Every finding on record at Intelicare Hospice Services, LLC

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Corrected on site.

Upon patient record review 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #7: SOC 7/30/2024, spiritual assessment occurred 8/9/2024.

Upon patient record review, 6 of 14 (Patient #2,#6,#8,#10,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: SN SOC notes identify O2 in residence. No evidence on medication profile for O2. Corrected on site. Patient #6: Medication profile dated 11/2/2022 included O2 2-4LPM PRN SOB, no evidence of a route. Corrected on site. Patient #8: Medication profile dated 7/23/2024 included Miralax 17GM QD for constipation, no evidence of a diluent. Dated 7/23/2023 O2 2-4LPM PRN with no evidence of a route or indication (there is a correct order). Corrected on site. Patient #10: Medication profile dated 7/11/2023 included O2 4-8 LPM cont. for comfort. No evidence of a route or titration guidelines. Corrected on site. Patient #13: Medication profile dated 7/3/2023 included Miralax 17GM PO QD, no evidence of a diluent. Patient #14: Medication profile dated 9/29/2023 included Miralax 17GM PO QD, no evidence of a diluent. SN notes 2/14/2024 included pt. on O2 at 4LPM. No evidence on the medication profile for O2.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #8: SOC 7/23/2024, bereavement assessment occurred 7/29/2024.

Upon patient record review, 9 of 14 (Patient #1,#2,#4,#5,#8,#11,#12,#13,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Pt admitted after admission to hospital for aspiration pneumonia. No evidence on POC of problems/goals/interventions for aspiration risk. Corrected on site. Patient #2: SN SOC identified pt. with seizures, dysphagia, Braden of 13 moderate risk for skin breakdown. No evidence on POC of problems/goals/interventions for dysphagia/aspiration, neuro/seizures or skin integrity. Corrected on site. Patient #4: SN SOC identified Braden score of 13- mod. risk for skin breakdown. MSW identified no funeral plans in place. No evidence on POC of problems/goals/interventions for skin integrity or funeral planning. Corrected on site. Patient #5: Diagnosis on admit dysphagia, No evidence on POC of problems/goals/interventions dysphagia/aspiration risk. Corrected on site. Patient #8: On O2, has colostomy noted on SOC. No evidence on POC of problems/goals/interventions for O2 and GI/Colostomy. Corrected on site. Patient #11: On O2, No evidence on POC of problems/goals/interventions for O2. Patient #12: On O2, No evidence on POC of problems/goals/interventions for O2. Patient #13:SN and MSW on SOC noted no funeral plans. No evidence on POC of problems/goals/interventions for funeral planning. Patient #14: On O2, no evidence on POC of problems/goals/interventions for O2.

Upon patient record review, 12 of 14 (Patient #1,#2,#3,#4,#5,#6,#8,#10,#11,#12,#13,#14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: SN visit frequency dated 7/9/2024 included 2x13 wks. with 9 PRN visits (excessive). Dated 7/14/2024 MA (massage therapy) 5 PRN, 9/8/2024 MA 1 PRN. Corrected on site. Patient #2: SN frequency dated 7/10/2024 included SN 2x13 6 PRN (excessive). Dated 7/10/2024 MA (massage therapist) 7 PRN. Corrected on site. Patient #3: MA frequency orders dated 7/7/2024 4 PRN, 7/14/2024 4 PRN, 7/2/2024 3 PRN, 9/1/2024 1 PRN and 9/15/2024 4 PRN. Corrected on site. Patient #4: MA frequency orders dated 8/18/2024 5 PRN. Corrected on site. Patient #5: MA frequency orders dated 8/16/2024 1 PRN, 9/15/2024 3 PRN. Corrected on site. Patient #6: MA frequency orders dated 8/25/2024 1 PRN. Corrected on site. Patient #8: MA frequency dated 7/28/24 5 PRN visits. Corrected on site. Patient #10: SC frequency order dated 9/9/2024 6 PRN visits. Corrected on site. Patient #11: MA frequency order dated 5/26/2024 6 PRN visits. Patient #12: MSW frequency order dated 6/13/2024 1M3 and 8 PRN visits. Patient #13: SC frequency order dated 9/28/2023 8 PRN visits. Patient #14: SC frequency order dated 12/26/2023 1 QOM x2 and 10PRN visits. MA frequency 12/26/2023 2 PRN. Dated 1/7/2024 MA frequency 6 PRN visits.

Upon patient record review, 6 of 14 (Patient #2,#6,#8,#10,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: SN SOC notes identify O2 in residence. No evidence of an order for O2. Corrected on site. Patient #6: Order dated 11/2/2022 O2 2-4LPM PRN SOB, no evidence of a route. Corrected on site. Patient #8: Order dated 7/23/2024 included Miralax 17GM QD for constipation, no evidence of a diluent. Corrected on site. Dated 9/11/2024 Cleanse wound to Rt lower leg with wound cleanser or soap and H2o, cover with ABD, wrap with kerlex and tape. Change daily and PRN. No evidence of who is to do dressing change (resides in ALF). Patient #10: Order dated 7/11/2023 included O2 4-8 LPM cont. for comfort. No evidence of a route or titration guidelines. Corrected on site. Patient #13: Order dated 7/3/2023 included Miralax 17GM PO QD, no evidence of a diluent. Patient #14: Order dated 9/29/2023 included Miralax 17GM PO QD, no evidence of a diluent. SN notes 2/14/2024 included pt. on O2 at 4LPM. No evidence of an order for O2.

Upon patient record review, 11 of 14 (Patient #1,#3,#5,#6,#8,#9,#10,#11,#12,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: Has O2, hospital bed, over bed table, w/c, Hoyer lift and air mattress. No evidence of these items on POC. Corrected on site. Patient #3: Has hospital bed, over bed table and w/c. No evidence of these items on POC. Corrected on site. Patient #5: Has O2, w/c and Hoyer lift. No evidence of these items on POC. Corrected on site. Patient #6: Has O2 and a nebulizer. No evidence of these items on POC. Corrected on site. Patient #8: Has O2, Hoyer lift, hospital bed, rails, overbed table and w/c. No evidence of these items on POC. Corrected on site. Patient #9: Has bedside commode, quad cane, raised toilet seat and walker. No evidence of these items on POC. Corrected on site. Patient #10: Has a walker. No evidence of these items on POC. Corrected on site. Patient #11: Has Hoyer lift, hospital bed, over bed table and walker. No evidence of these items on POC. Patient #12: Has w/c, over bed table and raised toilet seat. No evidence of these items on POC. Patient #13: Has over bed table and w/c. No evidence of these items on POC. Patient #14: Has O2, hospital bed and a Roho cushion. No evidence of these items on POC.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon patient record review, 10 of 14 (Patient #1,#2,#3,#5,#6,#8,#11,#12,#13,#14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Pt. admitted after hospitalization with aspiration pneumonia, identified by SN at SOC as fall risk, on O2. No evidence in aide POC/assignment of risk for falls,aspiration or O2 precautions. Corrected on site. Patient #2: SN at SOC identified pt. with seizures, diagnosed with dysphagia, on O2, and at risk for falls. No evidence in aide POC/assignment of risk for falls, aspiration, seizures or O2 precautions. Corrected on site. Patient #3: SN at SOC identified pt. at risk for falls. No evidence in aide POC/assignment for fall precautions. Corrected on site. Patient #5: SN at SOC identified pt. diagnosed with dysphagia and at risk for falls. No evidence in aide POC/assignment of risk for falls and aspiration. Corrected on site. Patient #6: SN at SOC identified pt. on O2, and at risk for falls. No evidence in aide POC/assignment of risk for falls or O2 precautions. Corrected on site. Patient #8: SN at SOC identified pt. on O2, and at risk for falls. No evidence in aide POC/assignment of risk for falls or O2 precautions. Corrected on site. Patient #11: SN at SOC identified pt. on O2, at risk of bleeding and at risk for falls. No evidence in aide POC/assignment of risk for falls, risk of bleeding or O2 precautions. Patient #12: SN at SOC identified pt. on O2, and at risk for falls. No evidence in aide POC/assignment of risk for falls or O2 precautions. Patient #13: SN at SOC identified pt. at risk for falls. No evidence in aide POC/assignment of risk for falls. Patient #14: SN at SOC identified pt. on O2, and at risk for falls. No evidence in aide POC/assignment of risk for falls or O2 precautions.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: Order dated 4/14/2024 and 9/8/2024 include aide 2x week. Weeks of 8/25, 9/8 and 9/15/2024 one aide visit occurred with no missed visits noted.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #11: No evidence of orientation on hospice philosophy.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #11: No evidence of orientation on specific job requirements.

Upon personnel record review, 1 of 14 (Personnel #10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation Personnel #10: No skills assessment at orientation prior to seeing first vigil patient.

Upon client record review, 2 of 14 (Patient #11,#12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patients #11 and #12: No evidence of a discharge summary forwarded to the patient's attending physician.

Upon client record review, 2 of 14 (Patient #11,#12) did not have evidence that the discharge summary includes all required information. Patients #11 and #12: there was no evidence of a complete discharge summary, only states reason for discharge with last day of service summary.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patients sign a consent including "I have received a copy along with verbal explanation of disposal of controlled substances and medication disposal policies". There was no evidence in the admission packet of the policy PC.140 Disposal of Controlled substances, and Administrator agrees the policy is not provided.

Upon patient record review, 3 of 14 (Patient #2,#3,#4) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #2: No evidence of recent POC, certification or recertification (last dated 4/11-7/9/2024), orders or EOB. Patient #3: No evidence of recent POC (last dated 8/30/2024), missing last recertification (last dated 7/2-8/30/2024), recent orders Patient #4: No evidence of POC, EOB,CTI's and orders.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.

Based on observation, record review and interview, the agency failed to provide a written medication list to the patient for 1 (P-10) of 14 records reviewed and failed to document an accurate medication list for 1 (P-8) of 14 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Finding include: --- P-8: The Start of Care (SOC) was dated 7/5/20. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 6/10/24, it was noted that on 5/26/24, the Licensed Practical Nurse documented, ";Equipment/Supplies: Oxygen Concentrator." The medication profile failed to include Oxygen. P-10: The Start of Care (SOC) was dated 4/23/24. The Plan of Care (POC) identified a terminal diagnosis of Renal Cancer. During record review on 6/12/24, it was noted that on 6/6/24, the Registered Nurse documented, ";Patient and her husband are having difficulty with keeping her medications straight. Husband stated theyve been getting into arguments about it. This nurse reviewed medications with patient and her husband and filled med planner. Also wrote out med list for them..." During an observation visit on 6/12/24, the medication profile in the SOC packet was blank. A printed medication profile dated 6/6/24 was noted on the table near the med planner. The agency failed to provide a written medication list at the SOC. These findings were reviewed with and acknowledged by the Staff-1 (Administrator) and Staff-2 (Clinical Manager) during an interview on 6/13/24 at 10:15 am.

Based on record review and interview, the hospice failed to ensure the plan of care included measurable outcomes for the palliation and management of the terminal illness for 14 of 14 (P-1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) records reviewed, resulting in the potential for poor patient outcomes. Findings include: --- P-12: The patient was readmitted to the Hospice on 8/22/2023. The Plan of Care for the certification period 8/22/23 to 11/9/2023 included diagnoses of Malignant Neoplasm of Lower-Inner Quadrant of Right Breast, Secondary Malignancies of Bones, Left Lung, Right Lung and Axilla and upper Limb Nodes. The patient was receiving Skilled Nurse, Medical Social Work, Home Health Aide and Chaplain services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress toward achieving the goals. Examples included: "Pain will be managed at a level acceptable to the patient; A chaplain plan of care will be established; Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. These goals are not objectively measurable to determine the patient's towards achieving the goals. P-13: The patient was admitted to the hospice on 3/14/2024. The Plan of Care for the certification period 3/14/2024 to 5/17/24 identified diagnoses of Multiple Myeloma, History of infectious and parasitic diseases, History of Methicillin Resistant Staph Infection, Downs Syndrome, Diabetes Type 2 with Diabetic Chronic Kidney Disease. The patient was receiving Skilled Nursing, Home Health aide, Medical Social work, Massage Therapy, and Volunteer Services. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patients progress toward achieving the goals. Examples included: "A nursing Plan of Care will be established; Pain will be managed at a level acceptable by patient; Patient will have safety needs met; A Chaplain Plan of Care will be established." These goals are not objectively measurable to determine the patients progress towards achieving the goals. P-14: This patient was admitted to the hospice on 7/13/23. The Plan of Care for the certification period 7/13/23 to 8/23/23 identified diagnoses of Bradycardia, Hyperlipidemia, Osteoarthritis, Urinary Tract Infection, and History of Transient Ischemic Attacks. This patient was receiving Skilled Nursing, Medical Social Work, Home Health Aide, and Chaplain Services. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patients progress toward achieving the goals. Examples included: "Patient/Caregiver verbalize understanding of need for adequate nutrition/hydration, as tolerated, to prevent skin breakdown; continuity of care among providers is achieved (this is for the providers, not the patient); Patient/Caregiver verbalize understanding of when to utilize PRN medications and to document each usage. These goals are not objectively measurable to determine the patient's progress towards achieving the goals. These findings were reviewed with and acknowledged by the Staff-1 (Administrator) and Staff-2 (Clinical Manager) during an interview on 6/13/24 at 11:45 am. P-8: The Start of Care (SOC) was dated 7/5/20. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 6/10/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Patient/caregiver will verbalize/demonstrate appropriate pain management. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-9: The Start of Care (SOC) was dated 1/18/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 6/11/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-10: The Start of Care (SOC) was dated 4/23/24. The Plan of Care (POC) identified a terminal diagnosis of Renal Cancer. During record review on 6/12/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Pain will be managed at a level acceptable to the patient. Patient/Caregiver will verbalize/demonstrate appropriate pain management. Patient will have safety needs met." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-11: The Start of Care (SOC) was dated 4/2/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 6/12/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Hospice nurse to monitor patients pain level and report ineffective pain control to the physician. Hospice nurse for assessment of patient safety, instruct safety measures as applicable." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. These findings were reviewed with and acknowledged by the Staff-1 (Administrator) and Staff-2 (Clinical Manager) during an interview on 6/13/24 at 10:15 am. P-4: This patient was admitted to hospice on 5/24/24 with diagnoses of hypertensive heart and chronic kidney disease with heart failure. During review of the medical record on 6/10/24, it was noted that the 5/24/24 plan of care failed to include measurable outcomes pertinent to the needs of the patient or family. One of the goals states that the patient's pain will be managed at a level acceptable to the patient. There was no indication what level of pain is acceptable to this patient. Another goal states that the patient/caregiver will verbalize knowledge of preventative measures/response in the event of hemorrhage. There was no indication how this goal would be measured to ensure patient/caregiver knowledge. P-5: This patient was admitted to hospice on 10/6/23 with diagnoses of cerebrovascular disease and palliative care. During review of the medical record on 6/11/24, it was noted that the 10/6/23 plan of care failed to include measurable outcomes pertinent to the needs of the patient or family. One of the goals states that the patient's pain will be managed at a level acceptable to the patient. There was no indication what level of pain is acceptable to this patient. Another goal states that the patient will have safety needs met. There was no indication of the safety needs for this patient and how this goal would be measured to ensure the patient's safety needs are met. P-6 This patient was admitted to hospice on 8/4/23 with diagnoses of spinal stenosis and dementia. During review of the medical record on 6/11/24, it was noted that the 8/4/23 plan of care failed to include measurable outcomes pertinent to the needs of the patient or family. One of the goals states that the patient's pain will be managed at a level acceptable to the patient. There was no indication what level of pain is acceptable to this patient. Another goal states that the patient's anxiety/agitation is minimized/controlled, and caregiver verbalizes understanding of its effects/origin/treatment. There was no indication how this goal would be measured to ensure the patient's anxiety/agitation is minimized or controlled. P-7: This patient was admitted to hospice on 10/9/23 with a diagnosis of senile degeneration of the brain. During review of the medical record on 6/11/24, it was noted that the 10/9/23 plan of care failed to include measurable outcomes pertinent to the needs of the patient or family. One of the goals states that the patient's pain will be managed at a level acceptable to the patient. There was no indication what level of pain is acceptable to this patient. Another goal states that the patient will have safety needs met. There was no indication of the safety needs for this patient and how this goal would be measured to ensure the patient's safety needs are met. The above findings were reviewed with and acknowledged by Staff-1 (administrator) and Staff-2 (clinical manager) during an interview on 6/13/24 at 9:30 a.m. P-1: The patient was admitted to the hospice on 2/13/24. The Plan of Care (POC) for the certification period 2/13/24 to 5/12/24, included diagnoses of heart failure, diabetes, cardiomyopathy. The patient was receiving Skilled Nurse, Medical Social Work, and Chaplain services. Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress toward achieving the goals. Examples included: "Patient will have safety needs met; Patient/Caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-2: The patient was admitted to the hospice on 4/11/24. The POC for the certification period 4/11/24 to 7/9/24, included diagnoses of respiratory failure and bilateral lower leg pain. The patient was receiving Skilled Nurse, Medical Social Work, Home Health Aide, Massage Therapy, and Chaplain services. Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress toward achieving the goals. Examples included: "Pain will be managed at a level acceptable to the patient; Patient will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease." There was no documented acceptable pain level, in the record, to base the pain goal on, and these goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-3: The patient was admitted to the hospice on 5/14/24. The POC for the certification period 5/14/24 to 8/11/24, included diagnoses of heart failure and kidney failure. The patient was receiving Skilled Nurse, Medical Social Work, Home Health Aide, Chaplain, and Massage Therapy services. Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress toward achieving the goals. Examples included: "Patient/Caregiver will verbalize adequate knowledge of required care to manage indwelling catheter; Patient will demonstrate improved comfort through Massage Therapy services." There was no documented evidence of how these goals are objectively measurable to determine the patient's progress towards achieving the goals. The findings were reviewed with and acknowledged by the administrator (Staff-1) and the clinical manager (Staff-2) on 6/13/24 at 1:15 p.m.

Based on record review and interview, it was determined that the hospice failed to ensure that skilled nursing coordinated and implemented the plan of care to meet the patient's continuous needs in 1 (P-9) of 14 records reviewed resulting in the potential for poor patient outcomes for all hospice patients. Findings include: --- **Agency policy "Coordination of Care" (Last Reviewed 10.01.21) stated, "Purpose: To ensure coordination of all care provided for patients receiving hospice services and/or services from other providers. Policy: I. The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the Hospice, or by other providers." P-9: The Start of Care (SOC) was dated 1/18/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 6/11/24, the Registered Nurse documented on 3/27/24, ";Message: Please call. Pt (Patient) was complaining of chest pain that was radiating down right arm. B/P (Blood Pressure) was 198/98 (manually)...This nurse contacted the facility and spoke with the nurse who called. She states pt is feeling better and B/P has come down since the first round of Nitro. Advised facility to continue to monitor and pass Nitro again if needed...Facility nurse stated SN (Skilled Nurse) visit not needed at this time...RNCM (Registered Nurse Case Manager) will follow up next day." There was no documented evidence that the RNCM followed up the next day, 3/28/24. The RNCM completed the next visit on 4/4/24. The agency failed to coordinate care between staff which has the potential for poor patient outcomes. This finding was reviewed with and acknowledged by the Staff-1 (Administrator) and Staff-2 (Clinical Manager) during an interview on 6/13/24 at 10:40 am.

Based on record review and interview, the hospice failed to ensure the registered nurse prepared written patient care instructions for the aide that included safety precautions pertinent to the needs of these patients for 9 of 11 (P-1, 2, 3, 4, 7, 11, 12, 13, 14) records reviewed with aide services, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: --- P-12: The patient was readmitted to the Hospice on 8/22/2023. The Plan of Care for the certification period 8/22/23 to 11/9/2023 included diagnoses of Malignant Neoplasm of Lower-Inner Quadrant of Right Breast, Secondary Malignancies of Bones, Left Lung, Right Lung and Axilla and upper Limb Nodes. The patient was receiving Skilled Nurse, Medical Social Work, Home Health Aide and Chaplain services. Home Health Aide services were ordered on 8/22/23 for 2 visits every 2 weeks for 11 weeks. The Plan of Care documented the patient had a vision The Skilled Nurse documented the following Safety Precautions on the Plan of Care: "Adequate Lighting, Clear Pathways, Fall Precautions, Oxygen Precautions, Removal of Throw Rugs, Remove Clutter. The Comprehensive Assessment also documented the patient had diminished visual acuity and a hearing deficit. Upon review of the Aide Care Plan, it was noted, there were no safety precautions to address the patient's need for adequate lighting, clear pathways, the removal of throw rugs and clutter to address the fall precautions. There were no fall precautions on the Aide Care Plan. In addition, there was no information on the Aide Care plan that communicated that the patient had diminished visual acuity and a hearing deficit. P-13: The patient was admitted to the hospice on 3/14/2024. The Plan of Care for the certification period 3/14/2024 to 5/17/24 identified diagnoses of Multiple Myeloma, History of infectious and parasitic diseases, History of Methicillin Resistant Staph Infection, Downs Syndrome, Diabetes Type 2 with Diabetic Chronic Kidney Disease. The patient was receiving Skilled Nursing, Home Health aide, Medical Social Work, Massage Therapy, and Volunteer Services. The Plan of Care included the following Safety Precautions: "Adequate lighting, Clean technique, Clear pathways, Emergency Plan, Fall Precautions, Oxygen Precautions, Universal Precautions". The Plan of Care also identified the following Functional Limitations: "Bowel/Bladder incontinence, Endurance, Dyspnea with minimal exertion, Assistive device to ambulate, forgetful, fall risk, cognitive impairment, Hoyer, two-person transfer, glasses, dyspnea on exertion, cancer. The aide care plan dated 3/17/24 ordered Home Health Aide visits 2 times a week for 3 weeks; 1 time a week for 1 week; 2 times a week for 3 weeks; 1 time a week for 1 week. However, the aide care plan failed to include any safety precautions or functional limitations for this patient. P-14: This patient was admitted to the hospice on 7/13/23. The Plan of Care for the certification period 7/13/23 to 8/23/23 identified diagnoses of Hypertensive Heart Disease, Bradycardia, Dizziness and Giddiness, Chronic Fatigue, Hyperlipidemia, Osteoarthritis, Sciatica, and need for assistance with personal care. This patient was receiving Skilled Nursing, Medical Social Work, Home Health Aide, and Chaplain Services. The Plan of Care included the following Safety Precaution: "Fall Precautions", and the Following Functional Limitations: "Bowel/Bladder (Incontinence), and Endurance. The Aide Care Plan dated 7/30/23 ordered Home Health Aide visits 2 visits every 2 weeks for 2 weeks; and 2 visits for 8 weeks; and 1 visit for 1 week. However, the aide care plan failed to include any safety precautions or functional limitations for this patient. These findings were reviewed with and acknowledged by the Staff-1 (Administrator) and Staff-2 (Clinical Manager) during an interview on 6/13/24 at 11:45 am. P-4: This patient was admitted to hospice on 5/24/24 with diagnoses of hypertensive heart and chronic kidney disease with heart failure. During review of the medical record on 6/10/24, it was noted that the 5/24/24 plan of care included anticoagulant and oxygen precautions as safety measures for this patient. The 5/24/24 aide care plan failed to include both precautions to alert the aide to these safety measures when caring for this patient. P-7: This patient was admitted to hospice on 10/9/23 with a diagnosis of senile degeneration of the brain. During review of the medical record on 6/11/24, it was noted that the 10/9/23 plan of care included the following safety measures: adequate lighting, clear pathways, fall precautions, and universal precautions. The 10/9/23 aide care plan failed to include these same safety precautions to alert the aide to these safety measures when caring for this patient. The above findings were reviewed with and acknowledged by the administrator (Staff-1) and the clinical manager (Staff-2) during an interview on 6/13/24 at 9:30 a.m. P-11: The Start of Care (SOC) was dated 4/2/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 6/12/24, it was noted that the 4/2/24 plan of care included the following safety measures: Adequate lighting, clean technique, clear pathways, emergency plan, fall precautions, removal of throw rugs, remove clutter, universal precautions. The 4/2/24 aide care plan failed to include any safety measures to alert the aide of the patient's health and safety concerns. These findings were reviewed with and acknowledged by the Staff-1 (Administrator) and Staff-2 (Clinical Manager) during an interview on 6/13/24 at 11:00 am. P-1: The patient was admitted to the hospice on 2/13/24. The Plan of Care (POC) for the certification period 2/13/24 to 5/12/24, included diagnoses of heart failure, diabetes, and cardiomyopathy. The patient was receiving Skilled Nurse, Medical Social Work, Home Health Aide, and Chaplain services. Upon review of the POC on 6/10/24, it was noted that the POC included the following safety measures: Adequate lighting, clean technique, clear pathways, anticoagulant precautions (Aide is ordered to shave the patient per patient request), fall precautions, O2 precautions, and universal precautions. There were no diabetic precautions on the POC. The 2/13/24 aide care plan failed to include any safety measures to alert the aide of the patient's health and safety concerns. P-2: The patient was admitted to the hospice on 4/11/24. The POC for the certification period 4/11/24 to 7/9/24, included diagnoses of respiratory failure and bilateral lower leg pain. The patient was receiving Skilled Nurse, Medical Social Work, Home Health Aide, Massage Therapy, and Chaplain services. Upon review of the POC 6/12/24, it was noted that the plan of care included the following safety measures: universal precautions. The 4/11/24 aide care plan failed to include any safety measures to alert the aide of the patient's health and safety concerns with nail care ordered every visit. P-3: The patient was admitted to the hospice on 5/14/24. The POC for the certification period 5/14/24 to 8/11/24, included diagnoses of heart failure and kidney failure. The patient was receiving Skilled Nurse, Medical Social Work, Home Health Aide, Chaplain, and Massage Therapy services. Upon review of the POC on 6/13/24, it was noted that the plan of care included the following safety measures: adequate lighting, clear pathways, diabetic precautions, fall precautions, O2 precautions, and universal precautions. The 5/14/24 aide care plan failed to include any safety measures to alert the aide of the patient's health and safety concerns with nail care ordered every visit. The findings were reviewed with and acknowledged by the administrator (Staff-1) and the clinical manager (Staff-2) on 6/13/24 at 1:15 p.m.

Based on record review and interview, the hospice failed to ensure the registered nurse correctly documented an on-site supervisory visit for 1 of 11 (P-7) records reviewed with aide services, resulting in the inability of the hospice to ensure patients received appropriate hospice aide care and services. Findings include: --- P-8: The Start of Care (SOC) was dated 7/5/20. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 6/10/24, it was noted that the Registered Nurse (RN) completed a RN Hospice Recert Assessment on 5/20/24. Under the ";Supervisory Functions" the RN documented, ";Indicate discipline of employee being evaluated: Home Health Aide. Does the aide follow the plan of care? Yes." The record has no indication that the patient has received Aide services. The agency failed to properly document supervisory functions. P-10: The Start of Care (SOC) was dated 4/23/24. The Plan of Care (POC) identified a terminal diagnosis of Renal Cancer. During record review on 6/12/24, it was noted that the RN completed a RN Hospice Subsequent with Supervisory Visit on 6/12/24. Under the ";Supervisory Functions" the RN documented, ";Indicate discipline of employee being evaluated: Home Health Aide. Does the aide follow the plan of care? Yes." The record has no indication that the patient has received Aide services. The agency failed to properly document supervisory functions. These findings were reviewed with and acknowledged by the Staff-1 (Administrator) and Staff-2 (Clinical Manager) during an interview on 6/13/24 at 10:50 am. P-7: This patient was admitted to hospice on 10/9/23 with a diagnosis of senile degeneration of the brain. During review of the medical record on 6/11/24, it was noted that the 5/22/24 plan of care update report orders the nurse to provide once weekly visits and the aide is to provide twice weekly visits. For a period of 26 days (5/17/24 through 6/11/24) there was no documented evidence of aide supervision. On the nursing visit notes dated 5/22/24 and 5/30/24, the nurse documented that supervisory functions were not performed because they were not applicable to today's visit. The next nursing visit on 6/6/24 was conducted by the licensed practical nurse. The findings were reviewed with and acknowledged by the administrator (Staff-1) and the clinical manager (Staff-2) during an interview on 6/13/24 at 9:30 a.m.