Every finding on record at Lake Superior Hospice Association

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care in 1 (P-7) of 16 records reviewed, resulting in the potential for unidentified and unmet care needs. Findings include: --- P-7: This 78-year-old patient was admitted to hospice on 10/27/23 with the terminal diagnoses of a cerebral infarction (stroke) and hypertension (high blood pressure). During record review on 10/15/24, it was determined the chaplain did not complete the evaluation until 11/10/23 – 14 days after the election of hospice care. Upon further review of the record, there was a verbal order for the chaplain to start care between 11/6/23 and 11/ 11/23, however, this was written on 11/10/23 - after the evaluation was completed and after it was already late. There was no documentation regarding the reason for the delay in care or that the physician was contacted prior to the verbal order on 11/10/23. Findings were reviewed with and acknowledged by the Administrator (Admin-1) and the Clinical Director (ClinD-1) during an interview on 10/17/24 at 11:50 AM.

Based on record review and interview, it was determined the Hospice failed to ensure the Initial Bereavement Risk Assessment included the identification of the potential bereaved individuals, including the social, spiritual and cultural factors that may impact their ability to cope with the patient's death in 8 (P-6, 7, 9, 10, 11, 12, 18, 19) of 16 records reviewed, resulting in the potential for ineffective grieving and lack of bereavement support for the family members, caregivers and others that may be affected upon the patient's death. Findings include: --- P-18: The patient was admitted to the Hospice agency on 10/9/23, with terminal diagnoses of hypertensive heart disease with heart failure and chronic obstructive pulmonary disease. On 10/16/24, review of the MSW's (Master of Social Work) initial comprehensive assessment (dated 10/10/23) found no evidence of a Bereavement Risk Assessment being performed. The MSW initial assessment narrative documented, "Bereavement information will be mailed to (daughter) who will be returning to Texas this Thursday. (Daughter) states she will come up again to visit her mom, likely in November, but "I will just sneak in and not tell my siblings." Writer (MSW) agreed to provide weekly updates to (daughter) from each discipline as staff will be contacting the local Marquette sister (P-18's local daughter)." Further record review noted the Bereavement Risk Assessment (BRA) was completed late (per policy referenced below) on 12/5/23. The BRA identified no individuals, only "Adult children" with an elevated "Moderate Risk" noted. Details which explained the moderate risk score amongst family members was not found. In addition, during a joint home visit with the Agency's Spiritual Counselor on 10/15/24, an interview was conducted with P-18 who was found to be alert and oriented x 4 (person, place, time, and awareness of surroundings). P-18 was queried the following: "Who would be significantly grieving and impacted upon your passing?" P-18 quickly responded, "All of my children of course, especially (daughter-different from other daughter above in Texas) and (son)." None of these stated individuals were found in the initial BRA, and no BRA updates were noted in the medical record through 10/16/24. P-19: The patient was admitted to the Hospice agency on 5/24/24, with terminal diagnoses of hypertensive heart disease with heart failure. On 10/16/24, review of the MSW's initial comprehensive assessment which included an initial BRA, was performed on 5/28/24. The BRA documented only one individual (P-19's niece) with no other family/individuals noted. During a joint home visit with the Agency's Skilled Nursing on 10/15/24, an interview was conducted with P-19 who was found to be alert and oriented x 4 (person, place, time, and awareness of surroundings). P-19 was queried the following: "Who would be significantly grieving and impacted upon your passing?" P-19 responded, "My sister and niece for sure." P-19's sister was not included in the BRA performed on 5/28/24, and no BRA updates were noted in the medical record through 10/16/24. These findings were reviewed with and acknowledged by the Administrator (Admin-1), Clinical Director (ClinD-1), and Quality Coordinator (QA-1) during an interview on 10/17/24 at 0945 AM. The Hospice agency failed to adhere to its policy referenced below. Further, it was noted that all 19 records reviewed by the survey team (3 of 3) found no examples of multiple individuals identified within any of the BRA's performed by MSW services. Agency Policy: "Bereavement Care Planning" PC. B10 (undated) stated, "A bereavement care plan is developed for identified family members and other involved individuals after the patient's death. During the comprehensive assessment of the patient, an initial bereavement assessment is conducted... Throughout the course of the patient's care, members of the IDG reassess, document and address the anticipatory bereavement needs of the patient, the patient's family, caregivers and significant others." P-6: This 77-year-old patient was admitted to hospice on 12/18/23 with the terminal diagnoses of pulmonary fibrosis and congestive heart failure. During record review on 10/14/24, it was noted social work evaluation dated 12/20/23 identified the patients sister on the initial bereavement risk assessment, with no other family/individuals listed. Upon further review of the social work evaluation, it was determined the patient stated he wanted his niece or caregiver to be his DPOA (Durable Power of Attorney) – indicating a close relationship with these individuals. Neither of these individuals were listed on the initial bereavement risk assessment and there were no updates to the bereavement risk assessment at the time of the review. P-7: This 78-year-old patient was admitted to hospice on 10/27/23 with the terminal diagnoses of a cerebral infarction (stroke) and hypertension (high blood pressure). During record review on 10/15/24, it was determined the nursing initial assessment dated 10/27/23 identified the patients wife in the initial bereavement risk assessment, with no other family/individuals listed. Upon further review of the record, it was noted the social work evaluation also dated 10/27/23 identified the patient had a daughter who lived locally. This daughter was not listed on the initial bereavement risk assessment and there were no updates to the bereavement risk assessment at the time of the review. P-9: This 98-year-old patient was admitted to hospice on 9/11/24 with the terminal diagnosis of chronic combined systolic and diastolic heart failure. During record review on 10/16/24, it was determined the social work evaluation dated 9/14/24 identified the patients daughter in the initial bereavement risk assessment, with no other family/individuals listed. Upon further review of the social work evaluation, it was noted the patient has a wife and 2 grown children who are ";local and are very supportive." The patients wife and son were not listed on the initial bereavement assessment and there were no updates to the bereavement risk assessment at the time of the review. P-10: This 88-year-old patient was admitted to hospice on 7/3/24 with the terminal diagnosis of Parkinsons disease with Lewy bodies. During record review on 10/16/24, it was determined the social work evaluation dated 7/8/24 identified the patients wife in the initial bereavement risk assessment, with no other family/individuals listed. Upon further review of the social work evaluation, it was noted the patient had 5 children, including a daughter who provided respite care and a son who lived across the street. None of the patients children were listed on the initial bereavement assessment and there were no updates to the bereavement risk assessment at the time of the review. P-11: This 94-year-old patient was admitted to hospice on 9/23/24 with the terminal diagnosis of hypertensive heart disease with heart failure. During record review on 10/16/24, it was determined the social work evaluation dated 9/24/24 identified the patients wife in the initial bereavement risk assessment, with no other family/individuals listed. Upon further review of the social work evaluation, it was noted one of the patients sons (who is his Durable Power of Attorney) was present during the evaluation. It was also noted the patient had 2 other children – a son and a daughter. None of the patients children were listed on the initial bereavement assessment and there were no updates to the bereavement risk assessment at the time of the review. P-12: This 95-year-old patient was admitted to hospice on 8/22/24 with the terminal diagnosis of congestive heart failure (CHF). During record review on 10/17/24, it was determined the social work evaluation dated 8/27/24 identified the patients daughter in the initial bereavement risk assessment, with no other family/individuals listed. Upon further review of the social work evaluation, it was noted the patient lived with his wife – who was a current hospice patient with this agency. The patients wife was not listed on the initial bereavement assessment and there were no updates to the bereavement risk assessment at the time of the review. Findings were reviewed with and acknowledged by the Administrator (Admin-1) and Clinical Director (ClindD-1) during an interview on 10/17/24 at 11:50 AM.

Based on record review and interview, the agency failed to ensure the patient and primary care giver received education and training as appropriate to their responsibilities for care in 1 (P-6) of 16 records reviewed, resulting in the potential for unmet care needs and unsafe conditions. Findings include: --- P-6: This 77-year-old patient was admitted to hospice on 12/18/23 with the terminal diagnoses of pulmonary fibrosis and congestive heart failure. During a joint home visit with the patient and social worker (LMSW-1) on 10/15/24 at 1:00 PM, it was noted there were 3 large oxygen tanks and 4 small oxygen tanks being stored on the floor near the apartment door. Oxygen tanks are highly flammable and are at risk for leaks that can ignite if tipped over. During the home visit, the patients caregiver (CG-1) was asked if the tanks were always stored there. CG-1 confirmed that is where they are always kept as there is ";nowhere else to store them" in his apartment. CG-1 stated she has worked with the patient for 5 years in the same apartment. Upon review of the initial nursing assessment dated 12/18/23 under the ";Home Oxygen Safety Risk Assessment," the following information was noted: ";9. Are the oxygen back up tanks stored properly? Yes....12. Review of oxygen safely information with the patient/family/caregiver? Yes, 13. Was the patient/family/caregiver informed of the findings of the oxygen safety risk assessment? Yes, 14. Was the patient/family/caregiver educated about the risk of fire, precautions that an prevent fire related injuries, and recommendations to address the specific identified risks? No" Based on the information above, it is unclear what the results of the safety risk assessment or what education was provided to the patient/caregiver. During an interview on 10/17/24 at 11:50 AM, the Administrator (Admin-1) was queried regarding what education is typically provided to patients and caregivers regarding oxygen safety. Admin-1 provided handouts that included a document titled ";OXYGEN CONENTRATORS" that included a safety precaution on page 5 that stated, ";18....Extra cylinders may be secured upright in a rack." Additionally, it was noted that 9 skilled nursing visit notes during the certification period of 12/18/23 to 2/15/24 noted, ";Safety: Oxygen tanks stored properly – Yes". There was no evidence in the record that tanks were noted to be stored incorrectly or that the patient/caregiver had to be re-educated as a result. Findings were reviewed with and acknowledged by the Clinical Director (ClinD-1) and Admin-1 during an interview on 10/17/24 at 11:50 AM.

Based on record review and interview, the Hospice Agency failed to ensure the plan of care included patient specific measurable goals in 16 (P-1, P-2, P-6, P-7, P-8, P-9, P-10, P-11, P-12, P-13, P-14, P-15, P-16, P-17, P-18, P-19) of 16 records reviewed for plan of care content, from a total of 19 sampled records reviewed, resulting in the potential for unmet patient care needs and goals. Findings include: --- P-13 through P-19: During survey record review from 10/14/24 through 10/17/24 concerning the preceding records, it was noted that the Plans of Care (POC) were generic, not individualized and quantifiable. All 7 (P-13, P-14, P-15, P-16, P-17, P-18, P-19) patient POC's goals written by the Hospice's core/main services of Skilled Nursing (SN), Medical Social Work (MSW), and Counseling/Spiritual Care (SC) failed to be written in measurable terms. Subsequently, progress made (or lack of) could not be tracked and trended to enable Hospice staff to accurately perform an objective evaluation of the patient's progress concerning the specified goal. Examples include: "SN: Patient/caregiver will be able to demonstrate safe and effective use of recommended DME (durable medical equipment) and assistive devices... MSW: Caregiver will acknowledge understanding of grief education; Family will have needed support at time of death... SC: Patient achieves feelings of spiritual comfort; Patient/caregiver will have spiritual needs met." These findings were reviewed with and acknowledged by the Administrator (Admin-1), Clinical Director (ClinD-1), and Quality Coordinator (QA-1) during an interview on 10/17/24 at 10:45 AM. The Hospice agency failed to adhere to its policy referenced below. Agency Policy: "Plan of Care - Content" PC. P45 (undated) stated, "The plan of care includes, but is not limited to: Measurable outcomes anticipated from implementing and coordinating the plan of care." P-6 through P-12: From 10/14/24 to 10/17/24, the records for P-6 through P-12 were reviewed. During review, it was determined the goals on the plans of care were generic, not individualized and not quantifiable. Goals for all 7 records (P-6, 7, 8, 9, 10, 11, 12) written by the agencys core services of skilled nursing (SN), medical social work (MSW), and counseling/spiritual care (SC) failed to be written in measurable terms. As a result, progress (or lack of) could not be effectively monitored to appropriately update plans and interventions to meet patient needs. Examples included: ";SN: Patient receives level of care appropriate to patient care needs...MSW: Patient will maintain optimal coping through hospice care....SC: Patient/caregiver will feel more connected to the religious or spiritual community." Findings were reviewed with and acknowledged by the Administrator (Admin-1) and Clinical Director (ClinD-1) during an interview on 10/17/24 a 11:50 AM. P-1 and P-2: During medical record review from 10/15/24 through 10/16/24 for the records of P-1 and P-2, it was noted that the goals on the plans of care were generic, not individualized and not quantifiable. Goals for both records (P-1 and P-2) written by the agencys core services of skilled nursing (SN) and medical social work (MSW) failed to be written in measurable terms. As a result, progress toward goals could not be effectively monitored to appropriately update plans and interventions to meet patient needs. Examples included: ";SN: Patient /family will express satisfactory control of symptoms"; ";MSW: Caregiver will acknowledge understanding of grief education". These findings were reviewed with and acknowledged by the Administrator (Admin-1) and Clinical Director (ClinD-1) during an interview on 10/17/24 a 11:15 a.m.

Based on record review and interview, it was determined the Hospice failed to ensure that the IDG (interdisciplinary group) maintained responsibility for directing and coordinating the care and services provided in 1 (P-17) of 13 records reviewed with aide services, out of a total sample of 19 records reviewed, resulting in aide services not being provided as ordered to help lesson patient/family care needs. Findings include: --- P-17: The SOC date to Hospice was 3/31/23 with diagnoses of chronic obstructive pulmonary disease. On 10/16/24, the last 3 recertification episodes for Hospice were reviewed with effective dates of 5/24/24 through 7/22/24; 7/23/24 to 9/20/24; and 9/21/24 to 11/19/24. Each certification period had a plan of care (POC) which ordered skilled nursing (SN) 1-2 times per week x 9 weeks and PRN (as needed) visit(s) for symptom management, Social Work for PRN visit(s), and Hospice aide services 1-2 times per week for 9 weeks and PRN visit(s) for increased personal care needs. Further record review revealed 16 of 23 scheduled aide visits were missed between the last 3 certification episodes. Additional review of missed visits (MV) by all the ordered services combined (5/31/24 through 10/7/24) found 16 of 16 were attributed solely to aide services. No explanation was found in the medical record, including IDT notes, why all MV's were only by aide services. No communication or coordination of care was evidenced by the Hospice agency to even acknowledge, problem-solve or implement interventions in an updated POC by the IDG (Physician, SN and Social Work) to increase compliance to furnish aide services as ordered since 5/24/24. The above findings were reviewed with and acknowledged by the Administrator (Admin-1), Clinical Director (ClinD-1), and Quality Coordinator (QA-1) during an interview on 10/17/24 at 10:10 AM. The Hospice agency failed to adhere to its policy referenced below and make a coordinated effort to meet the needs of the patient and family. Agency Policy: "Interdisciplinary Group Meeting" PC. I60 (undated) stated, "The interdisciplinary group reviews each patient's plan of care every two weeks, or more frequently if needed, in order to continually monitor the care and services provided... During the interdisciplinary group meeting the patient's plan of care is reviewed and updated and changes are communicated to the patient's attending physician with requests for new orders when needed."

Based on record review and interview, the Hospice agency failed to provide counseling services to meet the needs of the patient and family for 2 (P-14, P-17) of 16 records reviewed with Medical Social Work (MSW) services ordered, from a total sample of 19 records reviewed, resulting in a lack of assistance for these patients and family members in coping with the stress and problems that arise from the terminal illness and the dying process. Findings include: --- P-14: The patient's start of care (SOC) date to the Hospice agency was on 8/21/23, with terminal diagnoses of Parkinson's disease, chronic obstructive pulmonary disease, and heart failure. During record review on 10/16/24, it was noted that social work services were provided by a Bachelor of Social Work (Staff BSW-1) until 4/16/24, when Licensed Medical Social Worker (Staff LMSW-1) was hired on to take over the social work needs for the agency. Further review revealed the following visit discrepancies: Staff BSW-1 provided 12 visits between 8/22/23 through 4/16/24, complying with the Plan of Care (POC) visit frequency order of 1-2 visits a month times 3 months with no frequency changes noted in subsequent certification episodes. In comparison, Staff LMSW-1 provided only one visit since 5/13/24, with the POC changing the visit frequency to PRN (as needed) through date of survey exit on 10/17/24. Additionally, review of an IDT (inter-disciplinary team) social work note dated 6/28/24, by Staff LMSW-1 revealed the following documentation and social work needs: "Last IDT goal not met; (P-14) experiencing decline and mood is often depressed. Wife verbally abusive-shares room/has dementia, (P-14) often refused care and thinks he is leaving the SNF (skilled nursing facility)." Subsequent IDT meetings which are every 2 weeks, noted all (8 of 8) of P-14's social work goals (find some peace and accept SNF placement) within the IDT meetings have not been met since 6/28/24. Despite the poor findings above, no visits have been made by social work/Staff LMSW-1 for over the last 5 months. No documentation was found that indicated the patient, or family had declined counseling services. No explanation was found in the medical record why Social Work provided just one visit since 5/13/24 when needs were evident per above findings. Please note that Social Work visits were routinely made from admission through April 2024 while P-14 was content in his home based on record review but had dropped to zero while P-14 was clearly not at peace in the SNF over the last 4 months. P-17: The SOC date to Hospice was 3/31/23 with diagnoses of chronic obstructive pulmonary disease. During record review on 10/16/24, it was noted that social work services were provided by Staff BSW-1 until 4/26/24, when Staff LMSW-1 was hired on to take over the social work needs of the Agency. Further review revealed the following visit discrepancies: Staff BSW-1 provided 17 visits between 4/5/23 through 4/26/24, complying with the Plan of Care (POC) visit frequency order of 1-2 visits a month times 3 months with no frequency changes noted in subsequent certification episodes. In comparison, Staff LMSW-1 has yet to make a visit to see the patient. Review of the last three POC's effective 5/24/24 through 11/19/24, noted the same Social Work interventions (at least 10) for P-17 such as: "Assess need for ongoing support; Contact by phone or face to face; Coordinate with community resources to increase supports; Encouraging venting of concerns or fears; Monitor for signs of exhaustion with the CG (caregiver) caring for a totally dependent patient... " No explanation was found in the medical record or during interview (below) how these Social Work interventions could be performed when the Social Worker (Staff LMSW-1) has never seen the patient going back almost 6 months. The above findings concerning P-14 and P-17 were reviewed with and acknowledged by the Administrator (Admin-1), Clinical Director (ClinD-1), and Quality Coordinator (QA-1) during an interview on 10/17/24 at 8:50 and 9:50 AM. respectively. The Hospice agency failed to make available its Social Work services for at least the last 5 months to ensure the Hospice needs of patients and family were sufficiently met.

Based on record review and interview, the agency failed to ensure spiritual counseling was provided to meet the needs of the patient in 2 (P-6, 7) of 16 records reviewed, resulting in the potential for unmet spiritual care needs. Findings include: --- **Policy titled ";Spiritual Care Services" (not dated) stated, ";Visit frequencies, specified in the plan of care, are determined based on the individualized, assessed needs of the patient/family." P-6: This 77-year-old patient was admitted to hospice on 12/18/23 with terminal diagnoses of pulmonary fibrosis and congestive heart failure. During record review on 10/14/24, it was noted the chaplain initial assessment dated 12/21/24 stated, ";He (patient) does not get many visitors and appeared pleased when SCC (spiritual care coordinator) told him I could make visits to him.....SCC will visit him monthly." Additionally, a verbal order dated 2/2/24 ordered chaplain services 1 -2 times per month for 3 months and 2 PRN (as needed) between 12/18/24 and 2/15/24. After the initial visit, the next chaplain visits were documented on 2/2/24 and 3/1/24. On the visit note dated 3/1/24, it was documented the patient asked, ";Next week?" regarding when the chaplain could return. It was documented he ";takes comfort from spiritual visits", indicating a need/want for the chaplain to return. The chaplain explained ";a visit is not likely to be next week but in 2-3 weeks." There was no documented reason for the delay in a return visit. The next documented visit was 4/5/23 and it was noted again the patient was interested in the chaplain returning as he stated, ";You come back now!" The chaplain again reported she would likely visit ";in 3-4 weeks or PRN." The next documented visits were noted on 5/16/24 and 7/1/24. Although the chaplain visited monthly as ordered, the agency failed to ensure additional visits were made when the patient expressed interest and failed to come in the time frame given to the patient. There was no documentation as to why visits were kept at a monthly frequency or why the visits were delayed from the time frame the patient was told. During an interview on 10/17/24 at 11: 50 AM, the Clinical Director (ClinD-1) was asked why this patients frequency was not increased based on the information in the visit notes. ClinD-1 stated this patient is sometimes hard to get a hold of as he leaves his apartment often, however, there was no documentation of attempted or missed visits. ClinD-1 acknowledged the findings. P-7: This 78-year-old patient was admitted to hospice on 10/27/23 with the terminal diagnoses of a cerebral infarction (stroke) and hypertension (high blood pressure). During record review on 10/15/24, it was noted the spiritual care note dated 12/5/24 stated the patients wife ";would like to coordinate a visit with (the patient) when she can meet with SCC (spiritual care coordinator). SCC will contact her next week to arrange a joint visit." There was no documentation the SCC contacted the patients wife and there were no documented SCC visits for the remainder of the certification period ending 1/24/24 – 50 days after the last visit. Findings were reviewed with and acknowledged by ClinD-1 and the Administrator (Admin-1) during an interview 10/17/24 at 11:50 AM.

Based on observation, record review and interview, the agency failed to ensure the hospice aides provided services that were included in the plan of care and consistent with aide training in 1 (P-2) of 1 home visit with a hospice aide, and in 2 (P-6 and P-10) of 15 additional records reviewed, resulting in the potential for unsafe provision of care and poor patient outcomes. Findings include: --- **Policy titled ";Hospice Aide Assignments and Duties" (not dated) stated, ";2. A hospice aide provides services that are:...b. included in the plan of care;...d. consistent with the hospice aides training." P-6: This 77-year-old patient was admitted to hospice on 12/18/23 with terminal diagnoses of pulmonary fibrosis and congestive heart failure. During record review on 10/14/24, it was noted the aide care plan dated 12/18/23 included an intervention of ";Elimination: Document bowel movements each encounter." Upon further review of the record for the certification period from 12/18/23 to 2/15/24, it was noted there was no documentation of the last bowel movement on the aide visit notes dated 12/23/23, 1/6/24, 1/15/24, 1/19/24, 1/20/24, 1/26/24, and 2/9/24. Additionally, it was noted the aide care plan dated 12/18/23 included an intervention of ";Safety: Oxygen precautions each encounter." During review of the record for the certification period from 12/18/23 to 2/15/24, it was noted the aide visit notes dated 1/6/24, 1/12/24, 1/19/24, 1/26/24, 2/3/24, and 2/9/24 indicated the intervention was ";Done." Upon further review of the aide visit notes, it was noted in the visit dated 1/20/24 that the patient ";...was in the bathroom smoking. Not sure if that is allowed." Additionally, during a joint home visit on 10/15/24 at 1:00 PM, it was observed the patient keeps his back-up oxygen tanks stored on the floor where they can be a hazard and ignite if tipped over. The aide failed to complete oxygen precautions as documented in the visits above. P-10: This 88-year-old patient was admitted to hospice on 7/3/24 with the terminal diagnosis of Parkinsons disease with Lewy bodies. During record review on 10/16/24, it was noted the aide care plan dated 7/3/24 included an intervention of ";Elimination: Document bowel movements if needed at each visit." Upon further review of the record for the certification period 7/3/23 to 9/30/23, it was noted there was no documentation of the last bowel movement on the aide visit notes dated 7/9/24, 7/18/24, and 7/23/24. Findings were reviewed with and acknowledged by the Administrator (Admin-1) and Clinical Director (ClinD-1) during an interview on 10/17/24 at 11:30 AM. P-2: This 58-year-old was admitted to the Hospice Agency on 8/9/24 with a terminal diagnosis of ovarian cancer with brain metastasis. The medical record was reviewed on 10/16/24. It was noted during review that P-2 had a recent surgical procedure of the brain with a bone flap removed and now wears a helmet when out of bed for safety. On 10/15/24 at 9:45 a.m., a joint home visit was conducted with the hospice aide. During the visit, the hospice aide assisted P-2 up with a walker and provided a shower in an upstairs bathroom. During review of the Hospice Aide Care Plan dated 8/9/24, activity permitted included ";Assist with assistance of husband until further assessment determines she has strength and balance for 1 person assist", and ";Up in chair/wheelchair with assistance for safe transfers with husbands assistance", and ";Hygiene- Bath-Bed at each encounter". At the time of the visit, the hospice aide was queried to whether the husbands assistance should have been used for transfer and whether a bed bath was care planned versus a shower, and the hospice aide replied, ";well she is doing good today but last week we did a bed bath." On 10/15/24 at 1:05 p.m., query was made to the Clinical Director (ClinD-1) of whether there was an updated hospice aide care plan for P-2. ClinD-1 was not able to find an update and acknowledged that the hospice aide was not following the current care plan.

Based on record review and interview, the agency failed to ensure volunteer services were used in direct patient care roles per agency policy in 1 (P-6) of 16 records reviewed, resulting in the potential for unmet care needs. Findings include: --- **Policy titled ";Volunteers – Assignment" (not dated) stated, ";Volunteer assignments are made within three (3) working days after notification of the request." **Policy titled ";Volunteers – Documentation" (not dated) stated, ";3. All volunteer documentation is submitted within 1 week of the patient contact for incorporation into the patients clinical record." P-6: This 77-year-old patient was admitted to hospice on 12/18/23 with terminal diagnoses of pulmonary fibrosis and congestive heart failure. During record review on 10/14/24, it was noted the social work evaluation dated 12/20/23 indicated ";He (patient) would also very much like to have volunteers to pay friendly visits, play games and do puzzles with him." It was documented that a referral was made to volunteer services on that day. Upon further review of the record, it was noted the first visit made by a volunteer was 2/13/24 – 55 days after the date of the referral. There was no documentation of the reason for the delay in starting volunteer visits. During an interview on 10/17/24 at 11:50 AM, the Clinical Director (ClinD-1) was queried regarding the process of referring and assigning volunteers. ClinD-1 confirmed the policy is to have a volunteer assigned within 3 days of the request. ClinD-1 was unsure why a volunteer did not visit this patient right away, however, stated this patient is hard to get a hold of as he leaves his apartment often. ClinD-1 was asked if missed visits are typically documented in the record. ClinD-1 stated there should be communication of any missed visit in the record. During the same interview, the Volunteer Coordinator (VC-1) was asked how volunteers document their visits. VC-1 stated volunteers dont have access to the medical record, but they document their visits on a form and send it to her to be incorporated into the record. She stated missed visits are communicated by e-mail, but acknowledged they are not in the record. VC-1 was going to check for any missed visit e-mails regarding this patient, however, no documentation was provided by the conclusion of the survey. Findings were reviewed with and acknowledged by ClinD-1 and the Administrator (Admin-1) during the interview on 10/17/24 at 11:50 AM.

Based on record review and interview, the agency failed to ensure the clinical record was complete timely per agency expectation in 2 (P-6, 7) of 16 records reviewed, resulting in the potential for unmet care needs and poor communication between disciplines. Findings include: --- During an interview on 10/17/24 at 11:50 AM, the Clinical Director (ClinD-1) was asked what the policy was for completion of documentation after a visit. ClinD-1 stated she was unable to find a written policy, however, the expectation is that all documentation is to be completed within 24 hours of the visit. P-6: This 77-year-old patient was admitted to hospice on 12/18/23 with terminal diagnoses of pulmonary fibrosis and congestive heart failure. During record review on 10/14/24, it was determined the following notes were completed more than 24 hours after the visit: Aide visit for 1/12/24 was completed on 1/15/24 Aide visit for 1/26/24 was completed on 1/30/24 Aide visit for 2/10/24 was completed on 2/15/24 P-7: This 78-year-old patient was admitted to hospice on 10/27/23 with the terminal diagnoses of a cerebral infarction (stroke) and hypertension (high blood pressure). During record review on 10/15/24, it was determined the following notes were completed more than 24 hours after the visit: Skilled nursing visit for 10/30/23 was completed on 11/2/23 Skilled nursing visit for 11/20/23 was completed on 12/2/23 Aide visit for 11/20/23 was completed on 12/2/23 Aide visit for 11/30/23 was completed on 12/11/23 Skilled nursing visit for 12/6/23 was completed on 12/8/23 Aide visit for 12/7/23 was completed on 12/11/23 Aide visit for 1/2/24 was completed on 1/4/24 Aide visit for 1/8/24 was completed on 1/10/24 Findings were reviewed with and acknowledged by the Administrator (Admin-1) and ClinD-1 during an interview on 10/17/24 at 11:50 AM.

Based on document review and interview, it was determined that the agency failed to develop an Emergency Preparedness Plan that included procedures to follow up with on duty staff and reporting to state and local officials when staff are unable to be reached during an emergency or disaster, which had the potential to affect all 23 employees of the hospice and all 154 patients admitted in the past 12 months, resulting in the potential for untreated injury/harm to employees or patient's during an emergency or disaster. Findings include: During the review of the "Emergency/Disaster Plan" dated 9/15/21, it was noted that there was no procedures identified to follow up with on duty staff and patients and inform State and Local officials if any on-duty staff or patients that the agency is unable to contact. During an interview on 1/14/21 at 12:05 PM MSW #1 stated, "I don't see that in our emergency plan."

Based on document review and interview, it was determined that the agency failed to develop an Emergency Preparedness Plan that included procedures identified to inform State and local officials about homebound patients needing evacuation from their homes, based on the patient's medical and psychiatric condition and home environment, which had the potential to affect all 154 patients admitted in the past 12 months, resulting in the potential for untreated injury/harm to patient's during an emergency or disaster. Findings include: During the review of the "Emergency/Disaster Plan" dated 9/15/21, it was noted that there were no procedures identified to inform State and local officials about homebound patients needing evacuation from their homes, based on the patient's medical and psychiatric condition and home environment. During an interview on 1/14/21 at 12:05 PM MSW #1 stated, "I don't see that in our emergency plan."

Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness communication plan that includes the names and contact information for staff, entities providing services under arrangement, patient's physicians and other hospices, resulting in a lack of effective communication in the event of an actual emergency. This deficient practice has the potential to negatively affect the health and safety of the agency's 154 patients admitted in the past 12 months. Findings include: The agency's Emergency Preparedness Plan, dated 9/15/21, was reviewed on 10/14/21 at 12:30 p.m.. During the review, it was noted there was no documented evidence of a communication plan that included the names and contact information for staff, entities providing services under arrangement, patient's physicians and other hospices. The findings were reviewed with and acknowledged by the QC #1, V/B #1 and MSW #1 during an interview on 10/14/21 at 12:30 PM.

Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan that included both a primary and alternate means for communicating with staff, Federal, State, tribal, regional, and local emergency preparedness officials, resulting in a lack of a framework to coordinate an effective response during an emergency. This deficient practice could affect the health and safety of the agency's 154 patients admitted in the past 12 months and all hospice staff in the event of an actual emergency. Findings include: The agency's Emergency Preparedness Plan, dated 9/15/21, was reviewed on 10/14/21 at 2:30 p.m. During the review, it was noted that there was no documented evidence of a communication plan that included a primary and alternate means for communicating with staff, Federal, State, tribal, regional, and local emergency preparedness officials. The findings were reviewed with and acknowledged by QC #1, V/B #1 and MSW #1, during an interview on 10/14/21 at 12:30 PM, at the time of discovery.

Based on documents reviewed and interview, it was determined that the hospice failed to ensure the Emergency Preparedness Plan included a method for sharing information and medical documentation with other health care providers; a means to release patient information in the event of evacuation; and a means of providing information about the general condition and location of patients, which had the potential to affect all 154 patients admitted in the past 12 months, resulting in unrecognized and untreated needs of the patients. Findings include: During the review of the "Emergency/Disaster Plan" dated 9/15/21, it was noted that there was no procedures identified for sharing information and medical documentation with other health care providers; a means to release patient information in the event of evacuation; and a means of providing information about the general condition and location of patients. During an interview on 1/14/21 at 12:05 PM MSW #1 stated, "I don't see that in our emergency plan."

Based on record review and interview, it was determined the agency failed to ensure the physician was notified of potential medication interactions and took them into consideration when creating the patients' plan of care in 10 of 13 records reviewed out of a total of 13 records sampled (MR #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10), resulting in the potential for harm to the patient from adverse medication interactions. Findings include: MR #1: The patient was admitted for hospice services on 6/18/21 with the diagnosis of Alzheimer's Disease. The plan of care dated the period of 9/16/21 to 12/14/21 stated the patient was taking 21 medications daily. The medication interaction report done by the agency created in the agency's electronic medical record system (EMR) stated there were 11 severe interactions and 21 major interactions with this patient's medications. During the review of the patient's medical record it was noted that there was no evidence the physician was made aware of these potential interactions. There was no evidence the hospice considered these interactions when creating the patient's plan of care. MR #2: The patient was admitted for hospice services on 8/29/21 with the diagnosis of colon cancer. The plan of care dated 8/29/21 stated the patient was taking 14 medications daily. The medication interaction report done by the agency created in the agency's electronic medical record system stated there were 1 severe interaction and 1 major interaction with this patient's medications. During the review of the patient's medical record it was noted that there was no evidence the physician was made aware of these potential interactions. There was no evidence the hospice considered these interactions when creating the patient's plan of care MR #3: The patient was admitted for hospice services on 8/31/21 with the diagnosis of heart failure. The plan of care dated 8/31/21 stated the patient was taking 21 medications daily. The medication interaction report done by the agency created in the agency's electronic medical record system stated there were 2 severe interactions with this patient's medications. During the review of the patient's medical record it was noted that there was no evidence the physician was made aware of these potential interactions. There was no evidence the hospice considered these interactions when creating the patient's plan of care. MR #4: The patient was admitted for hospice services on 9/14/21 with the diagnosis of Parkinson's Disease. The plan of care dated 9/14/21 stated the patient was taking 9 medications daily. The medication interaction report done by the agency created in the agency's electronic medical record system stated there were 8 major interactions with this patient's medications. During the review of the patient's medical record it was noted that there was no evidence the physician was made aware of these potential interactions. There was no evidence the hospice considered these interactions when creating the patient's plan of care. MR #5: The patient was admitted for hospice services on 9/2/21 with the diagnosis of lung cancer. The plan of care dated 9/2/21 stated the patient was taking 11 medications daily. The medication interaction report done by the agency created in the agency's electronic medical record system stated there were 6 severe interactions with this patient's medications. During the review of the patient's medical record it was noted that there was no evidence the physician was made aware of these potential interactions. There was no evidence the hospice considered these interactions when creating the patient's plan of care. MR #6: The patient was admitted for hospice services on 10/1/21 with the diagnosis of alcoholic liver disease. The plan of care dated 10/2/21 stated the patient was taking 6 medications daily. The medication interaction report done by the agency created in the agency's electronic medical record system stated there were 2 severe interactions and 1 major interactions with this patient's medications. During the review of the patient's medical record it was noted that there was no evidence the physician was made aware of these potential interactions. There was no evidence the hospice considered these interactions when creating the patient's plan of care. MR #7 The patient was admitted for hospice services on 10/521 with the diagnosis of cancer of the esophagus The plan of care dated 10/5/21 stated the patient was taking 4 medications daily. The medication interaction report done by the agency created in the agency's electronic medical record system stated there was 1 severe interaction and 2 major interactions with this patient's medications. During the review of the patient's medical record it was noted that there was no evidence the physician was made aware of these potential interactions. There was no evidence the hospice considered these interactions when creating the patient's plan of care. The above findings were acknowledged by the Clinical Director (CD #1) during an interview on 10/14/21 at 3:00 p.m., who stated, "We have our Interdisciplinary Group Meetings which the Physician attends so he is aware of the medications the patient is taking." When asked if the Physician was made aware of the severe drug interactions identified during the drug review process, CD #1 replied, "No. We don't discuss the interactions." MR #8: The patient's start of care (SOC) was 7/7/21 with a terminal diagnosis of Exacerbation of chronic obstructive pulmonary disease (COPD). The clinical record review was conducted on 10/14/21 at 9:14 a.m. The "Hospice Initial Assessment" dated 7/7/21, completed by the Registered Nurse documented, "Review completed of prescription/non-prescription medications for new or changed medications and for issues including: effectiveness of therapy, side effects, actual/potential interactions, duplicate drug therapy, and drug therapy associated with lab monitoring. No issues identified." A "Medication Interaction Report", conducted by agency personnel, revealed that the patient had 4 severe drug to drug interactions and 37 major drug to drug interactions. Upon further review, there was no documented evidence that the Physician had been informed of the untoward drug interactions. MR #9: The patient's SOC was 10/8/21 with terminal diagnoses of Multiple Myeloma and Congestive Heart Failure. The clinical record review was conducted on 10/14/21 at 9:40 a.m. The Initial Assessment dated 10/8/21 documented, "The following was reviewed/provided before care initiated: Agency after hours emergency numbers, Emergency Plan." There was no mention of the drug review process. A Medication Interaction Report, conducted by agency personnel, revealed that the patient had 2 severe drug to drug interactions and 15 major drug to drug interactions. Upon further review, there was no documented evidence that the Physician had been informed of the untoward drug interactions. MR #10: The patient's SOC was 10/11/21 with a terminal diagnosis of Colon Cancer. The clinical record review was conducted on 10/14/21 at 10:00 a.m. There was no mention of the drug review within the Initial Assessment. A Medication Interaction Report, conducted by agency personnel, revealed that the patient had 6 severe drug to drug interactions and 35 major drug to drug interactions. Upon further review, there was no documented evidence that the Physician had been informed of the untoward drug interactions. The deficient findings noted in the above records were reviewed with and acknowledged by the Clinical Director (CD #1) during an interview on 10/14/21 at 3:00 p.m., who reported, "We have our Interdisciplinary Group Meetings which the Physician attends so he is aware of the medications the patient is taking." When asked if the Physician was made aware of the severe drug interactions identified during the drug review process, CD #1 replied, "No. We don't discuss the interactions."

Based on record review and interview, the Hospice agency failed to ensure the plan of care was individuated, accurate and painted a clear clinical status of the patient for 13 (MR's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11,12 and 13) records, from a total of 13 records reviewed, resulting in the potential for unidentified, untreated health concerns, unmet care needs and poor patient outcomes. Findings include: MR's #8 through 13: During a review of the identified records, it was noted that all the patients had several admitting diagnoses. It was further noted that all diagnoses had the same date of onset as the date of admission to this Hospice Agency. The plans of care were not specific to meet the individualized needs of the patients and failed to clearly indicate the actual treating diagnosis/diagnoses that the patients were admitted for. The findings from the above records were reviewed with and acknowledged by the Clinical Director (CD #1) during an interview on 10/14/21 at 3:00 p.m. who reported, "I feel bad about this because I'm the one who does this." MR #1 through 7: During a review of these records, it was noted that all the patients had multiple diagnoses listed on the plan of care. It was further noted that all diagnoses had the date of admission as the exacerbation date. The plans of care were not specific to meet the individualized needs of the patients related to the actual status of each disease..

Based on record review and interview, it was determined the Hospice Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2018 and 2019 and 2021, resulting in the Agency's inability to improve in patient care, health outcomes, patient safety, quality of care and the agency's performance. Findings include: On 10/13/21 during an interview with the QAPI (Quality Assessment Performance Improvement) Coordinator (QC #1), a request was made to review the agency's QAPI projects for the 2018, 2019 and 2021 calendar years. Upon review of the requested documents with QC #1 present, there was no evidence that agency developed a QAPI program that documented the quality improvement projects, the reasons for conducting these projects and the measurable progress achieved on these projects. These findings were reviewed with and acknowledged by QC #1 at the time of discovery who reported, "I'm taking notes so I'll know that I have to improve on my documentation."

Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned Hospice Aide provided specific guidance and care instructions on the needs of the patient, for 9 (MR's #1, 2, 3, 4, 7, 8, 9, 10, 11) of 10 records with Hospice Aide services ordered from a total of 13 records reviewed resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Policy: Hospice Aide Services", Reviewed 2021 stated, "Hospice aide services are assigned based on the Primary Nurse or designee's comprehensive assessment and reassessment of the patient's personal care needs; The Primary Nurse or designee develops a written hospice aide plan of care that provides instructions to the hospice aide of the care to be provided." MR #8: The patient's Start of Care (SOC) was 7/7/21 with a terminal diagnosis of Exacerbation of COPD (chronic obstructive pulmonary disease). The clinical record was reviewed on 10/14/21 at 9:14 a.m., and revealed, Hospice Aide services were ordered at a frequency of 1-2x/wk. x 13 weeks., with 2 prn (as needed) visits. The Plan of Care (POC) indicated the patient had fall precautions, transfer precautions, oxygen precautions, shower chair and had shortness of breath with minimal exertion. Upon review of the "Aide Care Plan", the Registered Nurse (RN) listed oxygen precautions as the only safety precaution and failed to include the frequency of visits to be made, the frequency in which each tasks was to be carried out, or any of the additional safety precautions. MR #9: The patient's SOC was 10/8/21 with a terminal diagnosis of Multiple Myeloma. The clinical record was reviewed on 10/14/21 at 9:40 a.m., and revealed, Hospice Aide services were ordered at a frequency of 1-2x/wk. x 13 weeks., During the record review, it was noted that the POC indicated the patient had oxygen precautions, aspiration precautions, fall precautions and instructions of "No ambulation without assist." The POC indicated that the patient had a bedside commode, rolling walker and a shower bench. it was further noted that the patient experienced shortness of breath with minimal exertion. Upon review of the Aide Care Plan, it was noted that RN only included fall precautions on the Aide Plan of Care. Additionally, there was no visit frequency that instructed the Aide on the number of visits to make per week or the frequency in which tasks were to be performed. MR #10: The patient's SOC was 10/11/21 with a terminal diagnosis of Malignant Cancer of Colon. During the review review on 10/14/21 at 10:00 a.m., it was noted that Aide services were ordered at a frequency of 1-2/wk. x 13 wks. The POC indicated the patient had fall precautions, required a Hoyer (brand name) lift for transfers, had hearing loss, and experienced shortness of breath with minimal exertion. The Aide Care Plan, completed by the RN, failed to include all of the above safety precautions and equipment. MR #11: The patient's SOC was 10/8/21 with terminal diagnoses that included Atherosclerotic heart disease and failure to thrive. The record review, conducted on 10/14/21, revealed that Aide services were ordered at a frequency of 1-3/wk. x 13 wks. The POC indicated that patient had bowel and bladder incontinence, transfer precautions, fall precautions, wheelchair, shower chair, required frequent supervision and required a Hoyer lift for transfers. The Aide Care Plan, completed by the RN, failed to include all the above precautions and only listed fall precautions. Additionally, there was no visit frequency that instructed the Aide on the number of visits to make per week or the frequency in which tasks were to be performed. The findings from the above records were reviewed with and acknowledged by the Clinical Director (CD #1) during an interview on 10/14/21 at 3:00 p.m. MR #1: The plan of care dated 9/16/21 stated the patient was admitted with a primary diagnosis of Alzheimer's Disease. The plan of care included orders for a home health aide to visit the patient at the frequency of 1-2x/wk for 14 weeks. The Plan of Care (POC) indicated the patient had aspiration precautions, fall precautions, infection control, lock wheelchair with transfers, no ambulation without assist, proper use of safety equipment, safe transfer, and skin breakdown prevention ordered. Upon review of the "Aide Care Plan", with a printed date of 10-13-21, unsigned and undated by the clinician who created the document, listed fall precautions as the only safety precaution and failed to include the frequency of visits to be made, the frequency in which each tasks was to be carried out, or any of the additional safety precautions. MR #2: The plan of care dated 8/29/21 stated the patient was admitted with a primary diagnosis of colon cancer. The plan of care included orders for a home health aide to visit the patient at the frequency of 2-3x/wk for 13 weeks with 1 additional as needed (PRN) visit. The Plan of Care (POC) indicated the patient had ambulation precautions, bath tub safety bars, fall precautions, keep pathways clear, no ambulation without assist and standard precautions ordered. Upon review of the "Aide Care Plan", with a printed date of 10-14-21, unsigned and undated by the clinician who created the document, listed emergency call system, fall precautions and standard precautions as the only safety precautions and failed to include the frequency of visits to be made, the frequency in which each tasks was to be carried out, or any of the additional safety precautions. MR #3: The plan of care dated 8/31/21 stated the patient was admitted with a primary diagnosis of heart failure. The plan of care included orders for a home health aide to visit the patient at the frequency of 1-3x/wk for 13 weeks with 1 additional as needed (PRN) visit. The Plan of Care (POC) indicated the patient had energy conservation, fall precautions, needs frequent supervision, oxygen precautions, head of bed elevated, skin breakdown precautions,lock wheelchair with transfers, home emergency plan, smoke detectors, bath tub safety bars, side rails up, no ambulation without assist, transfer precautions, proper use of safety equipment, bath tub safety bars, aspiration precautions, ambulation precautions, universal precautions, and infection control precautions ordered. Upon review of the "Aide Care Plan", with a printed date of 10-14-21, unsigned and undated by the clinician who created the document, listed emergency call system, fall precautions and standard precautions as the only safety precautions and failed to include the frequency of visits to be made, the frequency in which each tasks was to be carried out, or any of the additional safety precautions. MR #4: The plan of care dated 9/14/21 stated the patient was admitted with a primary diagnosis of Parkinson's Disease. The plan of care included orders for a home health aide to visit the patient at the frequency of 1-2x/wk for 13 weeks with 1 additional as needed (PRN) visit. The Plan of Care (POC) indicated the patient had 24 hour supervision, adequate lighting, ambulation precautions, fall precautions, head of bed elevated, keep pathways clear, no ambulation without assist, proper use of safety equipment, safe transfers, skin breakdown prevention and universal precautions ordered. Upon review of the "Aide Care Plan", with a printed date of 10-14-21, unsigned and undated by the clinician who created the document, listed fall precautions, side rails up and universal precautions as the only safety precautions and failed to include the frequency of visits to be made, the frequency in which each tasks was to be carried out, or any of the additional safety precautions. MR #7: The plan of care dated 10/5/21 stated the patient was admitted with a primary diagnosis of cancer of the esophagus. The plan of care included orders for a home health aide to visit the patient at the frequency of 1-3x/wk for 13 weeks with 2 additional as needed (PRN) visit and 1x/wk for 1 week starting 1/1/22. The Plan of Care (POC) indicated the patient had ambulation precautions, aspiration precautions, fall precautions, head of bed elevated, infection control, keep pathways clear, no ambulation without assist, oxygen precautions, proper use of safety equipment, skin breakdown preventions and standard precautions ordered. Upon review of the "Aide Care Plan", with a printed date of 10-14-21, unsigned and undated by the clinician who created the document, listed fall precautions and oxygen precautions as the only safety precautions and failed to include the frequency of visits to be made, the frequency in which each tasks was to be carried out, or any of the additional safety precautions.

Based on record review and interview, it was determined the hospice failed to maintain documentation of ongoing efforts to recruit and retain volunteers, resulting in the potential for unfulfilled patient volunteer requests. Findings included: Policy: "Volunteers-Services" 5/1/2012 stated, "Recruitment efforts are sufficient to ensure that the hospice has enough volunteers to meet the needs of patients and families and the requirements of Federal regulations." On 10/14/21 at 8:15 a.m., during an interview, the Volunteer Coordinator (VC #1) was queried. When asked how the hospice recruits and retains its volunteers, VC #1 reported, "We advertise at the University. We pass out brochures at our fall festival and information on volunteer trainings. We send out mailings and we have a social media page where we post opportunities. When asked to review documented evidence of the recruitment efforts, VC #1 stated, "I can get that for you." VC #1 had not provided documentation of recruitment and retention efforts by the end of the survey. The Volunteer Coordinator failed to maintain documentation of ongoing efforts to recruit and retain volunteers.

Based on record review and interview, the Hospice failed to ensure it's clinical documentation was appropriately authenticated with title of document, name of the bereaved and signed by the discipline completing the form for 5 (MR's # 2, 3, 12, 13, BR1, BR2 and BR3) of 5 discharged records from a total of 16 records reviewed, resulting in an incomplete clinical record and the potential for the lack of continuity of care. Findings include. Policy: "Documentation Requirements" 8/1/17 stated, "The last name of the patient, followed by the complete first name, not just initial, is noted on every page..., All documentation is signed using complete first and last name and title or electronically signed." MR #12: The patient's start of care (SOC) was 12/12/20 with a terminal diagnosis of Frontotemporal Dementia. During the record review on 10/14/21 at 11:37 a.m., it was noted that the patient passed away on 12/16/20. A document within the clinical record was titled "Interdisciplinary Team Care Plan." The document was undated and void of any signatures. The document further referenced the first name of a person and stated, "Amy will be knowledgeable of bereavement services..." The document was not appropriately authenticated. These findings were reviewed with and acknowledged by the Clinical Director (CD #1) during an interview on 10/14/21 at 2:40 p.m. When asked for clarity of what the document was, CM #1 reported that it was the post death bereavement plan of care. CD #1 was unable to explain why the document was void of title, name/s of bereaved and signed and dated by the discipline who completed the form. MR #13: The patient's SOC was 1/8/21 with a terminal diagnosis of Lung Cancer. During the record review on 10/14/21 at 12:35 p.m., it was noted that the patient passed away on 1/12/21. A document within the clinical record was titled "Interdisciplinary Team Care Plan." The document was undated and void of any signatures. The document further referenced the first name of a person and stated, "Jim will be knowledgeable of bereavement services..." The document was not appropriately authenticated. These findings were reviewed with and acknowledged by CD #1 during an interview on 10/14/21 at 3:00 p.m. When asked for clarity of what the document was, CM #1 reported that it was the post death bereavement plan of care. CD #1 was unable to explain why the document was void of title, name/s of bereaved and signed and dated by the discipline who completed the form. The above findings were also reviewed with and acknowledged by the Administrator (Adm #1) during the exit interview. MR #2, #3, BR #1, BR #2, BR #3: On 10/14/21 at 12:00 PM the Bereavement Plan of Care was requested for record BR #1. The QAPI Coordinator provided a printed, two page document titled "Interdisciplinary Team Care Plan." that was unsigned and undated. When a Bereavement Plan of Care was requested, the QAPI Coordinator provided a 1/2 page document, again unsigned and undated, which did not include the type and frequency of bereavement services to be provided. When asked why the two documents were so different the QAPI Coordinator stated I don't know. The QAPI coordinator stated "let me try printing it a different way and see what I get." The QAPI Coordinator returned and stated, "The Bereavement Plan of Care is embedded into the patient's plan of care that has both a "Grief" section and a "Grief Process and Grieving Bereavement" section. I don't know which version is actually the Bereavement Plan of Care." After a discussion between the QAPI Coordinator, Volunteer/Bereavement program staff member and a Social Worker at 12:15 PM on 10/14/21, all stated they think the "Grief Process and Grieving Bereavement" section was supposed to be the Bereavement Plan of Care. Upon review of the 1/2 page "Grief Process and Grieving Bereavement" section from the hospice patient's Plan of Care, it was noted that the documents printed by the QAPI Coordinator for the 5 bereavement cases, none were titled Bereavement Plan of Care, making it difficult to determine which document was the actual Bereavement Plan of Care. It was also noted that none of the documents were signed or dated by the clinician who created the document. It was also noted that the Bereavement Plan of Care did not identify the person for which the interventions were to be provided. The documents were not appropriately authenticated.