary; and- “MSW (medical social worker)- pt needs life alert necklace ASAP (as soon as possible)! Plus sisters are needing your help with Medicaid application;” and - “Nurse- placing on daily nurse visits throughout weekend until RNCM can re-evaluate.”  Review of the initial MSW visit note (completed by MSW-A), dated 09/09/2025, showed in part:- Referrals for long-term care (LTC) were submitted;- The patient was assessed for an emergency alert button; - The patient did not need emergency alert services (The documentation failed to explain why the patient no longer needed an emergency alert necklace);- Family/social support findings showed limited family members/friends available or supportive (The documentation failed to show a plan for limited available support while the patient was awaiting placement); and- The narrative note showed, in part: * The patient’s two sisters lived out of state and were in town to assist the patient * The patient was bedbound  * The patient was having a hard time coming to terms with needing 24-hour care that could only be provided in a nursing home (The documentation failed to show alternative methods available to provide 24-hour care while awaiting permanent placement) * The patient stated that he/she did not want to go to a nursing home but knew it was best * The MSW sent referrals to two (named) facilities for placement  * One facility declined the referral, and the second facility requested the last three months of bank statements * The patient’s sisters were to take the bank statements to the facility the following day * The patient denied fear of dying but reported that he/she had some fear of the dying process * The MSW assured the patient that their (hospice) goal was to keep him/her as comfortable as they (hospice) could and provide support along the way (The documentation failed to show how comfort and support was to be provided when the bedbound patient was home alone) * The MSW discussed visit frequency with pt and family and they were agreeable with the plan of care (POC) and the MSW visiting 1x (one time) weekly for the first month and then 1x monthly and as needed (PRN) after; and  * The MSW collaborated with IDG through documentation. Review of the SN (RN-C) visit note, dated 09/10/2025, showed in part:- The sisters were present during the visit and reported that they stayed with the patient during the day but left the patient alone at night (The documentation failed to show a plan that explained how symptoms would be managed and care provided while the bedbound patient was alone at night); and- They were seeking placement for the patient (The documentation failed to show emergency respite being offered while awaiting permanent placement).  Review of the SN (RN-B) visit note, dated 09/11/2025 at 9:58 AM, showed in part:- Neurological findings showed the patient was unable to communicate and there was no caregiver present (The documentation failed to show continuous care or emergency respite being offered to meet the needs of the patient); - The patient moaned when his/her head was turned;- The nurse looked through the house for the patient’s family, and there was no family present, but shortly thereafter, they arrived;- The patient was minimally responsive;- The patient was given “an extra dose” of morphine during the visit to help get the patient settled (The documentation failed to show an initial dose being given for pain, how many doses of pain medication was required to get the pain uncontrol, and how the patient’s pain and symptoms were to be managed when the patient was home alone, minimally responsive and moaning in pain);- The MSW was contacted regarding a status update on facility placement and the nurse was informed the patient was accepted (The documentation failed to show transfer arrangement details); - The sisters were informed that the patient was accepted for facility placement; and- The documentation failed to show how the needs of the patient were to be met while awaiting transfer to the nursing facility.  Review of the PRN SN (LPN-A) visit note, dated 09/11/2025 at 4:35 PM (six hours and thirty-seven minutes after the routine SN visit was made), showed in part:- A PRN nurse visit was made due to the patient needing wound care performed (wound care was not performed during the previous SN visit that day); - Upon arrival, the patient was found alone (This was the second time the patient was found home alone on this day); - The patient was alert to person only;- The nurse contacted the sister, and the sister requested that the nurse administer morphine prior to performing wound care;- The patient’s pain was a four/10 (4 out of 10; on a pain scale where zero equals no pain and 10 equals worst possible pain);- Apnea (temporary pauses in breathing that occur as a person approaches death) noted up to 25 seconds at times with respirations eight breaths per minute (bpm);- Heart rate irregular and tachycardic (fast heart rate); - The patient was transferring to the LTC facility the following day (09/12/2025); and- The minimally responsive patient was left home alone, unable to self-administer medications, and unable to manage pain. The clinical record failed to show how the patient’s continued care needs were to be met.   Review of a client coordination note, dated 09/12/2025, showed:- The note was entered by the volunteer coordinator (seven days after the patient was admitted to hospice services and the request for volunteer services was made); - Note type: narrative; and- Note: * Follow up- It was entered upon admission that the patient could benefit from volunteer services for companionship, household support and patient support. No volunteer request entered at this time * Report received on 09/08/2025. Collaboration with the MSW- In the process of getting patient admitted to facility * 09/12/25- Patient admitted to nursing facility who require patient to be admitted to a different hospice. Patient discharged at this time (The need for volunteer services was identified on admission and the patient never received volunteer services). Review of a client coordination note, dated 09/15/2025 (three days after the patient was discharged from the hospice provider), showed:- The note was entered by RN-E (The nurse that was assigned to make the discharge visit prior to the patient being transferred to the nursing facility);- Note type: missed visit notification; - Date of missed visit: 09/12/2025; and- Reason for missed visit: Discharged (The patient was discharged without a visit and an assessment). During an interview on 09/16/2025 at 12:35 AM, the patient's sisters stated that:- They lived out of state and came to assist the patient with nursing home placement; - They had to stay in a hotel room because there was no place for them to sleep at the patient’s home;- One sister was 78 years old, and the other was 73 years old; - They were physically unable to provide care to the patient due to not having the physical strength; - They asked the hospice staff about respite placement and were informed that the patient did not qualify for respite; - The hospice was aware that the patient was home alone at night;- The MSW did not get the life alert necklace because he/she informed them that it was not needed since the patient would be going to a nursing home; - There was no safety plan for the patient in the event of an emergency;- The patient was in excruciating pain until the other hospice company took over and were able to get the pain under control; and- A nurse was supposed to make a visit the morning of 09/12/2025 to help get the patient cleaned up and ready for the transfer to the nursing facility but the nurse never showed up and never called. During an interview on 09/16/2025 at 3:15 PM, the administrator stated that:- Continuous care would be offered for symptom management when eight hours of skilled care is needed; - The patient needed custodial care and that is not offered by hospice;- Respite would have been for caregiver fatigue and the sisters were not fatigued, they just were not willing to provide cares; - “It is not encouraged to go from respite to permanent placement”; and- The sisters were physically able to meet the needs of the patient, they just did not want to (the sisters were 73 and 78 years old). During an interview on 09/17/2025, at 11:14 AM, RN-A stated that:- He/she was the admitting nurse and the nurse that completed daily visits over the weekend; - The patient’s sisters were not at the home during the admission but were at the home the next day;- The sisters left the patient alone at night because they were staying at a hotel;- The house was unsanitary and there was nowhere for the sisters to stay at the patient’s home;- There was no food in the patient’s refrigerator;- RN-A went to his/her car and got snacks for the patient to have something to eat until the sisters could get there the next day;- He/she called the sisters and informed them that the patient needed food and bottled water;- He/she educated the sisters that they needed to bring food that could be left at bedside and within reach because the patient was bedbound;- He/she was very concerned about the patient’s living environment and physical condition (RN-A began crying during the interview while explaining the horrible conditions of the home and the patient);- He/she told the patient’s sisters that he/she needed 24-hour care because he/she could not take care of him/herself;- He/she offered respite to the patient on admission but the patient refused;- He/she did not know what continuous care was, but he/she did sign th e patient up for all the services he/she knew about so that there were more eyes on the patient;- He/she was not aware that the MSW did not make the initial visit until that Tuesday (09/09/2025, four days after admission);- He/she sent two emails to the MSW about the patient needing a life alert necklace ASAP and expected the MSW to see the patient that Monday (09/08/2025); - He/she was not aware that the patient never received the life alert necklace and volunteer services; and- He/she called his/her administrator on-call (AOC) and explained how bad the home was and the condition the patient was in.. During an interview on 09/17/2025 at 12:24 PM, the MSW stated that:- He/she received the emails regarding the patient on Monday (09/08/2025) morning but did not do the initial visit until Tuesday (09/09/2025, four days after admission); - He/she did not proceed with the life alert necklace due to working on permanent placement for the patient; and - He/she was not aware that the patient was home alone at night. During an interview on 09/17/2025 at 1:29 PM, RN-B (the RN case manager) stated that:- He/she had only seen the patient twice and did not perform wound care either time due to the patient having too much pain with wound care; - The patient was incontinent of bowels and had bowel movement up his/her back upon arrival;- The patient had black, tarry bowel movements (this was not documented); - He/she did not notify the physician about the pain, wound care not being provided, and the black, tarry stools because the patient was receiving daily nursing visits to monitor his/her status; and - He/she did not request emergency respite placement because the MSW was working on finding permanent nursing home placement for the patient.   During an interview on 09/18/2025 at 1:02 PM, the hospice medical director stated that:- He/she had not met the patient personally; - He/she thought that they (IDG) discussed emergency respite placement during the meeting on 09/10/2025; and - He/she would have expected emergency respite or hospitalization to meet the patient’s needs.

Based on policy review, record review, and interview, the hospice provider failed to ensure an individualized plan of care (POC) was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, in two of four full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the provision of care to all the patients served by the provider. --- RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 02/27/2025 with a primary terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided at home with his/her spouse who was the primary caregiver.  Review of the recertification assessment of the patient, dated 08/08/2025, showed the following:- Exertional dyspnea (shortness of breath that occurs during physical activity and improves with rest) when transferred from the wheelchair to the couch or ambulating five feet;- Required two liters of oxygen as needed;- Two plus edema (when excess fluid builds up in the body causing swelling, when pressure is applied to the swollen area, an indentation will remain) to the patient’s bilateral feet and ankles and the swelling extended up to the left leg calf and occasionally on the right leg despite the increase of Lasix (diuretic);- The patient had started using Ativan (antianxiety) due to the anxiety the pain caused and the decreased ability to move in the mornings;-The patient rated his/her pain a two (zero representing no pain and ten the worst pain possible), the worst pain level the patient reported in the past 24 hours was an eight in the lower right leg, which was burning, stinging, and tender, and the patient’s pain goal was a four;- The patient reported having pain daily and the pain was worst in the mornings in his/her hip, back and lower right leg - The patient had taken Tramadol (used to treat moderate to moderately severe chronic pain), Norco (used to relieve moderate to moderately severe pain) 5 milligrams (mg) as needed, and gabapentin (used to treat nerve pain) and now had pain in his/her right leg wound, the Norco was increased to 7.5 mg and desipramine (an antidepressant used to treat depression and sometimes is prescribed for conditions like neuropathic pain) was added at night;- The patient’s pain was frequent and the pain was relieved with positioning and prescription pain medicine; - The patient’s pain was exacerbated by walking, transitional movement, and all activity; and- The patient had a venous stasis ulcer (a wound that occurs due to poor blood flow), to the right lower leg; Review of the plan of care dated 09/03/2025, showed the following:- An intervention to assess effectiveness of medication used for respiratory distress or secretions. (The POC failed to include the specific medications used and non-pharmacological interventions used for the patient’s respiratory distress and secretions);- An intervention to instruct on reason for oxygen and appropriate liter flow per minute as per physician order. (The POC failed to include an order for the liter flow per minute for the patient’s oxygen);- An intervention to instruct care to reduce edema, relaxation techniques, “elevation” of head of bed. (The POC failed to include individualized interventions to reduce the patient’s edema); - An intervention for skilled nurse measures to decrease agitation and anxiety. (The POC failed to include individualized interventions and specific medications to decrease the patient’s agitation and anxiety);- An intervention to instruct family to notify hospice nurse of any change in patient’s pain intensity or if pain medication was not adequately controlling the patient’s pain and the skilled nurse to monitor the pain level using appropriate pain scale 0-10. (The POC failed to include specific pain medication and other treatments necessary to manage the patient’s symptoms); - On 08/26/2025, an order showed using clean technique, cleanse the wound to the lower right leg with wound cleanser, pat dry, apply skin prep to the periwound, apply crushed Flagyl (used to treat certain bacterial and parasitic infections) to wound bed, then MediHoney (medical grade honey) and cover with an adhesive foam dressing, and change twice a day when skilled nurse not present (this was the current treatment to the right leg wound);- Silvadene (used to prevent and treat serious infections in second and third degree burn wounds) 1% topical cream applied to the wound bed (no other specific) with dressing changes (this was no longer a current wound treatment);- An intervention for the skilled nurse to cleanse the lower right leg with wound cleanser, pat dry with gauze, apply a small mount of MediHoney to wound, apply SurePrep to periwound with foam dressing, and then cover with an occlusive dressing twice a week and as needed (this order was no longer a current treatment).Per interview conducted during observation on 09/16/2025 at 2:55 PM, registered nurse (RN) F stated that they were not using Silvadene for wound care treatment and they were using Flagyl and MediHoney.   During an interview on 09/16/2025 at 4:54 PM, the administrator stated that he/she would expect the plan of care to be current and have individualized interventions. Findings included: Review of the provider's policy titled, "Client Care Plan," last revised July 5th, 2021, showed in part, the following:- The in plan of care is based on the client's medical diagnosis, physician/healthcare practitioner’s order, comprehensive assessment, and client's input, and must include the following elements:* The types of services, supplies, and equipment needed* All medications and treatments* Client-specific interventions and education* Safety measures to protect against injury- Actions and interventions are consistent with the plan of care and are documented; and- Changes in the client's medical condition and environment are reflected in ongoing revisions made to the original plan of care by the clinical manager (CM) and/or field nurses. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/05/2025 with a primary diagnosis of gangrene (a condition where tissue dies due to a lack of blood supply) and resided at home alone. Review of the hospice initial comprehensive assessment, dated 09/05/2025 at 11:21 PM, showed:- The patient lived alone in unsanitary living conditions;- The type of safety and sanitary issues included; * Loose/unsafe flooring * Unclean/cluttered living area * Poorly controlled pets/animals * Structural problems (floor/roof/windows)- The patient’s mental status included alert, oriented to person, oriented to place, oriented to time, forgetful and confused;- Signs and symptoms that showed decline included uncontrolled pain, change in heart rate from baseline, and weakness;- The patient self reported pain 5/10 (zero being no pain and 10 being the worst pain) on a numeric pain scale, the nurse administered PRN (as needed) pain medication and the patient’s pain improved to 2/10;- The patient had a pain goal of 3;- The patient was unable to ambulate;- The patient was incontinent of bowel and bladder; - The patient was unable to transfer independently;- The patient required assistance with dressing;- The patient required total assistance with bathing;- The patient required assistance with food preparation and meals; - The patient had unstageable pressure ulcers (a type of pressure injury where the depth of the wound cannot be determined because it covered by slough (yellow, gray, or green dead tissue) or eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed) to the buttocks and right thigh;- The pressure sore risk assessment showed: * Physical condition- very bad * Mental condition- alert * Activity- bedridden * Mobility- immobile * Incontinence- urinary and fecal * Risk assessment score of eight indicated the patient was very high risk for pressure ulcers- With the patient being in the hospital for 10 days, it was unlikely that he/she would be able to walk or transfer to the wheelchair; - The patient had an unstageable necrotic wound to the right mid dorsum (the middle part of the top surface of the foot) measuring 40 centimeters (cm) in length and 20 cm in width with zero (0) cm in depth (the plan of care failed to show any open wounds and the plan of care did not have wound care orders);- The patient had an unstageable necrotic wound to the coccyx that measured nine (9) cm in length by 15 cm in width with 0 cm in depth;- The patient had an unstageable wound to the right mid-thigh (the middle part of the right thigh) measuring 10 cm in length and five (5) cm in width with 0 cm in depth; and- The narrative note showed, in part:  * The patient was alert and oriented x4 (person, place, time, and situation) * The patient lived alone and refused to live in a nursing facility despite it being beneficial for him/her to have 24-hour care * As the visit went on the patient got more tired and had some intermittent confusion which was to be expected with gangrene infection.Review of the POC, dated 09/05/2025 to 12/03/2025, showed in part:- The disciplines involved included skilled nursing (SN), medical social worker (MSW), home health aide (home health aide), and spiritual counselor (SC);- The POC failed to show volunteer services (indicated as a service that was needed during the initial comprehensive assessment);- Orders and treatments showed;  * Monitor pain level using appropriate pain scale (there was not a patient-specific pain scale listed) * Perform complete assessment with focus on integumentary status such as pressure reduction/relief, incontinence, decrease perfusion (circulation), poor nutrition and other disease processes that may contribute to wound development * Identify sources of pressure and implement pressure reduction measures in education regarding the pressure reduction measures * Instruct regarding proper hygiene after each episode of bowel incontinence * Instruct regarding effects of bladder incontinence on skin integrity as well as measures to protect skin * Perform multifactor falls risk assessment to include history of falls, accidents, medication regimen, impact of polypharmacy, cognitive status, mobility and environmental status * Educate caregiver on signs and symptoms of active dying that may include agonal breathing, terminal secretions, decreased oral fluid intake, decreased bowel and urine output * Educate on comfort medications, their usage, side effects and how to administer- Functional limitations: Bowel/bladder (incontinence), endurance, ambulation (the POC failed to show the patient was bedbound and required assistance with transfers);- Safety measures: clean technique, clear pathways, fall precautions, removal of throw rugs, standard precautions (the POC failed to include patient-specific safety measures for the bedbound patient that lived in the home alone);- Activities permitted: up as tolerated, wheelchair (the patient was unable to get up as tolerated due to being bedbound and unable to get out of bed without assistance);- Nutritional requirements: regular diet (the patient had poor nutrition and was unable to prepare meals); and- Mental status: oriented, forgetful (the POC failed to show the intermittent confusion that was identified on the initial comprehensive assessment). Review of the SN visit note, dated 09/08/2025 at 3:33 PM, showed in part:- Education was provided to the patient (pt) and patient caregivers (pcg’s) regarding the need for frequent repositioning and pericare (washing the genitals and anal area); - The sisters (pcg’s) did not appear interested in the pericare of the pt (the POC failed to include caregiver specific interventions for pericare); and- The pcg’s would require continued education with the personal care of the pt (the POC failed to include the specific personal care education that needed to be provided). Review of the initial MSW visit note, dated 09/09/2025 at 9:04 AM, showed in part:- Safety hazards included inadequate heating and pets (the POC failed to include these safety hazards);- The patient did not need emergency alert services (The clinical record failed to show documentation explaining why the patient no longer needed an emergency alert necklace and the POC failed to include an emergency plan in place);- Family/social support findings showed limited family members/friends available or supportive; and- The narrative note showed that the sister gave the patient pain medication during the visit (the POC failed to show that the patient required medication administration assistance and the plan of care failed to include interventions for medication administration when the patient was home alone). Review of the SN visit note, dated 09/11/2025 at 9:58 AM, showed in part:- Neurological findings showed the patient was unable to communicate and there was no caregiver present (The plan of care failed to show interventions for communication deficit); - Communication issues identified showed the patient was unable to make needs known;- The patient moaned when his/her head was turned (The plan of care failed to show patient-specific pain assessment scale and interventions); and- The patient was minimally responsive and home alone upon arrival (the POC failed to show interventions in place for pain and symptom management when the minimally responsive, bedbound patient that was unable to communicate, was left home alone). During an interview on 09/16/2025, at 11:30 AM, the administrator stated that:- The nurse (RN A) did not enter the wound care orders correctly, so the orders did not make it onto the POC; - There were no signed wound care orders;- None of the patient’s wound care orders were being done correctly; and - He/she would expect the POC to include the patient-specific orders and interventions.

Based on record review and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) maintained responsibility for coordinating and supervising the care and services of the patient, in one of four full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2025 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided at home with his/her spouse who was the primary caregiver.   Review of the client coordination note, dated 08/19/2025 at 5:08 PM, showed RN-F documented the following:- The patient’s spouse reported that they had a problem and that the patient got mad, grabbed his/her arms, scratched, and pushed him/her away;- The spouse stated that he/she was going to call his/her daughter, and was going to leave;- The spouse stated that he/she could not do "this" anymore;- The patient was not talking, and his/her breaths had increased with added effort;- The spouse stated that the patient was upset with him/her for getting him/her up and that he/she was dying;- The spouse responded that the patient was not dying today and that upset the patient;- The RN talked to the patient and spouse about respite and that the RN saw a change in the patient and was concerned that he/she was declining; and- The RN notified the MSW (Master of Social Work)-B of the possibility respite may be needed and the MSW will follow up with the patient’s spouse. Review of the coordination note, dated 08/19/2025 at 9:59 PM, showed MSW-B documented the following:- There was a “lengthy” phone call to the patient’s spouse regarding discussion of respite that the RN had with him/her earlier that day;- The MSW informed the spouse that when the patient stated that he/she was dying that the patient was declining and losing ground so the task of caring for him/her was going to increase, and if the spouse does not ask for help from the family or hire help, he/she could take advantage of respite for five days to get some rest;- The spouse talked about being tired and exhausted and trying the best he/she could;- The MSW validated the spouse when he/she stated he/she needed to be able to get a way for a short time or take a nap;- The MSW sent a message to the volunteer coordinator to follow up with the patient regarding consistent day/time the volunteer could provide a break to thecaregiver as he/she could not recall if a schedule was in place; and- The spouse would think about respite and the MSW would follow up with a visit on Friday (08/22/2025). The patient's clinical record failed to show any follow up regarding hospice on 08/22/2025. Review of a coordination note dated 08/26/2025 at 6:58 AM, showed a missed MSW-B visit on 08/25/2025 due to no answer at the time of his/her call.Review of the client coordination note, dated 09/06/2025, showed MSW-B documented the following:- The MSW met with the patient’s spouse and daughter for a “lengthy visit”;- They discussed the patient’s increase in agitation and frustration as well as negativity;- The spouse discussed his/her increase in emotional distress also due to feeling overwhelmed and underappreciated;- The MSW discussed the importance of setting boundaries and caring for him/herself was not selfish but imperative;- The MSW told the patient’s spouse if something happened to him/her the patient will be in a long-term care facility as family would not be able to provide “24/” (24/7) care as they were already limited in what they could or willing to do;- The patient’s spouse discussed again how he/she had “let” him/herself “go”;- The social worker encouraged the patient’s spouse to shower in the morning to start his/her day and get dressed as if he/she may go somewhere to potentially boost his/her mood;- The MSW then met with the patient and explained he/she met with his/her spouse and another family member regarding the patient’s increased agitation;- The patient gave valid reasons to feel frustrated, and the patient’s spouse provided understandable reasons for feeling overwhelmed and unappreciated;- The MSW discussed the importance for the patient and his/her spouse to have breaks from one another and understand what the other one was going through; and- The documentation failed to show discussion regarding respite care. During an interview on 09/16/2025 at 9:20 AM, the administrator stated that, on 08/19/2025, the social worker talked to the patient and spouse about respite care and the MSW reached out for follow up on 08/22/2025 and they refused his/her visit, there was a follow up scheduled for the following Monday which was not done.  The administrator was unable to find any further discussion of respite in the clinical record.Per interview conducted during observation on 09/16/2025 at 1:15 PM, the patient’s spouse stated the following:-  Hospice only brought respite care up once and the social worker was to follow up, and no one did;-  There was no mention of respite care on the last visit the social worker made;- The patient’s spouse became very tearful when talking about how exhausted he/she was, he/she was the only one that cared for the patient 24 hours a day, seven days a week;- The patient’s spouse eyes were reddened and puffy;- No one had gone into much detail on what volunteers can do, the patient had a volunteer (there was no current physician orders for a volunteer), but he/she never knew when the volunteer was coming, and he/she was not sure if he/she could leave while the volunteer was in the home; and- He/she might be interested in respite.Per interview conducted during observation on 09/16/2025 at 2:55 PM, RN-F stated that respite had been brought up, and he/she was unsure if there was any follow up.  He/she started a discussion regarding respite during the visit with the patient and spouse.  The volunteer called and let the patient know when he/she was available.

Based on policy review, record review, observation and interview, the provider failed to ensure that care was provided in accordance with the plan of care in one of two applicable records reviewed (Record/Patient #2). This deficient practice has the potential for unmet needs for all patients served by the agency. --- Findings included:Review of the provider's policy titled, "Client Care Plan," last revised July 5, 2021, showed in part, the following:- The in plan of care is based on the client's medical diagnosis, physician/healthcare practitioner’s order, comprehensive assessment, and client's input, and must include the following elements:* The types of services, supplies, and equipment needed* All medications and treatments* Client-specific interventions and education; and- Actions and interventions are consistent with the plan of care and are documented. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 02/27/2025 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided at home with his/her spouse who was the primary caregiver.  Review of a physician order, dated 08/26/2025, showed to cleanse the wound to the lower right leg with wound cleanser, pat dry, apply skin prep to the periwound, apply crushed Flagyl (used to treat certain bacterial and parasitic infections) to wound bed, then MediHoney (medical grade honey) and cover with an adhesive foam dressing, and change twice a day when skilled nurse not present.Review of the plan of care dated 09/03/2025, showed a treatment to the wound of the lower left leg, the treatment was to use clean technique, cleanse the wound with mild cleanser, pat dry, apply iodine, leave open to air and provide wound care two times a week and as needed if soiled.During observation on 09/16/2025 at 1:07 PM, showed registered nurse (RN)-F provided the following wound care:- The nurse removed the previous dressing which was a calcium alginate dressing (wound dressing that promotes healing by preserving moisture in the wound area) and a Kerlix Bandage wrap;- Then cleansed with wound on the right lower outer calf with wound cleanser and gauze, then sprinkled Flagyl all over the wound;- Applied MediHoney to 1/3 of the wound which had thicker yellow slough (a type of dead tissue that forms in wounds) and applied Xeroform dressing (made for use on low exudating wounds) over the whole wound;- Then applied skin prep to the periwound and covered the wound with a non-stick gauze, and then wrapped a Coban (a self-adherent wrap) wrap over the dressing.The nurse failed to provide care in accordance with the POC when he/she applied MediHoney to 1/3 of the wound, used a Xeroform dressing and Coban. The POC failed to show calcium alginate dressing and Kerlix Bandage wrap that the nurse removed. - The nurse cleansed the patient’s left lower leg above the ankle with wound cleanser and gauze, then applied MediHoney to the upper portion of the wound which had slough and left the lower part of the wound open due to not having orders, he/she then applied a Zetuvit plus dressing (used for wounds with moderate to high levels of exudate) to cover the wound. The nurse failed to provide care in accordance with the POC when he/she failed to apply iodine to the wound and leave the wound open to air. Per interview conducted during observation on 09/16/2025 at 1:07 PM, RN-F stated that he/she just got back from vacation and the patient had run out of supplies and he/she would have to change the wound orders because the wrong wound supplies were ordered. He/she had not been using Xeroform but that was the only dressing available.  Per interview conducted during observation on 09/16/2025 at 1:07 PM, the patient stated that:- He/she had run out of supplies and a large box was delivered with different wound supplies;- He/she was not familiar with what the last nurse that changed his/her dressing was doing and the nurse did not sprinkle Flagyl on his/her wound;- One of the nurses had done the right treatment, “closer anyway”;- He/she did not like when the nurses do different dressings to his/her wounds; and- The wound to his/her left leg was treated with iodine and left open to air until the last nurse came in and put a dressing (pointed to the Zetuvit plus dressing) on it. During an interview on 09/16/2025 at 4:54 PM, the administrator stated that the nurses should provide care according to physician orders.

Based on policy review, record review, and interview, the hospice provider failed to ensure:- That there was a complete physician’s order prior to treatment (L0678);- All entries were complete and dated in accordance with the hospice policy (L0679); and - The clinical record was made readily available on request by an appropriate authority (L0685).The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, record review, and interview, the provider failed to ensure the patient's clinical record included physician orders for treatments in, one of three applicable records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients receiving services from the provider. --- Findings included:Review of the provider's policy titled, "Interdisciplinary Group- Hospice," last revised January 1, 2024, showed in part, the following:- A registered nurse (RN) member of the interdisciplinary group (IDG) is designated to manage care for each client/caregiver;- The RN under physician orders and in coordination with all members of the IDG is responsible for coordinating the care and services provided and implementing the interdisciplinary plan of care; and- The IDG reviews and updates the client’s plan of care and changes are communicated to the client’s attending physician with requests for new orders when needed. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/20/2025, with the terminal diagnosis of diastolic heart failure (occurs when the left ventricle stiffens and cannot fill with blood properly between heartbeats). The patient resided at home.Review of a skilled nurse note dated 09/08/2025 at 11:36 AM, showed the following:- The patient had two to three plus edema (a type of swelling characterized by the presence of indentations (pits) in the skin when pressure is applied) to the bilateral lower extremities;- The patient started antibiotics for suspected cellulitis (a common and potential bacterial skin infection) to the bilateral lower extremities; and-  The nurse called the hospice provider’s office, and the administrator will be ordering Una boots (a semi-rigid, zinc-impregnated compression dressing applied to the lower leg, from the toes to the knee) for patient’s use due to excessive weeping to both lower extremities.Review of the clinical record failed to show a physician's order for Una boots.Review of a skilled nurse note dated 09/11/2025 at 12:59 PM, showed the Una boots were removed and reapplied without difficulty and the patient’s family member assisted the nurse.Review of the clinical record failed to show a physician's order for Una boots.Review of a skilled nurse note dated 09/14/2025 at 11:50 AM, showed the following:- Integumentary (skin) assessment findings showed wound(s) and documented details of wound in ICC (Integumentary Command Center, a specialized digital system or tab within an electronic health record used to record all integumentary findings);- Received a message from triage (a telephone-based assessment by nurses to determine the urgency of a patient's or caregiver's concern and the appropriate next steps) showed that the family was requesting a visit for wound care due to bandages sliding down and the family stated that they were unable to "do it" themselves;- The patient’s leg wraps had slid down below the mid-calf;- The nurse used aseptic technique, removed the old bandages and performed wound care to the bilateral extremities;- The patient’s family member reported that the patient had a small red area to the coccyx (a small triangular bone at the base of the spinal column), the patient refused to let the skilled nurse assess; and- The nurse delivered car stock (a set of basic medical and personal care supplies kept in the clinician's vehicle to address emergent patient needs quickly) two 4x4 Optifoams (a basic non adhesive dressing to absorb exudate and provide a moist wound environment) to place for protection and advised the family member to apply (to the coccyx) the next time the patient used the bathroom. Review of the clinical record failed to show physician orders for wound care, bandages, leg wraps, Una boots and Optifoam.During an interview on 09/16/2025 at 3:15 PM, the administrator stated that none of the patients wound care orders were done correctly (of the applicable sampled patients). During an interview on 09/17/2025 at 1:28 PM, the administrator stated that there was no wound documentation.  The patient had Una boots for weeping cellulitis and that was not the appropriate treatment.  There were wound orders (no physician orders were provided for wound care), but they were still not right and not placed in ICC.  The wound care order was not completed and there were no orders.

Based on policy review, record review, and interview, the hospice provider failed to ensure that all clinical record entries were clear, complete, and appropriate, in one of four records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's policy titled, "Chart Data Requirements & Format- Hospice," last revised June 2, 2025, showed in part, the following:- All paper chart contents must be entered into the client’s office chart within 15 days of receipt by the service office;- Electronic documentation must be completed and synced on the same day (before midnight) of each visit; - Syncing beyond this time frame requires approval from the office director.; and- Hospice maintains a complete client chart for every client receiving hospice services.  Review of the provider's policy titled, "Retention & Disposal of Records," last revised June 3, 2024, showed in part, that (named hospice provider) home health care retains charts, files, and records (electronically or on paper) in accordance with all applicable federal, state, and local laws. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/05/2025 with a terminal diagnosis of gangrene (a condition where tissue dies due to a lack of blood supply) and resided at home alone. Review of the skilled nurse (SN) (RN-B) visit note, dated 09/11/2025 at 9:58 AM, showed in part:- The patient was unable to communicate and there was no caregiver present; - Pain was reported by the patient (this conflicts with the patient’s inability to communicate);- The patient moaned when his/her head was turned;- The patient was given “an extra dose” of morphine during the visit to help get the patient settled (The documentation failed to show an initial dose being given for pain, how many doses of pain medication was required to get the pain uncontrol, and how the patient’s pain and symptoms were to be managed when the patient was home alone, minimally responsive and moaning in pain); and- The sisters did not want the patient touched or moved and refused wound care (this conflicts with the statement (see interview on 09/16/2025) made by RN-B regarding why the wound care was not performed and the sisters request for another nurse to go back to the home and provide wound care). Review of the PRN (as needed) SN (LPN-A) visit note, dated 09/11/2025 at 4:35 PM (six hours and thirty-seven minutes after the routine SN visit was made), showed in part:- A PRN nurse visit was made due to the patient needing wound care performed (wound care was not performed during the previous SN visit that day); - The patient was home alone and alert to person only;- Wound care was provided “to thighs and coccyx” and was refused to the wound on the foot (the patient was only alert to self and unable to refuse wound care); and- The clinical record only showed a wound to one thigh (the right) but the note had “thighs” documented. Review of a client coordination note, dated 09/15/2025 (three days after the patient was transferred to another hospice provider), showed:- Note type: missed visit notification; - Date of missed visit: 09/12/2025; and- Reason for missed visit: Discharged (patient transferred to another hospice).During an interview with the patient’s sister’s on 09/16/2025, that began at 12:35 PM, the sister’s stated that:- On 09/11/2025, the nurse (RN-B) was unable to provide wound care during the nursing visit due to having to leave for a family emergency;- They (sisters) never refused wound care; - They (sisters) had to contact the office (hospice) to request that another nurse be sent to provide the wound care; and- The nurse that came back to the home (LPN-A) was unable to do the wound care to the right foot because he/she did not have the supplies needed to perform the wound care (this was not documented but was confirmed by LPN-A during an interview). During an interview on 09/16/2025, at 4:20 PM, the RN identified by the provider as the "clinical manager" stated that:- He/she did receive a call from the patient’s sister regarding the RN case manager (RN-B) not providing wound care on 09/11/2025;- He/she sent another nurse to the home to do the wound care (LPN-A); and- He/she was informed by LPN-A that he/she was only able to provide wound care to two out of the three wounds because there was not any swabs that in the home that was needed for the third wound (right lower extremity, RLE). During an interview on 09/17/2025 at 1:29 PM, the RN-B (the RN case manager) stated that:- He/she did not perform wound care either time due to the patient having too much pain with wound care (this was not documented);- On 09/11/2025 he/she did have to leave during the nursing visit due to a family emergency;- He/she thought did inform the nurse (LPN-A) that all of the wound care supplies was in the home because that is what he/she thought; and- The patient had black, tarry bowel movements (this was not documented).

Based on record review and interview, the provider failed to ensure the clinical record, whether in hard copy or in electronic form, was made readily available on request when documentation from staff failed to be included in the medical record in but not limited to, one of four full records reviewed. (Record/Patient #2). This deficient practice has the potential to affect accurate documentation for all the provider's patients. --- Findings included:Review of the provider's policy titled, "Chart Data Requirements & Format- Hospice," last revised June 2, 2025, showed in part, the following:- All paper chart contents must be entered into the client’s office chart within 15 days of receipt by the service office;- Electronic documentation must be completed and synced on the same day (before midnight) of each visit; - Syncing beyond this time frame requires approval from the office director.; and- Hospice maintains a complete client chart for every client receiving hospice services.  RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2025 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided at home with his/her spouse who was the primary caregiver.  Review of the coordination note, dated 08/19/2025 at 9:59 PM, showed the MSW (Master of Social Work) B documented that the MSW sent a message to the volunteer coordinator to follow up with the patient regarding consistent days/times the volunteer could provide a break to the caregiver as he/she could not recall if a schedule was in place.Review of the clinical record failed to show documentation of the volunteer visit notes.Per interview conducted during observation on 09/16/2025 at 1:15 PM, the patient’s spouse stated that hospice staff had not gone into much detail on what the volunteers could do, the patient had a volunteer (the clinical record failed to show a current physician order for volunteer services), but he/she never knew when the volunteer was coming, and he/she was not sure if he/she could leave while the volunteer was in the home.  Per interview conducted during observation on 09/16/2025 at 2:55 PM, registered nurse (RN) F stated that the volunteer calls and lets the patient know when he/she was available.  During an interview on 09/16/2/025 at 3:56 PM, the volunteer coordinator stated that the volunteer visited the patient on 08/20/2025, 08/25/2025, 09/03/2025, and 09/11/2025.  The volunteer was on vacation and was unable to mail in his/her notes.During an interview on 09/10/2020 at 10:20 AM, the administrator stated that they will have to change their process to ensure the volunteer visit documentation is in the clinical record.

Based on personnel record review and interview, the hospice provider failed to ensure that initial training in emergency preparedness policies and procedures was provided to all new and existing hospice employees, and individuals providing services under arrangement consistent with their expected roles in two of 10 employee files reviewed (E-2 and E-3). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: E-2: Review of E-2s personnel file showed: - The hire date was 08/17/2021; and - The file failed to contain documentation that emergency preparedness training was completed during new-hire orientation. E-3: Review of E-3s personnel file showed: - The hire date was 03/13/2023; and - The file failed to contain documentation that emergency preparedness training was completed during new-hire orientation. Findings were reviewed with the administrator on 05/03/2023 at 12:40 PM. He/she stated that the emergency preparedness training usually performed during orientation could not be found in either employee file.

Based on policy review, record review and interview, the provider failed to maintain documentation to ensure complaints and/or grievances were investigated and resolved. This deficient practice has the potential to adversely affect all patients receiving hospice services. --- Findings included: Review of the providers policy titled ";11-368 Client Complaints," dated/revised 01/01/2021, showed: - The client services manager, clinical manager, and/or director investigate and respond to complaints from clients or their representatives promptly and in accordance with applicable state requirements; - The client is informed of the findings of the investigation and the decisions rendered to resolve the complaint; - All complaints, verbal and written are documented in the applicable electronic system. This includes the nature of the complaint, the investigation findings, any follow-up action that is needed and the date of the follow-up with the client; - Notification made to the client is also documented; - Written complaints are scanned and attached to the electronic complaint record; - The director must review to ensure the following and close out the completed report in the electronic system: * Corrective action is taken promptly; * The client/family rights are protected; * The follow-up and actions taken toward resolution sufficiently address the complaint; and * State specific requirements have been met as applicable. - All complaint documentation is maintained in the electronic system and may be printed as requested by external surveyors/auditors who are not willing to view the complaint documentation online; - The director or the administrator will review and trend data from incident reports on a quarterly basis to provided ongoing monitoring of reported complaints; and - All complaint documentation is maintained by the director and kept in a separate file that can easily be reviewed. The documentation constitutes the Complaint Log. Review of a complaint dated 05/19/2022 at 3:04 PM and processed 5/20/2022 at 7:55:30 AM, showed the following documentation failed to be completed: - Interventions: left blank; - Intervention/resolution comments: left blank; - Prevention: left blank; - Prevention Comments: left blank; and - Follow-up comments: left blank. Review of a complaint dated 07/08/2022 at 3:47 PM and processed 7/08/2022 at 3:51:34 PM, showed the following documentation failed to be completed: - Interventions: F/U (follow up) with clinical director/supervisor of clinician; - Intervention/resolution comments: left blank; - Prevention: left blank; - Prevention Comments: left blank; and - Follow-up comments: left blank. During an interview on 05/01/2023 at 2:05 PM the administrator stated that: - He/She (the clinical manager that was responsible for the complaint follow-up) didnt do the interventions correctly; - It was done here (as the administrator pointed to a different complaint form); and - The documentation was left off on a few. During an interview on 05/03/2023 at 12:05 PM the administrator stated that he/she would expect the investigation documentation to be complete.

Based on policy review, record review and interview the hospice provider failed to ensure an accurate/updated medication profile was maintained in one of five full records reviewed (Record/Patient #4). --- Findings included: Review of the provider's policy titled, "Chart Data Requirements and Format - Hospice," reviewed 03/30/2023, showed in part that the hospice medication profile is used when assessing, monitoring, and teaching medications in the home. It provides a medication history to the field nurse, as well, and includes notation of medications (prescribed and over-the-counter) currently used by the client. The clients must have an accurate and up-to-date medication list in the home. RECORD/PATIENT #4: Observation and interview during the patients home visit on 05/02/2023, beginning at 2:10 PM, showed the following discrepancies with the providers medication profile: - The patients caregiver stated that the patient took a multivitamin about once a week. He/she had taken this a long time. This was not included on the medication profile; - The patients caregiver stated that the patient took potassium 99 milligrams (mg) once a day for about six months to a year. This was not included on the medication profile; - The medication profile showed an order for Gabapentin (used to treat nerve pain) 100 mg one tablet in the AM, two tablets at noon, and one tablet at bedtime. The patients caregiver stated that he/she had given the patient one tablet three times a day for a long time; and - The medication profile showed an order for Florastor (probiotic) 250 mg one capsule twice daily. The patient stated that he/she had not taken this for about two months. During an interview on 05/03/2023 at 12:25 PM, the administrator stated that the former company required staff to review the medication list with the patient at admission, every 14 days, and if there was a change in level of care. He/she would look for the hospice policy with the current company. No further information was provided.

Based on policy review, clinical record review, and interview, the hospice provider failed to develop an individualized written plan of care in, but not limited to, two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice providers policy titled, ";Care Plan – Hospice Services," revised 10/01/2019, showed: - The hospices interdisciplinary group (IDG) collaborates with the clients attending physician, client/representative and primary caregiver to develop a client directed individualized plan of care; - The comprehensive plan of care reflects client/family goals based upon problems identified in the initial/updated assessments and includes all services necessary for palliation and management of the terminal illness and related conditions; - The plan of care content includes, but is not limited to: * Reduction in risk factors; * Individualized interventions to assist with end of life care; * Treatments, drugs, and interventions to manage pain and symptoms; * Medical supplies and appliances necessary to meet the patients needs; - The plan shall be reviewed and updated by the IDG at a minimum of every two weeks. These reviews shall be documented in the client record; and - Documentation on the plan of care shall reflect the changing needs of the client/family and the services required to meet those needs. RECORD/PATIENT #5: The patient was admitted to hospice services on 02/10/2023 with the terminal diagnosis of alcoholic cirrhosis of the liver (chronic liver damage that is the final stage of alcoholic liver disease) with ascites (abdominal swelling caused by accumulation of fluid). He/she had additional diagnoses of chronic viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), congestive heart failure (a chronic condition in which the heart doesnt pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), protein-calorie malnutrition and hypertension (high blood pressure). He/she lived in his/her home with his/her daughter, sister, and mother. Review of the initial assessment, dated 02/10/2023, showed the following: - The patient had an arrhythmia (an improper beating of the heart); - The patient had shortness of breath with moderate exertion; and - The shortness of breath was on a daily basis. Review of the POC, dated 02/10/2023, showed the following: - An intervention to instruct on measures to promote respiratory comfort; - An intervention to instruct on reason for oxygen and appropriate liter flow per minute as per physician order; - The POC failed to define the measures that promote respiratory comfort; and - The POC failed to include an order for the liter flow per minute for the patients oxygen. During an interview on 05/03/2023 at 11:45 AM, the administrator stated that he/she would expect the oxygen to have orders for the liter flow per minute either on the medication list or on the durable medical supply list. The staff can input problems into the system. The nurse documented the problems but did not list what the interventions and measures were, specifically non-pharmacologic measures. The software is pre-written so it is difficult to list individual interventions. He/she agrees that individual interventions could have been written in a narrative note but he/she didnt see anything documented in the current notes. RECORD/PATIENT #4: Review of the RN (registered nurse) initial assessment dated 04/07/2023 showed the patient was set up with oxygen at two to four liters per minute. Review of the POC dated 04/07/2023 and updated 04/19/2023 showed to instruct the patient on the reason for oxygen and appropriate liter flow per minute as per physician order. The POC failed to include an order for oxygen at two to four liters per minute. During an interview on 05/02/2023 beginning at 4:22 PM, the administrator stated that he/she would expect oxygen orders to be on the POC.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the revised plan of care included the patients progress toward outcomes and goals specified in the plan of care in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice providers policy titled, ";Interdisciplinary Group," dated/revised 10/01/2019, showed: - The interdisciplinary group (IDG) reviews each clients plan of care at least every 15 days, or more frequently as needed, in order to continually monitor the care and services provided to the client; and - The IDG conferences include evaluation of progress toward achievement of expected outcomes, revising goals as needed. Review of the hospice providers policy titled, ";Chart Data Requirements and Format -Hospice," dated/revised 10/24/2017, showed nursing documentation should include the patients progress towards goals. RECORD/PATIENT #5: Review of the plan of care (POC) dated 2/10/2023, showed the following goals: - Patient/caregiver verbalizes/demonstrates appropriate measures to minimize/control agitation/anxiety; - Patient/caregiver verbalize understanding of measures to manage cardiac symptoms; - Caregiver(s) verbalizes understanding of seizure precautions; - Patient has minimal problems with respiratory comfort; - Patient/caregiver verbalizes understanding of psychological effects of incontinence and measures to improve/maintain dignity; and - Patient/caregivers will verbalize understanding of care required secondary to bowel incontinence. Review of the documents titled, "IDG Summary Reports," and "Hospice IDG Comprehensive Assessment and Plan of Care Update Reports," with dates ranging from 03/01/2023 to 04/26/2023, showed the hospice provider failed to document any evidence of the patients progress toward the goals listed in the POC. During an interview on 11/03/2023 at 11:45 AM, the administrator stated that the software used for medical records does not allow the clinician to show progress toward goals. Thats the problem with the electronic medical records, the software has the ";PIG" list (problem, intervention, and goal) which allows the clinician to set the problems but it does not allow the clinician to go in and document progress towards the goals.

Based on policy review, clinical record review, and interview, the hospice provider failed to develop and maintain a system of communication and integration, in accordance with the hospices own policies and procedures to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice providers policy titled, ";Interdisciplinary Group," dated/revised 10/01/2019, showed: - The interdisciplinary group (IDG) reviews each clients plan of care (POC) at least every 15 days, or more frequently as needed, in order to continually monitor the care and services provided to the client; and - The IDG reviews and updates the clients POC and changes are communicated to the clients attending physician with requests for new orders when needed. RECORD/PATIENT #5: Review of the POC dated 02/10/2023, showed an order for a hospice aide one time a week for one week, then two times a week for 11 weeks, then one time a week for one week effective 02/12/2023. Review of the clinical record showed: - A hospice aide visit occurred on 02/20/2023; and - A physicians order, dated 02/22/2023, to discontinue the hospice aide per family request. Review of the document titled, ";IDG Summary Report," dated 04/26/2023, showed: - The hospice registered nurse documented ";Patient cannot shower or bathe" himself/herself. ";C.N.A (certified nurse aide) comes twice a week to assist;" and - The hospice aide had been discontinued since 02/22/2023. During an interview on 05/03/2023 at 11:45 AM, the administrator stated that the entry was probably a typographical error or the nurse was confused when he/she was doing the documentation.

Based on policy review, record review and interview, the provider failed to ensure all disciplines were informed of changes/updates regarding patients care and services in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to adversely affect the communication between staff and affect all patients served by the provider. --- Findings included: , Review of the providers policy titled, ";0-944 Client Care Coordination,", dated/revised 01/13/2018, showed: - Coordination of client services is the shared responsibility of the client services manager and clinical manager. Both are qualified professionals, with adequate amount of experience and knowledge to do the job effectively; - Both professionals regularly communicate with the staff directly providing care to the clients. The client services manager remains in the office, providing full-time case coordination. The clinical manager provides on-site supervision, oversees direct care of the clients, and coordinates referrals; - Regular communication is maintained among supervisors, field employees and clients by telephone, written reports, on-site supervisory visits, and interdisciplinary conferences. Documentation of such communication is made in the client chart; and - Communication can be documented on a coordination of services note. RECORD/PATIENT #1: Review of the clinical record showed the patient began receiving hospice care 01/04/2023 and resided in a LTCF (long-term care facility). Review of the MSW (medical social worker) note dated 04/25/2023 showed the patient stated that: - He/she does not feel good and then expressed wondering why his/her head was hurting; - He/she had a headache; and - He/she stated that his/her hands were also hurting. Further review of the MSW (medical social worker) note dated 04/25/2023 showed: - Details/Comments: Patient concerns this visit were related to having a headache and pain in his/her hands; and - It failed to contain any communication documented regarding patient concerns with the hospice RN (registered nurse). During an interview on 05/03/2023 at 11:40 AM, the administrator, while looking at the next RN visit, stated that this is where the coordination would be written and its not there.

Based on policy review, record review, and interview, the provider failed to ensure that the agency policy was followed regarding nursing supervision. The RN (registered nurse) failed to document monthly supervision of the licensed practical nurse (LPN) to assure that the nursing services being provided were in accordance with the plan of care (POC) in one record of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect all patients receiving nursing services by hospice LPNs. --- Findings included: Review of the providers policy titled, ";0-4547 Provision of Hospice Services," dated/revised 10/01/2019 showed, in part, when nursing services are delegated to a LPN, the RN makes home visits at least once every two weeks and documents that the LPN is routinely providing nursing services in accordance with the clients POC. Review of the providers policy titled, ";0-4849 Frequency of Staff Supervision – Hospice," dated/revised 03/11/2014 showed: - A home visit is made at least monthly, by the appropriate professional (RN, PT (physical therapist), OT (occupational therapist)) to clients being seen by a licensed practical/vocational nurse (LPN/LVN), licensed physical therapist assistant or certified occupational therapy assistant (more often if required by state law); and - Supervisory visits are documented in the electronic record on the discipline-specific clinical note. RECORD/PATIENT #3: Review of a SN (skilled nurse) visit note completed by the RN dated 03/10/2023, showed documentation of supervision of a named LPN. Further review of the clinical record showed: - SN visit notes completed by LPNs on 03/21/2023, 04/07/2023, 04/08/2023, 04/09/2023, 04/27/2023, and 05/01/2023; - The record failed to contain documentation of any further supervisory visits on the LPN. During an interview on 05/03/2023 at 12:05 PM, the administrator stated that: - He/she was unable to find another LPN supervisory visit; and - It was outside of the 30 days that the next one would have been due.

Based on policy review, clinical record review, and interview, the provider failed to ensure the hospice aide followed the plan of care in, but not limited to, one of five full applicable records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect all hospice patients receiving aide services. --- Findings included: Review of the providers policy titled, ";0-4556 Care Plan – Hospice Services," dated/revised 10/01/2019, showed, in part: - For hospice clients receiving home health aide services, the aide plan of care is established by the clinical manager, or case managing RN (registered nurse) or therapist in accordance with his/her assessment, participation of client/caregiver and the overall plan of care established by the interdisciplinary group; - At all times the aide or homemaker is directed regarding frequency, duration and care/services to be provided by the clinical manager or case managing clinician as documented on the plan of care; and - The aide must report and obtain approval for any changes in visit pattern or reduction in frequency. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to hospice services at his/her home on 02/23/2023; - A physician order dated 04/12/2023 12:02 PM: Description: Start HHA (home health aide) visits at 2 (two) times per week, Calendar Frequency: HHA effective 04/09/2023 1 wk 1 (one time a week for one week), 2 wk 5 (two times a week for five weeks), 1 wk 1; - The clinical record failed to contain a HHA visit week one (the week of 04/09/2023); - The clinical record failed to contain two HHA visits in the third week (week of 04/23/2023), with only one aide visit documented on 04/26/2023; and - The clinical record failed to contain orders to clarify the aide visit frequency or coordination notes with missed visit notifications. During an interview on 05/03/2023 at 12:05 PM, the administrator stated that: - There is a plotted visit; - The first visit was plotted for 04/14/2023; and - There was no missed visit documentation.

Based on policy review, record review, and interview, the provider failed to ensure the RN (registered nurse) conducted supervisory aide visits at least every 14 (fourteen) days in one record of five applicable records reviewed (Record/Patient #2). This deficient practice has the potential to negatively affect all hospice patients receiving aide services. --- Findings included: Review of the provider's policy titled, ";0-4849 Frequency of Staff Supervision," dated/revised 03/11/2014 showed: - For clients receiving home health aide (HHA) services and RN must make an on-site visit to the clients home no less frequently that every 14 (fourteen) days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the clients needs; and - Supervisory visits are documented in the electronic record on the discipline-specific clinical note. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted on 02/24/2023 with aides services effective 02/26/2023 for two times a week for twelve weeks; - An aide supervisory visit was documented on the SN (skilled nurse) visit note dated 03/16/2023 by the RN; - The next aide supervisory visit documented by an RN was 04/20/2023 (35 days later); - It was noted the patient was out of the service area 04/03/2023 to 04/16/2023 and a traveling agreement was made with ";named hospice," however an SN visit had been made 14 days (03/30/2023) after the first aide supervisory visit, but was completed by an LPN (licensed practical nurse) who does not meet the qualifications to supervise home health aides and therefore there failed to be an aide supervisory visit documented. During an interview on 05/03/2023 at 12:05 PM, the administrator stated that: - There was no supervisory visit completed between 03/16/2023 and 04/20/2023; - They (the hospice provider) missed the supervisory visit; and - The LPN did the visit fourteen days later (03/30/2023) and they cannot do aide supervisory visits.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure staff documented all care and services provided in one of five full records reviewed (Record/Patient #4). --- Findings included: Review of the hospice providers policy titled, ";Chart Data Requirements and Format," showed in part that nursing documentation should include the care and services provided. Review of the initial RN (registered nurse) assessment dated 04/07/2023 showed: -The patient had an infusion/intravenous site access; and -The hospice provider will not be providing any direct care to the site. Review of a physician order dated 04/20/2023 showed an order for heparin lock flush five milliliters (ml) for port flush monthly and as needed for port access and an order for normal saline flush 0.9% injection 10 ml as needed for port flush monthly and as needed for port access. Review of a nursing visit note dated 04/20/2023 showed the nurse ordered normal saline (a salt solution used to maintain patency of infusion accesses) and heparin (used to flush infusion site accesses to prevent clot formation). Review of the nursing visit notes from 04/20/2023 through 04/27/2023 showed no documentation that the patients port was flushed. Per interview conducted during the patients home visit on 05/02/2023 beginning at 2:10 PM, the hospice nurse stated that he/she flushed the patients port about two weeks ago. The patient stated that the port was flushed about two weeks ago. During an interview on 05/02/2023 beginning at 4:22 PM, the administrator stated that the/she would expect the nurse to document when they flushed the port and what they used to flush with.

Based on review of the hospice providers contract for respite services and interview, the hospice provider failed to ensure the contract included the requirement for a copy of the hospice patients discharge summary and/or clinical record will be supplied to the hospice at the time of discharge in one of one respite contract reviewed. This deficient practice has the potential to affect the provision of respite services to all patients served by the hospice provider. --- Findings included: During the survey entrance on 05/01/2023 at 10:15 AM, the respite contract was requested for review from the hospice administrator. The hospice providers respite contract with a long-term care facility titled ";Hospice Services Agreement," signed 07/21/2016, showed the document failed to include the requirement that a copy of the hospice patients discharge summary and/or clinical record will be supplied to the hospice at the time of discharge. During an interview on 05/03/2023 at 11:40 AM, the administrator stated that he/she was not able to find the required language in the contract but he/she sent it to "corporate" and had not heard anything yet. During an interview on 05/03/2023 at 2:30 PM, the administrator stated that ";corporate" had sent some additional information regarding the missing language in the respite contract. A different unsigned document titled ";Nursing Facility Services Agreement" was provided by the administrator. No additional information was provided regarding the missing requirement from the respite contract currently in use between the hospice provider and the long-term care facility.

Based on review of the hospice providers contract for respite services and interview, the hospice provider failed to ensure the contract included the requirement that the hospice is responsible for documentation of training of inpatient personnel and documentation of the names of those giving the training in one of one respite contract reviewed. This deficient practice has the potential to affect the provision of respite services to all patients served by the agency. --- Findings included: During the survey entrance on 05/01/2023 at 10:15 AM, the respite contract was requested for review from the hospice administrator. The hospice providers respite contract with a long-term care facility titled ";Hospice Services Agreement," signed 07/21/2016, showed the document failed to include the requirement that the hospice is responsible for the documentation of training of inpatient personnel and for the documentation of the names of those giving the training to the inpatient personnel. During an interview on 05/03/2023 at 11:40 AM, the administrator stated that he/she was not able to find the required language in the contract but he/she sent it to "corporate" and had not heard anything yet. During an interview on 05/03/2023 at 2:30 PM, the administrator stated that ";corporate" had sent some additional information regarding the missing language in the respite contract. A different unsigned document titled ";Nursing Facility Services Agreement" was provided by the administrator. No additional information was provided regarding the missing requirement from the respite contract currently in use between the hospice provider and the long-term care facility.

Based on policy review, record review, observation and interview, the provider failed to ensure the hospice/LTC facility (long-term care facility) coordinated task plan of care was complete/updated when the following omissions were noted: Wound care schedule or treatment (started 01/04/2023 and ended 01/16/2023); DME (durable medical equipment) including wheel chair and Spenco boots (used for the prevention of heel pressure ulcers); and SW (social worker), chaplain, and volunteer visit frequency, volunteer name, and treatment to buttocks which started 01/04/2023, in one of three home visit observations in a facility (Record/Patient #1). This deficient practice has the potential for miscommunication between the hospice provider and the facility with resulting unmet patient needs. --- Findings included: Review of the providers policy titled, ";0-4556 Care Plan – Hospice Services," dated/revised 10/01/2019 showed the following: - ";Named Hospice" Interdisciplinary Group (IDG) collaborates with the clients attending physician, client/representative and primary caregiver to develop a client directed individualized written plan of care; - The plan of care is reviewed at a minimum of every fifteen days, with updates documented on addendum to the plan of care, #0-300; - The plan of care contents includes, but is not limited to participation by the client/family/caregiver based on ability and response to care, individualized interventions to assist with end of life care, treatments/drugs and interventions to manage pain and symptoms, medical supplies and appliances necessary to meet needs, and detail of the scope and frequency of services to meet the client/familys needs; and - Documentation on the plan of care shall reflect the changing needs of the client/family and the services required to meet those needs. Review of the providers policy titled, ";0-944 Client Care Coordination," dated/revised 01/13/2018 showed: - Care coordination is provided in order to assure continuity of care; - Care coordination involves identification of additional services needed, contacting community resources for these services, discussions of the clients needs, and status and follow-up as appropriate; and - When more than one service is provided, whether directly or through contract, the client services manager and clinical manager will work together to assure that the actions and goals of the individual services are complementary. Regular communication is maintained among supervisors, field employees, and clients by telephone, written reports, on-site supervisory visits, and interdisciplinary conferences. Documentation of such is made in the client chart; updated care plans are also kept in the client chart in the home, to which all service providers have access. RECORD/PATIENT #1: Review of the coordinated task/care plan on 05/01/2023 beginning at 12:30 PM during the patient's LTC facility showed the following omissions: - Wound care schedule or treatment (started 01/04/2023 and ended 01/16/2023); - DME (durable medical equipment) including wheel chair and Spenco boots (used for the prevention of heel pressure ulcers); - SW (social worker), chaplain, and volunteer visit frequency; - Volunteer name; and - Treatment to buttocks which started 01/04/2023. Per interview conducted during the home visit observation, RN-A stated that the patient had a wound but it is healed now. During an interview on 05/03/2023 at 11:29 AM, the administrator stated that: - Its (the coordinated task/care plan) not filled out; - He/she would expect the Spenco boots to be on the supply list; and - We (provider staff) looked and they (Spenco boots) are not on the supply list either.

Based on record review, observation, and interview, the provider failed to ensure the long-term care facility (LTCF) record contained a copy of all required hospice documents in one of one applicable case (Record/Patient #1). This deficient practice has the potential to adversely affect all patients residing in nursing facilities served by the provider. --- Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient began receiving hospice care on 01/04/2023 and resided in a LTCF. Observation on 05/01/2023 at 12:30 PM, during the patients home visit, a review of the hospice binder showed: - It failed to contain the hospice election form; - It failed to contain the patients advance directives (start of care visit showed patient had an advance directive and copy obtained, however a copy failed to be printed from LTC facility record and placed in binder); and - It failed to contain a current medication profile (The one in the binder showed a date of 04/11/2023. The patient had changes to his/her medication regimen 04/12/2023 with the discontinuation of aspirin (taken for heart health), Miralax (used for constipation) and potassium (mineral supplement taken to increase potassium levels). Per interview conducted during observation, RN-A agreed these items were missing.