Every finding on record at Nurses & Company Health Care Services, Inc.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 04/24/2025 with a diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA)[Personnel Record 7] on 09/09/2025, the hospice medication profile (printed on 09/08/2025) was compared with the SNF medication list (printed on 09/09/2025). The following medication(s) were documented on the hospice medication profile and not documented on the SNF medication list: lorazepam 0.5 mg, one (1) tablet every 4 hours as needed (ordered 04/29/2025). The following medication(s) were listed on the SNF list and not present on the hospice list: Mucinex 600 mg, one (1) tablet every 12 hours as needed (ordered 08/15/2025); vitamin D 1000 mg, one (1) tablet daily (ordered 10/09/2024); cholecalciferol 50 mcg, one (1) tablet daily (ordered 05/31/2024). The last nursing visit was the previous week. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 07/17/2025 with a diagnosis of Parkinson's disease. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 09/09/2025, the hospice medication profile (printed on 09/08/2025) was compared with the ALF medication bottles. The hospice medication profile documented "morphine 0.25 ml every 2 hours as needed (ordered 07/22/2025) and the ALF medication bottle label documented morphine 0.25 ml every 3 hours as needed (ordered 07/25/2025). During an interview, the RN stated, "That's strange, we don't even order it every 3 hours." The last nursing visit was the previous week. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 03/17/2025 with a diagnosis of Huntington's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Music Therapist (MT) [Personnel Record 9] on 09/09/2025, the hospice medication profile (printed on 09/08/2025) was compared with the SNF medication list (printed on 09/09/2025). The following medication(s) were documented on the hospice medication profile and not documented on the SNF medication list: "Ingrezza 40 mg, one (1) capsule daily (ordered 04/09/2025); lorazepam 0.25 ml every 4 hours as needed (ordered 03/18/2025); multivitamin, one (1) tablet daily (ordered 03/18/2025); pantoprazole 40 mg, one (1) tablet (ordered 03/18/2025); and polysaccharide 150 mg daily (ordered 03/18/2025)." The following medications were documented on the SNF medication list and not on the hospice medication profile: "trazadone 50 mg, one (1) tablet at bedtime (ordered 05/22/2025), benztropine 1 mg, take one (1) twice daily (ordered 07/02/2025); bisacodyl 5 mg, one (1) tablet daily (ordered 05/16/2025). The last nursing visit was the previous week. During an interview and joint clinical record review on 09/11/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the findings and stated that the medications should be reconciled during weekly nursing visits.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the patient's plan of care included the patient's current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 04/24/2025 with a diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA)[Personnel Record 7] on 09/09/2025, the following medication(s) were listed on the SNF list and not included in the patient's plan of care: Mucinex 600 mg, one (1) tablet every 12 hours as needed (ordered 08/15/2025); vitamin D 1000 mg, one (1) tablet daily (ordered 10/09/2024); cholecalciferol 50 mcg, one (1) tablet daily (ordered 05/31/2024). The last nursing visit was the previous week. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 03/17/2025 with a diagnosis of Huntington's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Music Therapist (MT) [Personnel Record 9] on 09/09/2025, the following medications were documented on the SNF medication list and not included in the patient's plan of care: "trazadone 50 mg, one (1) tablet at bedtime (ordered 05/22/2025), benztropine 1 mg, take one (1) twice daily (ordered 07/02/2025); and bisacodyl 5 mg, one (1) tablet daily (ordered 05/16/2025). The last nursing visit was the previous week. During an interview and joint clinical record review on 09/11/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the findings and stated that the medications should be reconciled during weekly nursing visits.

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 18 (17%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient instructions to meet the patient's needs.. CLINICAL RECORD 4: The patient elected hospice care on 03/17/2025 with a diagnosis of Huntington's disease. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 03/24/2025 assigned the HA the relevant tasks: "assist to bedside commode, assist to toilet, assist with bedpan, assist with feeding, bathing (bed), bathing (partial sponge bath), bathing (shower), dressing, hair care, nail care, oral care, perineal care, provide incontinence care, shampoo, skin care, transfer assist, turn and position in bed, change linens, oxygen safety, provide vigil, report pain to nurse, report skin changes to nurse, RN to orient aide to care plan, safety." All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. The HA care plan did not provide the HA with specific instructions regarding the type of bath to be performed. CLINICAL RECORD 16: The patient elected hospice care on 05/01/2025 with a diagnosis of protein-calorie malnutrition. The patient resided in a SNF. The HA care plan dated 05/01/2025, and revised on 05/02/2025 assigned the HA the relevant tasks: "assist to toilet, turn and position in bed, assist with feeding, shampoo, hair care, skin care-full body lotion, perineal care, oral care, nail care, dressing, bathing (shower), provide incontinence care, transfer assist, change linens, report pain to nurse, report skin changes to nurse-in addition to reporting to RN case manager, ensure that caregiver is updated and it is logged on both communication record and electronic medical record, RN to orient aide to care plan, oxygen safety, provide vigil." All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. A physicians order dated 06/03/2025 ordered: "medial right foot wound covered with Opti foam." A physicians order dated 07/31/2025 ordered: "right dorsal foot wound covered with bordered gauze." The HA care plan did not notify the HA of the wounds, nor provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during care. CLINICAL RECORD 19: The patient elected hospice care on 02/28/2025 with a diagnosis of acute on chronic combined systolic and diastolic heart failure. The patient resided at home. The HA care plan dated 02/28/2025, revised 03/01/2025 and 05/01/2025 assigned the HA the relevant tasks: "assist to bedside commode, assist to toilet, assist with bedpan, assist with feeding, bathing (bed) with details assist of 1 to perform bed bath, half bath, sponge bath or shower, bathing (partial sponge bath), bathing (shower), bathing (tub bath), dressing, hair care, nail care, oral care, perineal care, shampoo, shaving, skin care, transfer patient, change linens, oxygen safety, report pain to nurse, report skin changes to nurse, safety." The 03/01/2025 revision added: "provide incontinence care, provide vigil, RN to orient aide to care plan-upon admission and with all changes." The 05/01/2025 revision unchecked the boxes for "assist to toilet, assist to bedside commode" but left the typed details as if they were still assigned tasks, and removed bathing (partial sponge bath), bathing (shower), bathing (tub bath). The revision on 05/01/2025 included the assigned tasks: bed bath, half bath, sponge bath, and shower. All tasks were to be completed on every visit. Aide frequency was twice weekly. The aide care plan did not provide the aide with specific instructions for the bath type to be performed. During an interview and joint clinical record review on 09/10/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the finding and stated, "There should only be one bath type to choose from or specific days on which to give a certain bath."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 18 (11%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. HOME VISIT 1/CLINICAL RECORD 1:The patient elected hospice care on 04/24/2025 with a diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 04/29/2025 assigned the HA the relevant tasks: "turn and position in bed, assist with feeding, skin care, oral care, dressing, bathing (shower), provide incontinence care, transfer assist, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, provide vigil." All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. During a home visit with the Hospice Aide [Personnel Record 7] on 09/09/2025, the HA shampooed the patient's hair, which was not included in the HA care plan. A clinical record review revealed that the HA visit notes dated 05/12/2025 and 06/05/2025 documented: "Shower N (no). Bed bath given" and "Shower N. Bed bath given," respectively. The HA visit note dated 07/31/2025 documented: "transfer/assist NA (not applicable)." CLINICAL RECORD 12: The patient elected hospice care on 05/25/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in a SNF. The HA care plan dated 06/27/2025 assigned the HA the relevant tasks: "assist to toilet, bathing (tub bath), dressing, oral care, perineal care, shampoo, shaving, skin care, transfer assist, oxygen safety, provide vigil, report skin changes to nurse, report pain to nurse, Registered Nurse (RN) to orient aide to plan of care, safety." All tasks were to be completed on every visit. The plan of care ordered HA services twice weekly. The HA visit note dated 07/14/2025 documented that a shower was provided: "Bathing (tub bath). Shower preferred. Facility tub not in working order." During an interview and a joint clinical record review on 09/10/2025, the Regional Director of Clinical Operations and Statewide Clinical Director confirmed the findings. They agreed that the HA should have had the "nurse adjust the plan of care before changing the bath types."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A joint review of the agency's volunteer program on 09/10/2025 with the Regional Clinical Officer and Manager of Volunteers revealed that the volunteer percentage for the last twelve (12) months (September 2024 to August 2025) averaged 1.1%. The Volunteer Manager advised that they "Were continuing to add to the volunteer team, trying to get each volunteer to add at least 2 hours to keep up with the census growth." A review of the volunteer program was conducted with the Regional Clinical Officer and Manager of Volunteers on 09/10/2025, during which time the volunteer percentage for the last twelve (12) months (September 2024 to August 2025) averaged to 1.1%. The Volunteer Manager advised they "were continuing to add to volunteer team, trying to get each volunteer to add at least 2 hours to keep up with the census growth."

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes Information from the patient’s updated comprehensive assessment and (a) record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 5 (60%) records reviewed, the agency did not ensure that new information from updated assessments and progress toward goals was included in revisions to the plans of care (POC). The requirement is the addition of measurable outcomes expected from implementing and coordinating the POC. Clinical Record 1: For the benefit period (recertification) dated 11/27/2022 through 1/25/2023, the diagnoses listed were Parkinson's, Chronic Kidney disease, and Cerebral Infarction. The skilled nurse (SN) visit dated 11/29/2022, documented a pulse at 50, with a blood pressure (BP- left arm) of 130/83. On 12/02/2022, her pulse was 49, with a BP (left arm) of 122/74. By 12/06/2022, the patient's pulse remained low at 46, with an elevated BP (left arm) of 175/95. On 12/08/2022, the patient's pulse was documented as 44, with a BP of 153/76. On 12/13/2022 (right arm) and 12/15/2022, (left arm) the patient's pulse remained at 46 with BPs consistent at 166/91 and 166/93. The POC did not evidence a revised POC based on the information regarding any progress toward goals. In this instance, the parameter requiring physician attention was pulse evaluations indicating bradycardia. Clinical Record 2: For the Election of Hospice Services, beginning 11/19/2022 through 2/16/2023, the diagnoses included Unspecified Severe Protein-Caloric Malnutrition. Pseudomonas, COVID-19, Diabetes Mellitus, Pressure Ulcers, Mid-Pretibial Unstageable Left and Right Extremities, Sacral Area Stage 3, Pain Thoracic Region, Greater Trochanter Stage 3, Paraplegic, and Foley Catheter. The patient is residing in a Long-Term Care Facility. The RN visit dated 11/19/2022, documented a BP left arm of 97/43. The LPN visit dated 11/21/2022 documented a BP right arm of 97/45. The RN visit dated 12/02/2022, documented a BP left arm of 94/56, followed by an LPN visit on 12/06/2022, documenting the left arm BP of 118/55, and pulse at 116, characterized as thready. The low diastolic BP coupled with an elevated pulse qualify as reportable issues with the potential for POC revisions. Clinical Record 4: For the Election of Hospice Services beginning 11/23/2022 through 11/27/2022, the diagnoses were listed as Cerebral Atherosclerosis, Vascular Dementia, Chronic Kidney Disease, and Hypertension. The SN on 11/25/2022 documented a lower pulse at 54, characterized as weak. The finding of a pulse-defining bradycardia is a reportable discovery with the potential of an action that may alter the POC when addressed with the physician or IDG group. During the exit interview with the Administrator and the Regional Director, it was stated that the agency will provide teaching to the RNs to ensure that they update progress toward goals in the POC.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient's plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 6 (50%) records reviewed, the agency’s Skilled Nurse (SN) failed to provide evidence of adherence to standards of practice. The observation was made that documentation of patient information, and evaluation of findings, were not present in the record, so as to be able to quantify and measure the effect of care on patient outcomes. There was no documented evidence in the clinical record, communications notes, or narratives that the patient's needs were consistently met as indicated by a review of assessments undertaken with each visit as weighed against a review of assessments on prior visits with regards to previous and the emergence of new problems. Clinical Record 1: For the benefit period (recertification) dated 11/27/2022 through 1/25/2023, the diagnoses were listed as Parkinson's, Chronic Kidney disease, and Cerebral Infarction. The SN visit of 11/29/2022 documented a pulse at 50, with a blood pressure (BP), left arm, of 130/83. On 12/02/2022, her pulse was 49, with a BP (left Arm) of 122/74. By 12/06/2022, the LPN documented that the patient's pulse remained low at 46, with an elevated BP (left arm) of 175/95. On 12/08/2022, the RN documented the patient's pulse at 44, with a BP of 153/76. On 12/13/2022 the LPN (right arm) and 12/15/2022, (left arm) documented the pulse remained at 46 with BPs consistent at 166/91 and 166/93. There was no documented evidence in the clinical record, communications notes, or narratives that the patient's needs were consistently met to address these symptoms, or that the physician had been informed of the vital signs. The primary concern would be the low pulse evaluations indicating bradycardia. Clinical Record 2: For the Election of Hospice Services, dated 11/19/2022 through 2/16/2023, the diagnoses were listed as Unspecified Severe Protein-Caloric Malnutrition. Pseudomonas, COVID-19, Diabetes Mellitus, Pressure Ulcers, Mid-Pretibial Unstageable Left and Right Extremities, Sacral Area Stage 3, Pain Thoracic Region, Greater Trochanter Stage 3, Paraplegic, and Foley Catheter. The patient resided in a Long-Term Care Facility. The RN visit dated 11/19/2022, documented a BP left arm of 97/43. The LPN visit dated 11/21/2022 documented a BP right arm of 97/45. The RN visit dated 12/02/2022, documented a BP left arm of 94/56, followed by an LPN, documenting, on 12/06/2022, left arm BP of 118/55, and pulse at 116, characterized as thready. There was no documented evidence in the clinical record, communications notes, or narratives that the patient's needs were consistently met to address these symptoms, or that the physician had been informed of the vital signs. The symptoms of note, in this case, are a low diastolic B/P indicating hypotension coupled with an elevated pulse (tachycardia). Clinical Record 4: For the Election of Hospice Services beginning 11/23/2022 through 11/27/2022. the diagnoses were listed as Cerebral Atherosclerosis, Vascular Dementia, Chronic Kidney Disease, and Hypertension. The SN, on 11/25/2022, documented a lower pulse rate at 54, and weak. There was no documented evidence in the clinical record, communications notes, or narratives that the patient's needs were consistently met to address this symptom, or that the physician had been informed of the vital signs. During the exit interview with the Administrator and the Regional Director, it was stated that the agency will provide teaching to the RNs to ensure that they address the needs of the patients.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interview. 3 of 13 (23%) records revealed that the agency did not ensure that oxygen was included on the medication profiles. Clinical Record 2: For the certification period 8/24/22 through 11/21/22, the plan of care (POC) order dated 8/9/2022 for the hospice recertification update includes orders for the hospice nurse to instruct in safe use of oxygen and monitor its effectiveness. The goal is documented as, "Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively." Oxygen is not included on the drug profile. Clinical Record 6: The start of care dated 11/5/2022, with a SN assessment on 11/5/22 documented that the patient is oxygen-dependent. Oxygen is not included on the medication profile effective 11/5/2022. Clinical Record 11: The SN assessment dated 5/25/2022 documented that patient uses oxygen. The POC dated 5/25/2022 includes interventions for teaching safe use of oxygen. The medication profile does not include oxygen. The Manager of Accreditation stated in interview on 11/9/2022, "I have confirmed the oxygen is not on the medication profiles." 3 of 13 (23%) of reviewed clinical records reveal that the agency did not ensure that oxygen was included on the medication profile.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. The IDG, in its entirety, supervises the care and services provided to the patient and family. THIS IS A CMS CONDITON-LEVEL DEFICIENCY This CONDITION was not met as evidenced by review of clinical records and interview revealing issues with care and services not being provided in accordance with the plans of care (HCPC.19.I/L543); issues with the individualized plans of care lacking required elements (HCPC.21.I/L550); and significant issues with plans of care not specifying the care and services to be delivered (HCPC.18.I/L538). The cumulative effect of these systemic practices has the potential to place patients at risk for unmet care needs and services, demonstrates a lack of IDG oversight of the plan of care process and could result in the inability of the hospice to provide effective ongoing care and services to all hospice patients.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interview. 5 of 13 (38%) records reviewed revealed that the agency did not ensure that the plans of care specified the care and services necessary to meet the individual needs of the patients. Clinical Record 4: The patient's start of care (SOC) date was 6/1/2022 with diagnoses of COPD, Unilateral Pulmonary Emphysema and Acute Respiratory Failure with hypoxia. The RN assessment on 6/1/2022 and medication profile reveals that patient is on 8L of O2 per NC (liters of oxygen by nasal cannula) continuously. The medication profile documented 8 L/M of O2 that can be titrated up to 20 L/M. The POC goals and interventions do not address the patient's respiratory status or oxygen except for one "prefilled" line that states "Hospice Nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment and comfort modalities." There are no specific interventions related to respiratory status, oxygen and when to titrate oxygen. Clinical Record 6: The SOC RN assessment on 11/5/2022 documented that the patient was oxygen-dependent. The SN visit note on 11/7/2022 documented that the patient utilized intermittent BiPAP. The POC dated 11/5/2022 does not include specific care and services to meet the patient's needs with respect to oxygen and BiPAP use. There are no orders for BIPAP or oxygen. Clinical Record 10: The SOC RN assessment on 11/03/22 documents that patient has a PEG tube; the patient also takes food by mouth and the PEG tube should be used per patient request. The POC dated 11/3/22 to 1/31/22 does not evidence any mention of care, management or assessment of the PEG tube. The assessment also indicates that the patient has oxygen PRN; the POC documents O2 precautions under safety measures. The aide POC, dated 11/3/2022, includes instruction to the aide related to oxygen. The POC does not include interventions related oxygen and oxygen is not documented on the medication list. Clinical Record 8: SN assessment on 10/5/21 reveals that patient has a suprapubic catheter. Plan of care for cert periods 10/17/21-12/15/21, 12/16/21-2/13/21, 2/14/22-4/14/2022, 4/15/22-6/13/22, 6/14/22-8/12/22, 8/13/22-10/11/22 and 10/12/22 and 12/10/22 do not contain clear and specific orders related to the care and management of the suprapubic catheter. Orders for all care plans contain generic statement, "Hospice nurse for instructions/reinforcement of care of indwelling catheter." Clinical record contains no other orders to change or manage suprapubic catheter or to indicate that it is a suprapubic catheter versus a foley catheter. Clinical Record 13: The patient was admitted on 10/28/19. The SN assessment on 7/12/22 documents that the patient has a Pleurex drain. The POC dated 7/12/2022 includes orders to change the dressing around the peritoneal wound site but does not include any orders to drain the Pleurex. No interventions or goals related to the Pleurex drain are included in POC. An interim "paper" order, written 7/12/22, reads, "Nurse to drain peritoneal site prn per patient request. Nurse to stop draining per patient discomfort. Notify physician if drains more than 5000ml. Monitor for signs and symptoms of dehydration." The order did not get transcribed to the POC to enable all staff to be able to see and access the order/interventions. The Manager of Accreditation in interview on 11/9/22 stated in part, "I have reviewed each of these care plans and the orders and interventions identified for records, 4, 6, 10, 8, 13 are not included on the care plan." The Manager of Accreditation also stated on 11/9/2022, the IDG team could not see the order for the Pleurex drain because it was never uploaded in the system." 5 of 13 ((38%) of clinical records reviewed revealed that the agency did not ensure that the plan of care specified the care and services necessary to meet the individual needs of the patient.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician. This standard was not met as evidenced by a review of clinical records and interview. 2 of 13 (15%) records reviewed revealed that the agency did not ensure that the care and services provided followed the individualized plans of care. Clinical Record 13: The patient was admitted on 7/12/22. The SN visit note, dated 7/15/22 and completed by a LPN, reads in part, "This nurse used sterile technique and attached drainage bag to pleural drain. 2800ml of clear fluid output. Patient tolerated well. After second bag patient said it was hurting so this nurse stopped the drainage process." The SN visit note, dated 7/17/2022, notes in part, "Drainage system connected and 2000ml yellowish-colored fluid drained. Patient tolerated procedure with facial grimacing noted." The clinical record contains no orders to drain the pleural drain. Clinical Record 8: The patient was admitted on 10/28/19. The SN visit note, dated 9/28/22, reads in part, "SP (suprapubic) catheter changed, draining clear yellow urine." The POC does not include orders to change suprapubic catheter. The Manager of Accreditation stated in part, on interview on 11/9/2022, "I have verified that suprapubic catheter changes are not on care plan for patient #8 and there are no orders on the care plan to drain the Pleurex drain for patient #13." 2 of 13 (15%) clinical records reviewed revealed that the agency did not ensure that the care and services provided followed the individualized plan of care.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care, and medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, interview and observation on home visits. 2 of 13 (15%) records reviewed revealed that the agency did not ensure that the patients' individualized plans of care identified interventions, measurable outcomes and medical supplies needed to meet the needs of the patient. Home Visit 2 (Clinical Record 2): During the home visit observation it was noted that the patient had urinary drainage bag. The RN stated that the patient had a condom catheter not a foley catheter. The plan of care (POC) dated 10/18/22 for the certification period 11/2/2022 to 12/31/2022 does not include interventions or goals related to a condom catheter. Clinical Record 6: The SOC RN assessment on 11/5/2022 documented that the patient was oxygen-dependent and intermittently uses a BIPAP. The POC does not contain orders for oxygen use and does not include orders for BiPAP. The Manager of Accreditation stated in part, on interview on 11/9/22, "I have verified the care plans do not include those items." 2 of 13 (15%) of clinical records reviewed revealed that the agency did not ensure that the patient's individualized plan of care identified interventions, measurable outcomes and medical supplies needed to meet the needs of the patient.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by document review, interviews and observation on home visits. 1 of 3 (33%) visits demonstrated that the agency did not ensure that all staff utilize effective bag technique. Policy No 7-016 "Bag Technique" reads in part, "The bag will be placed on a clean surface that can be easily disinfected in the care and the home. If paper towels/newspapers have been used as protective barrier for bag placement in the home, they will be discarded." Home Visit 2: During the home visit observation it was noted that the Chaplain placed the cloth visit bag directly on the floor on the carpet in the patient's home. The Manager of Accreditation stated in an interview on 11/8/2022, "Staff should never place their bags on the floor. We go over that with them multiple times." 1 of 3 (33%) of home visits demonstrated that the agency did not ensure that all staff utilize effective bag technique.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records, interview and observation on home visits. 3 of 11 (27%) records reviewed, of patients with aide services, revealed that the agency did not ensure that the written care instructions for the hospice aide were written by a RN and provided specific information to allow the aide to perform within the aide's scope of practice. Clinical Record 2: The patient was admitted on 5/26/22 and recertified for the benefit period dated 8/24/22-11/21/22. Observation and interview with the RN during the observed home visit on 11/8/2022 evidenced that patient utilizes a condom catheter to address incontinence. The aide plan of care (POC), dated 11/6/2022, did not include instruction to the aide related to the condom catheter. Clinical Record 8: The patient was admitted on 10/28/19 and recertified for the benefit period dated 8/18/21 to 10/16/21. The aide POC and updates dated 6/15/22, 6/22/2022, 7/6/22, 8/17/22, and 8/31/22 read, "Effective date of current care plan: Entered by LPN, approved by LPN." There is no indication that aide care plan was developed and approved by a RN. Clinical Record 11: The aide POC, updated 5/26/2022 and 6/8/22, reveals that the aide POC was entered and approved by a LPN. The Manager of Accreditation stated in interview on 11/9/2022, "The condom cath is not on the aide care plan for patient #2. I see when the aide care plans read that they were entered and approved by the LPN but I don't know how that happens because it has to be done by an RN in our QI Department. I spoke with the LPN and she stated she has to go into the aide care plan in order to finish her notes. She does not have to go into the aide care plan and we will educate her but I still can not figure out why or how it is documented that the LPN created and approved the aide care plan but that is what it says." 3 of 11 (27%) clinical records reviewed with aide services reveal that the agency did not ensure that the written care instructions for the aide were written by an RN and provided specific information to allow the aide to perform within the scope of practice.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records and interview. 3 of 13 (23%) records revealed that the agency did not ensure that the clinical record included physician orders for specific interventions required by the patients. Clinical Record 6: The start of care (SOC) RN assessment on 11/5/2022 documented that the patient was oxygen-dependent and intermittently uses a BIPAP. The clinical record does not contain orders for oxygen use and does not include orders for the BiPAP. Clinical Record #10: The SOC RN assessment on 11/03/22 documented that the patient has a PEG tube; the patient also takes food by mouth and the PEG (Percutaneous Endoscopic Gastrostomy) tube should be used per patient request. The plan of care dated 11/3/22 to 1/31/22 does not evidence any orders or mention of care, management or assessment of the PEG tube. the RN assessment also documented that the patient has oxygen PRN; there are no orders for oxygen present in the clinical record. Clinical Record 8: The patient's SOC was 10/28/19. The SN assessment on 10/5/21 documented that the patient has a suprapubic catheter. The plans of care (POC) for certification periods 10/17/21-12/15/21, 12/16/21-2/13/21, 2/14/22-4/14/2022, 4/15/22-6/13/22, 6/14/22-8/12/22, 8/13/22-10/11/22, 10/12/22 and 12/10/22 do not evidence clear and specific orders related to the care and management of the suprapubic catheter. There are no orders to change the suprapubic catheter. Orders for all POCs include a generic statement, "Hospice nurse for instructions/reinforcement of care of indwelling catheter." The clinical record includes no other orders to change or manage the suprapubic catheter or to indicate that it is a suprapubic catheter versus an indwelling foley catheter. In interview on 11/9/2022, the Manager of Accreditation stated in part, "I have reviewed charts 8 and 10 and verified there are no orders as described." 3 of 13 (23%) of clinical records reveal that the agency did not ensure that the clinical record included physician orders for specific interventions required by the patients.

Based on record review and interview, the agency failed to ensure staff were provided orientation and/or biennial Emergency Preparedness (EP) training consistent with their expected roles in one employee (Employee #5) of six employees files reviewed, and two Volunteers (Volunteers #1, and #2) of two volunteers files reviewed. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's undated policy titled "Emergency Management Plan", Policy No. 4-001, revised December 2018, showed: - The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness plan that meets those regulations; - The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable; - The training is provided at least every two (2) years unless more frequent training is necessary due to a significant update of the organization's policies and procedures; and - Organization leadership will provide for orientation and annually thereafter of all personnel regarding participation in the emergency management plan. EMPLOYEE #5 (E5): - Date of hire: 10/11/2021; - Position: Certified nurse aide (CNA); - No evidence of EP training consistent with his/her expected role. VOLUNTEER 1 (V1): - Date of hire: 11/17/2014; - Position: Volunteer; - No evidence of biennial EP training. VOLUNTEER 2 (V2): - Date of hire: 01/16/2015; - Position: Volunteer; - No evidence of biennial EP training. During an interview on 02/10/2022 at 10:42 AM, the administrator stated that: - The agency provides the same EP training for all the staff; and - The volunteers had no EP training on orientation or biennial.

Based on clinical record review and staff interview, the hospice failed to have a registered nurse (RN) conduct the initial assessment in person in the patient's place of residence as required by this regulation in one (Record/Patient #5) of five cases reviewed. The registered nurse completed the initial assessment via telephone. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Comprehensive Assessment", Policy No. 1-014, revised April 2019, showed in part: - A comprehensive patient assessment will be performed by the interdisciplinary group (physician, registered nurse, social worker, pastoral or other counselor); - During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant; - A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient's terminal illness; - Patient's functional status including, but not limited to, the degree of self-care and the amount and level of assistance needed; - An evaluation of the home environment and assessment of emergency preparedness of the patient; - Equipment presently in home and potentially needed by patient; - Review of current and related past medications, including prescription over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history and other medication information; and - The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patient's and family/caregiver's reaction to illness. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 12/22/2021, and the RN completed the comprehensive assessment via a phone visit. Review of the Visit Note Report dated 12/22/2021, for start of care, was signed by RN A Review of the Medical Record Coordination Notes Report dated 12/22/2021, showed the RN virtually met with the patient, patient's daughter and a hospice staff licensed practical nurse (LPN) to complete evaluation and admission to hospice services. During a review of findings and interview on 02/10/2022 at 12:20 P.M., the administrator stated that the RN who completed the admission assessment was from another office in another town (approximately 231 miles away), helping out because the office did not have enough staff, due to being out with COVID. He/she was in another town doing the admission virtually.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, but not limited to, four (Records/Patients #1, #2, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication Profile," dated revised 12/2018, showed in part the following: -Purpose: To define the use of the medication profile in evaluating a patient's regimen; -The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications; -During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen; and -Deviations from taking medications as ordered will be documented in the clinical notes, and the physician (or other authorized independent practitioner) will be notified. RECORD/PATIENT #1: Review of the patient's medication profile, showed the following: -On 12/3/2021 Ibuprofen 600 milligrams (mg) one every six hours as needed for pain; and -On 01/10/2022 Ibuprofen 800 mg one every six hours as needed for pain. The agency failed to clarify when the patient was to take 600 mg and when the patient was to take 800 mg, or if the 600 mg should have been discontinued. During an interview with the administrator on 02/10/2022 at 11:45 AM, the above findings were discussed and he/she agreed that the orders needed clarification, or one needed to be discontinued. RECORD/PATIENT #2: Review of the patient's Visit Note Report dated 01/01/2022, showed the following: - Gastrostomy tube (a surgically placed device used to give direct access to your stomach for supplemental feeding) placed 12/30/2021 with Jevity 1.2 Cal (fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) administered via g-tube, 400 cubic centimeter (cc) four times a day, with 150 cc flush four times a day. This was not on the hospice agency medication profile. Review of the patient's Client Coordination Note Reports dated 01/04/2022, showed the licensed practical nurse charted barrier cream to coccyx. This was not on the hospice agency medication profile. Review of the patient's Client Coordination Note Reports dated 01/04/2022, showed the registered nurse documented the following: - Patient tolerated coccyx wound care and right side coccyx wound healing appropriately. There was no wound care on the hospice agency medication profile; and - Patient receives 400 cc of Jevity 1.2 Cal four times a day with 200 cc flush four times a day. This was not on the hospice agency medication profile. Review of the patient's Client Coordination Note Reports dated 02/02/2022 showed the licensed practical nurse documented oxygen (O2) SAT (the fraction of oxygen-saturated hemoglobin relative to total hemoglobin (unsaturated + saturated) in the blood) 98%(normal is 95-100%) on 3 liters (L) continuous oxygen. This was not on the hospice agency medication profile. Observation on 02/08/2022 beginning at 9:10 AM, during the patient's home visit, showed the following medication discrepancies with the current medication profile and plan of care (POC): - The hospice agency medication profile showed an order for acetaminophen (analgesic for pain) 650 mg rectal suppository administer one tab by mouth every six hours as needed for pain and fever. This was not in the patient's home; - The hospice agency medication profile showed an order for midodrine (low blood pressure) 2.5 mg dissolve 2.5 mg, administer via G-tube three times a day with meals. This was not in the patient's home; - The hospice agency medication profile showed an order for risperidone (mood) 3 mg disintegrating tablet administer 0.5 (half) tab in AM and one tab at bedtime crushed via g-tube. The bottle was labeled half tab; - The hospice agency medication profile showed an order for sertraline (antidepressant) 100 mg tablet administer one tab crushed per g-tube daily. This was not in the patient's home; - Eliquis (blood thinner) 5 mg twice a day, located in box on table. This was not on the hospice agency medication profile; - Digoxin (heart failure) 125 micrograms (mcg) one time a day, located in box on table. This was not on the hospice agency medication profile; and - Metoprolol (treat high blood pressure) 25 mg twice a day and hold for blood pressure less than 90/50, located in box on table. This was not on the hospice agency medication profile. The family member/caregiver reported via telephone the patient takes all the medications in the box on the table. RECORD/PATIENT #3: Observation on 02/09/2022 beginning at 9:15 AM, during the patient's home visit, showed the following medication discrepancies with the current medication profile, plan of care (POC) and patient medication list on the electronic medical records (EMR) medication administration record (MAR) and treatment administration record (TAR) at the facility where the patient resided: -The facility medication profile showed an order for Med Pass (supplement) 90 milliliter (ml) three times a day. This order was not included on the agency medication profile; -The facility medication profile showed an order for Hydrocodone/acetaminophen (narcotic analgesic) 10/325 one twice a day. This order was not included on the agency medication profile; -The facility medication profile showed an order for Guaifensen (expectorant) 100 mg/5 ml every six hours as needed. This order was not included on the agency medication profile; -The facility medication profile showed an order for ondansetron (antimetic) 4 mg sublingual every four hours as needed for nausea and vomiting. this was not included on the agency medication profile; -The facility medication profile showed an order for Ipratropium/Albuterol (bronchodilator) one vial every six hours as needed for shortness of breath; and -The agency POC showed an order for Melatonin (an over-the-counter sleep supplement) 3 mg at bedtime. This was not included on the facility MAR. RECORD/PATIENT #4: Review of the patient's start of care Visit Note Report dated 02/04/2022 showed the patient was treated with oxygen for shortness of breath. This was not on the hospice agency medication profile. During an interview on 02/10/2022 at 11:45 AM, the administrator stated that the medications and treatments should be reconciled at every visit and she would expect them to match.

Based on policy review, home visit observations, record review, and interview, the hospice failed to ensure development of an individualized plan of care that reflects the patient and family/caregiver goals and interventions based on problems identified in the initial, comprehensive assessments and as the patient's conditions changed, in two (Records/Patients #1 and #3) of five full record reviews. This deficient practice has the potential to affect the care and services received by all patients served by the hospice. Findings included: Review of the agency's policy titled, "The Plan of Care (POC)," date revised 12/2018, showed in part the following: -Purpose: To ensure that an individualized plan of care is completed and complies with accepted standards of care and regulatory issues; -A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program; -The care provided to the patient must be in accordance with the plan of care; -The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process; -The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis, but no less than every 15 days; -This plan will focus on identified problems, goals, and interventions; -The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care; -This plan of care must be initiated at the start of care; -The plan of care will identify the patient's needs and services to meet those needs, including management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs; -Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care; and -Any change in the patient's condition must result in a change in the plan of care, prior to implementation of the new service. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 11/30/2021, with a terminal diagnosis of breast cancer with mets (metastasis - spread from initial or primary site, to a different or secondary site) to lung. Review of the brief narrative statement of terminal illness, showed the patient's co-morbidities included: frequent falls, pulmonary hypertension (high blood pressure in the arteries to your lungs), chronic pain (persistent pain that lasts weeks to years), pulmonary embolism (condition in which one or more arteries in the lungs become blocked by a blood clot), and respiratory failure with chronic oxygen dependence (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). The patient lived with family. Review of the POC dated 11/30/2021 to 02/27/2022, failed to show any individualized interventions, goals, or outcome for pulmonary hypertension, chronic pain, pulmonary embolism, and respiratory failure. The POC had pregenerated interventions and goals, not specific to each individual patient or family/caregiver. Review of the medication list dated 11/30/2021, showed the patient was on Eliquis (anticoagulant) 5 milligram (mg) twice a day. The POC failed to show any possible side effects or any interventions specific to the anticoagulant. Review of the skilled nurse's note, dated 01/04/2022, showed the patient gets short of air walking short distances. The nurse encouraged the patient to take short breaks in between walking to help with the shortness of air. The POC failed to show this intervention. Review of the skilled nurse's note, dated 01/07/2022, showed the patient ambulates with a walker and requires oxygen continuously. The POC failed to show interventions for the walker and failed to show the patient wears oxygen continuously. Review of the skilled nurse's note, dated 01/10/2022, showed the visit was a PRN (as needed) visit. The patient had called the agency with a bloody nose, upon the nurse's arrival, the patient no longer was having a bloody nose. The nurse assessed the patient and the oxygen humidifier was not connected to the oxygen concentrator, so the nurse got one and applied the humidifier to the oxygen concentrator and the patient felt immediate relief. The POC failed to show this intervention for the oxygen. Review of the skilled nurse's note, dated 01/21/2022, showed the patient complained of more fatigue and informed the nurse that he/she was not sleeping at night. Melatonin (an over-the-counter sleep supplement) was added to the bedtime medication planner. The POC failed to show an order for the Melatonin and the problem of difficulty sleeping at night. Observation on 02/08/2022 at 11:00 AM, during the patient's home visit, showed the patient was using a walker and had oxygen on at three liters per nasal cannula. The POC failed to show when the patient was to wear oxygen and at what liter, it also failed to show when the patient was to use the walker. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 03/19/2020, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the brief narrative statement of terminal illness, showed the patient's co-morbidities included: hypertension (elevated blood pressure), gastroesophageal reflux (GERD; a digestive disease in which stomach acid or bile irritates the food pipe lining), and depression (a mental health disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning). The patient lived in a skilled nursing facility. Review of the POC dated 09/17/2021 failed to show any individualized interventions, goals, or outcome for hypertension, GERD, and depression. The POC had pregenerated interventions and goals, not specific to each individual patient or family/caregiver. Review of the long-term care physician orders, dated 03/02/2021, showed the patient was on nectar thick liquids with mechanical ground meat. Special instructions: May have regular/thin liquids for comfort as desired. The POC failed to show this diet order or special instructions. Review of the chaplain's note, dated 11/23/2021, showed the chaplain to spoon feed the patient his/her lunch to ensure the patient eats the optimum amount he/she is able and/or desires to consume. The POC failed to show this intervention. Review of chaplain's note, dated 12/14/2021, showed the chaplain arrived close to lunch, intentionally to assist the patient in eating lunch to ensure the patient ate as much as he/she wanted and as he/she was able to eat. The POC failed to show this intervention. Review of the physician orders, dated 01/11/2022, showed the hospice nurse was to perform wound care to the patient's right buttock pressure ulcer. Using clean technique, cleanse the site with warm, soapy water, pat dry, and apply zinc barrier ointment twice weekly and as needed. Instruct facility staff on wound care. The hospice nurse to assess the wound at every visit. The POC failed to show the patient had an actual skin problem with specific interventions or goals. During an interview on 02/10/2022 at 11:45 AM, the administrator stated that she expected the POC to be individualized and could find no further documentation by the survey exit.

Based on policy review, record review, and interview, the agency failed to ensure the bereavement plan of care reflected the bereaved needs for two (Records/Patients #8 and #10) of two bereavement records reviewed. This deficient practice has the potential to affect the unmet bereavement needs for all bereaved served by the agency. Findings included: Review of the agency's policy titled, "Bereavement Services," dated revised 12/2018, showed the following: -Purpose: To ensure that appropriate and coordinated bereavement services are provided to families/caregivers; -The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patient's death in accordance with the plan of care. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing complicated grief reactions that may interfere with the eventual resolution and integration of their losses; -A bereavement risk assessment will be completed by the hospice social worker or Registered Nurse (RN) at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. Risk level will be reassessed at the post death and as needed throughout hospice services; -After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed; and -Persons deemed to be experiencing moderate or high-risk grief are followed by the bereavement program with increased services and contact as noted in the plan of care. Persons identified will be referred to the Bereavement Coordinator and intervention will be provided as follows: -The Bereavement Coordinator will evaluate each bereaved on a case-by-case basis and evaluate the need for individual counseling. If necessary, the bereavement, spiritual care, or social work hospice personnel provide individual counseling to the bereaved. Referrals to outside professionals may also be required. RECORD/PATIENT #8: Review of the clinical record showed: -The patient was admitted to hospice on 09/21/2021; -The date of the patient's death was 10/01/2021; -The bereavement assessment dated 10/06/2021, showed the bereaved at low risk; -The bereavement assessment dated 11/23/2021, showed the bereaved at moderate risk; and -Bereavement note dated 11/23/2021, showed first bereavement visit with the bereaved. The bereaved reports a long-term history of depression, which had become worse since the death of his/her parent. The bereaved explained that caring for his/her parent over the last 3 years had alleviated his/her depression as it gave him/her something to do, now without this, he/she finds his/herself feeling sad frequently and somewhat lost. The bereaved and his/her spouse are spending time exercising and watching television programs which help at times. The bereaved also discussed how he/she wants to help his/her child with career goals, the social worker provided resource for the bereaved and the family of volunteermatch.org and explained how volunteer opportunities can help people to learn about themselves and to feel productive in doing good for other people. The bereaved shared that he/she was working to get an appointment with a psychiatrist who he/she had used to see. The social worker provided resource packet with lists of support groups and local grief counselors sorted by area within the region. The social worker educated on the relative merits of individualized counseling versus support groups. The social worker provided validation for the bereaved and educated on how his/her feelings of guilt are common part of the grieving experience. The social worker provided additional education on the physical processes which occur at end of life. The social worker provided emotional support and empathetic listening to the bereaved whom became tearful during the visit. The bereaved denied having any suicidal ideation or intent. The bereaved said he/she believed they would get through the difficult season of life in time, but that it was very difficult for him/her right then. The social worker offered to follow up with the bereaved in one month and the bereaved agreed. Review of the bereavement plan of care showed no individualized interventions, it was a list of tasks to complete at different times. RECORD/PATIENT #10: Review of the clinical record showed: -The patient was admitted to hospice on 04/15/2021; -The date of the patient's death was 11/02/2021; -The bereavement assessment dated 11/04/2021, showed the bereaved at moderate risk; and -Bereavement coordinator performed initial bereavement call on 11/09/2021 with the bereaved. The bereavement coordinator offered condolences to the bereaved. The bereavement coordinator inquired about how the bereaved was coping. The bereavement coordinator acknowledged the plethora of losses the bereaved had experienced in the last year, including his/her spouse's parent and his/her spouse's sibling. The bereaved said, "It's been a year" and reflected on how he/she has not had time to properly grieve his/her losses. In reflection, the bereaved said it had been a difficult six years full of loss, since he/she had lost his/her own parents and a few years ago. The bereavement coordinator educated on bereavement program services such as phone support, in-person visits, and mailings. The bereaved considered the bereavement coordinator's offer for a visit and said he/she would likely benefit from receiving in-person grief support. The bereaved acknowledged that he/she had not been attending to his/her own self-care needs. The bereaved was feeling a mix of emotions in the recent days and as of that day he/she was just leaving the cemetery and visiting with family and friends. He/she said he/she was feeling "numb." The bereavement coordinator provided emotional support and empathetic listening. The bereaved said he/she did not want to schedule a bereavement visit right then, but welcomed a phone call again in two weeks. Review of the bereavement plan of care showed no individual interventions, it was a list of tasks to complete at different times. During an interview on 02/10/2022 at 9:15 AM, the bereavement coordinator stated that the bereavement plan of care was based off the bereavement assessment and interventions would be documented in his/her notes and on his/her calendar. He/she stated that the agency system would not allow them to add interventions, it was a generated plan of care based on if the bereaved was low, moderate, or high risk. A review of the clinical record findings for the patients was completed with the administrator on 02/10/2022 at 11:45 AM, nothing further was provided by the time of exit.

Based on policy review, record review, and interview, the agency failed to ensure physician orders were obtained in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the quality of care for all patients receiving services. Findings included: Review of the agency's policy titled, "Verification of Physician Orders," revised 12/2018, showed in part the following: -Purpose: To ensure that accurate physician (or other authorized independent practitioner) orders are obtained in accordance with applicable law and regulation; and -Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 11/30/2021 with a terminal diagnosis of malignant neoplasm of unspecified part of left breast. The patient lived with his/her granddaughter. Review of the start of care note, dated 11/30/2021, showed the patient had oxygen on at three liters per nasal cannula. Review of the skilled nurse's note, dated 12/28/2021, showed the patient had oxygen on at two liters per nasal cannula. Review of the skilled nurse's note, dated 01/07/2022, showed the patient ambulates with a walker and requires oxygen continuously. Review of the skilled nurse's note, dated 01/13/2022, showed the patient had oxygen on at three liters per nasal cannula. Review of the skilled nurse's note, dated 01/18/2022, showed the patient's oxygen level was 74% on room air and the nurse applied oxygen at three liters and within two minutes the oxygen level was 97%. Review of the skilled nurse's note, dated 01/21/2022, showed the patient's oxygen level was 85% on room air and the nurse applied oxygen at two and a half liters and that raised the oxygen level to 95%. The patient also complained of more fatigue but with decreased sleeping at night. Melatonin was added to the bedtime planner. Review of the skilled nurse's note, dated 01/29/2022, showed the patient opened the front door for the visit. Patient noted with severe shortness of air on exertion. Oxygen level was 81% on four liters per nasal cannula, noticed tubing was not attached to oxygen concentrator, reattached and waited 15 minutes and rechecked oxygen level and was up to 95% on four liters. Review of the clinical record failed to show the following physician orders: -On 11/30/2021 Oxygen three liters per nasal cannula; -On 12/28/2021 Oxygen two liters per nasal cannula; -On 01/07/2022 Oxygen continuously; -On 01/13 and 01/18/2022 Oxygen three liters per nasal cannula; -On 01/21/2022 Oxygen two and a half liters per nasal cannula and Melatonin at bedtime; and -On 01/29/2022 Oxygen four liters per nasal cannula. During review of findings and interview with the administrator on 02/10/2022 at 11:45 AM, he/she stated that there should be an order for any new medications or treatments. No further documentation was provided at exit.

Based on record review, policy review and interview the agency failed to document a complete discharge summary containing all the components required by this regulation in two patients (Records/Patients #6 and #7) who was discharged (patient #6) or transferred (Patient #7) from the agency in two of three discharge/transfer records reviewed. This deficient practice has the potential to adversely affect the post-hospice medical care of all the agency's live discharged patients. Findings included: Review of the agency's policy titled, "Discharge Summary," dated revised 12/2018, showed in part the following: - Purpose: To define the requirements for documentation of a discontinuation of a service and when patients are discharged from hospice; - All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record; - Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include as appropriate: - The patient's latest physician orders; and - In the event of a transfer, a copy of the discharge summary will be provided to the receiving facility, as appropriate, to ensure continuity of care. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 10/27/2021 and discharged to the hospital on 01/02/2022 to seek further treatment. Review of the clinical record provided showed the latest physician orders missing, from the discharge summary. RECORD/PATIENT #7: Review of clinical record showed the patient was admitted to hospice on 11/05/2021 and transferred to another on 12/03/2021 to have further care. Review of the fax sent to the accepting hospice agency on 12/03/2021, showed the patient's latest physician orders missing from the discharge summary. The findings were reviewed with the hospice administrator on 02/10/2022 at 11:44 AM and 12:20 PM. No information was provided.

Based on review of the clinical record review, contract review, and interview, the hospice agency failed to document they supplied the inpatient provider with a copy of the patient's plan of care which included the respite services to be furnished by the long-term care facility, in one of one applicable case reviewed for respite (Record/Patient #11) and the contract failed to show the specified inpatient services to be furnished. This deficient practice has the potential to affect all patients admitted for respite care while receiving hospice services from the agency. Findings included: RECORD/PATIENT #11: Review of the clinical record showed the patient was admitted to hospice services on 01/13/2021. The hospice staff failed to document they furnished the long-term care facility a current hospice plan of care that included the respite services to be provided from 07/22/2021 until 07/26/2021. Review of the respite contract, dated 08/14/2014 failed to show the specified inpatient services to be furnished. During an interview on 02/10/2022 at 11:45 AM, the administrator said there was no documentation to show the patient's care plan was provided or that it included the inpatient services to be furnished during respite care. Also he/she said they were working on updating their contracts.

Based on review of an agency contract for respite services, and interview, the hospice agency failed to ensure the contract included the skilled nursing facility has established patient care policies consistent with hospice, in one of one respite contract (Contract A) reviewed. This deficient practice has the potential to affect respite services for all patients served by the agency. Findings included: Review of the agency's respite contract, dated 08/14/2014 with a skilled nursing facility failed to include the requirement that the skilled nursing facility has established patient care policies consistent with hospice. During an interview on 02/10/2022 at 11:45 AM the above findings were reviewed with the agency administrator. The administrator stated that the contract is outdated and they are actively working on revising the respite contract.

Based on review of an agency contract for respite services, and interview, the hospice agency failed to ensure the contract included the requirement for the hospice patient's clinical record to include a record of all inpatient services furnished and events regarding care that occurred at the facility, that a copy of the discharge summary be provided to the hospice at the time of discharge and that a copy of the inpatient clinical record be available to the hospice at time of discharge, in one of one respite contract (Contract A) reviewed. This deficient practice has the potential to affect respite services for all patients served by the agency. Findings included: Review of the agency's respite contract, dated 08/14/2014 with a skilled nursing facility, failed to include the requirement for the patient's clinical record to include all inpatient services furnished and events regarding care that occurred at the facility, that there be a copy of the discharge summary provided at discharge and a copy of the inpatient clinical record be available to the hospice at the time of discharge. During an interview on 02/10/2022 at 11:45 AM the above findings were reviewed with the agency administrator. The administrator stated that the contract is outdated and they are actively working on revising the respite contract.

Based on contract review between the hospice agency and skilled nursing facility (SNF) for respite services, and interview, it was determined that the hospice failed to specify the requirements set forth at Section 418.108(b)(1)(ii) for inpatient care for respite services in a SNF meeting the standards for patient areas in one (Facility #1) of one facility contract reviewed. The deficient practice has to potential to affect all agency patients receiving respite services from the SNF and care of any patient that receives general inpatient care for symptom control. Findings include: Section 418.108(b)(1)(ii) states that inpatient care for respite purposes may be provided by a Medicare or Medicaid-certified nursing facility that also meets the standards specified in Section 418.110(e). Review of Facility #1's contract for respite services dated 08/14/2014, showed that it failed to include provisions that the SNF provided a home like atmosphere, space for private and family visiting, accommodations for family members to remain with patient throughout the night, space for family privacy after a patient's death, and for visitors at any hour, including infants and small children. During an interview on 02/10/2022 at 11:45 AM, the above findings were reviewed with the agency administrator. The administrator stated that the contract is outdated and they are actively working on revising the respite contract.

Based on review of Missouri state law, personnel file review and interview, the hospice agency failed to obtain the employee disqualification list (EDL) prior to hire, in two employees (Employee #1 and #5) out of six employee files and two volunteer files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo showed the statement, "No person, corporation, organization or association who received the employee disqualification list under subdivisions (1) to (5) of subsection 11 of this section shall knowingly employ any person who is on the employee qualification list." Employee #1 (E1): Review of the personnel file showed that the date of hire was 01/03/2022. There was no evidence of an EDL prior to hire. Employee #5 (E5): Review of the personnel file showed that the date of hire was 10/11/2021. There was no evidence of an EDL prior to hire. During a review of findings and interview on 02/09/2022 at 4:20 P.M., the administrator stated that he/she did not have an EDL prior to hire for Employee #1 and Employee #5.

Based on federal law and Missouri state law review, employee file review, and interview, the agency failed to assure Alzheimer's training was provided annually in one (Employee #2) of six personnel files reviewed and two volunteers (Volunteer #1 and #2) of two volunteer files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of 19 CSR 30-35.010 (2) (M) 1. B. (xiii) requires: "Alzheimer's disease and related dementias. Hospice agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. (a) At a minimum, the training required shall address the following areas: A. An overview of Alzheimer's disease and related dementias; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; and E. Understanding and dealing with family issues. (b) Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: A. An overview of Alzheimer's disease and related dementias; and B. Communicating with persons with dementia. (c) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be provided annually and updated as needed." 2. Volunteers are exempt from these provisions, except for dementia-specific training as specified at 19 CSR 30-35.010(2)(M)1.B(XIII), as their orientation and in-service requirements are defined in 19 CSR 30-35.010 (2)(J)4., 5. and 6. EMPLOYEE #2: Review of the employee's file showed the employee's date of hire was 11/12/2020. The file showed Alzheimer's and dementia training was not completed since 11/23/2020. Volunteer #1: Review of the volunteers file showed the volunteer date of hire was 11/17/2014. The file showed no documentation of annual Alzheimer's and dementia training. Volunteer #2: Review of the volunteers file showed the volunteer date of hire was 01/16/2015. The file showed no documentation of annual Alzheimer's and dementia training. The findings were reviewed with the hospice administrator on 02/10/2022 at 10:42 AM. He/she stated that there was no annual Alzheimer's training for the volunteers and no further information was provided for employee #2.