Every finding on record at Lawrence Community Health Services

Based on clinical record review and staff interview, the hospice failed to conduct and document a patient specific comprehensive assessment that reflects the severity of symptoms when notified by the on-call service of the urgent care needs of all patients. This was evident in one (1) of six (6) clinical records reviewed (Patient #1) Failure to conduct comprehensive assessments to include the severity of symptoms has the potential for negative patient outcomes.  Findings: --- Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for the certification Period of 2/28/25 to 5/28/25.  The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, "Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times  per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4  times per month and 2 visits as needed (PRN);  home health aide (HHA) 1 to 5 times per week and 2 visits as needed (PRN);   Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN);  continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”.  Statlinx On-call message log documents, “4/4/2025 taken 6:54 AM from patient’s daughter, patient is experiencing labored breathing. Patient is refusing medication”   Registered Nurse (RN) documents, “4/4/25 telephone call from patient’s daughter reporting patient refusing medications or anything by mouth reports patient sleeping and appears comfortable. Disease progression and signs and symptoms of end of life reviewed. Emotional support provided”.   There is no documented evidence of a hospice nurse assessment that documents the severity of the patient's symptoms following the patient’s daughter call on the morning of 4/4/2025 at 6:54 AM when it was reported that the patient is experiencing labored breathing.  On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on clinical record review, policy and procedure review, and staff interviews, the Hospice failed to ensure updated comprehensive assessments, that includes information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care is available to the interdisciplinary team (IDT). This was evident for one (1) of six (6) patient care records reviewed (Patient #1).  Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient and is available to the IDT has the potential for negative patient outcomes. --- Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, “Skilled Nursing 5 visits per week times 1 week, 2 visit per week times 12 weeks; Medical Social Worker 1 visit per month x 1 month, 3 visit per month times 1 month, 1 visit per month times 2 month; Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times  per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4  times per month and 2 visits as needed (PRN);  home health aide (HHA) 1 to 5 times per week and 2 visits as needed (PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN);  continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”. The Comprehensive Assessment Policy No. 2-030.4 documents, “the comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires; if no changes are needed, then that must be document” The following Interdisciplinary group (IDG) meeting minutes documents: 3/5/25 MD- "patient complaint of gastro-esophageal reflux disease, will manage with proton pump inhibiter (PPI). Recently discharge from hospital after treatment for Urinary Tract Infection, Stage II Sacral Wound and chronic hypoxic respiratory failure requiring Oxygen 2 liters” 3/19/25 RN Note- "Back onto Jansen Hospice Services after recent hospitalization this past week from the daughter’s report. Breathing with pursed lips on 4 liters of Oxygen through nasal cannula” 3/19/25-MD notes- "Stage II Sacral Wound and chronic hypoxic respiratory failure requiring Oxygen 2 liters” 4/2/25 RN note- "daughter express interest in Intravenous (IV) Hydration" There is no documented evidence of wound care order in the IDG meeting minutes and/or updated assessment for 3/5/25 and 3/19/25.  There is no documented evidence the IDG address the family interest in IV hydration. There is no documented evidence the interdisciplinary group documents in the meeting minutes if there has been changes and/or if no changes are needed to the plan of care.  On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on patient record reviews and staff interviews, the Hospice failed to ensure that the Interdisciplinary Group (IDG) developed, implemented, and maintained a Triage Policy and a complete On-Call Policy and Procedure for all healthcare personnel to follow. This was evident in review of the agency's policies and in one (1) of (6) patient records reviewed (Patient #1).   Failure to ensure that the IDG develops, implements, and maintains a Triage Policy and a complete On-Call Policy and Procedure, has the potential for negative patient outcomes.    Findings: --- Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification period of 2/28/25 to 5/28/25. Statlinx On-call message log documents, “4/4/2025 taken 6:54 AM from patient’s daughter, patient is experiencing labored breathing. Patient is refusing medication”.  On 5/28/25 the On-Call Policy was requested. The hospice provided a policy titled, “On-Call/Weekend Staffing Policy No. 2.032.1 revised 2024. The policy lacks documented evidence on triage procedure and when to escalate a call to the administrator on duty or physician.  There is no documented evidence the Hospice nurse promptly notified or communicated with a either Supervisor and/or Administrator or the Patient’s physician on the morning of 4/4/2025 at 6:54 AM when patient’s daughter called and reported that the patient is experiencing labored breathing. There is no documented evidence the IDG develop a complete On-Call policy to include triage procedure/process.   On 5/29/2025 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on patient record reviews and staff interviews, the hospice failed to ensure the patients Plan of Care include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. This was evident for one (1) of six (6) clinical records reviewed. (Patients #1)Failure to ensure the patients Plans of Care includes a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs has the potential for negative patient outcomes --- Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification Period of 2/28/25 to 5/28/25.   The Hospice Certification and Plan of Care for certification period 2/28/25 to 5/28/25 documents, “Routine home care Skilled Nursing 1 to 4 times  per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4  times per month and 2 visits as needed (PRN);  home health aide (HHA) 1 to 5 times per week and 2 visits as needed(PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN);  continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”.  The Hospice Plan of Care lacks documented evidence of: the number of PRN Volunteer services and the number PRN spiritual visits.  There is no documented evidence of a detailed statement of the task/s the hospice aide is to perform to meet the patient care needs.  On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on record reviews and staff interview, the agency failed to ensure all  services are provided in accordance with the Plan of Care for each patient. This was evident in two (2) of six (6) clinical records reviewed (Patients #2 and #4).Failure to ensure services are provided in accordance with the Plan of Care has the potential for negative patient outcomes. --- The findings are:1) Patient #2 has a start of care date of 02/25/25 with diagnoses including cerebrovascular disease, chronic kidney disease (stage 4), and moderate protein-calorie malnutrition as documented on “Hospice Certificate and Plan of Care” for certification period 02/25/25 – 05/25/25. The Plan of Care documents orders for: "skilled nursing 1-4 times per week plus 3 PRN (as needed), medical social worker 1-4 times per month plus 2 PRN, home health aide 1-5 days a week plus 2 PRN, spiritual 1-4 times a month plus PRN, and volunteer services PRN."In a “Hospice Home Health Aide Request” note dated 02/26/25, the Registered Nurse documented “Hospice home health aide request. Frequency: 5. Hours per day: 4. Wants 12-4pm.”In an “Interdisciplinary Group note” dated 02/26/25, the Social Worker documented “Services requested are registered nurse, social worker, home health aide, chaplain, and massage therapy.”There is no documentation the patient received the services of home health aide or chaplain prior to 03/02/25 when patient expired.In a “Missed Visit Notification” note dated 03/03/25, a chaplain documented “Reason for missed visit chaplain was not on the work schedule for 02/28/25.”On 5/29/25 at 10:20AM the Administrative Director was interviewed and stated “It looks like there was missed visits.” 2) Patient #4 has a start of care date of 05/16/25 with diagnoses including Parkinsonism as documented on “Hospice Certification and Plan of Care” for certification period 05/16/25 – 08/13/25. The Plan of Care has medical orders for: "skilled nursing 1-4 times per week plus 3 PRN (as needed), medical social worker 1-4 times per month plus 2 PRN, home health aide 1-5 days a week plus 2 PRN, spiritual 1-4 times a month plus PRN, and volunteer services PRN."In an “Interdisciplinary Group note” dated 05/16/25, the Registered Nurse documents: “Family requests home health aide.”The record lacks documentation that the patient received the services of home health aide prior to 05/23/25 when patient expired.On 5/29/25 at 12:57PM the Administrative Director was interviewed and stated “We have a process for home health aides where the nurse who opens the case puts in a coordination note with home health aide requests including days, hours, if there is already an agency involved. This starts the workflow for obtaining an aide. The nurse did not make a formal request for home health aide.”

Based on clinical records review and staff interviews, the agency failed to ensure Hospice care provided is consistent with the patient and/or family needs and goals to optimize care. This was evident for two (2) of six (6) clinical records reviewed (Patients #1 and #2).  Failure to ensure Hospice care is consistent with patient and family needs and goals as priority places the patient at risk for negative outcomes.  Findings: --- 2.   Patient #2 has a start of care date of 02/25/25 with diagnoses including cerebrovascular disease, chronic kidney disease (stage 4), and moderate protein-calorie malnutrition as documented on “Hospice Certificate and Plan of Care” for certification period 02/25/25 – 05/25/25.The patient expired on 03/02/25. On 03/03/25 the Registered Nurse documented in a “Narrative” note “Daughter reports father, spouse of patient having a difficult time, crying almost all day. Daughter is requesting bereavement counseling sooner than later.”The record lacks documentation that the family received any bereavement counseling.On 5/29/25 at 10:20AM the Administrative Director was interviewed and stated the social worker “did attempt to contact spouse multiple times.” Documentation of this communication was requested. On 5/29/25 at 11:42AM the Administrative Director was interviewed and stated, “There are no notes from social worker".    Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification Period of 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, “Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times  per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4  times per month and 2 visits as needed (PRN);  home health aide (HHA) 1 to 5 times per week and 2 visits as needed (PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN); continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”. Statlinx On-call message log documents, “4/4/2025 taken 6:54 AM from patient’s daughter, patient is experiencing labored breathing. Patient is refusing medication”.  Registered Nurse (RN) documents, “4/4/25 telephone call from patient’s daughter reporting patient refusing medications or anything by mouth reports patient sleeping and appears comfortable. Disease progression and signs and symptoms of end of life reviewed. Emotional support provided”.There is no documented evidence of a nursing visit to address the daughter's concerns. There is no documented evidence the hospice nurse provided care to the patient experiencing labored breathing that would optimizes comfort and dignity; and is consistent with patient and family needs.  On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview, the hospice failed to ensure in one (1) out of six (6) records that professional staff maintained an accurate, current, complete and clearly documented record related to the provision of the patient's care. (Patient #1)  Failure to maintain an accurate, current, complete and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Findings: --- Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site unspecified Female Breast documented on the Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, “Skilled Nursing 5 visits per week times 1 week, 2 visit per week times 12 weeks; Medical Social Worker 1 visit per month x 1 month, 3 visit per month times 1 month, 1 visit per month times 2 month; Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times  per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4  times per month and 2 visits as needed(PRN);  home health aide (HHA) 1 to 5 times per week and 2 visits as needed(PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN);  continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”.  ·      The record documents 2 orders for skilled nursing and medical social worker running simultaneously.    The record lacks documented evidence the caregiver was educated on the pronouncement and how to provide postmortem care.  There is no documented evidence the record is complete and/or the documentation is clear.   On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on record reviews and staff interviews, the hospice failed to identify all patients wound care needs on admission, and to ensure the Comprehensive assessments are completed to reflect the specific needs of the Patients, in collaboration with the Interdisciplinary Group (IDG), to ensure that IDG meeting notes are completed to include the patients wound status and wound treatments. This was evident for two (2) of four (4) patients with wounds. ( Patients #13, and #16). The hospice failed specifically to: Ensure completed comprehensive assessment includes the wound description, location, measurements, status of the wound, and medical orders for two (2) of four patients (4) with wounds. Ensure hospice nurses are performing complete review of the patients' status and identify all the wound care needs of the patients, and that hospice nurses are communicating patients' status, condition and treatments, and wound care needs to the Interdisciplinary Group (IDG) for two (2) of four (4) patients with wounds. (Refer to L 524). Ensure updated reassessments includes the patient's response to wound treatments for two (2) of four (4) patients with wounds. (Refer to L 533). The cumulative effect of the systemic issues identified in the agencys failure to ensure comprehensive assessments are, complete, current, and updated has the potential for negative patient outcomes. --- See L524 and L 533

Based on record reviews and staff interviews, the Hospice failed to complete a comprehensive assessment of patients to include wound measurements, characteristics of the wound bed and edges, drainage and odor present. and treatments. This was evident for two (2) of four (4) clinical records of patients with wound care. (Patient #13, and #16). Failure to complete a comprehensive assessment of patients that include wound measurements, characteristics of the wound bed and edges, odor and drainage present, and treatments has the potential for negative patient outcomes. The findings are: --- 2. Patient # 16 has a start of care date of 03/30/2023 with diagnoses of Senile Degeneration of Brain, Chronic Obstructive Pulmonary Disease as documented on the ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023. The ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023 documents an order for ";SN (Skilled Nurse) 4 wk. 1, 3wk 1, 2 wk. 1, 3 wk. 10, 1 wk. 1 (four visits a week for one week, three visits a week for one week, two visits a week for one week, three visits a week for ten weeks, one visit a week for one week). MSW (Medical Social Worker) 2 wk. 1, 1 wk. 3, 2 wk. 1, 1 Q2 wk. 2, 1 wk. 1 (two visits a week for one week, one visit a week for three weeks, 2 visits a week for one week, one visit every two weeks for two weeks, one visit a week for one week). SN to observe/assess integumentary status for early identification of complications. The Start of Care Assessment "Visit Note Report" dated 03/30/23, the SN documents the patients Integumentary system has ";1 (one) Pressure Ulcer Stage II". In the ";narrative" section of the assessment, the SN documents ";Patient with healing stage II to sacrum". The comprehensive assessment lacks documented evidence that includes wound measurements, characteristics of the wound bed and edges, and drainage and odor present. The Hospice did not ensure that the comprehensive assessment accurately identify the patient's physical/skin integrity status including wound measurements. The survey findings were reviewed with the Director of Patient Services on 07/20/2023 at 03:15 PM. No explanation was provided. 1. Patient # 13 has a start of care date of 12/1/22 and a discharge date of 12/26/20222 with diagnoses that include Malignant neoplasm of Pancreas Unspecified, Malignant neoplasm of Unspecified Site of Unspecified Female Breast as documented on the ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022. The ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022 documents:" Frequency and duration of visits: Skilled Nurse (SN) three times a week for 13 weeks. Orders of Discipline and Treatments: Hospice nurse to evaluated patient and develop plan of care to be signed by physician. Hospice nurse to monitor pain level using pain scale and report changes in pain level to physician. SN for Observation and Assessment of integumentary status for early identification of complications". The hospital referral ";Visit report ";dated 11/28/22 documents:" Patient admitted with a stage 3 pressure injury to her left buttock. The daughter states the patient had this wound for at least 2 weeks and was present on admission. The patient also has a healing wound to her left lower leg for which the patient goes to wound care. Wound #1 left anterior lower leg is a partial thickness ulcer unspecified and has received a status of not healed. Subsequent wound encounter measurements are 1cm wxo.1x 1sqcm and a volume of 0.1 cubic cm. There is a small amount of serous drainage which has no odor The wound margin is not attached to wound base. Wound bed has 76-100% epithelialization, no slough, no sign, and symptom of infection. Wound #3 Left buttock is a stage 3 pressure injury pressure ulcer and has received a status of not healed. Initial encounter measurements are 0.6x0.4o.2 with an area of 0.24 sq. cm and a volume of 0.048 cubic cm. There is a scant amount of serous drainage noted which has no odor Wound bed has 76-100% pink granulation. The peri wound skin texture is normal. The peri wound skin color is normal. The periwound skin exhibited: moist, maceration. The temperature of the peri wound skin is within normal limit". The Hospice admission ";Visit Note Report:" dated 12/1/2022 documents:" Integumentary: Number of pressure ulcer stage 3: one. Cardiovascular: edema lower right extremity/ ankle. Lower left extremity/ ankle. No measurement. Patient has stage 3 left buttock, left shin healing wound. Chronic bilateral pedal edema+4. Extremities + pulses +4 edema bilateral lower extremities. Blanchable redness to sacrum surrounding decubitus wound to left buttocks, length 0.6x0.4x0.2. Scant serous drainage. Wound bed granulating". The ";Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report ";dated start date 12/1/22 end date 12/14/22 documents:" Pain and symptom management update. Eligibility criteria: Patient now chair bound. Fentanyl patch for back and abdominal pain. Sacral wound. Minimal oral intake. Dependent in all ADL". The Comprehensive assessment lacked documented evidence of the wound on the left shin as it was identified by the referring hospital as not healed. The clinical record lacks documented evidence of a complete comprehensive assessment of the patient within 5 days of admission to Hospice care. The IDG meeting note dated 12/14/22 lacked documented evidence that wound care orders and treatments for the Stage 3 pressure ulcer of the buttocks and the left lower leg. The IDG meeting note lacked documented evidence of the specific wound care needs of the patient, and the physician orders and plan for treatment. On 7/21/22 at 10:40AM, the Administrator and the Manager of Patient Services were interviewed and did not provide an explanation for the findings.

Based on clinical record reviews, observations, and staff interviews, the hospice failed to ensure all updated comprehensive assessments were updated to reflect all patients' needs, treatments and responses, and is available to the Interdisciplinary Group (IDG). This was evident for three (3) of nineteen (19) clinical records reviewed. (Patients # 9, #13, and #16). Failure to ensure that comprehensive assessment is updated and reflect changes in the status of the patient and is available to the IDG has the potential for negative patient outcomes. The findings are: --- 2. Patient # 13 has a start of care date of 12/1/22 and a discharge date of 12/26/20222 with diagnoses that include Malignant neoplasm of Pancreas Unspecified, Malignant neoplasm of Unspecified Site of Unspecified Female Breast as documented on the ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022. The ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022 documents:" Frequency and duration of visits: Skilled Nurse (SN) three times a week for 13 weeks. Orders of Discipline and Treatments: Hospice Nurse to evaluate patient and develop plan of care to be signed by physician. Hospice Nurse to monitor pain level using pain scale and report changes in pain level to physician. SN for Observation and Assessment of integumentary status for early identification of complications". The referral "Visit Report ";dated 11/28/22 from the hospital documents:" Patient admitted with a stage 3 pressure injury to her left buttock. The daughter states the patient had this wound for at least 2 weeks and was present on admission. The patient also has a healing wound to her left lower leg for which the patient goes to wound care. Wound #1 left anterior lower leg is a partial thickness ulcer unspecified and has received a status of not healed. Subsequent wound encounter measurements are 1cm (centimeter) x o.1x 1sq (square) cm and a volume of 0.1 cubic cm. There is a small amount of serous drainage which has no odor The wound margin is not attached to wound base. Wound bed has 76-100% epithelialization, no slough, no sign, and symptom of infection. Wound #3 Left buttock is a stage 3 pressure injury pressure ulcer and has received a status of not healed. Initial encounter measurements are 0.6x0.4 x 0.2 with an area of 0.24 sq. cm and a volume of 0.048 cubic cm. There is a scant amount of serous drainage noted which has no odor Wound bed has 76-100% pink granulation. The peri wound skin texture is normal. The peri wound skin color is normal. The peri wound skin exhibited: moist, maceration. The temperature of the peri wound skin is within normal limit". The Hospice admission nursing ";Visit Note Report:" dated 12/1/2022 documents:" Integumentary: Number of pressure ulcer stage 3: one. Cardiovascular: edema lower right extremity/ ankle. Lower left extremity/ ankle. No measurement. "Patient has stage 3 left buttock, left shin healing wound. Chronic bilateral pedal edema+4. Extremities + pulses +4 edema bilateral lower extremities. Blanchable redness to sacrum surrounding decubitus wound to left buttocks, length 0.6x0.4x0.2. Scant serous drainage. Wound bed granulating". The agency policy titled:" Ongoing Comprehensive assessments" with a revision date of 2022, documents:" The nurse will assess the patient on each visit for: Skin integrity. If applicable wound care measurements (Length x width x depth) to be completed weekly, wound bed assessment, and location of wounds are included in the nurses' visit. Based on the assessment, the plan of care, including problems needs, goals and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case. Based upon the findings of the assessment, additional orders will be generated and forwarded to the physician for signature. The physician will be notified to verify any changes in medications, including over the counter medications, and treatments/ interventions that require physician approval". The ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 12/14/22 documents:" Pain and symptom management update. Eligibility criteria: Patient now chair bound. Fentanyl patch for back and abdominal pain. Sacral wound. Minimal oral intake. Dependent in all ADL The IDG meetings note date 12/14/22 lacked documented evidence of the IDG updating the comprehensive assessment to include the left lower leg wound and the left buttocks Stage 3 pressure ulcer. The Hospice Coordination notes (used as a summary of the nurse visit notes) dated 12/2/22, 12/6/22, 12/8/2212/13/22, 12/15/2212/16/22, 12/19/2212/21/2212/22/22, 12/24/22 lacked documented evidence of assessments measurements and wound care of the left lower leg wound was communicated to the IDG. The Hospice " Coordination notes" dated 12/13/22 and 12/15/22 lacked documented evidence of wound measurements for the left lower leg. Nurse documents:" skin hard no opening". The Hospice " Coordination notes dated 12/16/22 , 12/19/22, 12/21/2212/22/22, 12/23/2212/24/22 lacked documented evidence of the wounds assessment, measurements, characteristics of the wound bed and edges, drainage and odor present, and treatments. The clinical record lacked documented evidence complete assessment of the patient with known wounds to include a review and updated comprehensive assessment by the Hospices Interdisciplinary Group responsible for the care of the patient in collaboration with the individual attending physician. The comprehensive assessment lacked documented evidence of a complete assessment of a known left lower leg wound that includes measurement, characteristics of the wound bed and edges, and drainage and odor present. 3. Patient # 16 has a start of care date of 03/30/2023 with diagnoses of Senile Degeneration of Brain, Chronic Obstructive Pulmonary Disease as documented on the ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023. The ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023 documents an order for ";SN (Skilled Nurse) 4 wk. 1, 3wk 1, 2 wk. 1, 3 wk. 10, 1 wk. 1 (four visits a week for one week, three visits a week for one week, two visits a week for one week, three visits a week for ten weeks, one visit a week for one week). MSW (Medical Social Worker) 2 wk. 1, 1 wk. 3, 2 wk. 1, 1 Q2 wk. 2, 1 wk. 1 (two visits a week for one week, one visit a week for three weeks, 2 visit a week for one week, one visit every two weeks for two weeks, one visit week for one week). SN to observe/assess integumentary status for early identification of complications. The comprehensive assessment lacked documented evidence of a complete assessment the wound that includes measurement, characteristics of the wound bed and edges, and drainage and odor present. On 7/21/2022 at 10:30 AM, the Administrator and the Clinical Manager were interviewed and did not provide an explanation for the findings. 1. Patient #9 lives in a Nursing home, has a start of care date of 6/15/2023 with diagnoses of End Stage metastatic Breast Cancer with metastasis to Bone and Liver documented on the Hospice Recertification Certification Period 7/1/2023 to 8/29/2023 with Order date of 6/16/2023. The Plan of Care/Hospice Recertification Certification Period 7/1/2023 to 8/29/2023 with Order date of 6/16/2023 documents, ";SN (Skilled Nursing) 1 visit/week x1week, 3visits/week x 8 weeks, 1visit/week x1 week; MSW (Medical Social Worker) 6visits/month x1month;5 visits/month x1 month; HHA 5visits/week x 8weeks; 2visits/week x 1 week; CH (Chaplain) 6visits/month x1, 5visits/month x1month". The RN Assessment titled ";Visit Note Report" for 7/18/23 documents patient, ";complained of 6/10 pain but she had just received her Dilaudid so the RN (nursing home RN) explained that will take a little time for pain med (medication) to work". During a home visit conducted on 7/18/23 at 10:30 AM, the Surveyor did not observe the Hospice RN review the Medication Administration Record (M.A.R) to validate the administration time of the Dilaudid to ensure the effectiveness of the Dilaudid dose to relieve pain and comfort of the patient. The surveyor observed that the RN failed to assess the patient's pain. 7/12/23 RN report presented documents, ";pain and symptom management update: pain and SOB (Shortness of Breath) well controlled on current regimen visits twice weekly and or PRN (as needed)"; Medical Director- pain and SOB well controlled on current regimen visits twice weekly and or PRN, patient continues on a slow progressive decline more somnolent"; 6/28/23 RN report presented documents, "pain and symptom management. Pain controlled with current regimen"; Medical Director- "patient case and plan of care discussed at IDG". The Hospice RN failed to document the time patient received Dilaudid, and the time when patient continues to complain of pain. There is no documented evidence the Hospice RN did a complete pain assessment during the home visit to ensure the effectiveness pain medication. On 7/20/2023 at 2:05 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on observations, record reviews, review of agency Policies/Procedures and staff interviews, the agency failed to ensure that the Interdisciplinary Group supervises patient care and develops plans of care based on comprehensive assessments for hospice patients. eleven (11) of nineteen (19) clinical record reviewed. (Patients # 1, #2, #3, #8, #9, #13, #16, #17, #18, and #19). Specifically, the Hospice failed to: Ensure that all members of the Interdisciplinary Group actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, has the potential for negative patient outcomes. Refer to L545. Ensure that plans of care specify the care and services necessary to meet the patient/family needs as identified in the comprehensive assessments. Refer to L545. To develop/revise and follow individualized Plans of Care and ensure the provision of care in accordance with written Patient Plans of Care to include treatments necessary to meet the Patient needs. Refer to, L 552. The cumulative effect of the systemic issues identified in the agency's failure to ensure the Interdisciplinary Group specify the care and services to meet the patients' needs and prepare an individualized plan of care for the patients has the potential for negative patient outcomes. --- See L545 and L552

Based on record reviews and staff interviews, the hospice failed to develop/revise and follow individualized Plans of Care and ensure the provision of care in accordance with written Patient Plans of Care to address all Patient needs. This was evident for one (1) of nineteen (19) clinical records reviewed. (Patients #1). Failure to develop/ revise and follow individualized Plans of Care to address all Patient needs has the potential for negative patient outcomes. The findings are: --- 1. Patient #1 has a start of care date of 1/11/23 with diagnoses of Senile Dementia of the Brain and Dysphagia as documented on the Hospice Recertification/Plan of Care dated 6/25/23. The Hospice Recertification/Plan of Care dated 6/25/23 documents: SN (Skilled Nurse) 1 to 4 visits a week with 3 emergency visits; Hospice home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed); Patient lives alone with 24-hour private hire caregiver; Bisacodyl 10 mg rectal suppository daily as needed for constipation, Miralax 17 grams daily PRN for constipation. The order for the Bisacodyl and Miralax do not document the number of days with no bowel movements for medication administration. The SN note dated 7/3/23 documents ";last bowel movement 2 days ago, Miralax semi daily, encouraged to use Bisacodyl suppository as needed, private hire caregiver refuses to learn how to use the suppository; spoke to Patients family member". During a home visit on 7/18/23, the Nurse stated that he comes to the home to administer the suppository when the Private Hire Caregiver calls. This information is not documented in either the IDG meetings or in the Recertification/Plan of Care. The Plan of Care lacks documented evidence of when the nurse should visit the patient to administer the suppository. During an interview with the Administrator on 7/19/23 at 10:30 AM, the Administrator did not provide an explanation for the findings.

Based on clinical record review and staff interview, the Hospice failed to develop individualized Plans of Care that includes specific information Durable Medical Equipment and Supplies, treatments, and diet, Safety precautions, and other required services. This was evident for eleven (11) of nineteen (19) clinical records reviewed. (Patients #1, #2 #3, #8, #9, #10, #13 #16, #17, #18, and #19). Failure to develop individualized Plans of Care, has the potential for negative patient outcomes. The findings are: --- 8. Patient # 16 has a start of care date of 03/30/2023 with diagnoses of Senile Degeneration of Brain, Chronic Obstructive Pulmonary Disease as documented on the Hospice Recertification Certification Period 6/28/23 to 9/25/23. 9. Patient #17 has a start of care date of 06/07/2023 with diagnoses of Chronic Respiratory Failure with Hypoxia, Acute Chronic Diastolic Congestive Heart Failure, Chronic Pulmonary Disease and Pleural Effusion as documented on the ";Hospice Certification and Plan of Care" dated 06/07/2023 - 09/04/2023. The "Visit Note Reports" dated 06/08/23, 06/12/23, 06/17/23, and 06/20/23, the SN documents the patient uses CPAP Continuous Positive Airway Pressure (CPAP). 10. Patient #19 has a start of care date of 01/09/2023 with diagnoses of Alzheimers Disease and Lymphoid Leukemia as documented on the Hospice Recertification Certification Period 4/9/23 to 7/7/23. The Plans of Care/Hospice Recertification Orders for patient #16, #18, and #19 lacks documented evidence of the following specific patient information: DME and supplies, Functional Limitations, Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Status, and Allergies. There is no documented evidence the Plans of Care are complete. The survey findings were reviewed with the Director of Patient Services on 07/20/2023 at approximately 03:20 PM. No explanation was provided. 11. Patient #18 has a start of care date of 01/04/2023 with diagnoses of Non-Hodgkin Lymphoma and Decreased White Blood Cell Count as documented on the "Hospice Certification and Plan of Care dated 1/4/23 to 4/3/23" with a discharge date of 7/15/23. The "Hospice Recertification Certification Period for 4/4/23 to 7/2/23" and for the "Hospice Recertification Certification Period of 7/3/23 to 7/15/23", lacks an order for the patient's pertinent diagnoses, functional limitations, safety precautions, activities permitted, nutritional/dietary requirement, advanced directives, mental status, and allergies. The survey findings were reviewed with the Director of Patient Services on 07/20/2023 at 03:07 PM. No explanation was provided. 7. Patient #13, has a start of care date of 12/1/2022 with diagnoses that include Malignant Neoplasm of Pancreas, Malignant neoplasm of Unspecified site of Unspecified female Breast as documented on the " Hospice Certification and Plan of Care" for the Certification Period of 12/1/22 to 2/28/22. The ";Hospice Certification and Plan of Care" for the Certification Period of 12/1/22 to 2/28/22 lacks documented evidence of wound care orders for pressure ulcers and for wound on the left lower leg. On 7/20/23 at 3:05 PM, the Administrator was interviewed and did not provide and explanation for the findings. 4. Patient #8 lives in a Nursing Home, has a start of care date of 9/15/22 with diagnoses of End Stage Alzheimers Disease, Stage IV Sacral wound, Hypertension, Hyperlipidemia, Coronary Artery Disease and Osteomyelitis documented on the Hospice Recertification Certification Period 7/12/2023 to 9/9/2023. 5. Patient #9 has a start of care date of 6/15/2023 with diagnoses of End Stage metastatic Breast Cancer with metastasis to Bone and Liver documented on the Hospice Recertification Certification Period 7/1/2023 to 8/29/2023. 6. Patient #10 has a start of care date of 12/9/2022 with diagnoses of End Stage Heart Failure, Left Ventricular Failure, Diabetes Mellitus Type II, Gastroesophageal reflux disease (GERD) and Benign prostate hyperplasia (BPH) documented on the Hospice Recertification Certification Period 6/7/2023 to 8/5/2023. The Plans of Care/Hospice Recertification Orders for patients #8, #9, #10 lacks documented evidence of the following specific patient information: DME and supplies, Functional Limitations, Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Status, and Allergies. There is no documented evidence the Plans of Care are complete. On 7/20/2023 at 2:05 PM, the Administrator was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a start of care date of 1/11/23 with diagnoses of Senile Dementia of the Brain and Dysphagia as documented on the Hospice Recertification/Plan of Care dated 6/25/23. 2. Patient #2 has a start of care date of 5/12/22 with diagnoses of End Stage Alzheimer's Disease and Cerebral Vascular Accident as documented on the Hospice Recertification/Plan of Care dated 6/21/23. 3. Patient #3 has a start of care date of 2/14/22 with a diagnosis of End Stage Heart Failure as documented on the Hospice Recertification/Plan of Care dated 4/30/22. The Plans of Care/Hospice Recertification Orders for patients #1, #2, and #3 lacks documented evidence of the following specific patient information: DME and supplies, Functional Limitations, Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Status, and Allergies. There is no documented evidence the Plans of Care are complete. On 7/20/2023 at 2:05 PM, the Administrator was interviewed on 7/20/2023 at 2:05 PM, and did not provide an explanation for the findings.

Based on record reviews and staff interviews, the Hospice failed to ensure all Plans of care document all drugs and treatments to meet the need of the hospice patients. This was evident for three (3) of nineteen ( 19) clinical records reviewed. ( Patients # 10, #13, and #17). Failure to ensure all Plans of Care document all drugs and treatments to meet the needs of the patient has the potential for negative patient outcomes. The findings are: --- 1. Patient #10 has a start of care date of 12/9/2022 with diagnoses that include End Stage Heart Failure, Left Ventricular Failure, Diabetes Mellitus Type II, Gastrophageal Reflux Disease ( GERD), and Benign Prostate Hyperplasia ( BPH) as documented on the " Plan of Care/ Hospice Recertification for the Certification Period of 6/7/2023 to 8/5/2023. The" Plan of Care / Hospice Recertification " for the Certification Period of 6/7/2023 to 8/5/2023 with order date of 5/23/2023 documents:" SN ( Skilled Nursing) 1x per week for one week, 2x week for 8 weeks; MSW ( Medical Social Worker) 5x /month for one month; 6x/ for one month; 1x/month for one month; Hospice Health Aide ( HHA) 3x /week x1; 5x/week for 8 weeks; Chaplain ( CH) 3x/ month for one month; 3 small Stage II wounds to upper and lower sacrum; Medications: Optifoam one patch daily topically for sacral wound". The " Interdisciplinary Group) Summary Reports" dated 6/13/23, 6/27/23, and 7/11//23 documents:" Cleanse sacral wound with wound cleanser. Apply Calazime, cover with Optifoam". There is no documented evidence of an order to apply Calazime on the Plan of Care or an interim order for Calazime. There is no documented evidence of drugs and treatments necessary to meet the patient needs. On 7/20/2023 at 2:05 PM, the Administrator was interviewed and did not provide an explanation for the findings. 2. Patient #13 has a start of care date of 12/1/22 and a discharge date of 12/26/20222 with diagnoses that include Malignant neoplasm o Pancreas Unspecified, Malignant neoplasm of Unspecified Site of Unspecified Female Breast as documented on the ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022. The ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022 documents:" Frequency and duration of visits: Skilled Nurse (SN) three times a week for 13 weeks. Orders of Discipline and Treatments: Hospice nurse to evaluate patient and develop plan of care to be signed by physician. Hospice nurse to monitor pain level using pain scale and report changes in pain level to physician. SN for Observation and Assessment of integumentary status for early identification of complications". 12/2 2022, The ";Coordination notes" (used as a summary of the nursing visits) documents: ";Blanchable redness to sacrum surrounding decubitus wound to left buttocks, length 0.6 cm x0.4 cm width x 0.2 cm depth. Scant serous drainage. Wound bed 70-100% granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex". 12/6/22, The ";Coordination notes" documents: ";Blanchable redness to sacrum surrounding decubitus wound to left buttocks, length 0.6 cm x0.4 cm width x 0.2 cm depth. Scant serous drainage. Wound bed 70-100% granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex". 12/8/22, The ";Coordination notes" documents: ";Blanchable redness to sacrum surrounding decubitus wound to left buttocks, length 0.6 cm x0.4 cm width x 0.2 cm depth. Scant serous drainage. Wound bed 70-100% granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex". 12/13/22, The Coordination Notes" "; Extremities +4 edema to bilateral lower extremities, skin hard no opening. Discussed keeping legs elevated. Redness to sacrum surrounding decubitus increasing. Wound to left buttocks with minimal drainage. Wound bed pink, moist granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex". 12/15/22 documents: "; Extremities +4 edema to bilateral lower extremities, skin hard no opening. Discussed keeping legs elevated. Redness to sacrum surrounding decubitus increasing. Wound to left buttocks with minimal drainage. Wound bed pink, moist granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex". There is no documented evidence an order for Chlorhexidine and Mepilex in the Plan of Care. There is no documented evidence of an order for wound care treatment for the pressure ulcer on the sacrum and the left lower leg on the Plan of Care or an interim order. There is no documented evidence for drugs and treatments necessary to meet the patient needs in the Plan of Care or an interim order. On 7/21/23 at 10:40AM, the Administrator and the Manager of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient # 17 has a start of care date of 6/7/2023 with diagnoses that include Chronic Respiratory Failure with Hypoxia, Acute Chronic Congestive Heart Failure and Pleural Effusion as documented on the " Hospice Certification and Plan of Care" for the Certification Period of 6/7/2023 to 9/4/2023. The" Hospice Certification and Plan of Care" for the Certification Period oof 6/7/2023 to/9/4/2023 documents:" Skilled Nursing (SN) three visits a week for 13 weeks. SN instruct and monitor use of Oxygen. SN observation and assessment of respiratory status. Medications include Oxygen 2-5 Liters as needed for Dyspnea". The start of care assessment dated 6/7/2023, the SN documents the patient is on continuous Oxygen requiring " Continuous Positive Airway Pressure" (CPAP) at night. The" visit note reports" dated 6/8/23, 6/12/23, 6/17/23, and 6/20/23, the SN documents the patient uses CPAP. There is no documented evidence of an order for CPAP on the Plan of Care, or an interim order. There is no documented evidence of the drugs and treatment necessary to meet the patient's needs on the Plan of Care. The survey findings were reviewed on 7/20/23 at 3:15 PM with the Director of Patient Services. No explanation was provided.

Based on record reviews and staff interviews, the Hospice failed to ensure that the Interdisciplinary Group (IDG) reviews, revise and document the individualized plan of care as frequently as the patient condition requires. This was evident for five (5) of nineteen (19) clinical records reviewed. (Patients #2, #7, #9, #13, and #16). Failure to ensure the IDG review, revise and document the individualized plan of care as frequently as the patient condition requires has the potential for negative patient outcomes. The findings are: --- 1. Patient #2 has a start of care date of 5/12/22 with diagnoses of End Stage Alzheimer's Disease and Cerebral Vascular Disease as documented on the Hospice Recertification/Plan of Care dated 6/21/23. The Hospice Recertification/Plan of Care dated 6/21/23 documents: SN 1 to 4 visits a week with 3 emergency visits; home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed). The Registered Nurse note dated 7/11/23 documents the Patient has difficulty in swallowing. The Medical Social Worker note dated 7/12/23 documents the Patient has a problem with swallowing. There is no documented evidence in the IDG meeting regarding the Patient's swallowing difficulty and review and revision to the Plan of Care. 2. Patient #7 has a start of care date of 5/1/23 with diagnosis of Stomach Cancer as documented on the Recertification/Plan of Care dated 5/1/23. The Hospice Certification and Plan of Care dated 5/1/23 through 7/29/23 documents: SN 5 x week for one week, 3 x week for 12 weeks. The SN note dated 6/27/23 documents the Patient has no edema. The SN note dated 7/5/23 documents plus 3 pitting edemas to bilateral extremities (BLE), thighs, elbows, and upper arms; small blister noted to side of penis, site painted with Betadine. The SN note dated 7/12/23 documents worsening plus 4 pitting edemas to BLE, thighs and plus 4 weeping edemas to elbows, upper arms, significant other has arms wrapped in gauze due to weeping; reached out to PCP (Primary Care Physician) about ordering diuretic, awaiting call back. There is no documented evidence of the response from the physician regarding the increased edema and the blister to the penis. There is no documented evidence of review and revision to the Plan of Care regarding the edema and the care for the blister to the penis. 3. Patient # 13 has a start of care date of 12/1/22 and a discharge date of 12/26/20222 with diagnoses that include Malignant neoplasm o Pancreas Unspecified, Malignant neoplasm of Unspecified Site of Unspecified Female Breast as documented on the ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022. The ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022 documents:" Frequency and duration of visits: Skilled Nurse (SN) three times a week for 13 weeks. Orders of Discipline and Treatments: Hospice nurse to evaluated patient and develop plan of care to be signed by physician. Hospice nurse to monitor pain level using pain scale and report changes in pain level to physician. SN for Observation and Assessment of integumentary status for early identification of complications". The referral "; Visit report "; dated 11/28/22 from the hospital documents:" Patient admitted with a stage 3 pressure injury to her left buttock. The daughter states the patient had this wound for at least 2 weeks and was present on admission. The patient also has a healing wound to her left lower leg for which the patient goes to wound care. Wound #1 left anterior lower leg is a partial thickness ulcer unspecified and has received a status of not healed. Subsequent wound encounter measurements are 1cm wxo.1x 1sqcm and a volume of 0.1 cubic cm. There is a small amount of serous drainage which has no odor The wound margin is not attached to wound base. Wound bed has 76-100% epithelialization, no slough, no sign, and symptom of infection. Wound #3 Left buttock is a stage 3 pressure injury pressure ulcer and has received a status of not healed. Initial encounter measurements are 0.6x0.4o.2 with an area of 0.24 sq. cm and a volume of 0.048 cubic cm. There is a scant amount of serous drainage noted which has no odor Wound bed has 76-100% pink granulation. The peri wound skin texture is normal. The peri wound skin color is normal. The periwound skin exhibited: moist, maceration. The temperature of the peri wound skin is within normal limit". The Hospice nursing "; Visit Note Report:" dated 12/1/2022 documents:" Integumentary: Number of pressure ulcer stage 3: one. Cardiovascular: edema lower right extremity/ ankle. Lower left extremity/ ankle. No measurement." Patient has stage 3 left buttock, left shin healing wound. Chronic bilateral pedal edema+4. Extremities + pulses +4 edema bilateral lower extremities. Blanchable redness to sacrum surrounding decubitus wound to left buttocks, length 0.6x0.4x0.2.Scant serous drainage. Wound bed granulating". The agency policy titled:" Ongoing Comprehensive assessments" documents:" Skin integrity. If applicable wound care measurements (Length x width x depth) to be completed weekly, wound bed assessment, and location of wounds are included in the nurse's visit". The ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 12/14/22 documents:" Pain and symptom management update. Eligibility criteria: Patient now chair bound. Fentanyl patch for back and abdominal pain. Sacral wound. Minimal oral intake. Dependent in all ADL" The IDG meeting note lacks documented evidence of the discussion, intervention and goals of the wounds, There is no documented evidence that the attending physician and the IDG being notified in a timely manner of the patient admitted with wounds. There is no documented evidence of the IDG was updated to include a revision and review of the care plan regarding the wounds. On 7/21/2023 at 10:30 AM, the Administrator and the Clinical Manager were interviewed and did not provide an explanation for the findings. 4. Patient # 16 has a start of care date of 03/30/2023 with diagnoses of Senile Degeneration of Brain, Chronic Obstructive Pulmonary Disease as documented on the ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023. The ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023 documents an order for ";SN (Skilled Nurse) 4 wk. 1, 3wk 1, 2 wk. 1, 3 wk. 10, 1 wk. 1 (four visit a week for one week, three visits a week for one week, two visits a week for one week, three visits a week for ten weeks, one visit a week for one week). SN to observe/assess integumentary status for early identification of complications. The start of care assessment dated 03/30/23, the SN documents the patients Integumentary system has ";1 (one) Pressure Ulcer Stage II". In the ";narrative" section of the assessment, the SN documents ";Patient with healing stage II to sacrum". The ";Hospice IDG (Inter-Disciplinary Group) Comprehensive Assessment and Plan of Care Update Report" dated 03/31/23, and 04/12/23, lacks documented evidence of the patients Integumentary Sacrum status and the wound care treatment to the Sacrum Stage II Pressure Ulcer. The ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 04/26/23, documents ";Pt (patient with healing stage II to Sacrum, all other skin intact. Encourage use of Barrier Cream". There is no documentation of the type and frequency use of Barrier cream. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 05/10/23 documents ";L (left) Sacral crusted over healed stage II noted" Zinc Oxide applied". The Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 05/24/23, 06/07/23, 06/20/23, 07/04/23 document ";Healing Stage II noted to Sacrum with Zinc Oxide applied". There is no documented evidence of an order for the frequency of Zinc Oxide. The IDG/Plan of Care lacks specific wound care treatments necessary to meet the patient and family-specific needs identified in the comprehensive assessment relate to the Stage II Sacrum Pressure Ulcer. There is no documented evidence the IDG was updated to include a revision and review of the care plan regarding the wound. The survey findings were reviewed with the Director of Patient Services on 07/20/2023 at 03:15 PM. No explanation was provided. 5. Patient #9 has a start of care date of 6/15/2023 with diagnoses of End Stage metastatic Breast Cancer with metastasis to Bone and Liver documented on the Hospice Recertification Certification Period 7/1/2023 to 8/29/2023. The Plan of Care/Hospice Recertification Certification Period 7/1/2023 to 8/29/2023 with Order date of 6/16/2023 documents, ";SN (Skilled Nursing) 1 visit/week x1week, 3visits/week x 8 weeks, 1visit/week x1 week; MSW (Medical Social Worker) 6visits/month x1month;5 visits/month x1 month; HHA 5visits/week x 8weeks; 2visits/week x 1 week; CH (Chaplin) 6visits/month x1, 5visits/month x1month". The IDG Summary Report dated 7/12/23 RN report presented documents, ";pain and symptom management update: pain and SOB (Shortness of Breath) well controlled on current regimen visits twice weekly and or PRN (as needed)". The "Interdisciplinary Discipline Group (IDG) meeting dated 7/12/23 lacks documented evidence this information was discussed at the meeting. There is no documented evidence the Plan of Care was reviewed and revised to reflect the changes in the patient's pain assessment and status. On 7/20/2023 at 2:05 PM, the Administrator was interviewed and did not provide an explanation for the findings.

Based on record reviews and staff interviews the Hospice failed to ensure that licensed professionals delivered the Patients Hospice care in accordance with current professional standards and practice. This was evident for two (2) of four (4) patients with wounds. (Patients #13, and #16). The Hospice failed to: Ensure the Registered Nurse identify all the wound care needs for two (2) of four (4) patients with wounds. (Refer to L 585). Ensure the Registered Nurse coordinate with the physician and obtain orders document all the wound care treatments of for two (2) of four (4) patients. (Refer to L 585). Ensure the Registered Nurse communicate with the IDG to update the comprehensive assessments for the wound care needs of two (2) of four (4) patients. . Refer to L 585. Ensure the Registered Nurse review and update the comprehensive assessment with the IDG obtain physician orders to provide wound care and notify the physician to verify treatment that require physician approval for two (2) of four (4) patients with wound care. Refer to L 585. Ensure Registered Nurses are practicing within their scope of practice, (providing wound care treatments without physician orders). Refer lo L 585. The cumulative effect of the systemic issues identified in the agencys failure to ensure that licensed professionals delivered the hospice care in accordance with current professional standards of practice has the potential for negative patient outcomes. --- see L585

Based on record review and staff interviews, the Hospice failed to ensure that Licensed professionals provide the Hospices wound care in accordance with current professional standards and practice. This was evident for two (2) of four (4) clinical records reviewed of patients with wounds. (Patient #13, and #16.). Failure to ensure that Licensed professionals provide the Hospice care in accordance with current professional standards and practice has the potential for negative patient outcomes. The findings are: --- 1. Patient #13 has a start of care date of 12/1/22 and a discharge date of 12/26/20222 with diagnoses that include Malignant neoplasm o Pancreas Unspecified, Malignant neoplasm of Unspecified Site of Unspecified Female Breast as documented on the ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022. The ";Hospice Certification and Plan of Care" for the Certification Period 12/1/2022 to 2/28/2022 documents:" Frequency and duration of visits: Skilled Nurse (SN) three times a week for 13 weeks. Orders of Discipline and Treatments: Hospice nurse to evaluated patient and develop plan of care to be signed by physician. Hospice nurse to monitor pain level using pain scale and report changes in pain level to physician. SN for Observation and Assessment of integumentary status for early identification of complications". 12/1/22, The Initial assessment ";Visit Note report" documents:" Blanchable redness to sacrum surrounding decubitus wound to left buttocks, length 0.6 cm x0.4 cm width x 0.2 cm depth. Scant serous drainage. Wound bed 70-100% granulating. Integumentary: Number of pressure ulcer stage 3: one. Cardiovascular: edema lower right extremity/ ankle. Lower left extremity/ ankle. No measurement. Patient has stage 3 left buttock, left shin healing wound. Chronic bilateral pedal edema+4. Extremities + pulses +4 edema bilateral lower extremities". 12/2 2022, The ";Coordination notes" documents: "; Wound bed 70-100% granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex. Discussed appropriate skin care. Reinforced offloading pressure". 12/6/22, The ";Coordination notes" documents: "; Wound bed 70-100% granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex. Discussed appropriate skin care. Reinforced offloading pressure". 12/8/22, The ";Coordination notes" documents: "; Wound bed 70-100% granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex. Discussed appropriate skin care. Reinforced offloading pressure". 12/13/22, The Coordination Notes" ";Extremities +4 edema to bilateral lower extremities, skin hard no opening. Discussed keeping legs elevated. Redness to sacrum surrounding decubitus increasing. Wound to left buttocks with minimal drainage. Wound bed pink, moist granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex. Discussed appropriate skin care. Reinforced offloading pressure". 12/15/22 documents: ";Extremities +4 edema to bilateral lower extremities, skin hard no opening. Discussed keeping legs elevated. Redness to sacrum surrounding decubitus increasing. Wound to left buttocks with minimal drainage. Wound bed pink, moist granulating. Cleansed with Chlorhexidine. Pat dry. Apply Mepilex. Discussed appropriate skin care. Reinforced offloading pressure." There is no documented evidence of an order for Chlorhexidine and Mepilex in the Plan of Care. There is no documented evidence the Registered Nurse (RN) notified the physician and obtained wound care orders for the patient prescribed by a physician. There is no documented evidence the nurse actively participate in the IDG. There is no documented evidence the RN communicated with the IDG the need to obtain wound care orders for the patient. There is no documented evidence the RN notified the physician of the redness around the wound of the sacrum. There is no documented evidence the RN provided the patient's wound care in accordance with current professional standards and practice. There is no documented evidence of the RN practicing within the scope of practice and in accordance with current professional standards and practice. On 7/21/22 at 10:15 AM, the surveyor requested documentation of standing orders or wound care protocol. This information was not provided. The Administrator was interviewed and stated, " We do not have standing orders". No further information was provided. 2. Patient # 16 has a start of care date of 03/30/2023 with diagnoses of Senile Degeneration of Brain, Chronic Obstructive Pulmonary Disease as documented on the ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023. The ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023 documents an order for ";SN (Skilled Nurse) 4 wk. 1, 3wk 1, 2 wk. 1, 3 wk. 10, 1 wk. 1 (four visit a week for one week, three visits a week for one week, two visits a week for one week, three visits a week for ten weeks, one visit a week for one week). MSW (Medical Social Worker) 2 wk. 1, 1 wk. 3, 2 wk. 1, 1 Q2 wk. 2, 1 wk. 1 (two visits a week for one week, one visit a week for three weeks, 2 visit a week for one week, one visit every two weeks for two weeks, one visits a week for one week). SN to observe/assess integumentary status for early identification of complications. The Start of Care Assessment "Visit Note Report" dated 03/30/23, the SN documents the patients Integumentary system has ";1 (one) Pressure Ulcer Stage II". In the ";narrative" section of the assessment, the SN documents ";Patient with healing stage II to sacrum". There is no documented evidence the RN actively participate in the IDG. There is no documented evidence, the Hospice RN was performing wound care with physician's orders. There is no documented evidence the nurse was providing wound care in accordance with current professional standards and practice. There is no documented evidence the nurse was practicing within the scope of practice. The survey findings were reviewed with the Director of Patient Services on 07/20/2023 at 03:15 PM. No explanation was provided.

Based on record reviews and staff interview the agency failed to ensure that all Home Health Aides written plans of care instructions are complete and accurate. This is evident for three (3) of three (3) clinical records reviewed (Patients #1, #2, and #3)Failure to ensure that all Hospice Aides written plans of care instructions are complete and accurate, has the potential for negative patient outcomes.The findings are: --- 1. Patient #1 has a start of care date of 1/11/23 with diagnoses of Senile Dementia of the Brain and Dysphagia as documented on the Hospice Recertification/Plan of Care dated 6/25/23 The Hospice Recertification/Plan of Care dated 6/25/23 documents: SN 1 to 4 visits a week with 3 emergency visits; home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed). The Aide Plan of Care dated 5/26/23 documents ";the aide is to assist with transfers/ambulation. During a home visit on 7/18/23, the Patient was found in a hospital bed. Patient was found to not be able to turn in the bed. The Registered Nurse stated, "the Patient is no longer being transferred to the bed to the chair". There is no documented evidence the Aide Plan of Care was updated to remove assist with transfers/ambulation. 2. Patient #2 has a start of care date of 5/12/22 with diagnoses of End Stage Alzheimer's Disease and Cerebral Vascular Accident as documented on the Hospice Recertification/Plan of Care dated 6/21/22. The Hospice Recertification/Plan of Care dated 6/21/22 documents: SN 1 to 4 visits a week with 3 emergency visits; home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed). The Aide Plan of Care dated 5/12/22 documents ";the aide is to assist with transfers/ambulation, transfer from bed to chair, bathing by shower, and empty urinal. During a home visit on 7/18/23, the Patient was found in a hospital bed and did not respond to questions. The Registered Nurse stated that the Patient is total care and does not get out of bed. There is no documented evidence the Aide Plan of Care was updated to remove assist with transfers/ambulation, transfer from bed to chair, bathing by shower, and toileting needs. 3. Patient #3 has a start of care date of 2/14/22 with diagnoses of End Stage Heart Failure as documented on the Hospice Recertification/Plan of Care dated 6/21/22. The Hospice Recertification/Plan of Care dated 6/21/22 documents: SN 1 to 4 visits a week with 3 emergency visits; home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed), Patient requires two person assist to transfer, Hoyer Lift used PRN. The Aide Plan of Care dated 2/14/22 documents the aide is to assist with transfers/ambulation, transfer from bed to chair, sponge bath, routine catheter care and empty drainage bag. The initial Nursing assessment dated 2/14/22 documents the hospital staff removed the Foley catheter. There is no documented evidence the Aide Plan of Care was updated to remove assist with transfers/ambulation, bathing by shower, and toileting needs, and update the Plan of Care to transfer Patient with two person assist and a Hoyer Lift. During an interview with the Administrator on 7/19/23 at 10:30 AM, the Administrator stated that the Aide Plan of Care is to be updated at the time of recertification or if there is a change in condition. The Administrator did not provide the reason the Aide Plans of Care were not updated.

Based on patient record review and interview, the Hospice failed to provide supervision to ensure the quality of care and services provided by the hospice aides in accordance with patients' Plans of Care (POC). This was evident in three (3) of three (3) clinical records receiving home health aides (Patients #1, #2, and #3. Failure to ensure that patient services are provided in accordance with patients' Plans of Care place patients at risk for not receiving required services. The findings are: --- 1. Patient #1 has a start of care date of 1/11/23 with diagnoses of Senile Dementia of the Brain and Dysphagia as documented on the Hospice Recertification/Plan of Care dated 6/25/23 The Hospice Recertification/Plan of Care dated 6/25/23 documents: SN 1 to 4 visits a week with 3 emergency visits; home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed). The Aide Plan of Care dated 5/26/23 documents the aide is to assist with transfers/ambulation, assist with feeding, document date of last BM (Bowel Movement), bed bath. The aide activity sheets for the weeks dated 5/29/23, 6/5/23, and 6/12/23 were reviewed. The aide activity sheets document the aide is doing the following tasks: shampoo, shower, nail care, and laundry. These tasks are not on the Aide Plan of Care. The aide activity sheets do not document the aide assisted with feeding and a bed bath. 2. Patient #2 has a start of care date of 5/12/22 with diagnoses of End Stage Alzheimer's Disease and Cerebral Vascular Accident as documented on the Hospice Recertification/Plan of Care dated 6/21/22. The Hospice Recertification/Plan of Care dated 6/21/22 documents: SN 1 to 4 visits a week with 3 emergency visits; home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed). The Hospice Consent form dated 5/12/22 documents the Patient will receive up to 20 hours a week. The Plan of Care lacks documented evidence of the duration of aide services per week. During a home visit on 7/18/23, the Registered Nurse stated the aide goes to the home for four hours a day. The aide activity sheets for June 2023 document the aide is going to the home four hours a day. The Plan of Care lacks documented evidence the Plan documented the number of hours per day the aide is to go to the home. 3. Patient #3 has a start of care date of 2/14/22 with diagnoses of End Stage Heart Failure as documented on the Hospice Recertification/Plan of Care dated 6/21/22. The Hospice Recertification/Plan of Care dated 6/21/22 documents: SN 1 to 4 visits a week with 3 emergency visits; home health aide (hha) 1 to 5 days a week with 2 additional visits PRN (as needed), Patient requires two person assist to transfer, Hoyer Lift used PRN. The Aide Plan of Care dated 2/14/22 documents the aide is to assist with transfers/ambulation, transfer from bed to chair, sponge bath, routine catheter care and empty drainage bag. The aide activity sheets dated 6/1/22 through 7/15/22 lack documented evidence of the type of bathing, document BM, and catheter care/emptying drainage bag. During an interview with the Administrator on 7/19/23 at 10:30 AM, The Administrator did not provide an explanation for the above.

Based on clinical record reviews, observations, and staff interviews, the Hospice failed to ensure that all patient records include responses to all medications, treatments, and services. This was evident for two (2) of nineteen (19) clinical records. (Patients #9, #16). Failure to ensure that all patient records include responses to all medications, treatments, and services has the potential for negative patient outcomes. The findings include: --- Patient # 16 has a start of care date of 03/30/2023 with diagnoses of Senile Degeneration of Brain, Chronic Obstructive Pulmonary Disease as documented on the ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023. The ";Hospice Certification and Plan of Care" dated 03/30/2023 – 06/27/2023 documents an order for ";SN (Skilled Nurse) 4 wk. 1, 3wk 1, 2 wk. 1, 3 wk. 10, 1 wk. 1 (four visit a week for one week, three visits a week for one week, two visits a week for one week, three visits a week for ten weeks, one visit a week for one week). SN to observe/assess integumentary status for early identification of complications. The start of care assessment dated 03/30/23, the SN documents the patients Integumentary system has ";1 (one) Pressure Ulcer Stage II". In the ";narrative" section of the assessment, the SN documents ";Patient with healing stage II to sacrum". The ";Visit Note Report" dated 03/31/23, 04/03/23, 04/05/23, 04/14/23, 04/18/23, 04/21/23, 04/24/23, 06/07/23, 06/13/23, 06/22/23, and 06/27/23 the SN documents ";pt. (patient) with healing Stage II to Sacrum". There is no documented evidence of the wound measurement, characteristics of the wound bed and edges, drainage and odor present, treatments and the patient's response to treatment. The survey findings were reviewed with the Director of Patient Services on 07/20/2023 at 03:15 PM. No explanation was provided. Patient #9 has a start of care date of 6/15/2023 with diagnoses of End Stage metastatic Breast Cancer with metastasis to Bone and Liver documented on the Hospice Recertification Certification Period 7/1/2023 to 8/29/2023 with Order date of 6/16/2023. The Plan of Care/Hospice Recertification Certification Period 7/1/2023 to 8/29/2023 with Order date of 6/16/2023 documents, ";SN (Skilled Nursing) 1 visit/week x1week, 3visits/week x 8 weeks, 1visit/week x1 week; MSW (Medical Social Worker) 6visits/month x1month;5 visits/month x1 month; HHA 5visits/week x 8weeks; 2visits/week x 1 week; CH (Chaplin) 6visits/month x1, 5visits/month x1month". The RN ";Visit Note Report" for 7/18/23 documents patient, ";complained of 6/10 pain but she had just received her Dilaudid so the RN (nursing home RN) explained that will take a little time for pain med (medication) to work". The Hospice RN was not observed reviewing the M.A.R for the time the Dilaudid was administered. There is no documented evidence the Hospice RN did a complete pain assessment to evaluate the Dilaudid dose effectiveness. There is no documented evidence the RN document the response to the medication. On 7/20/2023 at 2:05 PM, the Administrator was interviewed and did not provide an explanation for the findings.