Every finding on record at Interim Healthcare Hospice of Western PA, Inc

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 4 of 19 (21%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient’s current medications. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 02/17/2026 with diagnoses of hemiplegia following cerebral infarct affecting the right side, aphasia, acquired absence of the right leg above the knee, hypertension (HTN), and vascular degeneration. The patient resided in a skilled nursing facility (SNF). During a home visit with the Chaplain (SCC) [Personnel Record 5] on 03/17/2026, a medication review revealed the following medications documented on the agency's medication profile were not documented on the SNF medication profile: lorazepam 0.5 mg, one (1) tablet every four hours as needed for anxiety, morphine sulfate oral solution 100 mg/mL, 0.25 mL every three hours as needed for pain or dyspnea, and Senna-S 8.6–50 mg, one (1) tablet orally daily as needed for constipation. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 12/04/2024 with diagnoses of Alzheimer’s Disease, type 2 diabetes, and gastro-esophageal reflux disease. The patient resided in a SNF. During a home visit with the Hospice Aide (HA) [Personnel Record 6] on 03/17/2026, a medication review revealed the following medications documented on the agency’s medication profile were not documented on the SNF medication profile: hydrocodone-acetaminophen 5-325 mg oral tablet, one (1) tablet every 6 hours as needed for pain, and lorazepam oral concentrate 2 mg/mL, 0.5 mg sublingually every 4 hours as needed for anxiety/restlessness. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/17/2025 with diagnoses of unspecified B-Cell lymphoma, unspecified diastolic congestive heart failure (CHF), HTN, and chronic pain. The plan of care dated 10/17/2025 ordered oxygen at 2 liters per minute via nasal cannula, to be used as needed. The patient’s medication profile did not include documentation of oxygen. CLINICAL RECORD 14: The patient elected the benefit on 01/23/2026 with diagnoses of end-stage heart failure, atrial fibrillation (A-Fib), chronic obstructive pulmonary disease (COPD), and sarcoidosis of the lung. A review of the clinical record revealed that the plan of care dated 01/23/2026 ordered oxygen 1-5 liters per minute via nasal cannula to be used as needed. Oxygen was not documented on the agency's medication profile. During interviews on 03/17/2026, the Clinical Director, Administrator, and Patient Care Coordinator (PCC), confirmed that the agency’s medication profile did not align with the SNF medication profile. The Clinical Director reported that medications not administered for more than two weeks are automatically removed (“fall off”) from the facility’s medication profile. Following clarification with the Hospice Medical Director, updated medication orders were issued to the facility on 03/18/2026. Additionally, they confirmed that oxygen was not listed on the agency’s medication profile, despite being an active order on the patient’s plan of care.

It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that hospice care and services provided to the patient followed the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). CLINICAL RECORD 3: The patient elected the hospice benefit on 06/26/2025 with diagnoses of heart disease, senile degeneration of the brain, chronic kidney disease, and benign prostatic hyperplasia (BPH). The plan of care dated 06/26/2025 ordered a 16 Fr coude catheter with a 10–30 cc balloon, to be changed monthly and as needed. The Skilled Nurse (SN) visit notes documented that on 09/04/2025: Foley replaced with 16 Fr, 10 cc balloon; 10/07/2025: Foley replaced with 18 Fr, 10 cc balloon; 02/12/2026: Foley replaced with 18 Fr, 10 cc balloon; and 03/12/2026: 18 Fr, 10 cc balloon. A review of the clinical record revealed that the catheter type and size were changed multiple times without updates to the plan of care or documented physician orders. During a joint record review and interview on 03/16/2026, the Clinical Director and Administrator confirmed that the plan of care was not updated based on the patient’s assessed needs and changes.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/16/2025 with diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), lupus, and type 2 diabetes mellitus. The plans of care dated 05/16/2025 through the recertification plan of care dated 03/12/2026 ordered a sliding-scale insulin regimen based on blood glucose monitoring, including Novolog FlexPen (100 units/mL), 2–9 units subcutaneously three times daily as needed for elevated blood glucose, as well as Insulin glargine (100 units/mL), 18 units subcutaneously once daily. The plans of care did not include documentation of interventions or goals addressing the patient's identified problem of diabetes management, despite active insulin therapy and ongoing blood glucose monitoring requirements. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/11/2025 with a diagnosis of esophageal cancer. The admission comprehensive assessment dated 01/11/2025 documented that the patient had a percutaneous endoscopic gastrostomy (PEG) tube, with nutritional status documented as “PEG Tube, Diet: formula, 2 meals a day.” Additionally, the hospice narrative dated 01/15/2025 documented that the patient “continues with tube feeding for nutrition,” confirming the ongoing use of the PEG tube. The plan of care included interventions for the patient’s identified problems with dyspnea, grief, nausea, and pain. The plan of care did not include documentation of interventions or goals addressing the patient's PEG-related needs. During a joint record review and interview, the Clinical Director, Administrator, and Patient Care Coordinator (PCC), confirmed that the patient’s plans of care did not include interventions specific to diabetes management and PEG tube care and maintenance.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of agency documentation revealed that no volunteer service percentage was calculated for 01/01/2024 through 12/31/2024. The agency reported a total volunteer service contribution of 4.8% for 01/01/2025 through 12/31/2025, which did not meet the required 5% threshold. During an interview on 03/18/2026, the Administrator stated that the program was almost "nonexistent" when they started in January of 2025. The agency has a current PIP in place related to the volunteer program. It was reported during the interview that the current Volunteer Coordinator assumed their role in February 2025. Based on interview and document review with the Volunteer Coordinator and the Administrator on 03/18/2026, it was determined that the agency failed to ensure that volunteer services met the regulatory requirement that volunteers provide at least 5% of the total patient care hours furnished by hospice employees and contract staff. Review of agency documentation revealed that no volunteer service percentage was calculated for calendar year 2024, and the agency reported a total volunteer service contribution of 4.8% for 2025, which did not meet the required 5% threshold. It was noted during the interview that the current Volunteer Coordinator assumed her role in February 2025.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that orders were obtained for all necessary services. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/26/2025 with diagnoses of heart disease, senile degeneration of the brain, chronic kidney disease, and benign prostatic hyperplasia (BPH). The plan of care dated 06/26/2025 included documentation of a Foley catheter and documented the goal: “Patient will experience no discomfort or signs/symptoms of urinary tract infection (UTI) with urinary catheter.” The POC ordered placement of a 16 French (Fr) coude catheter with a 10–30 cc balloon, to be changed monthly and as needed. A review of the clinical record revealed the Skilled Nurse (SN) visit notes documented on: 09/04/2025: Foley replaced with 16 Fr, 10 cc balloon; 10/07/2025: Foley replaced with 18 Fr, 10 cc balloon; 02/12/2026: Foley replaced with 18 Fr, 10 cc balloon; and 03/12/2026: 18 Fr, 10 cc balloon. A review of the clinical record revealed no evidence of communication with the physician or of a physician order changing the catheter type, size, or maintenance. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/16/2025 with diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), lupus, and type 2 diabetes mellitus. The plans of care dated 05/16/2025 through the recertification plan of care dated 03/12/2026 ordered a sliding-scale insulin regimen based on blood glucose monitoring, including Novolog FlexPen (100 units/mL), 2–9 units subcutaneously three times daily as needed for elevated blood glucose, as well as Insulin glargine (100 units/mL), 18 units subcutaneously once daily. The plan of care did not include documentation of the blood glucose parameters corresponding to each sliding scale insulin dose. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/11/2025 with a diagnosis of esophageal cancer. The admission comprehensive assessment dated 01/11/2025 documented that the patient had a percutaneous endoscopic gastrostomy (PEG) tube, with nutritional status documented as “PEG Tube, Diet: formula, 2 meals a day.” The hospice narrative dated 01/15/2025 documented that the patient “continues with tube feeding for nutrition,” confirming the ongoing use of the PEG tube. The plan of care did not include documentation of orders, including the specific formula, tube feeding regimen, or PEG tube maintenance. During a joint record review and interview, the Clinical Director, Administrator, and Patient Care Coordinator (PCC), confirmed that the patient’s plans of care did not include orders specific to diabetes management, catheter management, or PEG tube care and maintenance.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) of the clinical records reviewed, the agency did not ensure that each patient received a comprehensive assessment within 5 days of electing hospice. Clinical Record 3: Patient elected hospice on 10/4/2023. The clinical record contained a communication note on 10/6/2023 that read, "5-day SC assessment incomplete due to staffing." Spiritual counseling assessment and social work assessment were on 10/13/2023. There was no documentation in the record to identify why the social work assessment was not completed within 5 days. In an interview on 11/13/2023, the Director of Clinical Services confirmed finding. 1 of 5 (20%) of the clinical records reviewed revealed that the agency did not ensure that each patient received a comprehensive assessment within 5 days of electing hospice.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, and supplements. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. THIS IS A CONTINUED PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home visit observed, the agency did not ensure that the medication profile was updated when changes were made to patient medication orders. Home Visit 1: During a home visit on 11/13/2023, observed all patient medications and reviewed the current medication regime with the caregiver. The clinical record revealed that the medication list was developed on 9/14/2023. The clinical record does not have any medication reconciliations documented. The medication list included a Fiber oral capsule, one capsule oral, two times per day. The patient's caregiver reported that the Fiber capsule was discontinued upon admission to hospice, and the patient is no longer taking that medication. The caregiver reported Senna-S oral tablet 8.6-50mg, one tablet daily listed on the med profile as of 9/14/2023, was changed on 11/11/23 to 2 tablets twice a day after calling the nurse for constipation. The medication profile was not updated. In an interview on 11/13/2023, the Director of Clinical Services reported that she was on call and confirmed the caregiver's comments. A verbal order for Senna S Oral tablet 8.6.-50mg, two tablets every 12 hours, effective 11/11/2023, was documented in the clinical record. The medication profile contained Trazadone HCL oral tablet every night at bedtime, effective 10/11/2023. The caregiver reported that the Trazadone was discontinued after the first dose and should only be used PRN because the patient was knocked out. The medication profile was not updated. The medication profile included Vitamin D3 125mcg 1 capsule daily effective 9/14/2023. The caregiver reported that Vitamin D3 was discontinued weeks ago. The medication profile was not updated. In an interview on 11/13/2023, the Director of Clinical Services confirmed the finding. THIS IS A CONTINUED REQUIRED ACTION. 1 of 1 (100%) home visits observed revealed that the agency did not ensure that the medication profile was updated when changes were made to patient medication orders.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. THIS IS A CONTINUED PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the care plan was specific enough to provide clear direction to the Hospice Aide. Clinical Record 3: Skilled Nurse assessment on 10/4/2023 identified a pressure ulcer on the patient's coccyx with an order to cover it with foam border gauze. The Home Health Aide care plan created on 10/4/2023 by the Registered Nurse did not include any instruction for the Hospice Aide while performing personnel care related to the coccyx wound or dressing. In an interview on 11/13/2023, the Director of Clinical Services confirmed the finding. THIS IS A CONTINUED REQUIRED ACTION 1 of 5 (20%) of clinical records reviewed revealed that the agency did not ensure that the care plan was specific enough to provide clear direction.

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by document review and interview. The hospice did not ensure that patients were informed and provided with written information about its policies on advance directives. The agency policy "Withdrawing or Foregoing Life Sustaining Care" (effective 12/2/2008) stated in part, "A patient or his/her representative are provided written information regarding their rights to formulate Advanced Directives and advised of …. policies and procedures regarding advance directives prior to initiating care...." A review of the hospice sample admission packet on 5/23/2023 revealed the hospice sample admission packet and the admission packet provided to patients did not include written information about the hospice policies on advance directives. During a joint review of the sample admission packet and an interview on 5/26/2023. The Director of Compliance, Regulation, and Quality confirmed that the agency's written policy was not included or distributed to the patients and families A review of the agency sample admission packet revealed the agency did not include the agency's advance directive policy or distribute the written information to patients and families; however, the State specific applicable law and education were provided.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. 4 of 4 (100%) home visits observed, the hospice did not ensure that the drug profile was updated at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. Home Visit 1/Clinical Record 17: During the home visit on 5/24/2023 with the Registered Nurse (RN), a medication reconciliation was performed with the patient's mother, comparing the agency's medication profile printed on 5/23/2023 and the medicine bottles. The patient had a gastrostomy tube (G-Tube) for tube feedings and medication administration. The medication profile documented "Acetaminophen Children's Oral Suspension 160mg/5mL, 7.5 milliliters, oral, every 4 hours, as needed for fever and mild pain," effective 1/28/2022. The route of the Acetaminophen was incorrect and should have been documented via G-Tube. The medication profile listed "Atropine Sulfate Ophthalmic Solution 1%, one drop, ophthalmic, hourly, as needed for secretions." However, the patient received this medication sublingually to manage excess secretions. The Administrator/Registered Nurse (RN)[Personnel Record 5] and RN Case Manager were present for the visit, confirmed the inaccuracies, and updated the medication profile. The skilled nursing frequency was three (3) times weekly for eight (8) weeks, 3/25/2023 through 5/10/2023. Home Visit 2: During the home visit on 5/24/2023 with the RN, a medication reconciliation was performed with the patient's daughter comparing the medication profile provided by the agency on 5/23/2023 and the medicine bottles in the house. The patient had a primary diagnosis of chronic obstructive pulmonary disease (COPD). The medication profile documented "Synthroid Oral tablet 50 mcg, one tablet, oral, daily," and the medicine bottle documented "Synthroid Oral tablet 75 mcg." The medication profile documented "Sotalol HCI AF oral tablet 80 mg, one tablet, oral two (2) times per day." The daughter stated the patient takes one (1) tablet in the morning and a half (1/2) tablet in the evening. The medication profile documented "Prochlorperazine Maleate Oral Tablet 10 mg, one oral tablet every 4 hours, as needed for nausea." The Prochlorperazine Maleate was not in the home; the patient took "Zofran ODT 4mg sublingually every 4 hours as needed for nausea" instead. The medication profile documented "prednisone oral tablet 5 mg, one tablet, oral, two times per week." The patient took the prednisone twice daily. The medication profile documented a duplicate order for morphine sulfate, both effective 5/15/2023. One of the morphine orders was incorrect due to the concentration and dosage: "morphine sulfate 10mg/5mL, two (2) milliliters, oral, every three (3) hours, as needed for shortness of breath." The morphine bottle in the home read "100mg/5ml, 0.25mL, oral every three (3) hours, as needed for severe pain or dyspnea," which matched the second morphine order on the medication profile. The medication profile documented "Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml, 1 milliliter, inhalation, every 4 hours, as needed for shortness of breath and wheezing." The patient reported using the nebulizers around the clock. The medication profile documented "Hyoscyamine Sulfate sublingual tablet 0.125 mg, one tablet, sublingual, every 4 hours as needed for terminal secretions," however, this medication was not in the home. The RN Case Manager stated the Hyoscyamine Sulfate was changed to Atropine drops, which was not documented on the medication profile. Two inhalers, Spiriva and Albuterol Sulfate, found in the home were not documented on the medication profile. The daughter stated the Spiriva was started two weeks before the hospice admission. The patient reported using the Albuterol Sulfate, two puffs, as needed for shortness of breath. The RN Case Manager and Administrator/Registered Nurse [Personnel Record 5] present for the visit confirmed the discrepancies and corrected the medication profile. The skilled nursing frequency was three (3) times weekly for thirteen (13) weeks, 5/13/2023 through 8/11/2023. Home Visit 3/Clinical Record 16: During the home visit on 5/24/2023 with the hospice aide, a medication reconciliation was performed with the patient's private sitters comparing the medication profile provided by the agency on 5/23/2023 to the patient's medicine bottles. The patient had a primary diagnosis of COPD and was oxygen dependent. The following medications documented on the medication profile were not in the home: "Breao Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/inh, one puff inhalation daily; Calcium citrate plus/magnesium oral tablet 500mg, one tablet oral three times per day; Guaifenesin oral 600 mg, one dose oral every twelve (12) hours as needed for congestion; Haloperidol lactate oral concentrate 2mg/mL, 0.5 milliliters, oral, every four hours, as needed for nausea, vomiting, agitation; Iodine Strong (Lugols) oral 246 mcg, one milliliter (ml), oral daily; Multivitamin Adults 50+ oral, one dose, oral daily." The private sitter reported use of the following medications found in the home but not documented on the medication profile: "CBD Oil 2000mg, take 0.75ml by mouth three times per day and Lorazepam Intensol 2mg/mL, take 0.25ml by mouth every 4 hours as needed for anxiety, shortness of breath and restlessness." The Administrator/Registered Nurse [Personnel Record 5] present for the visit confirmed the medication profile was inaccurate. The skilled nursing frequency was two (2) times weekly for eight (8) weeks, 4/8/2023 through 6/2/2023. Home Visit 4/Clinical Record 18: During the home visit on 5/25/2023 with the chaplain, a medication reconciliation was performed with the patient's son comparing the medication profile provided by the agency on 5/23/2023 to the patient's medicine bottles. The medication profile documented "Duloxetine HCI oral capsule delayed release sprinkle 20mg," the son stated the medication was discontinued three weeks ago. The medication profile documented "Plavix Oral tablet 75mg, one tablet oral daily;" the son stated the medication was discontinued four weeks ago. The skilled nursing frequency was three (3) times weekly for eight (8) weeks, 5/8/2023 through 6/30/2023.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. 5 of 19 (26%) clinical records reviewed, the hospice did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient, who resides in an assisted living facility, elected hospice care on 3/14/2023. The Registered Nurse (RN) visit note dated 3/302023 documented, "buttocks and coccyx are extremely red from the irritation of urine and bowel...Telephone call made to daughter at the end of visit, and she is aware that he was found with dried fecal matter on his perineal area and coccyx, anal area. Spoke with the facility nurse and asked how often the caregivers check on him and she is uncertain but will talk to them, she is also aware that he was found to have moderate soiling." The hospice interdisciplinary team (IDT) note dated 4/6/2023 did not document an updated plan of care with interventions and goals addressing the incontinence and skin integrity problem. Additionally, the IDT meeting note dated 5/18/2023 with the current plan of care did not document the incontinence and skin integrity problem. A clinical record review revealed documentation that the patient was refusing care from hospice staff, including the hospice aide. The plan of care did not include documentation of interventions to address the patient's refusal of visits. An interview with the Director of Compliance, Regulatory, and Quality on 5/26/2023 confirmed the plan of care did not include the management of the skin integrity breakdown due to incontinence and behavior disturbances refusing hygiene care. Clinical Record 3: The patient elected hospice care on 2/7/2023 with a primary diagnosis of endometrial cancer. The initial comprehensive assessment completed by the RN on 2/7/2023 documented the patient had a new onset of ascites with a paracentesis performed before the hospice admission, and a Pleurx drain could not be placed due to the location of the fluid in the cavity. The hospice plan of care dated 2/7/2023 and reviewed on 2/9/2023 at the IDT meeting did not include documentation of interventions and goals to address the management of the patient's ascites. During the joint record review with the Director of Compliance, Regulatory, and Quality, it was confirmed that the plan of care was not updated to address the ascites. Clinical Record 12: The patient elected hospice care on 5/20/2022. The plan of care dated 5/20/2022 through 8/17/2022 ordered, "wound care to right gluteal fold: 1cm x 1cm...Cleanse and pat dry; cover with skin paste or Mepilex daily." The plan of care did not include documentation of the wound cleanser to be used. The Director of Compliance, Regulation, and Quality confirmed during the joint record review on 5/26/2023 that the first wound care order was missing the cleansing agent. Clinical Record 16: The patient elected hospice care on 4/7/2023 with the primary diagnosis of end-stage COPD. The patient was oxygen dependent. The physician certification of terminal illness statement signed on 5/14/2023 by the medical director stated in part..."COPD requires BiPaP 18+ hours per day...can only tolerate being off Bipap for an hour at a time then …. fluctuates into the 70s on nasal cannula O2." The plan of care documented an intervention to "monitor use of BiPaP for... hypercapnia." A clinical record review revealed the plan of care did not include documentation of interventions and goals for the Bilevel Positive Airway Pressure (BiPaP) and its settings. The Director of Compliance, Regulation, and Quality confirmed the finding during the joint record review on 5/26/2023 that there were no physician orders for the BiPAP. Clinical Record 19/Home Visit 2: The patient elected hospice care on 5/13/2023 with the primary diagnosis of chronic pulmonary disease (COPD). The initial comprehensive assessment completed by the RN on 5/13/2023 documented the patient had an implanted intravenous (IV) port and wore a BiPaP at night. During the home visit on 5/24/2023 with the RN [Personnel Record 9], the patient reported using a BiPAP machine at night for sleep apnea. The plan of care did not include documentation of interventions and goals for assessing or maintaining the implanted IV port and the BiPaP settings. During the joint record review on 5/23/2023 with the Director of Compliance, Regulation, and Quality, it was confirmed the assessed items were not included in the plan of care.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. 2 of 19 (11%) clinical records reviewed, the hospice did not ensure that the plan of care included drugs and treatments necessary to meet the need of the patient. Clinical Record 16/Home Visit 3: The patient elected hospice care on 4/7/2023 with the primary diagnosis of end-stage chronic pulmonary disease (COPD). During the home visit on 5/24/2023 with the hospice aide, a medication reconciliation was performed with the patient's private sitters comparing the medication profile provided by the agency on 5/23/2023 to the patient's medicine bottles. The private sitter reported use of the following medications found in the home: "CBD Oil 2000mg, take 0.75ml by mouth three times per day and Lorazepam Intensol 2mg/mL, take 0.25ml by mouth every 4 hours as needed for anxiety, shortness of breath and restlessness." The medications were not documented on the plan of care. The Administrator/Registered Nurse (RN) [Personnel Record 5] present for the visit confirmed the finding. Clinical Record 19/Home Visit 2: The patient elected hospice care on 5/13/2023 with the primary diagnosis of COPD. During the home visit on 5/24/2023 with the RN, a medication reconciliation was performed with the patient's daughter comparing the medication profile provided by the agency on 5/23/2023 and the medicine bottles in the house. The medication profile documented "Prochlorperazine Maleate Oral Tablet 10 mg, one oral tablet every 4 hours, as needed for nausea." The Prochlorperazine Maleate was not in the home; the patient's daughter stated the patient takes "Zofran ODT 4mg sublingually every 4 hours as needed for nausea" instead. The medication Zofran was not documented in the plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. The agency policy "Interdisciplinary Group (IDG) Plan of Care" (revised 6/21/2013) stated in part, "The IDG Plan of Care is a detailed statement of all services necessary for the palliation and management of the patient's terminal illness and related conditions...The plan of care includes...medical supplies and medical appliances necessary to meet the needs of the patient..." 9 of 19 (47%) clinical records reviewed, the hospice did not ensure that the written plan of care included medical supplies and appliances necessary to meet the patient's needs. Clinical Record 1: The patient elected hospice care on 3/14/2023. During an interview and a joint record review, the Administrator/Registered Nurse (RN) [Personnel Record 5] and Director of Clinical Services (DCS) stated that the patient received the following supplies from the hospice: wipes, medium briefs, underpads, and medium gloves. The plan of care (POC) dated 3/14/2023 did not include documentation of the medical supplies. The Administrator/RN and DCS confirmed the supplies were missing from the POC. Clinical Record 2: The patient elected hospice care on 9/29/2022. During an interview and a joint record review, the Administrator/RN and DCS stated that the patient received the following incontinence supplies from the hospice: irrigation water, catheter secure Stat Locks, and wipes. The POC dated 9/29/2022 for the benefit period dated 9/29/2022 through 12/27/2022 did not include documentation of the medical supplies. The Administrator/RN and DCS confirmed the supplies were missing from the POC. Clinical Record 3: The patient elected hospice care on 2/7/2023. During an interview and a joint record review, the Administrator/RN and DCS stated that the patient received the following incontinence supplies from the hospice: medium diapers, underpads, bladder control pads, and wipes. The on-call skilled nurse visit note dated 2/20/2023 documented the nurse ordered the patient a hospital bed and overbed table and inserted a Foley 16 French indwelling catheter. The POC for the benefit period dated 2/7/2023 through 5/7/2023 was not updated to include documentation of the medical supplies and equipment ordered on 2/20/2023. The Administrator/RN and DCS confirmed the supplies and medical equipment (DME) were missing from the POC. Clinical Record 4: The patient elected hospice care on 11/29/2022. During an interview and a joint record review, the Administrator/RN and DCS stated that the patient received the following medical supply and DME from the hospice: denture brushes and an oxygen concentrator setup. The POC dated 11/29/2022 for the benefit period dated 11/29/2022 through 1/27/2023 did not include documentation of the medical supplies and DME. The Administrator/RN and DCS confirmed the supply and DME were missing from the POC. Clinical Record 6: The patient elected hospice care on 3/30/2023. During an interview and a joint record review, the Administrator/RN and DCS stated that the patient received the following medical supplies from the hospice: urinary drain bags, catheter secure strips, and Foley catheter 16 French. The POC dated 3/30/2023 did not include documentation of the medical supplies. The Administrator/RN and DCS confirmed the supplies were missing from the POC. Clinical Record 10: The patient elected hospice care on 1/6/2023. During an interview and a joint record review, the Administrator/RN and Director of Clinical Services (DCS) stated that the patient received the following supplies from the hospice: wipes, pullups, and underpads. The POC dated 1/6/2023 did not include documentation of the medical supplies. The Administrator/RN and DCS confirmed the supplies were missing from the POC. Clinical Record 11: The patient elected hospice care on 6/24/2022. During an interview and a joint record review, the Administrator/RN and Director of Clinical Services (DCS) stated that the patient received the following supplies from the hospice: under pads, medium diapers, and wipes. The POC dated 6/24/2023 did not include documentation of the medical supplies. The Administrator and DCS confirmed the supplies were missing from the POC. Clinical Record 12: The patient elected hospice care on 5/20/2022. During an interview and a joint record review, the Administrator/RN and Director of Clinical Services (DCS) stated that the patient received the following supplies and equipment from the hospice: gel cushion, low air loss mattress, over-bed table, 5L oxygen concentrator, and setup. The POC dated 5/20/2022 for the benefit period dated 5/20/2022 through 8/17/2022 did not include documentation of the medical supplies and DME. The Administrator/RN and DCS confirmed the supplies and DME were missing from the POC. Clinical Record 18: The patient elected hospice care on 4/2/2023. During an interview and a joint record review, the Administrator/RN and DCS stated that the patient received the following supplies from the hospice: pullup briefs, underpads, lemon mouth swabs, pink mouth swabs, and diapers. The POC dated 4/2/2023 for the benefit period dated 4/2/2023 through 6/30/2023 did not include documentation of the medical supplies. The Administrator/RN and DCS confirmed the supplies were missing from the POC.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. The agency policy "Interdisciplinary Group (IDG) Services" (revised 6/21/2013) stated in part, "A hospice aide is assigned to a specific patient by the RN member of the IDG who is primarily responsible for the oversight of the patient's/family's care...The designated RN IDG member provides to the assigned hospice aide(s)…Written patient care instructions, including the frequency of services in accordance with the orders of the IDG..." 6 of 14 (43%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure that the hospice aide received specific written patient care instructions from the Registered Nurse (RN). Clinical Record 1: The patient elected hospice care on 3/14/2023 and received hospice aide services three times weekly. The hospice aide care plan dated 3/14/2023 assigned the hospice aide the tasks: "apply lotion, assist with dressing, assistive device recliner, change bed linens, electric shave, foot care, hair care, make patient bed, nail care, oral care, perineal care, shower, and tidy patient environment." The hospice aide care plan did not include documentation of the frequency of completing the assigned tasks. Clinical Record 4: The patient elected hospice care on 11/29/2022 and received hospice aide services twice weekly. The hospice aide care plan dated 11/29/2022 assigned the hospice aide the tasks: "apply lotion, assist with dressing, change bed linens, complete bed bath, empty patient trash, foot care, hair care, make patient bed, nail care, oral care, perineal care, and tidy patient environment." The hospice aide care plan did not include documentation of the frequency of completing the assigned tasks. Clinical Record 6: The patient elected hospice care on 3/30/2023. The initial comprehensive assessment completed by the RN on 3/30/2023 documented that the patient had a size 14 French Foley catheter. The hospice aide care plan dated 5/18/2023 did not include documentation of instructions for the Foley catheter. During an interview and a joint record review on 5/26/2023, the Director of Compliance, Regulatory and Compliance, and the Director of Clinical Services (DON) confirmed the Foley catheter care was missing from the hospice aide care plan. Clinical Record 7: The patient elected hospice care on 1/24/2023 and received hospice aide services twice weekly. The hospice aide care plan dated 5/28/2023 assigned the hospice aide the tasks: "apply lotion, assist with dressing, change bed linens, complete bed bath, empty patient trash, foot care, hair care, make patient bed, nail care, oral care, perineal care, and tidy patient environment." The hospice aide care plan did not include documentation of the frequency of completing the assigned tasks. Clinical Record 10: The patient elected hospice care on 1/6/2023 and received hospice aide services twice weekly at an assisted living facility. The hospice aide care plan dated 1/6/2023 assigned the hospice aide the tasks: "apply barrier cream to buttocks, assist to bedpan, assist with ambulation with device wheelchair, assist with dressing, assist with transfers gait/transfer belt, assistive device grab bar, assistive device recliner, change bed linens, complete bed bath, empty patient trash, feed patient, hair care, oral care, perineal care, report pain to RNCM greater than 3 or unacceptable, shampoo hair, tidy patient environment, transfer from bed to chair, transfer from chair to bed, and turn and reposition." The hospice aide care plan did not include documentation of the frequency of completing the assigned tasks. Clinical Record 17: The patient elected hospice care on 1/28/2022. The hospice aide care plan dated 5/18/2023 assigned the hospice aide the tasks: "apply barrier cream to buttocks, apply lotion, assist with dressing, change bed linens, complete bed bath, foot care, hair care, nail care, oral care, perineal care, transfer from bed to chair, turn and reposition." The hospice aide care plan did not include documentation of the frequency of completing the assigned tasks. During an interview and the joint records review, the Director of Compliance, Regulatory, and Quality confirmed the clinical records were missing the frequencies for the assigned instructions on the aide care plans.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and document review. The agency policy "Interdisciplinary Group (IDG) Services" (revised 6/21/2013) stated in part, "The hospice aide reports to an RN any changes in the patient's medical, nursing, rehabilitative or social needs that may relate to the patient's IDG plan of care or the hospice quality assessment and performance improvement (QAPI) activities..." 1 of 14 (7%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide reported changes in the patient's needs related to the IDG plan of care to the Registered Nurse (RN). Clinical Record 10: The patient elected hospice care on 1/6/2023 and received hospice aide services twice weekly at an assisted living facility. The hospice aide care plan dated 1/6/2023 assigned the hospice aide the tasks: "apply barrier cream to buttocks, assist to bedpan, assist with ambulation with device wheelchair, assist with dressing, assist with transfers gait/transfer belt, assistive device grab bar, assistive device recliner, change bed linens, complete bed bath, empty patient trash, feed patient, hair care, oral care, perineal care, report pain to RNCM greater than 3 or unacceptable, shampoo hair, tidy patient environment, transfer from bed to chair, transfer from chair to bed, and turn and reposition." The hospice aide documented on the visit notes dated 1/10/2023 through 5/25/2023, that the patient refused to allow the aide to complete the personal care tasks assigned. A review of the clinical record revealed no documented evidence that the Registered Nurse was notified of the refusals of personal care.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review, document review, and observation. 4 of 19 (21%) clinical records reviewed, the hospice did not ensure the clinical record included documentation of physician orders. Clinical Record 3: The patient elected hospice care on 2/7/2023 with a primary diagnosis of endometrial cancer. The on-call skilled nursing visit note dated 2/20/2023 documented, "Patient called back at 6:00 AM complaining of increased abdominal pressure. A visit was made, and we ended up placing a Foley 16FR with a 30cc balloon (filled only 20cc). Patient tolerated well, fully immediately drained clear dark urine. 700cc drained. Reviewed this information with (medical director's name), and we are still going to order an antibiotic..." A clinical record review revealed no physician order was documented for the visit and the insertion of the Foley catheter and no update to the plan of care. The Registered Nurse (RN) added the physician's order on 5/6/2023. Clinical Record 12: The patient elected hospice care on 5/20/2022. The Skilled Nurse (SN) visit note dated 6/8/2022 documented, "Cleanse with soap and water, pat dry, apply barrier cream. May apply Mepilex instead of barrier cream." The same visit note documented wound care performed on abrasion to the right anterior lower leg, "wash with mild soap and water, pat dry, cover with clear Opsite." No physician order was documented for the wound care performed on the abrasion to the right anterior lower leg. The Director of Compliance, Regulation, and Quality confirmed during the joint record review on 5/26/2023 that there was not a second wound care order in the record Clinical Record 13: The patient elected hospice care on 12/21/2022. On 1/2/2023, the physician ordered "Atropine Sulfate Ophthalmic Solution 1%, one drop, ophthalmic, every hour, as needed for terminal secretions." The documented medication route was inaccurate and should have read sublingually. The Director of Compliance, Regulation, and Quality confirmed the finding during an interview and a joint review of the record. Clinical Record 17/Home Visit 1: The patient with an election of hospice benefit dated 1/28/2022 had a gastrostomy tube for enteral feedings and medication administration. During the home visit with the Registered Nurse (RN) [Personnel Record 10] on 5/24/2023, the patient's mother stated the patient receives enteral feedings at a rate of 18 milliliters (ML) per hour. A clinical record review revealed no physician's order documenting the rate of the enteral feedings. During an interview and a joint record review on 5/24/2023, the Director of Compliance, Regulatory, and Quality confirmed the finding.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. The agency policy "Transfer, Benefit Revocation and Discharge" ( revised 6/21/2013) stated in part, "The hospice discharge summary and a record of other information provided to the receiving provider and/or attending physician or physician designee is documented in the patient/family record..." 2 of 2 (100%) clinical records reviewed of patients that revoked the hospice benefit or were discharged, the hospice did not ensure that a copy of the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient elected hospice care on 6/24/2022 and was discharged by the hospice on 9/20/2022 due to no longer being terminally ill. A clinical record review revealed no discharge summary was documented and forwarded to the patient's attending physician. Clinical Record 14: The patient elected hospice care on 10/27/2022 and was discharged by the hospice agency to seek curative cancer treatment. The hospice revocation form was signed and dated with an effective date of 11/4/2022. The "Agency Discharge" form completed by the Registered Nurse (RN) on 11/4/2022 documented the "patient called and decided to seek further treatment... Wants to sign off of Hospice for a while till she has more answers." A clinical record review revealed no discharge summary was documented and forwarded to the patient's attending physician. During an interview and the joint record reviews on 5/26/2023, the Director of Compliance, Regulatory, and Quality confirmed the discharge summaries were not forwarded to the physicians.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review, and interview. The agency policy "Transfer, Benefit Revocation and Discharge" (revised 6/21/2013) stated in part, "The hospice discharge summary and a record of other information provided to the receiving provider and/or attending physician or physician designee is documented in the patient/family record..." 2 of 2 (100%) clinical records reviewed of discharged patients, the hospice did not ensure that a discharge summary was documented. Clinical Record 11: The patient elected hospice care on 6/24/2022 and was discharged by the hospice on 9/20/2022 due to no longer being terminally ill. A clinical record review revealed no discharge summary was documented by the hospice. Clinical Record 14: The patient elected hospice care on 10/27/2022 and was discharged by the hospice agency to seek curative cancer treatment. The hospice revocation form was signed and dated with an effective date of 11/4/2022. The "Agency Discharge" form completed by the Registered Nurse (RN) on 11/4/2022 documented the "patient called and decided to seek further treatment... Wants to sign off of Hospice for a while till she has more answers." A clinical record review revealed no discharge summary was documented by the hospice. During an interview and the joint record reviews on 5/26/2023, the Director of Compliance, Regulatory, and Quality confirmed the discharge summaries were not created.

It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include expiration date. This standard was not met as evidenced by clinical record review, document review, interview, and observation. 1 of 4 (25%) home visits observed, the hospice did not ensure disposal of expired medications. The agency policy "Drugs and Biologicals - Administration, Use, and Disposal" (effective 6/8/2021), stated in part, "The designated RN is responsible for maintaining a current medication profile that includes prescription drugs and biologicals, over-the-counter drugs, herbal remedies and alternative treatments used by each patient, as well as the current dosage, frequency and route of administration...Proper disposal of unused or expired medications..." Home Visit 3/Clinical Record 16: During the home visit on 5/24/2023, a review of the patient's medication profile documented "Nystatin antifungal powder, 100000 Units/GM, applied topically twice daily" effective 8/6/2021. The patient's private sitter provided the box of current medications taken by the patient. Two bottles of Nystatin powder provided by the sitter were expired: one (1) 30-gram bottle expired on 9/20/2022 and one (1) 30-gram bottle expired in February 2023. The Administrator/Registered Nurse [Personnel Record 5] present for the visit confirmed the bottles were expired and instructed the private sitter to dispose of the two bottles and a new bottle was ordered for the patient.