Every finding on record at New Century Hospice, Inc.

Based on review of agency policies, review of agency documents, review of medical records (MR), observation, and interviews with staff (EMP), it was determined that the hospice failed to complete comprehensive assessments that addressed the patient's physical needs. This deficiency had the potential to impact all 56 patients of the agency. --- On October 21, 2024 at 9:24 AM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff education, a nurse evaluation for all patients, supervisory observation visits, and MR audits. The IJ was removed on October 21, 2024 at 2:01 PM after the State Survey Agency completed onsite verification that the facility implemented the corrective actions addressing the IJ. Cross Reference: §418.54(c) Content of the comprehensive assessment

Based on review of agency policies, review of agency documents, medical record review (MR), skilled nursing home visit observations, and interviews with staff (EMP), it was determined that the hospice failed to complete a full comprehensive assessment that identified the physical needs of the patient for 2 out of 6 patients (Patient #3 and #5) reviewed in the sample. Findings include: --- Review of agency policy "Comprehensive Assessment", last revised June 12, 2024, stated, "...During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including...A physical assessment, including...skin, and other relevant data related to pertinent physical findings and the patient's terminal illness...Specific, individualized patient needs/problems pertinent to the hospice care being provided..." Review of agency policy "Ongoing Assessments", last revised November 15, 2023, stated, "...The nurse may assess each patient on each visit for...skin integrity...Changes in patient condition..." Review of agency policy "Wound Assessment, Documentation and Clinical Oversight", last revised February 21, 2024, stated, "Procedure...Physician orders will be obtained for all wound treatments and will specify...Location...Type of Wound...Frequency of treatment...Cleansing agent...Rinsing agent...Product(s)/treatment(s) to be applied...Outer dressing to be applied...Product to secure dressing...Individual to perform treatment...The RN will perform wound assessments as ordered by the physician but no less than once weekly. At least once weekly, the RN assessment will include wound measurements...The RN retains the overall responsibility for patient care...The RN must directly observe and assess all newly identified wounds, obtain orders from the physician, and update the plan of care accordingly..." Review of MR5 "Visit Note Report", dated June 21, 2024, and signed by a registered nurse, revealed that a skin assessment was completed, and it was noted that the patient had a wound. No details regarding the location of the wound or descriptors of the wound were found. Review of MR5 "Visit Note Report", dated July 10, 2024, and signed by a nurse practitioner, revealed, "... Assessment...New Pressure sores to buttocks requiring cleanser and medihoney fiber with bordered gauze since 6/28/24...No falls or acute illness this benefit period. New pressure ulcer as above to buttocks..." Review of MR5 "Visit Note Reports" from July 25, 2024, until September 19, 2024, revealed no documentation indicating the patient had a wound, the condition of the wound, or treatment for the wound. Review of MR5 "Visit Note Report" dated October 17, 2024, and signed by a registered nurse, revealed, "...Was a comprehensive head to toe skin assessment completed? Yes...Indicate integumentary assessment findings...wound (s)...Narrative...Skin is thin, dry and intack [sic] over bony prominences..." Review of MR5 "Visit Note Report" dated October 19, 2024, and signed by a registered nurse, revealed, "...Narrative...Sacral wound measures 2.5 CM [centimeters] x 3 CM, is a stage 4 with slothy discharge. Necrotic odor noted..." During an interview on October 18, 2024, between 11:09 AM and 12:15 PM with EMP4, it was confirmed that the hospice failed to perform or document a wound assessment for a patient with a known pressure injury, for an extensive time period. An observation visit was conducted on October 17, 2024, between 12:33 PM and 12:46 PM with EMP5, registered nurse, conducting a visit for Patient #3. During the comprehensive visit, a full assessment was not completed. The nurse omitted completing a mid-arm circumference measurement, a full skin assessment, and a review of aide services. Review of MR3 "Visit Note Report" dated October 17, 2024, revealed that EMP5 documented a measurement for Patient #3's mid-arm circumference. It was also documented that a head-to-toe skin assessment was completed and that the aide plan of care was updated. Review of MR3 "Aide Care Plan Report" indicated that the effective date of the current aide care plan was August 21, 2024. No evidence was found indicating that the aide care plan had been reviewed or updated. During an interview on October 18, 2024, between 11:09 AM and 12:15 PM with EMP 4, it was confirmed that the visit documentation did not accurately represent the assessment that occurred during the visit. It was confirmed that the hospice failed to complete a full comprehensive assessment to identify the needs of the patient.

Based on review of agency policies, review of agency documents, review of medical records (MR), and staff interviews (EMP), it was determined that the hospice failed to ensure that the comprehensive assessment included a drug profile review for 3 out of 3 skilled nursing facility patients (Patient #'s 4, 5, and 6) reviewed in the sample. --- Review of agency policy "Comprehensive Assessment," revised June 12, 2023, revealed, "...During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including...Review of current and related past medications..." Review of agency policy "Administration and Documentation of Medications", revised December 21, 2023, revealed, "...As part of the assessment process, a drug history will be taken, and a comparison made between the physician's (or other authorized independent practitioner's) orders and the current medication the patient is taking. Any discrepancies should be reported to the physician for resolution..." Review of MR4 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated September 25, 2024, revealed a different list of active medications from the skilled nursing facility document "Medication Review Report," printed October 17, 2024. There were three medication discrepancies between the two medication lists. A review of hospice MR4, located at the skilled nursing facility where Patient #4 resides, revealed a medication list dated February 22, 2024, on the chart. This list contained 5 inaccuracies from the active medication list on file at the skilled nursing facility. During an interview with EMP5 on October 17, 2024, between 1:06 PM and 1:14 PM, it was confirmed that the medication list in the hospice chart and the medication list from the most recent IDG meeting were inaccurate. Review of MR5 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated September 25, 2024, revealed a different list of active medications from the skilled nursing facility document "Medication Review Report" printed October 17, 2024. There were a total of 9 medication discrepancies between the two medication lists. During an interview with EMP4 on October 18, 2024, between 11:09 AM and 12:15 PM, the above finding was confirmed. Review of MR6 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated September 3, 2024, revealed a different list of active medications from the skilled nursing facility document "Medication Review Report", printed October 18, 2024. There were a total of 7 medication discrepancies between the two medication lists. During an interview with EMP4 on October 21, 2024, at 3:31 PM, the above finding was confirmed.

Based on review of agency policies, review of agency documents, medical record review (MR), and interviews with staff (EMP), it was determined that the hospice failed to update the comprehensive assessment after a change in patient condition for 1 out of 6 patients (Patient #1) in the sample. Findings include: --- Review of agency policy "Ongoing Assessments" revised November 15, 2023, revealed, "...The nurse may assess each patient on each visit for...skin integrity..." Review of agency policy "Comprehensive Assessment" revised June 12, 2023, revealed, "...The Comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires...Updates to the comprehensive assessment may include...individual discipline assessments..." Review of agency document "Client Occurrence Report" for Patient #1, revealed that on October 12, 2024, the patient fell while transferring self from the wheelchair to the couch. Patient #1 was found on the floor with their head against the wall. Patient #1 sustained a large hematoma on the top left portion of the skull, approximately 9cm (centimeters) long by 2 to 3 cm wide. Review of MR1 "Visit Note Report", dated October 14, 2024, revealed no documentation of the hematoma in the skin assessment. This finding was confirmed with EMP4 on October 18, 2024, at 9:16 AM.

Based on medical record review (MR), review of agency policies, review of agency documents, and staff interview (EMP), it was determined that the hospice failed to provide appropriate pain assessments for 2 out of 6 patients with cognitive impairment (Patient #1 and #2) in the sample. Findings include: --- Review of agency policy titled "Pain Assessment" revised November 15, 2023, revealed, "...A pain assessment will be completed on all patients as part of the initial assessment and ongoing as part of the comprehensive assessment...Pain assessments will be appropriate to the patient's...cognitive status...If patient is unable to communicate pain using the rating scale or is cognitively impaired, the nurse will assess behavioral factors that signal pain or discomfort and include this information in the assessment..." Review of agency document titled "Pain Assessment Scales/Tools", revised August 30, 2024, revealed, "...Numeric Pain Rating Scale...Adults with no cognitive impairments...Wong-Baker Faces Pain Rating Scale...Adults...Face, Legs, Activity, Cry, Consolability-FLACC Pain Scale...Adults...who are unable to communicate needs...Pain Assessment in Advanced Dementia-PAINAD Scale...Patients with advanced Dementia, both verbal and nonverbal..." Review of MR1 "Visit Note Report" dated 10/14/2024 revealed that a pain assessment was completed and the type of standardized pain screen tool used was staff observation. Cognitive/Behavioral assessment stated that the patient was confused and unable to understand and participate in her/his care. No documentation of the specific pain assessment scale/tool utilized was found. Review of MR2 "Visit Note Report" dated 10/7/2024 revealed that a pain assessment was completed and the type of standardized pain screen tool used was staff observation. Cognitive/Behavioral assessment stated that the patient was confused and unable to understand and participate in her/his care. No documentation of the specific pain assessment scale/tool utilized was found. Review of MR2 "Visit Note Report" dated 10/17/2024 revealed that a pain assessment was completed and the type of standardized pain screen tool used was staff observation. The assessment stated that the patient was confused and disoriented times 3 (person, place, and time) at all times and had cognitive deficits. No documentation of the specific pain assessment scale/tool utilized was found. During an interview with EMP4 on October 18, 2024, between 9:53 AM and 10:00 AM, the above findings were confirmed.

Based on review of agency policy, review of agency documents, medical record review (MR), and interviews with staff (EMP), it was determined that the hospice IDG failed to identify updates needed to the plan of care based on changes in the patient assessments; the hospice failed to ensure that care planning was individualized and measurable; failed to assess a patient timely after a change in condition; and, failed to ensure that the IDG group maintained responsibility for directing, coordinating, and supervising the care and services provided. These deficient practices have the potential to affect all patients being serviced by the hospice. --- .

Based on review of agency policies, medical record review (MR), and staff interview (EMP), it was determined that the hospice failed to identify plan of care updates in the IDG (Interdisciplinary Group) for 2 out of 6 patients (Patient #2 and #5) in the sample. Findings include: --- Review of agency policy titled "The Plan of Care", revised August 30, 2023, revealed, "...The hospice interdisciplinary group will...develop a plan of care that identifies the patient's problems and needs and interventions and services to meet those needs..." Review of agency policy titled "Interdisciplinary Group Plan of Care", revised October 11, 2023, revealed, "...The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments...that defines patient...problems, goals, and interventions..." Review of Patient #2's "Hospice IDG Comprehensive Assessment and Plan of Care Update report" dated 10/09/2024 revealed that the registered nurse identified a problem of fatigue, falls and confusion. Plan of Care contained no evidence of any interventions and goals for Patient #2. This finding was confirmed with EMP4 on October 21, 2024, at 3:32 PM. Review of MR5 "Visit Note Report" dated July 10, 2024, revealed a new problem. It stated, "...New pressure sores to buttocks requiring cleanser and medihoney fiber with bordered gauze since 6/28..." Reivew of MR5 "Hospice IDG Comprehensive Assessment and Plan of Care Update reports" revealed no evidence of the new problem of wound.

Based on review of agency policies, medical record review (MR), and interviews with staff (EMP), it was determined that for 5 out of 6 (Patient #'s 1, 2, 3, 5, and 6) patients reviewed in the sample, there was no evidence of measurable outcomes anticipated from implementing the plan of care. Findings include: --- Review of agency policy "The Plan of Care", revised August 30, 2023, revealed, "...This plan will focus on identified problems, goals and interventions...Each patient will be monitored for his/her response to care...against established patient goals and patient outcomes..." Review of agency policy "Monitoring Patient's Response/Reporting to Physician", revised November 2020, revealed, "...Clinicians will monitor, document, and report the patient's response to care and treatment provided on each hospice visit. Progress of goals will be measured at regular intervals...During each hospice visit, the clinician will monitor the patient's response to care against established goals including...care interventions for pain and symptom management...Medications...Teaching...During interdisciplinary group meetings, as well as during the recertification process, the care will be evaluated to determine achievement of hospice goals..." Review of agency policy "Clinical Record", revised October 27, 2023, revealed, "...A clinical/service record will be...maintained for each patient...and will include...Patient response to care and services is analyzed and documented as measurable goals...Current patient status and progress toward goals..." Review of MR1 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated October 9, 2024, revealed a list of open-ended goals without measurable data elements. For example, goal stated, "Patient will maintain optimal mobility within disease process." Goal does not indicate what optimal mobility would be for the patient, and how that would be measured. This finding was confirmed during an interview on October 18, 2024, at 8:59 AM with EMP4. Review of MR2 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated October 9, 2024, revealed a list of open-ended goals without measurable data elements. For example, goal stated, "Patient will maintain optimal mobility within the disease process." Goal does not indicate what optimal mobility would be for the patient,and how that would be measured. This finding was confirmed during an interview on October 18, 2024, at 9:37 AM with EMP4. Review of MR3 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated October 10, 2024, revealed a list of open-ended goals without measurable data elements. For example, goal stated, "Patient will achieve optimal respiratory function and comfort within the disease process.". Goal does not indicate what optimal respiratory function for the patient would be, and how that would be measured. This finding was confirmed during an interview on October 18, 2024, between 11:09 AM and 12:15 PM with EMP4. Review of MR5 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated September 25, 2024, revealed a list of open-ended goals without measurable data elements. For example, goal stated, "Anxiety will be reduced/controlled." Goal does not contain measurable data elements to determine if the patient is progressing towards their goal. This finding was confirmed during an interview on October 18, 2024, between 11:09 AM and 12:15 PM with EMP4. Review of MR6 "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated October 1, 2024, revealed a list of open-ended goals without measurable data elements. For example, goal stated, "Patient will achieve optimal neurological function and comfort within the disease process." Goal does not indicate what optimal neurological function would be, and how that would be measured. This finding was confirmed during an interview on October 18, 2024, at 2:30 PM with EMP4.

Based on review of agency policies, review of agency documents, medical record review (MR), and interviews with staff (EMP), it was determined that the hospice failed to follow its policy regarding patient assessments to ensure that services were provided based on the patient needs for 1 out of 6 patients (Patient #2) in the sample. --- Review of agency policy "On-Call/Weekend Services", revised November 11, 2023, revealed, "...Staff on call will be responsible to participate in the identification, monitoring, reporting, investigation and documentation of all...incidents, accidents...If a visit is required, the on-call staff will attempt to arrive at the...facility as quickly as possible, but no later than (1) hour...problems that may require a visit from the hospice nurse...Report of patient falling (observed or unobserved)..." Review of agency document "Client Occurence Report", revealed that on October 6, 2024, Patient #2 had a fall and sustained a slight bump to the back of their head. Review of MR2 "Client Coordination Note Report", revealed that on October 6, 2024 at 7:11 PM, the triage nurse received a call reporting that the patient had a fall and hit his/her head. Report also revealed, "Triage has identified a PRN [as needed] visit need. Company policy dictates that a visit is now required to be completed..." Review of MR2 "Visit Note Report" , revealed that the PRN visit was completed on October 7, 2024 at 12:20 PM, 17 hours after the reported fall. This finding was confirmed with EMP4 on October 18, 2024 at 10:04 AM.

Based on agency policy review, medical record review (MR), and interviews with staff (EMP), it was determined that the hospice failed to provide for and ensure ongoing sharing of information between the hospice and skilled nursing facility for 1 out of 6 patients (Patient #5) in the sample. --- Review of agency policy "Provision of Care to Residents of SNF/NF, ICF/IID or ALF", last revised November 15, 2024, stated, "...The hospice provides hospice care to residents of a SNF [Skilled Nursing Facility]...and will abide by the following standards...The hospice will assume responsibility for professional management of the resident's hospice services provided...The hospice will ensure that the interdisciplinary group communicates with the SNF...The hospice will designate a member of each interdisciplinary group that is responsible for a patient who is a resident of the SNF...The designated member is responsible for...providing overall coordination of hospice care of the resident..." Review of agency policy "Wound Assessment, Documentation and Clinical Oversight", last revised February 21, 2024, stated, "Procedure...Physician orders will be obtained for all wound treatments and will specify...Location...Type of Wound...Frequency of treatment...Cleansing agent...Rinsing agent...Product(s)/treatment(s) to be applied...Outer dressing to be applied...Product to secure dressing...Individual to perform treatment...The RN will perform wound assessments as ordered by the physician but no less than once weekly. At least once weekly, the RN assessment will include wound measurements...The RN retains the overall responsibility for patient care...The RN must directly observe and assess all newly identified wounds, obtain orders from the physician, and update the plan of care accordingly..." Review of MR5 "Visit Note Report" dated July 10, 2024, revealed a new problem, "...New pressure sores to buttocks requiring cleanser and medihoney fiber with bordered gauze since 6/28..." Review of MR5 "Visit Note Reports" from July 25, 2024, until September 19, 2024, revealed no documentation indicating the patient had a wound. During an interview on October 17, 2024, between 12:51 PM and 12:55 PM, EMP5 stated that the patient has had a wound for about 2 or 3 months. EMP5 was unable to articulate the current status of the wound or treatment being provided by the facility. EMP5 stated that detailed information regarding the wound assessment and treatment would be found in the electronic medical record. A review of MR5 revealed no evidence of a detailed wound assessment, no evidence of wound care treatment orders, and no evidence of the wound being noted on the plan of care updates. Review of MR5 "Hospice IDG Comprehensive Assessment and Plan of Care Update reports" revealed no evidence of the new problem of a wound. During an interview on October 18, 2024, between 10:47 AM and 11:08 AM with EMP2, EMP4, and EMP6, it was stated that it is the expectation that the hospice nurse assigned to the patient will communicate with the facility staff assigned to the patient during each visit. During an interview on October 18, 2024, between 11:09 AM and 12:15 PM, EMP4 confirmed that the hospice failed to ensure adequate communication between the hospice and the SNF related to Patient #5's wound assessment, care, and treatment.

Based on review of agency policy, observation visits, review of medical records (MR), and staff interviews (EMP), it was determined that the agency failed to provide skilled nursing facilities (SNFs) with current, patient-specific information needed to coordinate the care of the hospice patient for 3 out of 3 patients (Patient #s 4, 5, and 6) reviewed. Findings include: --- Review of agency policy ";Provision of Care to Residents of SN/NF, ICF/IID or ALF", dated November 15, 2024, stated, ";...The hospice provides hospice care to residents of a SNF [skilled nursing facility] ...and will abide by the following standards...The hospice will assume responsibility for professional management of the residents hospice services provided...The hospice will provide the SNF...the following information specific to each patient...The most recent plan of care...Physician certification and recertification of the terminal illness...Instructions on how to access the hospices 24-hour-on-call system...Hospice medication information..." A review of hospice MR4, located at the skilled nursing facility where Patient #4 resides, revealed the following: - No evidence of a current hospice re-certification. - No evidence of instructions on how to access the hospices 24-hour on-call system. - No evidence of an accurate medication list. The above finding was confirmed during an interview with EMP5 on October 17, 2024, between 1:06 PM and 1:14 PM. A review of hospice MR5, located at the skilled nursing facility where Patient #5 resides, revealed the following: - No evidence of instructions on how to access the hospices 24-hour on-call system. - No evidence of an accurate medication list. The above finding was confirmed during an interview with EMP5 on October 17, 2024, at 1:37 PM. A review of hospice MR6, located at the skilled nursing facility where patient #6 resides, revealed the following: - No evidence of an accurate medication list The above finding was confirmed during an interview with EMP4 on October 21, 2024, at 3:31 PM.

Based on review of agency policies, review of agency documents, and interviews with staff (EMP), it was determined that the agency failed to provide adequate orientation for 8 out of 8 skilled nursing facilities (SNFs) where hospice patients currently reside. --- Review of agency policy "Provision of Care to Residents of SNF/NF, ICF/IID or ALF", revised November 15, 2023, revealed, "...The hospice will provide orientation and annual education of SNF...staff furnishing care to hospice patients to include the following...Hospice philosophy...Hospice policies and procedures regarding methods of comfort, pain control, and symptom management...Principles about death and dying and individual responses to death..." Review of agency contract "General Inpatient and Respite Care Skilled Nursing Facility Agreement", dated August 9, 2023, stated, "...Education and Inservices...Both Hospice and Facility are responsible for ensuring Facility staff are properly oriented and trained to furnish care to hospice patients...Hospice staff must consult with and thus share responsibility with the Facility to assure facility staff orientation and training of staff furnishing care to Hospice patients in the hospice philosophy including Hospice 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. A description of the training and names of those providing training will also be documented..." Review of agency document "Hospice 101", revised January 2024, used for SNF staff education, revealed, "...Objectives...Explain the hospice care philosophy...Discuss the goals of hospice care...Identify qualifications for hospice care eligibility...Discuss covered services under the hospice benefit...State hospice care payor sources...". No evidence was found that the education provided included hospice policies and procedures regarding methods of comfort, pain control, and symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record-keeping requirements. Review of SNF in-service training records revealed no evidence of hospice care in-services for 7 out of 8 contracted facilities with active hospice patients. In an interview on October 17, 2024, at 12:40 PM, SNF EMP3 (licensed practical nurse) revealed that no hospice education had been provided. SNF EMP3 stated that he/she had worked in the facility for 18 years and had never received an in-service on hospice care. In an interview on October 18, 2024, between 11:43 AM and 11:55 AM, SNF EMP1 (licensed practical nurse) and SNF EMP2 (nurse manager) revealed that neither could recall receiving any hospice education or training. SNF EMP1 stated, "I don't remember. We were told to call the hospice if we see signs of impending death." SNF EMP2 stated, "Not that I'm aware of. If they did, they did not provide me any documentation of the education." During an interview on October 18, 2024, at 3:00 PM with EMP6, the above findings were confirmed.

Upon patient record review, 2 of 11 (Patient #3, 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3 The 4/5/22 SOC assessment indicates O2 in use. Oxygen was not included on the medication profile. Patient #9 The 5/27/22 SOC assessment indicates O2 in use. Oxygen was not included on the medication profile.

Upon patient record review, 3 of 11 (Patient #3, 5, 11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient #3 The SOC assessment dated 4/4/22 contains no initial bereavement risk assessment to date. Patient #5 The SOC assessment is dated 7/1/22 and the initial bereavement risk assessment is dated 7/8/22 which exceeds the 5 day window. Patient #11 The SOC assessment is dated 6/22/22 and the initial bereavement risk assessment is dated 6/28/22 which exceeds the 5 day window.

Upon patient record review, 4 of 11 (Patient #1, 2, 5, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1 The 5/3/22 Plan of Care indicates interventions for aide however no evidence of orders or services to date. Patient #2 The patient has a diagnosis of a fib and polycythemia and is on anticoagulation therapy requiring monitoring however no related goals or interventions on plan of care to date. Patient #5 The 7/11/22 SOC note indicated patient requiring ostomy care however no related goals or interventions on plan of care to date. Patient #10 The plan of care includes diagnosis of DM and patient is on oral as well as sliding scale insulin however no goals or interventions related to DM to date.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2 The 6/9/22 PT frequency reads PT eval prn.

Upon patient record review, 4 of 11 (Patient #3, 4, 9, 10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 The record indicates the use of O2 however no order for O2 to date. Patient #4 The 5/25/22 wound care order reads clean with NS, apply dry dressing 2xday until healed but contains no wound location to date. Patient #9 The record indicates the use of O2 however no order for O2 to date. Patient #10 The 6/11/22 wound care order reads remove old dressing, clean with NS, pat dry, apply CA alginate, 4x4, skin prep, foam dressing daily however contains no location to date.

Upon patient record review, 4 of 11 (Patient #1, 2, 8, 11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1 The DME on the plan of care reads none. The patient had hospital bed per soc note. Patient #2 The DME on plan of care reads none however the record indicates O2 in use. Patient #8 The DME on plan of care reads none however the record indicates O2 in use. Patient #11 The DME on plan of care reads none however the record indicates hospital bed and O2 in use.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2 during the home visit the RN placed the nursing bag on the floor with no barrier and returned soiled gloves to the bag. According to Bag technique policy dated 5/20/22 soiled items are not to be returned to the bag.

Upon patient record review, 6 of 11 (Patient #2, 3, 4, 5, 6, 7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2 The 6/30/22 nursing visit note contains no signature. The 6/9/22 plan of care RN signature contains no credentials. Patient #3 The 6/14/22-6/28/22 aide visits contain no credentials with associated signature and date. Patient #4 The 6/14/22-6/28/22 aide visits contain no credentials with associated signature and date. The RN signature on the 7/3/22 physician order contains no credentials. Patient #5 The 7/1/22 plan of care and the 7/8/33 nursing note RN signature contains no credentials. Patient #6 The 7/11/22 Physician order RN signature contains no credentials. Patient #7 The 7/1/22-7/11/11 aide visits contain no credentials with the associated signature and date.

Upon personnel record review, 2 of 11 applicable (Personnel #3, 5) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #3 Expired license on file- verified while surveyor on site 7/13/22. Personnel #5 Expired license on file- verified while surveyor on site 7/13/22.

Upon personnel record review, 1 of 14 (Personnel #4) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #4 There was no evidence a background check had been completed only the consent to obtain prior to employment.