Every finding on record at Mercy Health Services, LLC

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in two of four records reviewed (Records/Patients #5 and #6). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's policy titled, "MHS HOSPICE Medication Monitoring Policy," dated 11/04/2025, showed in part:- Hospice will maintain a current, accurate list of all prescription, over-the-counter medications, supplements and home remedies taken by the patient, on the medication profile; - Medication reconciliation with a full bottle/medication check is completed during the initial nursing assessment, the nursing next day visit (visit the day following the admission), the first scheduled nursing visit of the week and at any time the patient moves home location. *For Hospice House inpatients, medications are reviewed and reconciled daily; and - The Hospice nurse will verify at all scheduled nursing visits if there have been any changes in medication orders, since the last visit. --- RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 06/27/2025 with a terminal diagnosis of chronic kidney disease (a long-term, progressive loss of kidney function). The patient had secondary diagnoses of protein calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and/or calories) and dysphagia (difficulty swallowing). The patient resided in a skilled nursing facility. During a home visit observation on 02/10/2026 at 12:00 PM, a comparison of the provider’s medication profile (PMP) to the facility’s medication administration record (FMAR) showed the following discrepancies: - The FMAR showed the patient was to use Remedy Clinical Silicone Cream (a cream used to protect the skin) to the patient’s buttocks, the PMP failed to list this medication; - The FMAR showed the patient was to receive a nutritional supplement three times per day, the PMP failed to list this medication; - The PMP showed the patient was to take acetaminophen (a nonnarcotic pain medication) as needed, the FMAR failed to list this medication; and- The PMP showed the patient was to use Eucerin cream daily (a petrolatum-based ointment), the FMAR failed to list this medication. During an interview on 02/11/2026 at 9:00 AM, the administrator designee (AD1) stated that they would expect the FMAR and PMP to contain the same medications, and they were unable to provide evidence to resolve the identified discrepancies.  RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 08/30/2025 with a terminal diagnosis of malignant neoplasm of pancreas (highly aggressive cancer with poor prognosis), alcoholic cirrhosis (severe, generally irreversible scarring of the liver caused by long-term, excessive alcohol consumption, leading to liver failure), esophageal varices without bleeding (swollen veins in the lower esophagus caused by high pressure in the liver (portal hypertension), usually due to cirrhosis), portal venous hypertension (elevated blood pressure, in the portal venous system, primarily caused by liver cirrhosis restricting blood flow from the spleen and intestines), and chronic diastolic heart failure (heart muscle becomes too stiff to properly relax and fill with blood, despite maintaining a normal pumping strength). The patient resided at his/her own home with spouse. On 02/11/2026 at 10:00 AM, during the home visit observation with RN (Registered Nurse) 2 and interview with the spouse (caregiver), showed the following discrepancies between the provider’s current medication profile on the plan of care, dated 01/27/2026 to 02/10/2026, and the patient’s home medication bottles:- The patient had Morphine (opiate for moderate to severe pain) 100 milligrams (mg)/5 milliliter (ml) (20 mg/ml) take 0.5 ml every two hours as needed, filled 09/04/2025. The patient’s medication list failed to include Morphine; - The patient had Glycopyrrolate (anticholinergic to treat peptic ulcers) 1 mg/5 ml, take 5 ml every four hours as needed, filled 09/04/2025. The patient’s medication list failed to include Glycopyrrolate;- The patient had hydrocortisone cream (mild topical corticosteroid for itching, redness, and inflammation and rashes) to apply to the face twice a day for rash. The patient’s medication list failed to include hydrocortisone cream. The patient’s spouse stated the patient had been using for one and a half months; - The patient’s medication list had albuterol sulfate aerosol inhaler (fast-acting bronchodilator to treat COPD or asthma) take two puffs by inhalation every six hours as needed for shortness of breath. The patient’s spouse stated that he/she hasn’t used for four to five years; - The patient’s medication list had diphenhydramine (antihistamine and sedative) 25 mg take 50 mg by mouth at bedtime. The patient’s spouse stated that he/she hasn’t used since September;- The patient’s medication list had diphenoxylate-atropine (opioid to treat diarrhea) 2.5 mg-0.025 mg tablet take one to two tablets by mouth four times daily as needed. The patient’s spouse stated that he/she hasn’t used since being on chemotherapy; - The patient’s medication list had heparin (anticoagulant) lock flush 10 unit/ml inject 5 units by intravenous injection one time as needed. The patient’s spouse stated it was stopped when the patient went on hospice; and- The patient’s medication list had ondansetron (to prevent nausea and vomiting) 8 mg dissolve one pill every eight hours as needed for nausea and/or vomiting after chemo. The patient’s spouse stated he/she hasn’t used for years and uses Protonix.     During an interview on 02/11/2026 at 1:55 PM, the Administrator stated that:- The nurse is to check medications on admission to the hospital discharge list;- The medication bottles are checked once a week on the first visit of the week;- Check the medication bottles and medication profile list and ask the patient and caregiver about any changes and over the counter medications; - Any medication discrepancies are to be followed up with the physician to get the medication profile to reflect with the medication bottles;  - The nurse is to ask every visit about medication changes and make sure there are enough medications to get through to next week.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure all care and services furnished to patients and their families follow an individualized, written plan of care (POC) in five of six full records reviewed (Records/Patients #1, #2, #5, #6, and #10). This deficient practice has the potential to affect the care of all the patients served by the provider.  Findings included: Review of the provider's policy titled, "MS EAST HOSPICE Plan of Care Policy," dated 11/24/2025, showed in part:- Hospice will complete an individualized plan of care update for each individual admitted to hospice. The care provided to the individual will be in accordance with the care plan which is based on the patient's goals and the time frames, settings and services required to meet those goals; - The plan of care will be reviewed and updated, at least every 14 days, by the attending physician, the medical director and the Interdisciplinary Group (IDG) and will be documented in the record. Documentation on the plan of care shall reflect the changing needs of the patient/family and the services required to meet those needs; - Content of the Plan of Care: The hospice will develop an individualized written plan of care for each patient which will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:   - Interventions to manage pain and symptoms;    - Identification of the patient’s/family’s problems and needs; and   - The detailed statement of the scope and frequency of services needed to meet the patients and family’s needs and by whom the services will be provided, prescribed and required medical equipment, supplies, medications, treatments and the level of care. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice on 08/01/2025 with a terminal diagnosis of oropharyngeal dysphagia (difficulty initiating a swallow, causing food to stick in the throat, coughing, choking, or nasal regurgitation). The patient was admitted to the inpatient hospice house on 02/09/2026.Review of the Hospice House Plan of Care (POC), dated 02/09/2026, showed an intervention dated 10/01/2025 for a clear liquid diet as tolerated. The POC also showed an order dated 02/09/2026 for a pureed diet as tolerated.During an interview on 02/10/2026 at 11:00 AM, the patient’s mother stated that the patient ate pureed foods at mealtimes.During an interview on 02/11/2026 at 2:00 PM, the inpatient hospice administrator stated that there were conflicting orders in the plan of care and only the current order should be listed.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 09/05/2025 with a terminal diagnosis of metastatic non-small cell lung cancer (occurs when cancer cells spread from the lungs to distant organs like the brain, bones, or liver). The patient was admitted to the inpatient hospice house on 09/22/2025.Review of the Hospice Plan of Care (POC), dated 09/17/2025, showed the interdisciplinary group (IDG) note that the patient/family refused chaplain at that time. The POC showed a chaplain visit frequency of one visit every 28 days for 28 days.During an interview on 02/11/2026 at 2:00 PM, the inpatient hospice administrator stated that chaplain service was not declined, and chaplain was visiting once every 28 days. The administrator stated that the IDG was documented in error. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 06/27/2025 with a terminal diagnosis of chronic kidney disease (a long-term, progressive loss of kidney function). The patient had secondary diagnoses of protein calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and/or calories) and dysphagia (difficulty swallowing). The patient resided in a skilled nursing facility.Review of the updated POC, dated 02/05/2026, showed that the patient had a secondary diagnosis of severe protein calorie malnutrition and dysphagia.Review of the facility medication administration records for 01/01/2026 to 02/10/2026 showed the orders for a monthly weight related to severe protein calorie malnutrition and Med Pass supplements (a high calorie/protein nutritional shake) three times per day related to abnormal weight loss.During an interview on 02/11/2026 at 9:00 AM, the administrator designee (AD1) stated that they would expect the patient’s protein calorie malnutrition to be addressed on the POC, and he/she was unable to locate interventions or goals to address the diagnosis on the current POC. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 08/30/2025 with a terminal diagnosis of malignant neoplasm of pancreas (highly aggressive cancer with poor prognosis), alcoholic cirrhosis (severe, generally irreversible scarring of the liver caused by long-term, excessive alcohol consumption, leading to liver failure), esophageal varices without bleeding (swollen veins in the lower esophagus caused by high pressure in the liver (portal hypertension), usually due to cirrhosis), portal venous hypertension (elevated blood pressure, in the portal venous system, primarily caused by liver cirrhosis restricting blood flow from the spleen and intestines), and chronic diastolic heart failure (heart muscle becomes too stiff to properly relax and fill with blood, despite maintaining a normal pumping strength). The patient resided at his/her own home with spouse.Review of the chaplain’s initial visit dated 09/04/2025, showed the following:- Patient and patient’s spouse have a couple of family friends who offer spiritual and emotional support; and- Chaplain will continue to visit once every 28 days and as needed.   Review of the chaplain’s visit dated 11/03/2025, showed the chaplain called the spouse to schedule routine visit and the spouse reported the patient was feeling well, but stated he/she was not quite ready for the chaplain. The spouse reports the patient has a friend who is a minister, and he/she feels more comfortable with that support. Chaplain offered to be as needed, and the spouse accepted. Chaplain will be as needed moving forward.  Review of the Hospice POC, updated 01/27/2026, showed a chaplain visit frequency of one visit every 28 days for 28 days and as needed. During an interview on 02/11/2026 at 1:55 PM, the administrator stated the POC should be updated to reflect what the chaplain visits are and what he is doing.   RECORD/PATIENT: #10Review of the clinical record showed the patient was admitted to hospice services on 02/08/2025 with a terminal diagnosis of left upper lobe small cell lung cancer (a fast-growing type of cancer that originates in the upper portion of the left lung).  The patient lived at home with three caregivers until his/her discharge on 06/13/2025. Review of the initial assessment, dated 02/08/2025, showed the following:- The patient complained of pain across his/her chest and into the left side of the neck and rated his/her pain as 6 out of 10 in severity on the pain scale (a tool used to assess the intensity of pain using a numerical scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable) and the pain was described as aches/cramping, constant, exacerbated by movement, and relieved by rest and positioning;- The patient’s highest pain rating on the pain scale was 8 out of 10 and the patient’s lowest pain rating was 5 out of 10;- The patient’s pain goal was 3 out of 10 on the pain scale;- The pain was further described as gradually worsening, affected the patient’s sleep, appetite, physical activity, and made the patient unable to complete tasks easily, the patient was no longer able to drive or work, and the caregiver’s perception of the patient’s pain was that it was uncontrolled;- PRN (pro re nata- as needed) medications available included Norco (a medication used to treat severe pain) which the patient had not taken since picking up from the pharmacy and THC products (substances derived from the cannabis plant and used to treat pain);- The patient verbalized fear of taking medications and being “foggy” and being unsure of side effects;- The skilled nurse (SN) discussed taking the Norco at bedtime to help with pain and sleep and the patient was agreeable to the plan; and- The pain level remained at 6 out of 10 at the end of the visit. Review of the plan of care, dated 02/08/2025, showed the following under physical discomfort:- Goals included patient’s pain/physical discomfort will be reduced to the level of patient’s stated goal or patient does not demonstrate s/s (signs or symptoms) of physical discomfort if unable to communicate in one week and throughout hospice care and patient/caregiver will verbalize understanding of the pain management plan in three days and throughout hospice care;- Interventions included assess and document:  the cause, location, intensity, quality, frequency and duration of pain; alleviating and aggravating factors; current medication regimen and treatments; effects of pain on patient’s sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity.  Assess patient’s pain utilizing an appropriate pain scale for age and cognition.  Evaluate the effectiveness of the current pain treatment regimen and notify physician for the need for changes in the plan of care.  Instruct patient/caregiver on pain medication regimen and alternative strategies to relieve pain; and- The plan of care failed to include the patient’s pain management goal, interventions for the patient’s reluctance or refusal to take pain medications, or any changes made to the patient’s pain treatment regimen based on the initial assessment. Review of a SN note, dated 05/01/2025, showed the following:- The patient complained of pain in his/her neck and rated his/her pain as 10 out of 10 in severity and the pain was described as aching and constant, exacerbated by movement, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 8 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening and having a high impact on the quality of life and the caregiver’s perception of the patient’s pain was that it was not being controlled with medication;- PRN medications taken in the last 24 hours included Norco one tablet every 4 hours PRN (three doses taken) and Morphine Concentrate (a medication used to treat severe pain) 0.5 milliliters (mL) every 4 hours PRN (two doses taken);- The patient’s pain level at the end of the visit showed that the patient was very teary eyed in pain and the patient stated that he/she had just taken a pain pill and was going to try to lay down and sleep;- The SN educated the patient and caregiver on pain medications and the patient agreed to be more consistent with using PRN medications for pain; and- The visit note showed, “current care plan reviewed, effective, and no changes at this time.” Review of a SN note, dated 05/07/2025, showed the following:- The patient complained of pain in his/her neck and rated his/her pain as 10 out of 10 in severity and the pain was described as aching, constant, exacerbated by movement, and relieved by medications and rest;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 9 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as having a high impact on the quality of life and the caregiver’s perception of the patient’s pain was that it was not being controlled with medication;- PRN medications taken in the last 24 hours included Roxanol (a medication used to treat severe pain and also known as Morphine Concentrate) 0.5 mL every 2 hours (two doses taken) and Fentanyl (a medication that comes in patch form and treats severe pain) 25 micrograms (mcg) per hour and change every three days was scheduled;- The patient’s pain level at the end of the visit showed that the patient still had pain 10 out of 10 in severity;- The SN educated the patient and caregiver on pain medications; and- The visit note showed, “current care plan reviewed, effective, and no changes at this time.” Review of a SN note, dated 05/09/2025, showed the following:- The patient complained of pain in his/her neck and rated his/her pain as 10 out of 10 in severity and the pain was described as stabbing and constant;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 10 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as having a high impact on the quality of life and the caregiver’s perception of the patient’s pain was that it was not being controlled with medication;- PRN medications taken in the last 24 hours included Fentanyl and Morphine Concentrate 0.5 mL every 2 hours PRN (12 doses taken);- The patient’s pain level at the end of the visit showed that the patient still had pain 10 out of 10 in severity;- The physician was notified, and a new order was received for the Fentanyl patch to increase to 50 mcg/hour and the Morphine to increase to 1 mL every 2 hours PRN and the SN educated the patient and caregiver on the new medication orders and instructed them to call the office if patient’s pain was not controlled; and- The visit note showed, “current care plan reviewed, effective, and no changes at this time.” Review of a SN note, dated 05/13/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 5 out of 10 in severity and the pain was described as aching/sharp, constant, exacerbated by deep breathing and movement, and relieved by medications and rest;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 2 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as waxing and waning (increasing and decreasing in severity), affected the patient’s sleep, mood, concentration, physical activity, had minimal impact on the patient’s quality of life, and the caregiver’s perception of the pain was that a new pain regimen had been started, and the patient was “trialing to see how effective it is”;- PRN medications taken in the last 24 hours included Morphine Concentrate 1 mL every 2 hours PRN (four doses taken);- The patient’s pain level at the end of the visit showed that the patient had pain 5 out of 10 in severity; and- The visit note showed the patient reported forgetting to change his/her Fentanyl patch the day before and that the caregiver reported using Morphine 0.75 mL instead of the 1 mL that was ordered by the physician and education regarding medication was given to the patient and caregiver. Review of a SN note, dated 05/16/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 7 out of 10 in severity and the pain was described as aching, constant, exacerbated by movement, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 3 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening, affected the patient’s concentration and physical activity, had minimal impact on the patient’s quality of life, and the caregiver’s perception of the pain was that it was controlled;- PRN medications taken in the last 24 hours included Morphine (three doses taken) and the patient reported only taking 0.5 mL or 0.75 mL per dose instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed that the patient had pain 7 out of 10 in severity; and- The visit note showed that the family did not appear to be consistent with administration of pain medication and was not using the correct dose of Morphine for breakthrough pain and education regarding medication was provided to the patient and caregiver. Review of a SN note, dated 05/20/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 10 out of 10 in severity and the pain was described as tight, constant, exacerbated by movement, and relieved by medications and rest; - The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 3 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening and affected the patient’s sleep and physical activity;- PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed 3 out of 10 in severity; and- The visit note showed that pre-filled Morphine syringes were left at the bedside for break-through pain management, the physician was notified of patient’s pain level and a new order was obtained for Methadone (a medication that is used to treat severe chronic pain) 10 mg every 12 hours, and the SN educated the patient and caregiver on the new medication regimen. Review of a SN note, dated 05/23/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 4 out of 10 in severity and the pain was described as tight and intermittent;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 0 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually improving and had minimal impact on the patient’s quality of life;- PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed 4 out of 10 in severity; and- The visit note showed that the patient reported hallucinations during the night related to taking Methadone and issues with nausea and vomiting related to taking Methadone.  The SN provided education to the patient regarding side effects of Methadone and notified the physician of the patient’s complaint of hallucinations. Review of a SN note, dated 05/27/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 4 out of 10 in severity, the pain was described as aching and tight, constant, exacerbated by movement and deep breathing, and relieved by rest, medications, and pressure;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 2 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as waxing and waning, associated with depression, affected relations with others and physical activity, and the impact on the patient’s life was gradually improving when he/she took pain medications consistently and was able to decrease severity to 3 out of 10 on the pain scale when consistent;- PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (three doses taken) instead of the 1 mL dose that was ordered by the physician; and- The patient’s pain level at the end of the visit showed 4 out of 10 in severity and controlled. Review of a SN note, dated 05/29/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 7 out of 10 in severity and the pain was described as tight, constant, exacerbated by movement and breathing, and relieved by medications and rest;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 3 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening, associated with nausea, affected the patient’s appetite, concentration, relations with others, and physical activity, and the impact on the patient’s quality of life was high;-PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed 7 out of 10 in severity and gradually coming down; and- The visit note showed that the patient reported he/she stopped taking Methadone the night before due to nausea and vomiting and that he/she was “withholding Morphine because he/she does not want his/her kids to see him/her sleepy and needing more assistance.”  The physician was notified and a new order was received to increase Fentanyl to 75 mcg/hour every 3 days and education was provided to the patient and caregivers. Review of a SN note, dated 06/03/2025, showed the following:- The patient complained of pain in bilateral shoulders, neck, and left rib cage and rated his/her pain as 10 out of 10 in severity and the pain was described as tight, constant, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 0 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening, associated with guarding (an involuntary or voluntary protective behavior used to prevent harm to an area), affected the patient’s sleep, mood, behavior, concentration, and physical activity, the impact of the pain on the patient’s quality of life was high, and the caregiver’s perception of the pain was that the patient did not appear to be taking Morphine at night and was waking up in an extreme amount of pain;-PRN medications taken in the last 24 hours included Morphine 0.5 mL every 1 hour PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient was asleep at the end of the visit; and- The visit note showed that the patient was not taking enough Morphine during the day and was not using it at night and would wake up in extreme pain, the physician was notified and a new order was obtained for MS Contin (a medication used for severe pain) 15 mg at bedtime, and education was provided to the patient and caregiver regarding medications. Review of a SN note, dated 06/06/2025, showed the following:- The patient complained of pain in bilateral shoulders, the left neck, and the left rib cage and rated his/her pain as 8 out of 10 in severity and the pain was described as aching and tight, constant, exacerbated by movement, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 0 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as waxing and waning, affected the patient’s sleep, mood, concentration, and physical activity, impact on quality of life is high, and the caregiver’s perception of the pain was that the patient was not getting any pain medication from 0800 (8AM) to 1200 (noon) and was waking up in pain around 1200 to 1300 (1PM); - PRN medications taken in the last 24 hours included Morphine 0.5 mL every 1-hour PRN (seven doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient was asleep at the end of the visit; and- The SN educated the patient and caregiver on pain medications and the need to give a dose of pain medication between 0800 and 0900 (9AM) to help prevent a pain spike around 1200. Review of the plan of care, dated 06/11/2025, showed the following under physical discomfort:- Goals included patient’s pain/physical discomfort will be reduced to the level of patient’s stated goal or patient does not demonstrate s/s (signs or symptoms) of physical discomfort if unable to communicate in one week and throughout hospice care and patient/caregiver will verbalize understanding of the pain management plan in three days and throughout hospice care;- Interventions included assess and document:  the cause, location, intensity, quality, frequency and duration of pain; alleviating and aggravating factors; current medication regimen and treatments; effects of pain on patient’s sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity.  Assess patient’s pain utilizing an appropriate pain scale for age and cognition.  Evaluate the effectiveness of the current pain treatment regimen and notify physician for the need for changes in the plan of care.  Instruct patient/caregiver on pain medication regimen and alternative strategies to relieve pain; and- The plan of care failed to include the patient’s pain management goal, interventions for the patient’s reluctance or refusal to take pain medications as prescribed, and interventions used to increase the likelihood of compliance with the medication regimen. During an interview on 02/11/2026 at 1:50 PM, the administrator stated that he/she would expect that the patient’s plan of care would be updated as changes were made and as the plan is adjusted those changes should be reflected in the plan of care.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure the plan of care (POC) specifically identified which provider was responsible for performing the respective functions that had been agreed upon at the skilled nursing facility (SNF) and was included in the POC in one of one record reviewed (Record/Patient #6). This deficient practice has the potential to affect the provision of care for all the provider’s patients that resides in a facility. Findings included: Review of the provider’s policy titled, “Hospice in Facility Policy,” approved 12/23/2025, showed that when the hospice patient resides in a nursing facility, the hospice collaborates with the nursing facility providing care to the patient/family to ensure coordination of services. There shall be a coordinated single plan of care in the nursing facility which may be multiple documents that identify the care and services which each shall provide; and is updated to reflect changes in the patient/family condition, needs, and care. Review of the provider’s coordinated task plan (CTP) instructions, dated 07/19/2017, showed that clinicians were to circle the days of the week the hospice aide planned to visit; update any on-going schedule changes on the next line; and list the frequency of foley catheter (a sterile tube placed in the bladder to drain urine) care under each party responsible. --- RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 06/27/2025 with a terminal diagnosis of chronic kidney disease (a long-term, progressive loss of kidney function). The patient had secondary diagnoses of protein calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and/or calories), dysphagia (difficulty swallowing), and required a foley catheter. The patient resided in a SNFReview of the POC, last updated 02/05/2026, showed that the hospice aide was to visit the patient two times per week, and the skilled nurse (SN) was to change the patient’s foley catheter every 30 days. Review of the patient’s clinical record, for the date period of 01/07/2026 to 02/06/2026, showed that the hospice aide had visited the patient two times per week on Tuesday and Friday. Review of the provider’s CTP last updated 01/27/2026, located in the patient’s binder at the facility, showed that the hospice aide was to visit on Tuesday and Thursday, and hospice would provide foley catheter supplies. The CTP failed to contain identification of who was responsible for the change of the patient’s foley catheter every 30 days and failed to be accurate with the days the hospice aide was going. During an interview on 02/10/2026 at 12:00 PM, the facility nurse (FN)-1 stated that he/she was unable to locate identification of who was responsible for changing the patient’s foley catheter every 30 days, and the hospice aide was to visit on Tuesday and Thursday. During an interview on 02/11/2026 at 9:00 AM, the administrator designee (AD)-1 stated that they would expect the CTP to identify who was responsible for changing the patient’s foley catheter and a visit schedule reflecting the actual days the aide visits were performed. He/she stated that the hospice clinical record contained a CTP dated 01/27/2026 that had identification of who was responsible to change the foley catheter and the correct visit schedule. This state agent (SA) informed the AD-1 that the CTP he/she had presented was not available in the facility binder at the time of the SA review.

Based on nationally recognized standards, observation, and interview the inpatient hospice provider failed to ensure a safe environment by storing oxygen cylinders in vacant patient rooms and bathrooms.  This deficient practice has the potential to affect all the patients, staff, and visitors. --- Findings included: Review of the National Fire Protection Association (NFPA) 101, 2012 edition, showed 8.7.3.2* No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure, unless otherwise permitted by 8.7.3.1. Review of the NFPA 99, 2012 edition, showed 5.1.3.3.2 Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1. (2) They shall be secured with lockable doors or gates or otherwise secured. (3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits. (4) If indoors, they shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. (5) They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations. (6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required. (7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty. (8) They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6. (9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials. (10) They shall protect electrical devices from physical damage.    Observation on 02/10/2026 beginning at 8:15 AM, showed the following:- Room one had an oxygen cylinder that was ¼ full stored in a closet;- Room five had an oxygen cylinder that was empty stored in the patient room;- Room six had an oxygen cylinder that was ¾ full stored in the patient room and an oxygen cylinder that was empty stored in the patient's bathroom;- Room seven had two oxygen cylinders stored in the patient bathroom that were empty;- Room eight had an oxygen cylinder that was ¼ full stored in the patient bathroom;- Room nine had an oxygen cylinder that was empty stored in the patient bathroom;- Room 10 had an oxygen cylinder that was empty stored in the patient bathroom;- Room 11 had an oxygen cylinder that was ¾ full stored in the patient room;- Room 12 had an oxygen cylinder stored in the patient room that was empty;- Room 13 had an oxygen cylinder that was ¼ full stored in the patient bathroom;- Room 14 had an oxygen cylinder stored in the patient bathroom that was empty;- Room 15 had an oxygen cylinder stored in the patient bathroom that was empty;- Room 17 had an oxygen cylinder stored in the patient room that was empty;- Room 18 had an oxygen cylinder stored in the patient room that was empty;- The utility room had two oxygen storage cylinders stored that were empty; and- By storing oxygen cylinders in vacant patient rooms and bathrooms the provider created a hazardous environment in the event of a fire. During an interview on 02/10/2026 at 9:48 AM, the inpatient clinical manager stated that the oxygen cylinders were usually stored in the patient’s bathroom and that this had been the practice for a few months or more. During an interview on 02/10/2026 at 2:20 PM, the director of public safety and security stated that the expectation would be for all oxygen to be stored in the storage area when not in use and not in the patient’s room or bathroom.

Based on nationally recognized standards, observation, and interview the inpatient hospice provider failed to ensure that the sprinkler system was maintained according to National Fire Protection Association (NFPA) standards, that sprinkler heads were not blocked in closet areas, and that ceiling tiles were in place to decrease the movement of smoke throughout the building.  This deficient practice has the potential to affect all the patients, staff, and visitors. --- Findings included: Review of the NFPA 25, 2011 edition, showed 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (a sprinkler head that has experienced degradation due to a chemical reaction with the environment) (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (a sprinkler head that has an accumulation of dust, debris, paint, or other foreign materials on its surface) (6) Painting unless painted by the sprinkler manufacturer. Review of the NFPA 25, 2011 edition, showed 5.2.1.2 The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.Review of the NFPA 13, 2010 edition, showed 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.Review of the NFPA 101, 2012 edition, showed 8.6 Vertical Openings. 8.6.1 Floor Smoke Barriers.  Every floor that separates stories in a building shall meet the following criteria: (1) It shall be constructed as a smoke barrier in accordance with Section 8.5. (2) It shall be permitted to have openings as described by 8.6.6, 8.6.7, 8.6.8, 8.6.9, or Chapters 11 through 43. 8.6.2 Continuity. Openings through floors shall be enclosed with fire barrier walls, shall be continuous from floor to floor, or floor to roof, and shall be protected as appropriate for the fire resistance rating of the barrier.  Observation on 02/10/2026 beginning at 8:15 AM, showed the following:- The linen storage room had an opening in a ceiling tile that measured 1 and ½-inches by ¼-inch and two ceiling tiles that were not in the tracks designed to keep them in place;- The biohazard room had a missing ceiling tile;- Room number one had a shelf in the closet containing several pillows wrapped in plastic bags that decreased the clearance of the sprinkler head to approximately 6-inches (clearance of the sprinkler head should be 18-inches to ensure that all areas of the closet are protected in the event of a fire);- Room number five had a shelf in the closet containing pillows that decreased the clearance of the sprinkler head to approximately 6-inches and a sprinkler head that was hanging down from the ceiling;- Room six had a missing escutcheon creating an opening in the ceiling approximately ¼-inch around the sprinkler head;- Room seven had a sprinkler head hanging out of the ceiling tile and the ceiling tile was not in the track designed to keep it in place;- Room ten had an escutcheon in the bathroom that was not flush with the ceiling that created ¼-inch gap around the sprinkler head;- Room nine had a sprinkler head that was corroded and rusted near the window;- Room 18 had a sprinkler head near the door that was leaking green fluid from the head of the sprinkler;- Room 15 had a missing escutcheon on the sprinkler near the door;- Room 17 had a sprinkler in the closet that was corroded and missing the escutcheon and the 18-inch clearance in the closet was blocked by the light fixture;- Room 16 had the 18-inch clearance in the closet blocked by the light fixture; and- The office closet had a sprinkler that was covered in dry wall dust. During an interview on 02/10/2026 at 2:20 PM, the facilities manager (person in charge of the fire alarms, sprinkler system, and cleanliness) stated that he/she would expect all ceiling tiles to be in place, the 18-inch clearance to be maintained to ensure that sprinklers were able to provide protection in the closet areas, and that all sprinklers should be clean and in good working order at all times.

Based on observation and interview the inpatient hospice provider failed to ensure that all intake and exhaust air ducts were maintained to prevent the entrance of dust, dirt, and other contaminating material into the facility.  This deficient practice has the potential to affect all the patients, staff, and visitors. --- Findings included:Observation on 02/10/2026 beginning at 8:15 AM, showed the following:- Room one had two ducts with dust build-up;- The laundry room had one duct with dust build-up;- The staff bathroom labeled 1122 had one vent with dust build-up;- Room nine had one duct by the window with dust build-up;- Room 12 had one duct in the bathroom with dust build-up;- The staff bathroom containing the locker room had one vent with dust build-up; and- The office labeled 1207 had one vent with dust build-up. During an interview on 02/10/2026 at 2:20 PM, the facilities manager (person in charge of the fire alarms, sprinkler system, and cleanliness) stated that he/she would expect ducts in the building to be clean and free of dust build-up.

Based on policy review, record review, and interview the agency failed to develop an individualized plan of care (POC) in two (Records/Patients #1 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Hospice Nursing Policy," dated 04/22/2020, showed in part: - Nursing services must ensure that the nursing needs of the patient are met as identified in the patients initial assessment, comprehensive assessment, and updated assessments; - The registered nurse (RN) initiates plan of care (POC) update with consultation from interdisciplinary group (IDG) members, attending physician and hospice medical director/hospice physician, reviews and revises the plan as necessary; - When a patient is a facility resident, will coordinate the implementation of the care plan with the facility and will respond to questions and concerns from the nursing facility; and - Completes all documentation within the hospice electronic medical record including plan of care updates. Review of the agency's policy titled, "Hospice Initial, Comprehensive Assessment Policy," dated 12/23/2021, showed in part: - The hospice IDG, in consultation with the patients attending physician and patient/family, will prepare a POC for the patient; and - The POC will specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. Review of the agency's policy titled, "Hospice Pain Assessment Policy," dated 01/03/2022, showed in part: - All patients right to pain management will be respected and supported; - The hospice IDG will plan, support, and coordinate interventions and resources to ensure each patients pain is recognized and addressed appropriately; - Pain is highly subjective, in which a variety of unpleasant sensations and a wide range of distressing factors may be experience by the patient; - Pain may be acute, following illness, injury, or surgery; - Alternatively, pain may be chronic, lasting longer than six months, resulting from long-term illness such as arthritis; - The hospice IDG is responsible for managing pain; - The physical discomfort plan will be opened on all patients who have an unacceptable pain level, and/or if they are actively utilizing any form of scheduled or as needed pain medications; and - For patients who have as needed pain medication ordered and available for a future need, and do not have pain as an active problem the Hospice End of Life Comfort and Support care plan would be opened. RECORD/PATIENT #4: Review of the skilled nurse hospice initial assessment, dated 12/23/2021 at 9:31 PM, showed: - The patient was admitted to hospice on 12/23/2022; - Primary diagnosis of protein-calorie malnutrition, severe; - Co-morbidities included, but not limited to, chronic obstructive pulmonary disease (COPD [a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing) and resulting in an accumulation of fluid in the lungs and other areas of the body]); - Aspiration risk precautions; - Hospitalized three times in past six months due to cellulitis (a common and potentially serious bacterial skin infection), aspiration (an accidental breathing in of food or fluid into the lungs), and sepsis (the bodys extreme response to an infection); - Patient had increased dysphagia (difficulty swallowing) in the past four months leading to aspiration; - The patients does have swallowing impairment that has made him/her aspirate several times in the past few months and only getting worst. The patients family member states the patient is doing well with his/her pills when crushed or in something soft and the skilled nurse education the family member on aspiration precautions; - The patient had back pain and rated the pain 5/10 (a scale used to rate pain, zero represents no pain and ten represents the worst pain possible); - The pain was described as aching, intermittent, the duration varied and exacerbating factors were physical activity, and relieving factors mediation and repositioning; - The patient had back pain for years and relieved by oxycodone (used to treat moderate to severe pain) and well controlled by current regimen; and - The patients pain was to be assessed at each visit and as needed. Review of the plan of care (POC), dated 12/23/2023, showed pain- call physician, there was no other interventions and goals regarding the patients pain and no problems, interventions, and goals addressing aspiration precautions. Review of a skilled visit note dated 12/27/2022 showed: - The highest pain in the past 24 hours was 5/10; - Patient had complaint of ";tailbone hurting"; - The patient used morphine (used to relieve moderate to severe pain) 10 milligrams (mg), one dose yesterday; - The patients family stated the patient frequently coughs after taking liquids or foods and they are crushing medications and have given one dose of morphine (used to relieve moderate to severe pain) in ";AMS" for pain relief and holding oxycodone ";xr" as patient cannot swallow whole tablet; and - The skilled nurse provided gentle touch and non-pharmacologic intervention. Review of a skilled note dated 01/04/2023 showed: - The patient complained of tailbone hurting and received oxycodone and morphine ";xl" dose in the last 24 hours; - The RN provided gentle touch and non-pharmacological interventions this visit; - The RN noted new + (plus) three pitting edema (occurs when excess fluid build-up in the body, causing swelling; when pressure is applied to the swollen area an indentation will remain, a grading system is often used to determine the severity of the edema on a scale from + one to + four) from mid shin to toes; - The skilled nurse educated the patient and family member on Lasix; and - Educated on non-pharmacology interventions such as elevate legs throughout the day, pedal pumps (exercises to manage swelling), compression stocking (snug-fitting, stretchy socks that gently squeeze your leg), changing positions during the day, decrease salty food intake, walk around home when possible, and lying in bed with feet elevated for naps. Review of the hospice plan of care updated 01/05/2023, showed the patient restarted Lasix, Fentanyl (a powerful opioid drug used in the treatment of severe pain) and massage therapy referral. The POC failed to show any other individualized interventions, and goals for aspiration precautions, pain, and increased edema to bilateral extremities. During an interview on 02/16/2023 at 10:00 AM, the administrator stated that the staff build out the POC with symptoms that need managed. The staff can manually add interventions. Problems discussed at the IDG meeting may include new interventions added to the POC and the POC updated. He/she was not surprised at the problems found with the POC. The agency already identified the POC has opportunity for improvement. They have already added these issues to their Quality Assurance and Performance Improvement. RECORD/PATIENT #1; Review of the skilled nurse hospice initial assessment, dated 12/21/2022 at 2:38 PM showed: The patient was admitted to hospice on 12/21/2022; The patient resided in a long term care (LTC) facility; Primary diagnosis of chronic combined systolic and diastolic heart failure (the heart's pumping ability is impaired, the heart can not beat strongly enough to maintain adequate circulation); Discharged from hospital 12/19/2022, due to patient's fracturing (breaking) left hip/thigh. Patient rolled out of bed and fractured his/her leg and was hospitalized; Co-morbidities included, but not limited to, chronic kidney disease (the kidneys filter waste and excess fluid from the blood. As the kidneys fail, waste builds up.), hypertension (high blood pressure) and large mass of right breast; Patient denies pain at rest, when attempted to turn patient in bed for skin assessment, patient began yelling and moaning with pain when touched, LTC nurse stated that patient had Norco (pain medication) approximately two hours ago , Norco order currently one every four hours as needed (prn), hospice nurse placed call to physician and an order was received to increase the Norco to two tablets prn, additional medication order received for Roxanol (pain medication) and Lorazepam (sedative/relaxant medication); The patient noted to have moderate nonpitting edema (swelling) to the left arm and bilateral lower legs; The patient's pain was to be assessed at each visit and as needed. Review of SN noted dated 01/06/2023 showed: Highest pain in last 24 hours was 10/10 (0 = least amount of pain and 10 = highest amount of pain); Moderate nonpitting edema bilateral lower legs and left arm; LTC nurse stated that the Norco and Roxanol do not help the pain that the patient experiences when he/she is moved, that they only make him/her sleepy; Review of POC dated 01/18/2023 failed to document patients pain and LTC facility compliance with pain medication administration, and failed to document patient's edema and/or interventions related to the edema. Review of SN visit dated 01/12/2023 showed: Highest pan in last 24 hours was 6/10; LTC medication record failed to document administration of prn pain medication for the patient's pain level; LTC nurse stated that Norco and Roxanol "just make the patient sleep, and that they really don't help with the pain that he/she has when moved"; Record failed to show LTC administration of prn pain medication; Review of POC dated 01/18/2023 failed to document patients pain and LTC facility compliance with pain medication administration, and failed to document patient's edema and/or interventions related to the edema. Review of SN visit dated 01/17/2023 showed: Highest pain in last 24 hours was 10/10 for left knee; LTC notes stated Roxanol given times two; Patient has a tendency to scream and yell when he/she is moved or turned; SN charted moderate nonpitting edema noted to bilateral lower legs and left arm; Review of POC dated 01/18/2023 failed to document patients pain and LTC facility compliance with pain medication administration, and failed to document patient's edema and/or interventions related to the edema. During an interview on 02/15/2023 at 10:50 AM, the administrated stated that we have already identified the need to improve care plan interventions. The administrator stated also that LTC facilities do not provide patient's with prn medications routinely, and that they do not like a prn scheduled for e.g. 30 minutes prior to hospice agency bathing, or providing patient cares.

Based on record review, and interview the agency staff failed to provide the frequency of services ordered on the patient's plan of care in, one (Record/Patient #2) of five records reviewed. This deficient practice has the potential to affect the services needed for all the agency's patients. --- Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 02/03/2023 with a terminal diagnosis of malignant neoplasm (cancer) right lung lobe. Review of the clinical record showed: An order for hospice aide one a week/one at start of care, and then two a week for five weeks. and Record showed no visit for the first week of care. During an interview on 02/15/2023 at 11:15 AM, the administrator concurred that the agency missed an aide visit for the first week for this patient.

Based on agency policy, clinical record review, and interview the agency failed to ensure the registered nurse (RN) prepared accurate written patient care instructions for the hospice aide assignment in one (Record/Patient #1) of five applicable records reviewed. This deficient practice has the potential to affect the aide assignments for all of the agency's patients. --- Findings included: Review of the agency's policy titled, "MHS Hospice Home Health Aide Homemaker Policy," dated 05/26/2021 showed the hospice aide is assigned and the assignment/Plan of Care (POC) is completed by the RN. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 12/21/2022, with a terminal diagnosis of chronic combined systolic and diastolic heart failure (the heart's pumping ability is impaired, the heart can not beat strongly enough to maintain adequate circulation), and the patient was discharged from the hospital on 12/19/2022, due to patient's fracturing (breaking) left hip/thigh. Patient rolled out of bed and fractured his/her leg. The patient resided in a long term care (LTC) facility. Review of the POC dated 12/21/2022 showed wound management: Keep left outer thigh/hip incisions covered with dry dressing.Change dressing daily and as needed. Do not submerge incision into water. No tub baths, hot tubs, or swimming pools. Review of the aide care plan failed to show any instructions related to the thigh/hip incision dressings. During an interview on 02/16/2023 at 11:10 AM, the administrator stated that dressing care should have been addressed in the aide assignment.

Based on policy review, record review, and interview the agency failed to ensure the hospice aide followed the plan of care assignment in one (Record/Patient #4) of five records reviewed that received aide services. This deficient practice has the potential to affect all patients receiving aide services. --- Findings included: Review of the agency's policy titled, "Home Health Aide Homemaker," dated 05/26/2021, showed in part, the hospice aide assignments and duties are ordered by the interdisciplinary group and included in the patients plan of care. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 12/23/2022. The primary diagnosis of protein-calorie malnutrition, severe. Co-morbidities included, but not limited to, chronic obstructive pulmonary disease (COPD [a term referring to chronic bronchitis and emphysema, characterized by obstruction of airflow that interferes with normal breathing) and resulting in an accumulation of fluid in the lungs and other areas of the body]). Review of the hospice aide visit note, dated 01/27/2023 showed the aide failed to follow the plan of care as ordered by the interdisciplinary group when the aide noted the patients third toe on the right foot had a sore that had a green color to it and believes it was infected. He/she applied prescribed medication to the area and placed a bandage on it, which was not included on the plan of care. During an interview on 02/15/2023 at 3:05 PM, the administrator stated that the aide should not have applied medication and bandage to the patients foot without it being on the plan of care. The aide could have called the skilled nurse to update the plan of care.

Based on policy review, record review and interview, the agency failed to ensure physician orders were obtained in, but not limited to, one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Hospice Orders," dated 01/03/2022, showed in part that the hospice will enter all orders into the electronic medical record and ensured they are signed by the ordering licensed independent practitioner in a timely manner. RECORD/PATIENT #3: Review of the most recent plan of care update, dated 02/02/2023, showed administer oxygen three liters/minute for shortness of breath. Review of the skilled nurse (SN) visit notes dated 02/04/2023, 02/10/2023, and 02/11/2023 showed the patient's supplemental oxygen was administered at four liters/minute via nasal cannula. Review of the medical record showed no physician's order for oxygen administered at four liters/minute. During an interview on 02/15/2023 at 1:50 PM, the registered nurse supervisor stated that the orders had ranges for oxygen use and when shown this patient had oxygen ordered at three liters/minute, he/she was unable to find an order for oxygen administered at four liters/minute.

Based on policy review, record review, and interview, the agency failed to document a transfer summary that included a summary of the patient's stay including treatments, symptoms, and pain management in one (Record/Patient #11) of one transfer record reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #11: Review of the record showed the patient transferred to another hospice on 11/21/2022. The record failed to include a transfer summary. During an interview on 02/15/2023 at 1:30 PM, the administrator stated that a transfer summary was not sent to the receiving hospice agency. Normally, paperwork and synopsis of care is sent to the receiving agency.

Based on record review, and interview, the agency failed to identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care (POC) in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the coordination of care for all the agency's patients who reside in a long term care facility (LTCF). --- Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 12/21/2022 with a terminal diagnosis of chronic combined systolic and diastolic heart failure (the heart's pumping ability is impaired, the heart can not beat strong enough to maintain adequate circulation). The patient was admitted post discharge from a hospital due to the patient's fracturing (breaking) his/her left hip/thigh. Patient rolled out of bed and fractured his/her leg and was hospitalized. The patient had a wound dressing on his/her left hip/thigh. Review of the LTC coordinated task plan of care failed to show the coordinated wound care responsibilities for both the agency and the LTC facility. During an interview on 02/16/2023 at 11:15 AM the administrator stated that wound care should have been addressed on the coordinated plan of care.