Every finding on record at Keystone Hospice, LLC

Upon patient record review, 3 of 19 (Patients #1, 9, 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: In the POC, the alternative therapies pathway does not include separate interventions and goals for massage therapy versus acupressure therapy versus music therapy. Patient #9: There is no evidence of interventions and goals for the use of oxygen in the plan of care. Patient #14: The patient is on service for cancer of the larynx. There are complaints for shortness of breath as well as medications provided for that symptom. The patient is a smoker. There are no interventions or goals related to smoking in the plan of care.

Upon patient record review, 4 of 19 (Patients #3, 7, 10, 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 #3: The Social worker is ordered to see the patient 0/month with 8 prn visits. PRN visits cannot stand alone. Patient #7: The social worker is ordered for frequency of 0/month and 2 prn visits. The SC is ordered for 0/month and 2 prn visits. Alternative therapies are ordered for 0/month and 2 prn visits. PRN visits cannot stand alone. Patient #10: The social worker is ordered to see patient 0/month with 2 prn. PRN visits cannot stand alone. Patient #14: The SC is ordered to see patient 0/month and one prn. PRN visits cannot stand alone.

Upon patient record review, 3 of 19 (Patients #2, 3, 4) 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: Patient has a wound labeled as "pressure ulcer to sacrum" The order reads "Pressure ulcer sacrum, 0.5x1.0cm. Absorbent dressing 2 times weekly and prn soiled. This order does not specify cleaning of wound, what absorbent dressing is being used (this wound was with alginate), what the cover dressing is, or who would change the dressing at each ordered treatment (ie. Nurse, caregiver) Patient #3: Patient has wound. Order reads, "wound, change prn and every day shift. There is no evidence of location/type of wound, what is the wound being cleansed with, type of primary and/or secondary dressing, Who will change dressing on what days, or reason for prn dressing changes. Patient #4: Patient is on service with breast cancer and has a fungating wound on left breast. Wound order reads, "wound to left chest, 1.7x2cm. Absorbent dressing 2 times weekly by wound care RN. This order does not specify cleansing method of wound, type of absorbent dressing to be used, if there is a cover dressing, or if there would be PRN changes for soilage and who would perform those dressings.

Upon client record review, 7 of 19 (Patients #1, 8, 10, 11, 12, 13, 14) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1: The IDG report from 06/26/25 has no evidence of an RN signature. The IDG report from 06/12/25 has no evidence of a SC signature. Patient #3: The IDG report from 06/12/25 has no evidence of an RN or SC signature. Patient #8: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #10: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #11: The IDG report from 06/12/25 has no evidence of an RN or SC signature. Patient #12: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #13: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #14: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature.

Upon client record review, 3 of 19 (Patient #1, 2, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Alternative therapies are ordered at 6 per month with 6 prn. There are 8 routine visits in June and no evidence of an added order for change in routine frequency. Patient #2: The wound RN is seeing the patient for wound care, however, the visits are all entered as prn rather than scheduled 2 times weekly. Patient #4: The wound RN is seeing the patient twice weekly in addition to the routine RN visits. All wound care visits are entered as prn visits despite the fact that they are scheduled.

Upon patient record review, 5 of 19 (Patient #3, 8, 9, 10, 11) 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 #3: The Aide assignment states, "Foot care by trimming OR applying lotion" and "Nail care trimming AND/OR cleaning fingernails". The aide assignment cannot leave choice to aide of which tasks to do. Patient #8: The aide assignment states, "Foot care by trimming OR applying lotion" and "Nail care trimming AND/OR cleaning fingernails". The aide assignment cannot leave choice to aide of which tasks to do. Patient #9: The aide assignment states, "offer to trim nails and toenails" and "offer skincare" The use of patient choice (in this case, "offer") is not acceptable. The assignment does not specify what skincare will be performed. Patient #10: The aide assignment states "oral care" There is no specification of what oral care is to be performed, for instance, denture care, brushing teeth, mouthwash. Patient #11: The aide assignment states, "Foot care by trimming OR applying lotion" and "Nail care trimming AND/OR cleaning fingernails". The aide assignment cannot leave choice to aide of which tasks to do. The assignment also states "offer showers". The use of patient choice (in this case, "offer") is not acceptable.

Upon patient record review 4 of 19 (Patients #3, 8, 9, 11) 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 #3: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation. Patient #8: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation. Patient #9: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation. Patient #11: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation.

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.

Based on medical record review, policy review, and staff interview, it was determined the hospice failed to ensure the IDG updated and revised care plans in response to patient changes in status for 4 of 6 patients (Patients #1, 2, 3 and 5) whose records were reviewed.  This had the potential to lead to unmet needs of patients and family.  Findings include: --- An agency policy titled, “Interdisciplinary Group Meeting,” Revised April 2018 stated the following: -  The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program.-  Problem solving for optimal care of the patient and family/caregiver will occur, and changes will be documented on the interdisciplinary group meeting form.-  Patient being discharged from hospice will be reviewed to ensure appropriateness of ongoing care.-  Grievances and issues of ethical concern will be discussed.-  Patient requesting transfer to another hospice or revocation of the hospice benefit will be reviewed to determine any assistance he/she may need to complete these processes.This policy was not followed.  Examples include: 1.  Patient #2 was an 80 year old female admitted to the hospice on 10/30/24 with the primary diagnosis of chronic obstructive pulmonary disease.  Patient #2 died on 4/19/25 while on hospice services. Patient #3’s medical record, including IDG meetings, was reviewed. Patient #2’s medical record documented an IDG meeting on 5/02/25. The IDG documentation did not include Patient #2 had died.  Patient #2’s medical record documented updates to the care plan including but not limited to, “Skilled nursing: Assess for dyspnea or shortness of breath …  Assess patient’s pain and comfort level related to skin breakdown … Assess sleep patterns …  Validate the patient’s feelings and experiences.”   Additionally, family engagement was documented as “The IDG team has discussed patient family/representative's engagement in the plan of care and has determined that the family/representative understands and agrees with the care plan and has demonstrated a willingness to engage with the plan.”  At time of the IDG meeting Patient #2 had been dead for 13 days. The IDG meeting did not reflect the patient or family’s status. 2.  Patient #3 was an 86 year old female admitted to the hospice on 4/03/25 with the primary diagnosis of acute respiratory failure with hypoxia. Patient #4 died on 4/04/25.  Patient #3’s medical record, including IDG meetings, was reviewed. Patient #3’s medical record documented an IDG meeting on 4/18/25.  Patient #3’s medical record documented updates to the care plan including but not limited to, “Skilled nursing: Assess for dyspnea or shortness of breath …  Assess patient’s pain and comfort level related to skin breakdown … Assess sleep patterns …  Validate the patient’s feelings and experiences.” Additionally, family engagement was documented as, “The IDG team has discussed patient family/representative's engagement in the plan of care and has determined that the family/representative is aware of and in agreement with the proposed plan of care and has shown enthusiasm for being involved with the plan.”  At time of the IDG meeting Patient #4 died earlier that day but it was not discussed in IDG. The IDG meeting did not reflect the patient or family’s status. 3. Patient #5 was a 90 year old female admitted to the hospice on 10/08/24 with the primary diagnosis of malignant neoplasm of head of pancreas.  Patient #5 died on 10/27/2024 while on hospice services. Patient #5’s medical record, including IDG meetings, was reviewed. Patient #5’s medical record documented a IDG meeting on 11/01/24.  Patient #5’s medical record documented updates to the care plan including but not limited to, “Skilled nursing: Assess patient's pain level and manage pain appropriately …  Assess patient’s pain and comfort level related to skin breakdown … Assess sleep patterns …  Validate the patient’s feelings and experiences.”Additionally, family engagement was documented as “The IDG team has discussed patient family/representative's engagement in the plan of care and has determined that the family/representative understands and is in alignment with the proposed plan of care and has conveyed a willingness to engage with the plan.”  At time of the IDG meeting Patient #5 had been dead for 4 days.The IDG meeting did not reflect the patient or family’s current status, and the care plan was not revised or updated based on Patient #5’s death status. 4.  Patient #1 was an 85 year old female admitted to the hospice on 3/06/25 with the primary diagnosis of cerebrovascular disease.  Patient #1 discharged from the hospice on 5/02/25.  Patient #1’s medical record, including IDG meetings, was reviewed.   Patient #1’s record included multiple care coordination notes from a Care Conference with the IDG and Patient #1’s daughter.  The notes included but were not limited to the following:-  Social work note dated 4/29/25 stated, “Phone call with patient daughter to discuss her frustration regarding a recent care conference that took place on 4/28/2025. There were various reports of how the hospice team did not advocate for the patient with some of the daughters complaints of falls happening to her mother.”-  Social work note dated 4/29/25 stated, “Hospice Admin asked if she was wanting to switch hospice companies due to the feelings and perception she has that our hospice team did not advocate for her the way she felt they should have. She said that she was thinking about it and would make a decision later.”-  Nursing note dated 4/29/25 stated, “[Daughter] explained that her mother resides at [Assisted Living Facility] and has experienced frequent falls, often remaining on the floor for extended periods. Additionally, Patient #1’s record included she fell on 4/25/25, 4/29/25, and 5/01/25.   Patient #1’s record included an IDG meeting on 5/15/25, 13 days after she discharged from the hospice.  The discussion related to falls stated, “[Patient #1] will experience reduction of risk of injury related to falls with the use of fall prevention measures as measured by reduction in fall events by 07/30/25.”  It did not include her progress towards the goal of reduction in falls, or include that she fell on 4/25/25, 4/29/25, and 5/01/25.  Additionally, under “Family engagement,” the note stated, “The IDG team has discussed patient family/representative's engagement in the plan of care and has determined that the family/representative understands and acknowledges the care plan and is in agreement with it, and is interested in being included in the plan.”  It did not include that Patient #1’s daughter was dissatisfied with the care or that there was a care conference with multiple staff members.  Additionally, the note did not include that Patient #1 had discharged to another agency on 5/02/25. The Clinical Director was interviewed on 6/17/25 beginning at 11:10 AM and Patient #1’s record was reviewed with her.  She confirmed the IDG from 5/15/25 did not reflect Patient #1’s current status. 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Based on medical record review, agency document review, and staff interview, it was determined the agency failed to ensure the plan of care included correct interventions to effectively manage pain and symptoms by not using drugs for their indicated reason for 1 of 5 patients (Patient #1) whose records were reviewed.  Failure to effectively manage pain and symptoms by not using drugs for their indicated reason had the potential to cause adverse drug reactions and uncontrolled symptoms related to the terminal diagnosis.  Findings include: --- Patient #1 was an 85 year old female admitted to the agency on 3/06/25 with a terminal diagnosis of cerebrovascular disease.  An additional diagnosis included Alzheimer’s disease.  She received SN, MSW, and aide services.  Her record for the certification period 3/06/25 to her discharge on 5/02/25 was reviewed. Patient #1’s record included the following medication orders: Haloperidol Lactate Concentrate 2 MG/ML Directions: Take 0.25 ml Concentrate Oral every 4 hours (q4h) as needed for Agitation, nauseaLORazepam Intensol Concentrate 2 MG/ML Directions: Take 0.25 ml Concentrate Oral every 4 hours (q4h) as needed for anxietyMorphine Sulfate (Concentrate) Solution 100 MG/5ML Directions: Take 0.25 ml Solution by mouth every 4 hours (q4h) as needed for Pain, shortness of breath Patient #1’s record included a care coordination note dated 3/13/25 authorizing the use of PRN medication.  It stated, “Pt is agitated, turning on the shower and kicking at doors which is upsetting other residents,” and authorized the use of lorazepam and haloperidol.  It was unclear why lorazepam was authorized when the note did not say Patient #1 had anxiety.   Patient #1’s record included a care coordination note dated 4/21/25 authorizing the use of PRN medication.  It stated, “Request for PRN agitated combative and in pain,” and authorized the use of haloperidol, morphine sulfate, and lorazepam.  It was unclear why lorazepam was authorized when the note did not say Patient #1 had anxiety.   Patient #1’s record included a care coordination note dated 4/28/25 authorizing the use of PRN medication.  It stated, “increased pain, anxiety,” and authorized the use of haloperidol and lorazepam.  It was unclear why haloperidol was authorized when the note did not include Patient #1 was agitated or nauseated.  It was unclear why morphine sulfate was not authorized despite the note stating Patient #1 had increased pain. The Clinical Director was interviewed on 6/17/25 beginning at 11:10 AM and Patient #1’s record was reviewed in her presence.  She confirmed Patient #1’s medications were not used for the indicated reasons. The agency failed to use drugs for the indicated reason as stated on the POC.

Upon client record review, 2 of 5 (Patient #2, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Plan of care dated 9/2/22 ordered SN 2xwk, One SN visit documented 9/2/22 for the first week of care. No evidence of second visit for the first week nor evidence of missed visit or correction order. Patient #5: Plan of care dated 9/8/22 ordered SN 2xwk, 3 prn, One SN visit documented on 9/8/22 for the first week of care. No evidence of second visit for the first week nor evidence of missed visit or correction order.

Upon patient record review 4 of 5(Patient #1, 2, 4, 5) 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: Plan of care dated 8/31/22 ordering frequency of HHA 2xwk. Evidence of 1 visit on 9/1/22. Only one visit first week. No evidence of missed visit or correction order. Patient #2: Plan of care dated 9/2/22 ordering frequency of HHA 2xwk. No visits in the first week of service. First visit documented 9/6/22. No evidence of missed visits or correction order. Patient #4: Plan of care dated 9/7/22 ordering frequency of HHA 2xwk. During the week of 9/11/22 only one visit documented for 9/13/22. No evidence of missed visit for second visit. Patient #5: Plan of care dated 9/8/22 ordering frequency of HHA 2xwk. During the first week only one visit documented 9/8/22, no evidence of missed visit for second visit that week.

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. The emergency preparedness plan provided was dated 2016.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. The emergency preparedness plan provided was dated 2016.

Upon patient record review, 2 of 13 (Patients #2,#6) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 2: The medical record contained election of benefit and consent forms signed by the granddaughter. There was no evidence of legal documentation to support legal authority and there was a daughter listed as a contact in the patient profile. Patient 6: The medical record contained election of benefit and consent forms signed by the daughter-in-law. There was no evidence of legal documentation to support legal authority.

Upon patient record review 1 of 13 (Patient #1) 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 1: The medical record contained an initial psychosocial assessment 6/16/22. The patient admitted 6/8/22.

Upon patient record review, 10 of 13 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#12,#13) 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. Patient 1: The medication profile did not contained oxygen as identified in an order 6/24/22. Patient 2: The medication profile contained lidocaine topical film and nystop powder with no defined area for administration. Patient 3: The medication profile contained cipro dated 6/24/22 with instructions to administer for 10 days. The medication was still active. The medication profile also contained hydrocortisone and nystatin topical creams with no defined area for administration. Patient 4: The medication profile contained tobramycin ophthalmic solution dated 2/14/22 with instructions to administer for 10 days. The medication was still active. The medication profile also contained diclofenac topical gel with no defined area for administration. Patient 5: The medical record contained an order for oxygen. There was no evidence of oxygen listed on the medication profile. Patient 6: The medication profile contained duplicative listing of diclofenac topical gels with no defined area for administration. Patient 7: The medication profile contained several duplicative listings of ABHR cream as needed with different frequencies and strengths. The medication profile contained duplicative haloperidol as needed dated 12/23/21 and 5/9/22 with only difference of indication, both for nausea, vomiting, and agitation, one 12/23/21 also included hallucinations. The medication profile contained duplicative seroquel listed with 4/14/22 for 100mg three times daily and 1/3/22 for 50 mg twice daily. Patient 8: The medication profile contained duplicative listings of polyethylene glycol, both dated 1/14/22. Patient 12: Order for oxygen 3/3/22. There was no evidence of oxygen listed on the medication profile. Patient 13: The plan of care contained problems, goals, and interventions related to oxygen use. There was no evidence of oxygen listed on the medication profile.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 6 of 13 (Patients #1,#3,#4,#7,#8,#9) 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: The medical record contained nursing documentation upon admission identifying patient had dyspnea and need for CPAP, massage therapy and acupuncture visits. There was no evidence of problems, goals, and interventions related to respiratory dysfunction, massage therapy or acupuncture. The plan of care contains a problem for mood disorder. There was no evidence of goals and interventions related to the mood disorder. Patient 3: The medical record contained nursing documentation 7/10/22 identifying patient use of catheter and 6/24/22 identifying dysphagia. There was no evidence of problems, goals, and interventions related to the catheter or dysphagia. Patient 4: There was no evidence of goals related to identified problems of dysfunctional bladder, nausea, need for assistance with personal care included on the plan of care. The medical record contained a music therapy visit 6/24/22. There was no evidence of problems, goals, or interventions related to music therapy. The medical record contained nursing documentation 7/11/22 identifying patient issue with recent falls. There was no evidence of problems, goals, or interventions related to safety. Patient 7: The medical record contained nursing documentation 7/24/22 identifying patient fall. There was no evidence of problems, goals, and interventions related to safety. Patient 8: The plan of care included problem of Alzheimer's disease with goal of pain management and interventions related to management of the disease process. Patient 9: Identified wound 7/20 and receiving massage therapy visits. No evidence of problems, goals or interventions for skin impairment or massage therapy.

Upon patient record review, 6 of 13 (Patients #1,#2,#3,#4,#11,#12) 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 1: The medical record contained nursing documentation upon admission identifying patient use of a CPAP. There was no evidence of an order for CPAP parameters. Patient 2: The medical record contained an order for a foley catheter 6/14/22. There was no evidence of catheter type, size, balloon size, or maintenance included on the order. Patient 3: The record contained orders for hydrocortisone and nystatin topical creams with no defined area for administration. Patient 4: The medical record contains an order for diclofenac topical gel with no defined area for administration. The record also contains foley catheter orders 3/9/22, 3/18/22, 7/8/22, and 7/12/22 with no defined balloon size, change frequency or maintenance. Patient 11: The medical record contained an order for a foley catheter 12/31/21 did not have defined catheter and balloon sizes. Patient 12: The medical record contained an order for oxygen 3/3/22 w delivery with no defined delivery method for administration.

Upon patient record review, 6 of 13 (Patients #1,#2,#3,#4,#5,#9) 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: The medical record contained nursing documentation upon admission identifying patient use of walker, oxygen, and CPAP. There was no evidence of the listed DME on the plan of care. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of wheelchair. There was no evidence of a wheelchair as DME included on the plan of care. Patient 3: The plan of care contains a goal to utilize appropriate DME and pressure relieving devices but does not define what equipment is included in the plan of care. Patient 4: The medical record contained nursing documentation 7/11/22 identifying patient use of walker. There was no evidence of the walker included as DME on the plan of care. Patient 5: The medical record contained order for oxygen and nursing documentation upon admission identifying patient use of a cane for ambulation. There was no evidence of the cane or oxygen supplies included as DME on the plan of care. Patient 9: Upon observation during home visit, it was identified the patient had a wheelchair and roho cushion. There was no evidence of the cushion and wheelchair included as DME on the plan of care.

Upon client record review, 7 of 13 (Patients #1,#2,#3,#4,#8,#9,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained massage therapy visits. There was no evidence of an order for massage therapy. The medical record contained weekly therapist visits with no documentation of what was completed, patient response, or progress toward goals. Leadership was able to verify by name of clinician which visits were acupuncture and which were massage, otherwise unable to determine services received. Patient 2: The medical record contained "Care Assist" notes by skilled nurses 6/30/22, 7/4/22, and 7/12/22 with no documentation of what was completed during the visits. The notes contained no assessment or narrative. The medical record contained an NP visit for symptom management 7/22/22. There was no evidence of an order for the visit. The medical record contains an ordered nursing frequency of twice weekly. There were 3 visits completed the week of 7/17/22 with one labeled as a "Care Assist" visit by the on-call RN. Patient 3: The medical record contained an ordered nursing frequency of twice weekly. There were 3 visits completed the week of 7/10/22 with one labeled as a "Care Assist" with documentation of an in person visit for catheter replacement. The medical record contains nursing documentation 7/10/22 identifying change of external catheter. There was no evidence of an order for catheter use included in the plan of care. The medical record contained a "Care Assist" note by the RN 7/6/22 with documented time in and out but no documentation of assessment or what was completed at the visit. Patient 4: The medical record contained a "Care Assist" note by the LPN 6/8/22 with no documentation of assessment or what was completed at the visits. The medical record contained massage therapy visit notes 6/23, 6/29, 7/8, and 7/12 with no documentation of what was completed at the visits, patient response, or progress toward goals. The medical record contained a music therapy visit 6/24/22 with no documentation of what was completed, patient response, or progress toward goals. There was no evidence of an order for music therapy. Patient 8: The medical record contained a spiritual care visit 5/5/22. There was no evidence of an ordered frequency for spiritual care included in the plan of care. Patient 9: The medical record contained nursing documentation identifying supplies provided for wound to coccyx. There was no evidence of an order for wound care. The medical record contained an order 3/16/22 for massage frequency of once weekly. There was no evidence of a visit between 6/15/22 and 6/29/22 or 6/29/22 and 7/13/22. The medical record contained therapist visits completed 6/8/22, 6/15/22, 6/29/22, and 7/13/22 with no documentation of what was completed, patient response, or progress toward goals. Leadership was able to verify by name of clinician which visits were massage therapy, otherwise unable to determine services received. Patient 12: The medical record contained nursing documentation 5/6/22, 5/9/22, 5/23/22, 5/25/22 and 6/6/22 stating nurse completed wound care. There was no evidence of an order for wound care.

Upon patient record review, 6 of 13 records (Patients #3,#4,#8,#10,#12,#13) 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 3: The aide care plan contained all tasks for once weekly with a frequency of visits three times weekly. There was no evidence the aide care plan was updated accordingly to identify frequency of tasks. Patient 4: The aide care plan contained tasks for both a tub bath and a complete bed bath. Patient 8: The aide care plan contained a task to provide ambulation with assistance of a walker. During home visit, the patient utilized a wheelchair and interview identified patient no longer able to use walker that was in the corner of the room. There was no evidence the aide care plan was updated to reflect the change of assistance needed. Patient 10: The aide care plan contained a task to shower even though shower not received after 2/8/22. All aide tasks were assigned once weekly even though frequency was six times weekly starting 2/13/22 and previous frequency was three times weekly. There was no evidence the aide care plan was updated accordingly to identify frequency of tasks. Patient 12: The aide care plan contained all tasks for once weekly with a frequency of visits twice weekly. There was no evidence the aide care plan was updated accordingly to identify frequency of tasks. Patient 13: The aide care plan contained both bathing tasks of shower every visit and bed bath once weekly.

Upon patient record review 6 of 13 (Patients #1,#2,#3,#4,#6,#11) 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: The aide care plan contained task of companionship visit once weekly. There was no evidence of visits completed. Patient 2: The medical record contained "Care Assist" notes 7/15/22, 7/22/22 by the CNA with identification of assisting with personal cares. There was no evidence on the aide care plan that two aides were required for the tasks. The medical record contains aide documentation 7/22/22 identifying assistance with shaving, changing clothes, and repositioning. There was no evidence of these tasks assigned on the aide care plan. Patient 3: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of a third visit completed the weeks of 6/19/22 and 6/26/22. Patient 4: The medical record contained "Care Assist" documentation for second aide to assist for 6/5/22 and 7/22/22. There was no evidence the aide care plan identified that two aides were required for the tasks. Patient 6: The medical record contained "Care Assist" documentation for second aide to assist 7/12/22 and 7/19/22. There was no evidence the aide care plan identified that two aides were required for the tasks. Patient 11: The medical record contained an order for aide frequency of once weekly. The aide was consistently visits twice weekly. The aide care plan contained a task to shower once weekly but was completed every visit twice weekly.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon personnel record review, 1 of 10 applicable (Personnel #8) 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 8: There was no evidence of an initial skills competency assessment completed for the chaplains inherited roles of bereavement coordinator and volunteer coordinator.

Upon patient client record review, 3 of 13 (Patients #4,#10,#11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients 4, 10, 11: There was no evidence that the notice of hospice non-covered items was received. Election of benefit form does not inform patient and responsible party of right to receive or give option to elect or decline.

Upon patient client record review, 3 of 13 (Patients #7,#8,#9) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 7: The medical record contained a signed CTI 6/8/22 for benefit period starting 6/21/22. There was no evidence the narrative included information from the required face to face encounter that was not completed until 6/22/22. Patient 8: The medical record contained a signed CTI 6/26/22 for benefit period starting 7/13/22, 17 days prior to the start of the benefit period. There was no evidence the narrative included information collected from the required face to face encounter that was not completed until 7/13/22. Patient 9: The medical record contained a signed CTI 4/20/22 for benefit period starting 5/9/22, 19 days prior to the start of the benefit period. There was no evidence the narrative included information collected from the required face to face encounter that was not completed until 4/25/22.

Upon patient client record review, 1 of 13 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: The medical record contained identification on the patient profile for primary hospice of diagnosis of bone cancer in error. The CTI identifies the primary diagnosis of metastatic prostate cancer.

Upon client record review, 2 of 2 applicable (Patients #12,#13) did not have evidence that the discharge summary includes all required information. Patients 12 and 13: There was no evidence of a discharge summary.