Every finding on record at Omega Hospice Care LLC

Based on record review and interview, the agency failed to protect the patient's right to a confidential clinical record for 1 (Patient #4) of 4 active patient records reviewed.  The failure placed the patients at risk of losing trust in the providers providing care. --- Patient #4:Record review of Patient #4's clinical record revealed a Plan of Care dated 2/24/3036 to 4/24/2026. The Plan of Care indicated that Patient #4 was admitted to the agency's services on 2/24/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary artery (reduced blood flow to the heart muscle due to buildup of fats, cholesterol and other substances in and on the walls of the heart arteries) without Angina Pectoris (chest pain) as the terminal diagnosis. The Plan of Care did not list Patient #4's medications. The surveyor received a phone call on 4/14/2026 from a Confidential Witness that a photo of Patient #4's medications and a medication list had been texted to a non-employee of the agency. The surveyor received an email on 4/14/2026 with a photo of medication bottles and a medication list for Patient #4. The photo showed the following medication bottles- Tylenol Rapid Relief 500 mg tablets- used to treat pain/fever, Sleep Quick- Melatonin 10 milligrams - used to regulate sleep, Divalproex 250 milligrams- used to treat seizures (abnormal electrical activity in the brain temporarily affecting consciousness, muscle control and behavior) and migraine (intense throbbing pain of the head lasting from hours to days) headaches, Clonidine (used to treat high blood pressure- the condition of the force of the blood against artery- blood vessel, walls being consistently too high) 0.1milligrams, Trazodone (used to treat major depressive disorder- persistent sadness, loss of interest or pleasure, and impaired daily functioning)  50 milligrams, Pantoprazole (used to reduce acid production in the stomach), Levothyroxine (used to treat condition where the thyroid gland does not produce enough thyroid hormone), another bottle with Melatonin 10 milligrams, and Cyclobenzap- the rest of the medication name was not visible, and a cough and congestion medication- name of medication not readable. The photo included a document of a list of medications with the name of Facility X on it. The document listed the following medications: Divalproex, Trazodone, Pantoprazole, Clonidine, Melatonin, and Levothyroxine. The document and seven medication bottles showed the name of Patient #4. The surveyor called the phone number that was indicated on the text message on 4/15/26 at 1:23 PM. The phone was answered by Registered Nurse D. Registered Nurse D confirmed that Registered Nurse D was employed at the agency. The surveyor asked Registered Nurse D if Registered Nurse D had texted a photo of medication bottles and a document with a list medications of Patient #4 to the wrong phone number yesterday (4/14/2024). Registered Nurse D stated, "Yes, I did." The surveyor asked what the policy regarding texting private health information to was. Registered Nurse D informed the surveyor that Registered Nurse D was not sure of the policy regarding texting of patient information. The surveyor asked why Registered Nurse D had texted the photos of Patient #4's medications. Registered Nurse D informed the surveyor that a caregiver (not named by Registered Nurse D) at a facility wanted the medications and gave Registered Nurse D the wrong phone number.  During an interview on 4/15/2026 at approximately 4:15 PM with the Administrator/Supervising Nurse and Chief Financial Officer, the surveyor asked what measures the agency used to keep patient records confident. The Administrator/Supervising Nurse stated, "The records are locked in the office; use of electronic medical records; make sure not to use patient full name in a business app that the agency utilized that was encrypted and secured, can send wound pictures; and we use an electronic prescription with the physicians. The surveyor asked if Patient #4 took medications. The Administrator/Supervising Nurse stated, "(Patient #4) takes medications." The surveyor asked if the Administrator/Supervising Nurse had known that a photo was texted to a non-employee that revealed medication bottles and a document with a list of medications for Patient #4. The Administrator/Supervising Nurse stated, "No, not until (Registered Nurse C) called after speaking to you. The Administrator/Supervising Nurse did not know why Registered Nurse C had texted the picture. Review of the agency's policy titled "Patient's Right and Responsibilities RI.10," last reviewed on 10/1/2022, read in part: "Purpose To ensure the patient, their representative (if any), and the Hospice staff acknowledge, protect, observe, and implement the patient's rights and responsibilities. Definition "Representative" means an individual who has the authority under State law (whether by statute or pursuant to an appointment by the courts of the state) to authorize or terminate medical care, or to elect or revoke the election of hospice care on behalf of a terminally ill patient who is mentally or physically incapacitated. This may include a legal guardian. Policy...II. The Hospice staff will receive in-service education regarding patient's rights and responsibilities on hire and annually thereafter...Procedure I. The Hospice staff will be responsible for knowing, observing, and implementing the patient's rights and patient responsibilities on an ongoing basis. The staff will also be responsible for protecting and promoting these rights...IX. Regarding patient's rights, the patient has a right to the following...E. To have a confidential clinical record..."

Based on record review and interview, the agency failed to include in the plan of care, all services necessary services for the palliation and management of the terminal illness and related condition including drugs and treatment necessary to meet the need of the patient, in that drugs were not included in the plans of care for 2 (Patient #2 and Patient #4) of 4 active patient records reviewed, and wound care treatment was not included in the plans of care for 1 (Patient #1) of 4 active patient records reviewed.  The failure placed the patients at risk of over-medication, under-medication, and adverse drug reactions, or worsening of wounds. --- Patient #1:Record review of Patient #1's clinical record revealed a Plan of Care dated 2/7/2026 to 4/7/2026. The Plan of Care indicated that Patient #1 started on the hospice's services on 8/11/2025. The Plan of Care listed End-stage Heart Failure (heart is too weak to pump blood through the body effectively) as the terminal diagnosis. The Plan of Care listed Sodium Chloride (sterile solution of salt and water used to clean wounds), telfa (dressing that does not stick to wounds) pads, and wound cleanser as supplies. The Plan of Care contained orders for Patient #1 to receive a skilled nurse visit twice the week of 2/8/2026 then skilled nurse visits once a week. The Plan of Care did not contain orders for wound care.  Registered Nurse C conducted a skilled nurse visit on 3/6/2026. Registered Nurse C documented that Patient #1 had ulcers under skin lesion under the skin integrity status of the clinical note. Registered Nurse C documented that Patient #1 had a Stage III pressure sore (wound caused by prolonged pressure to the skin and underlying tissues causing cell death) to the right hip and a Stage II pressure sore (wound caused by prolonged pressure to the skin and underlying tissues causing cell death) on the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care. Registered Nurse C conducted a skilled nurse visit on 3/12/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care. Registered Nurse C conducted a skilled nurse visit on 3/18/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care.  Registered Nurse C conducted a skilled nurse visit on 3/26/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C did not document that wound care was performed.  Registered Nurse C conducted a skilled nurse visit on 4/2/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care and that wound care supplies were provided.    Patient #2:Record review of Patient #2's clinical record revealed a Plan of Care dated 3/16/2026 to 6/13/2026. The Plan of Care indicated that Patient #2 started on the agency's services on 3/16/2026. The Plan of Care listed Senile Degeneration of the Brain as the terminal diagnosis. The Plan of Care listed Tylenol and Gabapentin as medications used for pain. The Plan of Care included interventions and goals for pain. The Plan of Care listed chronic back pain as an initial patient problem.  Registered Nurse E conducted an initial skilled nurse visit on 3/16/2026. Registered Nurse E documented that Patient #2's pain was controlled with medications; documented Patient #2 had a pain pump in the right abdominal region; documented that the family reported that the pump contained Fentanyl (used to treat severe, acute and chronic pain), Hydromorphone (used to treat moderate to severe pain), and Bupivacaine (anesthetic used to block nerve impulses, causing numbness in specific areas for pain relief). The Plan of Care did not include Fentanyl, Hydromorphone, and Bupivacaine. Patient #4:Record review of Patient #4's clinical record revealed a Plan of Care dated 2/14/2026 to 4/24/2026. The Plan of Care indicated that Patient #4 started on the agency's services on 2/24/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery Chronic condition where plaque builds up the the heart arteries (blood vessel) reducing blood flow to the heart muscle) without Angina Pectoris (chest pain) as the terminal diagnosis.  Patient #4's Plan of Care did not contain medications.  The surveyor received a phone call from a Confidential Witness and subsequent email that included a photo of medication bottles and a document that listed medications with Patient #4's name on them. The photo showed the following medication bottles- Tylenol Rapid Relief 500 mg tablets- used to treat pain/fever, Sleep Quick- Melatonin 10 milligrams - used to regulate sleep, Divalproex 250 milligrams- used to treat seizures (abnormal electrical activity in the brain temporarily affecting consciousness, muscle control and behavior) and migraine (intense throbbing pain of the head lasting from hours to days) headaches, Clonidine (used to treat high blood pressure- the condition of the force of the blood against artery- blood vessel, walls being consistently too high) 0.1milligrams, Trazodone (used to treat major depressive disorder- persistent sadness, loss of interest or pleasure, and impaired daily functioning)  50 milligrams, Pantoprazole (used to reduce acid production in the stomach), Levothyroxine (used to treat condition where the thyroid gland does not produce enough thyroid hormone), another bottle with Melatonin 10 milligrams, and Cyclobenzap- the rest of the medication name was not visible, and a cough and congestion medication- name of medication not readable. The photo included a document of a list of medications with the name of Facility X on it. The document listed the following medications: Divalproex, Trazodone, Pantoprazole, Clonidine, Melatonin, and Levothyroxine.  During an interview on 4/15/2026 at 11:10 AM with Registered Nurse E, the surveyor asked if Registered Nurse E performed Patient #2's admission and what had occurred during the visit. Registered Nurse E informed the surveyor that Registered Nurse E had conducted the admission visit; some of Patient #2's family were present; that Patient #2 had a pain pump. The surveyor asked Registered Nurse E why the pain pump medications were not included in the Plan of Care. Registered Nurse E stated, "I did the initial visit. The family did not have that information (pain pump medications) on hand. The surveyor asked who would be responsible for obtaining that information later. Registered Nurse E stated, "The other nurses would take over." During an interview on 4/15/2026 at 2:15 PM, with the Former Home Owner of the home that Patient #4 lived in, the surveyor asked whether Patient #4 took any medications. The Former Home Owner stated, "(Patient #4) was taking medication. When (Patient #4) got on hospice, I know I was hands off after that." During an interview on 4/15/2026 at approximately 4:15 PM with the Administrator/Supervising Nurse, the surveyor discussed Patient #2's pain pump medications were not included in the Plan of Care, Patient #4's medications were not included in the Plan of Care, and Patient #1's wound care treatments were not included in the Plan of Care. The surveyor asked if Patient #4 took medications. The Administrator/Supervising Nurse stated, "Yes, (Patient #4) takes medications.  The surveyor asked who would be responsible for ensuring that the medications/treatments were in the Plans of Care. The Administrator/Supervising Nurse stated, "The admitting nurse, then falls to the case manager." The surveyor asked why drugs/treatments were not included in the plans of care. The Administrator/Supervising Nurse did not know why it was not included in the plans of care but stated, "It should be there." The surveyor asked who would be responsible to ensure these were on the Plans of Care. The Alternate Administrator/Supervising Nurse stated, "The RN (registered nurse) case manager," The surveyor discussed that Registered Nurse C documented in the clinical notes for Patient #1; "Wound care performed per plan of care." The Administrator/Supervising Nurse informed the surveyor that the nurses were supposed to document the wound care that was performed. The surveyor asked what the current wound care for Patient #1 was. The Administrator/Supervising Nurse provided a copy of faxed documents dated 4/14/2026 from Wound Care Agency A. The documents contained orders for the wound care to Patient #1's right buttock/sacral (lower back) and right hip wounds. The wound care order contained orders for the following wound care: Right buttock/sacral wound was to be cleaned with Vashe (wound cleanser used for cleaning, irrigation, and moistening wounds) or wound cleanser, prep skin surrounding the wound with skin prep (used to protect the skin around the wound), apply Calcium Alginate (absorbs drainage), lightly pack the wound with gauze, Silvasorb (water-based gel used to treat infected or at risk wounds) and cover with a bordered foam dressing; Right hip clean with Vashe or wound cleanser, skin prep to the skin surrounding the wound, apply calcium alginate, pack with gauze, Silvasorb, and cover with a bordered foam dressing. The surveyor asked who the registered nurse case manager was. The Administrator/Supervising Nurse stated, "(Registered Nurse C) was the case manager." Registered Nurse C was not available for interview due to a family emergency and was out of the country.  Review of the agency's policy titled "Plan of Care Process," last reviewed on 3/16/2025. read in part; "Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs. Policy I. All hospice care and services furnished to patients and their families will follow an individualized written POC (plan of care) established by the Hospice Interdisciplinary Group/Team (IDG/IDT)...Procedure...VI. The POC includes, but is not limited to...D. Drugs and treatments necessary to meet the 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, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical record reviews revealed that the agency did not ensure the hospice designated a registered nurse member of the IDG provided coordination of care, ensured continuous assessment of each patient’s and family’s needs, and ensured the implementation of the interdisciplinary plan of care. CLINICAL RECORD 2/HOME VISIT 2: The Plan of Care from 02/24/2025 to 04/24/2025 included orders to assess skin integrity and the effectiveness of skincare each visit. During the home visit to observe the Registered Nurse (RN) (Personnel Record 2), the patient was not turned to assess the skin condition on the back and buttocks. CLINICAL RECORD 3/HOME VISIT3: The Plan of Care from 02/09/2025 to 04/09/2025 included orders to assess skin integrity and the effectiveness of skincare each visit. During the home visit to observe the RN (Personnel Record 2), the patient was not turned to assess the skin condition on the back and buttocks. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/2025, the administrator/DON stated that the nurse should have turned the patient and assessed the skin.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure that each patient’s individualized written plan of care included interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 02/24/2025 with diagnosis of Dysphagia following CNA, Hemiplegia and Hemiparesis, HTN. During the home visit with the registered nurse (RN) (Personnel Record 2), the patient had a diagnosis of a cerebrovascular accident with dysphagia and had a feeding tube with Glucerna 1.2 running at 40ml per hour for 22 hours daily and flushed with water. The order for the tube feeding was not included in the Plan of Care (POC) for the certification period of 02/24/2025 to 04/24/2025 and did not include interventions for aspiration precautions. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/025, the DON stated that the complete orders should have been included, and she believed the EMR was responsible for many of the errors.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. This standard was not met as evidenced by observation, document review, and interview. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as bag technique. Agency Policy titled Bag Technique IC.60 (09/01/2024) read in part, “When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe and/or antimicrobial soap and water as appropriate, hands are washed, and equipment and supplies are returned to the bag”. Home Visit 2: During the home visit on 03/19/2025 to observe the Registered Nurse (RN) (Personnel Record 2), the RN was observed after using and cleaning the stethoscope to put the stethoscope back into her nursing back without sanitizing her hands. The RN did not observe the agency policy on bag technique. In an interview with the RN (Personnel Record 2) after the visit, the RN stated that she was nervous during the visit.

It is required the hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments. This standard was not met as evidence by clinical record review, observation and interview. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure the nursing needs of the patient was met. CLINICAL RECORD 3/HOME VISIT 3: The Plan of Care (POC) for the certification period 02/09/2025 to 04/09/2025 included a fall mat as the patient was at high risk for falls. A home visit was conducted on 03/19/2025 to observe the RN (Personnel Record 2). During the visit, there was no fall mat in the patient's room. In an interview with the RN during the visit, the RN stated that the fall mat was probably in the patient's former room as the patient recently had a room change. The RN was unable to state when the patient had changed rooms, and no attempt was made to obtain the fall mat as ordered.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group and includes written patient care instructions for a hospice aide are prepared by an 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 1 of 14 (7%) clinical record reviews revealed that the agency did not ensure that hospice aides were assigned to a specific patient by a registered nurse who was a member of the Interdisciplinary Group (IDG) and included written patient care instructions for a hospice aide were prepared by an RN who was responsible for the supervision of the hospice aide. CLINICAL RECORD 3/HOME VISIT 3: The hospice aide care plan effective 04/15/2024 included the task of ambulating the patient with a walker. A home visit was conducted on 03/19/2025 to observe the Registered Nurse (RN) (Personnel Record 2). The patient was not ambulatory and required the assistance of two for transfers. In an interview with the Registered Nurse during the visit on 03/19/2025, the RN stated that the patient was not ambulatory and that this should have been changed.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 clinical record review and interview. In 7of 14 (50%) clinical record reviews revealed that the agency did not ensure that a patient clinical record containing past and current findings was maintained for each hospice patient and included physician orders. CLINICAL RECORD 1: The Plan of Care (POC) for the certification period 09/17/2024 to 12/17/2024 included a foley catheter 16-20 French with a 5 to 30 ml balloon as needed, but did not include an indication for use. There was no documented evidence that the plan of care included a description of the patient’s medical signs and symptom for the as needed foley catheter. CLINICAL RECORD 2: The Plan of Care for the certification 02/24/2025 to 04/24/2025 included an order for oxygen two (2) to five (5) LPM as needed (2-5 LPM), and oxygen 2 LPM continuously as needed for shortness of breath was included on the medication profile. The Plan of Care included an order for a Dietician to evaluate. The Dietician evaluated the patient on 02/25/2025 and recommended Banatrol Plus, one to two packs per day via enteral feedings for diarrhea. The patient was taking the Banatrol, however the order was not added to the Plan of Care (POC) and there was no subsequent physician order for the Banatrol. CLINICAL RECORD 4: The Plan of Care for the certification period of 01/24/2025 to 04/24/2025 included Lorazepam 1.75mg per ml, 0.5ml as needed for anxiety/agitation (effective 01/25/2025) and Zofran 4mg oral as needed for nausea and vomiting was included however, the plan of care orders did not include a frequency for these medications. CLINICAL RECORD 5: The Plan of Care for the episode 10/30/2024 to 12/28/2024 included Lorazepam 1.75mg PO as needed for anxiety/agitation and Zofran 4mg PO as needed for nausea/vomiting however, the plan of care orders did not include a frequency for these medications. CLINICAL RECORD 6: The Plan of Care for the episode 12/05/2024 to 02/02/2025 included Lorazepam 1.75mg PO as needed for anxiety/agitation, Zofran 4mg PO as needed for nausea/vomiting, Atropine 0.75% drops, two drops oral as needed for secretions, Bisacodyl 10 mg suppositories one as needed for constipation, and Morphine Sulfate 20mg per ml give 0.25ml as needed for pain or shortness of breath however, the plan of care orders did not include a frequency for these medications. CLINICAL RECORD 7: The Plan of Care for the episode 02/28/2025 to 05/28/2025 included Lorazepam 1.75mg PO as needed for anxiety/agitation, Zofran 4mg PO as needed for nausea/vomiting, however, the plan of care did not include a frequency for these medications. The Plan of Care also included Refresh Tears solution one time a day for dry eyes and Systane solution one time a day for dry eyes however the order did not include which eye or both eyes. CLINICAL RECORD 10: The Plan of Care for the certification period of 11/17/2024 to 01/15/2025 included oxygen 2% of 2 lpm continuously as needed for shortness of breath. The dose was incorrect at 2% as that is not measurable via the oxygen concentrator. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/2025, the administrator/DON stated that the nurses had not completed the orders but that they should have and that the nurses had a difficult time with the computer system.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Hospice medication information. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 2 (50%) home visit observations performed at a facility revealed that the agency did not ensure that facility was provided all patient medication information. CLINICAL RECORD 3/HOME VISIT 3: A home visit to the assisted living facility where the patient resided was conducted on 03/19/2025 to observe the Registered Nurse (RN) (Personnel Record 2). A review of the medications the assisted living facility (ALF) was giving the patient, and the hospice medication profile was compared. The Plan of Care (POC) for the certification period 02/09/2025 to 04/09/2025 included Acetaminophen 500 mg PO every eight (effective 04/12/2024) hours as needed, Acetaminophen suppository 650mg rectally as needed for fever or pain, Atropine 0.75% drops, two drops sublingual as needed for secretions, Bisacodyl 10mg suppository one rectal as needed for constipation, Lorazepam 1.75mg per ml, give 0.5ml PO as needed for anxiety/agitation, Morphine Sulfate 20mg per ml, give 0.25ml as needed for pain or SOB and Tylenol Extra Strength 500 mg tabs, take two tablets every eight hours as needed. These medications were not on the assisted living medication administration record or orders. The hospice medication profile did not include a frequency for the Acetaminophen 650mg rectal suppositories, Atropine 0.75% give two drops for secretions, Bisacodyl 10 mg rectal suppository, Lorazepam 1.75mg per ml, give 0.5ml as needed for agitation and restlessness, the morphine sulfate 20mg per ml, give 0.25ml for pain and/or shortness of breath. Tylenol Extra Strength 500mg, two tablets every eight hours as needed did not include the indication for use. The ALF orders also included Donepezil 10mg PO daily (effective 05/21/2024). The hospice POC did not include the Donepezil. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/025, the DON stated that the complete orders should have been included, and she believed the EMR was responsible for many of the errors.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) of the clinical records reviewed revealed that the agency did not ensure that each patient had an individualized plan of care that addressed the patient-specific needs. Clinical Record 1: The plan of care dated 10/17/2023 stated Foley catheter PRN but did not include any individualized specific instruction related to the size of the catheter or balloon or how often to change. There was no documented evidence of additional orders since the last site visit dated 10/24/2023. Clinical Record 4: The plan of care dated 10/9/2022 did not include any medications and duration of visits ordered. There was no documented evidence of any plan of care updates or revisions since 10/24/23. Clinical Record 5: The plan of care dated 10/25/2023 stated Foley catheter PRN. There was no documented evidence of individualized interventions for the catheter size or balloon, frequency of changing and the order for the orders for a Laxative/enema of choice PRN with no specific medication or dosage listed. In an interview on 12/5/2023 DON stated in part, “the last site visitor directed the agency not to fix prior care plans and just to wait until patients are recertified. We are going to fix it by just using the EMR instead of the paper forms that the consultant told us to use." THIS IS A CONTINUED REQUIRED ACTION 3 of 5 (60%) of the clinical records reviewed revealed that the agency did not ensure that each patient had an individualized plan of care that addressed the patient-specific needs.

It is required that a hospice aide provides services as ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed with home health aide services revealed that the agency did not ensure that the aides followed the plan of care. THIS IS A CONTINUED REQUIRED ACTION. In 3 of 4 (75%) of clinical records reviewed with home health aide services revealed that the agency did not ensure that the aides followed the plan of care. Clinical Record 1: The aide care plan by Registered Nurse (RN) dated 10/17/2023 included, "bathroom assistance, document output, light housekeeping bedroom and bathroom, encourage fluids, clothing assist, foot care, oral care. shampoo, shower. The aide visit note lists the task and next to the task are two boxes; acknowledged and completed. The aide visit note dated 12/4/2023 acknowledged bathroom assistance, document output, light housekeeping bedroom and bathroom, encourage fluids, clothing assist, foot care, oral care. shampoo, shower however did not mark them complete. There was no documented evidence that the aide completed those tasks. The aide note did not include any documented evidence that the RN was notified of assigned tasks that were not completed. Clinical Record 2: The aide plan of care by the RN dated 08/02/2023 assigned task included to: assist with feeding, encourage fluids, foot care and nail care. The aide visit note dated 12/4/2023 had two boxes next to each task; acknowledged and completed. The aide documented on visit note dated 11/29/2023 that assist with feeding, encourage fluids, foot care and nail care were acknowledged however were not documented as completed. The aide note did not include any documented evidence that the RN was notified of assigned tasks that were not completed. Clinical Record 4: The aide plan of care by the RN dated 10/11/23 included: document output, assist with feeding, encourage fluids, foot care and nail care. The aide visit note dated 10/13/2023 had two boxes next to each task; acknowledged and completed. The aide documented on visit note dated 10/13/2023 that document output, assist with feeding, encourage fluids, foot care and nail care were acknowledged however were not documented as completed. The aide note did not include any evidence that the RN was notified of assigned tasks that were not completed. In an interview on 12/6/2023 with the Director of Nurses (DON) confirmed that home health aide notes did not include completion of all tasks assigned. It is required that a hospice aide provides services as ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONTINUED REQUIRED ACTION. In 3 of 4 (75%) of clinical records reviewed with a home health aide revealed that the agency did not ensure that the aides followed the plan of care.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) of clinical records reviewed revealed that the agency did not ensure that the physician completed the recertification of terminal illness. Clinical Record 2: The patient elected the hospice benefit on 07/06/2023. There was no documented evidence of a signed physician recertification or plan of care for the certification period beginning 10/04/2023. In an interview on 12/5/2023 with the Director of Nursing (DON), the DON stated in part, "I was told to wait until the following certification period to fix things.” THIS IS AA CONTINUED REQUIRED ACTION 1 of 5 (20%) of clinical records reviewed revealed that the agency did not ensure that the physician completed the recertification of terminal illness.

It is required that if a patient revokes the election of hospice care or is discharged from hospice, the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) live discharge reviewed revealed that the agency did not ensure that a discharge summary was provided to the attending physician. Clinical Record 5: The patient elected the hospice benefit on 10/25/2023 and was discharged to the hospital on 11/28/2023. There was no documented evidence that the discharge summary in the clinical record was sent to the patient’s attending physician. The discharge summary dated 11/28/2023 read in part, " Patient attending physician notified – No.” In an interview on 12/5/2023 with the Director of Nursing (DON), the DON confirmed that the EMR documentation noted that the physician was not notified of discharge and there was no evidence of providing the physician with a discharge summary. THIS IS A CONTINUED REQUIRED ACTION: 1 of 1 (100%) live discharges reviewed revealed that the agency did not ensure that a discharge summary was provided to the attending physician.

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, [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of 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 measurements 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 and interview. 2 of 5 (40%) records reviewed revealed the hospice did not ensure the medication profiles were updated at time the time of each comprehensive assessment and drug regime reviews occurred when new medications were ordered for patients. Clinical Record 2: The patient’s date of election was 6/26/2023. A physician’s order on 6/26/2023 revealed oxygen 2-4L as needed for dyspnea. There was no documented evidence that the oxygen was updated to the medication profile. Clinical Record 4: The patient’s date of election was 9/27/2023. A physician’s order on 9/27/2023 ordered 4-5L oxygen continuously, MS Contin 30mg BID, MS IR 15mg 1 tab Q4H PRN breakthrough pain. There was no documented evidence that the oxygen, MS Contin and MS IR were updated to the medication profile. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing agreed, there was no documented evidence the medications were updated to the drug profile.

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 IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care [HCPC.19.I/L540] 20% noncompliance; Failed to ensure that all hospice care and services furnished to patients followed an individualized written plan of care [HCPC.19.I/L543] 20%noncompliance; Failed to ensure an individualized written plan of care was prepared for each patient based on the comprehensive assessment [HCPC.21.I/L545] 100% noncompliance; and Failed to ensure that the Interdisciplinary Group reviewed, revised, and documented the individualized care plan as frequently as the patient's condition required, but no less frequently than every 15 calendar days [HCPC.22.I/L552] 40% noncompliance. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

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. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 5 (20%) records reviewed revealed the hospice did not ensure the Registered Nurse coordinated care and services and ensured nursing needs were met through regular assessments and re-evaluation of the patient's status. Document 3: Agency policy, “Implementing Care and Treatment, PC.35,” stated in part, “The hospice designates a qualified Registered Nurse (RN) who is a member of the Interdisciplinary Group/Team (IDG/IDT), who will oversee the following when coordinating the assignments of patient care: the continuous assessment of each patient’s and family’s needs, the implementation of the IDG/IDT Plan of Care (POC) for each patient and family. The hospice will assign appropriate disciplines needed to provide patient care/treatment. The assigned discipline will be provided with information needed to provide patient care/treatment. The Hospice RN, who is a member of the IDG/IDT, will oversee the assignment of a Hospice Aide (HA) to a particulate patient, initiating hospice aide services within time frame to meet identified patient’s needs as identified in the POC and per physician’s orders.” Clinical Record 1: The patient’s date of election was 10/22/2022. The initial plan of care on 10/22/2022 ordered hospice aide 3 x week. During the week of 1/29/2023-2/4/2023 and 2/5/2023-2/11/2023, there was no documented evidence of a hospice aide visit or reason for the missed visits. The hospice aide plan of care on 1/16/2023 ordered shower every visit. The hospice aide visits on 1/16/2023 and 1/18/2023 did not include documentation of any completed tasks as ordered. There was no documented evidence that the Registered Nurse coordinated care and ensured the implementation of the hospice aide plan of care as ordered. Clinical Record 4: The patient’s date of election was 9/27/2023. The initial plan of care on 9/27/2023 ordered SN 3 x week for 5 weeks. The Registered Nurse assessment on 9/27/2023 documented wound care to be provided by SN 3 x week. The Registered Nurse assessment on 9/27/2023 documented wounds: skin tears to left forearm, right medial ankle, left lateral ankle, right elbow, bilateral heels, and peri wound. SN will continue to monitor skin integrity, perform wound care and monitor for s/s of infection to report to Dr. Wound Care as follows – SN to cleanse wound (bilateral heels) with wound cleanser or NS, pat dry with gauze, apply TAO and cover with bordered gauze three times a week. Apply skin protectant to peri wound (no sting barrier or zinc oxide), use tongue depressor and apply a thin layer or Medi honey to wounds, fill wounds with calcium alginate, cover with absorbent foam and wrap lightly with kerlix and tape 3 x week or until healed. Right medial ankle and left lateral ankle – irrigate BLE wounds with NS, moisten gauze with vashe or anasept and fill wounds, allow to be in wounds for 5-8 minutes then remove. Apply steri strips to left forearm and right elbow skin tears. The licensed vocational nurse documentation on 9/29/2023 and 10/3/2023 revealed, wound care provided was inconsistent with the plan of care: intact scab to L lateral ankle painted with betadine, intact scab to R medial ankle painted with betadine, intact scab from previous skin tear to L forearm painted with betadine, intact scab to r elbow painted with betadine. Wounds found to unopened blister to L heel, covered with dry gauze and wrapped with kerlix, opened blister to r heel Tao applied, covered with non-adherent dressing, and wrapped with kerlix. During the week of 10/1/2023-10/7/2023, a Licensed Vocational Nurse visit was documented on 10/3/2023. There was no documented evidence of a 2nd or 3rd nurse visit that week. During the week of 10/8/2023-10/14/2023, there was no documented evidence of a nurse visit that week. During the week of 10/15/2023-10/21/2023, there was no documented evidence of a nurse visit that week, to current date 10/23/2023. There was no documented evidence the wound care was completed. There was no documented evidence that the Licensed Vocational Nurse obtained physician orders for wound care. There was no documented evidence that the Registered Nurse coordinated the wound care, obtained physician’s orders for the wound care, and ensured continuous assessment of the patient’s needs. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing stated, some of these are standing orders, but we missed including it on readmission. Additionally, during interview on 10/24/2023, the Director of Nursing stated, “we were using a wound order from her previous admission, we need to get updated orders.”

It is required that the 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 (if any), the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) records reviewed revealed the hospice did not ensure hospice care and services were provided to patients as ordered and in accordance with the plan of care. Clinical Record 4: The patient’s date of election was 9/27/2023. The initial plan of care on 9/27/2023 ordered SN 3 x week for 5 weeks. The Registered Nurse assessment on 9/27/2023 documented wound care to be provided by SN 3 x week. The Registered Nurse assessment on 9/27/2023 documented wounds: skin tears to left forearm, right medial ankle, left lateral ankle, right elbow, bilateral heels, and peri wound. SN will continue to monitor skin integrity, perform wound care and monitor for s/s of infection to report to Dr. Wound Care as follows – SN to cleanse wound (bilateral heels) with wound cleanser or NS, pat dry with gauze, apply TAO and cover with bordered gauze three times a week. Apply skin protectant to peri wound (no sting barrier or zinc oxide), use tongue depressor and apply a thin layer or Medi honey to wounds, fill wounds with calcium alginate, cover with absorbent foam and wrap lightly with kerlix and tape 3 x week or until healed. SN to instruct CG to change dressing PRN between SN visits. Right medial ankle and left lateral ankle – irrigate BLE wounds with NS, moisten gauze with vashe or anasept and fill wounds, allow to be in wounds for 5-8 minutes then remove. Apply steri strips to left forearm and right elbow skin tears. The licensed vocational nurse documentation on 9/29/2023 and 10/3/2023 revealed, wound care provided, intact scab to L lateral ankle painted with betadine, intact scab to R medial ankle painted with betadine, intact scab from previous skin tear to L forearm painted with betadine, intact scab to r elbow painted with betadine. Wounds found to unopened blister to L heel, covered with dry gauze and wrapped with kerlix, opened blister to r heel Tao applied, covered with non-adherent dressing, and wrapped with kerlix. During the week of 10/1/2023-10/7/2023, a Licensed Vocational Nurse visit was documented on 10/3/2023. There was no documented evidence of a 2nd or 3rd nurse visit that week. During the week of 10/8/2023-10/14/2023, there was no documented evidence of a nurse visit that week. During the week of 10/15/2023-10/21/2023, there was no documented evidence of a nurse visit that week, to current date 10/23/2023. There was no documented evidence that the nursing visits were completed as ordered. There was no documented evidence the wound care was completed. There was no documented evidence that the Licensed Vocational Nurse and Registered Nurse obtained physician orders for the wound care. Home Visit 1: During the home visit (CR#4) on 10/24/2023 with the Hospice Aide (PR#1), the patient reported discomfort in the heels and coccyx from wounds. The patient stated, “only the hospice nurse does the wound care.” The patient was unsure when wound care was completed last, “maybe last week sometime,” and stated, “they are supposed to come three times a week and I don’t think they are, maybe twice” The Wellness Director of the Assisted Living Facility stated, “we don’t provide any of her wound care, only the hospice nurse does.” Additionally, the Wellness Director was unsure how many times a week the wound care is completed by the hospice nurse. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing stated, “some of these are standing orders, but we missed including it on readmission, we were using orders from a previous admission, we need to get updated orders.” Additionally, during an interview on 10/24/2023, the Director of Nursing stated, “I’m sure the nurse is going, but don’t see it documented"; and said “we were using a wound order from her previous admission, we need to get updated orders.”

It is required that each patient’s individualized written plan of care reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) records reviewed revealed the hospice did not ensure the Interdisciplinary Group (IDG) prepared a written plan of care for each patient that specified the hospice care and services necessary to meet the specific needs of the patient as identified in the comprehensive assessments in consultation with the patient’s attending physician. Clinical Record 1: Record 1: The patient’s date of election was 10/22/2022. The POC was documented for the benefit period 10/22/2022-1/19/2023. There was no documented evidence a POC was documented for the benefit period starting 1/20/2023. The Registered Nurse assessment on 10/22/2022 revealed the patient was a fall risk, BLE pain 6, acceptable level 2, uncomfortable due to pain yes, taking gabapentin, oxycodone and baclofen for pain, on an external ventilator. The Registered Nurse assessment on 10/26/2022 documented patient complains of sharp pain in BLE and pain controlled with gabapentin, oxycodone, baclofen for intestinal cramping. The Registered Nurse assessment on 11/2/2022 revealed pain 4, goal 4. The Registered Nurse assessment on 11/16/2022 revealed BLE pain 4, acceptable level 0. The Registered Nurse assessment on 11/30/2022 revealed BLE back pain 3. The Registered Nurse assessment on 1/11/2023 revealed pain 4. The Social Worker documentation on 12/28/2022 revealed, patient shared that he accidentally ripped his feeding tube out of his body, he showed me his temporary tube and stated that he will be having surgery soon to get his permanent tube replaced. The Social Worker documentation on 1/20/2023 revealed, patient continued to ask about having physical therapy and this SW explained to patient that it is unlikely that those services will be rendered while on hospice. There was no documented evidence the Social Worker communicated the changes with the patient’s feeding tube and patient request for physical therapy (PT) to the IDG. There was no documented evidence that the IDG revised the plan of care with problems, interventions, and goals for pain, fall risk, temporary feeding tube, external ventilator, and need for assessment of PT needs between 10/22/2022-2/9/2023. There was no documented evidence that the Interdisciplinary Group, in consultation with the patient's attending physician, prepared a written plan of care (POC) for the benefit period starting 1/20/2023 that specified the hospice care and services necessary to meet the specific needs of the patient and family. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing stated, I didn’t know about the feeding tube coming out. Additionally, during an interview on 10/24/2023, the Director of Nursing stated, I didn’t know he was requesting PT, our doctor doesn’t recommend PT. During an interview on 10/24/2023, the Hospice Medical Director stated, “I recall something about the tube coming out and he was going to have it put back in. I was not aware he requested Physical Therapy.” Clinical Record 2: The patient’s date of election was 6/26/2023. An initial POC was documented for the benefit period 6/26/2023-9/23/2023. There was no documented evidence that the Interdisciplinary Group, in consultation with the patient's attending physician, prepared a written plan of care (POC) for the benefit period 9/24/2023-12/22/23 that specified the hospice care and services necessary to meet the specific needs of the patient and family. Clinical Record 3: The patient’s date of election was 7/6/2023. An initial POC was documented for the benefit period 7/6/2023-10/3/2023. There was no documented evidence that the Interdisciplinary Group, in consultation with the patient's attending physician, prepared a written plan of care (POC) for the benefit period 10/4/2023-1/1/2024 that specified the hospice care and services necessary to meet the specific needs of the patient and family. Clinical Record 4: The patient’s date of election was 9/27/2023. The initial plan of care on 9/27/2023 ordered SN 3 x week for 5 weeks. The initial plan of care on 9/27/2023 did not include DME or wound supplies. The Registered Nurse assessment on 9/27/2023 documented wound care to be provided by SN 3 x week. The Registered Nurse assessment on 9/27/2023 documented wounds: skin tears to left forearm, right medial ankle, left lateral ankle, right elbow, bilateral heels, and peri wound. SN will continue to monitor skin integrity, perform wound care and monitor for s/s of infection to report to Dr. Wound Care as follows – SN to cleanse wound (bilateral heels) with wound cleanser or NS, pat dry with gauze, apply TAO and cover with bordered gauze three times a week. Apply skin protectant to peri wound (no sting barrier or zinc oxide), use tongue depressor and apply a thin layer or Medi honey to wounds, fill wounds with calcium alginate, cover with absorbent foam and wrap lightly with kerlix and tape 3 x week or until healed. Right medial ankle and left lateral ankle – irrigate BLE wounds with NS, moisten gauze with vashe or anasept and fill wounds, allow to be in wounds for 5-8 minutes then remove. Apply steri strips to left forearm and right elbow skin tears. The licensed vocational nurse documentation on 9/29/2023 and 10/3/2023 revealed, wound care provided, intact scab to L lateral ankle painted with betadine, intact scab to R medial ankle painted with betadine, intact scab from previous skin tear to L forearm painted with betadine, intact scab to r elbow painted with betadine. Wounds found to unopened blister to L heel, covered with dry gauze and wrapped with kerlix, opened blister to r heel Tao applied, covered with non-adherent dressing, and wrapped with kerlix. During the week of 10/1/2023-10/7/2023, a Licensed Vocational Nurse visit was documented on 10/3/2023. There was no documented evidence of a 2nd or 3rd nurse visit that week. During the week of 10/8/2023-10/14/2023, there was no documented evidence of a nurse visit that week. During the week of 10/15/2023-10/21/2023, there was no documented evidence of a nurse visit that week, to current date 10/23/2023. There was no documented evidence the wound care was completed between 10/4/2023-10/23/2023. There was no documented evidence that the Licensed Vocational Nurse obtained physician orders for wound care. There was no documented evidence that the Registered Nurse ensured continuous assessment of the patient’s needs. There was no documented evidence that the written plan of care identified the wounds as a problem, with scheduled treatment orders and a patient goal. Clinical Record 5: The patient’s date of election was 11/19/2022. An initial POC was documented for the benefit period 11/19/2022-1/10/2023. The POC on 11/19/2022 ordered nurse 1wk1, 2wk2, 1wk for remainder of quarter, hospice aide effective 11/21/2022 2 x week for remainder of the quarter. There was no documented evidence that the Interdisciplinary Group, in consultation with the patient's attending physician, prepared a written plan of care (POC) for the benefit period 11/2023-3/11/2023, 3/12/2023-5/10/2023, 5/11/2023-7/9/2023, 7/10/2023-9/7/2023 and 9/8/2023-11/6/2023 that specified the hospice care and services necessary to meet the specific needs of the patient and family. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing agreed, there was no documented evidence that the IDG prepared a written plan of care (POC) for the benefit periods identified. Additionally, during interview on 10/24/2023, the Director of Nursing stated, we have just been creating a plan of care when they admit, but not after the first benefit period, “I didn’t know we needed to.”

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 as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment; 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 clinical record review, document review and interview. 2 of 5 (40%) records reviewed revealed the hospice did not ensure the IDG reviewed, revised and documented the care plan as frequently as the patient’s condition requires, but no less frequently than every 15 days. Document 2: Agency Policy, “Interdisciplinary Group Roles and Responsibilities, PC.40,” stated in part, “IDG/IDT meetings will be held during the course of patient care to monitor and evaluate the patient’s interdisciplinary POC progress, at least every 15 days. The IDG/IDT will update the Comprehensive Assessment no less frequently than every 15 days. A revised interdisciplinary POC will include information from the patient’s updated Comprehensive Assessment and will note the patient’s progress toward outcomes and goals specified in the POC. Formal communication regarding the patient’s POC is documented at the IDG/IDT meeting ensuring care and services are provided in accordance with the POC. Informal verbal and written communication demonstrating coordination of care among staff members and others providing care is also documented in the medical record.” Clinical Record 1: The patient’s date of election was 10/22/2022. The plan of care dated 10/22/2022-1/19/2023 was reviewed. The Registered Nurse assessment on 10/22/2022 revealed the patient was a fall risk, BLE pain 6, acceptable level 2, uncomfortable due to pain yes, taking gabapentin, oxycodone and baclofen for pain. The Registered Nurse assessment on 10/26/2022 documented patient complains of sharp pain in BLE and pain controlled with gabapentin, oxycodone, baclofen for intestinal cramping. The Registered Nurse assessment on 11/2/2022 revealed pain 4, goal 4. The Registered Nurse assessment on 11/16/2022 revealed BLE pain 4, acceptable level 0. The Registered Nurse assessment on 11/30/2022 revealed BLE back pain 3. The Registered Nurse assessment on 1/11/2022 revealed pain 4. The Social Worker documentation on 12/28/2022 revealed, patient shared that he accidentally ripped his feeding tube out of his body, he showed me his temporary tube and stated that he will be having surgery soon to get his permanent tube replaced. The Social Worker documentation on 1/20/2023 revealed, patient continued to ask about having physical therapy and this SW explained to patient that it is unlikely that those services will be rendered while on hospice. There was no documented evidence the Social Worker communicated the changes with the patient’s feeding tube and patient request for physical therapy to the IDG. The IDG on 12/1/2022 documented the patient’s name-no changes. The IDG on 12/15/2022 documented only the patient’s name. The IDG on 12/29/2022 was incomplete and did not list any documented evidence that any patients were reviewed. The IDG on 1/12/2023 documented the patient’s name-no changes. The IDG on 1/26/2023 documented nutrition/hydration/feedings utilizing nutrin/jevity 1.5 The IDG on 2/9/2023 documented plan to dc due to noncompliance and seeking aggressive treatment. There was no documented evidence that the IDG reviewed and revised the plan of care with problems, interventions and goals for pain, fall risk, temporary feeding tube, and need for assessment of PT needs between 10/22/2022-2/9/2023. Clinical Record 5: The patient’s date of election was 11/19/2022. The plan of care dated 11/19/2022-1/10/2023 was reviewed. There was no documented evidence the IDG reviewed and revised the POC on 12/1/2022, 12/15/2022, 12/29/2022, and 1/12/2023. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing stated, “if there isn’t anything documented on the patients, its probably because there are no changes.”

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; and Permitted to be performed under state law and regulation. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 5 (20%) records reviewed reveled the hospice did not ensure the hospice aide followed the orders in the plan of care. Clinical Record 1: The patient’s date of election was 10/22/2022. The initial plan of care on 10/22/2022 ordered hospice aide 3 x week. During the week of 1/29/2023-2/4/2023 and 2/5/2023-2/11/2023, there was no documented evidence of a hospice aide visit or reason explaining the missed visits. The hospice aide plan of care on 1/16/2023 ordered shower every visit. The hospice aide visits on 1/16/2023 and 1/18/2023 did not include documentation of any completed tasks as ordered. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing stated, “that aide was let go because she wasn’t documenting on time.” Additionally, during an interview on 10/24/2023, the Director of Nursing agreed, there was no documented evidence the aide services were provided as ordered or reasons for the missed visits.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) records reviewed revealed the hospice did not ensure the hospice medical director or physician-designee provided written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Clinical Record 1: The patient’s date of election was 10/22/2022. There was no documented evidence a recertification was completed for the second benefit period starting 1/20/2023. During a joint review of the record and an interview on 10/23/2023, the Director of Nursing agreed there was no documented evidence the recertification was completed.

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 clinical record review and interview. In 2 of 5 (40%) records reviewed revealed the hospice did not ensure the clinical records included all physician orders. Clinical Record 1: The patient’s date of election was 10/22/2022. A physician’s order on 10/22/2022 revealed Ondansetron 8mg tab by mouth prn N/V. The physician’s order did not include a frequency for how often the Ondansetron can be administered. Clinical Record 4: The patient’s date of election was 9/27/2023. The initial plan of care on 9/27/2023 ordered SN 3 x week for 5 weeks. The Registered Nurse assessment on 9/27/2023 documented wound care to be provided by SN 3 x week. SN will continue to monitor skin integrity, perform wound care and monitor for s/s of infection to report to Dr. Wound Care as follows – SN to cleanse wound (bilateral heels) with wound cleanser or NS, pat dry with gauze, apply TAO and cover with bordered gauze three times a week. Apply skin protectant to peri wound (no sting barrier or zinc oxide), use tongue depressor and apply a thin layer or Medi honey to wounds, fill wounds with calcium alginate, cover with absorbent foam and wrap lightly with kerlix and tape 3 x week or until healed. Right medial ankle and left lateral ankle – irrigate BLE wounds with NS, moisten gauze with vashe or anasept and fill wounds, allow to be in wounds for 5-8 minutes then remove. Apply steri strips to left forearm and right elbow skin tears. The licensed vocational nurse documentation on 9/29/2023 and 10/3/2023 revealed, wound care provided, intact scab to L lateral ankle painted with betadine, intact scab to R medial ankle painted with betadine, intact scab from previous skin tear to L forearm painted with betadine, intact scab to r elbow painted with betadine. Wounds found to unopened blister to L heel, covered with dry gauze and wrapped with kerlix, opened blister to r heel Tao applied, covered with non-adherent dressing, and wrapped with kerlix. There was no documented evidence that the Registered Nurse obtained physician orders for wound care on 9/27/2023. There was no documented evidence of physician orders for the wound care or betadine on 9/29/2023 and 10/3/2023. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing agreed, there was no documented evidence of a physicians order for the wound care, betadine, or frequency indication on Ondansetron.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 1 (100%) records of discharged patients reviewed, revealed the hospice did not ensure that the patient’s attending physician received a copy of the discharge summary. Document 1: Agency policy, "Patient Discharge, PE.20," stated in part, "The Hospice will forward copies of the following to the patient’s Attending Physician upon discharge from the Hospice’s services: The hospice discharge summary." Clinical Record 1: The patient’s date of election was 10/22/2022. The patient was discharged from hospice on 2/11/2023. There was no documented evidence the discharge summary was forwarded to the patient’s attending physician. During a joint review of the record and an interview on 10/24/2023, the Director of Nursing agreed, there was no documented evidence the discharge summary was sent to the patient's attending physician.