Every finding on record at Michigan Palliative & Hospice Care, LLC

Based on record review and interview, the agency failed to have documented contact information for Federal, State, tribal, regional, and local emergency preparedness staff, resulting in the lack of essential information in the event of an actual emergency. Findings include: --- During a review of the agency's Emergency Preparedness Plan on 8/25/23, it was noted that there was no documented contact information for Federal, State, tribal, regional, and local emergency preparedness officials documented. During an interview on 8/25/23 at 2:05 p.m., the administrator (Staff-A) stated, "We do not actually have a communication plan documented anywhere."

Based on record review and interview, the hospice agency, failed to develop and maintain an emergency preparedness communication plan that included an alternate means for communicating with agency staff, Federal, State, tribal, regional, and local emergency preparedness officials, resulting in the lack of essential information in the event of an actual emergency. Findings include: --- During a review of the agency's Emergency Preparedness Plan on 8/25/23, it was noted that there was no alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency preparedness officials documented. During an interview on 8/25/23 at 2:05 p.m., the administrator (Staff-A) stated, "We do not actually have a communication plan documented anywhere." The agency failed to develop and maintain a communication plan that included an alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency preparedness officials.

Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. The training and testing program must be reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: --- During review of the agency's emergency preparedness program on 8/25/23, it was discovered that there was no documented evidence the agency had developed a training and testing program to guide personnel and agency actions during an emergent situation. All agency patients could be impacted by the agency's failure to develop and maintain an emergency preparedness training and testing program. During an interview on 8/25/23 at 2:05 p.m., the administrator (Staff-A) acknowledged the above findings.

Based on record review and interview, the agency failed to conduct exercises to annually test the emergency plan or provide documentation of an actual event that would qualify as a test of the emergency plan; failed to conduct an additional full-scale exercise or a table-top exercise; and failed to analyze the clinic's response to and maintain documentation of all drills, tabletop exercises, emergency events and revise the emergency plan as needed. This deficient practice could affect the health and safety of all clinic patients in the event of a facility emergency or disaster. Findings include: --- On 8/25/23, the agency's emergency preparedness documentation was reviewed. There was no documentation of a full-scale exercise or a table-top exercise in 2021 or 2022. There was no documentation of the following: an actual event that would qualify as a test of the emergency plan, an additional full-scale exercise or a table-top exercise, and an analysis of the clinic's response to all drills, tabletop exercises, emergency events and revisions to the emergency plan as needed. The findings were confirmed during an interview on 8/25/23 at 2:05 p.m. with the administrator (Staff-A).

Based on record review and interview, the agency failed to ensure the comprehensive assessment addressed the physical, psychosocial, emotional, and spiritual needs of the patient in 2 (P-6, 8) of 16 sampled records resulting in the potential for a reduction in well-being, comfort, and dignity throughout the dying process. Findings include: --- P-6: This 42-year-old patient was admitted to hospice on 7/23/22 with a terminal diagnosis of pancreatic cancer. During record review on 8/22/23, it was noted that the RN initial assessment, dated 7/23/22, failed to include a comprehensive pain assessment although the patient has pain medications ordered, including Fentanyl patch every 72 hours for pain, Morphine Sulfate 5mg every 3 hours as needed for pain, and Oxycodone 20mg every 2 hours as needed for pain. The initial assessment states ";no pain reported." There is no indication of where the patient experiences pain, pain intensity, and how often the patient is taking Morphine or Oxycodone. The finding was reviewed and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 2:35 p.m. P-8: This 88-year-old patient was admitted to hospice on 8/16/23 with the terminal diagnosis of atherosclerotic heart disease. During record review on 8/23/23, it was noted that the RN initial assessment, dated 8/16/23, failed to include a comprehensive pain assessment although there are orders for Dilaudid 2mg every 4 hours as needed for pain. The initial assessment states ";no pain reported." There is no indication of where the patient experiences pain, pain intensity, and how often the patient is taking Dilaudid. The finding was reviewed and acknowledged by Staff A and Staff B during an interview on 8/25/23 at 2:35 p.m.

Based on record review and interview, the agency failed to ensure a review of all the patient's medications was conducted in 6 (P-6, 8, 15,16, 17, 18) of 16 records reviewed, resulting in the potential for drug interactions, side effects, or duplicate drug therapy. Findings include: --- P-6: This 42-year-old patient was admitted to hospice on 7/23/22 with a terminal diagnosis of pancreatic cancer. No drug interaction/reconciliation report was found in the medical record during record review on 8/22/23. Duplicate drug therapies were noted in the admission orders for beta blockers (Atenolol & Metoprolol) and there was no indication that the nurse was alerted to the duplicate drug therapy or that the physician was informed. The finding was reviewed with the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 2:35 p.m. Staff A stated the electronic medical record (EMR) software verifies there are no drug interactions or duplications and acknowledged a report may be run through the Enclara (pharmacy) software and uploaded into the chart. There was no indication the EMR software alerted the agency regarding the duplicate therapy. P-8: This 88-year-old patient was admitted to hospice on 8/16/23 with the terminal diagnosis of atherosclerotic heart disease. No drug interaction/reconciliation report was found in the medical record during record review on 8/22/23. Duplicate drug therapies were noted in the admission orders for corticosteriods (Fludrocortisone & Cortef) and there was no indication that the nurse was alerted to the duplicate drug therapy or that the physician was informed. The finding was reviewed with Staff A and Staff B during an interview on 8/25/23 at 2:35 p.m. P-15: This 80-year-old patient was admitted to hospice on 6/30/23 with a terminal diagnosis of cancer to the pharynx (throat). No drug interaction/reconciliation report was found in the medical record during record review on 8/24/23. The patient medication record signed by the nurse on 6/30/23, acknowledges that all medications were reviewed for duplicate drug therapy. A review of the medication record notes the patient is taking 2 oral medications classified as opioid analgesics (pain relievers): Hydrocodone-Acetaminophen and Morphine Sulfate. There was no indication that the nurse was alerted to the duplicate drug therapy or that the physician was informed. The findings were reviewed with and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 11:10 a.m. P-16: This 71-year-old patient was admitted to hospice on 12/2/22 with a terminal diagnosis of leukemia. No drug interaction/reconciliation report was found in the medical record during record review on 8/24/23. The patient medication record signed by the nurse on 5/21/23, acknowledges that all medications were reviewed for duplicate drug therapy. A review of the medication record notes the patient is taking 2 oral medications classified as antianxiety agents: Lorazepam 0.5 mg 1 tab every 4 hours as needed, and Lorazepam concentrate 2 mg/ml dose 0.50 ml every 4 hours as needed. There was no indication that the nurse was alerted to the duplicate drug therapy or that the physician was informed. P-17: This 82-year-old patient was admitted to hospice on 3/30/23 with terminal diagnoses of Parkinson's disease and high blood pressure. No drug interaction/reconciliation report was found in the medical record during record review on 8/23/23. The patient medication record signed by the nurse on 3/31/23, acknowledges that all medications were reviewed for duplicate drug therapy. A review of the medication record notes the patient is taking 2 medications classified as laxatives: Bisacodyl rectal suppository and Senna S. There was no indication that the nurse was alerted to the duplicate drug therapy or that the physician was informed. The medication record also noted that the nurse checked the "No" prompt when answering the question if the physician was notified of severe medication interactions. The area to "please explain," the nurse documents "benefits outweigh the risk." There was no indication which severe medication interactions the nurse was referring to and no indication the physician was informed. P-18: This 83-year-old patient was admitted to hospice on 3/2/23 with terminal diagnoses of prostate cancer with metastases. No drug interaction/reconciliation report was found in the medical record during record review on 8/22/23. The patient medication record signed by the nurse on 3/5/23, acknowledges that all medications were reviewed for duplicate drug therapy. A review of the medication record notes the patient is taking 2 medications classified as antipsychotic/antimanic agents: Prochlorperazine Maleate and Haloperidol Lactate; and 2 antianxiety agents: Lorazepam and Hydroxyzine HCl. There was no indication that the nurse was alerted to the duplicate drug therapies or that the physician was informed.

Based on interview and record review, the hospice failed to provide initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death in 3 (P-6, 9, 16) of 19 sampled records resulting in the potential for lack of support for individuals who may be impacted by the patients death. Findings include: --- P-6: This 42-year-old patient was admitted to hospice on 7/23/22 with a terminal diagnosis of pancreatic cancer. During record review on 8/22/23, it was noted that the initial bereavement assessment was not completed. Medical social work notes dated 7/25/22 and 8/1/22 document attempt to schedule social work assessment. No other bereavement assessments were found in the medical record. The patient passed away on 9/7/22. The finding was reviewed and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 2:35 p.m. P-9: This 63-year-old patient was admitted to hospice on 4/8/23 with the terminal diagnosis of anal cancer. An initial bereavement assessment was completed by the medical social worker on 4/11/23, which indicates there are no children under age 14 in the home. During record review on 8/23/23, it was noted in the social work assessment dated 4/11/23, that the patient resides with her daughter and her two young sons ";ages 3 YO and 5 YO." No other bereavement assessments were found in the medical record. The finding was reviewed and acknowledged by Staff A and Staff B during an interview on 8/25/23 at 2:35 p.m. P-16: This 71-year-old patient was admitted to hospice on 12/2/22 with a terminal diagnosis of leukemia. During record review on 8/24/23, it was noted that the initial bereavement assessment was not completed. On 12/5/22, the medical social worker documented a missed visit note which stated the social worker attempted to reach the patient's friend to assess for bereavement risk, a message was left, and no return phone call by the end of the day. There was no further documentation to indicate attempts to conduct an initial bereavement assessment for the patient's friend/caregiver. The patient transferred to another hospice on 6/6/23. The hospice had approximately 6 months to conduct a bereavement assessment and failed to do so. The findings were reviewed with and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 11:10 a.m.

Based on record review and interview, the hospice failed to ensure the hospice plan of care included all services provided to the patient for 5 of 5 (P-11, 12, 13, 17, 19) records reviewed with massage therapy services, resulting in no oversight by the interdisciplinary group regarding massage therapy services for these patients: Findings include: --- P-17: This patient was admitted to hospice on 3/30/23 with diagnoses of Parkinson's disease and high blood pressure. During record review on 8/23/23, it was noted that massage therapy services were provided to this patient by hospice staff on 7/4/23. There were no physician orders to provide this service and no indication in the 7/3/23 plan of care that the interdisciplinary group (IDG) had added this service for the patient. The findings were reviewed with and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 11:10 a.m. P-18: This patient was admitted to hospice on 6/2/23 with a diagnosis of pancreatic cancer. During record review on 8/22/23, it was noted that massage therapy services were provided to this patient by hospice staff on 6/10/23, 7/8/23, 7/22/23, and 8/5/23. There were no physician orders to provide this service and no indication in the 6/2/23 plan of care that the IDG had added this service for the patient. P-11: The Start of Care (SOC) was dated 3/29/23. The Plan of Care (POC) for the certification period 3/29/23 through 6/26/23, identified diagnoses of systolic and diastolic congestive heart failure. Upon review of the POC, it was noted that massage therapy services were provided to this patient by hospice staff on 4/7/23 and 4/22/23. There were no physician orders to provide this service and no indication in the 3/29/23 plan of care that the interdisciplinary group (IDG) had added this service for the patient. P-12: The Start of Care (SOC) was dated 8/6/23. The Plan of Care (POC) for the certification period 8/6/23 through 11/3/23, identified diagnoses of heart disease. Upon review of the POC, it was noted that massage therapy services were provided to this patient by hospice staff on 8/12/23 and 8/19/23. There were no physician orders to provide this service and no indication in the 8/6/23 plan of care that the interdisciplinary group (IDG) had added this service for the patient. P-14: The Start of Care (SOC) was dated 2/15/23. The Plan of Care (POC) for the certification period 2/15/23 through 5/15/23, identified diagnoses of severe protein/calorie malnutrition. Upon review of the POC, it was noted that massage therapy services were provided to this patient by hospice staff on 2/18/23 and 3/4/23. There were no physician orders to provide this service and no indication in the 2/15/23 plan of care that the interdisciplinary group (IDG) had added this service for the patient. During an interview on 8/25/23 at 2:05 p.m., the administrator (Staff-A) and the director of nursing (Staff-B) acknowledged the above findings.

Based on record review, and interview, the agency failed to ensure the medical record contained a current Plan of Care that was complete with objectively measurable goals in 9 of 19 (P- 1, 2, 3, 4, 5,11, 12, 13 and 14) records reviewed out of a total sample of 19 records reviewed, resulting in the potential for failure to meet the patient's needs identified on the comprehensive assessment. Findings included: --- **Agency Policy: P-11: The Start of Care (SOC) was dated 3/29/23. The Plan of Care (POC) for the certification period 3/29/23 through 6/26/23, identified diagnoses of systolic and diastolic congestive heart failure. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Patient/caregiver will verbalize stated goals for pain control." Another stated, "Caregiver will verbalize understanding of behaviors that may indicate pain." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-12: The Start of Care (SOC) was dated 8/6/23. The Plan of Care (POC) for the certification period 8/6/23 through 11/3/23, identified diagnoses of heart disease. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Patient/caregiver will verbalize understanding of safety measures related to fall risk." Another stated, "Caregiver will verbalize understanding and demonstration related to oxygen safety measures." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-13: The Start of Care (SOC) was dated 5/4/23. The Plan of Care (POC) for the certification period 5/4/23 through 8/1/23, identified diagnoses of severe protein/calorie malnutrition. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Patient's personal needs at end of life are met by staff." Another stated, "Patient/Caregiver will verbalize understanding of expected disease progression and impending death." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-14: The Start of Care (SOC) was dated 2/15/23. The Plan of Care (POC) for the certification period 2/15/23 through 5/15/23, identified diagnoses of severe protein/calorie malnutrition. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Patient's/caregiver will verbalize understanding of pain medication administration and potential side effects." Another stated, "Caregiver will verbalize understanding of behaviors that may indicate pain." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 8/25/23 at 2:05 p.m., the administrator (Staff-A) and the director of nursing (Staff-B) acknowledged the above findings. **Agency Policy# 2-044.1: "The Plan of Care, revised 2020." The policy states, "The written plan of care will contain, but will not be limited to the following: Measurable outcomes anticipated from implementing and coordinating the plan of care." P-1: The Start of Care (SOC) was dated 1/20/2023. The Plan of Care (POC) for the certification period 1/20/2023 to 4/19/2023. The Plan of Care identified diagnoses of "Malignant neoplasm of Pancreas." Upon review of the POC, it was noted the goals were not patient specific or objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient will be in control of what, how much, and when to eat," "Patient/Caregiver will understand the disease process and that weight loss may occur despite nutritional support," "Patient will be monitored for functional decline AEB increased confusion, increased weakness, change to bedbound status, and fall incidents." These goals are not patient specific or measurable to determine the patient's progress towards obtaining the goals." P-2: The Start of Care (SOC) was dated 6/23/2023. The Plan of Care (POC) for the certification period 6/23/2023 to 7/02/2023. The Plan of Care identified diagnoses of "Chronic Systolic Congestive Heart Failure." Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient will be monitored for functional decline As Evidenced by increased confusion, increased weakness, change to bedbound status, and fall incidents." This goal is not individualized to the patient's specific needs, nor measurable to determine the patient's progress towards goals. Another goal: "Patient will maintain optimal level of functioning within limits of disease process." This goal is not objectively measurable to determine the patient's progress towards obtaining the goal. P-3: The Start of Care (SOC) was dated 6/15/2023. The Plan of Care (POC) for the certification period 6/15/2023 to 9/12/2023. The Plan of Care identified diagnoses of "Metastatic Cancer of the Colon and Liver." Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient/Caregiver will verbalize understanding and demonstration of fall prevention safety measures." "Patient will be monitored for functional decline as evidenced by increased confusion, increased weakness, change to bedbound status, and fall incidents." "Patient will maintain optimal level of functioning within limits of disease process." These goals are not individualized or objectively measurable to determine the patient's progress towards achieving the stated goals. P-4: The Start of Care (SOC) was dated 8/10/2023. The Plan of Care (POC) for the certification period 8/10/2023 to 4/19/2023. The Plan of Care identified diagnoses of "Metastatic Lung Cancer." Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient will be monitored by hospice and facility staff for functional decline as evidenced by increased confusion, increased weakness, change to bedbound status, and fall incidences." "Patient will maintain optimal level of functioning within limits of disease process." These goals are not measurable to determine the patient's progress towards achieving goals. P-5: The Start of Care (SOC) was dated 8/1/2023. The Plan of Care (POC) for the certification period 8/1/2023 to 10/29/2023. The Plan of Care identified diagnoses of "Malignant neoplasm of Pancreas." Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient will be knowledgeable, compliant, and safe related to medication regimen." "Patient will be in control of what, how much, and when to eat." "Caregiver will verbalize understanding of anorexia and cachexia in patients at end of life." These goals are not objectively measurable to determine the patient's progress towards achieving the goals.

Based on record review and interview, the agency failed to ensure personnel completed infection control education for 1 of 4 (Staff-E) personnel records reviewed, resulting in the potential for spread of infection and/or communicable disease. Findings include: --- During record review on 8/25/23 at 9:00 a.m., it was noted that 1 (Staff-E) of 4 personnel records reviewed failed to include infection control education in 2022 and 2023. Staff E was hired by the agency on 9/19/22 and assigned ";Standards for Infection Control: An Update for Healthcare Workers" in Healthstream and record indicates ";Past Due 10/21/22." The agency produced competency records related to infection control policies but failed to produce any completed education. The finding was reviewed and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 2:35 p.m.

Based on record review and interview, the hospice failed to ensure the registered nurse prepared written patient care instructions for the aide that included safety precautions, specific guidance, and care instructions pertinent to the needs of the patient for 6 of 14 (P-6, 11, 12, 13, 15, 17) records reviewed with aide services, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: --- P-15: This patient was admitted to hospice on 6/30/23 with a diagnosis of cancer to the pharynx (throat). Record review on 8/24/23 indicates the patient has a tracheostomy to enable breathing and a percutaneous endoscopic gastrostomy (PEG) tube for feedings. The patient takes nothing by mouth and is on aspiration precautions. The 7/14/23 aide care plan created by the registered nurse instructed the aide to provide 2 visits each week and to provide a bed bath every visit and a partial shower or complete shower as needed. There were no instructions informing the aide of the tracheostomy and the aspiration precautions for this patient. The findings were reviewed with and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 11:10 a.m. P-17: This patient was admitted to hospice on 3/30/23 with diagnoses of Parkinson's disease and high blood pressure. During record review on 8/23/23 it was noted that the patient resides in a skilled nursing facility (SNF). A joint survey home visit with the aide was conducted on Wednesday, 8/23/23 at 10:00 a.m. Upon entering the patient's room, the aide asked the patient if she was ready for her shower. The patient stated, "No, my shower days are Tuesday and Friday. Today is Wednesday." The hospice aide care plan dated 6/28/23, orders the aide to provide 2 visits each week and to provide a complete bed bath or partial bath/shower each visit. There were no instructions regarding the Tuesday and Friday shower days at the SNF. It was unclear why the hospice aide conducted a visit on Wednesday to provide a shower. P-6: This 42-year-old patient was admitted to hospice on 7/23/22 with a terminal diagnosis of pancreatic cancer. The 8/17/22 aide care plan created by the registered nurse instructed the aide to perform personal care with every visit. During record review on 8/22/23, it was noted in the plan of care that the patient is at risk for falls. There are no fall precautions in the aide care plan for this patient. The finding was reviewed and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 2:35 p.m. P-11: The Start of Care (SOC) was dated 3/29/23. The Plan of Care (POC) for the certification period 3/29/23 through 6/26/23, identified diagnoses of systolic and diastolic congestive heart failure. Upon review of the POC, it was noted that the patient had a history of falls and was on oxygen therapy. During review of the aide care plan dated 3/29/23, it was noted that the aide care planned failed to document oxygen precautions or fall precautions. P-12: The Start of Care (SOC) was dated 8/6/23. The Plan of Care (POC) for the certification period 8/6/23 through 11/3/23, identified diagnoses of heart disease. Upon review of the POC, it was noted that the patient had a history of falls and was on oxygen therapy. During review of the aide care plan dated 5/8/23, it was noted that the aide care plan failed to document oxygen precautions or fall precautions. P-13: The Start of Care (SOC) was dated 5/4/23. The Plan of Care (POC) for the certification period 5/4/23 through 8/1/23, identified diagnoses of severe protein/calorie malnutrition. Upon review of the POC, it was noted that the patient was on oxygen therapy. During review of the aide care plan dated 5/4/23, it was noted that the aide care plan failed to document oxygen precautions. During an interview on 8/25/23 at 2:05 p.m., the administrator (Staff-A) and the director of nursing (Staff-B) acknowledged the above findings.

Based on record review and interview, the hospice failed to ensure that aide services were ordered by the interdisciplinary group for 5 of 14 (P-6, 15, 17, 18, 19) records reviewed with aide services, resulting in no oversight by the interdisciplinary group regarding the provision of aide services for these patients. Findings include: --- P-6: This 42-year-old patient was admitted to hospice on 7/23/22 with a terminal diagnosis of pancreatic cancer. On admission to hospice, home health aide (HHA) services were offered twice weekly and were declined. An order to discontinue aide services was written on 7/27/22. During record review on 8/22/23, a nursing visit on 8/17/22 stated ";add NA (nurse aide) to visit patient weekly to assist with bed bath." There were no physician orders to resume HHA services and no indication that the interdisciplinary group (IDG) added this service for the patient in the IDG notes dated 8/15/22 or 8/29/22 or that the IDG provided oversight of these services. The finding was reviewed and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 2:35 p.m. P-15: This patient was admitted to hospice on 6/30/23 with a diagnosis of cancer to the pharynx (throat). The patient received skilled nursing, spiritual care, and social work services. During record review on 8/24/23, it was noted that on 7/17/23 the aide began providing care to this patient. The 7/14/23 aide care plan ordered the aide to provide 2 visits each week. There were no documented aide visits the week of 7/14/23. The week of 7/16/23, the aide documented that 3 visits were provided versus the 2 visits that were ordered. There was no physician order to add aide services. There was no documentation to indicate the interdisciplinary group (IDG) had ordered aide services and provided oversight of these services. During an interview on 8/25/23 at 11:10 a.m., the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) reviewed the medical record and acknowledged there were no orders for aide services. P-17: This patient was admitted to hospice on 3/30/23 with diagnoses of Parkinson's disease and high blood pressure. The patient receives skilled nursing, social work, and aide services. The aide provides 2 visits each week. During record review on 8/23/23, it was noted that there was no physician order for aide services. There was no documentation to indicate the IDG had ordered aide services and provided oversight of these services. P-18: This patient was admitted to hospice on 3/2/23 with a terminal diagnosis of prostate cancer. The patient receives skilled nursing, social work, and aide services. The aide provided visits on 3/7/23 and 3/9/23. During record review on 8/22/23, it was noted that there was no physician order for aide services. There was no documentation to indicate the IDG had ordered aide services and provided oversight of these services. P-19: This patient was admitted to hospice on 6/2/23 with a terminal diagnosis of pancreatic cancer. The patient receives skilled nursing, spiritual care, and aide services. The aide provided a visit on 8/18/23. During record review on 8/22/23, it was noted that there was no physician order for aide services. There was no documentation to indicate the IDG had ordered aide services and provided oversight of these services.

Based on observation, record review, and interview, the hospice failed to ensure the plan of care specifically identified the care and services to be provided by the hospice and the skilled facility for 1 of 1 (P-17) record reviewed for a patient residing in a skilled nursing facility, resulting in a lack of coordination of care between the two entities caring for this patient. Findings include: --- P-17: This patient was admitted to hospice on 3/30/23 with diagnoses of Parkinson's disease and high blood pressure. During record review on 8/23/23 it was noted that the patient resides in a skilled nursing facility (SNF). A joint survey home visit with the aide was conducted on Wednesday, 8/23/23 at 10:00 a.m. Upon entering the patient's room, the aide asked the patient if she was ready for her shower. The patient stated, "No, my shower days are Tuesday and Friday. Today is Wednesday." The hospice aide care plan dated 6/28/23, orders the aide to provide 2 visits each week and to provide a complete bed bath or partial bath/shower each visit. There were no instructions regarding the Tuesday and Friday shower days at the SNF. It was unclear why the hospice aide conducted a visit on Wednesday to provide a shower. A review of documented aide visits between 6/28/23 to 8/23/23, indicates the aide provided 16 visits in that time frame and only 5 of the visits were on a Tuesday or Friday. The patient could be receiving 2 showers from SNF staff and 2 showers from hospice staff each week. During the joint survey visit, the aide was not observed talking with or coordinating patient care with facility staff. At 10:30 a.m., an interview was conducted with the Director of Nursing (DON-A) at the skilled facility. DON-A states this is our first time working with this hospice and they are not very communicative. DON-A was able to view the patient's hospice plan of care in the electronic medical record. There was no indication of a delineation of duties between the two entities to ensure coordination of care. The findings were reviewed with and acknowledged by the administrator/chief clinical officer (Staff-A) and the director of nursing (Staff-B) during an interview on 8/25/23 at 11:10 a.m.