Every finding on record at Liberty Home Care II, LLC

Based on agency policy, clinical record review, and staff interviews, the agency failed to include treatment orders on the plan of care for 1 of 1 patient requiring a Trilogy (a mechanical device used to assist with breathing) (#8).Findings included: --- A policy, Admission and Initial Comprehensive Assessment and Development of the Plan of Care (revised 02/2025), received on 05/19/2025 at 12:27 PM from licensed practical nurse #13 stated, “Agency staff receiving or verifying a referral will try to obtain the following baseline information: … Treatment orders.”Patient #8 was admitted on 08/18/2023 with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. The plan of care for 04/09/2025-06/07/2025 included orders for skilled nurse visits 1 time a week for 9 weeks with 8 PRN (as needed). Review of the clinical record revealed that on 04/18/2025 clinical manager #8 documented, “has been using Trelegy [sic] every night.” Further review revealed that the Trilogy machine was not included in the plan of care.During an interview conducted on 05/20/2025 at 9:10 AM clinical manager #8 stated, “I would have expected that [Trilogy machine] to be included in the plan of care.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to coordinate care with the physician’s for 2 of 3 patients who are not taking medications as ordered. (#8 & 22)Finidngs included: --- A policy, Case Management, Coordination and Communication Activities (revised 11/2020) received on 05/21/2025 at 12:00 PM from the agency director stated, “Hospice staff maintains ongoing communication with the physician… that addressed the following, at a minimum: … Changes have occurred regarding … medications…”A policy, Clinical Record Content (revised 02/2025) received on 05/19/2025 at 12:27 PM from licensed practical nurse #13 stated, “Each time a patient is seen a clinical note is documented that includes: …Discussions with physician’s or other persons involved…”Patient #8 was admitted on 08/18/2023 with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. The plan of care for 04/09/2025-06/07/2025 included orders for skilled nurse visits 1 time a week for 9 weeks with 8 PRN (as needed). Review of the clinical record revealed that on 05/07/2025 clinical manager #8 documented, “Patient is refusing the use of Zyprexa [antipsychotic medication] … Patient has not performing [sic] breathing treatment.” Further review revealed no documentation that the physician was notified.      2. Patient #22 was admitted on 02/26/2025 with a diagnosis of hypertensive heart disease (high blood pressure) and chronic kidney disease with heart failure. The plan of care              for 02/26/2025-05/26/2025 included orders for skilled nurse visits 2 times a week for 13 weeks with 4 PRN (as needed). Review of the clinical record revealed that on                        04/17/2025 registered nurse #15 documented, “Patient had started on a new medication (Neurontin) [treats nerve pain] … Discussed with wife, who feels more comfortable              holding the medication.” Further review revealed no documentation that the physician was notified that order was not followed.

Based on agency policy, observation, and staff interviews, the agency failed to follow agency procedures to prevent the spread of infection for 3 of 5 conducted home visits. (patients #1, 3,19)Findings included: --- A policy, Bag technique, home care (revised 05/20/2024) received on 05/19/2025 at 4:00 PM from the clinical manager stated, “Perform hand hygiene before entering the bag… Never place any soiled or dirty items into the bag, Clean and disinfect reusable items according to your agency’s guidelines… Place a nonwheeled bag on a flat surface that appears clean and dry.”A policy, Hand Hygiene (revised 08/19/2024) received on 05/19/2025 at 4:00 PM from the clinical manager stated, “An alcohol-based hand rub is appropriate for decontaminating the hands: … after contact with the patient… after contact with inanimate objects in the patient’s environment…”Patient #1 was admitted on 11/23/2024 with a diagnosis of congestive heart failure and was a resident of a skilled nursing facility. The plan of care for 02/21/2025-05/21/2025 included orders for home health aide (HHA) 3 times a week for 1 week, 2 times a week for 1 week, and 5 times a week for 8 weeks. During a home visit conducted on 05/20/2025 at 8:00 AM HHA #3 placed the clinical bag on a chair, on top of the patient’s shoes.During an interview conducted on 05/21/2025 at 8:32 AM HHA #3 stated, “I didn’t notice the shoes under my bag. No, I would not normally place the bag on shoes.”During an interview on 05/21/2025 at 8:34 AM the agency administrator stated, “They [clinical bags] should be placed on a clean surface.”      2. Patient #3 was admitted on 10/09/2024 with a diagnosis of abnormal weight loss and was a resident of a skilled nursing facility. The plan of care for 05/07/2025-07/05/2025               included orders for medical social work (MSW) visits 1 times a month for 2 months with 2 PRN (as needed). During a home visit conducted on 05/20/2025 at 1:30 PM MSW               #4 placed the documentation tablet on the patient’s cloth chair then moved the tablet to the patient’s bedside table, documented on the tablet and placed the tablet into the                 clinical bag without sanitizing the tablet. MSW #3 touched personal items throughout the patient’s room and failed to perform hand hygiene prior to reaching into the clinical               bag.An interview conducted on 05/21/2025 at 8:37 AM with MSW#3 revealed that MSW #3 was not aware that cloth furniture is not considered clean, that hand hygiene must be performed prior to entering the clinical bag, and the documentation tablet should be cleaned prior to placing it in the clinical bag.      3. Patient #19 was admitted on 05/01/2025 with a diagnosis of abnormal weight loss and was a resident of an assisted living facility. The plan of care for 05/01/2025-07/29/2025           included orders for skilled nurse visits 1 time a week for 10 weeks. During a home visit conducted on 05/20/2025 at 2:00 PM licensed practical nurse (LPN) #9 placed a                     stethoscope on the patient’s bed and failed to sanitize the stethoscope prior to placing it in the clinical bag.LPN #9 was not available for an interview.During an interview on 05/20/2025 at approximately 2:30 PM the clinical manager stated, “They [staff] should clean the equipment before putting it back in the bag.”During an interview conducted on 05/21/2025 at 8:49 AM the agency administrator stated, “The expectation is that any staff member will sanitize their hands before they go into their clinical bag. Any equipment should be cleaned and sanitized before it goes back into the bag.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to document responses to medications for 2 of 2 facility patients with unmanaged symptoms. (patient #1, 21)Findings included: --- A policy, Clinical Record Content (revised 02/2025) received on 05/19/2025 at 12:27 PM from licensed practical nurse #13 stated, “Each hospice record will contain the following information, at a minimum: … A description of the patient’s condition … including response to medication, symptom management…”Patient #1 was admitted on 11/23/24 with a diagnosis of congestive heart failure (condition in which the heart doesn’t pump enough blood). The plan of care for 02/21/2025-05/21/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks, 8 PRN (as needed), and “skilled nurse observation of S/SX UTI [signs and symptoms of urinary tract infection].” Review of the clinical record revealed that on 04/14/2025 registered nurse (RN) #16 documented, “Facility staff suspect UTI d/t [due to] pts [patient’s] behavior… Nurse [facility nurse’s name] states they have already notified the facility provider and is waiting for a response. Plan for next 2 weeks is possibly treat UTI.” Further review revealed that there was no follow-up documentation.During an interview conducted on 05/21/2025 at 8:51 AM RN #16 stated, “I didn’t see her for 16 days [after the suspected UTI]. I didn’t feel like she had a UTI. Yes [normally communicates concerns to the licensed practical nurse [to follow-up].      2.  Patient #21 was admitted on 01/16/2025 with a diagnosis of chronic obstructive pulmonary disease (lung disease that blocks air flow). The plan of care for 04/16/2025-                       07/14/2025 included orders for skilled nurse (SN) visits 2 times a week for 8 weeks with 3 PRN (as needed) and “SN to assess exacerbations… that present themselves.”                 Review of the clinical record revealed that during the SN visit on 04/29/2025 registered nurse (RN) #14 documented, “Patient appears to be having an anxiety attack…                       Patient was assisted to bed, and encouraged to rest after receiving PRN dose of morphine… Will follow-up tomorrow.” Further review revealed that there was no follow-up                 documentation.During an interview conducted on 05/21/25 at 9:12 AM RN #14 stated, “I’m sure that I did [follow-up], it looks like another nurse saw her for me, I don’t remember. I do [normally document my follow-up]. I do know that I was there with her on 04/30 I did see her, I think that I just didn’t chart it.”During an interview on 05/21/2025 at 9:18 AM the agency administrator stated, “If an issue it identified, then it should be followed up on based on company policy or the limit that they set and document it.”

Based on agency policy, clinical record review, interviews with staff and family the agency failed to notify the healthcare power of attorney [HCPOA] when a new medication was ordered for 1 of 2 discharged patients [#4]. The findings included: --- The policy, Patient Rights and Responsibilities [revised 7/21], was provided by the branch administrator on 7/10/23 at 11 am. The policy stated, ";...On the first visit, the clinician will obtain the name of the patient-selected representative...The patient-selected representative participates in making decisions related to the patients care or well-being...To participate in, be informed about, and consent or refuse care in advance of and during treatment..." Patient # 4 had a Start of Care date of 12/21/22 and a terminal diagnosis of cerebral infraction due to unspecified occlusion or stenosis of left mid cerebral artery [stoke]. Review of the Plan of Care [POC] for the certification period 12/21/22 to 3/20/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 time a week for 11 weeks. Review of the POC revealed the patient had a healthcare power of attorney [HCPOA]. The patient resided in a skilled nursing facility [SNF]. Review of the comprehensive assessment completed on 12/21/22 by RN # 1 revealed the patient did not have an order for Lorazepam [antianxiety medication]. Review of the nurses note dated 12/21/22 revealed the following documentation, ";...Some noted anxiety during visits, repeating gotta go, gotta go. Would benefit from low dose antianxiety medications..." Review of the clinical record revealed RN # 1 obtained an order for Lorazepam 0.25 mg twice daily. On 1/3/23, a supplemental order was obtained by RN # 2 for Lorazepam 0.50 mg three times a day with a start date of 1/3/23. Further review of the clinical record revealed no evidence the HCPOA was notified when the new order for Lorazepam was initiated nor was she notified when the dose was increased. During a phone interview with the HCPOA on 7/10/23 at approximately 2:30 pm, she stated, ";I didnt even know my grandmother was taking any kind of medication for anxiety until I saw it on her discharge papers." [Patient was discharged from hospice services on 1/9/23 when she was moved out of the service area]. During an interview with RN # 1 on 7/10/23 at approximately 3 pm, RN # 1 stated, ";I cant find any documentation where we called and notified her [HCPOA]." During an interview with the branch administrator on 7/10/23 at approximately 1 pm the administrator stated, ";I can find nothing in the clinical record where the HCPOA did not want to be notified when any medications were added or discontinued, so yes, we should have notified her."

Based on clinical record review and staff interviews the Plan of Care [POC] failed to include an order for a speech evaluation for 1 of 1 patient [#1]; failed to include an order for a sling to the left arm for 1 of 1 patient with a fractured shoulder [#1]; failed to include an order for wound care for 1 of 1 patient with a wound [#2]. The findings included: --- 1A. Patient # 1 had a Start of Care date of 6/20/23 and a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure [heart doesnt pump effectively]. Review of the Plan of Care [POC] for the certification period 6/20/23 to 6/17/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 time a week for 11 weeks, 3 PRN [as needed] for exacerbation of disease process/complications/changes in condition. The patient resided in a skilled nursing facility [SNF]. Review of the clinical record revealed RN # 2 made a PRN visit on 7/2/23 when the facility called to report the patient had fallen. RN # 2 obtained an order for an x-ray to the left shoulder due to pain. On 7/3/23, the SNFs physician assistant contacted RN # 2 to report the patient had a fracture to the left shoulder as well as aspiration pneumonia [occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed]. An order was obtained for a speech evaluation. The speech evaluation was completed at the SNF. There was no order for a speech evaluation noted on the patients chart. During an interview with the branch administrator on 7/10/23 at approximately 12:30 pm, the administrator stated, ";The order is on the chart at the nursing home, we failed to get the order on the patients hospice chart. It should be in both places." 1B. Patient # 1 had a Start of Care date of 6/20/23 and a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure [heart doesnt pump effectively]. Review of the Plan of Care [POC] for the certification period 6/20/23 to 6/17/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 time a week for 11 weeks, 3 PRN [as needed] for exacerbation of disease process/complications/changes in condition. The patient resided in a skilled nursing facility [SNF]. Review of the clinical record revealed RN # 2 made a PRN visit on 7/2/23 when the facility called to report the patient had fallen. RN # 2 obtained an order for an x-ray to the left shoulder due to pain. On 7/3/23, the SNFs physician assistant [PA] contacted RN # 2 to report the patient had a fracture to the left shoulder. RN # 2 documented, ";TC [telephone call] from PA...States patient seen for eval of fracture to left shoulder. Treatment is support with sling..." Further review of the clinical record revealed no physicians order for a sling to the left arm. During an interview with the branch administrator on 7/10/23 at 12:30 pm, the administrator confirmed the there was no order for a sling. 2. Patient # 2 had a Start of Care date of 6/13/23 and a terminal diagnosis of Alzheimers disease. Review of the Plan of Care for the certification period 6/13/23-8/22/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 time a week for 9 weeks. Review of the nursing visit dated 6/19/23 revealed the following documentation by LPN # 3, ";Stage 2 pressure ulcer [intact blister or shallow open sore] noted on sacrum [area below spine] 2.9 cm x 7.5 cm x 0.1 cm. Wound cleaned, pat dry [sic], padded hydrocolloid [type of wound dressing] dressing applied..." Review of the clinical record revealed no order for a hydrocolloid dressing. During an interview with the branch administrator on 7/10/23 at approximately 12:30 pm, the administrator confirmed there was no order for the dressing.

Based on clinical record review and staff interviews the agency failed to include oxygen on the Plan of Care for 1 of 1 patient with an order for continuous oxygen [#1]. The findings included: --- Patient # 1 had a Start of Care date of 6/20/23 and a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure [heart doesnt pump effectively]. Review of the Plan of Care [POC] for the certification period 6/20/23 to 6/17/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 time a week for 11 weeks, 3 PRN [as needed] for exacerbation of disease process/complications/changes in condition. Review of the comprehensive assessment completed by RN # 2 on 6/20/23 revealed the following documentation, ";...He is new to oxygen therapy at 2 liters per minute by nasal cannula continuously, stating he was having shortness of breath while in the hospital..." Oxygen was not included on the POC. During an interview with RN # 2 on 7/10/23 at approximately 3 pm, RN # 2 confirmed the oxygen should be included on the POC

Based on agency policy, clinical record review and staff interviews the agency failed to update the hospice aide plan of care when there was a change in the patients needs for 1 of 1 patient with a fractured shoulder requiring the use of a sling [#1]. The findings included: --- The policy, Aide Care Plan and Documentation [no date], was provided by the branch administrator on 7/10/23 at 12:30 pm. The policy stated, ";...The aide will promptly receive notification of changes in the care plan or in the visit frequency..." Patient # 1 had a Start of Care date of 6/20/23 and a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure [heart doesnt pump effectively]. Review of the Plan of Care [POC] for the certification period 6/20/23 to 6/17/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 time a week for 11 weeks, 3 PRN [as needed] for exacerbation of disease process/complications/changes in condition and hospice aide 2 times a week for 13 weeks. The patient resided in a skilled nursing facility [SNF]. Review of the clinical record revealed RN # 2 made a PRN visit on 7/2/23 when the facility called to report the patient had fallen. RN # 2 obtained an order for an x-ray to the left shoulder due to pain. On 7/3/23, the SNF's physician assistant [PA] contacted RN # 2 to report the patient had a fracture to the left shoulder. RN # 2 documented, ";TC [telephone call] from PA...States patient seen for eval of fracture to left shoulder. Treatment is support with sling..." Review of the aide plan of care revealed the POC was not updated with the information related to the shoulder fracture and the use of a sling to the left arm. During an interview with the branch administrator on 7/10/23 at approximately 12:30 pm, the administrator stated, ";the aide care plan should have been updated to reflect the fracture and so the aide would know the patient was supposed to have a sling on."

Based on policy/procedure review, clinical record review, and staff interview, the nurse failed to document a comprehensive wound assessment on 1 of 4 patients with wounds (#8). Findings include: A policy/procedure, "Wound palliative care, home care" (revised 2/18/22), was provided by the agency administrator on 6/16/22 at 10:15 a.m. The policy/procedure stated, "A complete wound assessment is to be completed every visit and documented in the patient's medical record. Wound measurements are to be taken at least one time per week and documented in the clinical record ...Assess the general condition of the wound. Note the wound's type, size, shape, color, and anatomic location, as well as the presence of necrotic tissue (eschar or slough), odor, moisture ...Assess the surrounding skin (periwound area) for signs of infection, such as erythema [redness] and edema [swelling], as well as boggy or macerated tissue." Patient #8 was admitted on 5/9/22 with diagnoses of moderate protein-calorie malnutrition, stage 4 pressure ulcer of the left heel, unstageable pressure ulcer of the right hip, and an open wound to the right knee and right lesser toe. The Plan of Care (POC) for 5/9/22-8/6/22 included orders for skilled nursing weekly for 12 weeks. The POC wound care order for the left heel was cleanse with wound cleanser, apply Santyl ointment [a medication ointment that helps remove dead skin], cover with calcium alginate, cover with kerlix daily; the right hip cleanse with wound cleanser, pat dry, apply hydrocolloid dressing three times per week; right knee cleanse with wound cleanser, pat dry, apply xeroform and cover with gauze island dressing daily until healed; and the right 2nd toe cleanse with wound cleanser, pat dry, wipe with skin prep daily until healed. Between 5/9/22-6/10/22, there was no evidence of a comprehensive wound assessment for five of six skilled nursing visits. An interview was conducted with the clinical director on 6/16/22 at 10:00 a.m. The interview confirmed there was no evidence the complete comprehensive wound assessment was conducted on each visit.

Based on clinical record review and staff interview, the RN failed to update the hospice aide care plan as needed for 1 of 12 patients with hospice aide orders (#11). Findings include: Patient #11 was admitted on 5/12/22 with a diagnosis of chronic obstructive pulmonary disease (COPD-lung disease). The Plan of Care (POC) for 5/12/22-8/9/22 included orders for skilled nursing two times per week for two weeks, the weekly for 11; and hospice aide services three times per week for 12 weeks, then one time for one week to assist with activities of daily living. The RN completed the hospice aide care plan on 5/13/22. On 5/13/22, the aide visit note stated, "I spoke with nurse concerning the care plan and [the nurse] stated to answer the best I can and that she would take a look at it." On 5/18/22, the aide note stated, "Spoke to the nurse ______ RN/Clinical Manager concerning this pt [patient] care plan and she stated for me to just check off what I did and she get it straight [sic]." On 5/23/22, the aide note stated, "___ Rn [sic] notified of task not performed and need for care plan reviewed [sic]." On 5/25/22, the aide note stated, "Nurse notified task not performed, Need for care plan." The hospice aide care plan was updated on 5/57/22. An interview with the agency director on 6/16/22 at 11:15 a.m. revealed the care plan should be reviewed immediately when notified by the hospice aides.

Based on policy review, observation, and staff interviews the agency failed to perform hand hygiene during 1 of 4 staff observations. Findings include: Policy Hand Hygiene, home care (reviewed 08/20/21) was received from agency director on 06/16/2022 at 10:15 AM indicated that hand hygiene should be performed after contact with a patient. Patient #6 was admitted on 03/17/2022 with a diagnosis of Secondary malignant neoplasm of liver and intrahepatic bile duct, protein calorie malnutrition and congestive heart failure. The Plan of Care for 03/17/22 – 06/14/22 included skilled nurse visits 1 time a week for 12 weeks. On 06/14/2022a virtual home visit was observed with LPN #4. LPN # 4 performed a skin assessment on the coccyx, area around tailbone and picked up her documentation tablet and began medication review without removing her gloves and performing hand hygiene. In an interview with LPN #4 on June 16, 2022 at approximately 9:07 AM, LPN # 4 stated that during the skin assessment she noted a "small red blanchable [skin turned white when pressed] area on the sacrum coccyx area." LPN #4 confirmed that she did not remove her gloves and perform hand hygiene prior to the medication review. In an interview on June 16, 2022 at approximately 09:20 AM with the Clinical Director confirmed that the agency ' s expectation would be for hand hygiene to be performed immediately after the skin assessment.

3. Patient #12 was admitted on 05/23/22 with a diagnosis of Atherosclerotic heart disease of native coronary artery, non-pressure chronic ulcer of right ankle with fat exposed, non-pressure chronic ulcer of left foot, non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle, chronic atrial fabulation. Plan of Care for 05/23/22-08/20/22 included orders for skilled nursing visits 1 time a week for 13 weeks and home care aide 2 times a week for 1 week and 3 times a week for 12 weeks. Between 05/23/22-06/15/22, the hospice aide documented that the patient was not transferred to his chair on 7 of 7 visits, the patient was not shaved on 4 of 7 visits. There was no documentation that the RN was notified in the alteration of the plan of care for the hospice aide visits. An interview was conducted on 06/16/22 at approximately 10:30 AM with RN #7. RN #7 revealed that she was not made aware in changes to the plan of care, and she would expect the aide to make her aware. An interview with hospice aide #3 was conducted on 06/16/22 at approximately 9:30 AM. The aide revealed that she did not notify the RN of changes to the plan of care. An interview with the clinical director on 6/16/22 at 11:05 AM. confirmed the RN should be notified of changes. 4. Patient # 11 was admitted on 05/18/22 with a diagnosis of Cerebrovascular disease and vascular dementia with behavioral disturbance. The plan of care for 05/18/22 - 08/15/22 included orders for hospice aide 1 time a week for 1 week and 3 times a week for 12 weeks. Between 05/18/22 and 06/15/22, the hospice aide documented that the hair shampoo was not provided on 10 of 10 visits. There was no documentation that the RN was notified in the alteration of the plan of care for the hospice aide visits. An interview was conducted on 06/16/22 at approximately 10:30 AM with RN #7. RN #7 revealed that she was not made aware in changes to the plan of care and she would expect the aide to make her aware. An interview with hospice aide #3 was conducted on 06/16/22 at approximately 9:30 AM. The aide revealed that she did not notify the RN of changes to the plan of care. An interview with the clinical director on 6/16/22 at 11:05 AM confirmed that the RN should be notified of changes. 5. Patient # 15 was admitted 05/24/22 with a diagnosis of Unspecified systolic (congestive) heart failure. The plan of care for 05/24/22 - 08/21/22 included nursing visits 1 time a week for 14 weeks and hospice aide visits 2 times a week for 1 week and 3 times a week for 13 weeks. Between 05/24/22 and 06/15/22 hospice aide # 12 documented that the hair shampoo was not provided on 8 of 8 visits and peri care was not provided on 6 of 8 visits. An interview was conducted on 06/16/22 at approximately 11:00 AM with hospice aide #12. The hospice aide revealed that she didn't know that she was supposed to communicate alterations to the plan of care to the RN. An interview with the clinical director on 6/16/22 at 11:05 AM. confirmed the RN should be notified of changes. Based on policy review, clinical record review, and staff interview, the hospice aide failed to report changes in the plan of care to the registered nurse for 4 of 12 patients with hospice aide orders (#5, 14, 12, 11, and 15). Findings include: A policy, "Aide Care Plan and Documentation" (effective 10/2021), was provided by the clinical director on 6/16/22 at 11:45 a.m. The policy stated, "The hospice aide ...Notifies/informs the patient's RN case manager or supervisor ...If a task is not performed as ordered, or not allowed by the patient within the frequency week." 1. Patient #5 was admitted on 4/15/22 with a diagnosis of chronic obstructive pulmonary disease (COPD-a respiratory disease). The Plan of Care (POC) for 4/15/22-7/13/22 included orders for skilled nursing visits one time for the admission, then weekly for 12 weeks; and hospice aide services to assist with activities of daily living three times per week, then increased to four times per week starting the week of 6/9/22. For 15 of 26 hospice aide visits between 4/21/22-6/14/22, the hospice aide documented mouth care as not performed. Between 4/21/22-6/14/22, the hospice aide documented shampoo was not performed for 21 of 26 visits. There was no documentation that the RN was notified in the alteration of the plan of care for the hospice aide visits. An interview with RN #7 on 6/15/22 at 3:30 p.m. revealed the hospice aide should have notified the nurse of changes. RN #7 did not recall any notification that the hospice aide did not provide mouthcare or shampoo the patient's hair. An interview with hospice aide #3 was conducted on 6/15/22 at 4:00 p.m. The aide stated, "You are supposed to notify the nurse [of alterations in the plan of care], but I did not. An interview with the clinical director on 6/16/22 at 11:05 a.m. confirmed the RN should be notified of changes. 2. Patient #14 was admitted on 5/18/22 with a diagnosis of chronic diastolic (congestive) heart failure (a progressive heart disease that affects the pumping action of the heart muscles). The Plan of Care for 5/18/22-8/15/22 included orders for skilled nursing visits two times for 1 week, then weekly for 13 weeks; and hospice aide visits weekly for 13 weeks for assist with activities of daily living. Between 5/20/22-6/10/22, the hospice aide documented that the hair shampoo was not provided during four of four hospice aide visits. An interview with hospice aide #11 was conducted on 6/16/22 at approximately 11:00 a.m. The aide revealed the patient had someone come to her home weekly to provide shampoo and hair care. The aide stated, "I didn't know [to notify the RN], but I will now."