Every finding on record at Moments Hospice of Des Moines LLC

Based on observations, interviews, record reviews, and agency policy review, the agency failed to ensure the required Interdisciplinary group (IDG) team members had collaborated to develop and/or revise the plan of care (POC) for three of three patients (Patients (P) 5, P6, P7) observed during home visits out of a total sample of 14. The agency failed to revise the POC for P5 and P7 related the oxygen usage and failed to develop a POC for P6's move from one facility to another and the subsequent physical and emotional decline. This deficient practice placed all 32 patients who receive services from the Hospice agency at risk for unmet care needs and a diminished quality of life. Findings include: Review of the agency policy titled, "The Plan of Care," dated 08/25/22, revealed, ". . . A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program and the patient's family in collaboration with the primary/attending physician . . . The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days . . . This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care . . . Any changes in the patient's condition must result in a change in the plan of care, prior to implementation of the new service . . ." 1. Review of P5's "Hospice IDG Comprehensive and Plan of Care Update," located in the "IDG" tab of the electronic medical record (EMR), revealed P5 was admitted to the hospice agency with a start of care date on 01/07/25 with a terminal diagnosis of hypertensive heart disease without heart failure. Review of P5's "Aide Care Plan Report," dated 01/07/25 and provided by the Executive Director (ED) and confirmed on-site with CNA (Certified Nurse Aide)1, ". . . PRN [as needed] oxygen in place at 2 liters [L] via nasal cannula, practice oxygen safety, oxygen to be left on with all ADL [activities of daily living] cares; notify RNCM [Registered Nurse Case Manager] with any questions . . ." Review of P5's "Hospice POC Report," located in the "Clinical Entries" tab of the EMR and dated 01/07/25, revealed, ". . . Problem: Instruct on reason for oxygen and appropriate liter flow per minute as per physician order . . . Interventions: Instruct on safety issues related to oxygen use (how to connect and turn on oxygen, how to use either mask or nasal cannula, no smoking, need for no smoking signs, how to operate equipment and who and when/what number to call with any problems related to oxygen or oxygen equipment) . . . Goal: Patient/Caregiver(s) verbalizes understanding of indications of oxygen use and proper liter flow per minute . . ." During a home visit on 02/04/25 at 11:00 AM, P5 was observed in his/her recliner with oxygen being delivered via a nasal cannula. The oxygen concentrator was behind him/her with the liter setting at 3L/minute. P5 was asked if he/she knew why the liter setting on the oxygen concentrator was set at 3L instead of 2L, as per the "POC." P5 stated, "My [family member] changes the setting when [he/she] feels it's necessary for my breathing." During an interview on 02/05/24 at 1:30 PM, RNCM 1 was asked about the changes in P5's oxygen settings. The RNCM stated, "Yes, I am aware [the family member] changes the oxygen settings. [P5] had recently started using oxygen and I have educated the [family member] on oxygen settings and to call me first before changing them as I need to know if [P5] is having increased breathing problems. I will call the doctor and get the order changed to 2-4L/ min." The RNCM was asked why the Respiratory "POC" was not updated with individualized interventions related to the family member changing the settings and when to call prior to changing the oxygen settings. The RNCM stated, "I will do it today." 2. Review of P6's "Hospice IDG Comprehensive and Plan of Care Update," located in the "IDG" tab of the EMR, revealed P6 was admitted to the hospice agency with a start of care date on 02/20/24 with a diagnosis of hypertensive heart disease without heart failure. During a skilled nursing facility visit on 02/04/25 at 9:00 AM with RNCM 1, P6 was observed moaning and restless. His/her eyes were closed, and he/she refused to answer questions posed by the RNCM. The RNCM stated, "[He/she] was moved from another facility to this skilled nursing facility last week and [he/she] has not taken to the move easily. I was here on Friday, and [he/she] was having increased signs/symptoms of depression and anxiety with crying. [He/she] is 101 years old, and it now appears that [he/she] has declined as [he/she] is not eating or taking [his/her] medications." Review of P6's "Comprehensive POC" did not show an individualized problem, measurable goal or interventions related to moving P6 into a skilled nursing facility and the subsequent decline. 3. Review of P7's "Hospice IDG Comprehensive and Plan of Care Update," located in the "IDG" tab of the EMR, revealed P7 was admitted to the hospice agency with a start of care date on 07/24/24 with a diagnosis of chronic obstructive pulmonary disease (COPD). During a home visit on 02/04/25 at 1:00 PM, P7 was observed in his/her recliner and was receiving oxygen via a nasal cannula. Review of the "Comprehensive POC," dated 07/25/24 and located in the "Clinical Entries" tab of the EMR, revealed, "Problem . . . Need for skilled teaching and monitoring use of oxygen-hospice . . . Intervention . . . Instruct on proper use of oxygen for comfort in terminal patient . . ." Further review of the "POC" revealed that on 08/13/24, the interventions to "Instruct on reason for oxygen and appropriate liter per minute as per physician order and to instruct on safety issues related to oxygen use (how to connect and turn on oxygen, how to apply either nasal cannula or face mask, no smoking, need for not smoking signs, how to operate equipment and who/when/what to call with any problems related to oxygen or oxygen equipment)" were removed from the "POC" by RNCM2. During an interview on 02/04/25 at 2:00 PM, the Administrator and Executive Director were asked why the oxygen interventions were removed from the "POC" as P7 was utilizing oxygen for his/her terminal diagnosis. The Administrator stated, "The nurse who removed it was a PRN nurse and when you look at the care plan [on the nurses' laptop], there is a red button and if you click it, it will remove the intervention. He must have clicked on the wrong button." During an interview on 02/06/25 at 6:00 PM, the Executive Director was asked about the IDG meeting that was just held, and the many issues that were discussed regarding the above patients and if POC was developed or updated at that time. The Executive Director stated, "Yes, I agree there were many issues discussed. Our POCs are computer generated, and it is not an easy system to work with. They can be individualized, but there needs to be education on how to do it.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients transferred to a Medicare/Medicaid-certified facility, the agency did not ensure a copy of the discharge summary was forwarded to the receiving facility. Clinical Record 6: The patient elected the hospice benefit on 9/2/21. The patient was transferred to the care of another hospice agency on 9/30/21. For the benefit period dated 9/2/21 to 9/30/21, the discharge and coordination note completed by the Registered Nurse (RN) on 9/30/21 documented, “pt and family wanted to transfer to another hospice spoke with …Transfer form completed." A clinical record review revealed no documented evidence that a discharge summary was forwarded to the receiving hospice. During an interview, the Administrator/Clinical Director confirmed that the discharge summary was not sent to the receiving hospice.

Based on clinical record review, agency policy review and hospice staff interview, the agency failed to: 1) ensure hospice staff allowed the patient to exercise his/her rights without fear of reprisal (see L0505); 2) ensure hospice staff allowed the patient to exercise his/her rights to choose his or her attending physician (see L0515). and 3) ensure hospice staff provided information about the services covered under the hospice benefit (see L0518). The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the hospice promoted and supported the coordination of safe and effective delivery of care according to patient's advanced directives to the agency's 12 patients.

Based on record review, agency policy, family/patient interview and staff interview identified failure of the agency to assure that it's staff will protect patient rights and involve patients in decisions about their care, treatment and services. Findings include: Review of the undated policy titled, Complaint/Grievance Process identifies the organization will investigate complaints regarding treatment or care. The organization staff member receiving the complaint will discuss verbally and in writing, the grievance with a supervisor within 5 days of the alleged grievance. Complaints and any action taken will be documented on a complaint form. Review of the QI, (quality information), Event Report printed for the surveyor on 12/27/2021 identified no complaints for the period 12/27/2020 to 12/27/2021. Patient #6 had a hospice admission date of 9/02/21 and a transfer date of 9/30/21 and received services while residing in a private residence. Review of the clinical record revealed the following: a. The plan of care, (POC), dated 9/02/21 to 11/30/21, included orders for skilled nurse services 2 times a week for 13 weeks then 1 time per week for 1 week. The same POC identified the patient received nutritional requirements via peg tube, (percutaneous endoscopic gastrostomy). The same POC failed to list DME, (durable medical equipment) and supplies. The same POC lacked physician orders for tube feeding formula and supplies. b. The initial Interdisciplinary Group (IDG) meeting, dated 9/08/21, included physician documentation the patient required nutritional intake via peg tube, 4 bolus feedings daily. c. The IDG meeting, dated 9/08/21, did not identify any additional medical equipment and supplies used by the patient. During an interview 12/28/21 at 2:58 PM the patient's family, verbalized that about half way through the time with Moments Hospice we told Staff E, RN,CM (registered nurse, case manger), that if Moments Hospice can't deliver needed supplies than we will have to change hospices. During an interview 12/29/21 at 9:36 AM Staff E, RN, Case Manager identified that supplies are ordered through messaging on the computer. She reported that it took about a week from the time the order was entered to receive supplies. During an interview 01/05/22 at 3:45 PM the patient's family verbalized, "we didn't run out of tube feeding bags because we washed them out and continued to reuse the bag until it began to leak". He/she said one bag would last about a week. Family reported that when it looked like we would run out of bags a call was placed to their previous supplier of feeding formula and supplies and that resulted in a delivery of 10 bags. Family reported that the feeding formula that the patient used was leftover supply from the previous supplier. The agency failed to support the patients rights by not following their policy to process grievances and failed to provide supplies that put the patient at risk of not receiving care. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient representative and staff interview, the hospice failed to ensure hospice staff honored the right of the patient to choose his or her own attending physician as having the most significant role in the determination and delivery of medical care while the patient received hospice services for 6 of 7 sampled hospice patients (Patients #1, #2, #3, #4, #6 and #7). Failure to ensure hospice staff to allow the patient, or patient representative, to chose his or her own attending physician resulted in patients, or patient representatives, not having their rights honored. Findings include: According to the undated hospice policy titled Admission Criteria and Process the patient must be under the care of a physician. The patient's physician (or other authorized independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patient's resuscitation status with the patient and family/caregiver. 1. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. Review of the patient's Medicare Benefit Election Form, dated 8/16/21, included a section on the form which asked if the patient, or patient's representative, wanted to choose their own attending physician to collaborate with the hospice to provide care related to the patient's terminal illness and related conditions. The form included the name of the patient's attending physician and the name of the hospice's Medical Director. The patient's attending physician's name had a line drawn through it and the hospice staff's initials above it, but no date to indicate when hospice staff drew a line through the attending's physician's name. The form included a signature of the patient's representative and hospice staff, Staff F, former hospice Registered Nurse (RN). b. Review of a Medicaid Hospice Benefit Election form, signed and dated by the patient's representative and Staff F, former hospice RN on 8/16/21, identified only the hospice Medical Director as the patient's attending physician. c. Review of the patient's initial Certificate of Terminal Illness (CTI), dated 8/16/21, included documentation of a signature by the hospice's Medical Director only, and not an initial CTI signed by the patient's chosen attending physician. On 1/4/22 at 1:26 PM, in an interview during a home visit observation with Staff A, RN Clinical Manager, the patient's representative (also primary caregiver and family member) reported they had wanted the patient's primary care physician as the attending physician (the same physician identified on the Medicare Benefit Election form with a line crossed through the name) to continue to be involved in the patient's hospice care. The representative explained this hospice does it differently, and all orders go through the hospice's Medical Director. On 1/5/22 at 10:52 AM, during a phone call interview, the patient's representative explained the previous hospice they had chosen, sent all orders through the attending physician and involved the attending physician in the patient's hospice care. The representative reported thinking this hospice would work the same way, but they did not. The patient's representative reported this hospice does not work with the patient's attending physician and all orders go through the hospice's own Medical Director. The patient's representative reported the patient's primary care physician has provided care to the patient for years and knows the patient's needs best. The patient's representative reported the patient continues to see the primary care physician for care and services and the patient's representative is the one who keeps the primary care physician updated on all changes with hospice care, treatment and services. The patient's representative was unable to find the patient's copy of the admission paper work, but thought the representative had chosen the patient's primary care physician to be the attending physician for hospice. The representative stated, "I did not say I wanted the Medical Director only." On 1/5/22 at 12:08 PM, during an interview, Staff F, former hospice RN, reported having received maybe a day of training, and then she was on her own and had to figure things out for herself. She reported not knowing what she was doing. On 1/6/22 at 9:10 AM, during an interview, the RN Clinical Manager reported if a patient chooses his or her attending physician upon admission to hospice services, the hospice RN will call the patient's attending physician to notify the attending physician of the patient's admission to hospice. The hospice RN will contact both the hospice Medical Director and attending physician for all orders. The attending physician is not sent a copy of the patient's plan of care or Interdisciplinary Group (IDG) meetings. On 1/6/22 at 11:20 AM, during an interview, the hospice's Medical Director explained the RN Case Manager is responsible for coordination of care between the hospice and the patient's chosen attending physician. 2. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. Review of the patient's Medicare Benefit Election Form, dated 10/21/21, included a section on the form which asked if the patient, or patient's representative, wanted to choose their own attending physician to collaborate with the hospice to provide care related to the patient's terminal illness and related conditions. The form included the name of the patient's attending physician. The form included a signature of the patient's representative and hospice staff, Staff K, Regional Director of Business Development. b. Review of the patient's initial CTI, dated 10/21/21, included documentation of a signature by the hospice's Medical Director only and signed by the patient's chosen attending physician. c. Review of the Physician Orders dated 10/22, 10/25, 11/1, 11/4, 11/12, 11/18 and 12/16/21, included documentation of a signature by the hospice's Medical Director only and not signed by the patient's chosen attending physician. The hospice staff failed to honor the right of the patient's, or patient's representative, to choose his or her own attending physician to collaborate with the hospice to provide care. 3. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. Review of the patient's Medicare Benefit Election Form, dated 8/5/21, included a section on the form which asked if the patient, or patient's representative, wanted to choose their own attending physician to collaborate with the hospice to provide care related to the patient's terminal illness and related conditions. The form included the name of the patient's attending physician. The form included a signature of the patient's representative and hospice staff, Staff K, Regional Director of Business Development. b. Review of the patient's initial CTI, dated 8/5/21, included documentation of a signature by the hospice's Medical Director and signed by the patient's chosen attending physician. c. The Plan of Care, dated 8/5/21 to 11/2/21 and 11/3/21 to 1/31/21, included documentation of a signature by the hospice's Medical Director only and not signed by the patient's chosen attending physician. d. Review of the Physician Orders dated 11/4, 11/5, 11/30, 12/1, 12/16 and 12/27/21, included documentation of a signature by the hospice's Medical Director only and not singed by the patient's chosen attending physician. 4. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. Review of the patient's Medicare Benefit Election Form, dated 8/27/21, included a section on the form which asked if the patient, or patient's representative, wanted to choose their own attending physician to collaborate with the hospice to provide care related to the patient's terminal illness and related conditions. The form included the name of the patient's attending physician. The form included a signature of the patient's representative and hospice staff, Hospice Consultant. b. Review of the patient's initial CTI, dated 10/21/21, included documentation of a signature by the hospice's Medical Director only and signed by the patient's chosen attending physician. c. The Plan of Care, dated 8/27/21 to 11/24/21, included documentation of a signature by the hospice's Medical Director only and not signed by the patient's chosen attending physician. d. Review of the Physician Orders dated 10/28, 11/3, 11/11, 11/17 and 12/6/21, included documentation of a signature by the hospice's Medical Director only and not signed by the patient's chosen attending physician. 5. Patient #4 had a hospice admission date of 6/15/21 and a discharge date of 6/18/21 and received services while residing in a nursing facility. Review of the clinical record revealed the following: a. Review of the patient's Medicare Hospice Benefit Election Form, dated 6/15/21, identified the patient chose his/her attending physician to oversee care in collaboration with the hospice agency. The form included the name of the patients' attending physician. The hospice medical director was not identified. The form included the patients signature. b. Review of the patient's Medicaid Hospice Benefit Election Form, dated 6/15/21, identified the patient chose his/her attending physician to oversee care in collaboration with the hospice agency. The form included the patients signature. c. The verbal certification of terminal illness, (CTI), dated 6/15/21 lacked a attending physician signature. d. The POC dated 6/15/21 to 9/12/21 failed to include the attending physician signature. 6, Patient #6 had a hospice admission date of 9/02/21 and a transfer date of 9/30/21 and received services while residing in a private residence. Review of the clinical record revealed the following: a. Review of the patient's Medicare Hospice Benefit Election Form, dated 9/02/21, identified the patient chose his/her attending physician to oversee care in collaboration with the hospice agency. The form included the name of the patient's attending physician. The hospice medical director was not identified. The form included a signature of the patient's representative. b. The verbal certification of terminal illness, (CTI), dated 9/2/21 identified the hospice medical director. The medical record lacked a CTI signed by the attending physician. c. The plan of care, (POC), dated 9/2/21 to 11/30/21 identified the hospice medical director as the attending physician and failed to include the attending physician signature. During an interview 12/29/21 at 3:03 PM the patient's attending physician stated, hospice care is a gray area. Sometimes the hospice medical director is chosen to follow care. "I don't recall being involved". The physician identified that the patient and family have been in his care for 20 years and now that the patient is in the care of a different hospice he is signing all orders for care. The hospice staff failed to honor the right of the patient's, or patient's representative, to choose his or her own attending physician to collaborate with the hospice to provide care. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, family/patient representative interview, the hospice failed to ensure hospice staff honored the right of the patient to receive, if requested, information, verbally and in writing, which identified the services not covered under the hospice benefit for 5 of 7 sampled patients ( Patients #1, #2, #3, #5 and #6). Failure of hospice staff to ensure the patient or patient representative received information, verbally and in writing, which identified the services not covered under the hospice benefit resulted in patient not receiving necessary non-coverage information and placed patients at risk for being billed unexpectedly for treatment, medications or services. Findings include: According to the undated hospice policy titled Bill of Rights the patient has the right to be informed, verbally and in writing, of billing and reimbursement methodologies prior to the start of care/service and as changes occur, including fees for services/products provided, direct pay responsibilities and notification of insurance coverage. 1. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 10/21/21, included a section on the form which asked if the patient, or patient's representative, wanted to receive notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The hospice must furnish this notification within 5 days, if request the notification on the start of care date. The hospice must furnish the notification within 72 hours or 3 days if requested during the course of hospice care. The form failed to include documentation the responsible person elected or declined to receive the patient notification of hospice non-covered items, services and drugs. The form included a signature of the patient's representative and hospice staff, Staff K, Regional Director of Business Development. Review of the Election Statement Addendum Request History, dated 10/21/21, included documentation the beneficiary/representative declined. The document had no beneficiary/representative signature. The hospice failed to ensure the patient or patient representative received information, verbally and in writing, 2. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 8/5/21, included a section on the form which asked if the patient, or patient's representative, wanted to receive notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The hospice must furnish this notification within 5 days, if request the notification on the start of care date. The hospice must furnish the notification within 72 hours or 3 days if requested during the course of hospice care. The form included documentation the responsible person elected to receive the patient notification of hospice non-covered items, services and drugs or declined. The form included a signature of the patient's representative and hospice staff, Staff K, Regional Director of Business Development. Review of the Election Statement Addendum Request History, dated 8/5/21, included documentation the beneficiary/representative declined. The document had no beneficiary/representative signature. The hospice failed to provide an addendum that lists the items, services and drugs that are considered non-covered items. During an interview on 1/5/21 at 9:55 AM, the family stated they had requested for information for non-covered items. They further stated they were verbally told about the non-covered items and did not recall declining the request. As of the date of the interview, the family had not recived the requested information. 3. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 8/27/21, included a section on the form which asked if the patient, or patient's representative, wanted to receive notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The hospice must furnish this notification within 5 days, if request the notification on the start of care date. The hospice must furnish the notification within 72 hours or 3 days if requested during the course of hospice care. The form failed to include documentation the responsible person elected to receive the patient notification of hospice non-covered items, services and drugs or declined. Review of the Election Statement Addendum Request History, dated 10/21/21, included documentation the beneficiary/representative declined. The document had no beneficiary/representative signature. The hospice failed to ensure the patient or patient representative received information, verbally and in writing, 4. Patient #5 had a hospice admission date of 8/9/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: Review of the patient's Medicare Benefit Election Form, dated 8/9/21, failed to included a section on the form which asked if the patient, or patient's representative, wanted to receive notification of hospice non-covered items, services and drugs, addendum that lists the items, services and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions that would not be covered by the hospice. The hospice must furnish this notification within 5 days, if request the notification on the start of care date. The hospice must furnish the notification within 72 hours or 3 days if requested during the course of hospice care. The form included documentation the responsible person elected to receive the patient notification of hospice non-covered items, services and drugs. Review of the Election Statement Addendum Request History, dated 8/9/21, included documentation the beneficiary/representative declined. The document had no beneficiary/representative signature. The hospice failed to ensure the patient or patient representative received information, verbally and in writing, 5, Patient #6 had a hospice admission date of 9/02/21 and a transfer date of 9/30/21 and received services while residing in a private residence. Review of the clinical record revealed the following: a. The document dated 9/2/21 and signed by the patient representative titled Consent for Election of Medicare Hospice Benefit identified the patient/family selected yes to request patient notification of hospice non-covered items, services, and drugs. b. On 01/05/21 the agency provided the surveyor with a copy of the addendum request history. The record dated 9/2/21 identifies that the addendum notiification was declined by the beneficiary. c. The document dated 9/2/21 and signed by the patient representative titled Patient Notification of Hospice Non-covered items, Services and drugs failed to identify all related diagnosis, unrelated diagnosis, non-covered items, services and drugs, and reason for non-coverage. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) ensure a hospice registered nurse completed an initial assessment including documentation of spiritual assessment, (See L0524) 2) ensure the hospice interdisciplinary group completed a drug regimen review that included the required components with each comprehensive assessment, (See L0530) 3) ensure a hospice registered nurse completed an initial assessment including documentation of a bereavement assessment, (see L0531) 4) ensure the hospice nurse member of the interdisciplinary team updated the comprehensive assessment with changes to the patient condition at least once every 21 days and included wound assessment and measurements. (See L0533) The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and service needs in a timely manner to their hospice patients.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure members of the interdisciplinary group completed a comprehensive assessment which included a spiritual assessment within 5 days after the patient's election of hospice care for 1 of 7 sampled patients (Patient #7). Failure to complete an initial spiritual assessment increased the risk that patient's needs would not be identified and/ or addressed appropriately and the hospice would have an incomplete baseline assessment for comparison. Findings include: According to an undated hospice policy Titled Comprehensive Assessment, an assessment of the patient's and family/caregiver's spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by the registered nurse (RN), dated 8/16/21, lacked a documented assessment of the patient's spiritual needs. b. The initial assessment completed by the social worker, dated 8/18/21, included documentation which identified the patient was listening to gospel music and received support from faith community/clergy, but lacked a spiritual assessment. c. The Plan of Care, dated 8/16/21 to 10/14/21, included Interdisciplinary Group (IDG) orders for skilled nursing, social work and hospice aide services. On 1/5/22 at 4:18 PM, during an interview, the Quality Assurance Registered Nurse (RN) confirmed the record lacked documentation of a spiritual assessment, but reported this was due to the patient declining chaplain (spiritual counseling) services. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, home visit observation, hospice policy review, patient representative and staff interview, the hospice failed to ensure hospice staff completed drug regimen reviews (DRRs) for all of the patient's medications for 1 of 1 sampled patients with a home visit (Patient #7), and failed to ensure hospice staff completed medication reviews which included all the required components of a DRR for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed a DRR based on a review of all of the patient's medications and included all the required components of the DRR with each update to the comprehensive assessment increased the risk of the patient developing an undetected a side effect or adverse reaction in relation to medication therapy. Findings include: According to an undated hospice policy titled Medication Profile, a drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy and noncompliance with drug therapy. The interdisciplinary group will confer with an individual with education in drug management to ensure the drugs and biologicals meet the patient's needs. 1. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 8/16/21 to 10/14/21, and recertification orders, dated 10/15/21 to 12/13/21 and 12/14/21 to 2/11/22, included physician orders for medications, including Furosemide and Potassium, both medications associated with laboratory monitoring. b. The DRR documented on the hospice's "Client Medication Report" included documentation of a DRR completed by a RN, dated 8/16/21. The DRR failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. The Client Medication Report lacked documentation of staff completing any other reviews. c. The initial IDG meeting, dated 8/25/21, and all subsequent IDG meetings, dated 9/8, 9/22, 10/6, 10/13, 10/27, 11/10, 11/29, 12/13 and 12/27/21, included the following documented statement by the Medical Director: "I have reviewed with the IDG the patient's POC, including medication profile and orders, since the last interdisciplinary team meeting." None of the DRRs included a review of medications for the required component of drug therapy associated with laboratory monitoring. d. The IDG meeting, dated 9/8/21, included new physician orders for Morphine and Haldol concentrate solutions. The clinical record lacked documentation of the identification of potential interactions between Haldol and Seroquel (start date 8/16/21), Seroquel and Morphine and Haldol and Morphine. On 1/4/22 at 1:26 PM, during a home visit observation with the Registered Nurse (RN) Clinical Manager, the surveyor observed two different eye medications, Timolol and Lumigan. In an interview, during the same home visit observation, the patient's representative reported the patient had been using Timolol drops 0.5 percent, 1 drop twice per day in both eyes and Lumigan 1 drop in both eyes at night for years and continues to use these medications to treat glaucoma. The patient's representative reported the patient had been using Tylenol 500 milligrams (mg) two tabs 2 times per day scheduled since prior to hospice due to chronic pain. The patient has been taking another dose of 1000 mg of Tylenol, as well, when needed. The patient representative reported the patient also occasionally used Ibuprofen 200 mg 2 tablets as needed for pain. The patient's representative reported the patient had not taken Pantoprazole 40 mg daily since the start of hospice. e. The POC and clinical record lacked orders for Timolol, Lumigan, Tylenol and Ibuprofen. The IDG meeting, dated 8/25/21, included documentation by the nurse which identified she was aware the patient used Tylenol to treat pain. f. The POC and recertification orders continued to include an order for Pantoprazole 40 mg every day by mouth. On 1/6/22 at 9:10 AM, during an interview, the RN Clinical Manager reported she completed a DRR at start of care, at least one time per month, with recertification and with any new medication. She reported the Medical Director reviews the patient's medications during IDG and asked questions. On 1/6/22 at 11:20 PM, during an interview, the Medical Director reported doing DRRs at minimum with each recertification, upon admission, and every 2 weeks if needed during IDG meetings. The Medical Director reported he reviews drugs for their relatedness to hospice, comfort benefits, for adverse effects and side effects. 2. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 10/21/21 to 1/18/22, included physician orders for medications, including levothyroxine associated with laboratory monitoring. b. The DRR documented on the hospice's "Client Medication Report" included documentation of a DRR done by a RN, dated 10/21/21, 11/12, 11/16, 12/16 and 12/29/21. The DRR failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. The Client Medication Report lacked documentation of staff completing any other reviews. c. The initial IDG meeting, dated 10/27/21, and all subsequent IDG meetings, dated 11/10, 11/29, 12/13 and 12/27/21, included the following documented statement by the Medical Director: "I have reviewed with the IDG the patient's POC, including medication profile and orders, since the last interdisciplinary team meeting." None of the DRRs included a review of medications for the required component of drug therapy associated with laboratory monitoring. d. The IDG meeting, dated 10/27/21, included physician orders for Morphine and Lorazepam. The clinical record lacked documentation of the identification of potential interactions between Lorazepam and Morphine. The DRRs failed to include an accurate and complete review of all the patient's medications. 3. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/5/21 to 11/2/21 and recertification orders dated 11/3/21 to 1/31/21, included physician orders for medications, including levothyroxine associated with laboratory monitoring. b. The DRR documented on the hospice's "Client Medication Report" included documentation of a DRR done by a RN, dated 8/5/21 and 8/12/21. The DRR failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. The Client Medication Report lacked documentation of staff completing any other reviews. c. The IDG meeting, dated 8/18/21, and all subsequent IDG meetings, dated 9/1, 9/15, 9/29, 10/13, 10/27, 11/10, 11/29, 12/13 and 12/27/21, included the following documented statement by the Medical Director: "I have reviewed with the IDG the patient's POC, including medication profile and orders, since the last interdisciplinary team meeting." None of the DRRs included a review of medications for the required component of drug therapy associated with laboratory monitoring. d. The IDG meeting, dated 8/18/21, included physician orders for Oxycodone and Zoloft. The clinical record lacked documentation of the identification of potential interactions between Oxycodone and Zoloft. The DRRs failed to include an accurate and complete review of all the patient's medications. 4. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/27/21 to 11/24/21 and recertification orders dated 11/25/21 to 2/22/22, included physician orders for medications, including synthroid associated with laboratory monitoring. b. The DRR documented on the hospice's "Client Medication Report" included documentation of a DRR done by a RN, dated 8/27, 10/26 and 11/11/21. The DRR failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. The Client Medication Report lacked documentation of staff completing any other reviews. c. The initial IDG meeting, dated 9/1/21, and all subsequent IDG meetings, dated 9/1, 9/15, 9/29, 10/13, 10/27, 11/10, 11/29, 12/13 and 12/27/21, included the following documented statement by the Medical Director: "I have reviewed with the IDG the patient's POC, including medication profile and orders, since the last interdisciplinary team meeting." None of the DRRs included a review of medications for the required component of drug therapy associated with laboratory monitoring. d. The IDG meeting, dated 9/1/21, included physician orders for Morphine, Alprazolam, Paxil, Depakote and seroquel. The clinical record lacked documentation of the identification of potential interactions between Morphine, Alprazolam, Paxil, Depakote and seroquel. The DRRs failed to include an accurate and complete review of all the patient's medications. 5. Patient #5 had a hospice admission date of 8/9/21 and discharge date of 11/5/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 8/8/21 to 11/6/21, included physician orders for medications, including Glipizide and Januvia associated with laboratory monitoring. b. The DRR documented on the hospice's "Client Medication Report" included documentation of a DRR done by a RN, dated 8/9/21. The DRR failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. The Client Medication Report lacked documentation of staff completing any other reviews. c. The initial IDG meeting, dated 8/11/21, and all subsequent IDG meetings, dated 8/25, 9/8, 9/22, 10/6, 10/13 and 10/27/21, included the following documented statement by the Medical Director: "I have reviewed with the IDG the patient's POC, including medication profile and orders, since the last interdisciplinary team meeting." None of the DRRs included a review of medications for the required component of drug therapy associated with laboratory monitoring. d. The IDG meeting, dated 8/11/21, included physician orders for Morphine and Lorazepam. The clinical record lacked documentation of the identification of potential interactions between Lorazepam and Morphine. 6. Patient #4 had a hospice admission date of 6/15/21 a discharge date of 6/18/21 and received services while residing in a nursing facility. Review of the clinical record revealed the following: a. The initial Plan of Care (POC), dated 6/15/21 to 9/12/21, included Interdisciplinary Team (IDT) orders for skilled nursing services and physician orders for medications. b. The client medication report dated 6/16/21 included a drug regimen review, (DRR) completed by the Registered Nurse. The DRR failed to address the required component of drug therapy currently associated with laboratory monitoring. Medication ordered requiring laboratory monitoring included levothyroxine. 7. Patient #6 had a hospice admission date of 9/2/21 and a discharge date of 9/30/21 and received hospice services while residing in a private residence. . The client medication report dated 9/2/21 included a drug regimen review, (DRR) completed by the Registered Nurse. The DRR failed to address the required DRR components of drug therapy currently associated with laboratory monitoring and significant drug interactions. The initial POC, dated 9/2/21 to 11/30/21, included IDT orders for skilled nursing services and physician orders for medications. Medications with the potential for significant drug interactions included Haloperidol (sedation), Lorazepam (sedation), Morphine (sedation), Fentanyl (sedation) and Gabapentin (sedation). The DRRs failed to include an accurate and complete review of all the patient's medications The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on hospice policy review, clinical record review and staff interview, the hospice failed to perform an initial bereavement assessment, within 5 days of the patient's election to the hospice benefit and as part of the initial comprehensive assessment, to determine patient and/or family bereavement needs and risk factors in a timely manner for 3 of 7 sampled patients (Patients #3, #6 and #7). Failure to complete an initial bereavement assessment increased the risk that patient or family/caregiver grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors. Findings include: According to the undated hospice policy titled Comprehensive Assessment, the comprehensive assessment includes an 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. 1. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by the registered nurse (RN), dated 8/16/21, lacked a documented assessment of an initial bereavement risk assessment. b. The initial assessment completed by the social worker, dated 8/18/21, included documentation which identified the patient had a supportive family and the family was calm and peaceful, but lacked documentation of an initial bereavement risk assessment. c. The Plan of Care, dated 8/16/21 to 10/14/21, included Interdisciplinary Group (IDG) orders for skilled nursing, social work and hospice aide services, but lacked any initial bereavement assessment information. On 1/5/22 at 10:22 AM, during an interview, the Quality Assurance Registered Nurse (RN) confirmed the record lacked documentation of an initial bereavement risk assessment. 2. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by the RN, dated 8/27/21, lacked a documented assessment of an initial bereavement risk assessment. b. The initial assessment completed by the social worker, dated 8/30/21, included documentation which lacked an initial bereavement risk assessment. The assessment indicated not appropriate at the time of the evaluation. c. The initial assessment completed by the chaplain, dated 8/30/21, included documentation which lacked an initial bereavement risk assessment. d. The Plan of Care, dated 8/27/21 to 11/24/21, included Interdisciplinary Group (IDG) orders for skilled nursing, social work 1 time to assess, chaplain 1 time to assess and hospice aide services, but lacked any initial bereavement assessment information. 3. Patient #6 had an admission to hospice on 9/2/2021 and a transfer date of 9/30/21 and received services in a private residence. The clinical record review revealed: The initial assessment completed by the social worker, dated 9/7/21, lacked documentation of an initial bereavement risk assessment. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound description and measurement for 3 of 3 sampled patients with an open wound (Patients #1, #4 and #7). Failure by the hospice Interdisciplinary Group (IDG) registered nurses (RNs) to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. Findings include: According to the undated hospice policy titled Assessment/Staging of Pressure Ulcers, the assessment should be addressed consistently and include site, state of ulcer and size of ulcer (include length, width and depth). 1. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 8/16/21 to 10/14/21, included IDG orders for skilled nursing services two times per week the first week and then 1 time per week for 8 weeks. b. A skilled nursing visit the week of 10/3/21, dated 10/8, included documentation the nurse assessed the patient had a stage 2 (shallow open wound or blister) pressure ulcer on the left buttock. The nurse failed to document any further assessment information including a description of the wound bed, surrounding tissue, the presence of any drainage and/or odor and wound measurements. The clinical record did not include any mention of a wound on the left buttock prior to this visit. c. The IDG meeting, dated 10/13/21, included documentation the patient had a stage 2 pressure ulcer on the left buttock. d. A skilled nursing visit the week of 10/10/21, dated 10/15, included a description of the wound and measurements. The clinical record lacked documentation of a wound description and measurements for the left buttock wound prior to the visit on 10/15/21. On 1/5/22 at 4:18 PM, during an interview, the Quality Assurance Registered Nurse (RN) reported the expectation hospice nurses should assess wounds upon discovery. On 1/6/22 at 9:10 AM, during an interview, the RN Clinical Manager reported wounds should be assessed when first observed and at least weekly unless the patient/family objects. 2. Patient #4 had a hospice admission date of 6/15/21 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The plan of care, (POC) dated 6/15/21 to 9/12/21 included orders for skilled nurse services 2 times per week for 13 weeks and included the diagnosis pressure ulcer of sacral region stage 1. b. The Interdisciplinary group, (IDG), meeting notes, dated 6/16/21 included IDG orders for skilled nurse to provide assessment of pressure ulcer of sacral region stage 1. b. The initial skilled nurse comprehensive assessment dated 6/15/21 and the skilled nurse routine assessment dated 6/17/21 completed by a registered nurse (RN), included documentation the RN assessed the patient had one open area to his/her bottom. The assessments failed to include a description or measurements of the open area on his/her bottom. 3. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 10/21/21 to 1/18/21, included IDG orders for skilled nursing services two times per week for 13 weeks and then 1 time per week for 1 week and 3 as needed for symptom management. b. A skilled nursing visit the week of 10/31/21, dated 11/1, included documentation the nurse assessed the patient had a blister) on the right great toe. The blister measured 1.5 cm by 0.8 cm by 0 cm. c. The IDG meeting, dated 11/10/21, failed to included documentation the patient had a blister on the right great toe. d. The skilled nursing visits the week of 11/14/21, dated 11/15 and 11/16, included documentation the patient refused wound care or measurments of the right great toe. A skilled nursing visit, dated 11/18/21, included documentation of a blister on the right great toe. The documentation lacked wound assessment and measurements. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient representative interview and hospice staff interview, the hospice failed to: 1) ensure standing orders are individualized to meet the patient's needs (see L0547); 2) Ensure the medical supplies and appliances necessary to meet the needs of the patient are provided as directed by the Interdisciplinary Group in collaboration with the attending physician (see L0550); 3) ensure the revised plan of care includes patinet's progress toward outcomes and goals (see L0553); 4) Ensure the hospice Interdisciplinary Group developed and maintained a system of communication to direct, coordinate and supervise the care and services provided (see L0554) and 5) Ensure the hospice Interdisciplinary Group members ensured that the care and services are provided in accordance with the Plan of Care (see L0555) The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.

Based on clinical record review, review of hospice standing orders and staff interview, the hospice failed to ensure the ensure hospice staff used standing orders specific and individualized to the patient's assessed needs for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). Failure to establish the use of individualized standing orders rather than generalized, non-specific standing orders placed patients for potential risk of receiving medications, treatments and services that did not adequately meet the individualized needs of hospice patients. Findings include: Review of the hospice's standing orders, signed and dated by the hospice Medical Director on 6/3/2020, identified hospice staff could order the following medications, treatments and services under the hospice Medical Director's name without calling him and directions to decrease amounts of doses for actively dying patients: a. Pain: an ice/cold pack topically for 20 minutes four times per day as needed for injuries with inflammation; Acetaminophen 1000 milligrams (mg) by mouth 3 times per day or Acetaminophen 650 mg suppository four times per day. b. Fever: Acetaminophen 1000 milligrams (mg) by mouth 3 times per day or Acetaminophen 650 mg suppository four times per day. c. Sleep: Melatonin 5 mg by mouth or Trazadone 50 mg by mouth at bedtime as needed; if still awake after 2 hours, may give an additional 50 mg one time. d. Respiratory/Dyspnea: Oxygen via nasal cannula 1 to 4 liters per minute as needed or continuous for comfort; may discontinue or wean oxygen hourly until off following patient/family discussion; Guaifenesin 400 mg by mouth every 4 hours as needed for dyspnea/cough. e. Bowels/Constipation: Senna-S 1 tablet by mouth twice daily and may increase up to 2 tabs twice daily; Polyethylene Glycol 17 grams by mouth daily; Bisacodyl 5 mg by mouth if no stool for 3 days then daily till stool; contact the Medical Director if considering a suppository. f. Bowels/Diarrhea: hold all bowel softeners; Loperamide 2 mg by mouth after each loose stool (maximum of 16 mg in 24 hours). g. Urinary Retention: Foley or straight catheter as needed for comfort; may use Lidocaine 2 percent jelly during catheter insertion; irrigate with 50 milliliters (ml) Saline as needed until clear return for obstruction/sediment/poor flow. h. Indigestion: Famotidine 20 mg by mouth daily; Omeprazole 20 mg by mouth daily. i. Secretions: Levsin 0.125 mg by mouth/sublingual every 4 hours as needed; Scopolamine 1.5 mg patch, apply patch to hairless area behind ear and change patch every 72 hours. j. Pruritus: Hydrocortisone 1 percent topical cream, apply to affected areas three times per day as needed for itching. k. Dry Eyes: Artificial Tears 2 drops left, right or both eyes every one hour as needed. l. Mouth Care: Cleanse mouth with moist oral swabs as needed; Viscous Lidocaine 2 percent 15 ml by mouth, swish and spit, every 3 hours as needed with maximum of 8 doses in 24 hours; Nystatin 100,000 units 5 ml by mouth, swish and swallow, four times per day until thrush is resolved; if oral thrush does not resolve with Nystatin, then give Diflucan 200 mg by mouth 1 time. m. Active Dying/Death: okay to discontinue oral medications when patient is actively dying and has difficulty swallowing; if patient is on a scheduled antipsychotic, Benzodiazepine or antiepileptic, call hospice Medical Director first; okay to release body in expected death. n. Wound Care: Wound care may be provided and adjusted per hospice goals at the discretion of the hospice RN Case Manager and the facility nurse (hospice goals are to control pain, odor and drainage); Butt Paste for wounds requiring barrier protection, but keeping dressing in place is difficult; call this recipe into the pharmacy for Aquaphor 60 grams, Nystatin 15 grams and Stoma Paste 30 grams; cleanse area after incontinence, pat dry and apply Butt Paste to coat open areas. o. DME (durable medical equipment): may order DME required for comfort or support. p. Visit frequency orders: may add visits for symptom management; may discharge due to death; may adjust visit frequencies as determined by Registered Nurse (RN) Case Manager (for nursing or aide), medical social worker and chaplain. q. Miscellaneous: physical therapy one time evaluation for safety or transfers. Review of the medical record for sample patients (Patients #1 through #7) revealed a lack of signed, patient-specific, standing orders in any of the records and a lack of an order signed by the attending physician or hospice medical director to use hospice standing orders for any of the patients. On 1/6/22 at 9:10 AM, during an interview, the RN Clinical Manager reported the hospice had general standing orders which they used to apply to all patients. She explained if a patient had a wound, the hospice has a standing order for a 2 by 2 Mepilex dressing and to clean the wound with Normal Saline. If the hospice standing orders are enacted, the nurse notified the hospice Medical Director by phone call or team message to let him know they were implementing the order. On 1/6/22 at 11:11 AM, during an interview, the Administrator and Quality Assurance RN reported the nurse contacts the Medical Director before enacting the hospice standing orders and obtains a verbal order. The nurse writes the order and sends the order to the Medical Director for signature. On 1/6/22 at 11:20 AM, during an interview, the Medical Director reported in the patient's Certificate of Terminal Illness, he documents "medications reviewed", and this means he determined it's acceptable to use hospice standing orders. He reported the nurse always calls him before enacting standing orders to discuss the orders. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by the registered nurse (RN), dated 8/16/21, identified the patient had a 16 French 10 cubic centimeter (cc) bulb (balloon-like device inserted into the bladder and filled with fluid) urinary catheter. The Plan of Care (POC), dated 8/16/21 to 10/14/21, lacked an order or any mention of the patient's use of a urinary catheter. The initial IDG meeting, dated 8/25/21, did identify the patient used a Foley urinary catheter, but did not identify an order for the use of the catheter which included a specific size or bulb inflation amount. The standing orders for a urinary catheter did not include orders individualized to the patient's specific need. On 1/4/22 at 1:26 PM, in an interview during a home visit observation with the RN Clinical Manager, the patient's representative reported the patient had an indwelling urinary catheter since February 2021. The patient's representative reported being the one responsible for changing/maintaining the catheter and the hospice has been supplying the urinary catheters. b. The Plan of Care (POC), dated 8/16/21 to 10/14/21, included IDG orders for skilled nursing services. A skilled nursing visit, dated 10/8, included documentation the nurse assessed the patient had a stage 2 (shallow open wound or blister) pressure ulcer on the left buttock. The nurse documented she and the family member showered the patient and then the family placed a foam dressing on the wound. The clinical record did not include any mention of a wound on the left buttock prior to this visit. The IDG meeting, dated 10/13/21, included documentation the patient had a stage 2 pressure ulcer on the left buttock and the patient's family was completing the dressing change. The IDG meeting lacked documentation of any discussion of wound care orders. The clinical record lacked documentation of contact with the a physician regarding the left buttock wound prior to 10/13/21. The hospice standing orders for wound care are not patient-specific and allow the nurse to chose any type of wound care without physician direction. An interim physician order, dated 10/15/21, included orders to for the caregiver to cleanse the left buttock, apply foam dressing, change every 3 days and as needed and for the RN Case Manager to assess the wound weekly. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, policy review, family interview, and home visit observation and nursing home order summary report review, the hospice failed to ensure the Plan of Care (POC) for 7 of 7 sampled patients with home visit observation (Patient #7) included all medical equipment and supplies necessary to meet identified patient needs. The hospice reported a census of 12 patients at the time of survey. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: The undated policy titled The Plan of Care identified a written individualized patient and family/caregiver plan of care will be established for each individual admitted to the hospice program. The plan of care will include: DME, (durable medical equipment), medical supplies necessary to meet patient needs and drugs and treatments. 1. Patient #4 had a hospice admission date of 6/15/21 a discharge date of 6/18/21 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The plan of care, (POC) dated 6/15/21 to 9/12/21 included orders for skilled nurse services 2 times per week for 13 weeks. b. The skilled nurse visit notes dated 6/15 and 6/17/21 identified the patient requires assistive device for gait/balance, positioning aides including foot cradles, bolster, pillows and folded towels and a over bed table. c. The Hospice Interdisciplinary Group, (IDG) Comprehensive Assessment and Plan of Care Update Report dated 6/16/21 identified the patient required teaching related to ostomy care, urostomy and colostomy. d. The client coordination note report identified the patient used a foley catheter, (indwelling urinary catheter). The patients POC and IDG meeting notes failed to identify durable medical equipment, (DME) and supplies used by patient, assistive device for gait/balance, positioning aides including foot cradles, bolster, pillows and folded towels, over bed table, ostomy/urostomy/colostomy supplies and foley catheter supplies. 2. Patient #6 had a hospice admission date of 9/2/21 and a transfer date of 9/30/21 and received hospice services while residing in a private residence. . a. The plan of care, (POC) dated 9/2/21 to 11/30/21 included orders for skilled nurse services 2 times per week for 13 weeks and nutrition per Peg tube (Percutaneous Endoscopic Gastrostomy for feeding patients unable to take food orally). b. The skilled nurse visit notes dated 9/2, 9/3, 9/8, 9/10, 9/14, 9/15, 9/20 and 9/22/21 identified the patient uses a AVAP, (average volume assured pressure support external ventilator), Peg Tube, and a wheelchair. c. The coordination notes dated 9/2, 9/3, 9/7 and 9/14/21 identified the patient used a hospital bed, wheelchair and a Peg tube including gravity bags, syringes, formula and supplies. c. The Hospice Interdisciplinary Group, (IDG) Comprehensive Assessment and Plan of Care Update Reports dated 9/8 and 9/22/21 identified the patient used Peg tube, 4 bolus feeding per day for nutrition. During and interview on 12/28/21 at 2:58 PM the family identified equipment used in the home: nebulizer, cough assist machine, trilogy ventilator, hospital bed, gel mattress, shower chair, hand held shower, roller walker and power chair. He/she said that the agency provided gloves, alcohol wipes, split gauze dressings for peg tube site, tape and a package of incontinence products. The POC and IDG update reports failed to identify durable medical equipment, (DME) and supplies used by patient. 3. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by the registered nurse (RN), dated 10/21/21, identified the patient used incontinent briefs. b. The POC, dated 10/21/21 to 1/18/22, identified the patient did not use any medical equipment or supplies. c. The initial IDG meeting, dated 8/18/21, failed to identify the patient utilized incontinent briefs. d. The IDG meeting notes, dated 10/27, 11/10, 11/29, 12/13 and 12/27/21, failed to identify any medical equipment or supplies utilized by the patient. e. A skilled nursing visit note, dated 11/12/21, identified the patient utilized a wheelchair. f. A skilled nursing visit note, dated 11/18/21, identified the patient had a broda chair, high low bed with mat and half side rails ordered for use. The POC and IDG meetings failed to accurately and completely identify medical equipment and supplies used by the patient. 4. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/5/21 to 11/2/21, and the recertification orders, dated 11/3/21 to 1/31/21, identified the patient did not use any medical equipment or supplies. b. The initial comprehensive assessment completed by the registered nurse (RN), dated 10/21/21, identified the patient used incontinent pull-ups and a wheelchair. c. The initial IDG meeting, dated 8/25/21, failed to identify the patient utilized incontinent briefs. d. The IDG meeting notes, dated 9/1, 9/15, 9/29, 10/13, 10/27, 11/10, 11/29, 12/13 and 12/27/21, failed to identify any medical equipment or supplies utilized by the patient. e. A skilled nursing visit note, dated 8/10/21, identified the patient utilized Ted hose (anti-embolism stockings). The POC and IDG meetings failed to accurately and completely identify medical equipment and supplies used by the patient throughout the course of hospice care. 5. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/27/21 to 11/24/21, and the recertification orders, dated 11/25/21 to 2/22/21, identified the patient did not use any medical equipment or supplies. b. The initial comprehensive assessment completed by the RN, dated 8/27/21, identified the patient had a urinary Foley catheter. c. The initial IDG meeting, dated 9/1/21, failed to identified the patient utilized a Foley catheter. d. The IDG meeting notes, dated 9/1, 9/15, 9/29, 10/13, 10/27, 11/10, 11/29, 12/13 and 12/27, failed to identify any medical equipment or supplies utilized by the patient. e. The undated nursing home care plan revealed the patient utilized a wheelchair, hoyer lift, foley catheter and grab bars, all in place at the hospice start of care. The POC and IDG meetings failed to accurately and completely identify medical equipment and supplies used by the patient throughout the course of hospice care. 6. Patient #5 had a hospice admission date of 8/9/21 and discharge date of 11/5/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 8/9/21 to 11/6/21, identified the patient did not use any medical equipment or supplies. b. The initial comprehensive assessment completed by the RN, dated 8/9/21, identified the patient had a glucometer, walker and wheelchair. c. The initial IDG meeting, dated 8/11/21, failed to identify the patient utilized a glucometer, walker and wheelchair. d. The IDG meeting notes, dated 8/25, 9/8, 9/22, 10/6, 10/13 , failed to identify any medical equipment or supplies utilized by the patient. e. The undated nursing home care plan revealed the patient utilized a wheelchair, hoyer lift, foley catheter and grab bars, all in place at the hospice start of care. The POC and IDG meetings failed to accurately and completely identify medical equipment and supplies used by the patient throughout the course of hospice care. 7. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by the registered nurse (RN), dated 8/16/21, identified the patient had an indwelling urinary catheter or suprapubic catheter and used a wheelchair. b. The Plan of Care (POC), dated 8/16/21 to 10/14/21, identified the patient did not use any medical equipment or supplies. c. The initial IDG meeting, dated 8/25/21, identified the patient had a Foley urinary catheter. d. The IDG meeting, dated 10/13/21, identified the patient used a chair cushion and air mattress. e. The recertification orders for hospice, dated 10/15 to 12/13/21 and 12/14/21 to 2/11/22, lacked any mention of medical equipment and supplies used by the patient. f. A coordination note, dated 11/5/21, identified the patient used a shower chair. g. A coordination note, dated 12/10/21, identified the hospice supplied the patient with incontinent briefs. On 1/4/22 at 1:26 PM, during a home visit observation with the RN Clinical Manager, the surveyor observed the patient was laying in a hospital bed with rails, had an air mattress, overbed table, walker, waffle cushion and urinary catheter. The RN Clinical Manager spoke with the patient representative about a reddened area on the patient's right inner buttock and the use of a 2 by 2 Mepilex wound dressing to protect the area. In an interview, during the same home visit observation, the patient's representative reported the patient had been using a walker since prior to the start of hospice and up until last week. The patient representative explained the patient had a decline in the last week. The patient was also taking showers up until last week and using the toilet riser in the bathroom. The patient had a toilet riser prior to the hospice admission, but the hospice had supplied a new one due to the patient's toilet riser breaking. The patient had used incontinent briefs up until this last week. The patient representative explained they no longer put the briefs on the patient and just used an incontinent pad on the bed. The patient representative reported the patient had a hospital bed prior to the start of hospice through Medicaid, but hospice replaced the bed once the hospice admitted the patient. The patient had an overbed table prior to the start of hospice. The POC and IDG meetings failed to accurately and completely identify medical equipment and supplies used by the patient throughout the course of hospice care. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group revised the patient's plan of care based on the updated comprehensive assessment and include the patient's progress towards outcomes and goals specified in the plan of care for 5 of 7 sampled patients (Patients #1, #2, #3, #5 and #7) requiring an updated comprehensive assessment. Failure of the hospice to ensure the Interdisciplinary Group (IDG) revised the patient's plan of care based on the updated comprehensive assessment and include patients' progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. Findings include: According to the undated hospice policy titled The Plan of Care, the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input form the attending physician, the patient and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care. 1. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: The Plan of Care (POC), dated 8/16/21 to 10/14/21, included IDG orders for skilled nursing services, medical social worker services 1 time to evaluate and hospice aide services 1 time per week the first week and two times per week for 8 weeks. The POC included an intervention for hospice aide services to provide assistance with personal care and activities of daily living (ADLs) secondary to functional limitations which prevent self-care. The POC and clinical record lacked any goal or outcome for hospice aide services. a. The Hospice POC Report included the following medical social worker interventions, dated 8/18/21:assess patient/caregiver for readiness to discuss end of life issues, fears, concerns related to the dying process; instruct patient/family for signs/symptoms of depression; communicate to physician change in depression status; instruct patient/family on signs/symptoms of stress and how to manage stress appropriately;instruct patient/family on support and acceptance technique; initiate referral to mental health professional if mental illness identified; assist for integration of terminal illness and loss of loved one into meaningful experience; assess for complicated grief and bereavement, educate, counsel regarding grief stages and cycle: explore issues of forgiveness; invite patient to share life story;asses grief status of family members; provide support counseling, normalize patient and family through grief process;promote positive adaptation to loss and facilitate anticipatory grief; encourage verbalization of grief issues; b. The Hospice POC Report included the following medical social worker goals, dated 8/18/21: patient/caregiver has decreased fear/anxiety regarding death and dying process; patient's stress/anxiety is reduced to level of comfort; patient/family expresses an increased sense of closure and peacefulness at the end of life; patient/family are aware of resources and support throughout the grieving process and understand how to access these resources; patient/family verbalizing understanding of stages of grief; patient/family demonstrates and expresses love and forgiveness; patient discusses life experiences; family experiences a sense of accomplishment at having supported the dying person; family members will experience a continued relationship with the deceased, integrating memories and behavior that enhance their lives. c. The initial IDG meeting, dated 8/25/21, and the IDG meetings, dated 9/22, 10/6, 10/13, 10/27, 11/10, 11/29, 12/13 and 12/27/21, included the same documented statement by the social worker and no other information on interventions, outcomes or goal progress: "visit frequency 2 times per month; goal for next 2 weeks: patient and (family member) wish to keep (patient) at home as long as possible. Patient, family are in agreement with Plan of Care." d. The IDG meeting, dated 9/8/21, included documentation of the same social worker statement found in all of the other IDG meetings and the inclusion of an additional goal to assist for ways to prevent caregiver burnout. e. The IDG meetings lacked any information or an update on the provision of hospice aide services beyond a change in frequency. f. The IDG meeting, dated 10/27/21, included IDG orders for music therapy services 1 time per month for 1 month, 2 times per month for one month and 1 time per month for 1 month. The IDG meeting included an intervention for music therapy evaluation, music therapy to assist with spiritual concerns and music therapy to enhance quality of life. g. The Hospice POC Report included the following music therapy interventions and goals, dated 10/27/21: music therapist to assist with the reduction of pain and discomfort; patient/caregiver expresses thoughts/feelings or physical symptoms of decreased pain (dated 11/3/21); music therapist to provide music therapy to assist patient/caregiver with spiritual concerns; patient/caregiver expresses connection to personal spiritual practices/beliefs; patient/caregiver plan music for funeral/memorial service (dated 11/3/21); patient/caregiver report relief from spiritual suffering (dated 11/3/21); patient reports satisfaction with meaning and purpose (dated 11/3/21); music therapist to provide music therapy to enhance patient/caregiver quality of life; patient/caregiver verbalize positive interaction/memories, patient/caregiver experience positive interactions and build positive memories. h. The IDG meetings lacked documentation of outcomes and goals related to music therapy. 2. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 10/21/21 to 1/18/22, included IDG orders for skilled nursing services, medical social worker services 1 time a month, chaplain services 1 time a month and hospice aide services 2 times per week for 12 weeks then 1 time a week for 1 week. a. The Hospice POC Report included the following medical social worker interventions, dated 10/21/21: assess patient/caregiver for readiness to discuss end of life issues, fears, concerns related to the dying process; instruct patient/family for signs/symptoms of depression; communicate to physician change in depression status; instruct patient/family on signs/symptoms of stress and how to manage stress appropriately; instruct patient/family on support and acceptance technique;initiate referral to mental health professional if mental illness identified; Patient/caregiver has decreased fear/anxiety regarding death and dying process; Patient's stress/anxiety is reduced to level of comfort; assist for integration of terminal illness and loss of loved one into meaningful experience; assess for complicated grief and bereavement; educate, counsel regarding grief stages and cycle: explore issues of forgiveness; invite patient to share life story; asses grief status of family members; provide support counseling, normalize patient and family through grief process; promote positive adaptation to loss and facilitate anticipatory grief and encourage verbalization of grief issues. b. The Hospice POC Report included the following medical social worker goals, dated 10/21/21: patient/caregiver has decreased fear/anxiety regarding death and dying process; patient's stress/anxiety is reduced to level of comfort; patient/family expresses an increased sense of closure and peacefulness at the end of life; patient/family are aware of resources and support throughout the grieving process and understand how to access these resources; patient/family verbalizing understanding of stages of grief; patient/family demonstrates and expresses love and forgiveness; patient discusses life experiences; family experiences a sense of accomplishment at having supported the dying person; family members will experience a continued relationship with the deceased, integrating memories and behavior that enhance their lives. c. The initial IDG meeting, dated 10/27/21, and the IDG meetings, dated 11/10, 11/29, 12/13 and 12/27/21, included the same documented statement by the social worker and no other information on interventions, outcomes or goal progress: "visit frequency 2 times per month; goal for next 2 weeks: patient desires to have increase quality of life. Patient, family are in agreement and facility with Plan of Care." The IDG meetings lacked documentation of outcomes related to social services. 3. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC, dated 10/21/21 to 1/18/22, included IDG orders for skilled nursing services, medical social worker services 1 time to assess, chaplain services 1 time to assess and hospice aide services 1 time a week times 1 week then 3 times per week for 12 weeks then 1 time a week for 1 week. a. The Hospice POC Report included the following medical social worker interventions, dated 10/21/21:assess patient/caregiver for readiness to discuss end of life issues, fears, concerns related to the dying process; instruct patient/family for signs/symptoms of depression; communicate to physician change in depression status; instruct patient/family on signs/symptoms of stress and how to manage stress appropriately; instruct patient/family on support and acceptance technique; initiate referral to mental health professional if mental illness identified; Patient/caregiver has decreased fear/anxiety regarding death and dying process; Patient's stress/anxiety is reduced to level of comfort; assist for integration of terminal illness and loss of loved one into meaningful experience; assess for complicated grief and bereavement; educate, counsel regarding grief stages and cycle: explore issues of forgiveness; invite patient to share life story; asses grief status of family members; provide support counseling, normalize patient and family through grief process; promote positive adaptation to loss and facilitate anticipatory grief; b. The Hospice POC Report included the following medical social worker goals, dated 10/21/21: patient/caregiver has decreased fear/anxiety regarding death and dying process; patient's stress/anxiety is reduced to level of comfort; Patient/Family expresses an increased sense of closure and peacefulness at the end of life. c. The IDG meetings, dated 9/22, 10/6, 10/13, 10/27 11/10, 11/29, 12/13 and 12/27/21, included orders for social services 2 times a month and included the same documented statement by the social worker and no other information on interventions, outcomes or goal progress: "visit frequency 2 times per month; goal for next 2 weeks: family will demonstrate a normal grief. Patient, family are in agreement and facility with Plan of Care." The IDG meetings lacked documentation of outcomes related to social services. 4. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC, dated 8/27/21 to 11/24/21, included IDG orders for skilled nursing services, medical social worker services 1 time to assess, chaplain services 1 time to assess and hospice aide services 2 times per week for 12 weeks then 1 time a week for 1 week. a. The Hospice POC Report included the following medical social worker interventions, dated 8/30/21: assess for complicated grief and bereavement; educate, counsel regarding grief stages and cycle: explore issues of forgiveness; invite patient to share life story; asses grief status of family members; provide support counseling, normalize patient and family through grief process; promote positive adaptation to loss and facilitate anticipatory grief; encourage verbalization of grief issues. b. The Hospice POC Report included the following medical social worker goals, dated 8/30/21: patient/family expresses an increased sense of closure and peacefulness at the end of life; patient/family are aware of resources and support throughout the grieving process and understand how to access these resources; patient/family verbalizing understanding of stages of grief; patient/family demonstrates and expresses love and forgiveness; patient discusses life experiences; family experiences a sense of accomplishment at having supported the dying person; family members will experience a continued relationship with the deceased, integrating memories and behavior that enhance their lives. c. The initial IDG meeting, dated 9/1/21, and the IDG meetings, 9/1, 9/15, 9/29, 10/13, 10/27, 11/10, 11/29, 12/13 and 12/27/21, included the same documented statement by the social worker and no other information on interventions, outcomes or goal progress: "visit frequency 2 times per month; goal for next 2 weeks: patient will verbalize feeling emotionally supported. Patient, family are in agreement and facility with Plan of Care." The IDG meetings lacked documentation of outcomes related to social services. 5. Patient #5 had a hospice admission date of 8/9/21 and date of discharge of 11/5/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 8/9/21 to 11/6/21, included IDG orders for skilled nursing services, medical social worker services 1 time to assess, chaplain services 1 time to assess and hospice aide services 4 times per week for 1 week then 5 time a week for 12 weeks. a. The Hospice POC Report included the following medical social worker interventions, dated 8/10/21: assess patient/caregiver for readiness to discuss end of life issues, fears, concerns related to the dying process; instruct patient/family for signs/symptoms of depression; communicate to physician change in depression status; instruct patient/family on signs/symptoms of stress and how to manage stress appropriately; instruct patient/family on support and acceptance technique; initiate referral to mental health professional if mental illness identified; Patient/caregiver has decreased fear/anxiety regarding death and dying process; Patient's stress/anxiety is reduced to level of comfort;assist for integration of terminal illness and loss of loved one into meaningful experience; assess for complicated grief and bereavement; educate, counsel regarding grief stages and cycle: explore issues of forgiveness; invite patient to share life story; asses grief status of family members; provide support counseling, normalize patient and family through grief process; promote positive adaptation to loss and facilitate anticipatory grief; encourage verbalization of grief issues. b. The Hospice POC Report included the following medical social worker goals, dated 10/21/21: patient/caregiver has decreased fear/anxiety regarding death and dying process; patient's stress/anxiety is reduced to level of comfort; patient/family expresses an increased sense of closure and peacefulness at the end of life; patient/family are aware of resources and support throughout the grieving process and understand how to access these resources; patient/family verbalizing understanding of stages of grief; patient/family demonstrates and expresses love and forgiveness; patient discusses life experiences; family experiences a sense of accomplishment at having supported the dying person; family members will experience a continued relationship with the deceased, integrating memories and behavior that enhance their lives. c. The initial IDG meeting, dated 8/11/21, and the IDG meetings, dated 8/25, 9/8, 9/22, 10/6, 10/13 and 10/27/21, included the same documented statement by the social worker and no other information on interventions, outcomes or goal progress: "visit frequency 2 times per month; goal for next 2 weeks: family will verbalize resource education is adequate. Patient, family are in agreement and facility with Plan of Care." The IDG meetings lacked documentation of outcomes related to social services. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members and patients attending physician to ensure hospice staff provided treatment and services to the patients according to team decisions. The survey identified this concern with 6 of 7 sampled patients (#1, #2, #3, #4, #6 and #7). Failure of the hospice IDG members to communicate and collaborate with each other to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients. Findings include: According to the undated hospice policy titled Interdisciplinary Group Coordination of Care, it will be the responsibility of the Case Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician. 1. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. a. see L0515 The IDG members failed to coordinate hospice care and services with the attending physician chosen by the patient's representative. b. The Plan of Care (POC), dated 8/16/21 to 10/14/21, included IDG orders for skilled nursing services. A skilled nursing visit the week of 10/3/21, dated 10/8, included documentation the nurse assessed the patient had a stage 2 (shallow open wound or blister) pressure ulcer on the left buttock. The nurse documented she and the family member showered the patient and then the family placed a foam dressing on the wound. The clinical record did not include any mention of a wound on the left buttock prior to this visit. The visit note lacked documentation of an assessment of the wound including a length, width and depth. The IDG meeting, dated 10/13/21, included documentation the patient had a stage 2 pressure ulcer on the left buttock and the patient's family was completing the dressing change. The IDG meeting lacked documentation of any discussion of wound care orders. The clinical record lacked documentation of contact with the a physician regarding the left buttock wound prior to 10/13/21. c. The POC and IDG meetings included a physician order for Seroquel 25 milligrams (mg) half a tablet (12.5 mg) by mouth at bedtime The IDG meeting, dated 9/8/21, included a physician order for Morphine 100 mg per 5 milliliters (ml) concentrate solution, 5 mg every 2 hours as needed for pain. On 1/4/22 at 1:26 PM, in an interview during a home visit observation with the RN Clinical Manager, the patient's representative reported the patient had been taking Morphine 8 mg by mouth 2 to 3 times per day starting on the Morphine (9/8/21). The patient representative also reported the patient had not been able to take oral pill medications for the last two days and oral Potassium pills for the last 4 to 5 days due to the patient having difficulty swallowing. The RN Clinical Manager reported being aware since yesterday's skilled nursing visit (1/3/22) of the patient taking Morphine 8 mg instead of 5 mg and the hold on the medications. She reported she had spoken with the Medical Director about the medication changes. The patient representative questioned the RN Clinical Manager about what should be done with the patient's inability to take Seroquel, an antipsychotic medication. The patient's representative felt the patient benefited from the medication with better sleep, but the patient had not been able to take the medication in pill form. Review of the clinical record on 1/4/22 revealed a lack of documentation of contact or coordination with the hospice Medical Director regarding the patient's difficulty swallowing pills or the different dose of Morphine the patient representative had been giving the patient. An interim verbal physician order, dated 1/5/22 at 6:11 PM, included the following change in medication orders: Per standing order, after medication reconciliation, discontinue Morphine 0.25 ml/5 mg every 2 hours as needed, daily use of Medi-Honey and Haldol 0.25 mg every 2 hours as needed and add the following medications: Morphine concentrate 100 mg/5 ml, may give 8 mg/0.4 ml by mouth every 2 hours for pain or dyspnea; Acetaminophen 650 mg suppository per rectum up to 4 times daily as needed for fever; Levsin 0.125 mg by mouth/ sublingual every 4 hours as needed for increased secretions; apply thin layer of Medi-Honey to right facial cheek skin abrasion as needed; and, Haldol 2 mg/ ml may give 0.5 mg/ 0.25 ml every 2 hours for nausea, terminal agitation and paranoia. Review of the hospice's standing orders, signed and dated by the hospice Medical Director on 6/3/2020, revealed the following instructions for Active Dying/Death: okay to discontinue oral medications when patient is actively dying and has difficulty swallowing; if patient is on a scheduled antipsychotic, call hospice Medical Director first. The clinical record lacked documentation of a discussion about the patient's inability to take Seroquel in pill form with the Medical Director. On 1/6/22 at 9:10 AM, during an interview, the RN Clinical Manager reported she had "dropped the ball" and did not reach the Medical Director on Monday (1/3/22) when she assessed the patient had a change in condition. 2. Patient #1 had a hospice admission date of 10/21/21 and received services while residing in a private residence. See L0515 Hospice agency failed to provide care and services in collaboration with the attending physician. 3. Patient #2 had a hospice admission date of 8/5/21 and received services while residing in a nursing facility. See L0515 Hospice agency failed to provide care and services in collaboration with the attending physician. 4. Patient #3 had a hospice admission date of 8/27/21 and received services while residing in a nursing facility. See L0515 Hospice agency failed to provide care and services in collaboration with the attending physician. 5, Patient #4 had a hospice admission date of 6/15/21 and a discharge date of 6/18/21 and received services while residing in a nursing facility. See L0515 Hospice agency failed to provide care and services in collaboration with the attending physician. 6, Patient #6 had a hospice admission date of 9/02/21 and a transfer date of 9/30/21 and received services while residing in a private residence. See L0515 Hospice agency failed to provide care and services in collaboration with the attending physician. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, policy review, hospice staff interview and family interview the hospice failed to ensure the Interdisciplinary Group, (IDG) maintained a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care for 5 of 7 sampled patients (Patients #2, #3, #5 #6 and #7) with Interdisciplinary Group meeting updates. Failure of the hospice Interdisciplinary Group (IDG) members to maintain a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: The undated policy titled Missed Visits identified missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If an aide visit is missed the aide will contact the case manager or clinical supervisor and manager /supervisor will take the appropriate measures. 1. Patient #6 had a hospice admission date of 9/2/21 and a transfer date of 9/30/21 and received hospice services while residing in a private residence. . a. The plan of care, (POC) dated 9/2/21 to 11/30/21 included orders for skilled nurse services 2 times a week for 13 weeks and hospice aide services 1 time a week for 1 week, 4 times a week for 1 week and 5 times a week for 11 weeks. Clinical record review revealed: Hospice aide documentation indicated 1 missed visit for the 1st week, 2 missed visits for the 2nd week, 3 missed visits for 3rd week, 1 missed visit for 4th week and 5 missed visits for the 5th week. During an interview 12/28/21 at 9:28 AM . The family reported the bath aide just stopped showing up and no one from the office called to inform the patient of the missed visits. During an interview 12/29/21 at 8:50 AM .Staff D, RN was aware a hospice aide worked with the patient and the aide had a death in her family. Staff D did not know when the aide was scheduled to come back to work and thinks the aide contacted Staff B, the Administrator. Staff D stated Staff B, Administrator would have contacted the patients to inform them of the Aide not being able to complete her shifts During an interview 12/29/21 at 9:36 AM .Staff E, RN identified that missed visits are documented in the nurse visit note and another nurse would fill in when possible. She said the nursing director, Staff B, Administrator was to be notified of missed visits. During an interview 12/29/21 at 1:32 PM Staff A, RN, Clinic Supervisor reported that staff member M., hospice aide, had a death in her family and was off work for a week. She said the process for missed visits is to contact the scheduling department to reschedule and contact nurse case manager to arrange the visit. Staff A reported the patient and family are contacted by the nurse to arrange the time for visit. She said when the aide can't work the nurse may fill in and completes the aides' duties. Staff A stated scheduling is handled through the Golden Valley phone number in Minnesota or by email. She said the nurse is responsible to call the patient/family about scheduling. The IDG meeting, dated 9/8 and 9/22/21 lacked documentation the IDG members were aware the patient failed to receive hospice aide services as ordered. 2. Patient #26 had a hospice admission date of 8/5/21, and received hospice services while residing in a long term care facility. Clinical record review revealed the following: a. IDG meeting note, dated 9/8 and 9/22/21, included documentation the IDG had ordered hospice aide services 3 times a week. The week of 9/19/21 to 9/25/21 included documentation of 2 hospice aide visits. The IDG meeting note, dated 9/22/21, lacked documentation the IDG was aware of the missed hospice aide visit on 9/22/21. b. IDG meeting note, dated 11/10/21, included documentation the IDG had ordered skilled nursing services 2 times a week. The week of 11/14/21 to 11/20/21 included documentation of 1 skilled nursing visits. The IDG meeting note, dated 11/24/21, lacked documentation the IDG was aware of the missed skilled nurse visit on 11/19/21. 3. Patient #3 had a hospice admission date of 8/27/21, and received hospice services while residing in a long term care facility. Clinical record review revealed the following: IDG meeting note, dated 9/22/21, included documentation the IDG had ordered hospice aide services 2 times a week. The week of 9/26/21 through 12/2/21 included documentation of 1 hospice aide visit. The IDG meeting note, dated 10/6/21, lacked documentation the IDG was aware of the missed hospice aide visit on 9/28/21. 4. Patient #5 had a hospice admission date of 8/9/21, a discharge date of 11/5/21, and received hospice services while residing in a private home residence. Clinical record review revealed the following: IDG meeting note, dated 9/22/21, included documentation the IDG had ordered hospice aide services 3 times a week. The week of 9/26/21 to 10/2/21 included documentation of 1 hospice aide visit. The IDG meeting note, dated 10/6/21, lacked documentation the IDG was aware of the missed hospice aide visit on 9/27/21 or 9/29/21. 5. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. See L0625 b. The Plan of Care (POC), dated 8/16/21 to 10/14/21, included IDG orders for hospice aide services 1 time per week the first week and then 2 times per week for 8 weeks. 1) The week of 8/16, 8/22, 9/5, 9/19, 9/26,10/3, 11/7, 11/21 and 11/28/21 lacked documentation the hospice provided hospice aide visit per IDG orders. The IDG meeting, dated 8/25, 9/8, 9/22, 10/6, 10/13, 11/24, 11/29 and 12/10/21 lacked documentation the IDG members were aware the patient failed to receive hospice aide services as ordered. On 1/4/22 at 1:26 PM, in an interview during a home visit observation with the RN Clinical Manager, the patient's representative reported having a hospice aide when the patient began hospice services. The patient representative thought maybe the hospice aide quit, but did not know for sure and reported no one from the hospice explained what was going on. The patient representative reported the patient went without hospice aide services until the RN Clinical Manager (who was a RN Case Manager only at the time) started working with the patient. The patient representative explained the RN Clinical Manager assisted the patient with showers. Hospice IDG members failed to ensure collaboration and coordination among it's members and the patient's representative. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on review of hospice policy review, staff interview and clinical record review, the hospice failed to: 1) ensure hospice aides satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse prior to being assigned to perform the task independently (see L0613); 2) ensure the registered nurse provided written hospice aide instructions specific to the needs of each patient (see L0625); and 3) ensure the hospice aide provided services as directed by the hospice aide care plan (see L0626); The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure hospice aides provided patient care in a manner to meet the individualized needs of all patients effectively and safely.

Based on clinical record review, review of employee personnel files and staff interview, the hospice failed to ensure 2 of 2 sampled hospice aides (Staff H and I) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 2 sampled patients who required an extra skill task to be performed (Patients #5 &7). Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. According to the undated hospice policy titled Competency Based Orientation, hospice personnel are given the appropriate job category Orientation checklist during the orientation process. When the competency orientation skills checklist is completed, it is reviewed by the preceptor and/or the clinical supervisor. Additional training and education is performed as indicated until competence is demonstrated. During an interview on 1/6/22 at 11:00 AM, the Quality Assurance Nurse stated she could not locate further documentation of any extra skills. 1. Patient #5 had a hospice admission date of 8/8/21 and discharge date of 11/5/21, received hospice services while residing in a private residence. Review of the clinical record revealed Staff H, Hospice Aide, provided hospice aide services independently (without direct, on-site registered nurse supervision) to Patient #5. The hospice aide care plan included registered nurse (RN) instructions to the hospice aide to complete the task of shaving and ear care. a. Staff H, Hospice Aide, had a hire date of 7/20/21. Staff H's personnel file lacked documentation a RN had observed Staff H competently perform the task of shaving and ear care. 2. Patient #7 had a hospice admission dated of 11/29/21 and received hospice services while residing in a private residence. Review of the clinical record revealed Staff H and Staff I, both Hospice Aides, provided hospice aide services independently (without direct on-site registered nurse supervision) to Patient #7. The hospice aide care plan included RN instructions to the hospice aide to complete the task of urinary catheter care and emptying the urinary catheter bag. a. Staff H, Hospice Aide, had a hire date of 7/20/21. Staff H's personnel file lacked documentation a RN had observed Staff H competently perform the task of urinary catheter care and emptying the urinary catheter bag.. a. Staff I, Hospice Aide, had a hire date of 11/29/21. Staff I's personnel file lacked documentation a RN had observed Staff I competently perform the task of urinary catheter care and emptying the urinary catheter bag. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the registered nurses developed and updated individualized patient specific written instructions directing the care provided by each hospice aide for 6 of 6 sampled patients receiving hospice aide services. (Patients #1, #2, #3, #4, #5 and #7). Failure to provide patient specific written instructions for hospice aides directing them which tasks to perform and how frequently and update those instructions with changes for each patient increased the risk hospice patients did not receive the services to meet each patient's assessed needs. Findings include: Review of the undated hospice policy, titled Hospice Aide Services, the need for hospice aide services will be identified by the interdisciplinary group. Arrangements for hospice aide services will be made by either the Care Manger or Clinical Supervisor. Hospice aide assignments, plan of care and interventions will be documented and included in the patient's clinical record. 1. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 10/21/21 to 1/18/22, identified the patient had a diagnoses of cerebral infarction and vascular dementia and included Interdisciplinary Group (IDG) orders for skilled nursing and hospice aide. The assignment on the hospice aide care plan, dated 10/21/21, included the following assignments to occur 2 x weekly: transfer client form bed/chair, assist to toilet, assist with feeding, shower, hair care, shampoo, skin care, perineal, oral care, nail care, dressing, socialization and adjust lighting. The RNs failed to ensure the hospice aide assignment for specific skin care and nail care to include all necessary tasks to meet the needs of the patient. 2. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 8/5/21 to 11/2/21 and 11/3/21 to 1/31/22, identified the patient had a diagnoses of Alzheimer's Disease and included IDG orders for skilled nursing and hospice aide services. The assignment on the hospice aide care plan, dated 8/5/21, included the following assignments: . transfer client form bed/chair, assist to toilet, shower, shampoo, hair care, skin care, perineal care, oral care, dressing, empty trash, socialization, adjust lighting, use music and hand massage. The RN failed to ensure the hospice aide assignment for specific skin care included all necessary tasks to meet the needs of the patient. 3. Patient #2 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 8/27/21 to 11/24/21 and 11/25/21 to 2/22/22, identified the patient had a diagnoses of malignant neoplasm of the bladder and included written instructions to the hospice aide to provide services. The assignment on the hospice aide care plan, dated 8/27/21, included the following assignments: bed bath, hair care weekly and skin care. The RN failed to ensure the hospice aide assignment for specific skin care included all necessary tasks to meet the needs of the patient. 4. Patient #5 had a hospice admission date of 8/9/21 and discharge date of 11/5/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 8/9/21 to 11/6/21, identified the patient had a diagnoses of Parkinson's Disease and included IDG orders for skilled nursing and hospice aide services. The assignment on the hospice aide care plan, dated 8/5/21, included the following assignments: . transfer client form bed/chair, tub bath 2 times a week, shampoo 2 times a week, hair care, skin care, perineal care, shaving, oral care, nail care offer every visit, ear care offer every visit, dressing,, empty trash, empty urinal, socialization,, adjust lighting, use music and playfulness (i.e. bubbles). The RN failed to ensure the hospice aide assignment for specific skin care, nail care and ear care included all necessary tasks to meet the needs of the patient. 5. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 8/16/21 to 10/14/21, included IDG orders for hospice aide services 1 time per week the first week and then 2 times per week for 8 weeks. b. The hospice aide assignment, dated 8/16/21, included RN instructions to the hospice aide to complete the task of giving the patient a bed bath or chair bath. c. The hospice aide visit notes, dated 8/23, 9/1, 9/3, 9/10, 9/16, 9/22, 9/29, 11/5, 11/19, 12/10 and 12/17/21, included documentation the person completing the visit note assisted the patient with a bed bath. d. The coordination notes, dated 11/5, 11/19 and 12/10/21, included documentation the patient had a shower. On 1/4/22 at 1:26 PM, in an interview during a home visit observation with the RN Clinical Manager, the patient's representative reported the patient had been receiving a shower, not a bed bath or any type of sponge bath up until last week. On 1/5/22 at 10:52 AM, during an interview, the patient representative reported none of the hospice staff had assisted the patient with a bed bath or chair bath. Prior to the RN Clinical Manager working with the patient, the nurses had helped with showering the patient a few times. On 1/5/22 at 12:08 PM, during an interview, Staff F, former hospice RN, reported she was responsible for creating the hospice aide care plan. She reported having received maybe a day of training, and then she was on her own and had to figure things out for herself. She reported not knowing what she was doing. She explained the hospice was short-staffed, and only had one part-time hospice aide when she started. She and the other nurses determined it was best to take over hospice aide duties for the patients that lived in areas further from the office. After the first hospice aide visit (8/23/21), she confirmed taking over hospice aide duties. She explained she only assisted with bathing the patient in the shower and never provided a bed bath on 9/1, 9/3, 9/10, 9/16, 9/22 and 9/29/21. On 1/5/22 at 11:55 AM, during an interview, Staff I, Hospice Aide, confirmed she had provided hospice aide services to the patient on 12/17/21. She reported she assisted the patient in the shower and did not give the patient a bed bath. On 1/6/22 at 9:10 AM, during an interview, the RN Clinical Manager reported she had assisted giving the patient showers and not bed baths when providing hospice aide services on 11/5, 11/19 and 12/10/21. She reported she realized when she came back full-time to work at the hospice in October 2021 that there was a problem with the hospice aide assignment/care plans for patients. She did not get around to fixing Patient #7's hospice aide care plan until 12/23/21. The hospice RN failed to coordinate hospice aide services and ensure the hospice aide assignment accurately reflected the needs of the patient. 6. Patient #4 had a hospice admission date of 6/15/21 and a discharge date of 6/18/21 and received services while residing in a nursing facility. The Plan of Care, dated 6/15/2021 to 9/12/2021, documented the hospice provided hospice aide services. The clinical record review revealed the following: The hospice aide care plan, dated 6/15/21 included RN instructions for the hospice aide to turn and position patient in bed, bedbath, perineal care, hair care, skin care and nail care. Namaste care; provide music, hand massage and playfulness (bubbles). The care plan did not provide specific directions for hair care, skin care and nail care. The aide care plan failed to provide specific instructions to the hospice aide. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Team according to an individualized plan of care for 2 of 6 sampled patients who received hospice aide services (Patients #1 and #2). Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients' personal care needs were not met. Findings include: According to the undated hospice policy, titled Hospice Aide Services, the hospice aide will document care provided in accordance with the hospice aide assignment. 1. Patient #1 had a hospice admission date of 10/21/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 10/21/21 to 1/18/22, identified the patient had a diagnoses of cerebral infarction and vascular dementia. The POC included written Interdisciplinary Group (IDG) orders for skilled nursing and hospice aide to provide services 2 times a week. The assignment on the hospice aide care plan, dated 10/21/21, included the following RN instructions to the aide to complete: transfer client form bed/chair, assist to toilet, assist with feeding, shower, hair care, shampoo, skin care, perineal care, oral care, nail care, dressing, socialization and adjust lighting 2 times weekly. a. The aide visit note, dated 11/23 and 11/24/21 , lacked documentation the aide completed the task of shower, shampoo and skin care and included documentation to explain why the aide failed to complete as patient preference.. b. The aide visit note, dated 12/7, 12/9, 12/23 and 12/27/21 , lacked documentation the aide completed the task of shower, shampoo and skin care and included documentation to explain why the aide failed to complete as patient preference.. The aide failed to follow the care plan as written. 2. Patient #2 had a hospice admission date of 8/5/21, received hospice services while residing in a nursing home. The POCs, dated 8/5/21 to 11/2/21 and 11/3/21 to 1/31/22, included IDG orders for skilled nursing and aide services. The aide care plan included RN instructions to the aide to complete the tasks of transfer client form bed/chair, assist to toilet, assist with feeding, shower, hair care, shampoo, skin care, perineal care, oral care, nail care, dressing, socialization and adjust lighting 2 times weekly. a. An aide visits, dated 11/811/12, 11/15, 11/17, 11/19, 11/22, 11/24, 11/26 and 11/29/21, lacked documentation the aide completed the task of shower, shampoo and skin care and included documentation to explain why the aide failed to complete as patient preference. b. The aide visit note, dated 12/1, 12/6 and 12/8/21, lacked documentation the aide completed the task of shower, shampoo and skin care and included documentation to explain why the aide failed to complete as patient preference. The aide failed to follow the care plan as written. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on review of hospice policy review, staff interview and clinical record review, the hospice failed to: 1) ensure the Medical Director and attending Physician provides initial certification of terminal illness. (see L0667) The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure that all patients receiving hospice services received adequate and/ or appropriate care.

Based on patient clinical record review and hospice staff interview, the hospice failed to ensure the medical director of the hospice and the hospice physician designee, signed the initial written certification of terminal illness, for 4 of 7 sampled patients (Patients #3, #4, #6 and #7). Failure of the hospice to ensure the medical director or designee signed the Certificate of Terminal Illness placed patients at risk for not meeting the eligibility requirements for hospice and have unexpected medical expenses. Findings include: According to the hospice policy and procedure titled Admission Criteria and Process, the patient must have a life-limiting illness with a life expectancy of 6 months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by the local coverage determinations. 1. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. See L0515 Hospice staff failed to ensure the patient's chosen attending physician certified the patient's terminal illness. 2. Patient #7 had a hospice admission date of 8/16/21 and received hospice services while residing in a private residence. See L0515 Hospice staff failed to ensure the patient's chosen attending physician certified the patient's terminal illness. 3. Patient #4 had a hospice admission date of 6/15/21 and a discharge date of 6/18/21 and received services while residing in a nursing facility. See L0515 Hospice staff failed to ensure the patient's chosen attending physician certified the patient's terminal illness. 4. Patient #6 had a hospice admission date of 9/02/21 and a transfer date of 9/30/21 and received services while residing in a private residence. See L0515 Hospice staff failed to ensure the patient's chosen attending physician certified the patient's terminal illness. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on review of hospice policy review, staff interview and clinical record review, the hospice failed to: 1) ensure nursing home staff report all alleged violations of abuse within 24 hours of becoming aware (see L0771); 2) ensure hospice staff delineate care and services needed and identify which provider is responsible on the patient's plan of care (see L0774); 3) ensure hospice staff coordinates with nursing home staff in development of the plan of care (see L0778); 4) ensure the hospice provides the nursing home with patient's POC, hospice election form, CTI, names and contact information, instructions to access the hospice 24 hours on call system, medication information and hospice physician and attending physician (see L0781); and 5) ensure the hospice provides orientation and training of nursing home staff (see L0782). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure nursing homes provided patient care in a manner to meet the individualized needs of all patients effectively and safely.

Based on review of written contracts, the hospice failed to maintain a written contractual agreement with nursing homes which included a provision for hospice staff to report, to the nursing home administrator, within 24 hours, of any knowledge of alleged mistreatment, neglect or abuse perpetrated by non-hospice staff against nursing facility residents. The survey identified this deficient practice with 2 of 3 sampled contracted nursing homes. Failure to include this provision within the contractual agreement increased the potential of unreported acts and/or failure to investigate allegations of abuse, mistreatment or neglect against residents in a nursing homes. Findings include: The written agreement with a nursing home in Granger dated 7/23/2020, lacked a provision to address the need for the hospice to report all allegations of abuse by non hospice staff within 24 hours to the facility administrator. The written agreement with a nursing home in Carlisle dated 5/28/2021, lacked a provision to address the need for the hospice to report all allegations of abuse by non hospice staff within 24 hours to the facility administrator. On 1/6/2021, beginning at 9:45 AM, Staff C, Quality Assurance RN, received these findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and policy review, the hospice failed to specify on the hospice plan of care which provider maintained responsibility for medication and treatment administration for 3 of 3 sampled patients receiving hospice services while residing in a nursing home facility (Patients #2, #3 and #4). Failure to delineate which provider had specific responsibilities for patient care to patients residing in a nursing home increased the risk that patients failed to receive adequate care and treatments according to physician's orders and the plan of care. Findings include: According to the undated hospice policy titled Provision of Care Care to Residents of a Skilled Nursing Facility (SNF)/Nursing Facility (NF), a written plan or care must be established and maintained in consultation with SNF/NF. All hospice care provided must be in accordance with this plan of care. The plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions. 1. Patient #2 had an admission to hospice on 8/5/21 and received services while residing in a nursing home. Review of the medical record revealed the following: The Plans of Care (POCs), dated 8/5/21 to 11/2/21 and 11/3/21 to 1/31/22, and the Interdisciplinary Group (IDG) meeting notes, dated 9/8, 9/22, 10/6, 10/13, 10/27, 11/10, 11/24, 11/29 and 12/13/21, lacked evidence of any delineation of responsibilities in order to determine which services the hospice planned to provide and which services the facility was responsible to provide. The POC failed to delineate any responsibilities in order to determine which services the hospice planned to provide and which services the facility was responsible to provide. 2. Patient #3 had an admission to hospice on 8/5/21 and received services while residing in a nursing home. Review of the medical record revealed the following: The POC, dated 8/27/21 to 11/24/21 and 11/25/21 to 2/22/22, and the IDG meeting notes, dated 9/8, 9/22, 10/6, 10/13, 10/27, 11/10, 11/24, 11/29 and 12/13/21, lacked evidence of any delineation of responsibilities in order to determine which services the hospice planned to provide and which services the facility was responsible to provide. The POC failed to delineate any responsibilities in order to determine which services the hospice planned to provide and which services the facility was responsible to provide. 3. Patient #4 had a hospice admission date of 6/15/2021 and received hospice services while residing in a nursing home. Review of the hospice clinical record revealed the following: The Plan of Care (POC), dated 6/15/21 to 9/12/21, lacked any delineation of responsibility between the hospice's and the nursing home's responsibility for care and services of the patient. The POC failed to identify who was responsible for medication and treatment administration and activities of daily living. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, onsite visit observation, nursing home medication and treatment administration records and nursing home staff interview the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the long-term care (nursing home) staff for 2 of 2 sampled patients (Patients #2 and #3) with a review of the patient's nursing home residence medication and treatment administration records. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings Include: Review of the undated hospice's policy, titled Provision of Care Care to Residents of a Skilled Nursing Facility (SNF)/Nursing Facility (NF), a written plan or care must be established and maintained in consultation with SNF/NF. The plan of care must document any hospice approved changes in the plan of care and that changes were discussed with the patient or representative, and SNF/NF representatives.. 1. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 8/5/21 to 11/2/21 and 11/3/21 to 1/31/22, , included interdisciplinary group (IDG) orders for skilled nursing, social work, hospice aide and chaplain services. Review of the clinical record revealed the following: The hospice Plan of care, included the following orders: Bisacodyl 10 mg (milligram) suppository daily, miacalcin 200 unit/ml (milliliters) one spray alternating nostrils daily, oxycodone 5 mg 1 tablet every 3 hours as needed for pain and discomfort. The nursing home's medication and treatment administration record included the following order discrepancies: a. The nursing home had an order for Bisocodyl suppository 10 mg daily as needed for constipation. The nursing home did not have an order for 1 suppository daily. b. The nursing home had an order for Debrox 6.5% install 5 drops in both ears as needed ordered on 12/14/21. The hospice POC and clinical record did not have an order for this. c. The nursing home medication list did not include an order for Oxycodone as needed and Miacalcin daily. On 1/3/21 at 4:10 PM, the facility staff nurse stated the hospice communicates by writing in the communication section of the hospice book. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on hospice clinical record review, nursing home clinical record review, nursing home staff interview and hospice staff interview, the hospice failed to maintain all required hospice documents/information at the long term care facilities (nursing homes) where hospice patients reside for 2 of 2 patients receiving surveyor on-site visit to the nursing home (Patients #2 and #3). Failure to communicate hospice information to long term care staff placed patients at risk for not receiving effective, coordinated necessary care and services. Findings include: Review of the undated hospice's policy, titled Provision of Care Care to Residents of a Skilled Nursing Facility (SNF)/Nursing Facility (NF), the organization will provide the SNF/NF the following information specific to each patient: the most recent plan of care, hospice election form and advance directives, physician certification and recertification of the terminal illness, names and contact information for hospice personnel involved in hospice care, instructions on how to access the hospice's 24-hour on-call system and hospice medication information. 1. Patient #2 had a hospice admission date of 8/5/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 8/5/21 to 11/2/21, included interdisciplinary group (IDG) orders for skilled nursing, social work, hospice aide and chaplain services. The POC included documentation of certification of the terminal illness (CTI) and identified the patient had advance directives. On 1/3/21 at 4:10 PM, during a home visit at the patient's nursing home, the surveyor requested to review the information in the hospice's chart for the patient provided for the nursing home staff and maintained at the nursing home. The hospice chart did not include a POC, updates to the POC (IDG meeting notes), hospice benefit election form, CTI, advanced directives and information on the hospice personnel involved in the patient's care. 2. Patient #3 had a hospice admission date of 8/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC, dated 8/27/21 to 11/24/21, included interdisciplinary group (IDG) orders for skilled nursing, social work, hospice aide and chaplain services. The POC included documentation of certification of the terminal illness (CTI) and identified the patient had no advance directives. On 1/3/21 at 4:10 PM, during a home visit at the patient's nursing home, the surveyor requested to review the information in the hospice's chart for the patient provided for the nursing home staff and maintained at the nursing home. The hospice chart did not include a POC, updates to the POC (IDG meeting notes), hospice benefit election form, CTI, advanced directives and information on the hospice personnel involved in the patient's care. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on patient clinical record review and review of hospice documentation in nursing facilities, hospice policy review and nursing home staff interview the hospice failed to assess the education and training needs for staff of a long term care facility where 2 of 2 sampled patient (Patient #2 and #3) residing in a long term care facility at the time of the survey. Failure to educate and train the long term care (LTC) facility staff where a patient resides potentially puts the patient as risk for receiving substandard hospice philosophy based care. Findings include: Review of the undated hospice's policy, titled Provision of Care Care to Residents of a Skilled Nursing Facility (SNF)/Nursing Facility (NF), the hospice will consult with the SNF/NF regarding the shared orientation and training responsibilities of staff furnishing care to patients, including: hospice philosophy, hospice policies and procedures regarding methods of comfort, pain control, symptom management and post mortem care, principles about death and dying and individual responses to death, patient rights and appropriate forms and record keeping requirements. 1. Patient #2 had a hospice admission date of 8/5/21 and received care at a nursing home. The patient's terminal diagnosis was severe protein, calorie malnutrition. During an interview on 1/3/21 at 4:10 PM, the surveyor discussed Patient #2 with nursing home Staff Registered Nurse, who reported to the surveyor that the hospice had not provided any education or training to her regarding hospice philosophy, including policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements. 2. Patient #3 had a hospice admission date of 8/27/21 and received care at a nursing home. The patient's terminal diagnosis was malignant neoplasm of the bladder. During an interview on 1/3/21 at 2:40 PM, the surveyor discussed Patient #3 with nursing home Assistant Director of Nursing, who reported to the surveyor that the hospice had not provided any education to training to her regarding hospice philosophy, including policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements. The Hospice Administrator and Quality Assurance Nurse received the above findings. Hospice staff provided no further information prior to the end of the survey.