Every finding on record at New Century Hospice and Palliative Care, LLC

Based on record review and interview, the agency failed to ensure a review of all medications for significant drug interactions was completed for 4 (P-6, P-7, P-11, and P-12) of 12 records reviewed; and failed to document an accurate medication list for 1 (P-14) of 12 records reviewed, resulting in the potential for harmful drug interactions. Findings include: --- Patient #11’s (P-11) Start of Care (SOC) was dated 12/23/25. The Plan of Care (POC) identified a terminal diagnosis of Alzheimer’s. During record review on 3/4/26, it was noted that the “Medication Interaction” report within the EMR (Electronic Medical Record) noted 4 Drug-Drug interactions with “Severity: Major” interaction between: Xanax and Mirtazapine, Lisinopril and Lasix, Ibuprofen and Aspirin, Ondansetron and Imodium. There was no documented evidence that a drug review was completed per the policy.         Patient #12’s (P-12) Start of Care (SOC) was dated 1/14/26. The Plan of Care (POC) identified a terminal diagnosis of Intractable Seizures. During record review on 3/4/26, it was noted that the “Medication Interaction” report within the EMR noted 3 Drug-Drug interactions with “Severity: Major” interaction between: Baclofen and Prochlorperazine, Baclofen and Morphine, Baclofen and Lorazepam. There was no documented evidence that a drug review was completed per the policy.         Patient #14’s (P-14) Start of Care (SOC) was dated 4/23/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/2/26, it was noted that on 4/23/25 an order was completed stating, “Administer oxygen as needed for shortness of breath…Start at 2 LPM (Liters Per Minute) via nasal cannula and titrate up to 5 LPM to maintain comfort or oxygen saturation >88%...May use oxygen continuously or intermittently depending on patient comfort.” The medication profile failed to include Oxygen.A review of the agency policy occurred on 3/5/26 titled "Medication Monitoring" (Undated). The policy states, "2. A Registered nurse reviews all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy on an ongoing basis. This review is done in collaboration with other IDG members which may include a physician, and/or pharmacist during the IDG meeting and whenever needed. This review includes, but is not limited to: Actual or potential drug interactions…”The Administrator (Staff A) and Alternate Director of Nursing (Staff C) reviewed and acknowledged the findings listed above in an interview on 3/5/26 at 12:10 pm. Patient #7 (P-7) was admitted to hospice on 1/14/26 with the terminal diagnosis of senile degeneration of brain. During record review on 3/5/26, it was determined that the medication drug review dated 1/14/26 indicated a major drug interaction between Ondansetron Hydrochloride and Mirtazapine. There was no documented evidence in the record that the medication reconciliation was sent to the physician or what actions were taken regarding the interactions. The alternate director of nursing (Staff C) acknowledged the findings during an interview on 3/5/26 at 11:20 a.m. Patient #6 (P-6) was admitted to this hospice facility on 1/20/26 with the terminal diagnosis of a malignant neoplasm of the endometrium (endometrial cancer). During record review on 3/4/26, it was determined a drug interaction report run in the agency’s electronic medical record (EMR) system identified 2 major interactions and 1 contraindication.During an interview with the alternate director of nursing (Staff C) on 3/5/26 at 9:45 AM, Staff C was asked about the agency expectation for significant medication issues. Staff C stated there should be a note in the communication section regarding a discussion with the physician for any significant interactions. When asked to locate a note for this record, Staff C stated there wasn’t one. Staff C then stated they “usually just send the order directly to the physician to acknowledge it.” However, when questioned further, it was determined that just a full medication list was sent to the physician – not a list of the identified interactions. Staff C acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to ensure an initial bereavement assessment was performed for all individuals potentially affected by the death of the patient in 10 (P-1, P-2, P-3, P-4, P-5, P-7, P-10, P-12, P-13 and P-14) of 14 patients reviewed, resulting in the potential for inadequate grief support. Findings include: --- Patient #10’s (P-10) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/4/26, it was noted that the bereavement risk assessment was completed by the Registered Nurse (RN) on 12/8/25 for the patient’s daughter. On 12/8/25, the RN completed the SOC and stated, “Admission Visit - P-10 is a 99yr old widow who lives with daughter and SIL (son-in-law) …P-10 had a total of 7 children, 2 of which are now deceased…” The bereavement risk assessment failed to include the patient’s son-in-law and 4 other children.         Patient #12’s (P-12) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Intractable Seizures. During record review on 3/4/26, it was noted that the bereavement risk assessment was completed by the Bereavement Coordinator on 1/15/26 for the patient’s daughter. On 1/16/24, the Medical Social Worker (MSW) completed an assessment and documented a narrative note stating, “…P-12 shared that he is married and that his wife visits him at times…” The bereavement risk assessment failed to include the patient’s wife.         Patient #13’s (P-13) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/3/26, it was noted that a bereavement risk assessment was not completed. The agency failed to assess potential bereaved per policy.Patient #14’s (P-14) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/2/26, it was noted that a bereavement risk assessment was not completed. The agency failed to assess potential bereaved per policy.A review of the agency policy occurred on 3/5/26 titled "Bereavement Services" (Undated). The policy states, "Policy: …The services are available to assist the patient and family in minimizing stress and problems that arise from the terminal illness, related conditions and the dying process...2. An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members…”The Administrator (Staff A) and Alternate Director of Nursing (Staff C) reviewed and acknowledged the findings listed above in an interview on 3/5/26 at 12:10 pm. Patient #7 (P-7) was admitted to hospice on 1/14/26 with the terminal diagnosis of senile degeneration of brain. During record review on 3/5/26, it was determined that no initial bereavement assessment note had been documented in the record. There was no initial bereavement assessment performed for this patient. The alternate director of nursing (Staff C) acknowledged the findings during an interview on 3/5/26 at 11:20 a.m. Patient #1 (P-1) was admitted to this hospice agency on 2/24/26 with the terminal diagnosis of a cerebral infarct (stroke) and vascular dementia. During record review on 3/3/26, it was determined an initial bereavement assessment note had been opened on 2/28/26, however, the document was blank, not signed, and displayed a red “X” under the status as incomplete. There was no initial bereavement assessment completed for this patient.Patient #2 (P-2) was admitted to this hospice agency on 2/24/25 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer). During record review on 3/3/26, it was determined the initial bereavement assessment dated 4/2/25 included the name of one individual, who was determined to be a 2nd cousin according to the skilled nursing evaluation dated 2/24/25. However, upon further review of the initial bereavement assessment, it was determined the remainder was left blank, not signed, and displayed a red “X” under the status as incomplete. Additionally, the skilled nursing evaluation also identified another individual as a long-time friend and caregiver who was not included on the incomplete initial assessment.Patient #3 (P-3) was admitted to this hospice agency on 2/7/25 with the terminal diagnosis of unspecified severe protein-calorie malnutrition. During record review on 3/3/26, it was determined the section in the electronic medical record (EMR) titled “History of Bereavement Assessment” was empty. There was no initial bereavement assessment completed for this patient.Patient #4 (P-4) was admitted to this hospice agency on 1/30/25 with the terminal diagnosis of chronic ischemic heart disease.  During record review on 3/2/26, it was determined the initial bereavement assessment listed P-4’s daughter. Upon further review of the record, it was determined the skilled nursing evaluation dated 1/30/25 identified that P-4 lived with his grandson, and the social work evaluation dated 2/3/25 identified another daughter who was involved in his care.Patient #5 (P-5) was admitted to this hospice agency on 3/7/25 with the terminal diagnosis of unspecified protein-calorie malnutrition. During record review on 3/4/26, it was determined the initial bereavement assessment listed P-5’s wife. Upon further review of the record, it was determined that the social work evaluation dated 3/13/25 identified an adult daughter who often visited the patient.A review of agency policy titled “Bereavement Services” (not dated) revealed, “2. An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain or Bereavement Counselor. The plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery”During an interview with the bereavement coordinator (Staff E) on 3/3/26 at 11:30 AM, Staff E was asked how he determined who was included in the initial bereavement assessment. Staff E stated he assessed any individual who may be impacted the by the death of the patient. Staff E was also asked if more than one individual could be assessed. Staff E stated yes, the initial bereavement assessment often included more than one individual. When given the examples above, Staff E stated he only worked for the agency for 4-5 months and was not sure how the previous bereavement coordinator did it.The agency failed to ensure the initial bereavement assessment was completed and addressed all individuals potentially impacted by the death of the patient.The alternate director of nursing (Staff C) reviewed and acknowledged the findings during an interview on 3/5/26 at 9:45 AM.

Based on record review and interview, the agency failed to ensure the interdisciplinary group (IDG) worked together to meet the needs of the patient in 1 (P-6) of 12 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- Patient #6 (P-6) was admitted to this hospice facility on 1/20/26 with the terminal diagnosis of a malignant neoplasm of the endometrium (endometrial cancer). During record review on 3/4/26, it was noted the plan of care dated 1/20/26 revealed a gastrointestinal goal that, “The patient will have a productive bowel movement every 3 days.” Upon further review of the record, the following was noted regarding bowel movements greater than 3 days apart between 1/20/26 and 2/18/26:On 1/21/26, it was documented the patient had a bowel movement on 1/17/26 (4 days).On 1/27/26, it was documented the patient had a bowel movement on 1/22/26 (5 days).On 1/28/26, it was documented the patient had a bowel movement on 1/22/26 (6 days).On 1/30/26, it was documented the patient had a bowel movement on 1/23/26 (7 days).On 1/31/26, it was documented the patient had a bowel movement on 1/23/26 (8 days).On 2/1/26, it was documented the patient had a bowel movement on 1/23/26 (9 days).On 2/9/26, it was documented the patient had a bowel movement on 2/3/26 (6 days).On 2/10/26, 2/11/26, 2/12/26, and 2/13/26, no bowel movement date was documented, but the narrative section of the notes all stated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” Upon review of the interdisciplinary group (IDG) notes during this time (dated 1/26/26, 2/9/26, and 2/23/26), it was determined the IDG failed to discuss the patient’s bowel movement status and therefore failed to make changes to the care plan in order to help address the chronic constipation.A review of agency policy titled “IDG Care Planning Process” (not dated) revealed, “3. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of Hospice patients and families facing terminal illness and bereavement.”The alternate director of nursing (Staff C) reviewed and acknowledged the findings during an interview on 3/5/26 at 9:45 AM.

Based on record review and interview, the agency failed to ensure the patient or primary caregiver received education for 1 (P-6) of 12 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- Patient #6 (P-6) was admitted to this hospice facility on 1/20/26 with the terminal diagnosis of a malignant neoplasm of the endometrium (endometrial cancer). During record review on 3/4/26, it was determined an order for wound care was written on 1/22/26 which stated, “SACRAL WOUND CARE- CLEANSE WOUND WITH DERMAL SKIN CLEANSER, PAT DRY AND APPLY TRIAD PASTE TO WOUND BED, COVER WITH4X4 GAUZE AND SILICONE BORDER DRESSING. CHANGE DRESSING EVERY 48 HOURS AND PRN SOILING.” [sic]Upon review of the social work evaluation dated 1/21/26, it was determined P-6 had a caregiver at the assisted living facility where she resided. Upon review of the skilled nursing documentation, it was determined the patient's caregiver was not educated on how to take care of the wound if it became soiled.A review of agency policy tiled “Plan for Patient/Family Education” (not dated) revealed, “3. All patient/family education, the perceived comprehension, ability to demonstrate a taught skill and verbal recall will be documented in the patient’s record.”During an interview with the alternate director of nursing (Staff C) on 3/5/26 at 9:45 AM, Staff C was asked about the overall lack of wound care documentation in the nursing notes (see L591). Staff C stated the patient had a caregiver who may have done it when it was not documented by the nurse (although this was not documented either). When asked to provide evidence the caregiver was taught how to provide wound care in the event the dressing was soiled, Staff C confirmed there was no documentation of caregiver education and acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to ensure the medical record contained a current 485/Plan of Care (POC) that was complete with objectively measurable goals in 3 of 14 (P-7, P-8, P-9) records reviewed, resulting in the potential for unmet care needs. Findings include: --- Patient-7, (P-7): The Start of Care (SOC) was dated 1/14/26. The POC identified diagnoses of senile degeneration of brain, dysphagia, and malnutrition. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Patient will have all needs met daily and will have minimal episodes of agitation."  Another stated, "Patient will have adequate oral intake of foods and fluids as tolerated." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Patient-8, (P-8): The Start of Care (SOC) was dated 12/29/25. The POC identified diagnoses of congestive heart failure, chronic obstructive pulmonary disease, and atrial fibrillation. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Family is able to cope with changes."  Another stated, "Patient will have reduced edema." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Patient-9, (P-9): The Start of Care (SOC) was dated 10/31/25. The POC identified diagnoses of malignant neoplasm of rectum, neoplasm of liver, and kidneys. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Patient/Family/Caregiver will verbalize understanding of functional limitations as part of terminal condition and disease process."  Another stated, "Patient/Caregiver will verbalize/express understanding of medication/treatment orders and side effects." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The alternate director of nursing (Staff C) acknowledged the findings during an interview on 3/5/26 at 11:20 a.m.

Based on record review and interview, the agency failed to ensure nursing services were provided to meet identified needs and failed to accurately document aide supervision (see L591); failed to ensure social work services were provided according to the patient’s psychosocial assessment and failed to ensure services were provided at the frequency ordered in the plan of care (see L594); and failed to develop a bereavement plan of care (see L596). --- .

Based on observation, record review and interview, the agency failed to ensure nursing services were provided to meet identified needs in 3 (P-6, P-7 and P-13) of 12 patients reviewed and failed to accurately document aide supervision in 4 (P-4, P-7, P-9, and P-10) of 10 patients reviewed with aide services ordered, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- Patient #10’s (P-10) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/4/26, it was noted that the Home Health Aide (HHA) completed a visit on 12/11/25 and the RN completed a supervisory visit on 12/21/25. The RN completed supervisory visits on 1/4/26, 2/1/26, 2/8/26 2/15/26 and 2/22/26. The completed RN supervisory visits stated, “Demonstrates competence with assigned tasks: Yes. Good communication with Patient & Family? Yes. Do aide/LVN services meet patient’s need? Yes. Complies with infection control policies & procedures? Yes.” The Electronic Medical Record contains no evidence of additional HHA visits after 12/11/25. The agency failed to accurately document supervisory functions.Patient #13’s (P-13) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/3/26, it was noted that the POC documented a wound care order stating, “Cleanse sacral wound with wound cleanser, pat dry and apply hydrogel to wound bed, then cover with silicone dressing…” A home visit observation was completed on 3/3/26 with the Registered Nurse (RN). It was noted during the wound care that the RN cleansed the wound, patted dry, applied barrier cream, then covered the wound. The RN used the same single pair of gloves during the wound care process. The RN failed to follow the wound care policy.   A review of the agency policy occurred on 3/5/26 titled "Hospice Aide Supervision" (Undated). The policy states, "Procedure: 1. Hospice Aides are closely supervised to ensure their competence in providing care. At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met…”A review of the agency policy occurred on 3/5/26 titled "Wound Care" (Undated). The policy states, "Procedure: 1. Explain procedure. 2. Position patient in desired position and location. 3. Wash hands. 4. Assemble needed equipment. 5. Don gloves. 6. Remove old dressing and use alcohol gel prior to donning clean gloves. 8 Perform wound care as ordered by physician…”The Administrator (Staff A) and Alternate Director of Nursing (Staff C) reviewed and acknowledged the findings listed above in an interview on 3/5/26 at 12:10 pm. Patient #7 (P-7) was admitted to hospice on 1/14/26 with the terminal diagnosis of senile degeneration of brain. During record review on 3/5/26, it was determined that the RN documented an aide supervisory visit on 1/30/26, and 3/4/26. There should have been an aide supervisory visit by 2/13/26 and another supervisory visit by 3/27/26. There was a missing aide supervisory visit in February and the 3/4/26 visit was greater than 14 days. The RN also failed to make a patient visit during week 7 of the certification period. Two RN visits were ordered each week and only one was provided, with no documented evidence of an attempt to make up the missed visit.Patient #9 (P-9) was admitted to hospice on 10/31/25 with the terminal diagnosis of malignant neoplasm of rectum. During record review on 3/3/26, it was determined that the RN documented an aide supervisory visit on 12/24/25, 1/9/26, 1/21/26, 1/30/26, and 2/23/26. There should have been an aide supervisory visit by 1/7/26 and another supervisory visit by 2/13/26. There was a missing aide visit in February and the 1/9/26 visit was greater than 14 days. The alternate director of nursing (Staff C) acknowledged the findings during an interview on 3/5/26 at 11:20 a.m. Patient #6 (P-6) was admitted to this hospice facility on 1/20/26 with the terminal diagnosis of a malignant neoplasm of the endometrium (endometrial cancer). During record review on 3/4/26, it was determined an order for wound care was written on 1/22/26 which stated, “SACRAL WOUND CARE- CLEANSE WOUND WITH DERMAL SKIN CLEANSER, PAT DRY AND APPLY TRIAD PASTE TO WOUND BED, COVER WITH4X4 GAUZE AND SILICONE BORDER DRESSING. CHANGE DRESSING EVERY 48 HOURS AND PRN SOILING.” [sic]Upon further review of the subsequent skilled nursing notes from 1/22/26 through 2/18/26 regarding wound care, the following was noted:On 1/22/26 (the day the wound orders were written), the wound was measured, but there was no indication that wound care was performed on that day as ordered.On 1/23/26, there was no documentation of the wound or any wound care provided.On 1/24/26, there was no documentation of the wound or any wound care provided.On 1/25/26, wound care was completed.On 1/27/26, the wound was measured (no changes), but there was no documentation of any wound care provided.On 1/28/26, there was no documentation of the wound or any wound care provided.On 1/29/26, there was no documentation of the wound or any wound care provided.On 1/30/26, the wound was measured (no changes) and wound care was provided.On 1/31/26, it was documented that wound care was provided yesterday and the dressing was still intact.On 2/1/26, it was documented that wound care was provided.On 2/2/26, there was no documentation of the wound or any wound care provided.On 2/3/26, there was no documentation of the wound or any wound care provided.On 2/5/26, there was no documentation of the wound or any wound care provided.On 2/7/26, it was documented that wound care was provided.On 2/8/26, it was documented the wound was measured (no changes), but no documentation that wound care was provided.On 2/9/26, there was no documentation of the wound or any wound care provided.On 2/10/26, there was no documentation of the wound or any wound care provided.2/11/26, there was no documentation of the wound or any wound care provided.On 2/12/26, there was no documentation of the wound or any wound care provided.On 2/13/26, there was no documentation of the wound or any wound care provided.On 2/16/26, it was documented the wound was measured (no changes), but there was no documentation that wound care was provided.On 2/17/26, it was documented the wound was measured (no changes), but there was no documentation that wound care was provided.On 2/18/26, it was documented the wound was measured in a narrative section titled “other,” but it was not updated on the wound care form. It was also documented that wound care was performed.A review of agency policy titled “WOUND CARE” (reviewed 12/23) revealed, "1. Wound measurements, LxWxD, will be taken at least once per week and as needed and documented on the clinical visit note or wound addendum." [sic] The policy also stated, “2. Each visit note will reflect complete wound documentation….”. [sic]The skilled nurse measured the wound per agency policy (weekly), however, failed to document wound care was performed as ordered (every 48 hours) or that the wound care had been completed by a caregiver or somebody else if not completed during a nursing visit.The alternate director of nursing (Staff C) reviewed and acknowledged the findings during an interview on 3/5/26 at 9:45 AM. Additionally, a review of the plan of care dated 1/20/26 revealed a gastrointestinal goal that “The patient will have a productive bowel movement every 3 days.” Upon review of the subsequent skilled nursing notes regarding bowel movements from 1/20/26 through 2/18/26, the following was noted:On 1/21/26, it was documented the last bowel movement was on 1/17/26. The narrative section indicated “it’s been days since the last bowel movement but patient suffers from chronic constipation," however, there was no documentation of any interventions completed as a result.On 1/22/26, it was documented the patient had a bowel movement on 1/21/26.On 1/23/26, it was documented the patient had a bowel movement on 1/22/26, however, the narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” This statement is an inaccurate assessment as it has only been 1 day.On 1/24/26, it was documented the patient had a bowel movement on 1/22/26. The narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.”On 1/25/26, it was documented the patient had a bowel movement on 1/23/26. This date is conflicting with the information in the previous note.On 1/27/26, it was documented the patient had a bowel movement on 1/22/26. This date is conflicting with the information in the previous note. Additionally, the narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” There was no documentation of any interventions performed as it had been more than 3 days since her last bowel movement according to this documentation.On 1/28/26, it was documented the patient had a bowel movement on 1/22/26. The narrative section continues to state, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” There was no documentation of any interventions performed since it has been more than 3 days since her last bowel movement according to this documentation.On 1/29/26, it was documented the patient had a bowel movement “today” (1/29/26).On 1/30/26, it was documented the patient had a bowel movement on 1/23/26. This date is conflicting with the information in the previous note. It was documented the patient was given a dose of milk of magnesia during this visit (ordered twice a day).On 1/31/26, it was documented the patient had a bowel movement on 1/23/26. This date is conflicting with the information in the previous notes. It was documented the patient was given a dose of milk of magnesia during this visit (ordered twice a day).On 2/1/26, it was documented the patient had a bowel movement on 1/23/26. This date is conflicting with the information in the previous notes. It was documented the patient was given a dose of milk of magnesia during this visit (ordered twice a day).On 2/3/26, the date of the last bowel movement was not documented.On 2/5/26, it was documented the patient had a bowel movement on 2/1/26. The narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” There was no documentation of any interventions performed as it had been more than 3 days since her last bowel movement according to this documentation.On 2/7/26, it was documented the patient had a bowel movement on 2/5/26.On 2/9/26, it was documented the patient had a bowel movement on 2/3/26. This date is conflicting with the information in the previous note. Additionally, there was no documentation of any interventions performed since it has been more than 3 days since her last bowel movement according to this documentation.On 2/10/26, the date of the last bowel movement was not documented. Additionally, the narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” There was no documentation of any interventions performed as a result.On 2/11/26, the date of the last bowel movement was not documented. Additionally, the narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” There was no documentation of any interventions performed as a result.On 2/12/26, the date of the last bowel movement was not documented. Additionally, the narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” There was no documentation of any interventions performed as a result.On 2/13/26, the date of the last bowel movement was not documented. Additionally, the narrative section indicated, “it’s been days since the last bowel movement but patient suffers from chronic constipation.” There was no documentation of any interventions performed as a result.On 2/16/26, it was documented the patient had a bowel movement on 2/12/26. This date is conflicting with the narrative section of the previous notes.On 2/17/26, no bowel movement date was documented.On 2/18/26, no bowel movement date was documented.The skilled nurse failed to provide assessment, monitoring, and interventions regarding impaired bowel movement activity for this patient.During an interview with the alternate director of nursing (Staff C) on 3/5/26 at 9:45 AM, Staff C was asked about the documentation above. At 11:00 AM, Staff C stated she reached out to the case manager for this patient and stated that because the patient was ordered milk of magnesia twice a day, the intervention was not always documented. However, Staff C acknowledged the documentation failed accurately monitor (due to conflicting or lack of dates). The documentation also failed to provide documented interventions for bowel movement activity. Staff C acknowledged the findings at that time.Patient #4 (P-4) was admitted to this hospice agency on 1/30/25 with the terminal diagnosis of chronic ischemic heart disease.  During record review on 3/2/26, it was noted that hospice aide services were ordered 2 times per week plus PRN (as needed) according to the plan of care dated 1/30/25. Upon further review of the record, it was determined there were no notes documented by a hospice aide to indicate those visits were made to this patient. However, upon review of skilled nursing notes dated 2/19/25, 2/24/25, 3/8/25, and 3/11/25, it was determined the nurse performed supervisory visits on the aide and documented satisfactory performance.A review of agency policy titled “Hospice Aide Supervision” (not dated) revealed, “6. The RN must assess an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to: Following the patient’s plan of care for completion of tasks assigned to the Hospice Aide by the RN.” A review of agency policy titled “Hospice Aide Documentation” (not dated) revealed, “3. The Manager of Patient Services of designated RN is responsible for reviewing the Hospice Aide’s charting.”The skilled nurse failed to appropriately supervise hospice aide services.The alternate director of nursing (Staff C) reviewed and acknowledged the findings during an interview on 3/5/26 at 9:45 AM.

Based on record review and interview, the agency failed to ensure social work services were provided according to the patient’s psychosocial assessment and needs for 2 (P-4 and P-5) of 12 patients reviewed, and failed to ensure services were provided at the frequency ordered in the plan of care for 1 (P-12) of 12 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- Patient #12’s (P-12) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Intractable Seizures. During record review on 3/4/26, it was noted that the Medical Social Worker (MSW) was ordered at a frequency of 2 per month. On 2/13/26, the MSW noted a “Visit Note Declined Visit” stating, “Patient expressed feeling tired and requested that MSW visit another day.” The Electronic Medical Record contains no evidence that the MSW has attempted to complete a visit since 2/13/26. The agency failed to provide services as ordered.                                A review of the agency policy occurred on 3/5/26 titled "IDG Care Planning Process" (Undated). The policy states, "…A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...”The Administrator (Staff A) and Alternate Director of Nursing (Staff C) reviewed and acknowledged the findings listed above in an interview on 3/5/26 at 12:10 pm. Patient #4 (P-4) was admitted to this hospice agency on 1/30/25 with the terminal diagnosis of chronic ischemic heart disease.  During record review on 3/2/26, it was determined the plan of care ordered social work services at 1 visit for the first month (for the initial assessment) then “PRN” (as needed) monthly after that.Upon further review of the record, it was determined the skilled nursing initial assessment dated 1/30/25 indicated, “Patient states that his primary care physician recommended patient to look into assisted living due to his declining condition.” It also stated, “Patient is struggling with fear of death and dying and is requesting chaplain and social work services.” Additionally, review of the social work assessment dated 2/3/25 stated “Needs identified: Shower chair w/arms, blood pressure cuff.” [sic] However, there was no evidence the social worker followed up with this patient during his care between 1/30/25 and his revocation on 9/25/25. Lastly, an interdisciplinary group (IDG) meeting note dated 9/29/25 revealed the physician spoke with the patient on 9/25/25 (just prior to revocation) and documented the patient was “tearful” about his current living situation and taken advantage of by his family. The agency failed to provide needed social work services to address identified patient psychosocial needs and concerns.Patient #5 (P-5) was admitted to this hospice agency on 3/7/25 with the terminal diagnosis of unspecified protein-calorie malnutrition. During record review on 3/4/26, it was determined the plan of care ordered social work services at 1 visit for the first month (for the initial assessment) then “PRN” monthly after that. The plan of care also indicated “1 per cert period – 1 PRN” on the plan of care.Upon review of the social work evaluation dated 3/13/25, it was noted the social worker documented “The spouse states that she is overwhelmed with the care and support of patient….,”, and that “The spouse is having a difficult time handling the symptoms of patient’s dementia and blindness.” It was also determined the initial social work assessment documented, “Need identified: stroke type shoes, in home help.” Additionally, an IDG notes dated 3/31/25 and 4/14/25 stated, “Eval completed and will follow up regarding application and PRN visits will be utilized.” Upon further review of the record, it was determined the next social work visit was not documented until 9/26/25 – more than 6 months after the needs were initially identified.The agency failed to provide needed social work services to address identified patient psychosocial needs and concerns.A review of agency policy titled “JOB DESCRIPTION – Social Worker/Social Work Assistant” (not dated) revealed under “Essential Functions,” “2. Conducts on going reassessments of patient/family needs and counseling as required.”   During an interview with the social worker (Staff D) on 3/3/26 at 2:50 PM, Staff D was asked how social work frequency was determined. Staff D stated, it should be "one time a month if the patient has needs."The alternate director of nursing (Staff C) reviewed and acknowledged the findings during an interview on 3/5/26 at 9:45 AM. Staff C was unsure why the social worker was not more involved in the cases noted above after needs were identified and documented.

Based on record review and interview, the agency failed to develop a bereavement plan of care for 2 (P-2, P-3) of 2 patients who have passed away, resulting in the potential for inadequate grief support for those impacted by the death of the patient. Findings include: --- Patient #2 (P-2) was admitted to this hospice agency on 2/24/25 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer). During record review on 3/3/26, it was noted the section in the electronic medical record (EMR) titled “History of Bereavement POC” (plan of care) was empty. There was no evidence of a bereavement plan of care.Patient #3 (P-3) was admitted to this hospice agency on 2/7/25 with the terminal diagnosis of unspecified severe protein-calorie malnutrition. During record review on 3/3/26, it was noted the section in the EMR titled “History of Bereavement POC” was empty. There was no evidence of a bereavement plan of care.A review of agency policy titled “Bereavement Services” (not dated) revealed, “5. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated, which may include: Telephone support; Letters and cards; Referral to other community resources; Memorial services; Bereavement camps; Telephone contacts; Individual or family counseling and bereavement groups.” The policy also stated, “The plan of care will note the kind of bereavement services to be offered and frequency of service delivery.” Additionally, the policy indicated that, “9. Bereavement assessment and clinical notes are documented in the patient’s permanent clinical record.”During an interview with the bereavement coordinator (Staff E) on 3/3/26 at 11:30 AM, Staff E was asked if a bereavement plan of care was written for each patient. Staff E stated yes, however, he stated that the office manager (Staff F) would be able to show that in the record because she sent reminders on what tasks were due.During an interview with Staff F on 3/4/26 at 1:30 PM, Staff F was asked about the bereavement plan of care. Staff F stated she tracked mailings for the bereaved for 1 year following a death (and was able to provide evidence of this), however, she wasn’t sure about an actual plan of care.During an interview with the alternate director of nursing (Staff C) on 3/4/26 at 2:15 PM, Staff C was asked to locate the bereavement plan of care for the patients noted above. Staff C stated she did not think that part of the EMR system was being utilized since starting that system in January 2025. She also confirmed the agency sent out and tracked mailings following the death of the patient. However, Staff B confirmed there was no evidence of a bereavement plan of care in the records and acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to ensure hospice aide services were provided as ordered in the plan of care for 1 (P-4) of 10 patients reviewed with aide services ordered, resulting in the potential for unmet care needs. Findings include: --- Patient #4 (P-4) was admitted to this hospice agency on 1/30/25 with the terminal diagnosis of chronic ischemic heart disease.  During record review on 3/2/26, it was determined hospice aide services were ordered 2 times per week plus PRN (as needed) visits from 2/3/25 through 5/12/25. Upon further review of the record, it was determined there was no documentation of hospice aide visits during that time. There was also no documentation of missed visits during that time.A review of agency policy titled “Hospice Aide Documentation” (not dated) revealed, “1. The Hospice Aide will document services rendered to the patient on the appropriate Hospice Aide charting form.”During an interview with the alternate director of nursing (Staff C) on 3/3/26 at 10:00 AM, Staff C confirmed she could not find any documentation of aide visits completed or missed during that time and that she would look into it. At 10:13 AM, Staff C stated she texted the case manager about this case who stated it was “because the patient refused the aide.” However, Staff C was unable to provide documentation of this in the record. At 10:38 AM, Staff C returned and stated that upon further investigation, it was determined the aide visits were assigned to an aide the agency had “problems with” regarding completing documentation and she no longer worked for the agency. Staff C stated the visits were made; however, they did not bill for them as there was no documentation completed. Staff C acknowledged the record did not show evidence the visits were made as ordered and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure that each patient's record included appropriate clinical assessment notes to document the care provided in 1 (P-13) of 12 records reviewed, resulting in a lack of documented care. Findings include: --- Patient #13’s (P-13) Start of Care (SOC) was dated 2/11/26. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/3/26, it was noted that the Medical Social Worker (MSW) completed an assessment visit on 2/16/26 that was blank. The agency failed to accurately document the assessment notes per policy.A review of the agency policy occurred on 3/5/26 titled "Patient Record Content" (Undated). The policy states, "Policy: Hospice will provide an accurate and current patient record for every patient seen by Hospice...”The Administrator (Staff A) and Alternate Director of Nursing (Staff C) reviewed and acknowledged the findings listed above in an interview on 3/5/26 at 12:10 pm.

Based on record review and interview, the agency failed to ensure visit notes were clear and complete for 2 (P-1 and P-6) of 12 patients reviewed, resulting in the potential for an incomplete medical record. Findings include: --- Patient #1 (P-1) was admitted to this hospice agency on 2/24/26 with the terminal diagnosis of a cerebral infarct (stroke) and vascular dementia. During record review on 3/4/26, it was noted the following visit notes were marked with a red "X" as incomplete:Skilled nursing note dated 2/27/26Social work initial assessment dated 2/27/26A review of agency policy titled “Timely Submission of Patient Documentation” (not dated) revealed, “2. Itineraries, with all visit reports attached, must be submitted the next scheduled day, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, e.g., PT, SLP, etc.”During an interview with the alternate director of nursing (Staff C) on 3/5/25 at 9:45 AM, Staff C was asked about the status of the notes above. Staff C stated the nurse was “still in orientation” with another nurse, however, she could not explain why the visit note had not been completed. She was also unsure of why the initial social work assessment had not been completed. Staff C acknowledged the findings at the time of interview.Patient #6 (P-6) was admitted to this hospice facility on 1/20/26 with the terminal diagnosis of a malignant neoplasm of the endometrium (endometrial cancer). During record review on 3/4/26, it was noted the narrative section on the skilled nursing notes dated 2/10/26, 2/11/26, 2/12/26, and 2/13/26 all stated:“patient is bed crying in pain. SN administered narco. it's been days since the last bowel movement but patient suffers from chronic constipation. patient is having someincreased confusion as well becoming agitated at times. Patient is sleeping most of the day 12-15 hr. Pain is patient main concern. Very weak and very fatigued.” [sic]A review of agency policy titled "Patient Record Content" (not dated) revealed, "3. Each patient record will contain the following as applicable:...Responses to medications, symptoms management, treatments and services...".The narrative sections for the 4 treatment dates above are written word for word (including spelling errors) for these visits; therefore, the clinical record is not an accurate or complete assessment of patient treatment.The alternate director of nursing (Staff C) reviewed and acknowledged the findings during an interview on 3/5/26 at 9:45 AM.

Based on record review and interview, the agency failed to forward a copy of the patient’s discharge summary following revocation of hospice care for 1 (P-4) of 2 patients reviewed who revoked their hospice benefit, resulting in poor continuity of care. Findings include: --- Patient #4 (P-4) was admitted to this hospice agency on 1/30/25 with the terminal diagnosis of chronic ischemic heart disease.  During record review on 3/2/26, it was noted the patient revoked their hospice benefit on 9/25/25.A review of agency policy titled “Discharge Summary” (not dated) revealed, “2. If a patient revokes the election of Hospice care, or is discharged from Hospice, Hospice will forward to the patient’s attending physician, a copy of: The Hospice discharge summary; The patient’s record, if requested.”During an interview with the alternate director of nursing (Staff C) on 3/5/26 at 9:45 AM, Staff C was asked to provide evidence that a discharge summary was sent to the physician. Staff C was unable to provide evidence a discharge summary was sent to the physician and acknowledged the findings at the time of interview.

Based on record review and interview, the agency failed to document a discharge summary per agency policy for 2 (P-4 and P-14) of 2 patients reviewed who revoked their hospice benefit, resulting in the potential for poor continuity of care. Findings include: --- Patient #14’s (P-14) Start of Care (SOC) was dated 4/17/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/2/26, it was noted that the Registered Nurse (RN) completed a Discharge Summary on 1/19/26 and stated, “Based on the type of Discharge provide a brief summary related to; Diagnosis, health history, symptom and pain management, extent to which goals were and/or were not met, and if applicable, summarize post-discharge continuity of care orders. The patient’s condition has stabilized, though intermittent episodes of confusion persist. Some symptoms have shown improvement and are currently being managed. Overall, the patient’s condition has plateaued. Based on clinical assessment, the hospice team has determined that the patient no longer meets hospice criteria and will be discharged from hospice services. Care will be transitioned and endorsed to home health services with a palliative care focus. Patient and wife understood the discharge. Wife will sign the NOMNC (Notice of Medicare Non-Coverage form).” The hospice agency failed to ensure the discharge summary compiled the patient's course of care, including treatments, symptoms, and pain management.The Administrator (Staff A) and Alternate Director of Nursing (Staff C) reviewed and acknowledged the findings listed above in an interview on 3/5/26 at 12:10 pm. Patient #4 (P-4) was admitted to this hospice agency on 1/30/25 with the terminal diagnosis of chronic ischemic heart disease.  During record review on 3/2/26, it was determined the discharge summary (dated 9/25/25) only included: patient name, medical record number, date, reason for discharge, and a brief narrative summary of the reason for discharge.A review of agency policy titled “Discharge Summary” (not dated) revealed, “3. The Hospice discharge summary will include: A summary of the patient’s stay including treatments, symptoms and pain management; The patient’s current plan of care; The patient’s latest physician orders; Any other documentation that will assist in post-discharge continuity of care of that is requested by the attending physician of receiving facility; The date and reason for discharge; Any instructions or referral information given to the patient or family; Patient’s identifying information; Patient's physician; Hospice diagnosis; Significant health history; Discharge orders, instructions, medication profile and allergies, if discharge is other than patient death; A brief description of services provided and ongoing needs that cannot be met; Status of patient at time of discharge; Presence of Advanced Directives; End of life decisions; Any third party revocation or termination.” [sic]The alternate director of nursing (Staff C) reviewed and acknowledged the discharge summary lacked the required information and acknowledged the findings during an interview on 3/5/26 at 9:45 AM.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) records reviewed, it was revealed that the agency did not ensure that the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 4: The patient elected the hospice benefit on 11/26/22 with a diagnosis of Multiple Sclerosis. In review of the clinical record, it was documented on (11/26/22) by the Registered Nurse (RN) in the summary of the initial comprehensive assessment " Patient has had a cystectomy and has a urostomy tube. Pt also has a feeding tube. Pt is alert but non-verbal, but moans with position movement." The plan of care effective for the current benefit period, (BP#1) starting 11/26/22 did not contain any problems, goal or interventions to address pain, urostomy care or the feeding tube. Interview: A joint clinical record review was conducted with the Director of Nurses (DON) on 12/21/22, who confirmed that the plan of care did not include any problems, goal or interventions to address pain, urostomy care or the feeding tube.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 7 (14%) records reviewed it was revealed that the agency did not ensure that the Interdisciplinary Group (IDG) revised plan of care to include information from the patient’s updated comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 6/27/22 with a diagnosis of Chronic Lymphocytic Leukemia, B-type. It was documented in the Intradisciplinary Team (IDT) meeting on 12/12/22 that the patient had a suprapubic catheter. In the summary of the IDT meeting dated 12/12/22 it was documented that, "His Suprapubic catheter was intact with clear urine no foul odor noted and no blood in urine noted. Since last meeting the urologists has not changed his catheter yet". On 12/14/22 it was documented in a "Nursing Clinical Note" by the Registered Nurse, "Suprapubic catheter was changed by the urologist in the office a few days ago. No changes in treatment or meds at this time". The plan of care effective for the current benefit period dated 9/25/22 to 12/23/22 (BP#2) did not contain any problems, goals or interventions to address the patient's suprapubic catheter. Interview: In a joint clinical record review conducted with the Director of Nurses on 12/21/22 they did confirm that the plan of care did not contain any problems, goals or interventions to address the suprapubic catheter. They thought that since the suprapubic catheter was managed primarily by the urologist that it was not necessary to address in the hospice plan of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by a review of documents, interviews and home visit observations. In 1 of 3 (33%) home visits, the agency did not ensure that the staff member used standard precautions such hand hygiene that followed accepted standards of practice and agency policy. Policy: The agency's policy titled, Hand Hygiene Technique (undated) stated in relevant parts, "Procedure: Hand Decontamination with an alcohol-based hand rub (hand-sanitizer). 3. Hand decontamination using alcohol-based hand rub (sanitizer) should be performed: d. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. f. After contact with inanimate objects (including medical equipment) in the immediate area of the patient. g. After removing gloves." Home Visit 2: A home visit was conducted on 12/20/22 with the hospice aide (Staff 12), who was observed removing one soiled glove and replacing it without first performing hand hygiene. Staff 12 was also observed reaching into a drawer to access patients clean supplies without first removing soiled gloves and performing hand hygiene. Interview: 3 In an interview conducted on 12/7/22 with the Director of Nurses, they did verify that staff 12 did not follow standard precautions and established policy for hand hygiene as defined in agency policy.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. The plan addresses the patient population served, specifically, the care and safety of patients with limited mobility, and those requiring evacuation due to a medical or psychiatric condition, or their home environment; Addresses when emergency preparedness officials are contacted regarding evacuation of patients; Defines the type of care and services the hospice can provide in an emergency; Addresses continuity of business functions essential to operations, including identification of staff or positions that can assume key organization roles if current staff and leadership are not available. This standard was not met as evidenced by document reviews and interviews. The Emergency Preparedness Plan reviewed on 9/22/2022 did not specifically address the type of care and service the agency would be able to provide during an emergency or disaster, and how essential business functions would be carried out if current staff and leadership were not available. During interview with the Director of Nursing on 9/22/2022, she was not able to speak to that part of the emergency plan.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes: How information and medical documentation for patients under the hospice’s care is shared, as necessary, with other healthcare providers to maintain the continuity of care, information in the event of an evacuation concerning how to release patient information, including their general condition and location, as permitted by the Health Insurance Portability and Accountability Act (HIPAA). This standard was not met as evidenced by document reviews and interviews. Review of the Emergency Preparedness Plan revealed the agency did not ensure the communication plan met all of the requirements required for how information and medical documentation for patients under the hospice's care would be shared. The agency's Emergency Preparedness Plan did not have specifically describe how information and medical documentation for patients under the hospice’s care would be shared with other healthcare providers to maintain the continuity of care, and specifically how information would be released in the event of an evacuation as permitted by the Health Insurance Portability and Accountability Act (HIPAA). During interview with the Director of Nursing on 9/22/2022, she was unable to locate additional information that she thought was included in the plan.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 7 (29%) clinical records reviewed, it was revealed that the agency did not ensure that the drug profile included all prescription and over the counter medications in order to complete a comprehensive review of the medication regimen. Clinical Record 5 - The patient was admitted 8/11/2022 with a diagnosis of Dementia. The patient's date of death was 9/6/2022. The skilled nurse documented in the initial assessment, dated 8/11/2022, that the patient was using oxygen at 2 liters per nasal cannula and that the patient was oxygen dependent. Oxygen was not added to the patient's drug profile. Clinical Record 3 - The patient was admitted 8/4/2022 with a diagnosis of Pressure Ulcer Stage 4. An additional physician order dated 8/4/2022 ordered Calmoseptine/Vitamin A&D Ointment to be used topically on dry skin as needed. The ointment was not added to the patient's drug profile. During interview and joint review of records with the Director of Nursing on 9/22/2022, she acknowledged the information was not documented on the patient's drug profile.

It is required that 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 7 (43%) clinical records reviewed, it was revealed that the agency did not ensure an initial bereavement risk assessment was completed and documented in the clinical record. Clinical Record 1 - The patient was admitted 6/27/2022 with a diagnosis of Leukemia. There was no documentation of an initial bereavement risk assessment completed by any clinician found in the clinical record. Clinical Record 3 - The patient was admitted 8/4/2022 with a diagnosis of Stage 4 Pressure Ulcer. The social worker documented on her initial assessment visit dated 8/8/2022 that bereavement was not discussed. There was no documentation of an initial bereavement risk assessment completed by any clinician found in the clinical record. Clinical Record 4 - The start of care was dated 6/29/2022. The patient's diagnosis was Heart Failure and Alzheimer's Disease. The social worker documented on her initial assessment visit dated 7/6/2022 that bereavement was not discussed. There was no documentation of an initial bereavement risk assessment completed by any clinician found in the clinical record. During interview with the Director of Nursing on 9/22/2022, she stated that the social worker was responsible for completing the initial bereavement assessment.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records, policies, and interview with the Administrator and Director of Nursing which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the IDG to ensure patient plans of care contained documentation of orders for all hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions [HCPC.18.I/L538]; Failure of the hospice Interdisciplinary Group to ensure Hospice care and services were provided to patients and families in accordance with the individualized plan of care established by the hospice IDG in collaboration with the attending physician [HCPC.19.I/L543]; and Failure of the registered nurse, as a member of the interdisciplinary group, to provide coordination of care and to ensure continuous assessment of patients’ and families’ needs, and implementation of the interdisciplinary plan of care [HCPC.19.I/L540]. The cumulative effect of these deficiencies could negatively impact the organization’s ability to develop, update, and implement plans of care to ensure services are provided that will meet the care needs of patients.

It is required that the plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by review of clinical records and observations. In 1 of 1 (100%) clinical records of a patient receiving physical therapy services, it was revealed that the agency did not document the specific care and services necessary to meet the needs of the patient in the individualized plan of care.. Clinical Record 2 - The patient was admitted 6/8/2022 with a diagnosis of Parkinson's Disease. During the benefit period dated 6/8/2022-9/5/2022 the plan of care included orders for "PT to eval and treat". The initial physical therapy (PT) evaluation was documented as completed on 6/27/2022. There was no documented evidence of orders for PT interventions and visit frequency included on the plan of care. In addition, the plan of care for the recertification benefit period dated 9/6/2022-12/4/2022 included orders for "PT to eval and treat", and there were no additional orders for interventions and visits to be provided by the PT. During the home visit observation (Home Visit 2) conducted on 9/22/2022, the patient's caregiver stated that the PT came almost every week and she saw the difference it made with the patient's ability to move. The record contained evidence of weekly PT visits continuing into the new benefit period.

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; and Ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 7 (28%) clinical records reviewed the agency did not ensure a registered nurse consistently provided coordination of care to ensure patients' and families' were continuously assessed and addressed through implementation of the plan of care by the IDG. Clinical Record 5 - The patient was admitted on 8/11/2022 with a diagnosis of Dementia. The patient's date of death was 9/6/2022. The last SN visit note prior to death, dated 8/31/2022, documented imminence of death including changes in level of consciousness, decreased urine output, non communicative, slow shallow breathing, and that the patient was barely responding to staff or family. There was no documentation of additional support or education offered to the family or caregivers, or a review of the patient's plan of care to determine if any additional resources were needed. There was no documentation of communication or updates in the patient's condition provided to the members of the IDG during the regularly scheduled meeting. The next documented encounter was the nursing visit note documenting the death visit on 9/6/2022, which was 6 days after the previous visit. No other members of the IDG made a visit to the patient during this 6 day span. The record was reviewed with the Director of Nursing on 9/22/2022, who stated she made the death visit. Clinical Record 2 - The patient was admitted 6/8/2022. A verbal order for wound care was dated 7/29/2022. The order did not specify the type of treatment to be provided, including the location of the wound site, and the frequency and duration the treatment was to be provided. There was no documentation of discussion of the wound care ordered and the wound status noted in the IDG notes dated 8/1/2022.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records reviewed, it was revealed that the agency did not ensure the patient's individualized plan of care was followed. Clinical Record 4 - The patient was admitted 6/29/2022 as a transfer from another hospice agency. During the benefit period dated 8/6/2022-10/4/2022, social work visits were ordered as "1 month 1, and 1 PRN". At the time of the site visit review on 9/22/2022, there were no social work visit documents found in the clinical record for visits made during the benefit period. During interview on 9/22/2022 with the Director of Nursing, she stated she was not aware of the missed visits.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 4 (25%) clinical records reviewed of patients that received hospice aide services, it was revealed that the agency did not ensure that there were written instructions of care for the hospice aide to follow. Clinical Record 7 - The patient was admitted on 7/9/2022 with a diagnosis of Breast CA. The patient's date of death was 7/15/2022. The initial plan of care dated 7/9/22 ordered aide services as "2w9". No hospice aide plan of care was located in the clinical record. The aide performed 1 visit on 7/9/2022 and missed visit notes were documented for 7/14/2022 and 7/15/2022. During review of the record on 9/21/2022 with the Director of Nursing, she was unable to find a hospice aide plan of care for the patient.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; and Included in the plan of care. This standard was not met as evidenced by review of records and interview. Review of 2 of 4 (50%) clinical records of patients who received hospice aide services revealed aide visits were not provided in accordance with orders on the plan of care. Clinical Record 1 - The patient was admitted 6/27/2022 with a diagnosis of Leukemia. The initial plan of care dated 6/27/2022 ordered aide services to be provided as "2w9". An additional physician order dated 8/15/2022 increased aide visits to "3w3". During the weeks ending 8/27/2022 and 9/3/2022, 2 aide visits were provided during each week and there was no documentation present to explain why the 3rd visit was not completed. Clinical Record 7 - The patient was admitted on 7/9/2022 with a diagnosis of Breast CA. The patient's date of death was 7/15/2022. The initial plan of care dated 7/9/22 ordered aide services as "2w9". The aide performed only 1 visit on 7/9/2022, which the first week of service, and missed visit notes were documented for 7/14/2022 and 7/15/2022. Only one of the 2 aide visits ordered for the first week of service was provided. During interview on 9/22/2022 with the Director of Nursing, she stated she was not aware of the missed visits.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness; Education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by document reviews, interviews and personnel record reviews. In 3 of 14 (21%) personnel records reviewed the agency did not ensure an initial orientation was documented as provided to all of its employees when hired.. Staff 8 - The employee was hired 4/1/2022. There was no documentation of an initial orientation found in the employee's personnel file. Staff 9 - The contractor was hired 12/6/21. There was no documentation of an initial orientation found in the employee's personnel file. Staff 1 - The employee was hired 5/9/2022. The orientation checklist included the employee's name and was dated 5/9/2022. The rest of the form was blank. None of the boxes were checked to validate the items were reviewed. The agency's policy, "Personnel Records #4.15.2 (no revision date)", stated in the section titled, "Orientation on Hire or Change of Position", in part: "All new or reassigned personnel must complete an orientation program...". During record review and interview on 9/20/2022, the Director of Nursing was not able to locate additional information.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Outcome measure data elements per regulation; Physician certification and recertification of terminal illness as required; Any advance directives; Copies of inpatient discharge summary, as applicable; and Physician orders. THIS IS A CMS CONDITION LEVEL CITATION OF DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records and interviews with the Administrator, Director of Nursing and Medical Director which revealed issues with the agency's clinical records in the following areas: Failure to complete all required information on patients' Hospice Election forms [HSIM.3.I/L673]; Failure to complete documentation of the Certification of Terminal Illness and file the document in the clinical record [HSIM.3.I/L676]; Failure to ensure that all clinical visit notes are completed in a timely manner and filed in the clinical record [HSIM.3.I/L-672]; and Failure to document all necessary information on verbal physician orders [HSIM.3.I/L678]. The cumulative effect of these deficiencies could greatly impact the organization's ability to retrieve and share accurate information for use in delivering and coordinating hospice services.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records reviewed revealed that the agency did not ensure that updated and clinical visit notes were included in the clinical record and available to the physician and other hospice staff involved in the patient's care. . Clinical Record 4 - The patient's start of care was 6/29/2022. The benefit period reviewed was dated 8/6/2022-10/4/2022. Skilled nurse visits were ordered weekly, spiritual care visits were ordered 1 time per month and social worker visits were ordered 1 time per month. At the time of the site visit record review on 9/22/2022, there were no visit notes present in the clinical record for the chaplain or the social worker during this benefit period. In addition, the last documented skilled nurse visit note present in the clinical record was dated 8/25/2022, which was a period of 28 days without a documented nursing visit, at the time of the site visit review on 9/22/2022. During joint review of the clinical record with the Director of Nursing on 9/22/2022, she was unable to locate any additional documentation and/or visit notes.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 7 (28%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's election statement was completed as required in accordance with 418.24. Clinical Record 5 - The patient was admitted 8/11/2022 with a diagnosis of Dementia. The Election of Benefit form was signed 8/11/2022. The boxes on the form that covered the patient's right to choose the attending physician, and the right to request notification of non-covered items were not checked. There was no other documentation found in the record that stated the patient's caregiver made a choice of an attending physician or chose the medical director, and no other documentation that the patient's caregiver requested or declined the documentation of non-covered items. Clinical Record 3 - The patient was admitted 8/4/2022 with a diagnosis of Stage 4 Pressure Ulcer. The Election of Benefit form dated 8/4/2022 did not have an effective date of when services were to begin. The agency documented the benefit period as 8/4/2022-11/1/2022. During interview with the Director of Nursing on 9/21/2022,she acknowledged that the forms were not completed as required.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician certification and recertification of terminal illness as required. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records reviewed the agency did not ensure the patient's record contained documentation of the physician's certification of terminal illness. Clinical Record 3 - The patient was admitted 8/4/2022 with a diagnosis of Stage 4 Pressure Ulcer. There was no documented evidence of a completed Certificate of Terminal Illness found in the clinical record. During interview with the Medical Director and Administrator on 9/22/2022 they stated the certificate could not be located.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records reviewed, it was revealed that the agency did not ensure all physician orders were fully documented in the patient's record.. Clinical Record 2 - The patient was admitted 6/8/2022. A verbal order for wound care was dated 7/29/2022. The order did not specify the type of treatment to be provided, including the location of the wound site, and the frequency and duration the treatment was to be provided. There was no documentation of the wound care noted in the IDG notes dated 8/1/2022. During record review with the Director of Nursing on 9/22/2022, she stated she was not able to find any additional documentation.