Every finding on record at New Century Hospice Inc.

Upon patient record review, 1 of 5 (Patient #4) 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 4: The current order for social work visits was monthly and PRN without a quantity of PRN visits allowable.

Upon patient record review, 1 of 5 (Patient #1) 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 1: The medical record contained an order to discontinue vitamin D 4/24/26. The patient was on two different supplements containing vitamin D and the order did not specify if one or both supplements were to be discontinued.

Upon patient record review, 2 of 5 (Patients #3,#5) 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 3: The medical record contained nursing documentation upon recertification assessment 3/17/26 identifying patient use of a hospital bed, overbed table, and raised toilet seat. There was no evidence of current orders for the DME included in the plan of care. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a bed alarm and nebulizer. There was no evidence of orders for the DME included in the plan of care.

Upon patient record review, 7 of 19 (Patient #4,#6,#7,#9,#11,#13,#14) 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#4: The hospice medication profile indicates patient requires Oxygen 4 lpm continuous via nasal canula and Zoloft 25mg 1 daily for anxiety. There is no evidence of these medications on facility MAR during home visit. Patient#6: The medication profile indicates patient taking sertraline 100mg take 1.5 daily. On 2/17/26 the nurse documents that the family is going to talk to the VA physician about stopping this medication. On 3/4/26 the nurse documents that family reports they are titrating down the sertraline in order to work towards stopping it. There is no evidence of an a change to medication profile that this medication is being titrated down. Patient#7: There is no evidence that the purpose, directions for use, or side effects/interactions were reviewed for the following medications: allopurinol, cetirizine, furosemide, rosuvastatin, senna lax, and spironolactone. Patient#9: The hospice medication profile indicates acetaminophen 650mg rectal suppository is ordered as a PRN medication. During home visit, the facility MAR indicates acetaminophen 650mg is oral for PRN use. The medication profile for this patient also indicated Imodium is a scheduled medication of diarrhea and senna plus is also a scheduled medication for constipation. The agency confirmed the Imodium should be a PRN medication. Patient#11: The medication profile indicates to give Dilaudid every hour 0.25mg for mild, and 0.5mg for moderate. However, there is no evidence or specification on if this dose is for pain or shortness of breath as these are both listed as indications. Patient#13: The medication profile indicates that Thick it is ordered as scheduled and frequency is daily. There is no evidence of instructions that this is to be used throughout the day with all liquids patient is drinking. Patient#14: The medication profile indicates acetaminophen 650mg rectal suppository is scheduled however, the instructions states take as needed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 19 (Patient #7,#9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#7:During record review there was no evidence of measurements for the wound to the right heel for the week of 1/25/26 and the week of 2/1/26. Patient#9: During record review it was indicated the patient had wound to the right heel and the left heel. There is no evidence of measurements for these wounds for the week of 2/8/26 and the week of 2/15/26. The week of 2/8 the nurse notes on the 2/13 visit that patient refused measurements. There is also a nurse visit documented on 2/14 however, there is no evidence of measurements on this visit.

Upon patient record review, 3 of 19 (Patient #1,#6,#7) 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: There is no evidence of problems, goals, and interventions on plan of care for the 3/3/26 wound to left buttock Patient#6: The record indicates patient has issues with sleep regulation and is currently taking 2 prescribed medications to assist with this. There is no evidence of problems, goals, and interventions related to this issues on the plan of care. Patient#7: The record indicates patient is hearing impaired on the aide plan of care. There is no evidence of the hearing impairment on the main plan of care.

Upon patient record review, 3 of 19 (Patient #4,#6,#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 medications and treatments. Patient#4: The wound care order on 2/25/26 states patient has a skin tear and to clean with wound wash, rinse, pat to dry, apply petroleum jelly, and cover with foam dressing three times a week and PRN to be completed by hospice or facility nurse. There is no evidence of a specified location of the skin tear. Patient#6: The current order indicates patient taking sertraline 100mg take 1.5 daily. On 2/17/26 the nurse documents that the family is going to talk to the VA physician about stopping this medication. On 3/4/26 the nurse documents that family reports they are titrating down the sertraline in order to work towards stopping it. There is no evidence of an order indicating this medication is being titrated down. Patient#11: The order for Dilaudid indicates it is for pain and shortness of breath. In the instructions it states to give every hour 0.25mg for mild, and 0.5mg for moderate. However, there is no evidence or specification on if this dose is for pain or shortness of breath.

Upon patient record review, 4 of 19 (Patient #4,#7,#10,#14) 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#4: The admit nurse documents that the patient's blood sugar is being monitored. However, there is no evidence of glucometer or diabetic supplies order on the plan of care. Patient#7: The record indicates patient is diabetic. There is no evidence of glucometer or diabetic supplies order on the plan of care. Patient#10: The record indicates orders on plan of care for half rails and for full rails. It also list a glucometer however, patient is not a diabetic. Patient#14: The plan of care indicates the facility is monitoring patient blood sugar however, there is no evidence of order for glucometer on plan of care.

Upon patient record review, 3 of 19 (Patient #7,#11,#12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient#7: The nurse documents the patient received 6 staples to the head due to injury on 2/26/26. There is no evidence of the plan of care was updated with problems, goals, and interventions related to this. Patient#11: The nurse documents on 2/27/26 that the patient son advised her the patient is tolerating chips and donuts. The record indicates patient is ordered a puree diet and is on aspiration precautions. On 3/4/26 nurse documents patient refuses puree foods. There is no evidence of updates to plan of care problems, goals, and interventions to address these changes. Patient#12: The record indicates chaplain services were declined on 2/26/26 however, chaplain services with problems, goals, and interventions assigned to the chaplain remain on plan of care. In addition, there is evidence that on 2/26 an order was entered for a frequency for chaplain services as 2 PRN visits for spiritual support.

Upon client record review, 1 of 19 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#10: Plan of care indicates nurse is to perform SpO2 PRN and to report SpO2 below 90% to the physician. The nurse documents on 2/17/26, 2/23, 2/27, 3/3, 3/6, and 3/9 that the patient "has periods when O2 sat drops too low". On 3/3 the nurse also documents that "more O2 is needed" by the patient. However, there are no SpO2 levels documented in these visits and there is no evidence of low numbers being reported to physician.

Upon patient record review 1 of 19 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#4: The record indicates a pre-bereavement assessment was completed on 2/11/26 which indicated the person was at high risk. No evidence that a follow-up was completed or that anything was done to start supporting the person identified as high risk. No evidence that the high risk assessment was communicated with the IDG team to ensure the care and services were based on the needs of the person assessed.

Upon patient record review, 1 of 19 (Patient #19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient#19:During review of record there was no evidence of the 12 month letter being sent which was due on 2/22/26 per the bereavement plan of care.

Upon patient record review, 2 of 19 (Patient #7,#9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#7:During record review, it was documented by the nurse that patient received 6 staples to his head secondary to an injury. There is no evidence of the aide plan of care being update for bathing and shampooing the patient with the injury and staples. Patient#9: The main plan of care indicates the patient has a speech impairment. There is no evidence of speech impairment on the aide plan of care.

Upon patient client record review, 2 of 19 (Patient #1,#16) 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#1:The record indicates that the Social worker visit on 2/24/26 was scheduled and labeled as a phone visit. However, the narrative states this visit was completed in the home. Patient#16:The medical record indicates this patient revoked hospice care in order to seek aggressive treatment. However, the revocation form states patient transferred to another hospice after hospitalization.

Upon client record review, 4 of 19 (Patient #4, 9, 11,14) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient#4: The record indicates patient has visual impairment on the aide plan of care. There is no evidence of this on the main plan of care. The nurse also documents on admit that the patient has speech impairment making communication difficult and limiting patient ability to communicate needs. There is no evidence of problems, goals, and interventions related to this on the plan of care. The record also indicates a pre-bereavement assessment was completed on 2/11/26 which indicated the person was at high risk. No evidence that the plan of care reflected the persons needs. Patient#9: The record indicates patient is taking 2 scheduled eye drops and requires daily use of ocusoft lid scrub for follicular conjunctivitis. There is no evidence of problems, goals, and interventions related to the eyes on the plan of care. Patient#11: The nurse documents patient has dyspnea during conversations and gets short of breath when lays flat. There is no evidence of problems, goals, and interventions related to this issue on plan of care. Patient#14: The aide plan of care states patient is visually impaired due to cataracts and vision is blurry. There is no evidence of problems, goals, and interventions related to this issue on plan of care.

Based on record reviews and interviews, the agency failed to protect a Patient’s  right to be free from neglect in 1 (Client #51) of 5 Patient charts reviewed.  The registered nurse (RN A) neglected Patient #51 by failing to order pain medication resulting in Patient #51 experiencing uncontrolled pain.   This failure caused Patient #51 unnecessary pain and suffering at the end of life. --- Findings include:  Patient #51 chart review revealed an initial plan of care dated  4/11/2025 through 7/9/2025. The chart included an admission assessment on 4/11/25, dated and signed by RN A. The primary diagnosis was liver cancer (abnormal growth of cells). The plan of care included orders for skilled nursing 1 time week for 1 week, 2 times a week for 12 weeks and 1 time a week for 1 week, 4 as needed for care needs or symptom management; hospice aide 3 times a week for 12 weeks and 2 times a week for 1 week; medical social worker 1 time to evaluate for social and emotional support. Chaplain and volunteer services were declined at admission.  Record review of the comprehensive start of care assessment dated 4/11/25. RN A documented Patient #51 had a diagnosis of liver cell carcinoma (cancer of liver) with neoplasm (cancer) related pain. Patient #51 was alert and oriented to person and place, per family/caregiver disoriented and forgetful most of the time. Family/Caregiver reported Patient #51 not eating or drinking well with throwing up blood with hospital visit last week. Patient Required max assist during transfer and depends on family/caregiver for all activities of daily living. Patient #51 reported he was always in pain. Family/caregiver reported shortness of breath to Patient #51 during activities, has oxygen prn shortness of breath. Review of Patient Coordination Note report on 4/13/25 9:35 pm Family/caregiver called to report max  pain medication given per orders. Patient #1 requesting additional pain medication due to continued pain after maximum dose of Hydromorphone 1 ml administered by mouth (under tongue). Family/caregiver declined need for prn skilled nurse visit. Reported due to increase in pain to physician Patient #1 requesting additional pain medication. order for Fentanyl 25 mcg/hr patch apply/change to skin every 72 hours. Record review of nurse visit note on 4/14/25 2:15 pm Skilled nurse visit by RN B, noted medications not taken regularly for pain or nausea and vomiting, verbalized no pain at time of visit. 27 ml hydromorphone 1mg/ml remaining. Record review of Pharmacy F invoice indicated on 4/14/25 7:20 pm Pharmacy F delivered Fentanyl 25 mcg/hr – 5 patches delivered. Review of Patient Coordination Note report on 4/15/25 6:05 pm Family/caregiver called requesting refill on Hydromorphone 1mg/ml, Patient #51 will run out tonight. Family/caregiver denied need for visit at this time.  Review of Patient Coordination Note report on 4/16/25 6:07 pm Family/caregiver called reporting out of hydromorphone 1mg/ml, it was supposed to be delivered today.Record review of Pharmacy F invoice indicated on 4/16/25 7:40 pm Pharmacy F hydromorphone 1mg/ml, 30 ml delivered. Record review of  skilled nurse’s note by RN B on 4/17/25  1:47 pm, Patient #51 verbalized pain. 23 ml of hydromorphone 1mg/ml remaining. Review of Patient Coordination Note report on 4/20/25 8:46 am Family/caregiver called reported hydromorphone 1mg/ml increased to 2 mg every hour prn pain. Only 8 ml remaining. Denied need for visit.  Review of Hospice IDG Comprehensive Assessment and Plan of Care Update Report, Hydromorphone increased from 1mg/ml 0.25-1ml every 2 hours prn pain to 2mg every hour prn pain. Order signed by Physician J. Record review of Pharmacy F invoice indicated on 4/20/25 10:29 am Pharmacy F delivered 30 ml of hydromorphone 1mg/ml.  Record review of skilled nurse’s note by RN B on 4/21/25 12:35 pm. Patient #51 verbalized pain, pain not rated, Patient #51 appeared uncomfortable. Patient #51 had episode of dark colored emesis during visit, RN B administered Phenergan 12.5 suppository for nausea/vomiting per orders. 27 ml hydromorphone remaining. Review of Patient Coordination Note report on 4/22/25 7:09 pm Family/caregiver called and reported 12 ml of hydromorphone remaining request refill and increase in fentanyl patch. Family/caregiver denied need for visit at this time. Review of Hospice IDG Comprehensive Assessment and Plan of Care Update Report on 4/22/25 9:44 pm Order to increase Fentanyl to 50 mcg/hr  patch, change/apply to skin every 3 days. Record review PRN Skilled nurse visit note by RN B on 4/23/25 12:31 pm due to continuous nausea and vomiting. Patient #51 not taking nausea medication. Patient #51 not verbalizing pain at this time. 7 ml hydromorphone remaining. Increased skilled nurse visits to daily due to imminent. Family/caregiver denies need for skilled nurse visit at this time. Record review of Pharmacy F invoice indicated on 4/23/25  1 pm Pharmacy F delivered 30 ml hydromorphone 1 mg/ml and Fentanyl 50 mcg/hour patches-5 patches delivered. Record review of Pharmacy F invoice indicated on 4/23/25 5:57 pm Pharmacy F delivered promethazine suppository 25 mg for nausea and vomiting administered rectally. 12 delivered.Review of Patient Coordination Note report on 4/23/25 6:36 pm Family/caregiver called and reported pain not controlled with pain medications-waited 3 hours between doses of hydromorphone. Instructed to give as ordered to ensure pain control.Review of Patient Coordination Note report on 4/23/25 10:32 pm 2nd call from Family/caregiver reporting pain not controlled with max ordered dose of hydromorphone and Fentanyl patch as prescribed. Patient #51 moaning and unable to verbalize level of pain level. Family/caregiver request prn visit to assist with pain management.Record review PRN skilled nurse visit note by RN C on 4/23/25 11:36 pm due to uncontrolled pain. Patient #51 grimacing, tense with restlessness but unable to verbalize level of pain. No bowel movement in 3 days. Order received for bisocodyl suppository for daily prn constipation. Family/caregiver administered 1 bisocodyl suppository. Family/caregiver attempted to administer hydromorphone but Patient refused hydromorphone at that time. 24 ml hydromorphone remaining. Review of Hospice IDG Comprehensive Assessment and Plan of Care Update included an order for Bisocodyl suppository 1 rectally every day prn nausea and vomiting. Order signed by Physician J. Record review of Skilled nursing visit note by RN B on 4/24/25 3:24 pm. Patient #51 verbalized pain. 2 ml hydromorphone administered during visit. 27 ml hydromorphone remaining.  Review of Patient Coordination Note report on 4/25/25 5:01 am Family/caregiver called reporting uncontrolled pain, last dose of hydromorphone 2.2 ml administered 30 minutes ago. Patient #51 currently moaning in pain. Review of Patient Coordination Note report on 4/25/25 6:02 am PRN Skilled nurse visit by RN D due to restlessness due to pain and vomiting blood. Patient #51 resting with no pain at time of visit. No documentation of remaining hydromorphone. Record review of Pharmacy F invoice indicated on 4/25/25 10:34 am Pharmacy F delivered 30 ml hydromorphone 1mg/ml. Record review…4/25/25 4:30 pm Skilled nurse visit by RN B. No pain assessed at time of visit. 24 ml hydromorphone remaining.  Record review of Skilled nursing visit note by RN A on 4/26/25 1:27 pm. No pain assessed at time of visit. 20 ml of hydromorphone remaining. (20 ml at 2 ml an hour will last 10 hours.) Review of Patient Coordination Note report on 4/27/25 8:20 am Family/caregiver called and requested refill on hydromorphone and promethazine suppositories. Family/caregiver denied need for visit at this time. 2 doses left at this time. Review of Patient Coordination Note report on 4/27/25 10:10 am Family/caregiver called to follow up on refill request Review of Patient Coordination Note report on 4/27/25 12:38 pm Family/caregiver called and complained related to medication refills.Review of Patient Coordination Note report on 4/27/25 12:55 pm family friend reported Patient passed away.4/27/25 13:10 Skilled nurse visit by RN B-pronounced Patient #51 deceased at 13:10 pm. Controlled medications and amounts that were disposed of not documented. 10/21/25 1:10 pm The surveyor interviewed Family/caregiver of Patient #5. The Family/caregiver said, “The weekend Patient #51 passed, the weekend nurse (RN A) was horrible. RN A said he (Patient #51) was on the max dose of pain medication but the nurse on Friday didn’t say that. The surveyor asked had she called the agency and complained to anyone. Family/caregiver said, “I called the day Patient #51 passed away and complained to the answering service. Patient #51 was out of pain medication. I called 2 or 3 times. A friend that was there got on the phone the last time and told them to find out something and call back in 10 minutes. Patient #51 died a few minutes later. He (Patient #51) was dying and I (Family/caregiver) was on the phone. He (Patient #51) was facing away from me, so I (Family/caregiver) didn’t get to be where he could see me when he (Patient #51) passed away. When Family/caregiver first asked about continuous care, Family/caregiver was told Patient #51 didn’t qualify at the time. Family/caregiver was told it was for when Patient #51’s pain or something was not being managed. I (Family/caregiver) called the agency 3 nights in a row, maybe not in a row. I (Family/caregiver) would have to call because I (Family/caregiver) could not get his (Patient #51’s) pain under control. They (agency nurses) would come out for 10 minutes maybe. Family/caregiver just thought they (the nurses) would take care of things and order the meds when he needed more but I  (Family/caregiver) was having to track it and ask for it. The weekend nurse (RN A), I (Family/caregiver) couldn’t understand her. Patient #51 ran out of pain medication for a day and a half when he was first admitted because they ordered injectable instead of by mouth like the doctor ordered. I (Family/caregiver ) had to call multiple times about his (Patient #51’s) pain medication. The manager (Alternate Supervising Nurse called me in May and apologized. She (Alternate Supervising Nurse) told me she saw multiple failures that should not have happened. The surveyor asked did she (Family/caregiver) remember the manager’s name. Family/caregiver said, “The Alternate Supervising Nurse, I think.” 10/23/25 11:00 am An interview was conducted with the Alternate Administrator and the Alternate Supervising Nurse. The Surveyor reviewed the complaint log findings that indicated someone complained that Patient #51 ran out of medications the same day he (Patient #51) passed away. The Alternate Supervising Nurse said, “ The family/caregiver complained.” The surveyor asked what Family member/caregiver member complained about Patient #51 running out of medications. The Alternate Supervising Nurse said, “She (Family/caregiver) was about to run out of pain medication for Patient #51 and had to step out of the room with Patient #51 to call us and she didn’t think she should have had to call again.” Surveyor reviewed skilled nurse’s note for Patient #51 signed by RN A on 4/26/25 with the Alternate Admin and Alt Supervising Nurse during the interview. Surveyor noted that RN A documented that the amount of pain medication, hydromorphone, was 20 ml on 4/26/25 skilled nurse visit. The current dosage was 2 ml every hour prn pain. That was enough to last 10 hours. The visit was made on 4/26/24 started at 1:27 pm. The Patient did not have enough hydromorphone to last until the next day.  The Alternate Administrator said, “The nurse should have ordered more.” The Alternate Supervising Nurse said, “By the time I was notified of the situation, it was too late. My suggestion would have been to order the morphine STAT.” The surveyor asked why the morphine was not ordered when RN A made a visit on 4/26/25. The Alternate Supervising Nurse said, “I don’t know.” The Alternate Administrator said, “I don’t know.” The surveyor asked how neglecting to order pain medications timely affect the Patient’s. The Alternate Administrator said, “The Patient has a right to as painless a death as possible.” The Alternate Supervising Nurse said, “Everything we do up to that point is in vain if we don’t provide comfort at the end.” The Alternate Supervising Nurse went on to say, “I called the Family/caregiver and told her that I had investigated and found some failures that should not have happened.” On 10/23/25 1:10 pm An interview was conducted with RN A. The Surveyor reviewed visit note for 4/26/25 for Patient #51 in that RN A documented only 20 ml of morphine remained but there was no documentation for re-ordering hydromorphone. RN A said, “I thought I ordered it on 4/26/25. Surveyor reviewed RN A’s that her visit note for the visit did not contain any documentation of her ordering more and the chart failed to contain any documentation that RN A had ordered any medication on 4/26/25. RN A asked, “Must I document that on my note?” Surveyor asked where her evidence of her visit and findings were documented. RN A said, “in my note.” Surveyor asked RN A how she decided when to re-order a medication. RN A said, “I review the medications every visit, to see if they (the Patient) needed more.” Surveyor asked What was the agency’s policy for when to order refills. RN A said, “I’m not sure.” The surveyor asked how could the Patient be affected if the nurse neglected to order pain medications timely. RN A said, “That would not be following the plan of care or providing comfort to the Patient.” Agency policy: Patient Bill of Rights Policy No. 2-002 revised 10.23.25 read in part…”PURPOSE To encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning…PROCEDURE 1. The Patient Bill of Rights and Responsibilities defines the right of the patient to:… e. Patients have the right to receive effective pain management, ….be free from mistreatment, neglect or verbal, mental, sexual, physical abuse”…

Upon patient record review 1 of 19 records (Patient #19) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #19: The patient was admitted on 11/19/22. The record indicated that the spiritual assessment was completed on 11/30/22.

Upon patient record review 1 of 19 records (Patient #16) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #16: There was not evidence of a spiritual assessment.

Upon patient record review, 4 of 19 records (Patient #3,#4,#10,#11) 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 record indicated for oxygen 2-4L/min prn without evidence of a route. In addition, Miralax 17 GM oral powder daily without evidence of a diluent. Corrected on site Patient #4: The record indicated for oxygen 2-5L/min prn without evidence of a route. Corrected on site. Patient #10: The record indicated Acetaminophen 650mg rectal supp, 1 q4h prn mild pain or fever. There was not evidence of a parameter for the fever. Corrected on site. Patient #11: The record indicated Acetaminophen 650mg rectal supp, 1 q4h prn mild pain or fever. There was not evidence of a parameter for the fever. Corrected on site.

Upon patient record review, 2 of 19 records (Patient #9,#19) 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 #9: The patient was admitted on 2/16/23. The record indicated that the bereavement assessment was completed on 3/3/23. Patient #19: The patient was admitted on 11/19/22. The record indicated that the bereavement assessment was completed on 11/30/22.

Upon patient record review, 1 of 19 records (Patient #12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #12: The patient was admitted with a diagnosis of hypertensive heart disease and chronic kidney disease. There was not evidence that the hospice has developed an individualized written plan of care that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments for the patient's cardiac disease and problems. Corrected on site.

Upon patient record review, 4 of 19 records (Patient #3,#4,#10,#11) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3: The record indicated an order for oxygen 2-4L/min prn without evidence of a route. Corrected on site. In addition, Miralax 17 GM oral powder daily without evidence of a diluent. Corrected on site. Patient #4: The record indicated an order for oxygen 2-5L/min prn without evidence of a route. Corrected on site. Patient #10: The record indicated Acetaminophen 650mg rectal supp, 1 q4h prn mild pain or fever. There was not evidence of a parameter for the fever. Corrected on site. Patient #11: The record indicated Acetaminophen 650mg rectal supp, 1 q4h prn mild pain or fever. There was not evidence of a parameter for the fever. Corrected on site.

Upon client record review, 4 of 19 records (Patient #1,#2,#4,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The initial plan of care indicated, 'Respiratory Therapist to evaluate and set up plan of care.' There was not evidence of an evaluation by a respiratory therapist. Corrected on site. Patient #2: The skilled nurse visit frequency was 1w1, 2w12. For the week of 3/19/23-3/25/25, the record indicated only 1 visit on 3/20/23 and for the week of 4/9/23-4/15/23, the record indicated only 1 visit on 4/10/23. Corrected on site. Patient #4: The spiritual care counselor visit frequency was for an evaluation then 1 every 2m2 effective 2/10/23. The record indicated an evaluation on 2/15/23 then 2 routine visits on 3/22/23 and 4/22/23. Corrected on site. Patient #7: The record indicated that the skilled nurse conducted telehealth visits on 3/16/23 and 3/21/23. There was not evidence that telehealth was a part of the plan of care. Corrected on site.

Upon observation, and record review, 1 of 19 records (Patient #15) did not contain evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. The record indicated in nurse documentation dated 2/6/23 that the patient/caregiver was upset because the nurse did not make a visit the prior week (due to road conditions). He had a nurse friend come to his home and take his BP which she told him was high and to take another Losartan. (Ordered dosage was 100mg, 1 tab daily). There was not evidence of an occurrence report regarding the medication error. Corrected on site.

Upon medical record review, 1 of 19 records (Patient #4) did not contain evidence that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family's desires which include: • Providing spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service and in a manner consistent with their beliefs and desires • Making all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of their ability Patient #4: The chaplain evaluation/assessment indicated that the patient requested connecting with his Parrish. The spiritual care counselor documented that he would begin to work on this. There was not evidence of follow up by the spiritual care counselor. Corrected on site.

Upon patient record review 5 of 19 patients (Patient #4,#7,#9,#10,#13) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #4: The aide plan of care indicated to shave weekly. The aide visit frequency was 5x/week and decreased to 3x/week on 3/10/23. The record indicated that this task was performed at most all visits. Patient #7: The aide plan of care indicated to provide hair care the first visit of the week. The aide visit frequency was 3x/week. The record indicated that hair care was provided at all visits since February. Patient #9: The aide visit frequency was 3x/week . For the weeks of 3/19/23-3/25/23 and 3/26/23-4/1/23, the record indicated only 2 visits each of these weeks. Corrected on site. Patient #10: The visit frequency for the aide was 3w1, 5w12. The patient was admitted on 2/21/23. The record indicated only 2 visits for the first week (2/23/23 and 2/24/23). For the weeks of 3/12/23- 3/18/13 and 3/19/23-3/25/23, the record indicated only 4 visits each of these weeks with no evidence of missed visit documentation. Corrected on site. Patient #13: The aide plan of care indicated to provide nail care and shampoo weekly. The record indicated that nail care was provided at each visit (5x/week) and a shampoo was provided 3x/week with a shower.

Upon patient client record review, 1 of 19 records (Patient #6) did not have evidence that each patient record contains Advance Directives. Patient #6: The admission legal documentation indicated that the patient had an advance directive The initial plan of care and subsequent updates to the plan of care all indicated that there was not an advance directive. Corrected on site. (The agency discovered the AD)

Upon client record review, 1 of 19 records (Patient #9) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #9: The record indicated a visit frequency for the volunteer at 1x/week to start 2/27/23. There was not evidence of a visit for the week of 3/5/23-3/11/23. In addition, the spiritual care counselor visit frequency for the benefit period 2/16/23-4/16/23 was for an evaluation and then 2 every 2m2. The record indicated that the evaluation was performed on 2/20/23 and subsequent routine visits were conducted on 3/3/23, 3/15/23, and 4/11/23. Also, the social worker visit frequency for the benefit period 2/16/23-4/16/23 was for an evaluation and then 2 every 2m2. The record indicated that the evaluation was performed on 2/20/23 and subsequent routine visits were conducted on 3/17/23, 3/31/23, and 4/10/23. Corrected on site.