Every finding on record at Lakes Regional Healthcare

Based on staff interviews, clinical record review and agency policy review, the agency failed to: Ensure during the initial assessment visit in advance of furnishing hospice care, patients were provided with verbal and written notice of the patient's rights and responsibilities in a language and manner that the patient understands. (See L0502). --- Findings include: The cumulative effects of this systemic practice resulted in the failure to ensure the organizational framework of the hospice, promoted and supported the coordination of safe and effective delivery of care according to patient's rights and responsibilities.

Based on staff interviews, clinical record review and agency policy review, the agency failed to ensure all patients were provided with verbal and written notice of patient rights and responsibilities in a language and manner the patient understands. Failure to provide the patients with verbal and written notice of the patients rights and responsibilities, denies patients the necessary information to understand their hospice entitlements and the ability to make informed decisions related to the care they receive. --- Findings Include: Review of agency policy titled Patient Rights and Responsibilities, dated 3/2024, indicated a copy of the agency Patient Rights and Patient Responsibilities, is provided and reviewed with patients and family members upon admission to the agency.  The purpose of this policy is to inform patients of their rights and responsibilities under agency policy and under state and federal law.  During interview on 3/25/25 at 3:15 PM, Administrator stated, "there were some concerns raised during a team meeting regarding the wishes of the Durable Power of Attorney (DPOA) for Patient #14.  Patient #14's DPOA insisted  Patient #14, not be told he/she would be admitted to hospice care, and for agency staff and facility staff (where patient #14 was residing) not inform or talk about hospice with the patient #14." The Administrator stated patient #14 did have some mild dementia and a history of multiple lacunar infarcts (small strokes that affect areas of the brain), but acknowledged there were no attempts to explain or review the hospice philosophy or the patients rights and responsibilities to the patient, due to the DPOA wished  the patient not be informed he/she was admitted to hospice services.  Patient #14 had a start of care date of 12/14/24, and a death date of 12/23/24, with a primary diagnosis of heart failure and received hospice services in a long term care facility.  Clinical record review revealed the following: a. The Plan of Care (POC), dated 12/14/24 to 3/13/25, included advanced directives, physician orders for services, medications, goals and interventions. The POC indicated agency would collaborate with patient and family to provide hospice cares.  b. The Medicare Benefit Election form, Patients Rights, and Advanced Directives consent forms were all dated and signed by the DPOA on 12/14/24 at the time of admission and were marked as the patient unable to sign.  c. In the Coordination Note for admission, dated 12/13/24, referral for hospice received from the hospital with primary diagnosis of heart failure. The case was reviewed with the primary care physician, family and the nursing home where the patient resided. The documentation did not include communication with patient #14  d. The comprehensive admission assessment, dated 12/14/24, completed by Staff F, Registered Nurse (RN), documented patient #14, was alert and orientated to person, place, time and situation at the time of the admission. Patient #14 was able to attend and concentrate on stimuli with out distraction and aware of normal external and internal stimuli and able to interact in a meaningful way.   The assessment included documentation that patient #14's family did not want the patient to know hospice services had been started and indicated the DPOA signed all the paperwork and consents. The documentation indicated the facility staff was also directed not to talk to patient #14 about hospice services.   e. The initial assessment completed by the Social Worker, (SW) dated 12/16/24, indicated the following: patient was alert and orientated to person, place, time and situation, patient was able to concentrate and was not easily distracted, patient was able to register, retain and recall information both new and old, patient was able to organize and communicate ideas, patient had no presence of misperceptions of environment, patient was aware of physical condition and situation and patient was able to evaluate a situation and determine appropriate action. The assessment documented patient was mentally clear and able to communicate effectively.  The initial assessment noted SW did not address advance directives with the patient and did not address funeral planning, all documented as not appropriate as family did not want patient #14 to know he/she was on hospice services.  f. The Interdisciplinary group (IDG) note, dated 12/19/24, indicated per the DPOA request, staff was not telling patient #14 he/she was on hospice services.  The agency failed to provide patient #14 with both verbal and written notice of the Patient Rights and Responsibilities before and during the time hospice services were provided.  The above findings were reviewed with the Hospice Director and Clinical Manager.

Based on clinical record review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound descriptions and measurements for 2 of 5 sampled patients with a wound (Patient #4 and #11). Failure by the IDG registered nurses (RN) to update the comprehensive assessment with complete wound descriptions and measurements placed the patients at risk for ineffective staff collaboration and communication regarding patients' wound status and effectiveness of treatments and interventions. Findings include: --- 2. Patient #4 had a start of care date of 11/16/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/9/25 to 3/9/25, included orders for skilled nurse services 1-2 times a week. The POC identified the patient had a diagnosis of Parkinson's disease. b. The skilled nurse visit note, dated 1/20/25, completed by Staff E, RN, included documentation of two small open areas to patient's buttocks. Staff E, RN, identified a 1 cm by 1 cm open area where the top layer of skin sloughed off and another open area on the left buttock that measured 0.5 cm by 0.5 cm. The documentation of wounds failed to include wound depth. c. The skilled nurse visit note, dated 1/30/25, completed by Staff E, RN, included documentation of wounds being almost healed and measuring 0.25 cm by 0.25 cm. The documentation failed to include wound depth for identified wound and failed to include a weekly measurement of the other wound. d. The skilled nurse visit note, dated 2/3/25, completed by Staff E, RN, included documentation of wounds measuring 0.25 cm by 0.25 cm by 0.0 cm. The documentation failed to include an accurate wound depth for identified wound and failed to include a weekly wound measurement for the other wound. Hospice staff failed to include accurate wound measurements for both wounds on a weekly basis. The above findings were reviewed with the Hospice Director and Clinical Manager. According to the hospice policy titled Wound Assessment, revised 1/2022, wounds will be measured at the time of admission to hospice or when first reported/observed, unless it is a surgical wound that has a dressing that cannot be removed; at least weekly; and/or based on the recommendations of the Wound Care Nurse. The frequency of the wound assessment and dressing change shall occur in accordance to physician orders. During an interview on 3/19/25 at 9:00 AM the Clinical Manager stated staff expected to document wound measurements weekly, which includes length, width and depth measurements. 1. Patient #11 had a hospice admission date of 10/9/24 and revoked services on 11/21/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The plan of care (POC), dated 10/9/24 to 1/6/25, included orders for skilled nurse services 1 to 2 times a week. The POC identfied the patient had a diagnosis of Interstitial pulmonary disease. b. The skilled nurse visit note, dated 10/14/24, Staff E, Registered Nurse (RN) included documentation of a new open area to the right buttock that measured 1 centimeters (cm). The documentation failed to include measurements of the wounds width or depth. c. The skilled nurse visit notes, dated 10/21/24 and 10/28/24, Staff E, RN included documentation the patient had a wound. The documentation failed to include wound measurements. d. The skilled nurse visit note, dated 11/5/24, Staff G, RN included documentation the patient had a wound on the right buttock that measured 0.5 cm length by 0.5 cm width by 0.1 cm depth. Hospice staff failed to include wound measurements of the patient's right buttock on a weekly basis.

Based on clinical record review and agency policy review, the hospice failed to ensure accurate completion of all components comprising the Plan of Care, including all medical supplies/equipment used by the patient for 5 of 14 sampled patients (Patients #4, #6, #10, #11 and #13). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies and/or treatments according to assessed needs and physician orders. Findings include: --- 3. Patient #6 had a start of care date of 2/6/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/6/25 to 5/6/25, identified the patient had a primary diagnosis of heart failure. The POC identified the patient required use of the following medical supplies and equipment: raising bed, gait/transfer belt, commode, bedrails, bath bench, baby monitor, wheelchair, walker, scale, pulse oximeter, medbox, manual wheelchair, grab bars-toilet and shower. b. The comprehensive assessment at admission, dated 2/6/25, completed by Staff G, RN, identified the patient had incontinence and required incontinence products. c. The IDG meeting notes, dated 2/13, 2/27/25 and 3/13/25, failed to identify the incontinence products required by the patient. The hospice failed to update the POC to identify all medical supplies and equipment used by the patient, including incontinence products. 5. Patient #13 had a start of care date of 3/19/24 and date of death of 5/9/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/19/24 to 6/16/24, identified the patient had a primary diagnosis of heart failure. The POC identified the patient required use of the following medical supplies and equipment: Oxygen condenser, oxygen tank, shower chair, gait belt, ROHO cushions, incontinent supplies, walker, wheelchair, toilet riser, electric lift bed with siderail, grab bars, toilet/shower, medboxes, glasses and lifeline. b. The comprehensive assessment at admission note, dated 3/19/24, completed by Staff O, RN, identified the patient had equipment that included a nebulizer. c. The IDG meeting notes, dated 3/28/24, 4/11, 4/25/24 and 5/9/24, failed to identify the nebulizer required by the patient. The hospice failed to update the POC to identify all medical supplies and equipment used by the patient, including a nebulizer The above items were reviewed with the Hospice Director and Clinical Manager. According to the agency policy titled Hospice Plan of Care, dated 1/2025, the plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less that every fifteen days. The plan of care will contain, but will not be limited to, the following: diagnosis, medical equipment and supplies, frequency of services and interdisciplinary group assessment of needs. 1.Patient #4 had a start of care date of 11/16/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 1/9/25 to 3/9/25, identified the patient had a primary diagnosis of Parkinson's disease and the patient required use of the following medical supplies and equipment: EZ stand, Hoyer lift, incontinent supplies, bath bench, commode, gait belt, glasses, wheelchair, electric lift chair, continuous positive airway pressure (CPAP) and oral swabs. b. The skilled nurse visit note, dated 2/7/25, completed by Staff F, Registered Nurse (RN), identified she delivered heel protectors to the patient. c. The comprehensive assessment, dated 2/10/25, completed by Staff E, RN, identified heel protectors are utilized by the patient. d. The Interdisciplinary Group (IDG) meeting note, dated 2/13/25 identified hospital bed, air mattress and over the bed table were delivered to home but failed to identify heel protectors as additional medical supplies and equipment used by the patient. The POC and the IDG meeting note to update the POC failed to identify all medical supplies and equipment used by the patient, including heel protectors. 2.Patient #10 had a start of care date of 3/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/10/25 to 6/7/25, identified the patient had a primary diagnosis of Prostate Cancer and the patient required use of the following medical supplies and equipment: wound supplies, transport chair, bed extender, walker, stool riser, pulse oximeter, medication box, incontinent supplies, hospital bed with bedrails, grab bars, gait belt, compression hose, commode, cane and blood pressure cuff. b. The skilled nurse visit note, dated 3/11/25, completed by Staff G, RN, identified a urinal being delivered. c. The IDG meeting note, dated 3/13/25 identified no additional medical supplies and equipment used by the patient. The POC and the IDG meeting note to update the POC failed to identify all medical supplies and equipment used by the patient, including urinal.

Based on staff interview, review of employee personnel files, clinical record reviews and hospice policy review, the hospice failed to ensure 3 of 5 hospice aides (Staff K, Staff L and Staff M) demonstrated competency in the performance of any skills which exceeded the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 4 of 12 sampled patients (Patients #2, #7, #10 and #12) who required an extra skill to be performed. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: --- The Medicare Conditions of Participation direct the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. According to the hospice agency policy, titled Home Care/Hospice Aide Competency Evaluation, dated 1/2025, the agency is responsible for training hospice aides, as needed, for skills not covered in the basic skills checklist. The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. During an interview on 3/25/25 at 1:43 PM, the Human Resources Assistant stated the hospice had no further documentation of hospice aide competencies. 1.Patient #2 had a start of care date of 2/27/25 and received hospice services while residing in a private home. a. The aide care plan included Registered Nurse (RN) instructions to the aide to apply barrier cream (clear aide) to the coccyx every visit. b. Review of the clinical record showed Staff K, Hospice Aide, provided aide services independently for Patient #2. c. Staff K, Hospice Aide, had a hire date of 7/1/1996. Staff K's personnel file lacked documentation an RN had observed Staff K competently perform the task applying barrier cream. 2.Patient #7 had a start of care date of 3/14/25 and received hospice services while residing in a nursing home. a. The aide care plan included RN instructions to the aide to assist with whirlpool bath every visit. b. Review of the clinical record showed Staff L, Hospice Aide, provided aide services independently for Patient #7. c. Staff L, Hospice Aide, had a hire date of 4/9/24. Staff L's personnel file lacked documentation an RN had observed Staff L competently perform the task of bathing patient in whirlpool tub. 3.Patient #10 had a start of care date of 3/10/25 and received hospice services while residing in a private home. a. The aide care plan included RN instructions to the aide to apply barrier cream to the buttocks every visit. b. Review of the clinical record showed Staff K, Hospice Aide, provided aide services independently for Patient #10. c. Staff K, Hospice Aide, had a hire date of 7/1/1996. Staff K's personnel file lacked documentation an RN had observed Staff K competently perform the task applying barrier cream. 4.Patient #12 had a start of care date of 1/26/24, a discharge date of 11/11/24 and received hospice services while residing in a nursing home. a. The aide care plan included RN instructions to the aide to apply barrier cream (clear aid) to coccyx every visit, assist with whirlpool bath every visit and use assistive device of Hoyer lift for transferring patient with assistance from nursing facility Certified Nursing Assistant. b. Review of the clinical record showed Staff K and Staff M, Hospice Aides, provided aide services independently for Patient #12. c. Staff K, Hospice Aide, had a hire date of 7/1/1996. Staff K's personnel file lacked documentation RN had observed Staff K competently perform the tasks applying barrier cream and bathing patient in whirlpool tub. d. Staff M, Hospice Aide, had a hire date of 9/4/19. Staff M's personnel file lacked documentation RN had observed Staff M competently perform the tasks of applying barrier cream, bathing patient in whirlpool tub and transferring patient with Hoyer lift. The above findings were reviewed with the Hospice Director and Clinical Manager.

Based on clinical record review and hospice staff interview, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patients needs for 9 of 13 sampled patients receiving hospice aide services (Patients #1, #3, #4, #5, #6, #10, #11, #12 and #13). Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task leads to the potential risk that patients may fail to receive necessary services ordered on the plan of care. Findings include: --- 7. Patient #3 had a start of care date of 9/10/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/9/24 to 3/8/25, included orders for aide services 1-2 times a week. The POC identified the patient had a diagnosis of bladder cancer. b. The undated aide assignment sheet included aide instructions every visit, to provide lotion, assist with nutrition and hydration, perform shower using a shower chair, shampoo, clip/file fingernails and toenails, assist with dressing, change incontinent briefs, check patient is wearing the life line, and to assist with ambulation using patient's cane. The assignment did not include instruction on areas for the hospice aide to apply lotion and lacked the correct appliance patient used with ambulation, a walker. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion and the correct safety appliance for ambulation. 8. Patient #5 had a hospice admission date of 2/4/25 and received hospice services in a long term care facility. a. The POC, dated 2/4/25 to 5/4/25, included orders for aide services 1 time per week. The POC identified the patient had a diagnosis of Alzheimer's disease. b. The undated aide assignment sheet included aide instructions to provide lotion every visit. The assignment did not include instruction on areas for the hospice aide to apply lotion. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. 9. Patient #12 had a hospice admission date of 1/26/24 and a discharge date of 11/11/24 and received services in a long term care facility. Clinical record review revealed the following: a. The POC, dated 9/22/24 to 11/20/24, included orders for aide services 1-2 times per week. The POC identified the patient had a diagnosis of dysphagia (difficulty swallowing) following a stroke. b. The undated aide assignment sheet included aide instructions to provide lotion every visit. The assignment did not include instruction on areas for the hospice aide to apply lotion. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. The above findings were reviewed with the Hospice Director and Clinical Manager. 5. Patient #4 had a start of care date of 11/16/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/10/25 to 5/8/25, included orders for aide services 4-5 times a week. The POC identified the patient had a diagnosis of Parkinson's disease. b. The undated aide assignment sheet included aide instructions to provide lotion every visit, use walker if able to ambulate with maximum assistance of two or use wheelchair for mobility with someone else pushing wheelchair every visit, patient uses assistive devices of EZ stand or Hoyer Lift, make sure they use it when transferring every visit. The assignment did not include instruction on areas for the hospice aide to apply lotion and did not provide specific instruction related to safely transferring patient. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion and to transfer the patient. 6. Patient #10 had a start of care date of 3/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/10/25 to 6/7/25, included orders for aide services 4-5 times a week. The POC identified the patient had a diagnosis of Prostate cancer. b. The undated aide assignment sheet included aide instructions to provide lotion every visit and lip care every visit. The assignment did not include instruction on areas for the hospice aide to apply lotion or complete lip care. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion or complete lip care. According to the hospice policy titled Aide Services, revised 5/2023, home health aides are assigned to a specific patient by an RN Case Manager or the Director of Home Care & Hospice. An Aide Plan of Care for a Home Health Aide must be developed by a Registered Nurse who is responsible for the supervision of the Home Health Aide. During an interview on 3/19/25 at 9:00 AM the Clinical Manager stated the aide care plan is created by the nurse doing the admission or when the aide service is first ordered. 1. Patient #1 had a hospice admission date of 7/29/24 and resided in a nursing home. a. The Plan of Care (POC), dated 1/25/25 to 3/25/25, included orders for aide services 1-2 times per week. The POC identified the patient had a diagnosis of cancer of the fallopian tubes. b. The undated aide assignment sheet included aide instructions to provide lotion every visit. The assignment did not include instruction on areas for the hospice aide to apply lotion. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. 2. Patient #6 had a start of care date of 2/6/25 and received hospice services in a private residence. a. The POC, dated 2/6/25 to 5/6/25, included orders for aide services 1-2 times per week. The POC identified the patient had a diagnosis of heart failure. b. The undated aide assignment sheet included aide instructions to provide lotion every visit. The assignment did not include instruction on areas for the hospice aide to apply lotion. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. 3. Patient #11 had a start of care date of 10/9/25 and revoked services on 11/21/24 and received hospice services in a private residence. a. The POC, dated 10/9/24 to 1/6/25, included orders for aide services 1-2 times per week. The POC identified the patient had a diagnosis of interstitial pulmonary disease. b. The undated aide assignment sheet included aide instructions to provide lotion every visit. The assignment did not include instruction on areas for the hospice aide to apply lotion. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. 4. Patient #13 had a start of care date of 3/19/24 and date of death on 5/9/24 and received hospice services in a private residence. a. The POC, dated 3/19/24 to 6/16/24, included orders for aide services 4-5 times per week. The POC identified the patient had a diagnosis of heart failure. b. The undated aide assignment sheet included aide instructions to provide lotion every visit and lip care evey visit. The assignment did not include instruction on areas for the hospice aide to apply lotion or what lip care included. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion or lip care.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice aides provided care to the patients only as directed by the interdisciplinary group, (IDG) and according to the hospice aide care plan for 5 of 13 sampled patients receiving hospice aide services ( Patient #1, #3, #5, #8 and #11). Failure to ensure that the hospice aide services are provided only as ordered by the physician, and according to the hospice aide care plan increased the risk that patients personal care needs were not adequately met. Findings include: --- 3. Patient #3 had a start of care date of 9/10/24 and received hospice services in a private residence. Clinical record review revealed the following: a. The POC, dated 12/9/24 through 3/8/25, included orders for hospice aide services 1 to 2 times a week. The POC identified the patient had a diagnosis of cancer in the bladder. b. The undated assignment sheet included hospice aide tasks which included clip/file fingernails and toenails. c. The hospice aide visit notes, dated 2/3, 2/6, 2/10, 2/13, 2/14, 2/17, 2/20, 2/21, 2/24, 2/27, 2/28, 3/3, 3/6, 3/10, 3/13, 3/14, and 3/17/25. Staff K, Hospice Aide, documented the task of clip/file fingernails and toenails accomplished. The documentation failed to include which of the task instructions were accomplished. The hospice aide failed to identify which specific services were provided as instructed by the RN assignment. 4. Patient #5 had a start of care date of 2/4/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 2/4/25 through 5/4/25, included orders for hospice aide services 1 to 2 times a week. The POC identified the patient had a diagnosis of Alzheimer's disease. b. The undated assignment sheet included hospice aide tasks which included clip/file fingernails and toenails. c. The hospice aide visit notes, 2/5, 2/12, 2/19, 2/26, 3/5, 3/12, 3/19, dated Staff K, Hospice Aide, documented the task of clip/file fingernails and toenails accomplished. The documentation failed to include which of the task instructions were accomplished. The hospice aide failed to identify which specific services were provided as instructed by the RN assignment. The above findings were reviewed with the Hospice Director and Clinical Manager. According to the agency policy titled, Hospice Aide Services, revised 5/2023, home care aides must complete appropriate documentation of the home care aide services provided to the patient, as in the patient's plan of care and per compliance with the home care documentation policy. During an interview on 3/19/25 at 9:00 AM, the Clinical Manager stated if the hospice aide is unable to complete an assignment the documentation must reflect an answer of yes or no it was completed and then the reason is given in the documentation. During an interview on 3/25/25 at 8:10 AM Staff N, Hospice Aide stated she does not always clip the nails at every visit. She checks with the patients to see if they want the task completed. She further stated she may only clip the fingernails or the toenails and documents which task she completed. 1. Patient #1 had a start of care date of 7/29/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The plan of care (POC), dated 1/25/25 through 3/25/25, included orders for hospice aide services 1 to 2 times a week. The POC identified the patient had a diagnosis of cancer of the fallopian tubes. b. The undated assignmnet sheet included hospice aide tasks which included clip/file fingernails and toenails. c. The hospice aide visit notes, dated 1/14, 1/17, 1/21, 1/24/25, 2/4, 2/11, 2/18, 2/25/25, 3/4 and 3/11/25, Staff L, Hospice Aide, documented the task of clip/file fingernails and toenails accomplished. The documentation failed to include which of the task instructions were accomplished. The hospice aide failed to identify which specific services were provided as instructed by the RN assignment. 2. Patient #11 had a start of care date of 10/9/24 and revoked services on 11/21/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The POC, dated 10/9/24 through 1/6/25, included orders for hospice aide services 1 to 2 times a week. The POC identified the patient had a diagnosis of interstitial pulmonary disease. b. The undated assignmnet sheet included hospice aide tasks which included clip/file fingernails and toenails. c. The hospice aide visit notes, dated 10/15, 10/22, 10/25, 10/29/24, 11/1, 11/5, 11/12, 11/15 and 11/19/24, Staff L, Hospice Aide, documented the task of clip/file fingernails and toenails accomplished. The documentation failed to include which of the task instructions were accomplished. The hospice aide failed to identify which specific services were provided as instructed by the RN assignment.

Based on clinical record review and hospice policy review, the hospice failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards of practice for 5 of 14 sampled patients (Patients #1, #4, #6, #8 and #11). Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: --- 2. Patient #1 had a hospice admission date of 7/29/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/25/25 to 3/25/25, identified the patient had a diagnosis of cancer of the fallopian tubes and included orders for skilled nurse, social worker and hospice aide services. b. The IDG note, dated 3/13/25, included orders to begin massage therapy services 1 to 3 times a month and 3 additional times as needed. c. The massage therapy visit note, dated 11/7/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of clinician completing the visit note. The hospice failed to ensure all completed documentation included appropriate authentication. 3. Patient #6 had a hospice admission date of 2/6/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/6/25 to 5/6/25, identified the patient had a diagnosis of heart failure and included orders for skilled nurse, social worker, chaplain and hospice aide services. b. The chaplain visit notes, dated 2/11, 2/20/25, 3/3 and 3/13/25, completed by Staff I, Chaplain, included a signature but lacked a title of clinician completing the visit note. 4. Patient #8 had a hospice admission date of 1/2/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/2/25 to 4/1/25, identified the patient had a diagnosis of intra-abdominal and pelvic swelling, mass and lump and included orders for skilled nurse, social worker, massage therapy and hospice aide services. b. The massage therapy visit notes, dated 3/10/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of clinician completing the visit note. The hospice failed to ensure all completed documentation included appropriate authentication. 5. Patient #11 had a hospice admission date of 10/9/24, date of discharged on 11/21/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, identified the patient had a diagnosis of cancer of the interstitial pulmonary disease and included orders for skilled nurse, social worker, chaplain and hospice aide services. b. The IDG note, dated 10/10/24, included orders to begin chaplain services. c. The chaplain visit notes, dated 10/15, 10/23, 10/30/24, 11/5, 11/14 and 11/20/24, completed by Staff I, Chaplain, included a signature but lacked a title of clinician completing the visit note. The hospice failed to ensure all completed documentation included appropriate authentication. The above findings reviewed with the Hospice Director and Clinical Manager. According to the agency policy titled Medical Record Completion/Filing, dated 5/2024, all entries in the medical record will be timed, dated and signed with a written or electronic signature. 1.Patient #4 had a hospice admission date of 11/16/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/10/25 to 5/8/25, identified the patient had a diagnosis of Parkinson's disease and included orders for skilled nurse, social worker, hospice aide and massage therapy services. b. The Massage Therapy visit note, dated 3/10/25, completed by Staff H, Massage Therapist, included a signature and date but lacked title of clinician completing the visit note. The hospice failed to ensure all completed documentation included appropriate authentication.

Based on clinical record review, hospice policy review and nursing home medication administration records, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient's medications with the nursing home for 1 of 1 sampled patients (Patient #1) with a nursing home medication review. Failure to ensure the hospice staff provided overall coordination of the patient's medications with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: --- According to the hospice's policy, titled Coordination of Care with Contract Agreements, revised 5/2020, the hospice will communicate with staff at the contracted facility during each patient encounter, no less than every two (2) weeks, or as warranted by changes in care/services provided. Patient #1 had a hospice admission date of 7/29/24 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 1/25/25 to 3/25/25, included Interdisciplinary group (IDG) orders for skilled nursing services 1 to 2 times per week and included physician orders for medications. Review of the patient's nursing home Medication Administration Record (MAR), dated March 2025, identified the following medication discrepancies with the hospice's POC and Medication Profile for the patient: a. The hospice POC had an order for Bezonatate (cough suppressant) 100 milligrams (mg) oral tablet one three times daily. The hospice's Medication Profile identified a start date for the medication, dated 7/29/24. The nursing home's MAR lacked an order for this medication. b. The hospice POC had an order for Promethazine-codeine (antihistamine) 6.25 mg-5 mg 1 oral tablet every 6 hours as needed. The hospice's Medication Profile identified a start date for the medication, dated 7/29/24. The nursing home's MAR lacked an order for this prn medication. c. The hospice POC had an order for Cetirizine (allergy medication) 10 mg oral tablet one tab daily. The hospice's Medication Profile identified a 7/29/24 start date for the medication. The nursing home's MAR lacked an order for this medication. d. The hospice POC had an order for Simvastatin (lower cholesterol) 40 mg oral tablet one tab every hour of sleep. The hospice's Medication Profile identified a 7/29/24 start date for the medication. The nursing home's MAR lacked an order for this medication. e. The nursing home's MAR had orders for Amlodipine besylate (lower blood pressure) 2.5 mg one tablet daily and a 2/22/25 start date. The hospice's Medication Profile lacked an order for this medication. f. The nursing home's MAR had orders for Escitalopram oxalate (antidepressant) 10 mg every morning and a 1/30/25 start date. The hospice's Medication Profile had orders for Escitalopram oxalate 10 mg every hour of sleep and a 7/29/24 start date. g. The nursing home's MAR had orders for Zolpidem (treat insomnia) 5 mg every hour of sleep and a 2/13/25 start date. The hospice's Medication Profile had orders for Zolpidem 5 mg every hour of sleep as needed and a 7/29/24 start date. h. The nursing home's MAR had orders for Acetaminophen (pain/fever) 500 mg 2 tablets every 6 hours as needed and a 1/29/25 start date. The hospices Medication Profele had orders for Acetaminophen 325 mg 2 tablets every 6 hours as needed and a 7/29/24 start date. i. The nursing home's MAR had orders for Albuterol Sulfate (bronchodilator) ( 90 micrograms (mcg) 2 puff every 4 hours as needed and a 1/29/25 start date. The hospices Medication Profele had orders for Albuterol Sulfate 90 mcg 1 puff every 4 hours as needed and a 7/29/24 start date. Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home. The above findings were reviewed with the Hospice Director and Clinical Manager.

Based on clinical record review, home visit observation, hospice policy review and staff interview the hospice failed to ensure hospice staff completed medication reviews which included all the required components of a DRR for 2 of 11 sampled patients (Patients #6 and #9). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed a DRR based on a review of all of the patient's medications and included all the required components of the DRR with each update to the comprehensive assessment increased the risk of the patient developing an undetected a side effect or adverse reaction in relation to medication therapy. Findings include: According to a hospice policy titled Medication Administration, Drug Regimen Review, dated 3/2022, a drug regimen review is completed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, noncompliance with drug therapy and lab monitoring. During an interview on 4/4/22 at 2:15 PM the Clinical Manager stated a Drug regimen review (DRR) completed with all admissions. The medications are sent to meditech and a report given to the nurse. The DRR is also completed with all comprehensive assessments and recertifications. 1. Patient #6 had a hospice admission date of 2/18/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/18/22 to 5/18/21, included physician orders for medications, including Morphine (narcotic analgesic) and Lorazepam (antianxiety). b. The IDG meetings, dated 3/1, 3/15 and 3/29/22, included documentation of completed DRR. The clinical record lacked documentation of the identification of potential interactions between Morphine and Lorazepam. The DRRs failed to include an accurate and complete review of all the patient's medications. 2. Patient #9 had a hospice admission date of 2/25/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/25/22 to 4/20/22, included physician orders for medications, including Morphine and Lorazepam. b. The IDG meetings, dated 2/1, 2/15/22, 3/1, 3/15 and 3/29/22, included documentation of completed DRR. The clinical record lacked documentation of the identification of potential interactions between Morphine and Lorazepam. The DRRs failed to include an accurate and complete review of all the patient's medications. The Hospice Administrator received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Team developed patient plans of care which specified the scope and frequency for all services required by and provided to patients for 3 of 13 sampled patients (Patients #7, #8 and #10) Failure to identify a scope and frequencies for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: According to the hospice policy, titled Plan of Care, last revised 3/2022, the plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregiver's needs and established patient goals and outcomes. 1. Patient #8 had a hospice admission date of 2/21/22, received hospice services while residing in a private home residence. The POC, dated 2/21/22 to 5/21/22, included IDG orders for skilled nursing and social work services. a. The Chaplain visit notes, dated 2/23/22, 3/2 and 3/23/22, documented chaplain services provided. b. The IDG meetings to update the POC, dated 3/1, 3/15 and 3/22/22, lacked documentation of an IDG order for a frequency of the chaplain services. The POC failed to identify specific frequencies for chaplain visits. 2. Patient #10 had a hospice admission date of 12/10/21 and discharge date of 2/10/22, received hospice services while residing in a nursing home. The POC, dated 2/21/22 to 5/21/22, included IDG orders for skilled nursing, hospice aide and social work services. a. The Chaplain visit notes, dated 12/15/21 and 1/27/22, documented chaplain services provided. b. The IDG meetings to update the POC, dated 1/18/22, documented chaplain services "as needed" and lacked documentation of an IDG order for a frequency of the chaplain services. The POC failed to identify specific frequencies for chaplain visit 3. Patient #7 was admitted to hospice on 1/11/22 and received services while residing in a private home. Clinical record review revealed: a. The Plans of Care, dated 1/11/22 to 3/11/22 and 3/12/22 to 5/10/22, included orders for Chaplain services as needed per request. b. The initial Interdisciplinary Group (IDG) meeting note, dated 1/18/22, included documentation Chaplain services 1-3 times per week. c. The IDG meeting notes, dated 2/1/22, 2/15/22 and 3/15/22, included documentation Chaplain services as needed. d. The IDG meeting note, dated 3/1/22, included documentation Chaplain services 2-3 times per month after 3/7/22 and 0-1 time per month for 3/1/22 through 3/7/22. e. The IDG meeting note, dated 3/28/22, included documentation Chaplain services 1-2 times for April. The Plan of Care and IDG meeting notes failed to correctly identify the Chaplain frequency for services. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, medication/treatment administration record and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 3 of 4 sampled patients with a home visit (Patients #1, #3 and #4). Failure to ensure the plan of care included physician orders for all necessary medications and and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: According to the hospice policy, titled Plan of Care Content, dated 11/20/08, the the plan of care for each patient which will include drugs to meet the needs of the patient. 1. Patient #3 had a hospice admission date of 11/20/21 and received hospice services while residing in a nursing home. a. The Plan of Care (POC), dated 11/20/21 to 2/17/22 and 2/28/22 to 4/18/22, included orders for current medications. b. The Nursing Home's Medication Administration Record, dated April, 2022, included the following orders: probiotic 3 billion cell 1 capsule 2 times a day, vitamin D3 25 mcg (micrograms) 1 tablet daily, donepezil 5 mg (milligrams), 1 tablet daily and multivitamin 1 tablet daily. The hospice failed to ensure the patient's medications on the POC. 2. Patient #1 had a hospice admission date of 2/23/22 and received hospice services while residing in a private home. a. Clinical record review revealed the Plan of Care, dated 2/18/22 to 5/18/22, included interdisciplinary group orders for medications, including Lasix. b. During a home visit observation on 4/5/22 at 9:32 AM, with Staff A, RN (registered nurse), the surveyor reviewed the medication bottles in the home. Tamsulosin 0.4 mg (milligrams) daily with a refill date of 3/15/22 and Isosorbide ER (extended release) 30 mg daily with a refill date of 3/15/22, were medication bottles in the home. A bottle of Lasix was not located in the home. The patient and Staff A reported the patient spouse takes pill bottles to the pharmacy for refills when needed. The patient spouse was at work at the time of the home visit observation. Tamsulosin and Isosorbide ER were not listed as medications the patient was taking on the plan of care. c. On 4/6/22 at 10:01 AM, the surveyor interviewed the spouse of Patient #1, the spouse reported the patient has not taken Lasix since before hospice admission or shortly after hospice admission. The patient is taking Tamsulosin and Isosorbide ER, the medications were refilled on 3/15/22, they were not new prescriptions. The hospice failed to include all medications the patient was taking at the time of admission on the plan of care. 3. Patient #4 had a hospice admission date of 3/30/22 and received hospice services while residing in a nursing home. a. Clinical record review revealed the Plan of Care, dated 3/30/22 to 6/27/22, included interdisciplinary group orders for medications, including acetaminophen 650 mg every 4 hours as needed for pain/fever. b. The surveyor reviewed the medication administration record from the facility that included acetaminophen 650 mg every four hours as needed for pain/fever effective 2/19/22 and acetaminophen 650 mg four times a day for pain effective 3/2/22. The hospice failed to include all medications the patient was taking at the time of admission on the plan of care. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and staff interview, the hospice failed to ensure 3 of 6 sampled hospice aides (Staff E, F and G) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 3 of 6 sampled patients who required an extra skill task to be performed (Patients #4 #5 &10). Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. According to the undated hospice policy titled Hospice Aide Competency Evaluation, last revised 2/2014, the competency evaluation must address specific subjects that are evaluated by observing an aide's performance of the task with a paint, as well as, evaluated through written examination or oral examination. The evaluation includes any other task that Hospice may choose to have an aide perform. Hospice is responsible for training hospice aides, as needed, for skills not covered in the basic checklist. During an interview on 1/6/22 at 11:00 AM, the Quality Assurance Nurse stated she could not locate further documentation of the extra skills. 1. Patient #4 had a hospice admission date of 3/30/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed Staff E, Hospice Aide, provided hospice aide services independently (without direct, on-site registered nurse supervision) to Patient #4. The hospice aide care plan included registered nurse (RN) instructions to the hospice aide to complete the task of providing edema wear. a. Staff E, Hospice Aide, had a hire date of 1/24/22. Staff E's personnel file lacked documentation a RN had observed Staff H competently perform the task of edema wear. 2. Patient #5 had a hospice admission dated of 1/14/22 and received hospice services while residing in a private residence. Review of the clinical record revealed Staff G, Hospice Aide, provided hospice aide services independently (without direct on-site registered nurse supervision) to Patient #5. The hospice aide care plan included RN instructions to the hospice aide to complete the task of oxygen safety. a. Staff G, Hospice Aide, had a hire date of 7/26/21. Staff G's personnel file lacked documentation a RN had observed Staff H competently perform the task of oxygen safety. 3. Patient #10 had a hospice admission dated of 12/1/21 and discharge date of 2/10/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed Staff F, Hospice Aide, provided hospice aide services independently (without direct on-site registered nurse supervision) to Patient #10. The hospice aide care plan included RN instructions to the hospice aide to complete the task of using an EZ stand lift. a. Staff F, Hospice Aide, had a hire date of 8/19/20. Staff F's personnel file lacked documentation a RN had observed Staff H competently perform the task of an EZ stand lift. The Hospice Administrator received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the registered nurses developed and updated individualized patient specific written instructions directing the care provided by each hospice aide for 2 of 7 sampled patients receiving hospice aide services. (Patients #3 and #5). Failure to provide patient specific written instructions for hospice aides directing them which tasks to perform and how frequently and update those instructions with changes for each patient increased the risk hospice patients did not receive the services to meet each patient's assessed needs. Findings include: According to the hospice policy titled Home Care Aide services, last revised 12/2019, home health aides are assigned to a specific patient by an (registered nurse) case Manager or the Director of Home Care & Hospice. An Aide Plan of Care must be developed by a registered nurse who is responsible for the supervision of the Home Health Aide. During an interview on 4/4/22 at 2:15 PM, the Clinical Manager stated the admission nurse or the nurse available when aide services are requested completes the hospice aide care plan. 1. Patient #3 had a hospice admission date of 11/20/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 11/20/21 to 2/17/22 and 2/18/22 to 4/18/22, identified the patient had a diagnoses of abnormal weight loss and pressure ulcer of the sacral region and included Interdisciplinary Group (IDG) orders for skilled nursing, social worker and hospice aide. The POC identified the patient had a Foley catheter. b. The undated Aide Assignment Sheet included the following assignments to occur every visit: skin care, bath, oral care, hair care, dressing, incontinence care, reposition and assist with the environment. During an interview on 4/6/22 at 10:35 AM, Staff E, Hospice aide stated she provides catheter care for the patient when he/she is incontinent. The RN failed to ensure the hospice aide assignment for catheter care to meet the needs of the patient. 2. Patient #5 had a hospice admission date of 1/14/22, and received services while residing in an assisted living facility. Clinical record review revealed: a. The hospice aide visit notes, dated 2/9, 2/11, 2/14, 2/16, 2/18, 2/21, 2/23, 2/25, 2/28/22; 3/2, 3/4, 3/7, 3/9, 3/11, 3/14, 3/16, 3/18, 3/21, 3/23, 3/25, 3/28, 3/30/22; and 4/1/22; included the task aide provide safe environment - oxygen, 3 liters/minute per nasal cannula. b. Physician order, dated 2/7/22, for oxygen at 2 liters/minute per nasal cannula as needed for air hunger. The aide care plan tasks failed to be updated with the change in the oxygen liter flow ordered for the patient. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Team according to an individualized plan of care for 2 of 7 sampled patients who received hospice aide services (Patients #3 and #4). Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients' personal care needs were not met. Findings include: According to the hospice policy titled Home Care Aide services, last revised 12/2019, home care aides must complete appropriate documentation of the home care aide services provided to the patient, as in the patient's plan of care and per compliance with the home care documentation policy. A home care aide may not provide tasks to a patient that is not on the plan of care. During an interview on 4/4/22 at 2:15 PM, the Clinical Manager stated the hospice aide are to not do any tasks not stated on the aide care plan. 1. Patient #3 had a hospice admission date of 11/20/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 11/20/21 to 2/17/22 and 2/18/22 to 4/18/22, identified the patient had a diagnoses of abnormal weight loss and pressure ulcer of the sacral region and included Interdisciplinary Group (IDG) orders for skilled nursing, social worker and hospice aide. The POC identified the patient had a Foley catheter. b. The undated Aide Assignment Sheet included the following assignments to occur every visit: skin care, bath, oral care, hair care, dressing, incontinence care, reposition and assist with the environment. c. The aide visit note, dated 2/1, 2/9, 2/16, 2/23/22, 3/2, 3/9, 3/23 and 3/30/22, lacked documentation the aide completed the task of catheter care. During an interview on 4/6/22 at 10:35 AM, Staff E, Hospice aide stated she provides catheter care for the patient when he/she is incontinent. The aide failed to follow the care plan as written. 2. Patient #4 had a hospice admission date of 3/30/22, and received services while residing in a nursing home. Clinical record review revealed the hospice aide visit notes, dated 3/31/22 and 4/4/22, included the tasks of bath-shower and bath-bed. Both tasks were documented as completed by the hospice aide. During an interview on 4/7/22 at 9:38 AM with the Administrator, she agreed only one bath type should be marked as completed. The aide visit notes failed to correctly identify which bath type had been provided for the patient. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and hospice policy review the hospice failed to ensure all entries completed in the clinical records included an appropriate date, signature and title for 4 of 11 sampled patients (Patients #6, #7, #8 and #10). Failure to ensure all clinical record documentation included accurate information and were completed timely may result in ineffectively coordinated patient care. Findings include: According to the hospice policy titled Clinical Service Data Collection, dated 2/2020, signature authorization of clinical/service documentation will include the staff member's name and credentials (as specified on professional licenses and/or certification documents). 1. Patient #6 had a hospice admission date of 2/18/22 and received services while residing in a private residence. The clinical record review revealed the following: a. The Chaplain note, dated 2/19/22, included a handwritten signature and date of signature but lacked a title. 2. Patient #8 had a hospice admission date of 2/21/22 and received services while residing in a private residence. The clinical record review revealed the following: a. The Chaplain note, dated 2/23/21, 3/2 and 3/23/22, included a handwritten signature and date of signature but lacked a title. 3. Patient #10 had a hospice admission date of 12/1/21 and discharge date of 2/10/22 and received services while residing in a nursing home. The clinical record review revealed the following: a. The Chaplain note, dated 2/19/21, included a handwritten signature and date of signature but lacked a title. 4. Patient #7 had a hospice admission date of 1/11/22 and received hospice services while residing in a private home. Clinical record review revealed: a. Chaplain visit notes, dated 1/13/22, 3/4/22, 3/10/22 and 3/25/22, included hand written signature with staff name and date but lacked documentation of staff title. b. Chaplain visit note, dated 2/19/22, lacked documentation of hand written signature, title and date. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.