Every finding on record at Legacy Hospice of the East, LLC

Upon patient record review, 7 of 19 (Patient #1,#5,#7,#8,#9,#11,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1,5,7,8,9,11,14: The medication profile included oxygen with no instructions for a delivery method. Corrected on site, Patient 9: Lidocaine patch does not include placement location on Medication Administration Record. Corrected on site.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 7: The medical record contained an initial bereavement assessment completed 5/3/23 with a start of care 4/22/23.

Upon patient record review, 2 of 19 (Patient #12 and 13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 12: The medical record contained an order on 5/11/23 to administer a Rocephin injection. The nursing documentation stated the patient refused injection. There was no evidence of documentation present to support that physician was contacted and notified of refusal or patient condition related to progress of infection status. No assessment of infection after 5/11/23. Patient 13: The medical record contained an order for wound care starting 3/23/23. There was no evidence of RN assessment of the wound documented between 3/23/23 and 4/24/23, and between 4/24/23 and 5/16/23.

Upon patient record review, 3 of 19 (Patient #4,#9,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 4: The medical record contained nursing documentation 5/5/23 identifying patient risk for aspiration requiring education. There was no evidence of problems, goals, and interventions related to risk for aspiration included in the plan of care. Patient 9: The medical record contained problem, goals and interventions related to self administration of medication. The patient resides in a skilled nursing facility and the nurse provides medication management. Patient 14: The medical record contains documentation that antibiotic therapy was initiated on 5/24/23 to treat a Urinary Tract Infection. There was no evidence of problems, goals and interventions related to infection.

Upon patient record review, 1 of 19 (Patient 1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be soley a response to a crisis. Patient 1: The medical record contained an order for spiritual care frequency of once monthly and PRN. There was no evidence of a quantity defined for allowable number of PRN visits. Plan of care included SCC frequency of PRN visits with no scheduled visits.

Upon patient record review, 8 of 19 (Patient #1,#2,#5,#7,#8,#9,#11,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1,5,7,8,9,11,14: The medical record contained orders for oxygen with no instructions for a delivery method. Corrected on site. Patient 2: The medical record contained nursing documentation 3/23/23 identifying patient change of condition and oxygen in use at 3 liters per minute. The order for oxygen in the plan of care contained a dosage of 2 liters per minute with no range or instructions for an increase. Patient 8: The medical record contained nursing documentation of oxygen in use at 3.5 liters per minute on 5/15/23, 3 liters per minute on 5/18/23 and 3.5 liters per minute on 5/22/23. The order for oxygen in the plan of care contained a dosage of 2 liters per minute with no range or instructions to increase. Patient 9: Lidocaine patch does not include placement location on order. Corrected on site. Patient 14: The medical record contained nursing documentation of oxygen in use at 4 liters per minute on 5/16/23, 4 liters per minute on 5/21/23, and 3 liters per minute on 5/21/23. The order for oxygen in the plan of care contained a dosage of 2 liters per minute with no range or instructions to increase.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: The medical record contained documentation that a TB skin test was place on 5/23/23 in anticipation of upcoming respite stay. No physician order was located in the medical record for placement. Corrected on site.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: The Aide Plan of Care included tasks for both bed bath and shower to be completed every visit.

Upon patient record review, 5 of 19 (Patient #8,#11,#12,#13,#14) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 8: The medical record contained a CTI for benefit period starting 4/29/23 stating face to face visit was completed 4/4/23. Evidence in the face to face documentation confirmed face to face was completed 3/31/23. Patient 11: The medical record contained a CTI for benefit period starting 12/26/22 stating face to face visit was completed 12/6/22 . Evidence in the face to face documentation confirmed face to face was completed 12/1/22. The medical record contained a CTI for benefit period starting 2/24/23 stating face to face visit was completed 2/1/23 . Evidence in the face to face documentation confirmed face to face was completed 1/27/23. The medical record contained a CTI for benefit period starting 4/25/23 stating face to face visit was completed 4/3/23. Evidence in the face to face documentation confirmed face to face was completed 3/31/23. Patient12: The medical record contained a CTI for benefit period starting 11/6/22 stating face to face visit was completed 10/13/22. Evidence in the face to face documentation confirmed face to face was completed 10/12/23. The medical record contained a CTI for benefit period starting 1/5/23 stating face to face visit was completed 12/13/23. Evidence in the face to face documentation confirmed face to face was completed 12/7/23.The medical record contained a CTI for benefit period starting 3/6/23 stating face to face visit was completed 2/10/23. Evidence in the face to face documentation confirmed face to face was completed 2/8/23. The medical record contained a CTI for benefit period starting 5/5/23 stating face to face visit was completed 4/17/23. Evidence in the face to face documentation confirmed face to face was completed 4/13/23. Patient 13: The medical record contained a CTI for benefit period starting 11/17/22 stating face to face visit was completed 10/20/22. Evidence in the face to face documentation confirmed face to face was completed 10/19/22. The medical record contained a CTI for benefit period starting 1/16/23 stating face to face visit was completed 12/29/22. Evidence in the face to face documentation confirmed face to face was completed 12/28/22 . Patient 14: The medical record contained a CTI for benefit period starting 12/7/22 stating face to face visit was completed 11/11/22. Evidence in the face to face documentation confirmed face to face was completed 11/12/22. The medical record contained a CTI for benefit period starting 2/5/23 stating face to face visit was completed 1/11/23. Evidence in the face to face documentation confirmed face to face was completed 1/5/23. The medical record contained a CTI for benefit period starting 4/6/23 stating face to face visit was completed 3/21/23. Evidence in the face to face documentation confirmed face to face was completed 3/19/23.

Upon inpatient contract review, 1 of 5 (Washington GIP/respite contract) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon inpatient contract review, 1 of 5 (Washington GIP/respite contract) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 3 of 12 (Personnel #9,#11,#12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 9: There was no evidence the agency obtained a criminal background check. Corrected on site. Personnel 11,12: The agency was unable to obtained criminal background checks from contracted agency.

Upon personnel record review, 2 of 12 (Personnel #11,#12) did not have evidence that all personnel have been fully vaccinated for COVID-19. Personnel 11,12: The agency was unable to obtain vaccination status from contracted agency.

Based on observation, review of agency policy and procedure, Hospice Aide (HA) Relias training "Giving a complete bed bath" provided by the agency, and staff interviews, it was determined the agency failed to ensure staff: 1. Performed a bed bath per agency training. 2. Followed agency policy for bag technique. This deficient practice affected 2 of 3 home visits (HV) performed and did affect HV # 1 and HV # 2, and had the potential to affect all patients served by the agency. Findings include: Relias Learning, Giving a Complete Bed Bath: Washing: ...5. Perineal Area. Change the water in the basin before performing perineal care...For females...using a clean mitt, cleanse the area...Use a clean area of the mitt and towel for each swipe...For males...use a clean area of the mitt and towel for each swipe... Change the water in the basin.... Agency Policy: Legacy Hospice Bag Technique Procedure Policy Number Reference: 6-013.1 and 6-013.2 Policy Date: 8/21/2020 Policy: As part of the infection/exposure control plan, Legacy Hospice personnel will consistently implement principles to maximize efficient use of the patient's care supply bag... Purpose: To prevent contamination of bag and equipment, avoid cross contamination, and establish a clean work area... Procedure: ...4. Once in the patient's home, ...Never place bag on the floor... 1. HV # 1 was admitted to hospice services on 4/5/21, and recertified for continued care 3/31/22 to 5/29/22 with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure, and Anemia Unspecified. Review of the Hospice Recertification Plan of Care Update dated 3/16/22 revealed a HA ordered visit frequency of 2X (times) per week effective 4/3/22. Review of the Hospice Physician Order dated 4/7/22 revealed a clarification for the HA visit frequency effective 4/3/22 of 3X per week. Review of the Aide Care Plan Report printed on 5/2/22 revealed a Bed Bath was assigned to be performed every visit by the HA. A HV was conducted on 5/2/22 at 3:00 PM to observe care provided by Employee Identifier (EI) # 2, HA, which included a bed bath. During the bed bath, EI # 2 was observed cleansing the face, neck, chest, abdomen, upper legs, and then perineal area utilizing the same bath water and bath cloth. EI # 2 then washed the lower legs and feet, then washed the back and buttocks, still utilizing the same bath cloth and bath water. EI # 2 failed to change the bath water prior to and again after cleansing the perineal area, and use a clean bath mitt/cloth to wash the perinal area as per agency training. In an interview conducted on 5/4/22 at 1:42 PM, EI # 1, Registered Nurse (RN) Administrator, confirmed the HA did not follow agency training for giving a complete bed bath, and should have used a clean bath cloth/mitt and changed the bath water. 2. HV # 2 was admitted to the agency on 7/21/21 and recertified for continued care 3/18/22 to 5/16/22 with diagnoses including Hypertensive Heart Disease with Heart Failure and Rheumatic Tricuspid Insufficiency. A HV was conducted on 5/2/22 at 2:14 PM to observe EI # 3 RN, perform wound care. EI # 3 placed a clean barrier on the floor then placed the equipment bag on the barrier. EI # 3 completed wound care, performed hand hygiene and donned gloves to place previously cleaned equipment back into the bag on the floor... An interview was conducted 5/4/22 at 1:27 PM with EI # 1, who confirmed the staff did not follow the agency policy for bag equipment and should not have placed the bag on the floor.

Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to ensure the Hospice Aide (HA) performed all tasks as assigned on the Aide Care Plan Report (ACPR). This deficient practice affected 7 of 9 active records reviewed, including home visit (HV) # 1, MR # 5, MR # 6, MR # 3, MR # 4, MR # 2, and MR # 1, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hospice Aide Services Policy Number: 4-003.1 Revision Date: April 2020 Purpose: To specify the role of the hospice aide and/or homemaker in hospice care. Policy: Hospice aide services will include personal care services provided by trained hospice aides... Procedure: ...4. Hospice aides will document care provided in accordance with the hospice aide assignment. 1. HV # 1 was admitted to hospice services on 4/5/21, and recertified for continued care 3/31/22 to 5/29/22 with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure, and Anemia Unspecified. Review of the Hospice Recertification Plan of Care Update dated 3/16/22 revealed a HA ordered visit frequency of 2X (times) per week effective 4/3/22. Review of the Hospice Physician Order dated 4/7/22 revealed a clarification for the HA visit frequency effective 4/3/22 of 3X per week. Review of the ACPR printed for the surveyor on 5/2/22 by the agency, revealed the HA was to perform the following tasks every visit: Transfer Client From Bed/Chair Transfer Client From Chair/Bed Assist to Bedside Commode Assist With Bedpan Shampoo Skin Care Oral Care Change Linens Review of the HA Visit Note Reports (VNR) dated 4/5/22, 4/11/22, 4/18/22, and 5/2/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Bedside Commode (BSC), Assist With Bedpan, Shampoo, and Change Linens were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/6/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, Shampoo, Oral Care, and Change Linens were not completed due to, "Not Required This Visit." Review of the HA VNRs dated 4/8/22, 4/14/22, 4/25/22, and 4/29/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, and Shampoo were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/13/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, Shampoo and Skin Care were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/27/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, and Change Linens were not completed due to, "Not Required This Visit." An interview was conducted on 5/4/22 at 1:42 PM with Employee Identifier (EI) # 1, Registered Nurse (RN) Administrator, who confirmed the HA was not performing all tasks assigned for every visit per the ACPR. 2. MR # 5 was admitted to hospice services on 6/10/21, and recertified for continued care 4/6/22 to 6/4/22 with diagnoses including Malignant Neoplasm Of Upper Lobe Right Bronchus Or Lung, and Other Fronto-Temporal Dementia. Review of the Hospice Recertification Plan of Care Update dated 3/22/22 revealed a HA visit frequency of 2X per week, effective 4/6/22, then 3X per week, effective 4/10/22. Review of the ACPR printed for the surveyor on 5/2/22 by the agency, revealed the HA was to perform the following tasks every visit: Stand By Assistance With Ambulation Shampoo Review of the HA VNR dated 4/13/22 and 5/2/22 revealed the task Shampoo was not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/29/22 revealed the task Stand By Assistance With Ambulation was not completed due to, "Not Required This Visit." In an interview conducted 5/4/22 at 1:53 PM, EI # 1 confirmed the HA was not performing all tasks assigned for every visit per the ACPR. 3. MR # 6 was admitted to hospice services on 4/1/22 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, and Disorder Of The Autonomic Nervous System, Unspecified. Review of the Hospice Certification and Plan of Care dated 4/1/22 to 6/29/22 revealed an ordered HA visit frequency of 2X per week, effective 4/3/22. Review of the ACPR printed for the surveyor on 5/2/22 by the agency, revealed the HA was to perform the following tasks every visit: Transfer Client From Bed/Chair Transfer Client From Chair/Bed Assist To Toilet Assist With Feeding Shampoo Offer Fluids Review of the HA VNR dated 4/4/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Toilet, and Offer Fluids were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/14/22 and 4/18/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, and Assist to Toilet, were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/25/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Toilet, and Shampoo were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/29/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Toilet, and Assist With Feeding were not completed due to, "Not Required This Visit." In an interview conducted 5/4/22 at 1:28 PM, EI # 1 confirmed the HA was not performing all tasks assigned for every visit per the ACPR. 4. MR # 3 was admitted to the hospice agency on 3/27/21 with a diagnosis of Malignant Neoplasm of the Prostate. Review of the Hospice Certification and Plan of Care dated 3/27/22 to 5/25/22 revealed the HA was to visit 3 times a week. Review of the ACPR dated 3/2/22 revealed the following tasks were assigned to be completed every visit: Shampoo Shave Oral Care Nail Care Change Linen Review of the HA VNR dated 3/23/22 revealed the tasks Shave, Nail Care and Change Linens were not completed due to, "Not required This Visit." Review of the HA VNR dated 3/25/22, 3/28/22, 4/4/22, 4/14/22, 4/25/22, and 5/2/22 revealed the tasks Nail Care and Change Linens were not completed due to, "Not required This Visit." Review of the HA VNR dated 3/30/22 revealed the tasks Shave and Nail Care were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/1/22 and 4/20/22 revealed the tasks Shampoo, Nail Care and Change Linens were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/6/22 revealed the tasks Shampoo, Shave, Nail Care and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/8/22, 4/11/22, 4/18/22, and 4/29/22 revealed the task Nail Care was not completed due to, "Not required This Visit." Review of the HA VNR dated 4/13/22 and 4/27/22 revealed the tasks Shampoo, Shave and Nail Care were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/22/22 revealed the tasks Shampoo and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/29/22 revealed the task Nail Care was not completed due to, "Not required This Visit." An interview was conducted on 5/3/22 at 4:50 PM with EI # 1. EI # 1 verified the HA was not conducting each task every visit. 5. MR # 4 was admitted to the hospice agency on 4/6/22 with a diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. Review of the Hospice Certification and Plan of Care dated 4/6/22 to 7/4/22 revealed a HA visit frequency of 1 time a week times 1 week and then 2 times a week. Review of the ACPR dated 4/6/22 revealed the following tasks to be preformed every visit: Shampoo Shave Oral Care Change Linen. Review of the HA VNR dated 4/7/22 revealed the tasks Shave and Oral were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/21/22 revealed the tasks Shampoo and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/28/22 revealed the task Shampoo was not completed due to, "Not required This Visit." An interview was conducted on 5/3/22 at 4:55 PM with EI # 1. EI # 1 verified the HA was not conducting each task every visit. 6. MR # 2 was admitted to the hospice agency on 4/4/22 with diagnoses including Myocardial Infarction and Chronic Obstructive Pulmonary Disease. Review of the Hospice Certification and Plan of Care dated 4/4/22 revealed the HA was to visit 2 times a week. Review of the ACPR dated 4/6/22 revealed the following tasks to be preformed every visit: Shampoo Nail Care Change Linen. Review of the HA VNR dated 4/7/22 revealed the tasks Shampoo, Nail Care and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/11/22, 4/12/22, 4/13/22, 4/14/224/26/22 and 4/29/22 revealed the task Shampoo was not completed due to, "Not required This Visit." A written response was submitted on 5/6/22 at 11:51 AM by EI # 1 which verified the HA did not perform all assigned tasks. 7. MR # 1 was admitted to the hospice agency on 1/5/22 with a diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. Review of the recertification orders dated 3/21/22 revealed the HA visit frequency was 2 times a week. Review of the ACPR dated 1/5/22 revealed the following tasks to be preformed every visit: Shampoo Change Linen. Review of the HA VNR dated 4/21/22 revealed the task Change Linen was not completed due to, "Not required This Visit." Review of the HA VNR dated 4/28/22 revealed the tasks Shampoo and Change Linen were not completed due to, "Not required This Visit." A written response was submitted on 5/6/22 at 11:51 AM by EI # 1 which verified the HA did not perform all assigned tasks.

Based on medical record (MR) review, policies and procedures, and interview with staff, it was determined the Registered Nurse (RN) did not assess the Hospice Aide (HA) completion of assigned tasks as instructed on the Aide Care Plan Report (ACPR). This deficient practice affected 7 of 9 active records reviewed, and did affect MR # 3, MR # 4, MR # 2, MR # 1, Home Visit (HV) # 1, MR # 5, MR # 6, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hospice Aide Services Policy Number: 4-003.1 Revision Date: April 2020 Purpose: To specify the role of the hospice aide and/or homemaker in hospice care. Policy: Hospice aide services will include personal care services provided by trained hospice aides...These activities...will be assigned and supervised by a hospice registered nurse. Procedure: ...4. Hospice aides will document care provided in accordance with the hospice aide assignment. Agency Policy: Internal Control Systems/Accountabilities Policy Number: 2-041.1 Revision Date: April 2020 Policy: An ongoing evaluation process will be established utilizing existing and new monitoring procedures...This policy includes key areas for monitoring... Procedure: ...3. Clinical/Documentation Compliance: The skilled care/hospice eligibility requirements for Medicare coverage are assessed using several methods: ...2. Supervisory visits with staff. ...E. Hospice Aide Services: This includes the following: ...3. Care Plan matches orders, aide schedule matches orders and services provided match documentation... 1. MR # 3 was admitted to the hospice agency on 3/27/21 with a diagnosis of Malignant Neoplasm of the Prostate. Review of the Hospice Certification and Plan of Care dated 3/27/22 to 5/25/22 revealed the HA was to visit 3 times a week. Review of the ACPR dated 3/2/22 revealed the following tasks were assigned to be completed every visit: Shampoo Shave Oral Care Nail Care Change Linen Review of the HA Visit Note Report (VNR) dated 3/23/22 revealed the tasks Shave, Nail Care and Change Linens were not completed due to, "Not required This Visit." Review of the HA VNRs dated 3/25/22, 3/28/22, 4/4/22, 4/14/22, 4/25/22, and 5/2/22 revealed the tasks Nail Care and Change Linens were not completed due to, "Not required This Visit." Review of the HA VNR dated 3/30/22 revealed the tasks Shave and Nail Care were not completed due to, "Not required This Visit." Review of the HA VNRs dated 4/1/22 and 4/20/22 revealed the tasks Shampoo, Nail Care and Change Linens were not completed due to, "Not required This Visit." Review of the HA VNR dated 3/23/22 revealed the tasks Shave, Nail Care and Change Linens were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/6/22 revealed the tasks Shampoo, Shave, Nail Care and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/8/22, 4/11/22, 4/18/22, and 4/29/22 revealed the task Nail Care was not completed due to, "Not required This Visit." Review of the HA VNRs dated 4/13/22 and 4/27/22 revealed the tasks Shampoo, Shave and Nail Care were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/22/22 revealed the tasks Shampoo and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/29/22 revealed the task Nail Care was not completed due to, "Not required This Visit." Review of the RN VNRs dated 3/25/22, 3/30/22, 4/1/22, 4/4/22, 4/8/22, 4/11/22, 4/13/22, 4/18/22, and 4/20/22 revealed the following documentation, "Is the Home Health Aide Following The Aide Care Plan? YES." An interview was conducted on 5/3/22 at 4:50 PM with Employee Identifier (EI) # 1, RN Administrator, who stated the nurse did not document the aide was not performing all assigned tasks. 2. MR # 4 was admitted to the hospice agency on 4/6/22 with a diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. Review of the Hospice Certification and Plan of Care dated 4/6/22 to 7/4/22 revealed a HA visit frequency of 1 time a week times 1 week and then 2 times a week. Review of the ACPR completed dated 4/6/22 revealed the following tasks to be preformed every visit: Shampoo Shave Oral Care Change Linen. Review of the HA VNR dated 4/7/22 revealed the tasks Shave and Oral Care were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/21/22 revealed the tasks Shampoo and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/28/22 revealed the task Shampoo was not completed due to, "Not required This Visit." Review of the RN VNRs dated 4/7/22, 4/26/22, 4/27/22 and 5/2/22 revealed the following documentation, "Is the Home Health Aide Following The Aide Care Plan? YES." An interview was conducted with EI # 1 on 5/3/22 at 4:55 PM. EI # 1 verified the RN did not document the aide was not performing all assigned tasks. 3. MR # 2 was admitted to the hospice agency on 4/4/22 with diagnoses including Myocardial Infarction and Chronic Obstructive Pulmonary Disease. Review of the Hospice Certification and Plan of Care dated 4/4/22 revealed the HA was to visit 2 times a week. Review of the Aide Plan of Care Report completed by the RN dated 4/6/22 revealed the following tasks to be preformed every visit: Shampoo Nail Care Change Linen. Review of the HA VNR dated 4/7/22 revealed the tasks Shampoo, Nail Care and Change Linen were not completed due to, "Not required This Visit." Review of the HA VNR dated 4/11/22, 4/12/22, 4/13/22, 4/14/224/26/22 and 4/29/22 revealed the task Shampoo was not completed due to, "Not required This Visit." Review of the RN VNRs dated 4/18/22 and 4/20/22 revealed the following documentation, "Is the Home Health Aide Following The Aide Care Plan? YES." The RN did not document the aide did not complete all assigned tasks. 4. MR # 1 was admitted to the hospice agency on 1/5/22 with a diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. Review of the recertification orders dated 3/21/22 revealed the HA visit frequency was 2 times a week. Review of the ACPR dated 1/5/22 revealed the following tasks to be preformed every visit: Shampoo Change Linen. Review of the HA VNR dated 4/21/22 revealed the task Change Linen was not completed due to, "Not required This Visit." Review of the HA VNR dated 4/28/22 revealed the tasks Shampoo and Change Linen were not completed due to, "Not required This Visit." Review of the RN VNRs dated 4/21/22, 4/22/22, and 5/2/22 revealed the following documentation, "Is the Home Health Aide Following The Aide Care Plan? YES." The RN did not document the aide did not complete all assigned tasks. 5. HV # 1 was admitted to hospice services on 4/5/21, and recertified for continued care 3/31/22 to 5/29/22 with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure, and Anemia Unspecified. Review of the Hospice Recertification Plan of Care Update dated 3/16/22 revealed a HA ordered visit frequency of 2X (times) per week effective 4/3/22. Review of the Hospice Physician Order dated 4/7/22 revealed a clarification for the HA visit frequency effective 4/3/22 of 3X per week. Review of the Aide Care Plan Report printed for the surveyor on 5/2/22 by the agency, revealed the HA was to perform the following tasks every visit. Transfer Client From Bed/Chair Transfer Client From Chair/Bed Assist to Bedside Commode Assist With Bedpan Shampoo Skin Care Oral Care Change Linens Review of the HA Visit Note Reports (VNR) dated 4/5/22, 4/11/22, 4/18/22, and 5/2/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Bedside Commode (BSC), Assist With Bedpan, Shampoo, and Change Linens were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/6/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, Shampoo, Oral Care, and Change Linens were not completed due to, "Not Required This Visit." Review of the HA VNRs dated 4/8/22, 4/14/22, 4/25/22, and 4/29/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, and Shampoo were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/13/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, Shampoo and Skin Care were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/27/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to BSC, Assist With Bedpan, and Change Linens were not completed due to, "Not Required This Visit." Review of the RN VNRs under the heading "Supervisory Functions," dated 3/31/22, 4/4/22, 4/7/22, 4/14/22, 4/18/22, 4/21/22, 4/25/22, and 4/27/22 revealed the RN documented, "yes," to the question asking if the aide was following the aide care plan. The RN failed to document the aide was not completing all assigned tasks. In an interview conducted 5/4/22 at 1:42 PM, EI # 1 confirmed the HA did not perform all tasks as assigned on the aide care plan. 6. MR # 5 was admitted to hospice services on 6/10/21, and recertified for continued care 4/6/22 to 6/4/22 with diagnoses including Malignant Neoplasm Of Upper Lobe Right Bronchus Or Lung, and Other Fronto-Temporal Dementia. Review of the Hospice Recertification Plan of Care Update dated 3/22/22 revealed a HA visit frequency of 2X per week, effective 4/6/22, then 3X per week, effective 4/1022. Review of the ACPR printed for the surveyor on 5/2/22 by the agency, revealed the HA was to perform the following tasks every visit: Stand By Assistance With Ambulation Shampoo Review of the HA VNR dated 4/13/22 and 5/2/22 revealed the task Shampoo was not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/29/22 revealed the task Stand By Assistance With Ambulation was not completed due to, "Not Required This Visit." Review of the RN VNR under the heading "Supervisory Functions," dated 4/28/22, revealed the RN documented, "yes," to the question asking if the aide was following the aide care plan. The RN failed to document the aide was not completing all assigned tasks. In an interview conducted 5/4/22 at 1:53 PM, EI # 1 confirmed the HA did not perform all tasks as assigned on the aide care plan. 7. MR # 6 was admitted to hospice services on 4/1/22 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, and Disorder Of The Autonomic Nervous System, Unspecified. Review of the Hospice Certification and Plan of Care dated 4/1/22 to 6/29/22 revealed an ordered HA visit frequency of 2X per week, effective 4/3/22. Review of the ACPR printed for the surveyor on 5/2/22 by the agency, revealed the HA was to perform the following tasks every visit: Transfer Client From Bed/Chair Transfer Client From Chair/Bed Assist To Toilet Assist With Feeding Shampoo Offer Fluids Review of the HA VNR dated 4/4/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Toilet, and Offer Fluids were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/14/22 and 4/18/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, and Assist to Toilet, were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/25/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Toilet, and Shampoo were not completed due to, "Not Required This Visit." Review of the HA VNR dated 4/29/22 revealed the tasks Transfer Client From Bed/Chair, Transfer Client Chair/Bed, Assist to Toilet, and Assist With Feeding were not completed due to, "Not Required This Visit." Review of the RN VNR under the heading "Supervisory Functions," dated 4/4/22, 4/6/22, 4/11/22, 4/22/22, and 4/27/22 revealed the RN documented, "yes," to the question asking if the aide was following the aide care plan. The RN failed to document the aide was not completing all assigned tasks. In an interview conducted 5/4/22 at 1:28 PM, EI # 1 confirmed the HA did not perform all tasks as assigned on the aide care plan.