Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 5 (Patient #2) 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 2: RN admission documentation indicated that the patient has altered mobility and uses a walker, wheelchair. No evidence that problems, interventions, and goals related to altered mobility was included in the plan of care.

Upon patient record review 1 of 19 (Patient #7) 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 7: The medical record contained an initial spiritual assessment completed 5/14/25 with start of care 5/8/25.

Upon patient record review, 4 of 19 (Patients #3,#6,#9,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medical record contained nursing documentation 11/10/25 identifying patient is on oxygen. There was no evidence of oxygen on the medication profile. Corrected on site with clarification order received and medication profile updated. Patient 6: Upon home visit medication reconciliation the facility and hospice medication profiles did not match. The facility profile contained a lorazepam PRN that was not on the hospice profile. Corrected on site with clarification order received and medication profile updated. Patient 9: Upon home visit medication reconciliation the facility and hospice medication profiles did not match. The facility profile contained supplements including ascorbic acid, chlorthalidone, multi-vitamin and zinc that were not on the hospice profile. Corrected on site with clarification order received and medication profile updated. Patient 10: The medication profile contained two continuous oxygen instructions with differing doses. Corrected on site with clarification order received and medication profile updated.

Upon patient record review, 2 of 19 (Patients #8,#14) 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 8: There was no evidence of an RN physical assessment between 10/31/25 and 11/26/25. Patient 14: There was no evidence of an RN physical assessment between 11/6/25 and 11/28/25.

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

Upon patient record review, 1 of 19 (Patient #5) 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 5: There was no evidence of wound assessments and measurements between 10/3/25 and 11/6/25. Agency requires weekly wound assessments and measurements per policy.

Upon patient record review, 3 of 19 (Patients #1,#5,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record indicated patient is on Plavix. There was no evidence of problems, goals, and interventions related to the risk for bleeding included in the plan of care. Corrected on site with plan of care update. Patient 5: The medical record indicated patient is on Clopidogrel and contained nursing documentation since admission identifying issues of bed bug infestation. There was no evidence of problems, goal, and interventions related to risk for bleeding and bed bug precautions included in the plan of care. Corrected on site with plan of care update. Patient 14: The medical record contained nursing documentation upon admission identifying patient had previous Tylenol overdose and history of substance abuse. There was no evidence of problems, goals, and interventions related to medication management and substance abuse included in the plan of care. Corrected on site with plan of care update.

Upon patient record review, 4 of 19 (Patients #1,#3,#6,#9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained an order 11/28/25 to place foley catheter. There was no evidence of an order for catheter size, change frequency or maintenance. Corrected on site with order received. Patient 3: The medical record contained nursing documentation 11/10/25 identifying patient is on oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site with order received. Patient 6: Upon home visit medication reconciliation the facility and hospice medication orders did not match. The facility contained a lorazepam PRN order that was not in the hospice medical record. Corrected on site with order received. Patient 9: The medical record contained a wound care order 11/12/25 with no location of wound or frequency of wound care to be completed. Upon home visit medication reconciliation the facility and hospice medication orders did not match. The facility contained orders for supplements including ascorbic acid, chlorthalidone, multi-vitamin and zinc orders that were not in the hospice medical record. Corrected on site with orders received.

Upon patient record review, 6 of 19 (Patients #3,#5,#7,#9,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The medical record contained nursing documentation 11/10/25 identifying patient use of a hospital bed, overbed table, and oxygen. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of bedrails, low air loss mattress, and nebulizer. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a cane. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer, wheelchair, and trapeze. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, and 10/13/25 identifying use of a walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received.

Upon patient record review, 2 of 19 (Patients #8,#9) 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 8: The medical record contained nursing documentation 12/23/25 identifying patient has suffered intermittent nausea and vomiting in the benefit period. There was no evidence the plan of care was updated to include problems, goals, and interventions related to nausea and vomiting. Corrected on site with plan of care update. Patient 9: The medical record contained documentation of wound inactivation for coccyx wound 11/12/25 and right lower leg 12/17/25. The plan of care contained active problems, goals, and interventions related to wound care. There was no evidence the plan of care was updated to reflect the progress of the healed wounds. Corrected on site with plan of care update.

Upon client record review, 2 of 19 (Patients #3,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 12/14/25. Corrected on site with late data entry of reason for missed visit. Patient 14: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 11/30/25. Corrected on site with late data entry of reason for missed visit.

Upon patient record review 1 of 19 (Patient #5) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 5: The medical record contained nursing documentation upon admission informing the patient's responsible party that hospice aides cannot be provided due to bed bug infestation.

Upon patient record review, 2 of 19 (Patients #5,#9) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 5: The medical record contained nursing documentation 11/14/25 identifying the patient had former wound care visits weekly from an outside company. There was no evidence of documentation of the company's wound assessments and visits for collaboration of care. Patient 9: The medical record contained nursing documentation 12/1/25 identifying the facility has wound care provider that oversees wound care orders. There was no evidence of documentation from the facility regarding the wound for collaboration of care.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 12: The medical record contained nursing documentation 12/8/25 identifying patient had 2 falls the day prior. There was no evidence of an incident report and investigation to develop a plan of correction. Corrected on site with late data entry of event.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Patient 5: The medical record contained nursing documentation identifying the patient received wound care from Priority Wound Care one time weekly with hospice to provide wound care twice weekly. Treatment by the outside agency was within nursing scope of practice.

Upon patient record review, 2 of 19 (Patients #16,#17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan ofcare • Ensuring that bereavement services reflect the needs of the bereaved Patient 16,17: The bereavement care plans contained tasks of sending sympathy card, holiday letter, and memorial service invitation. There was no evidence of the assigned tasks completed. Corrected on site with late data entry of date tasks completed.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of oxygen and assessment as a high fall risk. The aide care plan did not include instructions regarding oxygen use and fall safety. Corrected on site with update to aide care plan.

Upon patient record review 2 of 19 (Patients #11,#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 11: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 11/23/25. Corrected on site with late data entry of reason for missed visit. Patient 12: The medical record contained an order for aide visits three times weekly. There was no evidence of visits completed the week of 11/9/25 and a third visit missing the week of 11/16/25. Corrected on site with late data entry of reason for missed visits.

Upon patient record review 1 of 19 (Patient #7) 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 7: There was no evidence of an aide supervisory visit since 11/23/25.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency volunteer utilization rate for 2025 was 2.85%.

Upon contract review, 1 of 7 (Priority Wound Care) the agency did not have evidence of an agreement to furnish any services for wound care under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care Patient 5: The medical record contained uploaded wound care orders Priority Wound Care. There was no evidence of a contract with the wound company.

Upon personnel record review, 1 of 15 (Personnel #6) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 6: There was no evidence of orientation to the job requirements. Corrected on site with documentation of orientation.

Upon patient client record review, 1 of 19 (Patient #17) did not have evidence that each patient record contains Advance Directives. Patient 17: The plan of care identified the patient as DNR. There was no evidence of a DNR form or living will in the medical record. Corrected on site with reception of DNR orders from the hospital where patient was receiving GIP.

Upon patient client record review, 1 of 19 (Patient #10) 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 10: The medical record contained nursing documentation upon admission identifying patient use of a ventilator in the DME assessment. There was no further evidence of a ventilator and after agency investigation, the documentation was in error.

Upon client record review, 1 of 19 (Patient #7) 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 7: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the weeks of 11/9/25 and 11/16/25.

Upon client record review, 1 of 19 (Patient #9) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 9: The medical record contained an order for wound care 11/12/25 with no specification for nursing facility and hospice responsibilities.

Upon patient record review 2 of 13 (Patient #9,#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 #9: The patient was admitted on 3/13/22. The record indicated that the spiritual assessment was completed on 5/6/22. Patient #10: The patient was admitted on 12/6/22. The record indicated that the spiritual assessment was completed on 12/16/22.

Upon patient record review 1 of 13 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4: There was not evidence of a spiritual assessment.

Upon patient record review, 7 of 13 (Patient #1,#3,#4,#7,#8,#11,#13) 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 #1: The medication profile indicated Polyethylene Glycol 3350 17 GM oral powder packet prn daily constipation as directed, per instructions. There was not evidence of a diluent. Corrected on site. Patient #3: The record indicated Bactrim for a UTI for 14 days. The dates listed were 1/3/23-1/13/23 which is less than the 14 days. Corrected on site. Patient #4: The medication profile indicated Triamcinolone cream 0.1% 2x daily to affected area. There was not evidence of a specific location. Corrected on site Patient #7: The medication profile indicated for Medrol dose pak 4mg tabs 11/1/22-11/8/22. Take as directed on package. There was not evidence of complete dosing instructions. Corrected on site. Patient #8: The medication profile indicated for Polyethylene Glycol 3350 17 GM oral powder packet, 1 daily. There was not evidence of a diluent. Corrected on site. Patient #11: The record indicated for Acetaminophen 650mg rectal supp, 1 q6h prn fever and Acetaminophen extra strength 500mg tabs, give 1000mg qh8 prn for mild to moderate pain, headache. There was not evidence of a parameter for the fever or a maximum allowable dose of Acetaminophen per 24h. Patient #13: The record indicated for Acetaminophen 650mg rectal supp, 1 q4h prn fever and Hydrocodone 5mg-Acetaminophen 325mg,1 4x/day prn pain. There was not evidence of a parameter for the fever or a maximum allowable dose of Acetaminophen per 24h.

Upon patient record review, 1 of 13 (Patient #4) 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 #4: The patient was admitted on 11/22/22. The record indicated that the bereavement assessment was completed on 12/2/22.

Upon patient record review, 3 of 13 (Patient #1,#3,#9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient was admitted with a diagnosis of malignant neoplasm unspecified site left breast. She had a history of a neoplasm of the right breast, and abnormal findings of her liver and lungs. Her recertification assessment by the nurse indicated that pain was an active problem. She was having episodes coughing and choking. There was not evidence that pain or comfort was reflected in the goals and interventions of the care plan. Corrected on site. In addition, the patient was admitted on 1/30/22 and was a full code. The record indicated that she was short of breath, and weaker. The physician narrative in the certification of terminal illness indicated that she was sleeping more, she was incontinent, had recent falls, now had a private aide several hours per day. Also short of breath with conversation and without exertion, and she was hallucinating. There was not evidence of end of life planning was a part of the plan of care. Corrected on site, Patient #3: The patient was admitted with a diagnosis of Parkinson's disease. He was weak, had rigidity, was incontinent, had sustained numerous falls, had a Foley catheter and also had lost 28 pounds. He was also on Divalproex for his tremors. There was not evidence that goals and interventions related to his neurological disease was a part of the plan of care. Corrected on site. Patient #9: The patient was admitted with a diagnosis or neurocognitive disorder with Lewy Bodies. He required assistance with 5 of 6 ADL's He was confused, forgetful, had difficulty with recall and frequent falls. He had jerky kick movements with ambulation, was disoriented to place and time and was starting to hallucinate. There was not evidence that goals and interventions related to his neurological disease was a part of the plan of care. Corrected on site.

Upon patient record review, 9 of 13 (Patient #1,#3,#4,#6,#7,#8,#11,#12,#13) 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 record indicated an order for Polyethylene Glycol 3350 17 GM oral powder packet prn daily constipation as directed, per instructions. There was not evidence of a diluent. Corrected on site. Patient #3: The record indicate an order to cleanse with NS, pat dry, apply mupirocin ointment and cover with dry dressing daily and prn until healed, There was not evidence of a location for the wound care. Corrected onsite. In addition, the record contained an order for Bactrim for a UTI for 14 days. The dates listed were 1/3/23-1/13/23 which is less than the 14 days. Corrected on site. Patient #4: The record indicated an order for Triamcinolone cream 0.1% 2x daily to affected area. There was not evidence of a specific location. Corrected on site. Patient #6: The record indicated an order dated 11/16/22 to cleanse with NS, pat dry and cover with dry gauze and secure with tape. There was not evidence of a location of the wound or a frequency to re-dress and provide wound care. Corrected on site. Patient #7: The record indicated an order dated 11/1/22 for Medrol dose pak 4mg tabs 11/1/22-11/8/22. Take as directed on package. There was not evidence of complete dosing instructions. Corrected on site. Patient #8: The record indicated an order for Polyethylene Glycol 3350 17 GM oral powder packet, 1 daily. There was not evidence of a diluent. Corrected on site. Patient #11: The record indicated orders for Acetaminophen 650mg rectal supp, 1 q6h prn fever and Acetaminophen extra strength 500mg tabs, give 1000mg qh8 prn for mild to moderate pain, headache. There was not evidence of a parameter for the fever or a maximum allowable dose of Acetaminophen per 24h. Patient #12: The record indicated that the patient had a stage 4 sacral wound, a wound on the posterior edge of his right foot and a wound on the mid edge of his right foot. Wound care was being provided including packing with alginate dressing to the sacral wound. There was not evidence of an order. Patient #13: The record indicated orders for Acetaminophen 650mg rectal supp, 1 q4h prn fever and Hydrocodone 5mg-Acetaminophen 325mg,1 4x/day prn pain. There was not evidence of a parameter for the fever or a maximum allowable dose of Acetaminophen per 24h.

Upon client record review, 6 of 13 (Patient #1,#2,#7,#11,#12,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The social work visit frequency was 2x/month and 2 prn. The record indicated only 1 visit during the month of December (on Dec 7). Corrected on site. Patient #2: The visit frequency for the skilled nurse was 3x/week for 2 weeks then 2x/week. For the week of 12/18/22-12/24/22, the record indicated only 1 visit on 12/19/22. Corrected on site. Patient #7: The social work visit frequency was 2x/month. For the month of November, the record indicated routine visits on 11/3/22, 11/9/22 and 11/22/22. Corrected on site. Patient #11: The social work visit frequency was for an evaluation and then 1x/month with 2 prn. The record indicated that the social work evaluation was conducted on 10/5/22 and subsequent routine visits in October were conducted on 10/10/22 and 10/18/22. Patient #12: The social work visit frequency effective 6/14/22 was 2x/month. The record indicated only 1 visit in July on 7/29/22. Patient #13: The record indicated an order for a social work visit on 7/13/22. There was not evidence of this visit.

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 #8, Aide: On observed home visit,there was not evidence of the staff member washing or sanitizing her hands prior to donning gloves and providing care. Patient #9, RN: On observed home visit, the staff member was observed removing equipment from her nursing bag, using it and placing it back in the bag without cleaning the equipment. The staff member continued to go in and out of the nursing bag to retrieve equipment while she had gloves on. Dirty equipment was placed in two sections of the bag without cleaning. Policy #6-013 Bag Technique indicates to remove supplies from the bag and place them on a clean dry surface barrier as needed. Do not re-enter the bag with gloves on. Remove, perform hand hygiene and then re-enter the bag. Clean equipment and supplies that had direct patient or environmental contact. The policy also contains information indicating that nothing inside the bag should be dirty therefore there does not need to be a designated clean and dirty side.

Upon patient record review, 3 of 13 (Patient #1,#6,#12) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions including precautions and alerts for a hospice aide that must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The aide plan of care dated 10/12/22 and 12/15/22 listed the task of ear care as 'every visit weekly.' The aide visit frequency was 3x/week. Corrected on site. Patient #6: The record indicated that the patient was on Eliquis 5mg, 1 tab daily. There was not evidence that bleeding precautions were a part of the plan of care. Corrected on site. In addition, the aide plan of care indicated to empty the trash on M-W-F. The record indicated that the aide visit frequency was 2x/week and care was most frequently provided on Tuesday and Thursday. Corrected on site. Patient #12: The aide plan of care indicated to provide a bed bath at every visit and to provide a shower at every visit.

Upon patient record review 6 of 13 (Patient #1,#3,#6,#8,#9,#11) 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 Patient #1: The aide plan of care indicated for the task of shampoo to be performed weekly. The aide visit frequency was 3x/week. For the weeks of 12/25/22-12/31/22 and 1/1/23-1/7/23, the record indicated only 2 visits each of these weeks. Shampoo was performed at both visits the week of 1/1/23. And, from 12/12/22-12/23/22 shampoo was performed at all visits. Patient #3: The aide plan of care indicated for the aide to take the patient's temperature, pulse, respirations and blood pressure at every visit. For the dates of 12/9/22, 12/12/22, 12/14/22, 12/16/22, 12/19/22, 12/21/22, 12/22/22, the documentation by the aide indicated, 'no, N/A.' Patient #6: The aide plan of care indicated for the task of nail care to be provided weekly. The record indicated that nail care was performed at all visits. The aide visit frequency was 2x/week. Patient #8: Upon observed home visit, the aide was observed shaving the patient. Shave was not a task on the aide plan of care. Patient #9: The aide visit frequency was 2x/week. There was not evidence of an aide visit for the week of 11/20/22-11/26/22. Corrected on site. Patient #11: The aide visit frequency ordered on admission (10/4/22) was 1w1, 2w12. There was not evidence of an aide visit until 10/11/22.

Upon patient record review 1 of 13 records (Patient #3) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures. Patient #3: On 12/7/22, and 12/9/22, the aide documentation indicated that the patient was unable to ambulate due to weakness. There was not evidence that the nurse was notified of the change in the patient condition.

Upon client record review, 3 of 13 (Patient #5,#8,#9) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #5: The skilled nurse visit frequency was 2x/week and 4 prn. For the week of 12/18/22-12/24/22, the record indicated only 1 visit on12/23/22. Patient #8: The visit frequency for the skilled nurse was 2x/week. From 12/4/22-12/31/22, the record indicate only 1 visit each week (12/7/22, 12/13/22, 12/19/22, 12/27/22). Corrected on site. Patient #9: The visit frequency for the social worker for the certification beginning 11/8/22 was 1x/month and 2 prn. There was an order dated 11/23/22, that indicated the social work visits to be 2x/week. The record indicated that visits were conducted on 11/17/22, 11/24/22, 12/5/22, 12/15/22, 12/20/22. Corrected on site.

Upon client record review, 1 of 13 (Patient #6) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #6: The record indicated an order dated 11/16/22 to cleanse with NS, pat dry and cover with dry gauze and secure with tape. There was not evidence of which provider was to provide the care. Corrected on site.

Upon patient record review, 2 of 13 (Patient #8,#9) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election forms specific to each patient Patient #8: There was not evidence of the most recent plan of care update in the SNF record. Corrected on site. Patient #9: There was not evidence of the most recent plan of care update or hospice election form in the SNF record. Corrected on site.