Every finding on record at Keystone Hospice

Based on a review of clinical records (CR), agency policy, and an interview with the administrator, the Hospice failed to ensure that the plan of care included route and dosage of necessary drugs to meet the needs of the patients for fourteen (14) of nineteen (19) clinical records reviewed (CR#1, 2, 4, 5, 6, 7, 9, 11, 12, 14, 16, 17, 18 and 19). --- Findings include: A review of policy ";Medication Assessment and Teaching Requirement Policy" on November 17, 2023, at approximately 11:30 AM, reads in part, "Documentation on the Keystone Medication Profile will include: ... name of medication, dosage, frequency and route." A review of clinical records (CR) was conducted on November 13, 2023 starting at approximately 2:00 PM, on November 14, 2023 starting at approximately 10:00 AM, on November 15, 2023 starting at approximately 9:00 AM, and on November 16, 2023, starting at 8:00 AM. The start of care (SOC), Certification Period (CP) and Discharge Date (DD) are indicated below. CR#2 SOC:4/1/23, DD: 9/30/23, CP: 6/30/23 – 9/27/23. Plan of Care included six (6) medication orders without indication of the dosage or route. Medication order reads, ";acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting." Medication profile includes the above medication and does not include medication dosage or route. CR#4 SOC: 1/16/23, DD: 4/17/23, CP: 1/16/23 – 4/15/23. Plan of Care included four (4) medication orders without indication of the dosage or route. Medication order reads, ";acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting." Medication profile includes the above medication and does not include medication dosage or route. CR#5 SOC:9/9/22, DD: 12/16/22, CP: 12/8/22 – 2/5/23. Plan of Care included five (5) medication orders without indication of the dosage or route. Medication order reads, ";Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting." Medication profile includes the above medication and does not include medication dosage or route. CR#7 SOC: 2/17/23, CP: 10/15/23 – 12/13/23. Plan of Care included four (4) medication orders without indication of the dosage or route. Medication order reads, ";acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea." Medication profile includes the above medication and does not include medication dosage or route. CR#11 SOC:6/27/23, CP: 9/25/23 – 12/23/23. Plan of Care included six (6) medication orders without indication of the dosage or route. Medication order reads, ";BDR suppository(ies) 1; every 6 hours as needed; every six hours for constipation, bowel obstruction, or severe N/V. acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea." Medication profile includes the above medication and does not include medication dosage or route. CR#12 SOC:8/13/23, CP: 8/13/23 – 11/10/23. Plan of Care included seven (7) medication orders without indication of the dosage or route. Medication order reads, ";BDR suppository(ies) 1; every 6 hours as needed; every six hours for constipation, bowel obstruction, or severe N/V. acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting." Medication profile includes the above medication and does not include medication dosage or route. CR#13 SOC:4/5/23, CP: 10/2/23 – 11/30/23. Plan of Care included three (3) medication orders without indication of the dosage or route. Medication order reads, ";acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting." Medication profile includes the above medication and does not include medication dosage or route. CR#16 SOC:10/7/23, CP: 10/7/23 – 1/4/23. Plan of Care included seven (7) medication orders without indication of the dosage or route. Medication order reads, ";BDR suppository(ies) 1; every 6 hours as needed; every six hours for constipation, bowel obstruction, or severe N/V. acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting."; Medication profile includes the above medication and does not include medication dosage or route. CR#17 SOC: 3/29/23, CP: 9/25/23 -11/23/23. Plan of Care included four (4) medication orders without indication of the dosage or route. Medication order reads, ";acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting." Medication profile includes the above medication and does not include medication dosage or route. CR#19 SOC:9/3/23, CP: 9/3/23 – 12/1/23. Plan of Care included six (6) medication orders without indication of the dosage or route. Medication order reads, ";acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temp > 100.5. Fleet Bisacodyl suppository (ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting." Medication profile includes the above medication and does not include medication dosage or route. An interview conducted with the administrator on November 17, 2023 starting at 12:00 PM confirmed the above findings. CR#1 SOC: 11/23/22, DD: 2/8/23, CP: 11/23/22 – 2/10/23. Plan of Care included seven (7) medication orders without indication of the dosage or route. Medication orders read, ";BDR suppository(ies) 1; every 6 hours as needed; every 6 hours for constipation, bowel obstruction, or severe nausea or vomiting. Acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temperature > 100.5. Fleet Bisacodyl suppository(ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting". Medication profile includes the above medication and does not include medication dosage or route. CR#6 SOC: 2/24/23, CP: 10/22/23 – 12/20/23. Plan of Care included six (6) medication orders without indication of the dosage or route. Medication orders read, ";BDR suppository(ies) 1; every 6 hours as needed; every 6 hours for constipation, bowel obstruction, or severe nausea or vomiting. Acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temperature > 100.5. Fleet Bisacodyl suppository(ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting". Medication profile includes the above medication and does not include medication dosage or route. CR#9 SOC: 4/6/23, CP: 10/3/23 – 12/1/23. Plan of Care included two (2) medication orders without indication of the dosage. Medication orders read, ";Fleet Bisacodyl suppository(ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Gas-x oral tablet as directed tablet, chewable; Administer 1 tab(s) orally every 12 hours as needed; PRN (as needed)". Medication profile includes the above medication and does not include medication dosage. CR#14 SOC: 6/22/23, CP: 9/20/23 – 12/18/23. Plan of Care included six (6) medication orders without indication of the dosage or route. Medication orders read, ";BDR suppository(ies) 1; every 6 hours as needed; every 6 hours for constipation, bowel obstruction, or severe nausea or vomiting. Acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temperature > 100.5. Fleet Bisacodyl suppository(ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting". Medication profile includes the above medication and does not include medication dosage or route. CR#18 SOC: 10/19/23, CP: 10/19/23 – 1/16/24. Plan of Care included seven (7) medication orders without indication of the dosage or route. Medication orders read, ";BDR suppository(ies) 1; every 6 hours as needed; every 6 hours for constipation, bowel obstruction, or severe nausea or vomiting. Acetaminophen suppository(ies) 1 rectal; every 4 hours as needed; every 4 hours for temperature > 100.5. Fleet Bisacodyl suppository(ies) 1 rectal; once a day as needed; if no bowel movement for 3 days or Opiate therapy begun. Haldol tab(s) 1 oral; 2 times a day as needed; twice a day for hallucinations. Hyoscyamine tab(s) 1 sublingual; every 6 hours as needed; as needed for excessive secretions. Lorazepam tab(s) 1 oral; every hour as needed; every hour for anxiety, dyspnea. Prochlorperazine suppository(ies) 1 rectal; every 6 hours as needed; for nausea or vomiting". Medication profile includes the above medication and does not include medication dosage or route. An interview with the administrator on 11/17/2023 at approximately 12:00PM confirmed the above findings.

Based on review of Hospice policy, clinical records (CR), and interview with the administrator and alternate administrator, the hospice failed to follow the Hospice Plan of Care and/or Physician orders for eight (8) of nineteen (19) clinical records (CR # 2, 4, 11, 12, 14, 15, 16 and 18). --- Findings include: A review of the Hospices policies and procedures occurred on 11/15/2023 at approximately 12:30PM and 11/16/2023 at approximately 12:00PM and revealed the following: Policy titled, "Physician Orders Hospice – 1.42" stated, "All patient treatment is carried out under the written orders of a physician, signed and dated by the physician...Procedure: The original plan of treatment, any subsequent plan of treatment (re-certification), and verbal orders must be confirmed in written form, dated and signed by the professional receiving the verbal orders and mailed to the physician for signature for the start of care or completion of re-certification..." Policy titled, "Clinical Documentation Policy – 6.13" stated, "...All clinically relevant communication with or about a patient not otherwise documented as part of a visit note must be documented as a Communication note in the patient record..." A review of clinical records (CR) was conducted on 11/13/2023 from approximately 1:55PM until 3:00PM, 11/14/2023 from approximately 8:40AM until approximately 3:00PM, and 11/15/2023 from approximately 10:20AM until approximately 11:30AM revealed the following: CR#14 (Inpatient Unit) SOC: 6/22/2023, CP: 9/20/2023 – 12/18/2023. Clinical record contained Hospice Aide orders for 4 - 5 times weekly for 14 weeks effective 9/20/2023. During the week of 9/24/2023, only 3 visits were conducted. Clinical record did not contain missed visit documentation for the 1 missing visit, and there was no documentation that the physician was notified about the missed visit. Clinical record contained Social Worker orders for 1 visit per month for 3 months and 10 PRN (as needed) effective 9/20/2023. The Social Worker order was discontinued on 9/25/2023. However, the Social Worker made 10 additional visits after the order was discontinued, and there were no new physician orders to resume Social Worker visits. CR#15 (Inpatient Unit) SOC: 11/11/2023, CP: 11/11/2023 – 2/8/2024. Clinical record contained Skilled Nursing orders to assess and evaluate effective 11/9/2023 – 11/18/2023. The initial RN assessment was conducted on 11/11/2023. Skilled Nursing visits were conducted each day thereafter. However, there were no physician orders for any Skilled Nursing visits after the initial assessment was conducted. CR#18 SOC: 10/19/2023, CP: 10/19/2023 – 1/16/2024. Clinical record contained Hospice Aide orders for 4 - 5 times weekly for 13 weeks effective 10/23/2023, then 2 – 3 visits per week for 10 weeks, then 2 – 3 visits per week for 1 week, then 1 visit per week for 1 week. During the week of 10/23/2023, only 1 visit was conducted. Clinical record did not contain missed visit documentation for the 3 - 5 missing visits, and there was no documentation that the physician was notified about the missed visits. An interview with the administrator on 11/17/2023 at approximately 12:00PM confirmed the above findings. Findings include: A review of policy ";Clinical Documentation Policy" conducted on 11/17/23 at approximately 11:00 AM revealed the following: Policy reads in part, ";All clinically relevant communication with or about a patient not otherwise documented as part of a visit note must be documented as a Communication note in the patient record." A review of clinical records (CR) was conducted on November 13, 2023, starting at approximately 2:00 PM, on November 14, 2023, starting at approximately 10:00 AM, on November 15, 2023, starting at approximately 9:00 AM, and on November 16, 2023, starting at 8:00 AM. The start of care (SOC), Certification Period (CP) and Discharge Date (DD) are indicated below. CR#2 SOC:4/1/23, DD: 9/30/23, CP: 6/30/23 – 9/27/23. CR contained Skilled Nursing orders for 1-2 times weekly for 14 weeks. During week of 6/30/23, no visit was conducted. CR did not contain missed visit documentation. CR contained Hospice Aide orders for 4 – 5 times weekly for 14 weeks. During week of 6/30/23, no visit was made. CR did not contain missed visit documentation. During week of 7/3/23, only 3 visits were conducted. CR did not contain missed visit documentation. During the week of 8/14/2023, only 2 visits were conducted. CR did not contain missed visit documentation, there was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order. CR#4 SOC: 1/16/23, DD: 4/17/23, CP: 1/16/23 – 4/15/23. CR contained Hospice Aide orders for 4 – 5 times weekly for 13 weeks. During the week of 1/17/23, only 2 visits were conducted. CR contained only 1 missed visit documentation, there was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order. CR#11 SOC:6/27/23, CP: 9/25/23 – 12/23/23. CR contained Hospice Aide orders for 7 times weekly for 12 weeks. During the week of 10/2/23, only 5 visits were conducted. CR did not contain missed visit documentation. During the week of 10/9/23, only 4 visits were conducted. CR contained only 1 missed visit documentation. During the week of 10/16/23, only 5 visits were conducted. CR did not contain missed visit documentation. There was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order. CR#12 SOC:8/13/23, CP: 8/13/23 – 11/10/23. CR contained Hospice Aide orders for 4 – 5 times weekly for 13 weeks. During the week of 8/14/23, no visit was conducted. CR did not contain missed visit documentation. During the week of 8/21/23, no visit was conducted. CR did not contain missed visit documentation. During the week of 8/28/23, only 3 visits were conducted. CR did not contain missed visit documentation. There was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order. CR#16 SOC:10/7/23, CP: 10/7/23 – 1/4/23. CR contained Hospice Aide orders for 3 -5 times weekly for 14 weeks effective of 10/7/23. During the week of 10/7/23, no visits were conducted. CR did not contain missed visit documentation. CR contained Hospice Aide orders for 4 -5 times weekly for 13 weeks effective 10/9/23. During the week of 10/9/23, only 2 visits were conducted. CR did not contain missed visit documentation. There was no documentation that the physician was notified about the above missed visits, and there was no verbal order to update or discontinue the order. An interview with the administrator on November 17, 2023 at approximately 12:00 PM confirmed the above findings.

Based on review of personnel files (PF), and interview with the administrator and alternate administrator, the hospice failed to document that Hospice Aides had completed at least 75 hours of classroom and supervised practical training prior to providing Hospice Aide services for one (1) of two (2) personnel files reviewed (PF8). --- Findings include: A review of personnel files (PF) was conducted on 11/15/2023 from approximately 1:25PM until 3:15PM, and 11/16/2023 from approximately 9:00AM until approximately 10:50APM revealed the following: PF8 – Date of Hire: 4/3/2023 – File contained an initial competency exam on hire. However, file did not contain evidence that the Hospice Aide met the full requirements of a qualified Hospice Aide (i.e., current Nursing Aide certification, completed a 70 hour training program, etc.). An interview with the administrator on 11/17/2023 at approximately 12:00PM confirmed the above findings.

Based on a review of clinical records (CR), agencys policy, and an interview with the administrator, the Hospice failed to ensure a registered nurse assess the quality of care and services provided by hospice aide at a minimum of every 14 days for six (6) of nineteen (19) clinical records (CR #2, 4, 5, 10, 13 and 16). --- Findings include: A review of policy ";Home Health Aide Assignment and Supervision Policy" conducted on 11/17/23 at approximately 11:00 AM revealed the following: Policy reads in part, ";The home health aide is to be supervised at a minimum of 14 days by the clinician to evaluate compliance with the plan of care and patient satisfaction with care." A review of clinical records (CR) was conducted on November 13, 2023, starting at approximately 2:00 PM, on November 14, 2023, starting at approximately 10:00 AM, on November 15, 2023, starting at approximately 9:00 AM, and on November 16, 2023, starting at 8:00 AM. The start of care (SOC), Certification Period (CP) and Discharge Date (DD) are indicated below. CR#2 SOC:4/1/23, DD: 9/30/23, CP: 6/30/23 – 9/27/23. CR contained Hospice Aide orders for 4 – 5 times weekly for 14 weeks. CR contains documentation that Registered Nurse conducted supervisory visit only on 8/10/23. CR#4 SOC: 1/16/23, DD: 4/17/23, CP: 1/16/23 – 4/15/23. CR contained Hospice Aide orders for 4 – 5 times weekly for 13 weeks. CR contains documentation that Registered Nurse conducted supervisory visits only on 2/10/23, 2/24/23 and 4/13/23. CR#10 SOC: 4/19/23, CP: 10/16/23 – 12/14/23. CR contained Hospice Aide orders for 4 – 5 times weekly for 8 weeks, 3 – 4 times for 1 week. CR contains documentation that Registered Nurse conducted supervisory visits only on 10/16/23, 10/25/23 and 11/13/23. CR#13 SOC: 4/5/23, CP: 10/2/23 – 11/30/23. CR contained Hospice Aide orders for 4 – 5 times weekly for 9 weeks. CR contains documentation that Registered Nurse conducted supervisory visits only on 10/12/23, 10/18/23, 10/20/23 and 10/26/23. CR#16 SOC:10/7/23, CP: 10/7/23 – 1/4/23. CR contained Hospice Aide orders for 3 -5 times weekly for 14 weeks effective of 10/7/23, 4 – 5 times weekly for 13 weeks effective 10/9/23. CR contains documentation that Registered Nurse conducted supervisory visit only on 10/19/23. An interview with the administrator on November 17, 2023 at approximately 12:00 PM confirmed the above findings.

Based on a review of clinical records (CR), agencys policy, and an interview with the administrator, the Hospice failed to forward a copy of discharge summary to the patients attending physician for three (3) of nineteen (19) clinical records (CR #3, 4 and 5). --- A review of policy ";Discharge & Transfer of Hospice and Home Care Patients" conducted on 11/17/23 at approximately 11:00 AM revealed the following: Policy reads in part, ";Discharges and transfers are appropriate in the following cases: the patient expires.... Common Process for Home Care and Hospice Discharge: A discharge summary will be completed and sent to the physician upon request." A review of clinical records (CR) was conducted on November 13, 2023, starting at approximately 2:00 PM, on November 14, 2023, starting at approximately 10:00 AM, on November 15, 2023, starting at approximately 9:00 AM, and on November 16, 2023, starting at 8:00 AM. The start of care (SOC), Certification Period (CP) and Discharge Date (DD) are indicated below. CR#3 SOC:3/10/23, DD: 5/2/23, CP: 3/10/23 – 6/7/23. CR does not contain discharge summary. CR#4 SOC: 1/16/23, DD: 4/17/23, CP: 1/16/23 – 4/15/23. CR does not contain discharge summary. CR#5 SOC: 9/9/22, DD: 12/16/22, CP: 12/8/22 – 2/5/23. CR does not contain discharge summary. An interview with the administrator on November 17, 2023 at approximately 12:00 PM confirmed the above findings.

Based on a review of hospice policies, clinical records (CR), and interviews with the executive director and senior vice president operations, the hospice failed to ensure that home health aide visits were provided in accordance with the visit frequency ordered by the physician on the hospice plan of care for two (2) of three (3) CR's reviewed: CR#1 and CR#2. --- Findings Include: A review of the following policies occurred on July 19, 2023 at approximately 11:00 AM: Clinical Documentation Policy (Number 6.13) reads in part, ";All clinically relevant communication with or about a patient not otherwise documented as part of a visit note must be documented as a Communication note in the patient record." Development of Plan of Care Hospice (Number 1.14) states in part, ";A written plan of care must be established and maintained for each individual admitted to the hospice program, and the care provided to an individual must be in accordance to the plan." A review of clinical records (CR) was conducted on July 19, 2023 starting at 10:30 AM. The Start of Care (SOC) and Benefit Election Period (BEP) for the Hospice Certification Period (CP) and Plan of Care (POC) are indicated below. CR#1 SOC 05/22/2023, CP 05/22/2023 to 08/19/2023 contained orders on the POC for Home Health Aide visits as follows: ";Home Health Aide (HHA): two to 3 times per week for week one (1), then four (4) to five (5) times per week for twelve (12) weeks beginning during week of 05/24/2023 and ending on 08/19/2023." A review of the record found the following: Week of 5/24 to 5/27: there were no HHA visits. Week of 05/28 to 6/3: there was one (1) missed visit. Week of 07/09 to 07/15: there was one (1) missed visit. There were no comments contained in the clinical record regarding the missed visits, no documentation regarding physician notification of the missed visits, nor any physician orders to support a change in HHA visit frequency. CR#2 SOC 05/23/2022, CP 05/23/2023 to 08/20/2023 contained orders on the POC for HHA visits as follows: ";HHA: two (2) times per week for one (1) week, then four (4) to five (5) times per week for twelve (12) weeks beginning during week of 05/23/2023 and ending on 08/19/2023." A review of the record found the following: Week of 05/24: there were no HHA visits. Week of 05/28 to 6/3: there were two (2) missed visits. Week of 06/04 to 06/10: there were two (2) missed visits. Week of 06/11 to 06/17: there were no HHA visits. Week of 06/18 to 06/23: there were three (3) missed visits. Week of 06/25 to 07/01: there were no HHA visits. Week of 7/2 to 7/8: there were no HHA visits. Week of 7/9 to 7/15: there were no HHA visits. There were no comments contained in the clinical record regarding the missed visits, no documentation regarding physician notification of the missed visits, nor any physician orders to support a change in HHA visit frequency. An interview with the Executive Director and Senior Vice President of Operations conducted on July 19, 2023 starting at 2:00 PM confirmed the above findings.