Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 5 records (Patient #4) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4: The record indicated pressure wound care orders to the sacrum dated 9/27/24. There was not evidence of wound care or assessments regarding this wound. For the dates of 10/3/24, 10/10/24, and 10/16/24, documentation revealed, skin not assessed, 'patient in common room.' For the date of 10/24/24, documentation revealed skin not assessed, deferred. Agency policy indicates wounds are to be assessed weekly.

Upon patient record review, 1 of 5 records (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3: The record indicated that the patient is admitted with COPD and wears oxygen continuously. She also continues to smoke 1/2 to 1 pack of cigarettes/day. There was not evidence of specific goals and interventions based on the safety issues in regards to smoking and oxygen safety.

Upon patient record review, 1 of 5 records (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: The record indicated that the patient had a fall on 11/5/24. There was not evidence that the care plan was updated to include fall precautions as a safety measure.

Upon patient record review 1 of 5 records (Patient #1) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The visit frequency for the aide was 2x/week. For the week of 10/27/24-11/2/24, the record indicated only 1 missed visit document and no visits.

Upon patient client record review, 2 of 5 records (Patient #1,#3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. . Patient #1: The record indicated an order dated 10/23/24, HS 1W1, 2W8, effective 10/23/24. Leadership confirmed that this was most likely an aide frequency. There was not evidence that HS is an acceptable abbreviation for the aide. Patient #3: Documentation in an IDG dated 10/31/24, regarding the question in the narrative section asking if the patient was a full code, and the social worker responded, "yes." The record indicated that the patient has an Advance Directive indicating a DNR which is a part of the record.

Upon patient record review, 6 of 19 (Patient #3,5,6,7,12,16) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3 Antibiotic ordered on 8/23/24 for 7 days, no evidence of an end date on medication profile. Patient #5 SN note on 9/6/24 states patient with oxygen in place, no evidence on medication profile Patient #6 SN note on 9/11/24 states the patient using oxygen via NC @ 6LPM, order on 5/12/24 states Oxygen administration via NC at 3-5LPM and via non-rebreather mask at 6-8LPM. Patient #7 SN note on 8/20/24, 8/27/24, 9/1024 and 9/13/24 state the patient is using oxygen at 4LPN via NC continuously, no evidence of oxygen on medication profile Patient #12 SN note on 7/25/24 state patient utilizing oxygen @ 32LPM, 8/5/24 @ 4LPM, 8/15/24 @ 3-4LPM, 8/21/24 and 8/26/24 @ 2LPM, however order in place on 4/1/24 for oxygen administration @ 3LPM continuous, no evidence on medication profile Patient #16 SN note on 8/2/24 states the patient is using oxygen 2-4lpm and order is for oxygen 2lpm QHS however, there is not evidence of oxygen order on medication profile.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #16 did not have a bereavement risk assessment completed.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #16 had a nurse visit with comprehensive assessment on 8/2/24 and did not receive the next one until 8/19/24.

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

Upon patient record review, 2 of 19 (Patient #3,8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3 Plan of Care does not include Bleeding Precautions Patient #8 Plan of Care does not include Oxygen Precautions

Upon patient record review, 6 of 19 (Patient #3,7,8,12,16,17) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3 Order on 7/5/24 state Chaplain frequency of 1PRN and MSW of 1PRN. Patient #7 Order on 8/16/24 for Chaplain frequency of 1PRN EVAL and MSW 1PRN EVAL. On 8/20/24 the Chaplain Add-on visit order states frequency of 1MO3, effective 8/16/24 and on 8/20/24 the MSW add on visit order states frequency of 1MO3 effective 8/20/24. Patient #8 Order on 6/10/24 for MSW visit frequency of 1PRN Patient #12 Order on 4/9/24 MSW visit frequency 1PRN, Chaplain frequency 1PRN Patient #16 Order on 6/11/24 MSW visit frequency 1PRN and on 6/17/24 MSW visit frequency order for MSW 3PRN effective 6/11/24 1MO4, 4 PRN. On 6/11/24 Chaplain visit frequency 1PRN and on 6/17/24 has 2 different orders for Chaplain frequency, one is written by MSW with frequency of 1MO3 and an additional order written by the Chaplain with frequency of 3 PRN effective 6/11/24 1EVERY2M2, 1M1 Patient #17 Order on 4/25/24 state Chaplain frequency of 1PRN and MSW 1PRN

Upon patient record review, 6 of 19 (Patient #3,5,6,7,12,16) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 Antibiotic ordered on 8/23/24 for 7 days, no evidence of an end date on order. Patient #5 SN note on 9/6/24 states patient with oxygen in place, no evidence of an order. Patient #6 SN note on 9/11/24 states the patient using oxygen via NC @ 6LPM, order on 5/12/24 states Oxygen administration via NC at 3-5LPM and via non-rebreather mask at 6-8LPM. Patient #7 SN note on 8/20/24, 8/27/24, 9/1024 and 9/13/24 state the patient is using oxygen at 4LPN via NC continuously, no evidence of oxygen order in place. Patient #12 SN note on 7/25/24 state patient utilizing oxygen @ 32LPM, 8/5/24 @ 4LPM, 8/15/24 @ 3-4LPM, 8/21/24 and 8/26/24 @ 2LPM, however order in place on 4/1/24 for oxygen administration @ 3LPM continuous. Patient #16 SN note on 8/2/24 states the patient is using oxygen 2-4LPM, however order in place for oxygen 2LPM QHS.

Upon patient record review, 2 of 19 (Patient #16,19) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #16 Patient utilizes a walker for mobility, however it is not on the plan of care. Patient #19 Patient utilizes a cane for mobility, however it is not on the plan of care.

Upon patient record review, 1 of 19 (Patient #13) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #13 the Plan of Care still has music therapy included, however music therapy is no longer provided.

Upon client record review, 6 of 19 (Patient #3,4,6,8,15,16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 MSW note on 8/13/24 states patient frequency of 2x/month and order in place is for 2M1, MSW visit made 8/13/24 with no evidence of a 2nd visit made per order. Patient #4 Order on 8/5/24 states MSW frequency is 1M1, 2M2 with effective date of 8/1/24 in addition to an order on 8/1/24 for MSW x1 EVAL, however MSW visits made on 8/5/24 and 8/20/24 with no evidence of an order for an additional visit. Patient #6 SN note on 8/15/24 states wound care completed to skin tear, no evidence of wound care orders in place. Patient #8 Order on 6/10/24 states SN visit frequency is 1WK9. SN visits were made 8/8/24, 8/22/24 and 9/5/24. No evidence of visit made or evidence of missed visits the week of 8/11/24 and 8/25/24. Patient #15 Order on 6/20/24 with effective date of 6/29/24 states MSW 1 visit every month. No evidence of visits made or missed visit documentation for June, July and August. Patient #16 Order on 6/11/24 states MSW visit frequency is 1M4, however the patient received MSW visits on 6/17/24 and 6/24/24.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #14, during the home visit with the Aide did not wash her bag or place a barrier down, the infection control bag technique was not followed per policy.

Upon patient record review 3 of 19 (Patient #3,8,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3 Aide care plan states patient to utilize walker at every visit however, Aide documented on 9/9/24, "Patient does not walk", 9/12/24 "Not needed" and on 9/16/24 "Patient uses wheelchair" Aide care plan included bathing the patient at every visit. On 8/30/24, 9/4/24, 9/9/24 and 9/11/24, aide documented she did a bed bath. Aide care plan includes use of bed side commode. On 9/9/24 aide documented "Pt does not use BSC" and 9/12/24, aide documented bed side commode "Not needed". Patient #8 Aide care plan includes obtaining weight on the 1st visit of every month. Aide documented "per visit frequency, not needed this visit" on 8/1/24 and 9/5/24, which were the 1st visits of the month. Patient #12 Aide care plan included shaving to be completed at every visit. Aide documented "Shaving not needed" on 7/18/24 and 8/22/24

Upon patient record review 1 of 19 (Patient #16) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #16 had a supervisory visit on 8/2/24, however the next visit was not completed until 8/19/24.

Upon patient client record review, 1 of 19 (Patient #5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #5 SN note on 8/6/24 and 8/13/24 state "Wound care completed as ordered" which did not include clear, complete details of care provided or how the patient tolerated the care.

Upon client record review, 1 of 19 (Patient #12) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #12 had orders for MSW frequency 2 PRN and 2 visits monthly effective 7/1/24. Visits were made on 7/8/24 and 7/25/24, however no visits were made in August

Upon patient record review, 2 of 19 (Patient #12, 13) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #12, 13 There was no documentation in the clinical record that the SNF received the update on the most recent hospice plan of care.

Based on record review, interview and policy review, the agency failed to ensure a nurse was present during a patient's death. This affected one (Patient #1) of three patients reviewed for nursing services. The agency census was 231. Findings include: Review of Patient #1's medical record revealed the agency was notified by the Patient #1's friend on 01/23/22 at 3:23 PM that Patient #1 was transitioning to death, but had declined a hospice visit at this time. The friend was advised to notify the hospice if the patient expired. The agency email documentation on 01/23/22 at 6:50 PM documented Patient #1 had expired and that Staff Nurse F would do a phone visit. Interview with Administrative Staff B on 04/06/22 at 11:00 AM confirmed the RN did not physically go to the home of the Patient #1, pronounce the death or follow the agency's policy on Patient Death but only completed a telephone visit. Staff B verbalized there was inclement weather on 01/23/22 but the agency had not activated its emergency plan for weather so the expectation was for the RN to be present in the home of the deceased and completed the expected tasks per agency policy. Staff B verbalize he was not notified of the telephone visit until he arrived at the office the next day. Review of the job description of the registered nurse case manager revealed the registered nurse was to attend the death of patients to assist and support the family. Review of the agency's policy titled "Patient Death", dated February 2022, directed the registered nurse complies with state and local regulations regarding pronouncement of death; notifies the designated patient contact person; performed post mortem care; remains in the home until funeral home personnel arrive; and instructed daily members to discard all medications.

Based on record review, interview and policy review, the agency failed to ensure bereavement services were offered to a family after a patient expired. This affected one (Patient #1) of three patients reviewed for nursing services. The agency census was 231. Findings include: Review of the medical record for Patient #1 revealed the natural son was documented as the first emergency contact with a grandson listed as a second emergency contact. The patient made her home with the grandson until 11/03/21 when the patient moved into a niece's home. The niece then became the patient's primary caregiver. The medical record revealed the the agency had completed the initial risk bereavement risk assessment for the grandson at the time of the initial start of care visit on 10/05/21 and who was assessed as no risk at that time. The medical record contained no other bereavement risk assessments, although the medical record documented the patient was living with a niece from 11/03/21 until the date of death on 01/23/22. The medical record contained no documentation of the nieces' full name and contact information. There medical record lacked documentation a bereavement risk assessment was completed for any additional family members or caregivers other than the grandson during the start of care visits. The immediate post death observation note documented a niece and family were present at the time of the death. The agency failed to make a death visit and no observations were made by the nurse to determine the identity of all the bereaved nor were any additional bereavement risk assessments completed other than for the grandson. During interview on 04/07/22 at 9:47 A.M., Staff D, the social worker, stated the agency process was to complete a bereavement risk assessment during the start of care. The bereavement risk assessment was usually completed by the social worker although the nurse could complete the assessment. This assessment was usually completed for the primary caregiver, in this case it was completed for the grandson who the patient lived with. There was a complex family dynamic with Patient #1 and her family. Bereavement risks assessments would then be completed as necessary during the course of the patient's care by the agency and as the agency staff became aware of the patient's close contacts and caregivers. The medical record would then be updated to reflect the identity of the potential bereaved who would be most effected by the patient's death and risk assessments should then be completed. This information should be updated and added to the medical record. If the medical record was not updated with this new information and bereavement risk assessments not completed, the bereavement plan of care, which goes into effect after the patient's death, would not capture these additional people. Staff D verified there were no additional contacts identified in the medical record for the niece and her significant other who the patient made her home until the time of the patient's death nor for the patient's primary emergency contact who was the natural son of the patient. Staff D confirmed there were no additional bereavement risks assessments completed except for the grandson at the start of care and after the patient had expired. Review of the agency's "Bereavement Coordinator Guidebook", dated September 2021, directed the bereavement risk assessment was completed by the registered nurse along with he social worker within five days and was part of the comprehensive assessment of the patient's admission to the agency. It further directed it was important to understand the assessment was not a single event, but rather a continuous process throughout contacts with the bereaved individual. At the time of death an Immediate Post Death Observation Coordination Note, was completed by the RN who attended the death to ensure the caregiver and family bereavement needs were identified. In order to be listed as a bereavement contact, a bereavement risk assessments needed completed at appropriate timepoints; A death event indicated in the electronic medical record (EMR) would generate a list of bereaved provided contacts were entered and the bereaved were selected for the contact.

Based on record review, interview and policy review, the staff failed to properly dispose of opioid medications or other controlled medications after a patient's death. This affected one (Patient #1) of three patients reviewed for nursing services. The agency census was 231. Findings include: Review of the Patient #1's medical record revealed the agency was notified by the Patient #1's friend on 01/23/22 at 3:23 PM that Patient #1 was transitioning to death. The friend declined a hospice visit at this time and was advised to notify the hospice if the patient expired. The agency email documentation on 01/23/22 at 6:50 PM documented Patient #1 had expired and that Staff Nurse F would do a phone visit. Review of the patient's medication profile revealed the patient had a physician's order for Morphine Sulfate Concentration (opioid medication) 100 milligrams in a 5 milliliter solution (20 milligrams per ml) for treatment of pain and shortness of breath and Ativan (anti-anxietal medication) 0.5 milligrams for agitation Interview with Administrative Staff B on 04/06/22 at 11:00 AM confirmed the RN did not physically go to the home of the Patient #1, pronounce the death or dispose of the controlled substances in the patient's home. Staff B confirmed the agency has no documentation of the amount of controlled medications remaining in the home, any documentation of the disposal of the medications or the final disposition of these medications. Staff B verbalized there was inclement weather on 01/23/22 but the agency had not activated its emergency plan for weather so the expectation was for the RN to be present in the home of the patient at the time of death or shortly after and complete the expected tasks per agency policy. Staff B verbalized he was not notified of the death visit via a telephone visit until he arrived at the office the next day. Review of the job description of the registered nurse case manager revealed the registered nurse was to attend the death of patients to assist support the family. Review of the agency's policy titled "Patient Death", dated February 2022, directed the registered nurse complies with state and local regulations regarding pronouncement of death; notifies the designated patient contact person; performed post mortem care; remains in the home until funeral home personnel arrive; and instructed daily members to discard all medications. Review of the agency's policy titled "Management and Disposal of Controlled Substances and Other Medications in the Patient's Home", dated February 2022, directed under the heading of Drug Disposal and item number 3, The nurse together with the household member, counts and documented the amount of each drug and verified against the patient's electronic medical record. Following disposal of the controlled substances the nurse documented the following, type of controlled substances/prescription drugs, dosage, dosage form, route of administration, quantity disposed of, and date time and manner of disposal. The household member reviewed, signed and dated the Drug Disposal and or Refusal Form FHL-12022 acknowledging witnessing drug disposal. This completed form was scanned into and maintained in the patient's electronic medical record. Drug disposal was performed by the facility staff or pharmacist per the nursing facility policy for facility patients. Review of the agency's policy titled Patient Death Policy 835 with a date of 02/22 directed that the agency procedures comply with respective state and local rules and regulations for pronouncement of death and provide emotional support of the bereaved. The procedure directed that the Registered Nurse (RN) was to notify the designated contact person, perform post mortem care, remain in the home until the funeral home personnel arrive, and for home health, instruct the family members to discard all medications.

Upon patient record review, 4 of 5 (Patient #1-4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1 The 11/12/21 plan of care wound care frequency reads daily and prn with no qualifier. Patient #2 The 11/5/21 plan of care reads PICC site care daily but does not specify what PICC care to be performed is. Patient #3 The 11/3/21 plan of care wound care frequency reads daily and prn with no qualifier. Patient #4 The 11/1/21 plan of care wound care frequency reads daily and prn with no qualifier.

Upon observation, there was no evidence that emergency preparedness training and testing program analyzed the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed The agency activated their emergency plan on 9/21/20 for a power outage, on 11/30/20 and 12/1/20 for snow, and on 9/1/21 for a power outage. No evidence of an evaluation of the emergency response to the weather events.

Upon patient record review 1 of 16 (Patient #10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #10: Admitted on 1/31/21, spiritual assessment not completed until 2/19/21.

Upon patient record review, 15 of 16 (Patient #1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15 and #16) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1, #6, #8, #9: Medical record contained evidence of oxygen use by the patient. No evidence of oxygen on medication profile. Patient #2, #10: Initial plan of care included DME for oxygen. No evidence of oxygen on medication profile. Patient #3, #4, #13, #16: Medication profile included oxygen 2-5LPM prn sob. No evidence of the route of administration on medication profile. Patient #5: Medication profile included oxygen 1-4LPM. No evidence of route of administration on medication profile. Patient #11: Medication profile included oxygen 2-4LPM prn sob. No evidence of the route of administration. Patient #12: RN visit on 9/4/21 documented Morphine IV and Ativan IV. No evidence of Morphine or Ativan on medication profile. Patient #14: Medication profile included oxygen 2-5LPM continuous. No evidence of the route of administration. Patient #15: RN visit on 6/2/21 documented Lasix 20mg po daily for 1 week. No evidence of Lasix on medication profile.

Upon patient record review, 5 of 16 (Patient #4, #5, #9, #11 and #14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient #4: Admitted on 9/13/21, bereavement risk assessment was not completed until 9/23/21. Patient #5: Admitted on 6/7/21, bereavement risk assessment was not completed until 8/5/21. Patient #9: Admitted on 12/5/20, no evidence of a bereavement risk assessment as part of the comprehensive assessment. Patient #11: Admitted on 4/15/21, bereavement risk assessment was not completed until 4/21/21. Patient #14: Admitted on 12/11/20, bereavement risk assessment was not completed until 12/18/20.

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

Upon patient record review, 3 of 16 (Patient #3, #11 and #13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: Admitted on 8/27/21. RN visits on 8/27/21, 8/28/21, and 9/2/21 document wound. No evidence of assessment of wound until 9/10/21 RN visit. Patient #11: Patient had a Pleurex drain to right flank. No evidence of nursing assessment of the Pleurex drain site during nursing visits from 9/14/21-10/12/21. Patient #13: RN visit 8/18/21 indicated a new assessment of skin tear/wound to left lower back. No evidence of nursing assessment of skin tear/wound on 8/25/21 and 9/2/21 RN visits. RN visit on 9/8/21 documented skin tear/wound healed.

Upon patient record review, 1 of 16 (Patient #15) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #15: There was no evidence of patient/caregiver teaching or education for the following medications: AYR Saline Nasal Spray, Biotene, Celebrex, CO Q10, Fish Oil, Simethicone, Nasocort, Refresh Optive eyedrops, Saline Nasal Mist, Vision tablets, and Zinc Oxide.

Upon patient record review, 8 of 16 (Patient #1, #3, #4, #5, #7, #9, #10, and #12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. Patient #1: Initial RN visit on 5/27/20 documented diet downgraded from regular to mechanical soft due to coughing and choking on food while eating. No evidence of goals and interventions for aspiration precautions. Patient #3: Medical record contained information identifying patient as having aspiration precautions. Patient was also on Plavix and had a sacral wound. No evidence of goals and interventions for aspiration precautions, bleeding precautions, or skin breakdown on the plan of care. Patient #4: Medical record contained information identifying patient as having aspiration precautions. No evidence of goals and interventions for aspiration precautions. Patient #5: Patient on Aspirin. No evidence of goals and interventions for bleeding precautions. Patient #7: Order dated 8/23/21 for mechanical soft diet with thickened liquids. No evidence of goals and interventions for aspiration precautions. Patient #9: Order dated 12/5/20 for mechanical soft diet. Patient was also on Plavix. No evidence of goals and interventions for aspiration precautions or bleeding precautions. Patient #10: Certification of terminal illness on 9/13/21 documented mechanical soft diet due to dysphagia. No evidence of goals and interventions for aspiration precautions. Patient #12: RN visit on 9/4/21 documented Morphine IV and Ativan IV. No goals or interventions for IV care and maintenance.

Upon patient record review, 3 of 16 (Patient #2, #11 and #14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #2: Initial plan of care dated 8/20/21 included visit frequency of 2w1, 1w8, 2w1, 1w1 and 3prn. No evidence of the discipline for the visit frequency. Patient #11: Order dated 9/27/21 for social work visit frequency of 3prn. Patient #14: Order dated 7/24/21 for social work visit frequency of 3prn.

Upon patient record review, 14 of 16 (Patient #1, #2, #3, #4, #6, #8, #9, #10, #11, #12, #13, #14, #15, and #16) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1, #6, #8, #9: Medical record contained evidence of oxygen use by the patient. No evidence of oxygen on the plan of care. Patient #2, #10: Initial plan of care included DME for oxygen. No evidence of an order for oxygen. Patient #3, #4, #13: The plan of care included oxygen 2-5LPM prn sob. No evidence of the route of administration. Patient #5: Medication profile included oxygen 1-4LPM. No evidence of route of administration on medication profile. Patient #11: Order dated 9/27/21 for oxygen 2-4LPM prn sob. No evidence of the route of administration. Patient #12: RN visit on 9/4/21 documented Morphine IV and Ativan IV. No evidence of an order for Morphine or Ativan. Patient #14: The plan of care included oxygen 2-5LPM continuous. No evidence of the route of administration. Patient #15: RN visit on 6/2/21 documented Lasix 20mg po daily for 1 week. No evidence of an order for Lasix. Patient #16: Initial plan of care dated 4/29/21 included oxygen 2-5LPM prn sob. No evidence of the route of administration. RN visit on 4/29/21 documented Jevity 1.5 bolus feeds x4 daily, no evidence of an order for Jevity.

Upon patient record review, 3 of 11 (Patient #2, #9, and #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Initial plan of care dated 8/20/21 included spiritual care frequency effective 8/22/21 of 1w1. Order on 8/23/21 for Spiritual care frequency of 1 visit within every 30 days x 2 months and 3prn. Spiritual care visit made on 8/23/21, no evidence of spiritual care visit or refusal of visit for the month of September. Patient #9: Order dated 9/10/21 for facility nurse to perform wound care to sacrum every other day. Hospice RN visit on 9/24/21 and 10/1/21 provided wound care. No evidence of an order for hospice nurse to provide wound care. Patient #11: Order dated 9/27/21 for spiritual care visit frequency effective 10/12/21 of 1 visit within every 30 days x 2 months and 3prn. Spiritual care visit made on 8/24/21, no evidence of a visit or refusal of a visit for September.

Upon observation 2 of 4 applicable (Patient #1 and #2), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1 during RN visit with surveyor, RN placed cleaned equipment on the barrier where she had previously had the dirty equipment. Patient #2 during the RN visit with the surveyor, the RN placed the dirty equipment (thermometer, BP cuff, and pulse oximeter) into the clean bag.

Upon patient record review, 3 of 13 applicable (Patient #6, #7 and #10) did not have evidence in the patient record that hospice aide assignments and duties are: assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group and written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #6: Record indicated patient was on a pureed diet and identified as high risk for aspiration. No evidence of aspiration precautions on aide care plan. Patient #7: Order dated 8/23/21 for mechanical soft diet with thickened liquids. No evidence of aspiration precautions on aide care plan. Patient #10: Certification of terminal illness dated 9/13/21 documented mechanical soft diet due to dysphagia. No evidence of aspiration precautions on aide care plan.

Upon patient record review 7 of 13 applicable (Patient #1, #2, #3, #4, #7, #9 and #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: ordered by the interdisciplinary group and included in the plan of care Patient #1: Orders dated 7/6/21 and 9/4/21 for aide visit frequency of 1x/week. No aide visits documented in July, 1 aide visit documented on 8/23/21 for August, No aide visit documented for week of 9/12/21 or 9/19/21. No evidence of refusal of missed visits during this time frame. Patient #2: Aide visit frequency ordered as 2x/week. Record only contained evidence of 1 aide visit documented each week. Blank missed visits note entered on 8/24/21, 9/3/21, 9/9/21, 9/14/21, 9/21/21, 9/30/21 and 10/7/21. No evidence of a second visit these weeks or a refusal of a visit for these weeks. Patient #3: Aide visit frequency ordered as 2x/week. Record only contained evidence of 1 aide visit documented each week on 9/2/21, 9/23/21 and 9/30/21. No evidence of a second visit these weeks or a refusal of the second visits. Patient #4: Order on 9/13/21 for aide visit frequency of 1w1, 2w6, 1w1. No evidence of aide visit or refusal of aide visit the week of 9/13/21. Record only contained evidence of 1 aide visit on 9/23/21 for week of 9/19/21, no evidence of a second visit or refusal of visit this week. Patient #7: Order on 8/23/21 for aide visit frequency effective 9/7/21 of 2w9. Record only contained evidence of 1 aide visit made on 9/14/21. No evidence of visits the week of 9/7/21 or a second visit the week of 9/12/21. Patient #9: Aide care plan included weight weekly. Aide visits 2x/week. Both aide visits for weeks of 9/12/21, 9/19/21 and 9/26/21 all document weight not required this visit. Patient #13: Aide care plan included shower and shampoo as every visit. Aide visit on 8/11/21 documented shampoo not required this visit. Aide visit on 8/19/21 documented for shower "no" partial bed bath provided, no evidence of communication to change the bath. Aide visit on 8/24/21 documented shampoo not required this visit and shower "no" not patient shower day. Aide visit on 9/7/21 documented shower "no" not hospice day to shower.

Upon patient record review, 1 of 9 applicable (Patient #8) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #8: Order dated 7/8/21 for 7/23/21 certification period identified severe protein calorie malnutrition as the terminal diagnosis. Recertification of terminal illness dated 7/8/21 documented congestive heart failure as terminal diagnosis.

Upon patient record review, 3 of 16 (Patient #7, #10 and #15) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #7 order on 8/31/21 in order description documented volunteer 6x in 30 days and 4prn visits, under calendar frequency documented 10prn visits. Patient #10 order on 10/6/21 in order description documented volunteer 4x in 30 days, under calendar frequency documented 4prn visits. Patient #15 order on 5/28/21 in order description documented discontinue aide, under calendar frequency documented effective 5/30/21 11w1, 1every2w2.

Upon patient record review, 1 of 5 applicable (Patient #8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #8: Order dated 7/8/21 for spiritual care visit frequency effective 7/21/21 of 2 visits within 30 days for 3 months and 3prn. Spiritual care visits made on 9/1/21, 9/13/21, 9/27/21, and 10/13/21.