Every finding on record at North Carolina In-Home Partner-IV, LLC

Based on agency policy, clinical record review, and staff interviews, the agency failed to update the plan of care goals with each new episodes of care for 3 of 3 records [# 17, 18, and 19] reviewed. The findings included: --- The policy, Interdisciplinary Group [IDG] Membership and Responsibilities [revised 2/1/25], was provided by the office manager on 3/2/26 at 1 pm. The policy stated, “...The hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized plan of care...The responsibilities include but are not limited to...Reviewing, revising, and documenting the individualized plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 days...”1. Patient # 17 had a Start of Care [SOC] date of 5/30/25 with a terminal diagnosis of basal cell carcinoma of skin [skin cancer] and malignant neoplasm of maxillary sinus [sinus cancer]. Review of the Plan of Care [POC] for the certification period 1/25/26-3/25/26 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week; hospice aide 1 time a week for 8 weeks; MSW [medical social worker] 1 time a month for 3 months; Chaplin 1 time a month for 1 month, 2 times a month for 2 months. Review of the Plan of Care goals for the period 1/25/26-3/25/26 revealed the same goals as the SOC POC to include, “Within one week of hospice admission, patient/caregiver will verbalize understanding of hospice services, hospice philosophy, care for the hospice patient, and the ability to contact hospice agency 24 hours a day, 7 days a week...Patient/caregiver will verbalize/demonstrate understanding of medications within 48 hours of admission to hospice services...Patient will demonstrate an increased in interest in socialization and activities by 12/1/25...”2. Patient # 18 had a Start of Care [SOC] date of 12/3/25 with terminal diagnoses of COPD [chronic obstructive pulmonary disease-lung condition] and neoplasm of lung [cancer]. Review of the Plan of Care [POC] for the certification period 2/1/26-4/1/26 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 1 time a week for 9 weeks; MSW [medical social worker] 1 time a month for 2 months; Chaplin 1 time a month for 2 months. Review of the Plan of Care goals for the period 2/1/26-4/1/26 revealed the same goals as the SOC POC to include, “...Patient/caregiver will verbalize/demonstrate understanding of medications within 48 hours of admission to hospice services...”3. Patient # 19 had a Start of Care [SOC] date of 8/11/25 with a terminal diagnosis of antineutrophilic cytoplasmic antibody [autoantibodies that attack neutrophils, causing them to damage small blood vessels and leading to systemic vasculitis- a group of rare diseases characterized by inflammation of blood vessels, leading to narrowing, weakening, or scarring that restricts blood flow and damages tissues/organs]. Review of the Plan of Care [POC] for the certification period 2/7/26-4/7/26 included order for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a month for 1 week; MSW [medical social worker] 1 time every 2 months for 2 months, 1 time a month for 1 month. Review of the Plan of Care goals for the period 2/7/26-4/7/26 revealed the same goals as the SOC POC to include, “Within one week of hospice admission, patient/caregiver will verbalize understanding of hospice services, hospice philosophy, care for the hospice patient, and the ability to contact hospice agency 24 hours a day, 7 days a week...Patient/caregiver will verbalize/demonstrate understanding of medications within 48 hours of admission to hospice services...”During an interview with the agency administrator on 3/4/26 at approximately 11:30 am, it was confirmed the agency failed to update the plan of care goals accordingly.

Based on agency policy, clinical record review and staff interviews the MSW [medical social worker] failed to project visit projections for the next 15 days for 17 of 22 records [# 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, and 22] reviewed with MSW orders; and the Chaplin failed to project visit frequencies for the next 15 days for 15 of 22 records  [# 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 17, 18, 20, and 21] reviewed with Chaplin orders. --- The policy, Interdisciplinary Group [IDG] Membership and Responsibilities [revised 2/1/25], was provided by the office manager on 3/2/26 at 1 pm. The policy stated, “...The hospice IDG collaborates with the patient’s attending physician to develop and maintain a patient-directed, individualized plan of care...The responsibilities include but are not limited to...Reviewing, revising, and documenting the individualized plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 days...”1. Patient # 4 had a Start of Care date 1/28/26 with a terminal diagnosis of protein calorie malnutrition. Review of the Plan of Care for the certification included orders for SN [skilled nursing] 3 times a week for 13 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 1 month; Chaplin 1 time a month for 4 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed an IDG meeting was conducted on 2/4/26 [the patient expired on 2/8/26]. Review of the IDG minutes for the 2/4/26 meeting revealed no visit projections for the next 15 days from the MSW or the Chaplin.2. Patient # 5 had a Start of Care date of 2/4/26 with a terminal diagnosis of COPD [chronic obstructive pulmonary disease-lung condition]. Review of the Plan of Care for the certification period 2/4/26-5/4/26 included orders for SN [skilled nursing]  3 times a week for 13 weeks, 1 time a week for 1 week; hospice aide 2 times a week for 1 week, 5 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social worker] 2 times a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were conducted on 2/11/26 and 2/18/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.3. Patient # 6 had a Start of Care date of 1/24/26 with a terminal diagnosis of unspecified severe protein calorie malnutrition [the body does not take in enough calories/nutrients to sustain itself]. Review of the Plan of Care for the certification period 1/26/26-4/3/26 included orders for SN [skilled nursing] 1 time a week for 1 week; MSW [medical social worker 1 time a month for 1 month; Chaplin 1 time a month for 1 month. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were conducted 1/28/26, 2/11/26, and 2/25/26. Review of the IDG minutes revealed no visit projection plans for the next 15 days by the MSW or the Chaplin for the 2/11/26 or 2/25/26 meetings.4. Patient # 7 had a Start of Care date of 1/7/26 with a terminal diagnosis of hypertensive heart disease with heart failure [heart does not pump effectively]. Review of the Plan of Care for the certification period 1/7/26-4/8/26 included orders for SN [skilled nursing] 2 times a week for 13 weeks; MSW [medical social worker] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were conducted on 1/14/26, 1/28/26, and 2/11/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.5. Patient # 9 had a Start of Care date of 2/12/26 with a terminal diagnosis of breast cancer and lung cancer. Review of the Plan of Care for the certification period 2/12/26-5/12/26 included orders for SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 12 weeks; hospice aide 3 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 1 month; Chaplin 1 time a month for 4 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed an IDG meeting was conducted on 2/18/26. Review of the IDG minutes revealed no visit projection plans for the next 15 days by the MSW or the Chaplin.6. Patient # 10 had a Start of Care date of 1/12/26 and a terminal diagnosis of end-stage malignant neoplasm of the pancreas [cancer]. Review of the Plan of Care for the certification period 1/12/26-4/11/26 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 12 weeks; hospice aide 2 times a week for 13 weeks; MSW [medical social worker] 1 time a month for 4 months; Chaplin 1 times a month for 4 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 1/14/26, 1/21/26, 2/4/26 and 2/18/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.7. Patient # 11 had a Start of Care date of 2/11/26 with a terminal diagnosis of Alzheimer’s Disease. Review of the Plan of Care for the certification period 2/11/26-5/11/26 included orders for SN [skilled nursing] 2 times a week for 13 weeks; MSW [medical social worker] 1 time a month for 4 months; Chaplin 2 times a month for 1 month, 1 time a month for 1 month. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were conducted on 2/18/26 and 2/25/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin. 8. Patient # 12 had a Start of Care date of 1/21/26 with a terminal diagnosis of liver cell carcinoma [cancer]. Review of the Plan of Care for the certification period 1/21/26-4/20/26 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 4 months; Chaplin 2 times a month for 2 months, 1 time a month for 1 month. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 1/28/26, 2/4/26, and 2/18/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.9. Patient # 13 had a Start of Care date of 1/29/26 with a terminal diagnosis of protein calorie malnutrition [body does not take in enough calories or nutrients to sustain life]. Review of the Plan of Care for the certification period 1/29/26-4/28/26 included orders for SM [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 1 week; hospice aide 1 time a week for 1 week, 2 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were conducted on 2/4/26, 2/11/26, and 2/25/26.  Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.10. Patient # 14 had a Start of Care date of 2/3/26 with a terminal diagnosis of neoplasm of right upper lobe [lung cancer]. Review of the Plan of Care for the certification period 2/3/26-5/5/26 included orders for SN [skilled nursing 3 times a week for 1 week, 2 times a week for 12 weeks; MSW [medical social worker] 3 times a month for 1 month, 1 time a month 2 months; Chaplin 2 times a month 3 month. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 2/11/26 and 2/25/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.11. Patient # 15 had a Start of Care date of 1/30/26 with a terminal diagnosis of senile degeneration of the brain [a progressive, age-related deterioration of mental ability]. Review of the Plan of Care for the certification period 1/30/26-5/1/26 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 2/4/26 and 2/18/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.12. Patient # 17 had a Start of Care date of 5/30/25 with a terminal diagnosis of basal cell carcinoma of skin [skin cancer] and malignant neoplasm of maxillary sinus [sinus cancer]. Review of the Plan of Care for the certification period 1/25/26-3/25/26 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week; hospice aide 1 time a week for 8 weeks; MSW [medical social worker] 1 time a month for 3 months; Chaplin 1 time a month for 1 month, 2 times a month for 2 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 1/28/26, 2/11/26, and 2/25/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.13. Patient # 18 had a Start of Care date of 12/3/25 with terminal diagnoses of COPD [chronic obstructive pulmonary disease-lung condition] and neoplasm of lung [cancer]. Review of the Plan of Care for the certification period 2/1/26-4/1/26 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 1 time a week for 9 weeks; MSW [medical social worker] 1 time a month for 2 months; Chaplin 1 time a month for 2 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 2/11/26 and 2/25/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.14. Patient # 19 had a Start of Care date of 8/11/25 with a terminal diagnosis of antineutrophilic cytoplasmic antibody [autoantibodies that attack neutrophils, causing them to damage small blood vessels and leading to systemic vasculitis- a group of rare diseases characterized by inflammation of blood vessels, leading to narrowing, weakening, or scarring that restricts blood flow and damages tissues/organs]. Review of the Plan of Care for the certification period 2/7/26-4/7/26 included order for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a month for 1 week; MSW [medical social worker] 1 time every 2 months for 2 months, 1 time a month for 1 month.  Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 2/11/26 and 2/25/26. Review of the IDG minutes revealed no visit projection plans for the next 15 days by the MSW.15. Patient # 20 had a Start of Care date of 2/4/26 with a terminal diagnosis of cerebral atherosclerosis [the buildup of plaque—cholesterol, fat, and calcium—within the artery walls in the brain]. Review of the Plan of Care for the certification period 2/4/26-5/13/26 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 1 month, 2 times a month for 1 month; Chaplin 1 time a month for 4 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 2/11/26 and 2/18/26. Review of the IDG minutes for the meeting dates revealed no visit projections for the next 15 days from the MSW or the Chaplin.16. Patient # 21 had a Start of Care date of 2/17/26 with a terminal diagnosis of atherosclerosis heart disease [plaque buildup in arterial walls]. Review of the Plan of Care for the certification period 2/17/26-5/17/26 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 12 weeks; MSW [medical social worker] 1 time a month for 2 months, 2 times a month 1 month; Chaplin 1 time a month for 4 months.  Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed an IDG meeting was conducted on 2/25/26. Review of the IDG minutes for that meeting date revealed no visit projections for the next 15 days from the MSW or the Chaplin.17. Patient # 22 had a Start of Care date of 12/18/25 with a terminal diagnosis of multiple myeloma [blood cancer]. Review of the Plan of Care for the certification period 12/18/25-3/17/26 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 4 months. Review of the IDG [Interdisciplinary Group - team of professionals responsible for the holistic care of the hospice patient and their family] Summary Report revealed IDG meetings were on 12/24/25, 1/7/26, 1/21/26, 2/4/26, and 2/18/26. Review of the IDG minutes revealed no visit projection plans for the next 15 days by the MSW.An interview was conducted with the MSW and the Chaplin on 3/4/26 at approximately 3 pm. During the interview, it was confirmed the visit frequencies where not projected for the next 15 days during IDG.

Based on policy review, clinical record review and staff interview, the agency failed to complete a spiritual assessment within five days for 2 of 14 current patients (#10 and 13). Findings included: --- 2. Patient #13 had a Start of Care of 01/29/23 with diagnoses of emphysema (lung disease), hypertensive heart disease, heart failure, and acute and chronic respiratory failure. The Plan of Care for certification period of 01/29/23 to 04/28/23 included orders for skilled nursing 2 times a week for 13 weeks, home health aide 1 time a week for 1 week, 2 times a week for 12 weeks, chaplain 1 month 1, and medical social work 1 month 1. Review of the clinical record revealed the start of care was completed on 01/29/23 by the skilled nurse. The chaplain assessment was completed on 02/06/23 8 days after the start of care on 01/29/23. The election of hospice care was signed on 01/29/23. Interview with the chaplain on 3/22/23 at 11:37 a.m. revealed, ";I dont have a note of the delay". Interview with the director on 03/22/23 at 11:40 a.m. revealed, ";If the chaplain is off the nurse will do the spiritual assessment." The nurse did not do the spiritual assessment per director on 3/22/23 at 11:41 a.m. A policy, ";Initial & Comprehensive Assessment & Plan of Care" (revised 4/1/22), was provided by the office manager on 3/22/23 at 11:17 a.m. The policy stated, ";The comprehensive assessment will be completed no later than 5 calendar days after the date of election of hospice services...and includes a thorough assessment of the patient's physical, psychosocial, emotional, and spiritual status related to the terminal illness and related conditions and the caregivers and familys willingness and capability to care for the patient...The Chaplain will complete the spiritual evaluation identifying goals and interventions needed no later that 5 days after the date of hospice election as part of the comprehensive assessment." 1. Patient #10 was admitted on 1/30/23 with a diagnosis of chronic obstructive pulmonary disease (COPD—respiratory disease). The Plan of Care for 1/30/23-4/29/23 included orders for skilled nursing weekly for 13 weeks, medical social worker evaluation, and chaplain evaluation. The nursing completed the initial assessment on 1/30/23. The medical social worker completed the initial evaluation on 2/2/23. There was no evidence a spiritual assessment was conducted within the five-day required timeframe. The chaplain conducted the spiritual assessment on 2/6/23. An interview with the chaplain on 3/22/23 at 11:47 a.m. revealed the chaplain was off the previous week. An interview with the executive director on 3/22/23 at 11:47 a.m. confirmed the spiritual assessment was not conducted until 3/22/23.

Based on clinical record review and staff interviews the agency failed to provide hospice aide visits in accordance with the Plan of Care for 1 of 9 patients with aide services [#14]. The findings included: --- Patient # 14 had a Start of Care date of 9/13/22 with a terminal diagnosis of nonrheumatic aortic valve stenosis [aortic valve in the heart becomes narrowed or blocked]. Review of the Plan of Care for the certification period 12/12/22 to 3/11/23 included orders for SN [skilled nursing] 1 time a week for 13 weeks, 3 PRN [as needed] for change in condition. Review of the clinical record revealed a supplemental order was written on 1/3/23 for hospice aide to assist with bathing 2 times per week. On 1/13/23, an order was written to decrease hospice aide services to 1 time per week. A third order was written on 1/24/23 to discontinue the hospice aide. Further review of the clinical record revealed no aide visit was attempted until 1/18/23 when the aide documented the patient refused the aide visit. An interview was conducted with the aide on 3/22/23 at approximately 10:30 am. During the interview the aide stated, ";I went out to the house and met with the patient and the wife. I told them what services I could provide, and they decided they didnt need me. I told the nurse. I dont know why the order wasnt discontinued until 1/24/23. During an interview with the agency director on 3/22/23 at approximately 10:15 am, the director stated, ";I know he was refusing visits, I dont know where the missed visits or the documentation related to his refusals are".

Based on clinical record review, home visits and staff interviews the Plan of Care failed to include current medications for 1 of 4 patients receiving a home visit [#12]. The findings included: --- Patient # 12 had a Start of Care date of 1/8/23 with a terminal diagnosis of sepsis [infection in the blood stream]. Review of the Plan of Care for the certification period 1/8/23 to 4/7/23 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 11 weeks, 1 time a week for 1 week, 3 PRN [as needed] changes in condition; MSW [medical social worker] 2 times a month for 2 months. On 3/21/23 at approximately 1 pm a joint visit was made with the MSW to the skilled nursing facility [SNF] where the patient resided. A medication review was conducted during the visit using a medication profile provided by the agency and the medication administration record provided by the SNF. The following discrepancy was noted: Ativan [used for anxiety] 0.5 mg tablet. Take 1 tablet every 6 hours as needed for anxiety was listed on the agency medication profile but was not listed on the SNF medication administration record. During an interview with RN # 1 on 3/22/23 at approximately 9:15 am, the RN stated, ";The facilitys record should match the med profile."

Based on policy review, clinical record review, and staff interview, the agency failed notify the patient/caregiver the hospice aide service was discontinued due to staffing for 2 of 8 patients with hospice aide services (#8 and 4). Findings included: --- 2. Patient # 4 had a Start of Care date of 4/3/21 with a terminal diagnosis of traumatic subarachnoid hemorrhage [bleeding in the space between the brain and the tissue covering the brain]. Review of the Plan of Care for the certification period 1/23/23 to 3/23/23 included orders for SN [skilled nursing] 1 time a week for 8 weeks, 3 PRN [as needed] for changes in condition; hospice aide 2 times a week for 8 weeks, 1 time a week for 1 week. Review of the clinical record revealed an order dated 2/17/23 to ";Decrease HHA [hospice aide] visits to once weekly". A second order was noted on 3/6/23 to ";Discontinue HHA visits at this time due to staffing". Further review of the clinical record revealed no evidence the patients family was consulted prior to the change in the plan of care. During an interview with RN # 1 on 3/22/23 at approximately 9:50 am, RN # 1 confirmed the family was not notified of the change in the plan of care. A policy, ";Coordination of Care from Admit through Discharge" (revised 8/1/19), was provided by the executive director on 3/20/23 at 1:55 p.m. The policy stated, ";Written information obtained from the plan of care will be provided to the patient and caregiver outlining...Visit schedule including frequency of visit by agency staff...Ongoing the patient/caregiver will be notified of...Changes to the plan of care..." 1. Patient #8 was admitted on 10/23/21 with a diagnosis of Alzheimer's disease. The Plan of Care for 2/15/23-4/15/23 included orders for skilled nursing weekly for nine weeks; and hospice aide one time for one week, then twice weekly for eight weeks. On 2/23/23, a ";Client Care Coordination Note" stated that the aide missed a visit on 2/16/23 due to ";staff emergency/illness." On 3/2/23, a ";Client Care Coordination Note" stated that the aide missed a visit on 2/28/23 due to ";staff emergency/illness." On 3/3/23, a ";Client Care Coordination Note" stated that the aide missed a visit on 2/24/23 due to ";staff emergency/illness." On 3/6/23, an order was received to ";Discontinue HHA (hospice aide) visits for now due to staffing." On 3/22/23 at 9:18 a.m., an interview was conducted with RN #1. The RN revealed she had notified the caregiver that the aide services was discontinued. The RN confirmed there was no evidence in the clinical record the caregiver was notified.

Based on policy review, clinical record review and staff interview, the medical social worker failed to project visit frequency for the upcoming 15-day period for 12 of 15 patients receiving MSW services (#1, 3, 9, 13, 16, 4, 5, 7, 12, 14, 2, and 10); and the chaplain failed to project visit frequency for the upcoming 15-day period for 12 of 14 patients receiving spiritual care services (#1, 3, 9, 13, 4, 5, 7, 12, 14, 2, 10, and 8). Findings included: --- 11. Patient #2 was admitted on 1/20/23 with diagnosis of liver cell carcinoma. The Plan of Care (POC) for 1/20/23-4/19/23 included orders for medical social work services one time for one month, then twice monthly for three months. Between 1/25/23-3/15/23, there were no projections for medical social work visit frequency for the upcoming 15 days for 3 of 4 Interdisciplinary Group Meetings. 12. Patient #10 was admitted on 1/30/23 with a diagnosis of chronic obstructive pulmonary disease (COPD—respiratory disease). The Plan of Care for 1/30/23-4/29/23 included orders medical social worker twice monthly. Between 2/8/23-5/15/23, there were no projections for medical social worker visits for 3 of 3 Interdisciplinary Group Meetings. The POC also included orders for chaplain two times per month for three months. Between 2/8/23-5/15/23, there were no projections for chaplain visits for 3 of 3 Interdisciplinary Group Meetings. 13. Patient #8 was admitted on 10/23/21 with a diagnosis of Alzheimer's disease. The Plan of Care for 2/15/23-4/15/23 included orders for chaplain services every two months for two months, then monthly for one month. Between 2/22/23-3/15/23, there were no projections for chaplain visit frequency for the upcoming 15 days for 3 of 3 Interdisciplinary Group Meetings. An interview with the medical social worker on 3/22/23 at 11:40 a.m. confirmed there were no visit projections made. An interview with the chaplain on 3/22/23 at 11:44 a.m. confirmed there were no visit projections made. 6. Patient # 4 had a Start of Care date of 4/3/21 with a terminal diagnosis of traumatic subarachnoid hemorrhage [bleeding in the space between the brain and the tissue covering the brain]. Review of the Plan of Care for the certification period 1/23/23 to 3/23/23 included orders for SN [skilled nursing] 1 time a week for 8 weeks, 3 PRN [as needed] for changes in condition; hospice aide 2 times a week for 8 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 2 month, 2 PRN for urgent psychosocial needs; Chaplain 2 times a month for 2 months, 2 PRN for urgent spiritual care needs. The patient was discussed in IDG [interdisciplinary group] meetings on 2/1/23, 2/15/23, 3/1/23 and 3/15/23. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report revealed no visit projections from the MSW or Chaplin for the next 15 days for any of the IDG meeting dates. 7. Patient # 5 had a Start of Care date of 5/27/22 with a terminal diagnosis of alcoholic cirrhosis [advanced stage of liver failure that causes liver to become scarred and swollen]. Review of the Plan of Care for the certification period 1/22/23 to 3/22/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 3 PRN [as needed] for changes in condition; Chaplain 2 times a month for 2 months; MSW [medical social worker] monthly phone visits for 2 months. A supplemental order was written on 2/6/23 for MSW visits with a frequency of 4 times a month for 1 month, 3 times a month for 1 month. The patient was discussed in IDG [interdisciplinary group] meetings on 1/25/23, 2/8/23, 2/22/23, 3/8/23 and 3/15/23. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report revealed no visit projections for the next 15 days from the chaplain for any of the IDG meeting dates. The MSW had no visit projections for the next 15 days from 2/8/23-3/15/23. 8. Patient # 7 had a Start of Care date of 2/3/23 with terminal diagnoses of malignant neoplasm of lower lobe, right bronchus or lung [lung cancer] and secondary and unspecified malignant neoplasm of lymph node. Review of the Plan of Care for the certification period 2/3/23 to 5/3/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 12 weeks, 1 time a week for 1 week, 3 PRN [as needed] for change in condition; MSW [medical social worker] 2 times per month for 2 months; Chaplain 2 times a month for 2 months. The patient was discussed in IDG [interdisciplinary group] meetings on 2/8/23, 2/22/23, 3/8/23 and 3/15/23. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report revealed no visit projections from the MSW or Chaplin for the next 15 days for any of the IDG meeting dates. 9. Patient # 12 had a Start of Care date of 1/8/23 with a terminal diagnosis of sepsis [infection in the blood stream]. Review of the Plan of Care for the certification period 1/8/23 to 4/7/23 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 11 weeks, 1 time a week for 1 week, 3 PRN [as needed] changes in condition; MSW [medical social worker] 2 times a month for 2 months; Chaplain 2 times a month for 2 months. The patient was discussed in IDG [interdisciplinary group] meetings on 1/18/23, 2/1/23, 2/15/23, 3/1/23 and 3/15/23. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report revealed no visit projections from the MSW or Chaplin for the next 15 days for any of the IDG meeting dates. 10. Patient # 14 had a Start of Care date of 9/13/22 with a terminal diagnosis of nonrheumatic aortic valve stenosis [aortic valve in the heart becomes narrowed or blocked]. Review of the Plan of Care for the certification period 12/12/22 to 3/11/23 included orders for SN [skilled nursing] 1 time a week for 13 weeks, 3 PRN [as needed] for change in condition; MSW [medical social worker] 1 time a month for 3 months, 3 PRN urgent psychosocial needs; Chaplain 1 time a month for 1 month, 2 times a month for 2 months, 2 PRN urgent spiritual care needs. The patient was discussed in IDG [interdisciplinary group] meetings on 12/14/22, 12/21/22, 1/4/23, 1/11/23, 1/25/23, 2/8/23, 2/22/23 and 3/8/23. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report revealed no visit projections from the MSW or Chaplin for the next 15 days for any of the IDG meeting dates. Review of a policy ";Interdisciplinary Group Membership and Responsibility", revised 11/01/21 was received from the director of nursing on 03/20/23 at 1:55 p.m. The policy stated," ...reviewing, revising, and documenting the individualized plan of care as frequently as the patients condition requires, but no less frequently than every 15 calendar days..." 1. Patient #1 was admitted on 01/31/23 with diagnoses of amyotrophic lateral sclerosis (nervous system disease that weakens the muscles), iron deficiency anemia, GERD (gastro esophageal reflux disease), and depression. The Plan of Care for 01/31/23 -04/31/23 included orders for skilled nursing 1 time a week for 1 week, and 2 times a week for 8 weeks, medical social work 1 time a month for 2 months, and chaplain 2 times a month for 2 months. The IDG meetings between 02/15/23-03/15/23 did not include a projected individualized plan for the next 2 weeks for the medical social work or the chaplain for 2 of 2 meetings. 2. Patient #3 had a Start of Care date of 02/27/23 which included diagnoses of Progressive Supranuclear Opthalmoplegia (disorder that affects the way the brain controls movement), Parkinsons (a disorder of the nerves system that affects movement), Hyperlipidemia (high cholesterol), and Overweight. The Plan of Care for certification period 02/27/23 to 05/27/23 included orders for skilled nursing 2 times a week for 12 weeks, and 1 time a week for 1 week, home health aide 1 time a week for 1 week, 2 times a week for 11 weeks, and 1 time a week for 1 week, medical social work 1 time a month for 1 month, and chaplain 1 time a month for 1 month. The IDG meeting for 03/15/23 did not include a projected individualized plan for the next 2 weeks for the medical social work or the chaplain for 2 of 2 meetings. 3, Patient #9 was admitted on 02/10/23 with diagnoses of Parkinsons disease, abnormal weight loss, obstructive sleep apnea, and hypertensive kidney disease. Review of the Plan of Care for 02/10/23 to 05/10/23 had orders for skilled nursing 1 time a week for 1 week, and 2 times a week for 12 weeks, home health aide 2 times a week for 12 weeks, and 1 time a week for 1 week, medical social work 1 time a month for 1 month, and chaplain 1 time a month for 1 month. The IDG meeting for 03/15/23 did not include a projected individualized plan for the next 2 weeks for the medical social work or the chaplain for 1 of 1 meetings. 4. Patient #13 was admitted on 01/29/23 with diagnoses of emphysema (lung disease), hypertensive heart disease, heart failure, and acute and chronic respiratory failure. The Plan of Care for certification period of 01/29/23 to 04/28/23 included orders for skilled nursing 2 times a week for 13 weeks, home health aide 1 time a week for 1 week, 2 times a week for 12 weeks, chaplain 1 month 1, and medical social work 1 month 1. The IDG meetings between 02/22/23-03/15/23 did not include a projected individualized plan for the next 2 weeks for the medical social work or the chaplain for 2 of 2 meetings. 5. Patient #16 was admitted on 12/11/22 with diagnoses of unspecified severe protein calorie malnutrition, epilepsy (seizures), essential hypertension, and peripheral vascular disease. The Plan of Care for 12/11/22 to 03/10/23 had orders for skilled nursing 2 times a week for 1 week, 1 time a week for 12 weeks, and medical social work 1 time a month for 1 month. The IDG meeting for 01/11/23 did not include a projected individualized plan for the next 2 weeks for the medical social work. Interview with the director on 03/22/23 at approximately 11:40 a.m. confirmed the social work did not have projections for the next 2 weeks for IDG meetings.

Based on agency policy, clinical record review and staff interviews the agency failed to coordinate with the physician prior to advising patients caregiver to increase a medication/start using herbal tea for 1 of 4 patients who had a home visit [#14]; failed to coordinate with the physician related to an unwitnessed fall for 1 of 4 patients receiving a home visit [#14]; and failed to coordinate a Chaplain visit at request of the patient for 1 of 1 patients requesting a chaplain visit [#5]. The findings included: --- The policy, Coordination of Care, From Admit Through Discharge [8/2019], was provided by the executive director on 3/22/23 at 12:55 pm. The policy stated, ";...Coordination of care with physician...when changes occur in the patients condition...when there is a need to change the patients plan of care...Coordination of care among disciplines...Patient care is coordinated among various disciplines and services through care plan processes to ensure continuity of care...Appropriate, timely communication with the patient, caregivers, and staff..." 1A. Patient # 14 had a Start of Care date of 9/13/22 with a terminal diagnosis of nonrheumatic aortic valve stenosis [aortic valve in the heart becomes narrowed or blocked]. Review of the Plan of Care for the certification period 12/12/22 to 3/11/23 included orders for SN [skilled nursing] 1 time a week for 13 weeks, 3 PRN [as needed] for change in condition. Review of the clinical record revealed RN # 10 made a PRN [as needed] visit on 12/20/22 per the wifes request to assess the patient for a cough. RN # 10 documented the following information, ";...Clearly in distress...Patient states that his anxiety level is out of control...Patient wife [sic] states that she had talked to ______ [name of hospice nurse] about increasing Clonazepam [used for anxiety] to one and a half tablets twice a day. This RN advised wife to begin that regimen immediately...Also recommended Valerian Tea [herbal tea] at bedtime as needed for insomnia..." Further review of the clinical record revealed no evidence the physician was notified regarding the increase in the Clonazepam or the use of the herbal tea. RN # 10 was not available for interview. The executive director was interviewed on 3/22/23 at approximately 11 am. During the interview the executive director confirmed the physician was not notified prior to advising the wife to increase the Clonazepam or the use of herbal tea. 1B. Patient # 14 had a Start of Care date of 9/13/22 with a terminal diagnosis of nonrheumatic aortic valve stenosis [aortic valve in the heart becomes narrowed or blocked]. Review of the Plan of Care for the certification period 12/12/22 to 3/11/23 included orders for SN [skilled nursing] 1 time a week for 13 weeks, 3 PRN [as needed] for change in condition. Review of the clinical record revealed RN # 6 made a routine visit on 3/2/23 and documented the following information, ";...Pt [patient] has bruise at top of forehead froman [sic] unreported fall last week. No further injury related tofall [sic]..." Further review of the clinical record revealed no evidence the physician was notified of the fall. During an interview with RN # 6 on 3/22/23 at approximately 10:45 am, the RN confirmed the physician was not notified. ";I should have notified him, but I didnt. I dont know why I didnt." 2. Patient # 5 had a Start of Care date of 5/27/22 with a terminal diagnosis of alcoholic cirrhosis [advanced stage of liver failure that causes liver to become scarred and swollen]. Review of the Plan of Care for the certification period 1/22/23 to 3/22/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 3 PRN [as needed] for changes in condition; Chaplain 2 times a month for 2 months. Review of the clinical record revealed RN # 11 made a routine visit on 1/24/23. The RN documented Patient # 5 is declining, she has not ate [sic] in about 9 days...nurse asked patient if she would like a visit from the pastor [chaplain]. The patient shook her head yes..." Further review of the clinical record revealed no evidence the Chaplain was notified of the patients desire for a visit. A PRN visit was made Chaplain # 13 on 2/2/23 at the request of RN # 14. RN # 11 was not available for interview. An interview was conducted with the executive director on 3/22/23 at approximately 9:45 am. During the interview the executive director stated, ";The regular chaplain was out at that time. I have gone back to emails and notes, and I cant find where the RN notified the person filling in for the chaplain the patient wanted a visit."

Based on policy and procedure, clinical record review and staff interviews the agency failed to notify the physician of a fall for 1 of 17 records reviewed [#3]; and to measure wounds in accordance with the plan of care for 1 of 5 patients with a wound [#14]. The findings included: --- Patient # 14 had a Start of Care date of 9/13/22 with a terminal diagnosis of nonrheumatic aortic valve stenosis [aortic valve in the heart becomes narrowed or blocked]. Review of the Plan of Care for the certification period 12/12/22 to 3/11/23 included orders for SN [skilled nursing] 1 time a week for 13 weeks, 3 PRN [as needed] for change in condition. Review of the clinical record revealed Patient # 14 had a fall on 12/23/22. The following order was written on 12/23/22 ";RN/CG [caregiver] to cleanse scalp wound with wound cleanser. Apply steristrips [sic]. Cover with dry dressing. Change dry dressing daily and as needed for soiling or loosening. RN to measure [wound] weekly or as needed." Review of the clinical record revealed the wound was not measured the week of 12/25/22 or the week of 1/1/23. During an interview with the executive director on 3/22/23 at approximately 11:30 am, she confirmed the head wound was not measured in accordance with the plan of care. A policy, ";Coordination of Care from Admit to Discharge" revised 08/01/19 was provided by agency director on 03/20/23 at 1:55 p.m. stated, ";...significant changes in the patient condition i.e. (new or worsening symptoms, new or changed orders..." Patient #3 had a Start of Care date of 02/27/23 which included diagnoses of Progressive Supranuclear Opthalmoplegia (disorder that affects the way the brain controls movement), Parkinsons (a disorder of the nerves system that affects movement), Hyperlipidemia (high cholesterol), and Overweight. The Plan of Care for certification period 02/27/23 to 05/27/23 included orders for skilled nursing 2 times a week for 12 weeks, and 1 time a week for 1 week. A review of the skilled nursing visit on 03/06/23 revealed the patient reported a fall with a bruise to the temple. There was no evidence in the record that the skilled nurse communicated with the physician regarding the fall. Interview with the skilled nurse on 03/22/23 at 9:42 a.m. revealed, ";I was notified afterwards, so I didnt do a fall report, I thought the on-call nurse had already completed the fall report".

Based on agency policy, clinical record review and staff interviews the agency failed to complete a post death bereavement assessment and a bereavement Plan of Care for 1 of 3 bereaved charts reviewed [#17]. The findings included: --- The policy, Bereavement Assessment [3/1/21], was provided by the executive director on 3/22/23 at 1 pm. The policy stated, ";...After death occurs, the Bereavement Coordinator or designee will contact the bereaved to perform a bereavement risk assessment...The Bereavement Coordinator will develop a Plan of Care based on the needs and requests of the bereaved..." Patient # 17 had a Start of Care date of 1/22/22 with a terminal diagnosis of heart disease with heart failure [heart does not pump enough blood for the bodys needs]. Review of the clinical record revealed the patient died on 5/25/22. The initial bereavement assessment was conducted on 1/28/22. The risk level was determined to be moderate for the patients son/caregiver. Further review of the clinical record revealed no post death bereavement assessment or bereavement plan of care was completed. During an interview with the executive director on 3/21/23 at approximately 3 pm, the director stated, ";We must have missed that one. It was probably the time we were switching locations."

Based on policy review, clinical record review, and staff interview, the RN failed to complete a hospice aide care plan for 2 of 8 patients that received aide services (#2 and 12). Findings included: --- 2. Patient # 12 had a Start of Care date of 1/8/23 with a terminal diagnosis of sepsis [infection in the blood stream]. Review of the Plan of Care for the certification period 1/8/23 to 4/7/23 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 11 weeks, 1 time a week for 1 week, 3 PRN [as needed] changes in condition. Review of the clinical record revealed a supplemental order was written on 1/8/23 for hospice aide services weekly to assist with bathing. A second order was written on 1/18/23 to increase aide services to 2 times per week. The aide care plan was initiated on 1/8/23. The aide care plan called for ADL [activities of daily living-bathing and perineal care] once a week. The aide plan of care was not updated when the aide services were increased to 2 times per week. During an interview with hospice aide # 7 on 3/22/23 at approximately 11:50 am, the aide reported the patient is bathed 2 times per week. During an interview with the executive director on 3/22/23 at approximately 12:15 pm, the director confirmed the aide plan of care indicated assistance with ADLs [bathing] only weekly. A policy, ";Plan of Care" (revised 12/1/21), was provided by the agency director on 3/20/23 at 1:55 pm. The policy stated, ";An aide plan of care will be developed by the Registered Nurse...that is familiar with the patient if aide services have been ordered." 1. Patient #2 was admitted on 1/20/23 with diagnoses of liver cell carcinoma, cirrhosis of the lover, viral Hepatitis C, and a below the knee amputation of the left leg. The Plan of Care (POC) for 1/20/23-4/19/23 included orders for skilled nursing one time for one week, weekly for 12 weeks, the one time for one week; and hospice aide services twice weekly for 12 weeks, then one time for one week. On 1/26/23, the aide was discontinued due to patient request. On 3/14/23, aide services were ordered one time for one week, then two times per week for two weeks. An updated aide care plan was not completed. On interview with RN #3 on 3/22/23 at 9:45 a.m. revealed a new aide care plan was not completed. The RN indicated that the aide tasks had not changed between the initial assessment and the new aide order on 3/14/23. An interview with the executive director on 3/22/23 at 9:45 confirmed there was no evidence the aide plan of care had been reviewed.

Based on personnel file review and staff interview, there was no evidence that aide had demonstrated competency with sponge baths, tub baths, showers, shampoo, or nail care for 1 of 1 aide personnel files reviewed (Employee #7). Findings included: --- Employee #7 was hired 1/5/23. The personnel record did not include evidence the aide was competent in bathing patients. An interview with the executive director on 3/22/23 at 3:30 p.m. revealed the aide competency for baths/showers was by the executive director, but the date was unknown. The interview confirmed there was no evidence of competency of bathing.

Patient #9 was admitted on 02/10/23 with diagnoses of parkinsons disease, abnormal weight loss, obstructive sleep apnea, and hypertensive kidney disease. Review of the Plan of Care for 02/10/23 to 05/10/23 had orders for skilled nursing 1 time a week for 1 week, and 2 times a week for 12 weeks, home health aide 2 times a week for 12 weeks, and 1 time a week for 1 week. Review of the home health aide visit note for 02/21/23 revealed a completed visit note and a documented missed visit note for 02/21/23. Interview with the home health aide on 3/22/23 at 10:43 a.m. revealed, ";Im not sure why it would pop up as a missed visit, it looks like a did a visit". Patient #13 had a Start of Care of 01/29/23 with diagnoses of emphysema (lung disease), hypertensive heart disease, heart failure, and acute and chronic respiratory failure. The Plan of Care for certification period of 01/29/23 to 04/28/23 included orders for skilled nursing 2 times a week for 13 weeks, home health aide 1 time a week for 1 week, 2 times a week for 12 weeks, chaplin 1 month 1, and medical social work 1 month 1. Review of the home health aide visit note for 02/21/23 revealed a completed visit note and a documented missed visit note for 02/21/23. Interview with the home health aide on 3/22/23 at 10:43 a.m. revealed, ";Im not sure why it would pop up as a missed visit, it looks like a did a visit".

Based on policy and procedure, clinical record review and staff interview the agency failed to show evidence of an order for removing a catheter for 1 of 1 patients with a catheter [#11] and provided wound care without an order for 1 of 1 patients with a wound [#11]. Findings included: --- A policy, ";Physician Orders" revised 11/01/21 was provided by agency director on 03/20/23 at 1:55 p.m. stated, ";...medications, treatments, diagnostics, studies or therapeutics will not be administered without the written order of a qualified physician..." 1a. Patient #11 had a Start of Care of 05/07/21 with diagnoses of heart failure, NSTEMI, (heart attack) COPD (chronic obstructive pulmonary disease), polyneuropathy (malfunction of the peripheral nerves). The Plan of Care for certification period of 02/26/23 to 04/26/23 included orders for skilled nursing 3 times a week for 8 weeks, and 2 times a week for 1 week. Review of the skilled nurse visit for 03/08/23 had documentation of the indwelling catheter being removed per patient request. There was no evidence in the record of a physician order to remove the foley catheter. Interview with nurse #6 on 03/22/23 at 10:15 a.m. revealed, ";that was an on-call day- I had an order to discontinue the catheter, I must have forgotten to put the order in". 1b. Patient #11 had a Start of Care of 05/07/21 with diagnoses of heart failure, NSTEMI, (heart attack) copd (chronic obstructive pulmonary disease), polyneuropathy (malfunction of the peripheral nerves). The Plan of Care for certification period of 02/26/23 to 04/26/23 included orders for skilled nursing 3 times a week for 8 weeks, and 2 times a week for 1 week Review of the skilled nurse visit for 03/17/23 had documentation of the skin tear being covered with Neosporin (antibiotic ointment) and a bandage. There was no evidence in the record of a physician order to cover the skin tear with Neosporin or a bandage. Interview with the skilled nurse on 03/22/23 at 8:52 a.m. revealed, ";... I did not write the order for the Neosporin or gauze after I finished my charting..."