Every finding on record at Op Hospice LLC

Upon patient record review, 1 of 5 (Patient #3) 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 MSW visit frequency effective 12/29/24 was 1 wk 2, no visit was completed visit week 2.

Upon patient record review, 1 of 5 (Patient #2) 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 #2 - Visit note on 01/14/25 and 01/21/25 stated tube feeding at 65cc hour but should be 40cc/hour. The tube feeding order written to increase on 01/28/24 from 40cc per hour to 65cc per hour. The plan of care has SN to instruct dressings care to peg site with no individualized orders.

Upon patient record review, 1 of 5 (Patient #2) 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 #2 - POC dated 01/05/25 did not have who is responsible for performing the G-tube site care.

Upon patient record review, 9 of 23 (Patient #1,#2,#4,#5,#7,#11,#12,#16#17) 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 includes entries for Lidocaine 4% patch daily and Gavi lax powder 17 grams 2 times daily. There is no evidence that the entry includes a location for application of the Lidocaine patch or a type and amount of diluent for administration of Gavi lax. Patient 2:The medication profile includes entries for Lidocaine 4% patch daily, Nystatin powder to affected areas BID and MiraLAX 17 grams daily. There is no evidence that the entry includes a location for application of the Lidocaine patch, a location for administration of Nystatin powder or a type and amount of diluent for administration of MiraLAX. Patient 4, 7 and 17:The medication profile includes an entry for oxygen 3 liters per minute as needed for dyspnea. There is no evidence of a route for administration of oxygen. COS Patient 5:The medication profile includes entries MiraLAX 17 grams daily and oxygen 2-4 liters per minute as needed for dyspnea. There is no evidence that the entries include a type and amount of diluent for administration of MiraLAX or a route for administration and titration instructions for oxygen. Patient 11:The medication profile includes entries for MiraLAX 17 grams daily. The entries do not include a type and amount of diluent for administration of MiraLAX. Patient 12:The medication profile includes an entry for oxygen 2-4 liters per minute as needed for dyspnea. There is no evidence that the entry includes a route for administration and titration instructions for oxygen. Patient 16:The medication profile includes entries for oxygen 2-6 liters per minute as needed for dyspnea, Acetaminophen Arthritis Relief ER 650 every 6 hours and acetaminophen 650 mg supp every 6 hours. There is no evidence that the entry includes a route for administration and titration instructions for oxygen or instructions not to exceed the 4000 maximum daily dose of acetaminophen.

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

Upon patient record review, 3 of 23 (Patient #3,#11,#13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3:The SN documentation includes notation of a skin tear to the right hand requiring wound care biweekly. There is no evidence that the wound was assessed and measured from 11/9/24 to 12/2 with reason noted as unable to assess. Patient 11:The SN documentation includes a wound on the sternum noted as a "cancer spot" with subsequent order for wound care. There is no evidence of wound measurements from 10/10/24 to present. The SN visit note documentation on 11/22 noted that patient had fallen that morning and had open areas to left forearm and both elbows with wound dressings applied by daughter. SN documented that she did not assess wounds. Patient 13:The medical record includes SN documentation of coccyx wound during admission assessment on 4/19/24 with subsequent orders present for wound care. Initial documented assessment on 5/22 and wound was inactivated on 10/10. There is no evidence of measurements of wound from 5/22 through 10/10.

Upon patient record review, 2 of 23 (Patient #2,#5) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 2:The medical record includes entries for Bisacodyl, Lorazepam and MiraLAX on the medication profile. There is no evidence that training on purpose, directions for use and side effects was provided to the patient/caregiver. Patient 5:The medical record includes entries for Gabapentin, Melatonin, Diltiazem CD. There is no evidence that training on purpose, directions for use and side effects was provided to the patient/caregiver.

Upon patient record review, 10 of 23 (Patient #1,#2,#4,#5,#10,#11,#13,#14,#16,#17) 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 includes documentation on admission that patient requires anticoagulant therapy with Eliquis and is at risk for bleeding. There is no evidence that the plan of care includes problems, goals and interventions for the management of potential for bleeding/hemorrhage. Patient 2:The medical record includes that patient is at risk for bleeding due to anticoagulant therapy using Eliquis and requires the use of Nystatin powder for treatment of a chronic infection. There is no evidence that the plan of care includes problems, goals and interventions for the management of potential for bleeding/hemorrhage and active infection. Patient 4:The medical record includes documentation on admission that the patient is at risk for aspiration. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of aspiration. Patient 5:The medical record includes documentation of a primary diagnosis of atherosclerotic heart disease of the native coronary artery. There is no evidence that the plan of care includes problems, goals and interventions for the management of cardiac disease. Patient 10:The medical record includes documentation on admission that patient is at risk for bleeding due to anticoagulant therapy using Eliquis and has a comorbidity of cardiac disease. There is no evidence that the plan of care includes problems, goals and interventions for the management of potential for bleeding/hemorrhage or cardiac disease. Patient 11:The medical record includes documentation on admission that the patient is at risk for aspiration, falls and requires the use of nephrostomy tubes. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of aspiration, falls or the management of nephrostomy tubes. Patient 13:The medical record includes documentation on admission that patient at risk for seizures and requires medication management using Keppra. There is no evidence that the plan of care includes problems, goals and interventions for the management of potential for seizures. Patient 14:The medical record includes documentation that the patient requires a gastrostomy tube, is at risk for bleeding due to anticoagulation therapy using Eliquis and is at risk for skin breakdown due to inability to reposition self, anxiety with staff assisted repositioning and incontinence of bowel and bladder. There is no evidence that the plan of care includes problems, goals and interventions for the management of a gastrostomy tube, the potential for bleeding and to maintain of skin integrity. Patient 16:The medical record includes documentation that the patient is at risk for skin breakdown due to inability to reposition self and incontinence of bowel and bladder. There is no evidence that the plan of care includes problems, goals and interventions to maintain skin integrity. Patient 17:The medical record includes documentation on admission that patient at risk for seizures and requires medication management using Keppra. There is no evidence that the plan of care includes problems, goals and interventions for the management of potential for seizures.

Upon patient record review, 9 of 23 (Patient #3,#4,#5,#7,#12,#14,#16,#17,18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3:The plan of care includes an order on 11/19/24 for wound care to skin tear on right hand that instructs to cleanse wound 2x weekly, apply xeroform petroleum gauze, telfa and tape. There is no evidence of who is to perform wound care. Patient 4, 5, 7, 12, 16 and 17:The plan of care includes an order for oxygen as needed for dyspnea. There is no evidence that the order includes a route for administration of oxygen. Patient 14:The plan of care includes an order for a tracheostomy tube for ventilation, an order for oxygen, an order for levsin and an order for Acetylcysteine. There is no evidence that the orders include size of tracheostomy tube or a correct route of administration for oxygen, Levsin or Acetylcysteine. Patient 18:The medical record includes RN documentation on 11/22, 11/25 and 11/29 that oxygen was being delivered at 4 liters per minute with no adjustment made to correct liter flow. The liter flow for oxygen is ordered at 3 liters per minute.

Upon patient record review, 3 of 23 (Patient #1,#6,#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 1:The medical record includes documentation that the patient requires a wheelchair for mobility. There is no evidence that a wheelchair is included on the plan of care as DME. Patient 6:The medical record includes SN documentation that the patient requires a hospital bed. There is no evidence that a hospital bed is included on the plan of care as DME. Patient 14:The medical record includes an order to suction patient. There is no evidence that suctions equipment and supplies in included on the plan of care as DME and supplies.

Upon patient record review, 6 of 23 (Patient #3,#5,#10,#11,#14,#16) 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 3:Ketoconazole cream was ordered on 11/12/24 for dermatitis. There is no evidence of an update to the plan of care with problems, goals and interventions for management of the infection Patient 5:Oxygen 2-5 LPM via nasal cannula for new onset of dyspnea on 11/29/24. There is no update to the plan of care for problems, goals and interventions for the safety and use of oxygen, Patient 10:Integumentary problem statement includes goals and interventions for to wound care to skin tear on right forearm. The wound was inactivated on 11/5/24. Patient 11:Skilled nursing documentation on 11/25 and 11/27 noted increased shortness of breath, cough, increased phlegm and secretions. There is no evidence of update to plan of care with problems, goals and interventions to manage respiratory symptoms. Patient 14:Skilled nursing documentation of symptoms of infections on 6/22, 10/18 and 12/4 requiring subsequent orders for pharmacological interventions. There is no evidence of an update to the plan of care, goals and interventions for management of risk for potential infections. Patient 16:The plan of care includes an order to discontinue use of foley catheter on 10/23/24. There is no evidence of an update to the plan of care to remove problems, goals and interventions for the management of the foley catheter.

Upon patient record review, 1 of 23 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6:The medical record includes an order on 10/25 for placement of a 14 french foley catheter with balloon to be inflated 10cc. The plan of care notes the intervention with the placement of a 16 french foley catheter.

Upon patient record review, 3 of 23 (Patient #5,#9,#16) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; 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 5 and 9:The patient was noted to be at risk for bleeding. The aide plan of care did not include bleeding precautions. Patient 16:The foley catheter was discontinued per order on 10/23/24. Catheter care remains an assigned task on the aide plan of care.

Upon patient record review 2 of 23 (Patient #6,#16) 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 6:The aide plan of care includes the tasks of bed bath, foot care, nail care and shampoo assigned for 1st visit of week. The aide documented tasks completed on 10/25, 10/31 and 11/8, the 2nd visit of each week. Patient 16:The foley catheter was removed per order on 10/23/24. The aide documented completion of catheter care on all visits from 10/23/24-12/3/24.

Upon patient record review, 1 of 23 (Patient #14) 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 14:The plan of care with oxygen ordered at 4 LPM. SN documentation on 11/18, 11/8, 11/4 and 10/31 notes that patient is using oxygen at 5 LPM with no documentation of noncompliance or SN adjustment.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient 1: The agency reports the patient's caregiver called in to report the patient was taken to ER 12/25/23 and needed a ride home. The clinical manager stated to surveyor she thought patient was discharged and did not follow up. The agency reports the patient's caregiver did call and complain to the Account Executive who states they never filed a grievance or complaint they just listened to her over the phone. This hospice did not have evidence that Ÿthere was the following: an appropriate person to be notified of the grievance/complaint/concern, time frames for investigation activities, to include after hours Reporting of information Review and evaluation of the collected information Communication with the patient/family Documentation of all activities involved with the grievance/complaint, investigation, analysis and resolution.

Upon patient record review, 1 of 5 (Patient #1) 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 1: The medical record contains an order for a PRN visit to be completed 12/25/23 due to patient having uncontrolled symptoms. There is documentation of triage phone calls at 2:05pm that patient is symptomatic and caregiver refused visit, another triage call at 5:09pm for patient symptoms and caregiver refused visit. At 6:05pm another triage call and the nurse documented they offered a PRN visit and the caregiver accepted a visit as symptoms were not controlled. At 9:46pm another triage call regarding increased moaning at rest and they increased the Ativan over the phone and no visit offered. At 9:51pm the nurse documented "visit triaged over phone, symptoms controlled with new medications". There is no evidence the PRN visit was made to assess the patient as the offered by the agency and accepted by the caregiver. The medical record contains documentation by the nurse that the patient had fallen out of bed on 12/3/23. The nurse documented they informed the caregiver they were going to make a visit that day. They did not make a visit to assess the patient and there is no evidence the caregiver refused the visit.

Upon patient record review, 1 of 5 (Patient #5) 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 5: The POC contains an order for "Aseptic technique of dressing change of peg site". There is no type of dressing or frequency of dressing changes noted in order.

Upon client record review, 3 of 5 (Patient #1,2,5) 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 SN documented on 12/22/23 "Instructed caregiver to hold atenolol if SBP less than 100 and DBP less than 60. There is no evidence of an order for these directives. The SN documented 12/24/23 "Morphine given per order". There is no evidence she followed the POC orders. The POC has orders for visits twice daily beginning 12/27/23. There is evidence the SN made 3 visits on 12/27/23 without an order for the 3rd visit that day. The medical record contains an order for a PRN visit to be completed 12/25/23. There is documentation of triage phone calls at 2:05pm that patient is symptomatic and caregiver refused visit, another triage call at 5:09pm for patient symptoms and caregiver refused visit. At 6:05pm another triage call and the nurse documented the caregiver accepted a visit as symptoms were not relieved. At 9:46pm another triage call regarding increased moaning at rest and they increased the Ativan over the phone and no visit offered. At 9:51pm the nurse documented "visit triaged over phone, symptoms controlled with new medications". There is no evidence a visit was made to assess the pt as ordered. Patient 2: The nurse documents goals and interventions for Oxygen on the SOC 12/21/23 and then documents Oxygen is properly stored on 12/14/23. There is no evidence of an order for Oxygen dosing or frequency in the client record. Patient 5: The Nurse documented wound care on 12/12/23 as performed and the documentation is restating the physician order and is not in past tense indicating SN performed the wound care. 12/25/23 the SN documented "This RN changed gauze on neck". 12/24/23 The RN documented "cleaned client neck and applied new dressing and holder" There is no evidence the orders were followed for these wound care dressing changes or how patient tolerated. The medical record contains an order for SN twice daily starting 12/22/23. The nurse made once daily visits from 12/23/23-12/26/23. There is no documentation of patient refusing visits or an order to decrease the visits for those days. In addition, the RN documented 12/18/23 "This RN obtained an order to place a Foley 18 French...patient grimacing with catheter placement." There is no evidence of an order in the medical record.

Upon patient client record review, 2 of 5 (Patient #1,2) 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 1: The SN documented on 12/26/23 "NIT" and "SIOS". These are not approved abbreviations. Patient 2: The SN documents in coordination notes "REQ". This is not an approved abbreviation.

Based on record review and interviews, it was determined that the hospice agency failed to document communication to all disciplines in the interdisciplinary group (IDG) meetings, for 1 of 2 records (P-1) reviewed, resulting in the potential for patient decline or injury. Findings include: --- P-1: This patient was admitted to the agency on 3/21/23, with diagnoses of autonomic dysreflexia secondary to cerebral vascular accident (CVA). The patient resided in a long-term care/rehabilitation facility while on service with the hospice agency. During review of the hospices incident log on 7/13/23, it was found that P-1 had a fall on 4/21/23. During review of the patients record, it was discovered that there were 3 IDG meetings dated 3/30/23, 4/25/23, and 5/10/23. There was no documentation in the 3 IDG meeting notes or in P-1's record of the hospice agencys IDG discussing the patients falls or injuries. During an interview on 7/13/23 at 2:30 p.m., the Area Vice President (AVP) and the Clinical Team Manager (CTM) acknowledged the above findings.

Based on record review and interview, it was determined the hospice agency failed to communicate falls and injuries to the family for 1 of 2 records (P-1) reviewed, resulting in family needs not being met. See Findings: --- P-1: This patient was admitted to the agency on 3/21/23, with diagnoses of autonomic dysreflexia secondary to cerebral vascular accident (CVA). The patient resided in a long-term care/rehabilitation facility while on service with the hospice agency. During review of the hospices incident log, it was found that P-1 had a fall on 4/21/23 with physician notification but no documented evidence of family notification. Review of a skilled nursing note dated 4/21/23 documented a patient fall on 4/17/23, with no documented evidence of family notification. During review of the patients record, including the plan of care, interdisciplinary meeting notes, and all visit and communication notes, on 7/13/23, it was discovered that there was no documentation in the record of the hospice agency contacting P-1s family regarding the falls or injuries. During an interview on 7/13/23 at 2:30 p.m., the Area Vice President (AVP) and the Clinical Team Manager (CTM) acknowledged the above findings.

Upon patient record review, 2 of 20 (Patient #3,6) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3 and #6: Review of the Hospice consents, revealed the patient had chosen an Attending Physician during the admission process. The Attending Physician was not listed on the Plan of Care and there was no documentation to indicate the Attending Physician was involved in the oversight and management of the Patient's care.

Upon patient record review 2 of 20 (Patients #16 and #18) did not have evidence in the patient record that the comprehensive assessment identifies the psychosocial and/or 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 #16: Missing evidence of a Psychosocial Assessment conducted. Patient #18: Missing evidence of a Spiritual Assessment conducted.

Upon patient record review, 1 of 20 (Patient #9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #9: On the RN Initial Assessment, dated 11/17/2021, the RN documented oxygen use. The oxygen was not listed on the med profile.

Upon patient record review, 2 of 20 (Patients #4 and #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 #4: The Initial Plan of Care obtained wound care orders. There was no location of the wound included in the order. Patient #13: Physician orders for wound care were noted on 12/6/2021, 12/13/2021 and 12/28/2021. The order from 12/6/2021 did not include the type and location of the wound and who was responsible for providing the wound care. The order from 12/13/2021 and 12/28/2021 did not include who is responsible for providing the wound care.

Upon patient record review, 5 of 20 (Patients #3, #4, #6, #7 and #16) did not have evidence the plan of care included all DME. Patient #3: RN Initial Assessment revealed documentation that the patient had a hospital bed. The hospital bed was not listed on the Plan of Care. Patient #4: RN Initial Assessment revealed documentation that the patient required a wheelchair. The wheelchair was not listed on the Plan of Care. Patient #6: RN Initial Assessment, revealed documentation that the patient required a hospital bed and a wheelchair. There was no DME listed on the Plan of Care. Patient #7: RN Initial Assessment, revealed documentation that the patient required a walker and a wheelchair. Neither was listed on the Plan of Care. Patient #16: RN Initial Assessment, revealed documentation that the patient required a wheeled walker and a wheelchair. Neither was listed on the Plan of Care.

Upon client record review, 7 of 20 (Patients #3, #10, #11, #12, #13, #14, #18) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #3: Initial Plan of Care orders for Chaplain frequency 2 x week. During the first week of care, the Chaplain only provided 1 visit. No missed visit documentation noted. Patient #10: Initial Plan of Care orders for Social Work frequency 2 x week. During the first week of care, there was only one Social Work visit. No missed visit documentation noted. Patient #11: Patient receiving monthly Social Work services. The evaluation was done on 10/12/2021. An attempt was made on 11/17/2021 where a voice mail was left. On 12/15/2021, a call was made by the Social Worker. The plan of care did not include that the SW would provide telehealth visits in lieu of in-person visits. Patient #12: The Social Work evaluation was conducted on 11/5/2021 with frequency of 1 visit every 3 weeks. A visit was not noted for the week of 11/28/21. On 12/3/2021 @ 8:33, a new order was written for frequencies of 1 x week, then 1 visit every 3 weeks. On 12/3/2021 at 11:05 pm a new order was written for frequencies of 1 visit every 4 weeks. There was no additional documentation from the Social Worker until a missed visit on 12/20/2021. The missed visit note was incomplete with no documentation of why the visit was missed. Patient #13: The Social Work evaluation was conducted on 12/1/2021. On 12/17/2021 & 12/28/2021, the Social Worker made phone calls to the patient. The plan of care did not include that the SW would provide telehealth visits in lieu of in-person visits. Patient #14: A Physician order (dated 12/2/2021 and effective 11/30/2021) listed frequencies of the Social Worker at 2 visits for the first week then, 1 visit every 3 weeks. There was only 1 visit for the first week. The next visit was not conducted until 1/13/2022. There was no missed visit documentation for the visit that was due week of 12/19. Additionally, the Social Work evaluation was conducted by phone on 12/2/2021. On 1/13/2021, another phone call was made by the Social Worker. The plan of care did not include that the SW would provide telehealth visits in lieu of in-person visits. Patient #18: The Social Work evaluation was conducted on 6/28/2021. Although the RN documented that the family was accepting of all services, the Social Worker failed to establish a frequency and documented on IDG Meeting on 7/21/2021 the frequency would be "as requested". There were missed visit notes by the Social Worker dated 7/30/2021, 10/15/2021, 11/1/2021, and 11/28/2021. None of the documents listed why the visits were missed.

Upon patient record review, 2 of 20 (Patient #17, 18) 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 #17: The Social Work evaluation was conducted on 1/24/2021 where documentation stated ..."son agreeable to additional phone calls at 1 x month." There was no additional phone calls until 3/20/2021. Patient #18, revealed the patient had requested to obtain Volunteer Services. There was no volunteer services provided to the patient. There was missing evidence the patient's volunteer need was met by other hospice staff.

Upon patient record review, 6 of 19 applicable (Patients #6, #8, #9, #11, #14, #15) did not have evidence in the patient record that hospice aide assignments and duties included the tasks to be provided and the frequency of those tasks. Patient #6: Patient documented to be very hard of hearing. This precaution was not included on the plan of care. Patient #8: Patient was utilizing oxygen on a continuous basis. There was no oxygen precaution listed on the Aide Care Plan. Patient #9: Aide Care Plan assigns shower on every visit. On a nursing visit conducted on 1/3/2021, the RN documented ..."Per daughter, patient is not able to ambulate on his own and his legs are buckling..." Aide care plan not updated to reflect this change. Patient #11: Aide Care Plan assigns a shower on every visit. On the Aide visits conducted on 12/30/2021 and 1/4/2021, the Aide documented providing a bed bath because the patient had become bed bound. On 1/6/2022, the RN documented ..."patient bedbound as end of life is near..." Although the patient was no longer able to get up, the Aide Care Plan was not updated to change the bath type. Patient #14: Aide Care Plan assigns a shower on every visit. On a RN visit conducted on 1/9/2022, the RN documented, ..."client no longer getting up to the chair..." Aide care plan not updated to reflect this change. Patient #15: Aide Care Plan with both a shower and bed bath assigned every visit.

Upon patient record review, 4 of 19 applicable (Patients #2, #3, #5 and #11) did not have documentation in the patient record that a hospice aide provided services that ordered by the IDG and included in the plan of care. Patient 2: Aide assignment directed the Aide to provide a bed bath during every visit. On 12/16/2021, the Aide documented giving a shower. Patient #3: Initial Plan of Care with orders for Aide frequency 2 x week. During the first week of care, the Aide only provided 1 visit. There was no documentation to indicate why the visits had been missed. Patient 5: During a Surveyor conducted home visit, the Aide provided a shower to the patient. Shower was not listed as a service to provide on the Aide assignment sheet. Patient 11: Aide assignment sheet, directed the Aide to provide a shower to the patient on every visit. On 1/4/2021, the Aide documented giving a bed bath instead.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. Review of Clinical Record #18, revealed the patient had requested to obtain Volunteer Services. There was no volunteer services provided to the patient.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. Missing evidence of recruitment and retention activities for 2021.

Upon patient record review, 2 of 20 (Patients #3 and #13) did not have evidence that the medical director or physician designee provided written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient #3: The written certification included only the primary and secondary diagnosis. There was no additional narrative documentation to indicate the Physician had considered current subjective and objective medical findings, current medication/treatment orders and information about the medical management. Patient #13: The written certification included only the primary and secondary diagnosis. There was no additional narrative documentation documentation to indicate the Physician had considered current subjective and objective medical findings, current medication/treatment orders and information about the medical management.

Upon patient client record review, 4 of 20 (Patients #1, #3, #11, and #12) 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 #1: On 11/30/2021, the Social Worker documented a missed visit note. The note was incomplete as to the reason. Patient #3: On 1/10/2022, the Aide documented a missed visit. The note was incomplete in that there was no reason given as to why the visit was missed. Patient #11: On 10/9/2021 and 10/10/2021, the LPN documented missed visits. On 10/9/2021, the LPN left blank the reason for the missed visit. On 10/10/2021, the reason for the missed visit was left blank. Patient #12: On 12/20/2021, the Social Worker documented a missed visit. The reason of the missed visit was left blank.

Upon client record review, 1 of 2 applicable (Patient #17) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #17: On 12/13/2021, the Patient transferred to another Hospice provider. There was no documentation to indicate the transfer summary was sent to the receiving hospice.