Every finding on record at Mary, Queen of Angels Hospice

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&Ps included the procedures to inform the State and local officials of any on-duty staff or patients that they were unable to contact in the event of an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan dated 1/26/22 was initiated on 1/17/23. The hospices emergency preparedness P&P included the procedures to utilize the employee call logs to ensure the patients and staff were accounted for during an emergency. However, it did not specifically include the procedures to inform both the State and local officials of any on-duty staff or patients that they are unable to contact. On 1/23/23 at 1126 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&Ps included the procedures to inform the State emergency preparedness officials about the patients in need of evacuation from their residences at any time due to an emergency situation, based on the patients medical and psychiatric condition and home environment. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan dated 1/26/22, was initiated on 1/17/23. The P&P showed the hospice would notify the emergency community resource for the patients who need assistance in case of a disaster; however, it did not specifically address the hospice would inform the State emergency preparedness officials about the patients in need of evacuation based on their medical, psychiatric condition, and home environment. On 1/23/23 at 1126 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&Ps included the process and role of integration of State and Federally designated healthcare professionals to address the surge needs during an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency in the event the hospices and local agencies resources were exhausted. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Management Plan dated 1/26/22, was initiated on 1/17/23. The P&P included the process of how it will utilize the chain of command to communicate in the event of an emergency. The P&P also listed the contact information of the emergency preparedness agencies; however, it did not specifically address the process of how the hospice would integrate the State and Federally designated healthcare professionals to address the surge needs during an emergency. On 1/23/23 at 1126 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to conduct exercises that tested the hospices emergency preparedness plans. This failure created the risk of not identifying the gaps in the hospices emergency program including the staffs knowledge in responding to various types of emergencies. --- Findings: Review of the hospices Emergency Management Program showed the hospice conducted fire and earthquake drills for the years of 2021 and 2022. Howerver, there was no documented evidence showing the hospice conducted other types of emergency drills. In addition, there was no documented evidence showing the emergency drills were conducted for the years of 2019 and 2020. On 1/23/23 at 1126 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the initial and comprehensive assessment of patient was provided to meet the patients' care needs as evidenced by: --- Findings: 1. The hospice failed to ensure the comprehensive assessments were completed no later than five calendar days. Cross reference to L523. 2. The hospice failed to ensure the comprehensive assessments had identified the physical, emotional, psychosocial, and spiritual needs. Cross reference to L524. 3. The hospice failed to include all current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments and the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use. Cross reference to L530. 4. The hospice failed to ensure the updated comprehensive assessments were completed and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses. Cross reference to L533. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the initial and comprehensive assessment of patient to meet the patients' care needs.

Based on record review and interview, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days for six of 14 sampled patients (Patients 1, 2, 3, 5, 7, and 12), creating the risk of not identifying the care needs for these patients. --- 6. Review of Patient 3's closed clinical record was initiated on 1/10/23. The clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the certification period from 11/9/22 to 2/6/23. Review of the patients closed clinical record showed the initial Psychosocial Assessment was completed by the MSW on 12/19/22, more than five days after the election of hospice care. On 1/23/23 at 0929 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The initial nursing comprehensive assessment dated 11/18/22, failed to show documented evidence the body systems assessments, including genitourinary/reproductive, sleep/rest, and musculoskeletal were completed. Further review of the clinical record showed no documented evidence of the comprehensive psychosocial assessment. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. Review of the clinical record showed no documented evidence of the comprehensive psychosocial assessment. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. Review of the clinical record showed no documented evidence of the initial comprehensive psychosocial assessment. On 1/23/23 at 1040 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 4. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. Review of the clinical record showed no documented evidence of the initial comprehensive psychosocial assessment. On 1/23/23 at 1120 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 5. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. The initial Comprehensive Nursing Assessment dated 4/19/21, showed the need for volunteer was not assessed. On 1/23/23 at 1200 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the physical, emotional, psychosocial, and spiritual needs for seven of 14 sampled patients (Patients 1, 2, 4, 5, 6, 7, and 12), creating the risk of not providing care and services to meet the care needs for these patients. --- 6. Review of Patient 4's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 10/18/22. The patient was certified for hospice services during the certification period from 10/18/22 to 1/15/23. Review of the clinical record showed the initial nursing and spiritual comprehensive assessments were completed on 10/19/22. However, further review of the clinical record showed no documented evidence the patients psychosocial needs were assessed. On 1/23/23 at 0954 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 7. Review of Patient 6s clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22.Review of the clinical record showed the initial Comprehensive Nursing Assessment was completed on 9/20/22. However, there was no documented evidence the Nutrition and Personal Care and Support Needs sections were completed. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The initial nursing comprehensive assessment dated 11/18/22, showed the assessments for genitourinary/reproductive, sleep/rest, and musculoskeletal were incomplete. There was no documented evidence of the initial comprehensive psychosocial assessment was completed by the MSW. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. There was no documented evidence of the initial comprehensive psychosocial assessment completed by the MSW. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. There was no documented evidence of the initial comprehensive psychosocial assessment completed by the MSW. On 1/23/23 at 1040 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 4. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. There was no documented evidence of the initial comprehensive psychosocial assessment completed by the MSW. On 1/23/23 at 1120 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 5. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. There was no documented evidence of the initial comprehensive included the need for volunteer was assessed. On 1/23/23 at 1200 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on observation, interview, and record review, the hospice failed to include all current medications' side effects, actual or potential drug interactions, and duplicate drug therapy in the comprehensive assessments and the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use for 10 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 7, 9, 10, 11, and 12). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. --- 7. Review of Patient 4's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 10/18/22. The patient was certified for hospice services during the period from 10/18/22 to 1/15/23. The Medication Profile for the certification period from 10/18/22 to 1/15/23, showed the patient was taking Ativan 0.5 mg one tablet PO Q four hours PRN for anxiety, agitation, and/or shortness of breath and morphine sulfate 15 mg PO Q two hours PRN moderate to severe pain. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the potential drug interactions were identified. On 1/23/23 at 0954 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 8. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23.On 1/11/23 at 1130 hours, a joint home visit was conducted with RN 1 to Patient 10's home. Review of the patient's medications with RN 1 showed the patient was taking Protonix (used to decrease acid in the stomach) 40 mg PO BID instead of Protonix 40 mg PO QD as written in the medication profile. Patient 10 was also taking Aspirin (nonsteroidal anti-inflammatory drug) 81 mg PO QD which was not listed in the medication profile. On 1/11/23 at 1220 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and verified the finding. 9. Review of Patient 3's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the period from 11/9/22 to 2/6/23. The Medication Profile for the certification period from 11/9/22 to 2/6/23, showed the patient was taking Ativan 0.5 mg one tablet PO Q four hours PRN for anxiety, agitation, and/or shortness of breath and morphine sulfate 15 mg PO Q two hours PRN moderate to severe pain. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the potential drug interactions were identified. On 1/23/23 at 0929 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 10. Review of Patient 9's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/26/21. The patient was certified for hospice services during the period from 11/10/22 to 1/8/23. The Medication Profile for the certification from 11/10/22 to 1/8/23, showed the patient was taking paroxetine (antidepressant) 30 mg PO QD and trazodone (antidepressant) 50 mg PO QD. According to Lexi-Comp's pharmacology website, the combined use of paroxetine and trazodone may result in a serious drug reaction leading to serotonin syndrome (caused by high levels of serotonin in the body). Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the potential drug interactions were identified. On 1/23/23 at 1014 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Review of the hospice's P&P titled Medication Profile dated 4/14, showed the patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluation effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and non-compliance issues, omissions, and unclear information. Each patient and/or family/caregiver will receive appropriate written teaching materials for specific medications he/she is receiving. The material should contain information on actions of the medication, potential side effects, contraindications, and any special instructions when taking the specific medication. 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The Medication Profile for the certification period 11/17/22 to 2/14/23, showed the patient was on Ativan (antianxiety) 0.5 mg one tablet PO Q four hours PRN for anxiety and morphine sulfate (opioid analgesic) one half tablet Q two hours PRN for moderate to severe pain. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the IDG had identified the potential drug interactions between Ativan and morphine sulfate. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. The Medication Profile for the certification period 11/16/22 to 2/13/23, showed patients medication included docusate sodium (laxative) 250 mg one capsule Q HS PRN for constipation, milk of magnesia (laxative) 30 ml PO QD PRN for constipation, and Tylenol (analgesic) 325 mg two tablets Q four to six hours PRN for pain. * However, there was no documented evidence of specific instructions on which medication will be given first for constipation. A joint home visit with HA 1 to the patient's ALF was conducted on 1/11/22 at 1315 hours. Review of the patient's medications at the ALF showed the patient was on Bisacodyl (laxative) 10 mg suppository one rectal PRN for constipation if not relieved within 24 hours after milk of magnesia was given for constipation, which was not included the patients hospice medication profile. In addition, the patient had Tylenol 325 mg two tablets PO Q four hours PRN for total body pain, which was not consistent with the frequency on when Tylenol will be administer in the hospices medication profile. * The hospice failed to update patients medication profile. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 5s clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. The Medication Profile for the certification period 12/26/22 to 3/25/23, showed the patient was on Xanax (antianxiety) 0.5 mg one tablet PO Q four hours PRN for anxiety and morphine sulfate 20 mg one half tablet Q two hours PRN for moderate to severe pain. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Xanax included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the IDG had identified the potential drug interactions between Xanax and morphine sulfate. On 1/23/23 at 1040 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 4. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. The Medication Profile for the certification period 12/3/22 to 3/2/23, showed the patients medication included acetaminophen (analgesic) 325 mg one to two tablets Q four hours PRN for mild pain, pantoprazole sodium (used to treat peptic ulcer disease) 40 mg one tablet PO QD, ipratropium bromide/albuterol sulfate (used for COPD) 0.5 mg-3 mg solution one solution TID, and Eliquis (anticoagulant) 2.5 mg one tablet PO BID, * However, there was no documented evidence when to administer one or two tablets of acetaminophen. According to Lexi-Comp's pharmacology website, Eliquis may increase the risk of bleeding. Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the potential adverse reaction was identified and what preventative measure was implemented regarding the adverse reaction from the medication. A joint home visit with LVN 1 to the patient's home was conducted on 1/11/23 at 930 hours. Review of the medications was conducted with LVN 1 and family member. The family member stated the following information: the patient was no longer taking pantoprazole; ipratropium bromide/albuterol sulfate was being administered once a day instead of three times a day; and the patient was on ";Salonpas" for decades. * The hospice failed to update patients medication profile. On 1/23/23 at 1040 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 5. Review of Patient 11's closed clinical record was initiated on 1/9/23. The clinical record showed the SOC was 2/24/22. The patient was certified for hospice services during the period from 2/24/22 to 5/24/22. The Medication Profile for the certification period 2/24/22 to 5/24/22, showed the patient was on Ativan 0.5 mg one tablet PO Q six hours PRN for anxiety, morphine sulfate one half tablet Q two hours PRN for moderate to severe pain, milk of magnesia 30 ml Q 72 hours PRN for constipation, and bisacodyl 10 mg one suppository rectal QD PRN for constipation. * However, there was no documented evidence which laxative was to be administered first for constipation. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the IDG had identified the potential drug interactions between Ativan and morphine sulfate. On 1/23/23 at 1150 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 6. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. The Medication Profile for the certification period 6/1/22 to 7/30/22, showed the patient was on Ativan 0.5 mg one tablet PO Q four hours PRN for anxiety, morphine sulfate (opioid analgesic) IR 20 mg/ml 0.25 ml PO Q eight hours PRN, temazepam (used for insomnia) 30 mg PO Q HS, bisacodyl 10 mg suppository rectal QD PRN for constipation, and Senna Plus (laxative) 50-8.6 mg one tablet PO PRN for constipation. However, there was no documented evidence which laxative was to be administered first for constipation. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan and temazepam included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the Medication Profile showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence the IDG had identified the potential drug interactions between Ativan, temazepam, and morphine sulfate. There was no documented evidence the potential drug interaction was identified. On 1/23/23 at 1150 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments were completed and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses for 12 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 12), creating the risk of not addressing the care needs for these patients. --- #. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the clinical record showed the initial comprehensive assessment was completed on 9/20/22. However, there was no documented evidence showing the patients need for volunteer services was assessed. The POC/IDG Review completed during the certification period also showed no documented evidence the need for volunteer was assessed Q 14 days. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. (MOVE TO #1 as an example) h. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the HA Assignment dated 9/20/22, showed for the HA to check the patients vital signs every visit and to call the hospice office for any changes or issues noted in the patients condition. Review of the clinical record showed the HA visited the patients home on 10/11, 11/10, and 12/1/22 and assessed the patients blood pressure to be 170/80, 180/75, and 181/82, respectively.However, there was no documented evidence showing the HA notified the RN of the patients blood pressure readings. In addition, there was also no documented evidence showing the IDG discussed and updated the comprehensive assessment to include any changes in the plan of care. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. i. Review of Patient 9's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/26/21. The patient was certified for hospice services during the certification periods from 9/11/22 to 11/9/22 and 11/10/22 to 1/8/23. Review of the POC/IDG Review dated 9/20/22, cited LVN visits once per week plus three PRN visits and RN visits one per month plus three PRN visits. There was no documented evidence showing the SN visit frequencies were changed for both certification periods. Reviewof the RN Visit Notes dated 10/13, 10/27, and 11/17/22, showed the visits were conducted via telehealth in place of LVN visits as per the RN notes. Further review of the clinical recrod showed there was also no documented evidence the IDG discussed and updated the comprehensive assessment to include any changes in the plan of care regarding the patient's missed and telehealth visits. On 1/23/23 at 1014 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. The CFO stated telehealth visits were conducted in place of LVN visits as agreed upon with the patient because the patient lived far. The CFO acknowledged this was not discussed with the IDG. Findings: 1. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 12 showed no documented evidence the need for volunteer was assessed during the ongoing assessment with the IDG. For example: 2. Review of the clinical records for Patients 1, 2, 5, 6, 7, 8, 9, and 12 showed no documented evidence the patients' comprehensive assessments for these patients were updated and included the changes that had occurred since the initial assessment. For example: a. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The SN note dated 12/8/22, showed the patient complained of headaches. Documentation showed the patient rated the headaches as 3/10 pain. Documentation showed the patients BP was 170/80 mm Hg. The note showed the patient was on amlodipine besylate (antihypertension) 10 mg one tablet PO QD and lisinopril (antihypertension) 40 mg one tablet PO QD Review of the POC/IDG 12/14/22, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the patients headaches and blood pressure. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. b. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. The SN note dated 12/4/22, showed the patient had a rash under breasts being treated with nystatin powder (antifungal). Review of the POC/IDG 12/14/22, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the patients rash under breasts. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. c. Review of Patient 5's clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. The SN note dated 11/30/22, showed the patient had concerns about a grey mole with black center on either side of the neck below the ears. Documentation showed the patient stated the mole was itchy sometimes. Documentation showed the physician ordered hydrocortisone (corticosteroid) cream 1% BID PRN. Review of the POC/IDG 11/30 and 12/14/22, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the grey mole with black center. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. d. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. The SN note dated 9/7/22, showed the patient was constipated. The SN note dated 9/9/21, showed the patient was constipated with a bulge in the stomach. Documentation showed suppository was administered as requested by the daughter. Documentation showed the patients last BM was 9/6/22. The SN note dated 9/11/22, showed the patient had no bowel movement in five days. Documentation showed the abdomen was distended and high impaction noted. Documentation showed Fleet enema (laxative) given per family request. Documentation showed new order from the physician with Senna-S (laxative) and magnesium citrate (laxative). The SN note dated 9/13/22, showed small amount of stool throughout the day and abdominal bulge dissipated. Documentation showed according to the family member the patient was constipated and continued to have moments of increased heart rate. The SN note dated 9/15/22, showed the patient was constipated and now having large watery bowel movements. The SN note dated 9/20/22, showed the family member stated the patient had relief from constipation and have not been using stool softeners. Review of the POC/IDG 9/21/22, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the patient's GI status. On 1/23/23 at 1120 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. e. Review of Patient 8's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 5/25/22. The patient was certified for hospice services during the periods from 11/21/22 to 1/19/23. The SN note dated 11/23/22, showed the rash on the right check has returned. Documentation showed there was still some flaking on the right shoulder. Review of the POC/IDG 11/30/22, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the right check rash and flaking on the right shoulder. On 1/23/23 at 1130 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. g. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. The SN note dated 6/28/22, showed the patients BP was 180/70 mm Hg. Documentation showed clonidine (antihypertension) 0.1 mg tablet PO was given. Review of the POC/IDG 6/29/22, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the patients BP. On 1/23/23 at 1200 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients' care needs as evidenced by: --- Findings: 1. The hospice failed to ensure all IDG members had participated in the ongoing assessments and care planning process. Cross reference to L537. 2. The hospice failed to ensure the care and services were provided in accordance with the POC. Cross reference to L543. 3. The hospice failed to ensure the individualized care plans were developed. Cross reference to L545. 4. The hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN discipline visits. Cross reference to L547. 5. The hospice failed to ensure the POCs included measurable outcomes. Cross reference to L548. 6. The hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs. Cross reference to L553. 7. The hospice failed to maintain a system of communication and integration in accordance with their P&P to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided. Cross reference to L554. 8. The hospice failed to coordinate the patients care needs for three of 14 sampled patients. Cross reference to L558. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning, and coordination of services to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure all IDG members had participated in the ongoing assessments and care planning process for three of 14 sampled patients (Patients 4, 5, and 6), creating the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. --- 2. Review of Patient 4's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 10/18/22. The patient was certified for hospice services during the certification period from 10/18/22 to 1/15/23. Review of the POC/IDG Review dated 10/19, 11/2, 11/16, and 11/30/22, showed no documented evidence the MSW had electronically signed for their participation at the meeting. In addition, there was no documented evidence showing the MSWs notes. On 1/23/23 at 0954 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 3. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the POC/IDG Review during the certification period showed there were multiple dates where the IDG members did not electronically sign for their participation during the meetings. For example, the POC/IDG Review dated 9/20/22, showed no documented evidence of the physicians and MSWs electronic signatures. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: The hospices P&P titled Interdisciplinary Group Meeting dated 04/18, showed the interdisciplinary group will meet on a regular basis to discuss patient and family caregiver changes and progress and updates to the plan of care, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patients plan of care will be updated utilizing the results from ongoing comprehensive assessment no less frequently than Q 15 days or more frequently if the patients condition requires. Members of the IDG meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. The P&P titled Interdisciplinary Group Membership and Responsibilities dated 04/18, showed the hospices Interdisciplinary Team/ Group will include at a minimum: physician, registered nurse, social worker, pastoral or other counselor. 1. Review of Patient 5's clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. However, the POC/IDG Review dated 10/5/22, 10/11/22, 1/2/22, 11/16/22, 11/30/22, showed no documented evidence the MSW had participated in the IDG meetings. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She stated the MSW was attending the IDG via telephone.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for 12 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. --- 8. Review of Patient 9's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/26/21. The patient was certified for hospice services during the certification periods from 9/11/22 to 11/9/22 and 11/10/22 to 1/8/23. Review of the POC/IDG Review dated 9/20/22, cited LVN visits once per week plus three PRN visits and RN visits once per month plus three PRN visits. There was no documented evidence showing the SN visit frequencies were changed for both certification periods. Review of the clinical record showed no documented evidence the LVN visited the patients home during Week 3 (9/25/22 to 10/1/22), Week 9 (11/6/22 to 11/12/22), and Weeks 3 to 9 of the following certification period (11/20/22 to 1/7/22). In addition, review of the RN Visit Notes dated 10/13, 10/27, and 11/17/22, showed the visits were conducted via telehealth in place of LVN visits as per the notes. There was no documented evidence showing the IDG had discussed the patients missed and telehealth visits. On 1/23/23 at 1014 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. The CFO stated telehealth visits were conducted in place of LVN visits as agreed upon with the patient because the patient lived far. The CFO acknowledged this was not discussed with the IDG. Cross reference L554, example #3. 9. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Review of the POC/IDG Review dated 12/28/22, cited LVN visits once per week plus two PRN visits. Review of the clinical record showed no documented evidence the LVN visited the patients home during Week 4 (1/1/23 to 1/7/23) as cited in the POC. In addition, there was no documented evidence showing the HA visited the patients home from Week 1 to Week 3 (12/13/22 to 12/31/22) as cited in the POC. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 10a. Review of Patient 3's closed clinical record was initiated on 1/10/23. The clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the certification period from 11/9/22 to 2/6/23. Review of the POC/IDG Review dated 11/16/22, cited LVN visits two times per week plus three PRN visits. Review of the clinical record showed no documented evidence the LVN visited the patients home during Week 3 (11/20/22 to11/26/22), Week 7 (12/18/22 to 12/24/22), and Week 9 (1/1/23 to 1/7/23) as cited in the POC. b. Review of the LVN Visit Notes dated 12/21/22, revealed a note showing the nurse applied triple antibiotic on the patients skin tear. However, review of the physicians orders, showed no documented evidence the triple antibiotic was ordered. On 1/23/23 at 0929 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 11. Review of Patient 4s clinical record was initiated on 1/10/23. The clinical record showed the SOC was 10/18/22. The patient was certified for hospice services during the certification period from 10/18/22 to 1/15/23. Review of the POC/IDG Review dated 11/2/22, cited HA visits three times per week. Review of the clinical record showed no documented evidence the HA visited the patients home during Weeks 4 to 9 (11/6/22 to 12/17/22) as cited in the POC. On 1/23/23 at 0954 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 12. Review of Patient 6s clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification periods from 9/20/22 to 12/18/22 and 12/19/22 to 3/18/23 Review of the POC/IDG Review dated 12/14/22, cited LVN visits once per week plus three PRN visits. Review of the clinical record showed no documented evidence the LVN visited the patients home during Week 2 (12/25/22 to12/31/22) as cited in the POC. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The POC/IDG Review dated 11/30, 12/14, and 12/28/22, showed HA visits 3W, LVN visits 2W and 3 PRN, and RN visits 1 per 2 weeks and 3 PRN visits. The HA notes showed no documented evidence the HA visited the patient during Week 3 (11/27/22 to 12/3/22), Week 4 (12/4/22 to 12/10/22), and Week 5 (12/11/22 to 12/17/22), instead of three visits. * The HA notes showed the HA visited once per week during Week 6 (12/18/22 to 12/24/22), Week 7 (12/25/22 to 12/31/22), and Week 8 (1/1/23 to 1/27/23), instead of three visits. * The SN notes showed the LVN visited once per week during Week 3 (11/27/22 to 12/3/22), Week 4 (12/4/22 to 12/10/22), and Week 5 (12/11/22 to 12/17/22), instead of two visits. * The SN notes showed no documented evidence the LVN visited the patient during Week 6 (12/18/22 to 12/24/22) and Week 7 (12/25/22 to 12/31/22), instead of two visits. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. The POC/IDG Review dated 11/30/23, showed LVN visits 2W and 3 PRN; and RN visits 1 per 2 weeks and 2 PRN visits. The POC/IDG Review dated 12/14 and 12/28/22, showed HA visits 2W; LVN visits 2W and 3 PRN; and RN visits 1 per 2 weeks and 2 PRN visits. * The HA notes showed no documented evidence the HA visited the patient during Week 5 (12/11/22 to 12/17/22), instead of two visits. * The HA notes showed the HA visited once per week during Week 6 (12/18/22 to 12/24/22), instead of two visits. * The SN notes showed the LVN visited once per week during Week 3 (11/27/22 to 12/3/22), Week 4 (12/4/22 to 12/10/22), Week 5 (12/11/22 to 12/17/22), Week 6 (12/18/22 to 12/24/22) and Week 7 (12/25/22 to 12/31/22), and Week 8 (1/1/23 to1/7/23), instead of two visits. * The SN notes showed no documented evidence the RN visited the patient during Week 8 (1/1/23 to1/7/23), instead of one per two weeks. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. The POC/IDG Review dated 10/5, 10/19, 11/2, 11/16, 11/30, and 12/14/22, showed LVN visits 1 W and 2 PRN and recertification; and RN visit 1 per 2 weeks and 2 PRN. The SN notes showed no documented evidence the LVN conducted visits during Week 2 (10/2/22 to 10/8/22) and Week 3 (10/9/22 to 10/15/22), instead of one visit per week. The SN notes showed no documented evidence the RN conducted visits during Week 9 (11/20/22 to 11/26/22) and Week 11 (12/4/22 to 12/10/22). On 1/23/23 at 1040 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. She stated the POC should have been changed to RN visit once Q month. She stated the LVN visit frequency should have been updated for no LVN visit for the first three weeks. 4. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. The certification period from 9/4/22 to 12/2/22, showed the POC/IDG Review dated 9/7, 9/21, 10/5, 10/19, and 10/26/22, included HA visits 3W, LVN visits 1W and 3 PRN visits. * The HA notes showed no documented evidence the HA visited the patient during Week 1 (9/4/22 to 9/10/22), instead of three visits. * The HA notes showed the HA visited two times per week during Week 3 (9/18/22 to 9/24/22), Week 5 (10/2/22 to 10/8/22), Week 6 (10/9/22 to 10/15/22) and Week 7 (10/16/22 to 10/22/22), instead of three visits. * The SN notes showed no documented evidence the LVN visited the patient during Week 6 (10/9/22 to 10/15/22), instead of one visit. The certification period from 12/3/22 to 3/2/23, showed the POC/IDG Review dated 12/14 and 12/28/22 included HA visits 3W and RN two visit per month. * The HA notes showed no documented evidence the HA visited the patient during Week 5 (12/25/21 to 12/31/21), instead of three visits. * The HA notes showed the HA visited two times per week during Week 5 (1/1/23 to 1/7/23), instead of three visits. * The SN notes showed the RN conducted one visit during the month of December 2022, instead of two per month. On 1/23/23 at 1120 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 5. Review of Patient 8's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 5/25/22. The patient was certified for hospice services during the period from 11/21/22 to 1/19/23. The POC/IDG Review dated 11/16 and 11/30/22, showed LVN visits 1W and 3 PRN visits and RN visits 1 per 2W and 3 PRN visits. * SN notes showed no documented evidence the LVN conducted visit for Week 1 (11/21/22 to 11/26/22), instead of one visit. * The SN notes showed no documented evidence the RN conducted visit for Week 3 (12/4/22 to 12/10/22), instead of one Q two weeks. On 1/23/23 at 1130 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 6. Review of Patient 11's closed clinical record was initiated on 1/9/23. The clinical record showed the SOC was 2/24/22. The patient was certified for hospice services during the period from 2/24/22 to 5/24/22. The POC/IDG Review dated 3/9/22, showed HA visits 2W and LVN visits 2W. * The HA notes showed no documented evidence the HA conducted visits for Week 3 (3/6/12 to 3/12/12) and Week 4 (3/13/22 to 3/19/22), instead of two visits. * The SN notes showed the LVN conducted one visit for Week 3 (3/6/12 to 3/12/12) and Week 4 (3/13/22 to 3/19/22), instead of two visits. On 1/23/23 at 1140 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 7. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. The POC/IDG Review dated 6/1, 6/15, 6/29, and 7/13/22, showed LVN visits 3W and MSW visits 1M and 2 PRN. * The SN notes showed the LVN conducted two visits for Week 2 (6/5/22 to 6/11/22), Week 3 (6/12/22 to 6/18/22), Week 5 (6/26/22 to 7/2/22), Week 6 (7/3/22 to 7/9/22) and Week 7 (7/10/22 to 7/16/22), instead of three visits. * The SN notes showed no documented evidence the LVN conducted visit for Week 4 (6/19/22 to 6/25/22), instead of three visits. * The HA notes showed visits conducted from Week 1 (6/1/22 to 6/4/22), Week 2 (6/5/22 to 6/11/22), Week 3 (6/12/22 to 6/18/22), Week 4 (6/19/22 to 6/25/22), Week 5 (6/26/22 to 7/2/22), Week 6 (7/3/22 to 7/9/22), Week 7 (7/10/22 to 7/16/22, and Week 8 (7/17/21 to 7/16/21). However, there was no documented evidence of a physicians order for the HA visits. * The SN notes showed the RN visits conducted from Week 2 (6/5/22 to 6/11/22), Week 4 (6/19/22 to 6/25/22), Week 6 (7/3/22 to 7/9/22), and Week 8 (7/17/21 to 7/16/21). However, there was no documented evidence of a physicians order for the RN visits. * The clinical record showed no documented evidence the MSW had conducted a visit for the June 2022, instead of one per month. On 1/23/23 at 1200 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for 12 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health conditions. --- 5. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the LVN Visit Notes dated 9/26/22, showed a note revealing the patient had three wounds to the right inner thigh, Stage 1 PI to the right buttocks, and a new scab at the top of the head. Review of the POC showed a care plan problem was developed for altered skin integrity related to high potential for pressure sores. However, there was no documented evidence showing an individualized POC was developed to specifically address all of the patients skin issues. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 6. Review of Patient 3s closed clinical record was initiated on 1/10/23. The clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the certification period from 11/9/22 to 2/6/23. Review of the RN Visit Notes dated 12/22/22, showed a note revealing the patient had problems sleeping. The note showed the patient was unable to sleep throughout the night. The patient fell asleep for 30 minutes, woke up, then would be unable to go back to sleep. Review of the POC failed to show a care plan problem was developed to address the patients sleeping issues. On 1/23/23 at 0929 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 7. Review of Patient 9s clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/26/21. The patient was certified for hospice services during the certification period from 9/11/22 to 11/9/22. Review of the RN Visit Notes dated 11/3/22, showed a note revealing the patient wore an eye patch over the left eye due to blurry vision. The note showed the patient had several eye surgeries resulting in poor eyesight and blurry vision. The eye patch helped decrease eye strain. Review of the POC failed to show a care plan problem was developed to address the patients vision issues. On 1/23/23 at 1014 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 showed no documented evidence the individualized care plans were developed to address the identified problems and care needs for these patients. For example: 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The SN note dated 11/25/22, showed ";reported being scared of hypotensive episode, reporting fainting and falling to the ground." The SN note dated 12/15/22, showed the patient got headaches in the mornings at times, and pain on the left side of the neck. Documentation showed the patient used neck pillow with relief. However, review of the patient's plan of care showed no documented evidence the care plan problems were developed to address the recent fall and headaches. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. The SN note dated 11/16/22, showed the patient tested positive for influenza on 11/16/22. The SN note dated 11/18/22, showed the patient tested for flu. The SN note dated 11/21/22, showed the patient had a pink area under the breast which was controlled by nystatin powder (antifungal). However, review of the patient's plan of care showed no documented evidence the care plan problems were developed to address patients flu and the pink area under the breast. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. The SN note dated 11/30/22, showed the patient had concerns about a grey mole with black center on either side of the neck below the ears. Documentation showed the patient stated the mole was itchy sometimes. Documentation showed the physician ordered hydrocortisone (corticosteroid) cream 1% BID PRN. However, review of the patient's plan of care showed no documented evidence the care plan problems were developed to address the grey mole with black in the center which was sometimes itchy. On 1/23/23 at 1040 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. Review of Patient 8's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 5/25/22. The patient was certified for hospice services during the periods from 11/21/22 to 1/19/23. The SN note dated 11/23/22, showed the patients G-tube was clean, dry, and intact. Documentation showed the patient was on Jevity (enteral formula) with small amount of cranberry juice mixed in feeding per gravity. The SN note dated 1/7/22, showed audible chest congestion noted and the physician ordered Z pack (antibiotic) in liquid form. However, review of the patient's plan of care showed no documented evidence the care plan problem was developed to address chest congestion and the use of antibiotics. In addition, there was no documented evidence the patients specific enteral feeding was included in the patients POC. On 1/23/23 at 1140 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN discipline visits for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8 , 9, 10, 11,12, 13, and 14). This failure created the risk of not providing necessary services for these patients. --- Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 failed to show documented evidence of the discipline visit frequencies and/or the indication for the PRN discipline visits on the revised POCs. For example: 1a. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Review of the POC/IDG Review dated 12/28/22, cited one LVN visit per week plus two PRN visits, one MSW PRN and recertification visits, one RN visit per week plus two PRN visits, and one SC PRN and recertification visits. However, there was no documented evidence showing the specific frequencies and the indication for the PRN discipline visits.b. Further review of the clinical record showed the RN visited the patient's home on 12/13/22, and the LVN visited the patient's home on 12/21/22. However, there was no documented evidence showing the frequency of services for Week 1 (12/13/22 to 12/17/22) and Week 2 (12/18/22 to 12/24/22). Review of the POC/IDG Review dated 12/14/22, also showed no documented evidence of the frequency of visits for each discipline. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 2. Review of Patient 9's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/26/21. The patient was certified for hospice services during the certification period from 11/10/22 to 1/8/23.Review of the POC/IDG Review dated 11/16/22, cited one LVN visit per week plus three PRN visits, one MSW visit per month plus two PRN visits, one RN visit per month plus three PRN visits, and one SC PRN and recertification visits. However, there was no documented evidence showing the specific frequencies and the indication for the PRN discipline visits. On 1/23/23 at 1014 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 3. Review of Patient 13's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 8/25/22. The patient was certified for hospice services during the certification period from 8/25/22 to 11/22/22. Review of the closed clinical record showed the SN visited the patients home on 8/25, 8/26, 8/27, and 8/29/22. However, there was no documented evidence showing the frequency of services for each disciple for Weeks 1 and 2 (8/25/22 to 8/29/22). On 1/23/23 at 1038 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 4. Review of Patient 14's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 10/21/22. The patient was certified for hospice services during the certification period from 10/21/22 to 1/18/23. Review of the closed clinical record showed the SN visited the patients home from 10/21/22 to 10/28/22. However, there was no documented evidence showing the frequency of services for each disciple for Weeks 1 and 2 (10/21/22 to 10/28/22). On 1/23/23 at 1049 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 5. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. a. The POC/IDG Reviews dated 11/30, 12/14, and 12/28/22, showed LVN visits 2W and 3 PRN, MD visits 1M and 1 PRN, MSW visits 1 PRN and recertification, NP visits1M and 1 PRN, RN visits 1Q2W and 3 PRN, and SC visits 1 PRN and recertification. However, there was no documented evidence the initial and updated POCs included the indication for the PRN visit. b. The SN notes dated 11/23 and 11/25/22, showed the SN visited the patient for Week 2 (11/20 to 11/26/22). However, there was no documented evidence of the frequency of services for Week 2. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 6. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. The POC/IDG Reviews dated 11/30, 12/14, and 12/28/22, showed LVN visits 2W and 3 PRN, MSW visits 1 PRN and recertification, NP visits 1M and 2 PRN, RN visits 1Q2W and 2 PRN, and SC visits 1 PRN and recertification. However, there was no documented evidence the initial and updated POCs included the indication for the PRN visit. The SN notes dated 11/21 and 11/22/23 showed a visit from LVN and RN for Week 2 (11/20 to 11/26/22). However, there was no documented evidence of the frequency of services for Week 2. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 7. Review of Patient 11's closed clinical record was initiated on 1/9/23. The clinical record showed the SOC was 2/24/22. The patient was certified for hospice services during the period from 2/24/22 to 5/24/22. a. The POC/IDG Review dated 2/24/22, showed no documented evidence of the frequency of services for the SN, MSW, SC, and HA. b. The POC/IDG Review dated 3/9/22, showed HA visits 2W, LVN visits 2W, and RN visit 1 per week and 1 PRN visit. However, there was no documented evidence of the indication for the PRN visit. On 1/23/23 at 1150 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the POCs included measurable outcomes for 13 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, and 14), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. --- 3. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Review of the POC showed the patients identified problems included the potential for altered bowel elimination related to constipation. The goals listed included the patient will have optimal bowel elimination and comfort and the patient/PCG will verbalize having elimination needs met at an acceptable level. There was no documented evidence showing the measurable goals for each of the goals listed. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 4. Review of Patient 4's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 10/18/22. The patient was certified for hospice services during the certification period from 10/18/22 to 1/15/23. Review of the POC showed the patients identified problems included the potential for altered nutritional status related to reduced food portions. The goals listed included the patient will have adequate food and fluids to maintain comfort as exhibited by verbal and nonverbal communication and as tolerated or desired. There was no documented evidence showing the measurable goals for each of the goals listed. On 1/23/23 at 0954 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 12, 13, and 14, showed the initial and updated/revised POCs did not include the measurable outcomes anticipated to evaluate the effectiveness of the plan of care to meet the patients' needs. For example: 1.. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The POC/IDG Review dated 12/14/21, showed the patient's identified problems included potential for high blood sugars, with the goal to achieve optimal blood sugar management for patient comfort. * However, there was no documented evidence of the measurable outcome as to what optimal blood sugar management for patient comfort would be. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. The Plan of Care dated 1/10/23, showed the patient's identified problems included potential for altered bowel elimination related to history of black stools, with the goal of optimal bowel elimination and comfort. * However, there was no documented evidence of the measurable outcome as to what optimal bowel elimination and comfort would be. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs for 12 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. --- 2. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Review of the POC for the certification period showed the hospice identified multiple patient care problems such as the potential for altered bowel elimination related to constipation and ineffective tissue perfusion related to hypertension. Further review of the clinical record showed documented evidence the IDG reviewed the POCs Q 14 days. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 3. Review of Patient 4's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 10/18/22. The patient was certified for hospice services during the certification period from 10/18/22 to 1/15/23. Review of the POC for the certification period showed the hospice identified multiple patient care problems such as the potential for altered nutritional status related to reduced food portions and potential for altered neurological status related to depression. Further review of the clinical record showed documented evidence the IDG reviewed the POCs Q 14 days. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 1/23/23 at 0954 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 was conducted from 1/9/23 to 1/23/23. The clinical records showed the IDG had reviewed and revised the POCs every 14 days. However, the revised POCs did not include the patients' progress toward the goals as specified in the POCs. For example: 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. The POC/IDG Review dated 12/28/22, showed the patient's identified problems included potential for altered cardiac status related to arrhythmia and irregular pulse, potential for high blood sugars, potential for risk of infection related to diabetes mellitus, altered mental status related to disease process and aging, and potential for altered respiratory status related to progression of heart disease and impaired gas exchange. The goals were established for these identified problems. Further review of the clinical record showed the IDG had reviewed the POCs Q 14 days. However, there was no documented evidence the POCs included the patient's progress toward goals. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to maintain a system of communication and integration in accordance with their P&P to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided for 12 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not addressing the care needs for these patients. --- 2. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the HA Assignment dated 9/20/22, showed for the HA to check the patients vital signs every visit and to call the hospice office for any changes or issues noted in the patients condition. Review of the clinical record showed the HA visited the patients home on 10/11, 11/10, and 12/1/22 and assessed the patients blood pressure to be 170/80, 180/75, and 181/82, respectively. However, there was no documented evidence showing the HA notified the RN of the patients blood pressure readings. In addition, there was also no documented evidence showing the patients blood pressure was discussed in the IDG meetings to determine any changes in the plan of care. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Cross reference L 626, example 9. 3. Review of Patient 9's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/26/21. The patient was certified for hospice services during the certification periods from 9/11/22 to 11/9/22 and 11/10/22 to 1/8/23. Review of the POC/IDG Review dated 9/20/22, cited LVN visits once per week plus three PRN visits and RN visits once per month plus three PRN visits. There was no documented evidence showing the SN visit frequencies were changed for both certification periods. Review of the clinical record showed no documented evidence the LVN visited the patients home during Week 3 (9/25/22 to 10/1/22), Week 9 (11/6/22 to 11/12/22), and Weeks 3 to 9 of the following certification period (11/20/22 to 1/7/22). In addition, review of the RN Visit Notes dated 10/13, 10/27, and 11/17/22, showed the visits were conducted via telehealth in place of LVN visits as per the notes. There was no documented evidence showing the IDG had discussed the patients missed and telehealth visits. On 1/23/23 at 1014 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. The CFO stated telehealth visits were conducted in place of LVN visits as agreed upon with the patient because the patient lived far. The CFO acknowledged this was not discussed with the IDG. Cross reference to 543, example 8. Findings: The P&P titled Interdisciplinary Group Membership and Responsibilities revised date 4/18, showed the IDG will participate in the POC for each patient admitted to the hospice service, participate in periodic review and updating the POC for each patient and family receiving hospice services, provide and/or supervise and coordinate hospice care services. 1. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 failed to show documented evidence the POC related the discipline visits were followed. For example: Review of Patient 1's clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. Cross reference L 543 example ## Review of Patient 2's clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. Cross reference L 543 example ## Review of Patient 3's closed clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the certification period from 11/9/22 to 2/6/23. Cross reference L 543 example ## Review of Patient 4's clinical record showed the SOC was 10/18/22. The patient was certified for hospice services during the certification period from 10/18/22 to 1/15/23. Cross reference L 543 example # Review of Patient 5's showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. Cross reference L 543 example ## Review of Patient 6's clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification periods from 9/20/22 to 12/18/22 and 12/19/22 to 3/18/23. Cross reference L 543 example ## Review of Patient 7's clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. Cross reference L 543 example ## Review of Patient 8's clinical record showed the SOC was 5/25/22. The patient was certified for hospice services during the periods from 11/21/22 to 1/19/23. Cross reference L 543 example ## Review of Patient 9's clinical record showed the SOC was 4/26/21. The patient was certified for hospice services during the certification periods from 9/11/22 to 11/9/22 and 11/10/22 to 1/8/23. Cross reference L 543 example ## Review of Patient 10's clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Cross reference L 543 example ## Review of Patient 11's closed clinical record showed the SOC was 2/24/22. The patient was certified for hospice services during the period from 2/24/22 to 5/24/22. Cross reference L 543 example ## Review of Patient 12's closed clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. Cross reference L 543 example ## * The IDG failed to maintain the responsibility of directing and coordinating the care and services for the patients. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to coordinate the patients care needs for three of 14 sampled patients (Patients 3, 6, and 10). This failure created the risk of not providing the necessary care and services to these patients. --- Findings: 1. Review of Patient 3's closed clinical record was initiated on 1/10/23. The clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the certification period from 11/9/22 to 2/6/23. Review of the LVN Visit Note dated 11/10/22, showed the PCG wanted a PT consult to help the patient get out of bed. The note showed the RN was informed of the request. However, further review of the clinical record showed no documented evidence of a PT consult. There was no documentation to explain why a PT consult was not arranged. On 1/23/23 at 0929 hours, an interview and concurrent clinical record review was conducted with the CFO. The CFO was asked if the PT was able to evaluate the patient. The CFO stated the PT completed the evaluation and treatment of the patient. When asked to show the assessments and documentation of treatment, the CFO stated the hospice did not keep the PT assessments and documentation because the PT was contracted. 2. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Review of the LVN Visit Note dated 12/21/22, showed the PCG requested for someone to check the patients feet and toenails. The note showed the RN was informed of the podiatry consult request. Review of the LVN Visit Note dated 12/29/22, showed the PCG requested for a PT evaluation and podiatry consult. The note showed the RN was informed of the request. Further review of the clinical record showed no documented evidence of the PT and podiatry consults. On 1/23/23 at 1025 hours, an interview and concurrent clinical record review was conducted with the CFO. The CFO stated the patient was examined by the PT and podiatrist; however, the CFO stated they did not keep the documentation of the assessments. 3. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the HA Assignment dated 9/20/22, showed the HA to check the patients vital signs every visit and call the hospice office for any changes or issues noted in the patients condition. Review of the clinical record showed the HA visited the patients home on 10/11, 11/10, and 12/1/22, and checked the patients blood pressure to be 170/80 mmHg, 180/75 mmHg, and 181/82 mmHg, respectively. However, there was no documented evidence the HA notified the RN of the patients high blood pressure readings. In addition, there was also no documented evidence the patients high blood pressure was discussed in the IDG meetings to determine any changes in the plan of care. On 1/23/23 at 1003 hours, an interview and concurrent clinical record review was conducted with the CFO. The CFO was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to develop an effective, on-going, hospice-wide date-driven QAPI program as evidenced by: --- 1. The hospice failed to develop, implement, and maintain an effective, on-going, and hospice-wide data-driven QAPI program. Cross reference to L560. 2. The hospice failed to utilize the quality indicator data in the design of its program. Cross reference to L563 3. The hospice failed to ensure the PI project for the year 2019 and 2020 was conducted. Cross reference to L571. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the QAPI to ensure quality of care provided to the patients.

Based on interview and record review, the hospice failed to develop, implement, and maintain an effective, on-going, and hospice-wide data-driven QAPI program, creating the increased risk of not identifying areas for performance improvement to improve care and services provided to the patients. --- Findings: According to the Hospice Standards Article 6, Section 6.5 (f) Quality Assessment and Performance Improvement, each hospice will conduct a review of quality improvement and performance improvement policies at least annually. This review will be by a group composed of at least the following: 1. the administrator; 2. the hospice medical director; 3. the patient care coordinator or director of patient care services; and 4. a hospice social worker or counselor. Review of the hospice's P&P titled Improving Organizational Performance dated 04/18 showed senior management will report the results of QAPI activities to the Governing Body on a quarterly basis. The Hospice's QAPI Plan dated 1/24/22, showed the QAPI program is an outcome-based performance model which assesses and measures the quality of overall hospice program. The QAPI program will use contributions from all agency departments and committees who are involved in the provision or monitoring of care/services to patients and patient's families. The following representatives will make up to the QAPI committee: governing board, medical director, administrator, nursing services, social services, and spiritual counselor. The administrator, director of nursing, infection control and prevention officer, medical director, therapists, and chosen field staff members will provide QAPI leadership by being on the QAPI committee. Review of the hospice's QAPI programs for 2019, 2020, 2021, and 2022, was conducted on 1/19/23. The following were identified: 1. Review of the QAPI documents failed to show documented evidence of an ongoing quality assessment and performance improvement for 2019 and 2020. There was no documented evidence of data collection and analysis to identify, prioritize, implement, and evaluate performance improvement projects for 2019 and 2020. There was no documented evidence of QAPI meeting for 2019 and 2020 showing the discussion of the QAPI program including QAPI recommendations or QAPI actions taken. 2.a. Review of the PI meeting minutes for 2021 and 2022 failed to show documented evidence of the participation of the hospices Administrator. b. Review of the quarterly 2021 and 2022 PI meetings showed the human resource audits were performed for the 2nd, 3rd, and 4th quarters of 2021 and every quarters of 2022. Documentation showed all missing credentials were requested to ensure all up to date. Review of the annual 2021 and 2022 PI meetings showed all annual competencies and performance audits were completed for the year of 2021 and 2022. * However, there was no documented evidence of the human resource audits discussed in the annual meetings. On 1/23/22 at 1400 hours, the CFO was informed of the findings. The CFO stated the new ownership was effective in May 2021. She was not able to provide documented evidence of QAPI activities for 2019 and 2020.

Based on interview and record review, the hospice failed to utilize the quality indicator data in the design of its program. This created the risk of not improving care and services provided to the patients. --- Findings: Review of the hospice's QAPI programs for 2019, 2020, 2021, and 2022 was conducted on 1/19/23. There was no documented evidence the hospice had collected quality indicator data for 2019 and 2020 to evaluate to hospice program and identify opportunities for improvement and to prioritize needs. On 1/19/23, the CFO was informed of the findings. The CFO stated the new ownership was effective on May 2021. She was not able to provide documented evidence of QAPI activities for 2019 and 2020.

Based on interview and record review, the hospice failed to ensure the PI project for the years 2019 and 2020 was conducted. This created the risk of not improving the care and services provided to the patients. --- Findings: Review of the hospice's QAPI programs for the years 2019. 2020, 2021, 2022 was conducted on 1/19/23. However, there was no documented evidence the hospice had conducted the PI projects for the years of 2019 and 2020. On 1/23/23 at 1400 hours, an interview and document review were conducted with the CFO. The CFO stated the new ownership was effective in May 2021. She was not able to provide documented evidence of QAPI activities for the years of 2019 and 2020.

Based on interview and record review, the hospice failed to implement the bereavement program as per the hospices P&P to address the needs of the bereaved family members for two of three sampled deceased patients (Patients 12 and 14). This failure created the risk of not addressing the bereavement needs of the bereaved family members. --- 2. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. The patient expired on 7/21/22. The Bereavement POC by the SC dated showed 8/12/22, showed the patient was identified as low risk with interventions documented. Further review of the POC showed the last IDG meeting was conducted on 7/13/22. There was no documented evidence an IDG meeting was conducted after the patients death occurred to discuss the patients needs. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed and acknowledged the finding. Review of the hospices P&P titled Bereavement Service dated April 2018, showed after a death has occurred, the bereaved assessment will be updated and the family/caregiver will be discussed at the next interdisciplinary group meeting. 1. Review of Patient 14s closed clinical record showed the SOC was 10/21/22. The patient was certified for hospice services during the certification period from 10/21/22 to 1/18/23. Review of the Visit Note dated 10/28/22 showed the patient expired on 10/28/22. Further review of the clinical record showed no documented evidence an IDG meeting was conducted following the patients death. On 1/23/23 at 1049 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the HAs provided services in accordance with the POCs for nine of 14 sampled patients (Patients 1, 2, 3, 6, 7, 8, 10, 11, and 12). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- 7. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Review of the POC dated 1/9/23, cited HA visits two times per week. Review of the HA Assignment dated 12/5/22, showed to check the patients vital signs every visit. Review of the HA Visit Notes showed there were multiple dates where the HA did not check the patients vital signs. For example, on 12/23/22, there was no documented evidence showing the patients respirations and blood pressure were checked. In addition, there was no documented evidence showing the HA visited the patients home from Week 1 to Week 3 (12/13/22 to 12/31/22) as cited in the POC. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 8. Review of Patient 3's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the certification period from 11/9/22 to 2/6/23. Review of the HA Assignment dated 11/9/22, showed to record bowel movements. Review of the HA Visit Notes showed there were multiple dates where the HA did not record the date of the patients last bowel movement as per the HA assignment. For example, on 11/9/22, the HA Visit Note showed the HA placed a check mark to indicate the task was completed; however, there was no documented evidence showing the date of when the patient had the bowel movement. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 9a. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the HA Assignment dated 9/20/22, showed to record bowel movements, check the patients vital signs every visit and to call the hospice office for any changes or issues noted in the patients condition. Review of the HA Visit Notes showed there were multiple dates where the HA did not record the date of the patients last bowel movement as per the HA assignment. For example, on 9/23/22, the HA Visit Note showed the HA placed a check mark to indicate the task was completed; however, there was no documented evidence showing the date of when the patient had the bowel movement. b. Further review of the clinical record showed the HA visited the patients home on 10/11, 11/10, and 12/1/22 and assessed the patients blood pressure to be 170/80, 180/75, and 181/82, respectively. However, there was no documented evidence showing the HA notified the RN of the patients blood pressure readings. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. Review of the HA Assignment dated 11/18/22, showed to record bowel movements and check vitals every visit. * The HA note dated 12/23 and 12/28/22, and 1/6/23, showed no documented evidence bowel movements were recorded as per the HA's assignment. * The HA note dated 12/23/22 showed ";na" on the section of respiration; and the HA note dated 1/6/23, showed no documented evidence of the patients respiration. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. Review of the HA Assignment dated 11/16/22, showed to record bowel movements and check vitals every visit. * The HA note dated 12/23, 12/28, 12/30, 1/6, and 1/9/23 /22 showed no documented evidence bowel movements were recorded. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 2/3/22 to 3/2/23. The certification period from 9/4/22 to 12/2/22, showed the HA Assignment dated 9/4/22, included to record bowel movements and check vitals every visit. Documentation showed to notify RN of any changes or deviations from norm. a. The HA note dated 9/12, 9/14, 9/16, and 9/19/22, showed the patients vital signs were not completed. b. The HA note dated 9/23, 9/26, 9/28, 10/7, 11/4, 11/7, 11/18, and 11/21/22, showed no documented evidence bowel movements were recorded. c. The HA note dated 9/26/22, showed ointment was applied on the perineum. Documentation showed the patient had a rash on the back and on the back of the legs. Documentation showed the family member will call the nurse. Documentation showed the ointment was prescribed by the doctor. The HA dated 10/7/22, showed the patient had a rash; ointment was applied to the upper part of the thighs ";outside." The HA dated 11/9/22, showed applied ointment on the inner thigh of the right leg. Documentation showed a rash or possible spider bite was observed. * However, there was no documented evidence the application of the ointment was in the HAs assignment. In addition, there was no documented evidence the HA had reported the patients rash on 10/7/22; and a rash or possible spider bite on 11/9/22 to the RN. The certification period from 12/3/22 to 3/2/23, showed the HA Assignment dated 9/4/22, included to record bowel movements and check vitals every visit. Documentation showed to notify RN of any changes or deviations from norm. The HA note dated 12/19/22, showed the patient had a small rash on the upper front thighs. Documentation showed ";cortizone" applied. The HA note dated 12/21/22, showed rash on both ";tights up." Documentation showed applied clobetasol (corticosteroid). * However, there was no documented evidence the application of the ";cortisone" and clobetasol was in the HAs assignment. In addition, there was no documented evidence the HA had reported the patients rash on 12/19 and 12/21/22 to the RN. On 1/23/23 at 1120 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. She stated the HA Assignment dated 9/4/22, was also for the certification period from 12/3/22 to 3/2/23. 4. Review of Patient 8's clinical record was initiated on 1/12/23. The clinical record showed the SOC was 5/25/22. The patient was certified for hospice services during the periods from 11/21/22 to 1/19/23. The HA Assignment dated 12/23/22, showed to check vitals Q visit. The HA note dated 1/3/22, showed no documented evidence of the patients pulse and respiratory rate. On 1/23/23 at 1140 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 5. Review of Patient 11's closed clinical record was initiated on 1/9/23. The clinical record showed the SOC was 2/24/22. The patient was certified for hospice services during the period from 2/24/22 to 5/24/22. The HA Assignment dated 2/25/22, showed to record bowel movements and check vitals every visit. Documentation showed RN additional instructions included to report/assess pain and report change of condition. The HA note dated 2/26/22, showed mild redness observed on patients bottom. Documentation showed applied Calmoseptine (barrier ointment) and informed PCG. * However, there was no documented evidence the application of Calmoseptine was in the HAs assignment. In addition, there was no documented evidence the HA informed the RN of the mild redness observed on patients bottom, On 1/23/23 at 1150 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 6. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. The HA Assignment dated 2/25/22, showed to record bowel movements and check vitals every visit. Documentation showed RN additional instructions included to let RN know for any problem. * The HA note dated 6/1, 6/3, 6/6, 6/8, 6/10, 6/13, 6/15, and 7/18/22, showed no documented evidence the bowel movements were recorded. On 1/23/23 at 1150 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the hospice's RN provided supervision to the HA to ensure quality of care and services provided for six of 14 sampled patients (Patients 1, 3, 6, 7, 10, and 12), creating the risk of substandard health outcomes to these patients. --- 4. Review of Patient 10's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 12/13/22. The patient was certified for hospice services during the certification period from 12/13/22 to 3/12/23. Review of the clinical record for Patient 10 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example 7. The SN notes dated 12/28/22, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 5. Review of Patient 3's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 11/9/22. The patient was certified for hospice services during the certification period from 11/9/22 to 2/6/23. Review of the clinical record for Patient 3 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example 8. The SN notes dated 12/22/22, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 1/23/23 at 1025 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 6. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the clinical record for Patient 6 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example 9. The SN notes dated 10/4/22, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. Review of the clinical record for Patient 1 showed the HA did not provide HA service in accordance with the POC for this patient. Cross reference L626, Example ### The SN note dated 1/9/23, showed the RN had conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 2. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. Review of the clinical record for Patient 7 showed the HA did not provide HA service in accordance with the POC for this patient. Cross reference L626, Example ### The SN notes dated 9/23/23 and 11/14/23, showed the RN had conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 1/23/23 at 1120 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. Review of the clinical record for Patient 12 showed the HA did not provide HA service in accordance with the POC for this patient. Cross reference L626, Example ### The SN notes dated 6/6 and 6/20/23, showed the RN had conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 1/23/23 at 1200 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure the COP regarding Organization and Administration of Services was met. --- Findings: The GB failed to assume full legal authority and responsibility for the management of the hospice, provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with all COPs. Cross reference to L651. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Organization and Administration of Services.

Based on interview and record review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with the COPs under 418.54 (Initial & Comprehensive Assessment); 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:58 (Quality Assessment & Performance Improvement); and 418.100 (Organization and Administration of Services). --- 3. The P&P titled Discharge Summary dated 4/18, each patient discharged from a service and from hospice will have a discharge summary file in the clinical record. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include as appropriate: the date of discharge, including the date the physician and the patient were informed of discharge, the reason for discharge, including the name of the organization to which the patient is being transferred, the status of problems identified at admission and during the provision of care, the resolution of identified problems, continuing symptom management needs, the overall status of the patient, a summary of care or services provided, the patients current plan of care, the physicians latest physician orders. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. Review of Patient 11's closed clinical record was initiated on 1/9/23. The clinical record showed the SOC was 2/24/22. The patient was certified for hospice services during the period from 2/24/22 to 5/24/22. Review of the Discharge Summary date 3/22/22, showed the patient was transferred to another hospice. However, the Discharge Summary was incomplete as there were no documented evidence of the name of the organization to which the patient was being transferred, the status of problems identified at admission and during the provision of care, the resolution of identified problems, continuing symptom management needs, the overall status of the patient as per the P&P. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical records and acknowledged the finding. 4. According to the Hospice Standards Article 6, Section 6.2 B Contractual Services, when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to the roles and responsibilities of the program and contracted individual or organization in the patient/family admission process, patient/family assessment, the development, review, and revision of POCs, interdisciplinary team conferences, scheduling of visits or hours, discharge planning, bereavement, and submission of documentation of services provided to the agency. Review of the written agreements between the hospice and contracted MD1, MD2, and Contractor 1 was initiated on 1/17/23. The written agreement with contracted MD1, MD2, and Contractor 1 did not include a statement showing the roles and responsibilities of the program and the contractors in the bereavement follow-up. On 1/23/23 at 1330 hours, the Administrator was informed of the finding. She reviewed the written agreements and acknowledged the finding. Review of the hospice's P&P titled Executive Director/Administrator dated April 2017, showed the Executive Director/Administrator is responsible for the overall direction of the day-to-day operations of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; and is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. 1. According to Standards of Quality Hospice Care, 2005 under Section 5.8 C (1) (C), there shall be personnel file for each volunteer that include, but are not limited to health record to confirm TB screening. Review of the employee file for the Volunteer showed the date of hire was 1/28/22. Review of the file showed no documented evidence of the Volunteers TB screening. On 1/23/23 at 1104 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. 2. Review of the hospices P&P titled Competency Assessment dated April 2017, showed the competency assessments will be completed at least one time per year. Additional competencies may be required for performance problems, new technology, or other appropriate indications. Review of the hospices P&P titled Performance Evaluations, showed all hospice staff will be evaluated at periodic intervals based on their job descriptions during the probationary period, at the end of the first three months of employment, annually based on personnels annual evaluation date, after a promotion and/or transfer, and other occasions as performance warrants. a. Review of the employee file for RN 1 showed the date of hire was 9/29/21. The initial skills competency was completed on 9/30/21. However, there was no documented evidence showing the skills competency and performance evaluations were completed for the year 2022 as per the hospices P&P. b. Review of the employee file for RN 2 showed the date of hire was 5/14/21. The initial skills competency was completed on 5/14/21. However, there was no documented evidence showing the skills competency and performance evaluations were completed for the year 2022 as per the hospices P&P.c. Review of the employee file for the Chaplain showed the date of hire was 4/14/21. The initial performance evaluation was completed on 7/14/21. However, there was no documented evidence showing the performance evaluation was completed for the year 2022 as per the hospices P&P. On 1/23/23 at 1104 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding.

Based on interview and record review, the hospice failed ensure the clinical records were complete and accurate for six of 14 sampled patients (Patients 1, 2, 5, 6, 7, and 12), creating the risk of substandard care provided to the patients as their clinical information were not accurate and complete. --- 6. Review of Patient 6's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/20/22. The patient was certified for hospice services during the certification period from 9/20/22 to 12/18/22. Review of the LVN Visit Note dated 9/29/22, showed the SN documented the patients blood pressure and temperature as "1411/71" and "977", respectively, which were inaccurate. On 1/23/23 at 1003 hours, an interview and concurrent record review was conducted with the CFO. The CFO was informed and acknowledged the finding. Findings: 1. Review of Patient 1's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/17/22. The patient was certified for hospice services during the period from 11/17/22 to 2/14/23. * The HA note dated 12/28/22 showed ";92" on the section of patients respiration. On 1/23/23 at 0940 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 1/9/23. The clinical record showed the SOC was 11/16/22. The patient was certified for hospice services during the period from 11/16/22 to 2/13/23. * The SN note dated 12/21/22, showed the patients last bowel movement was not completed. On 1/23/23 at 1020 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 3. Review of Patient 5's clinical record was initiated on 1/11/23. The clinical record showed the SOC was 9/27/22. The patient was certified for hospice services during the periods from 9/27/22 to 12/25/22 and 12/26/22 to 3/25/23. * The Spiritual Counselor note date 10/28/22, showed the COVID -19 screening was not completed. On 1/23/23 at 1040 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 4. Review of Patient 7's clinical record was initiated on 1/10/23. The clinical record showed the SOC was 9/4/22. The patient was certified for hospice services during the periods from 9/4/22 to 12/2/22 and 12/3/22 to 3/2/23. * The SN note dated 10/14, 10/19, 11/2, and 12/14/22, showed the patients last bowel movement was not completed. On 1/23/23 at 1120 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding. 5. Review of Patient 12's closed clinical record was initiated on 1/12/23. The clinical record showed the SOC was 4/19/21. The patient was certified for hospice services during the periods from 6/1/22 to 7/30/22. * The HA note showed, the patients last BM on 7/1, 7/4, 7/6, 7/8, 7/11, 7/13, 7/15/22, showed the patients last BM was on 7/1/22. The SN note dated 7/5/22, showed the patients last BM was 7/4/22. The SN note dated 7/8/22, showed the patients last BM was 7/8/22. The SN note dated 7/12/22, showed the patients last BM was 7/12/22. The SN note dated 7/15/22, showed the patients last BM was 7/14/22. However, the patients last BM was not consistent. On 1/23/23 at 1150 hours, the Administrator was informed of the finding. She reviewed the clinical record and acknowledged the finding.