Every finding on record at Pec Hospice

Based on observation, interview, and record review, the hospice failed to ensure care and services were provided in accordance with the POC for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients.Findings: --- Review of the hospice's P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program.  The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.  The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief.  It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. Review of the hospice's P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting.  Missed visit will be documented in the clinical record.  If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.  If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit.  If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 1. Review of Patient 1's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/9/25.  The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. The POC/IDG Review, for the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25, showed HA visit two times per week for assistance with ADL and personal cares. However, review of the HA Visit Notes showed there was no documented evidence of a HA visit for the weeks of 6/9/25 to 6/14/25 and 8/3/25 to 8/9/25.  In addition, for the weeks of 6/15/25 to 6/21/25 and 8/31/25 to 9/6/25, there was only one HA visit a week instead of two visits a week as ordered in the POC. The POC/IDG Reviews dated 6/18, 7/2, 7/16, 7/30, 8/13, 8/27, and 9/10/25, showed SN visit once per week and two PRN visits for changes in condition and symptom management. However, review of the SN Visit Notes showed there was documented evidence of the SN visits for the weeks of 6/15/25 to 6/21/25 and 9/7/25 to 9/13/25. Further review of the clinical record failed to show documented evidence of an attempt to reschedule the visit within the same week as per the hospice's P&P. On 9/23/25 at 1057 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/19/25.  The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a.  The POC/IDG Review dated 9/10/25, showed in the nursing section, a new wound care treatment to Stage 4 sacrococcygeal pressure injury dated 9/2/25, as follows: to cleanse wound with normal saline, pat peri wound dry with a 4x4 gauze, apply a thin layer of topical Bactroban (antibiotic) ointment  on wound bed, apply a thin layer of calmoseptine (moisture barrier) to peri wound, and cover wound bed with a 4x4 bordered foam dressing three times per week for 14 days. A joint home visit with LVN 1 was conducted on 9/19/25 at 0855 hours, to Patient 2’s home.  LVN 1 was observed performing a head-to-toe assessment and providing wound treatment.  During the wound treatment to the patient’s pressure injury wound to the sacral area, LVN 1 removed the old dressing, assessed, and took a picture of the patient’s wound.  Then, LVN 1 sprayed the wound with a wound cleanser, patted the wound dry with a 4x4 gauze, applied barrier moisture ointment, and covered the wound with a foam dressing. On 9/19/25 at 1208 hours, an interview and concurrent clinical record review was conducted with LVN 1.  LVN 1 verified he applied barrier moisture ointment and stated it was an equivalent ointment for hydrogel ointment (used to facilitate debridement in wounds with necrotic and slough tissues).  LVN 1 showed a documentation of a physician’s wound treatment order dated 8/7/25, to cleanse Stage 2 pressure injury to sacral area with mild cleanser, pat dry, apply hydrogel, and cover with a border dressing. On 9/23/25 at 1221 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee reviewed the physician’s wound treatment order for the patient and verified LVN 1 did not follow the new treatment wound order dated 9/2/25, and POC.  The DPCS/Administrator Designee was informed and acknowledged the finding. b. The POC/IDG Review for the certification periods of 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25, included an intervention under the Integumentary/Skin section for the SN to assess changes in wound status which included to check the size, integrity, location, type/stage, signs and symptoms of infection, drainage, and effectiveness of current treatment. However, review of the LVN Visit Notes dated 7/10, 8/7, 8/19, 9/4, and 9/11/25, failed to show documented evidence of a wound assessment  as per the POC. On 9/23/25 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee verified there was no documented evidence the LVN completed a wound assessment.  The DPCS/Administrator Designee was informed and acknowledged the finding.  Cross reference to L651, example b.

Based on interview and record review, the hospice failed to ensure individualized care plans were developed for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk to cause an inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health conditions.Findings: --- Review of the hospice's P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program.  The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.  The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief.  It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs 1. Review of Patient 1's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/9/25.  The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. Review of the Psychosocial Assessment dated 9/13/25, showed the MSW conducted a visit.  The narrative notes showed the MSW recommended continuation of current palliative care measures with close monitoring for changes in the patient’s condition and planned to visit the patient once per the recertification period and as necessary.   However, review of the POC/IDG Reviews dated 6/18, 7/2, 7/16, 7/30, 8/13 and 8/27/25, failed to show documented evidence a psychosocial care plan was developed to address the MSW assessment. On 9/23/25 at 1111 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee was informed and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/19/25.  The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. Review of the Psychosocial Assessment dated 6/24/25, showed the MSW conducted a visit.  The narrative notes showed the MSW would maintain periodic contact with the patient and PCG to monitor the patient’s health, emotional well-being, and care needs; and planned to visit the patient once per the recertification period and additionally as required.   However, review of the POC/IDG Reviews dated 7/16, 7/30, 8/13, 8/27, and 9/10/25, failed to show documented evidence a psychosocial care plan was developed to address the MSW assessment. On 9/23/25 at 1141 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the POC/IDG Review dated 8/27/25, showed in the nursing section, new symptoms/updates: on 8/25/25, the discoloration was noted on the patient’s bilateral hands during the RN’s visit.  However, there was no documented evidence a plan of care was developed to address the patient’s bilateral hands discoloration. On 9/23/25 at 1225 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk for not providing appropriate, consistent, and quality care to Patients 1 and 2.Findings: --- Review of the hospice’s P&P titled the Plan of Care revised April 2020 showed the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis but no less than every fifteen (15) days. 1. Review of Patient 1's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/9/25.  The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25.The physician’s orders showed the following frequency of visits:- Dated 6/9/25, HA visits two times per week for assistance with ADLs and personal care.- Dated 6/13/25, MSW visit once every recertification period and as needed for psychosocial support. The POC/IDG Review dated 6/18, 7/2, 7/16, 7/30, 7/30, 8/13, 8/27, and 9/10/25, in the section of Frequency of Visits, showed HA visit once per week for assistance with ADL and personal care and MSW one visit for initial assessment.  However, the section of the Frequency of Visit was not revised to reflect the HA and MSW visits as per the physician’s order. On 9/23/25 at 1124 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated the HA visit frequency was incorrect and should be two times per week.  The DPCS/Administrator stated the MSW frequency visit order and recommendations should be reflected in the POC/IDG Review.  The DPCS/Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/19/25.  The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. The POC/IDG Review dated 7/16/25, showed a physician’s order dated 7/2/25, for HA to visit the patient two times per week for assistance with ADLs and personal care.  In the section of the Frequency of Visit, showed HA visit three times per week for assistance with ADLs and personal care.  However, the section of the Frequency of Visit was not revised to reflect the physician’s order of HA frequency visit. On 9/23/25 at 1134 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated the HA visit frequency was incorrect and should be changed to two times per week because the patient had a private caregiver.  The DPCS/Administrator stated the section in the frequency visit should have reflected HA visits two times per week instead of three times per week.  The DPCS/Administrator Designee was informed and acknowledged the finding. b. The POC/IDG Review dated 9/10/25, showed a physician’s order dated 9/2/25, to cleanse stage 4 sacrococcygeal pressure injury wound with normal saline, pat peri wound dry with a 4x4 gauze, apply a thin layer of topical Bactroban ointment on wound bed, apply a thin layer of calmoseptine to peri wound, and cover wound bed with a 4x4 bordered foam dressing three times per week for 14 days.  However, in the Integumentary/Skin section, the intervention showed for stage 2 sacrococcygeal pressure injury to cleanse the wound with normal saline, pat peri-wound area dry with 4x4 gauze as ordered, apply Medihoney (antibacterial honey-based dressing) to the wound bed, cover with 4x4 bordered foam dressing every two days or as needed if soiled or non-adherent.  *The POC did not reflect the new wound treatment for the patient’s sacrococcygeal pressure injury wound. On 9/23/25 at 1227 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated the new wound treatment order to the patient’s sacrococcygeal pressure injury should had been reflected in the POC and the staging for the new wound treatment order should be stage 4 and not stage 2.  The DPCS/Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk of not addressing the care needs for these patients.  Findings: --- Review of the hospice’s P&P titled IDG Coordination of Care revised April 2020 showed the hospice will utilize a case management system to guide an IDG to provide comprehensive, coordinated hospice care to patients and family/caregivers.  It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a RN.  The Case Manager will be responsible for coordination of services with the IDG from referral to discharge.  The type and scope of services provided by the IDG will be based upon the comprehensive and ongoing assessment regarding the needs of the patient and the family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions.  The IDG will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients. Review of the hospice's P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting.  Missed visit will be documented in the clinical record.  If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.  If a visit is missed and not rescheduled the clinician will notify the IDG and the clinical supervisor of the missed visit.  If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 1. Review of Patient 1’s clinical records showed the HA and SN did not conduct the visits as cited in the POC.  Cross reference to L543, example 1.However, there was no documented evidence of IDG notification regarding the missed visits as per the hospice’s P&P.  There was no documented evidence of an IDG discussion regarding the missed visits during the IDG meetings for Patient 1.  The IDG failed to maintain the responsibility for supervising the care and services provided to Patient 1. On 9/23/25 at 1057 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated there should be a documented communication for the missed visit to a patient.  The DPCS/Administrator Designee stated the missed visit should be discussed and coordinated with the physician and IDG.  The DPCS/Administrator Designee was informed and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/19/25.  The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. The POC/IDG Review dated 9/10/25, showed a physician’s order dated 9/2/25, to cleanse Stage 4 sacrococcygeal pressure injury wound with normal saline, pat peri wound dry with a 4x4 gauze, apply a thin layer of topical Bactroban ointment  on wound bed, apply a thin layer of calmoseptine to peri wound, and cover wound bed with a 4x4 bordered foam dressing 3 times per week for 14 days.  However, the intervention showed for Stage 2 sacrococcygeal pressure injury, to cleanse the wound with normal saline, pat peri-wound area dry with 4x4 gauze as ordered, apply Medihoney to the wound bed, cover with a 4x4 bordered foam dressing every two days or as needed if soiled or non-adherent.  The Wound Progress Report from the Wound Specialist visits dated 9/9 and 9/16/25, showed Stage 2 pressure injury to sacroccocyx wound treatment order was to cleanse the wound with normal saline, pat the peri-wound dry with a 4x4 gauze, apply thin layer of hydrogel ointment on the wound, apply thin layer of calmoseptine to peri-wound, and cover the wound bed with a 4x4 bordered foam dressing three times a week for 14 days. However, there was no documented evidence of communication or coordination with the IDG and physician on the updated wound treatment orders for the patient’s Stage 2 sacrococcyx pressure injury. On 9/23/25 at 1259 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated if the Wound Specialist had an immediate change in wound treatment orders, the Wound Specialist would email the treatment order to the hospice.  The DPCS/Administrator Designee stated the Wound Specialist would send their visit wound progress report within two days of the visit date.  The DPCS/Administrator Designee verified the Wound Specialist wound treatment orders for the patient’s Stage 2 pressure injury to the sacrococcyx was not coordinated in the IDG meeting to update the treatment orders or reflect on the POC so the disciplines could follow the most updated order from the Wound Specialist.  The DPCS/Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all care provided as evidenced by:- The Administrator failed to ensure wound care policy was implemented for one of two sampled patients (Patient 2).- The Administrator failed to ensure the supervision for the LVN policy was implemented for one of two sampled patients (Patient 2).These failures had the potential risk to negatively impact the hospice’s operational performance.Findings: --- Review of the hospice’s Administrator Job Descriptions revised April 2020 showed the Administrator of the hospice will be responsible for the day-to-day operations of hospice. Review of the hospice’s P&P titled Responsibilities/Supervision of Clinical Services revised April 2020 showed the Clinical Director will be responsible for the direction of hospice and will take reasonable steps to ensure that care and services provided by the hospice personnel and contracted personnel are coordinated and integrated; policies and procedures that guide and support the provision of care and services are developed and implemented.  The Clinical Director will ensure that the following supervision is maintained within hospice: LVN will be supervised by a registered nurse at least every 14 days or as directed by the State Practice Act, whichever is more frequent. Review of the hospice’s P&P titled Comprehensive Wound Care Assessment (undated) showed for ongoing reassessment of a wound, at each skilled nursing visit, the RN/LVN reassesses the wound.  Weekly progress review at the IDG meeting.  Documentation requirement for all wound notes must include objective data (measurements, staging, and condition of the wound), skilled nursing interventions performed, patient/PCG teaching provided, pain management strategies, and MD notification/orders obtained. Review of Patient 2's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/19/25.  The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. Review of the Comprehensive Nursing Assessment dated 6/19/25, showed the patient had Stage 2 pressure injury to sacrococcygeal area. Review of the SN Visit Notes Dated 7/17, 7/24, 7/31, 8/14, 8/26, 9/9, and 9/16/25, showed the wound assessments failed to include the measurements of the patient’s Stage 2 pressure injury to the sacrococcyx area.  In addition, the SN Visit Notes dated 7/10, 8/7, 8/19, 9/4, and 9/11/25, failed to show documented evidence of wound assessments as per the hospice’s P&P. On 9/23/25 at 1233 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated for each SN visit, the nurse should assess the patient’s wound including the location, measurements, characteristics, signs of infection, and changes in appearance of the wound, and documented.  The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the Updated Assessment dated 7/17, 7/31, 8/14, 8/26, 9/9, and 9/16/25, showed in the section of Supervisory Note, RN 1 evaluated LVN 3.  With the question if LVN 3 demonstrated competence with assigned task, the documentation showed, “Yes.”  However, review of the LVN Visit Notes dated 7/10, 8/7, 8/19, 9/4, and 9/11/25, failed to show documented evidence wound assessments were completed as per the hospice’s P&P. On 9/23/25 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated every two weeks, as part of the coordination with the LVN and RN, the RN would do supervisory visits to provide education to the LVN about wound management, abnormal vital signs, reporting of changes of condition and checking if the LVN is following the patient’s POC.  The DPCS/ Administrator showed the LVN was in continuous communication with her regarding the patient’s progress; however, the DPCS/Administrator Designee verified there was no documented evidence the LVN completed wound assessments.  The DPCS/Administrator Designee was informed and acknowledged the finding.  Cross reference to L543, example 2.b.

Based on interview and record review, the hospice failed to ensure the patients' clinical records were complete, accurate and submitted timely for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete, inaccurate, and untimely submitted documentation.Findings: --- Review of the hospice's P&P titled Content of Clinical Records (undated) showed the hospice maintains complete, accurate, timely, and readily retrievable clinical records for all patients and families served.  Entries must be completed, signed, and submitted within seven days of service.  1. Review of Patient 1's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/9/25.  The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. a. Review of the HA Visit Notes dated 7/28, 7/30, 8/13, 8/15, 8/18, 8/21, 8/25, 8/27, 9/5, 9/10, and 9/13/25, showed the HA conducted a home visit and a status of a red “X” symbol.  However, the HA visit notes were incomplete. On 9/23/25 at 1101 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated the disciplines’ visit notes should be completed and submitted within seven days of the visit date. The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the POC/IDG dated 6/18, 7/2, 7/16, 7/30, 8/13, and 8/27/25, showed a genitourinary problem of potential for altered bladder elimination related to BPH. Review of the Physician Order dated 6/9/25, showed an order to administer Tamsulosin hydrochloride (alpha blocker) 0.4 mg one caplet by mouth once daily for BPH. However, review of the Demographics showed the patient’s gender was female. On 9/23/25 at 11124 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated the documented diagnosis of BPH was an incorrect.  The DPCS/Administrator Designee was informed and acknowledged the finding. 2. Review of Patient 2's clinical record was initiated on 9/18/25.  The clinical record showed the SOC was on 6/19/25.  The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. Review of the POC/IDG dated 7/16, 7/30, 8/13, 8/27, and 9/10/25, showed a POC in the genitourinary section, a goal the patient will manifest improved urine output within the target limit set by the healthcare provided; and the patient will participate in dialysis treatments as prescribed.  In addition, the intervention included to explain the importance of dialysis. Review of the CTI, for the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25, did not include documented evidence the patient had a diagnosis of End Stage Renal Disease nor was receiving dialysis treatment. On 9/23/25 at 1136 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated the patient was not on dialysis treatment.  The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the HA Visit Note dated 7/28/25, showed in the narrative section, “wound care to the sacral area was performed per MD orders and the patient tolerated the procedure well.”  *However, review of the HA assignment dated 6/19/25, showed a task for the HA to visualize the condition of the skin and report to the RN every visit but not to provide wound treatment. On 9/23/25 at 1242 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee.  The DPCS/Administrator Designee stated the HA’s documentation was inaccurate.  The DPCS/Administrator Designee stated the HA was only supposed to report to the RN if there were changes in the patient’s skin condition and not provide wound treatment.  The DPCS/Administrator Designee was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments identified the emotional, psychosocial, and spiritual needs for one of two sampled patients (Patient 2).  This failure had the potential risk of not providing care and services to meet the care needs for Patient 2.Findings: --- Review of the hospice’s P&P titled Comprehensive Assessment revised April 2020 showed a physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness.Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Review of the Comprehensive Nursing Assessment dated 6/23/25, showed RN 1 had performed the initial comprehensive assessment.  The assessment included the Vitals and Measurements sections.  However, the section for height was left blank.On 9/2/25 at 1514 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and stated the sections in the assessment should all be completed.

Based on interview and record review, the hospice failed to ensure the initial bereavement assessment was completed for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients. Findings: --- Review of the hospice’s P&P titled Initial Assessment revised April 2020 showed admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment.  Nursing and bereavement sections will always be identified.Review of the hospice’s P&P titled Bereavement Assessment revised April 2020 showed on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator.  The Bereavement Coordination will review the bereavement risk assessment to determine the potential needs of the survivors.1. Review of Patient 1’s clinical record was initiated on 8/29/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Further review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/2/25 at 1453 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Further review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/2/25 at 1515 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the finding.

Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the POC for two of tow sampled patients (Patients 1 and 2).  This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients.Findings: --- Review of the hospice's P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program.  The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.  The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief.  It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs.Review of the hospice's P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting.  Missed visit will be documented in the clinical record.  If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.  If a visit is missed and not rescheduled the clinician will notify the IDG and the clinical supervisor of the missed visit.  If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above.1. Review of Patient 1’s clinical record was initiated on 8/29/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.*The POC/IDG Review for certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25, showed HA visit two times per week for assistance with ADL and personal cares.However, review of the HA Visit Notes showed the following:- For week 1 (from 6/23 to 6/28/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 2 (from 6/29 to 7/5/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 3 (from 7/6 to 7/12/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 6 (from 7/27 to 8/2/25), there was one HA visit instead of two visits as ordered in the POC.- For week 7 (from 8/3 to 8/9/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 8 (from 8/10 to 8/16/25), there was no documented evidence of two HA visits as ordered in the POC.*The POC/IDG Review dated 6/23, 6/26, 7/16, 7/30, and 8/13/25, showed SN visits two times per week and two PRN visits for change in condition and symptom management.However, review of the SN notes showed the following:- For the week of 6/23 to 6/28/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 6/29 to 7/5/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/6 to 7/12/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/13 to 7/19/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/20 to 7/26/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/27 to 8/2/25, there was no documented evidence of a SN visit as ordered in the POC.- For the week of 8/3 to 8/9/25, there was no documented evidence of two SN visit as ordered in the POC.- For the week of 8/10 to 8/16/25, there was no documented evidence of a SN visit as ordered in the POC.- For the week of 8/17 to 8/23/25, there was no documented evidence of two SN visits as ordered in the POC.- For the week of 8/24 to 8/30/25, there was one SN visit instead of two visits as ordered in the POC.*The POC/IDG Review dated 6/23, 6/26, 7/16, 7/30, 8/13, and 8/27/25, showed RN visit once every 14 days for comprehensive assessment and supervisory visit.Review of the SN Visit Notes dated 7/16 and 8/27/25, showed the RN had a home visit.  However, further review of the SN Visit Notes failed to show documented evidence of the RN visit completed every 14 days for comprehensive assessment and supervisory visit as ordered per the POC.*The physician’s order dated 6/28/25, showed MSW visit once per month and as needed for psychosocial support to the patient and family.However, review of the clinical record failed to show documented evidence of a MSW visit for the month of July as per the physician’s order.Further review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice's P&P.On 9/2/25 at 1322 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS stated if there was a missed visit, the nurse should attempt to reschedule another visit within the same week.  The DPCS further stated the missed visit should be reported to the physician and IDG, and the reason should be documented. The DPCS was informed and acknowledged the findings.2. Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.*The POC/IDG Review for the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25, showed RN visit once every 14 days for comprehensive assessment and supervisory visit.Review of the SN Visit Notes dated 7/9 and 7/20/25, showed the RN had a home visit.  However, further review of the SN Visit Notes failed to show documented evidence of the RN visit completed every 14 days for comprehensive assessment and supervisory visit as ordered per the POC.*The POC/IDG Review dated 7/30/25, showed SN visit once per week and three PRN visits for changes in condition and symptom management.However, review of the SN Visit Notes showed the following:- For the week of 8/3 to 8/9/25, there was no documented evidence of an SN visit as ordered in the POC.- For the week of 8/17 to 8/23/25, there was no documented evidence of an SN visit as ordered in the POC.The POC/IDG Review dated 6/26, 7/15, 7/30, and 8/13/25, showed HA visit two times per week – declined.However, review of the HA Visit Notes showed the following:- For the week of 7/27 to 8/2/25, there was one HA visit.- For the week of 8/3 to 8/9/25, there was no documented evidence of two HA visits as ordered.- For the week of 8/10 to 8/16/25, there was no documented evidence of two HA visits as ordered.Further review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice's P&P.On 9/2/25 at 1453 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS clarified the HA visit should had been two visits per week and the word "decline" was an inaccurate documentation.  The DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk to cause an inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health conditions.Findings: --- Review of the hospice's P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program.  The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.  The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief.  It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs.1. Review of Patient 1’s clinical record was initiated on 8/29/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Review of the Psychosocial Assessment dated 6/28/25, showed the MSW conducted a visit.  The narrative notes showed the MSW planned to visit the patient once per the recertification period and as necessary.  In addition, the POC/IDG Reviews dated 7/16 and 7/30/25, showed the MSW visit once per recertification period and as necessary; and The POC/IDG Reviews dated 8/13 and 8/27/25, showed in the section of psychosocial, the MSW visit once per month offering psychosocial support to the patient and family.However, review of the POC/IDG Reviews dated 7/16, 7/30, 8/13 and 8/27/25, failed to show documented evidence a psychosocial care plan was developed to reflect the MSW assessment.On 9/2/25 at 1318 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Review of the Psychosocial Assessment dated 6/28/25, and MSW Visit Note dated 8/26/25, showed the MSW conducted a visit.  The narrative notes showed the MSW visit once every recertification period and as needed to continue to assess the patient’s needs and provide the appropriate resources and assistance.However, review of the POC/IDG Reviewa dated 7/16, 7/30, 8/13 and 8/27/25, failed to show documented evidence a psychosocial care plan was developed to reflect the MSW assessment.On 9/2/25 at 1515 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for two of twp sampled patients (Patients 1 and 2).  This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: --- Review of the hospice's P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program.  The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.  The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days.  This plan will focus on identified problems, goals, and interventions.  The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions.  The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.  The written plan of care will contain, but not limited to, the following: under letter T, measurable outcomes anticipated from implementing and coordinating the plan of care.1. Review of Patient 1’s clinical record was initiated on 8/29/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.The POC/IDG Reviews dated 6/26, 7/16, 7/30, 8/13, and 8/27/25, showed the patient’s identified problems with the established goal and interventions.  However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example:- The goal for impaired skin integrity related to immobility and incontinence was for the patient to experience maximized comfort and preserved dignity during end-of-life care.- The goal for self-care deficit related to cognitive and physical decline was for the patient to maintain level of comfort, dignity, and function.On 9/2/25 at 1411 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.The POC/IDG Reviews dated 6/25, 7/15, 7/30, 8/13, and 8/27/25, showed the patient’s identified problems with the established goal and interventions.  However, the POC failed to include measurable outcomes for the patient’s identified problems.  For example:- The goal for decreased cardiac output related to disease process as evidenced by unstable blood pressure was for the patient’s blood pressure to be normal range of the disease process and for the patient to have a stable cardiac rate in the next two weeks of treatment.- The goal for risk for adverse effects related to use of cholesterol-lowering medication was for the patient’s comfort and dignity will be maintained through minimized medication burden.- The goal for altered sleep pattern related to progression of disease process as evidenced by difficulty falling or staying asleep, fatigue, and verbal reports of poor sleep quality was for the patient to experience reduced anxiety and discomfort at bedtime.On 9/2/25 at 1520 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days for one of two sampled patients (Patient 2).  This failure had the potential risk for not providing appropriate, consistent, and quality care to Patient 2.Findings: --- Review of the hospice’s P&P titled the Plan of Care revised April 2020 showed the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis but no less than every fifteen (15) days.Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.The physician’s order dated 6/28/25, showed MSW visit once every recertification period and as needed for psychosocial support.The initial Spiritual Assessment dated 6/27/25, showed the patient and PCG declined the offer of a spiritual care services.Review of the POC/IDG Reviews dated 6/25, 7/15, 7/30, 8/13, and 8/27/25, the section of the Frequency of Visit, showed HA visit two times per week-decline and SN visit once per week and three PRN visits.  *However, the section of the Frequency of Visit  was not revised to reflect the MSW visit as per the physician’s order and the spiritual care services decline as per the Spiritual Assessment.On 9/2/25 at 1525 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS stated the HA frequency visit was supposed to be two times per week and should not be declined.  The DPCS further stated the POC should had been updated to reflect the services the patient received per the POC.  The DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk of not addressing the care needs for these patients.  Findings: --- Review of the hospice’s P&P titled IDG Coordination of Care revised April 2020 showed the hospice will utilize a case management system to guide an IDG to provide comprehensive, coordinated hospice care to patients and family/caregivers.  It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a RN.  The Case Manager will be responsible for coordination of services with the IDG from referral to discharge.  The type and scope of services provided by the IDG will be based upon the comprehensive and ongoing assessment regarding the needs of the patient and the family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions.  The IDG will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients.Review of the hospice's P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting.  Missed visit will be documented in the clinical record.  If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.  If a visit is missed and not rescheduled the clinician will notify the IDG and the clinical supervisor of the missed visit.  If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above.Review of Patients 1 and 2's clinical records showed the disciplines did not conduct the visits as cited in the POC.  Cross reference to L543, examples #1 and #2.However, there was no documented evidence the IDG notification regarding the missed visits as per the hospice’s P&P.  There was no documented evidence of the IDG discussion regarding the missed visits during the IDG meetings for these patients.  The IDG failed to maintain the responsibility for supervising the care and services provided to the patients.On 9/2/25 at 1322 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS stated there should be a documented communication for the missed visit to a patient.  The DPCS stated the missed visit should be discussed and coordinated with the physician and IDG.  The DPCS stated during the IDG meetings every two weeks, the IDG discussed the hospice’s admission, discharges, patient's changes of condition, psychosocial needs, spiritual needs, new physician's orders, and missed visits.  The DPCS was informed and verified there was no documented evidence to show the disciplines' missed visits were communicated and coordinated to the physician or the IDG.

Based on interview and record review, the hospice failed to ensure the physician reviewed the patient’s clinical information to recertify the patient for hospice services for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk of not identifying the care needs for these patients.Findings: --- Review of the hospice’s P&P titled Certification of Terminal Illness revised April 2020 showed the patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director.  Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period.  A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director.  At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient’s medical record or, if applicable, examination of the patient.  A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period.  The signed and dated certification must be present prior to billing for each recertification period.1. Review of Patient 1’s clinical record was initiated on 8/29/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and “8/22/25 to 10/20/25.”Review of the Physician’s Certification for Hospice Benefit showed Certification #27: Re-Certification Statement for the Next 60-day period for the effective date of certification from 8/22/25 to 10/20/25.  However, the sections for RN prognosis summary, physician narrative, certifying physician narrative, and physician signature were left blank.Further review of the clinical record showed the patient continued to receive hospice services on 8/22, 8/25, 8/27, and 8/28/25.However, there was no documented evidence the certification of terminal illness was completed prior to the patient receiving hospice services on 8/22/25.  On 9/2/25 at 1312 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS stated the CTI was pending for the physician to complete.  The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and “8/22/25 to 10/20/25.”Review of the Physician’s Certification for Hospice Benefit showed Certification #8: Re-Certification Statement for the Next 60-day period for the effective date of certification from 8/22/25 to 10/20/25.  However, the section for the RN prognosis summary, physician narrative, certifying physician narrative, and physician signature were left blank.Further review of the clinical record showed the patient continued to receive hospice services on 8/23, 8/26, and 8/28/25.However, there was no documented evidence the certification of terminal illness was completed prior to the patient receiving hospice services on 8/23/25.  On 9/2/25 at 1531 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the patients' clinical records were complete, accurate and submitted timely for two of two sampled patients (Patients 1 and 2).  This failure had the potential risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete, inaccurate, and untimely submitted documentation.Findings: --- Review of the hospice's P&P titled Content of Clinical Records (undated) showed the hospice maintains complete, accurate, timely, and readily retrievable clinical records for all patients and families served.  Entries must be completed, signed, and submitted within 7 days of service.  The POC is established by IDG, updated at least every 15 days, signed by the physician.1. Review of Patient’s 1’s clinical record was initiated on 8/29/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.a. Review of the Visit Notes dated 7/3, 7/8, and 7/24/25, showed a LVN conducted a home visit, and a status of a red “X” symbol.  However, the visit notes were incomplete.On 8/29/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator stated the red “X” symbol meant the visit notes were not submitted and incomplete.  The Administrator was informed and acknowledged the finding.b. Review of the POC/IDG Reviews dated 6/26/25 and 7/16/25, showed the IDG meetings were conducted on 6/26 and 7/16/25, more than 15 days.On 9/2/25 at 1335 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS stated there was an IDG meeting held on 7/2/25.  The DPCS provided documentation of the sign-in sheet for the IDG meeting dated 7/2/25, and a summary report description for each of the hospice’s patients.  The DPCS stated when the IDG meeting was held, the patient’s change of condition and care needs were discussed.  However, the DPCS verified there was no documented evidence of a completed comprehensive assessment for Patient 1.2. Review of Patient 2’s clinical record was initiated on 9/2/25.  The clinical record showed the SOC was on 6/23/25.  The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.a. Review of the POC/IDG Reviews dated 6/26, 7/15, 7/30, 8/13, and 8/27/25, showed the section of the frequency of visits HA visit two times per week showing “decline.”On 9/2/25 at 1525 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS stated the word decline was a wrong documentation.  The DPCS stated the patient was receiving HA visits two times per week.  The DPCS was informed and acknowledged the finding.b. Review of the POC/IDG Review dated 6/25 and 7/15/25, showed an IDG meeting was conducted on 6/25 and 7/15/25, more than 15 days.On 9/2/25 at 1510 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated there was an IDG meeting held on 7/2/25.  The DPCS provided documentation of the sign-in sheet for the IDG meeting dated 7/2/25 and a summary report description for each of the hospice’s patients.  The DPCS stated when the IDG meeting was held, the patient’s change of condition and care needs were discussed.  However, the DPCS verified there was no documented evidence of a completed comprehensive assessment for Patient 2.

Based on interview and record review, the hospice failed to ensure the comprehensive assessment was completed no later than five calendar days after the election of hospice care for one of one sampled patient (Patient 1).  This failure created the potential risk for not addressing the care needs for this patient. Findings: --- Review of Patient 1’s closed clinical record was initiated on 7/2/25.  The clinical record showed the SOC was on 5/30/25.  The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25.  The patient was discharged and revoked hospice services on 6/10/25.The election of hospice benefit form dated 5/30/25, showed Patient 1 signed for hospice services.The initial Spiritual Care Assessment dated 6/7/25, showed no documented evidence the SCC assessed the sections for "ALTERATIONS/PROBLEMS REPORTED OR SUSPECTED" and "REPORTED OR SUSPECTED ASSISTANCE NEEDS."   Documentation showed the patient's bereavement risk was not completed.* However, there was no documented evidence the comprehensive spiritual assessment was completed no later than five calendar days after the election of hospice care.On 7/3/25 at 1407 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner.  The Administrator/Owner stated the spiritual care assessment was completed more than five days of the election of hospice care because of the patient or family’s schedule request.  However, there was no documented evidence to show the SCC visit was requested for 6/7/25.  The Administrator/Owner was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the medication profile was reviewed and updated to reflect the current medications and include the specific instructions for its use for one of one sampled patient (Patient 1).  This failure had the potential for the patient to not receive the appropriate care and necessary services and negatively affect the patients' well-being.Findings: --- Review of the hospice's P&P titled Medication Profile revised 3/1/12, showed the nurse responsible for the tuck in visit and/or initial comprehensive assessment will complete the medication profile ordered by the attending physician during the admission process.  The medications listed on the POC are those related to the palliation and management of the terminal illness as covered medication.  The RN case manager and/or QA personnel will review and update, correct as necessary.Review of Patient 1’s closed clinical record was initiated on 7/2/25.  The clinical record showed the SOC was on 5/30/25.  The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25.  The patient was discharged and revoked hospice services on 6/10/25.The physician’s order dated 6/8/25, showed the following orders:-morphine concentrate (opioid analgesic) 5 mg (20 mg/ml) SL for moderate breakthrough pain 4-6 (on a 0-10 pain scale, with 0=no pain and 10=worst pain) Q four hours PRN-morphine concentrate 10 mg (20 mg/ml) SL for severe breakthrough pain level of 7-10 Q four hours PRN* However, the morphine orders did not have specific instructions of how much the amount of 5 mg or 10 mg were equivalent to in ml(s) to administer to the patient.On 7/3/25 at 0810 hours, an interview and concurrent closed clinical record review was conducted with RN 1.  RN 1 stated the morphine bottle that was delivered to Patient 1 had a medication label showing to give 0.25 ml for 5 mg and 0.5 ml for 10 mg dose.  RN 1 stated there should be specific equivalence of the dosage of mg to ml in the physician’s orders.  RN 1 was informed and acknowledged the above finding.On 7/3/25 at 1407 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner.  The Administrator/Owner was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of one sampled patient (Patient 1).  This failure had the potential risk of not providing appropriate, consistent, and quality care to Patient 1. Findings: --- Review of Patient 1’s closed clinical record was initiated on 7/2/25.  The clinical record showed the SOC was on 5/30/25.  The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25.  The patient was discharged and revoked hospice services on 6/10/25. The physician’s order dated 6/8/25, showed the following orders:-morphine concentrate (opioid analgesic) 5 mg (20 mg/ml) SL for moderate breakthrough pain 4-6 Q four hours prn-morphine concentrate 10 mg (20 mg/ml) SL for severe breakthrough pain 7-10 Q four hours prn The Hospice Nursing Clinical Note dated 6/9/25, showed the following documentation:- “1545, Morphine 5 mg administered PO/SL administered PO/SL for pain management.”- “1800, pt noted with episode of grimace, moaning rate pain 5/10, SN administered Morphine prn 5mg PO/SL for pain management with good effective.”- “2000, Morphine 5 mg administered PO/SL for pain management.”- “2200, Pt noted with episode of grimace, moaning rate pain 4/10.  Morphine 5 mg administered PO/SL for pain management.” *However, there was no documented evidence of the physician’s orders or plan of care for morphine 5 mg to be administered every two hours to the patient. On 7/3/25 at 1319 hours, a telephone interview was conducted with RN 1.  RN 1 was informed and stated when a patient was in continuous care, an order for morphine in small doses can be given every two hours to relieve anxiety and shortness of breath to help the patient’s condition when the patient was struggling.  RN 1 further stated the LVN should have clarified the morphine order to be given every two hours routinely or as needed.  RN 1 acknowledged the above finding. On 7/3/25 at 1415 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner.  The Administrator/Owner was informed and acknowledged the above finding.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for one of one sampled patient (Patient 1).  This failure created the potential risk to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patient's health conditions.Findings: --- Review of the hospice’s P&P titled Hospice Plan of Care and Treatment dated 5/10/02, showed an individualized plan of care/treatment will be established for every patient accepted for the care.  This written plan shall be developed in consultation with the Interdisciplinary Team.  The plan will be reviewed and updated at intervals specified.  The care is to be used as a treatment guide for all disciplines and will be part of the patient’s permanent record.  The content of the plan of care include:- diagnoses- assessment of patient/family needs including medical, nursing, functional, psychosocial, and spiritual status- appraisal of and need for symptom control- mental status- assessment of family needs as related to care of patient- types of services and equipment required- frequency of visits, treatments, and medications- instructions to patient and family- nutritional problems/requirements- statement of treatment goals, rehab potential- prognosis, discharge, referral plan- activities/ functional limitations/ safety measures- identifications of discipline responsible for each intervention/ service-methods of evaluation/ follow up Review of Patient 1’s closed clinical record was initiated on 7/2/25.  The clinical record showed the SOC was on 5/30/25.  The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25.  The patient was discharged and revoked hospice services on 6/10/25. a.  The admission physician’s orders dated 5/30/25, showed the following orders:-Okay to access left chest port for IVF, IV Zofran (a drug to prevent nausea and vomiting)-NS 1000 ml Q 24 hours via port over 2-4 hours at 250-500 ml per hour-Zofran 8 mg IV Q eight hours for nausea and vomiting.* However, there was no documented evidence the IDG had developed an individualized POC to address Patient 1’s left chest port site, access care, and IV medication administration. b.  The Medication Profile showed an order dated 5/31/25, for morphine sulfate (opioid analgesic) 2 mg (20 mg/ml) Q one hour PRN for break through pain.Review of the Hospice Nursing Clinical Note dated 6/6/25, showed documentation of “Pt stated last night had severe pain, her daughter gave her Morphine liquid 20 mg=1ml at 11 pm with effective.”The physician’s order dated 6/8/25, showed the following orders:-morphine concentrate (opioid analgesic) 5 mg (20 mg/ml) SL for moderate breakthrough pain 4-6 Q four hours prn-morphine concentrate 10 mg (20 mg/ml) SL for severe breakthrough pain 7-10 Q four hours prnThe Hospice Nursing Note dated 6/8/25, showed, “Family Reports although Patient with No S/S pain, patient was requesting 20 MG MORPHINE SL instead of 5-10 Mg as Ordered."  Documentation showed the SN assessed the patient would then become sedated with decreased verbal response and change in breathing.  Documentation showed the patient was receiving morphine 20 mg in AM and sleeping with decreased level of consciousness after the dose.* However, there was no documented evidence the IDG had developed an individualized POC to address Family Member 1’s noncompliance of administering morphine 20 mg to the patient. c. Review of the hospice’s P&P titled Change in Condition-Continuous Care revised 3/1/02, showed during periods of acute medical crisis for patients residing at home or nursing facility, boarding care, a change of condition where frequent SN visits do not meet the patient’s medical need, “continuous care” may be necessary.  The patient must require primarily skilled nursing care for palliation or management of acute medical symptoms to be eligible to receive continuous care.  The hospice case manager will, under section number 5, update the plan of care.The physician’s order dated 6/9/25, showed to start continuous care on 6/9/25, for pain and respiratory management.Review of the Hospice Nursing Clinical Note dated 6/9/25, showed care plan problems for pain, respiratory, GI/GU/nutritional/endocrine, and integumentary.* However, there was no documented evidence the IDG had developed an individualized POC to reflect Patient 1’s start of continuous care. On 7/3/25 at 0810 hours, an interview and concurrent closed clinical record review was conducted with RN 1.  RN 1 was informed and acknowledged the above findings. On 7/3/25 at 1415 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner.  The Administrator/Owner was informed and acknowledged the above findings.

Based on interview and record review, the hospice failed to ensure the clinical record was authenticated and dated timely in accordance with the hospice's P&P for one of one sampled patient (Patient 1).  This failure had the potential risk of substandard care provided to Patient 1 as the clinical information was not completed timely.Findings: --- Review of the hospice’s P&P titled Authentication of Clinical Record revised 3/1/23, showed to ensure the integrity of documentation correction and submission, the hospice establishes and implements a monitoring system to track medical record charting, correction process, timely submission per state and federal regulations.  At the time, before, after or during the visit, the discipline opens/creates a visit note or start of care as the assignment.  This visit note includes the date, the time arrival and time leave, and mileage.  After the visit, the discipline completes the visit documentation and select “Send To the Office” button.  If it is a start of care, the initial documentation is to be done within 2 to 3 days and complete within 5 days.  If it is a routine visit note, the documentation is to be done within 30 days or sooner pending on payer’s rule. Review of Patient 1’s closed clinical record was initiated on 7/2/25.  The clinical record showed the SOC was on 5/30/25.  The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25.  The patient had revoked hospice services and was discharged on 6/10/25. Review of the initial Medical Social Services Assessment showed on 6/3/25, the MSW conducted a visit.   *However, the MSW’s documentation was electronically signed on 6/7/25.  In addition, the MSW did not include a documentation of her mileage information.  The MSW did not complete the signature within 5 days nor include the mileage information per the hospice’s P&P. On 7/3/25 at 1415 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner.  The Administrator/Owner was informed and acknowledged the above finding.  The Administrator/Owner stated the comprehensive assessment should be signed within 5 days of the election of hospice care.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&P included the process for cooperation and collaboration with the State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospice's emergency preparedness P&P titled Emergency Preparedness and Emergency Response Plan revised 6/1/18 was initiated on 9/15/22. The hospice's P&P showed the process for cooperation and collaboration with the local officials; however, it did not include the specific process outlining how and when the hospice would cooperate and collaborate with the State and Federal emergency preparedness officials during a disaster or emergency situation. On 9/19/22 at 1200 hours, an interview and concurrent record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&P included the procedures to inform the State emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This failure created the risk of not providing the necessary care and services to the patients during the emergency. --- Findings: Review of the hospice's emergency preparedness P&P titled Emergency Preparedness and Emergency Response Plan revised 6/1/18 was initiated on 9/15/22. The hospice's P&P showed the policy shall address the procedures for informing the State and local officials who would need to be evacuated from their homes. The P&P addressed the hospice would inform the local officials; however, it did not include the specific procedures informing the State emergency preparedness officials about the patients in need of evacuation. The P&P did not address when and how the appropriate information would be communicated to the State officials to facilitate the patient's evacuation and transportation. On 9/19/22 at 1200 hours, an interview and concurrent record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&P included the process and role of integration of State and Federally designated healthcare professionals to address the surge needs during an emergency. This failure created the risk of not providing the necessary care and services to the patients during an emergency in the event the hospice's and local agencies' resources were exhausted. --- Findings: Review of the hospice's emergency preparedness P&P titled Emergency Preparedness and Emergency Response Plan revised 6/1/18, was initiated on 9/15/22. The hospice's P&P showed the policy shall address the procedures for the use of volunteers or other staffing to address the surge needs during an emergency. However, it did not specifically address how it would integrate the roles of the State and Federal designated health officials. On 9/19/22 at 1200 hours, an interview and concurrent record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&P included the State and Federal emergency preparedness staff's contact information in their communication plan. This failure created the risk for the patients not receiving adequate and timely assistance in the event that the local agencies were inundated during emergency crises. --- Findings: Review of the hospice's emergency preparedness P&P titled Emergency Preparedness and Emergency Response Plan revised 6/1/18, was initiated on 9/15/22. The hospice's P&P included the contact information for the local emergency preparedness staff; however, it did not include the contact information for the State and Federal emergency preparedness staff. On 9/19/22 at 1200 hours, an interview and concurrent record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. On 9/19/22 at 1546 hours, a follow-up interview was conducted with the Administrator. After informing the Administrator about the findings, the Administrator stated the hospice had a process for informing both the State and Federal officials regarding emergency situations. The Administrator provided a document titled Emergency Preparedness Questionnaire where a list of authority emergency references was listed. However, review of the document showed the references listed were only for the county agencies' mass notification system that disseminates emergency information to the public. The document did not include the contact information of the State and Federal officials that the hospice may correspond with in the event of an emergency. The Administrator then stated she did not understand why they still needed to inform the State and Federal agencies regarding emergencies when they already had to inform the local agency.

Based on interview and record review, the hospice failed to conduct an additional exercise that tested the hospice's emergency preparedness plans. This failure created the risk of not identifying the gaps in the hospice's emergency program including the staff's knowledge in responding to various types of emergencies. --- Findings: Review of the hospice's Educational Training Calendars for 2019, 2020, and 2021 showed the hospice provided education regarding emergency preparedness drills and response plan. Review of the educational materials showed the hospice conducted fire prevention drills annually; however, there was no documented evidence showing the hospice had conducted other types of emergency drills. On 9/19/22 at 1200 hours, an interview and concurrent record review was conducted with the QA Coordinator. When asked about the hospice's emergency exercises, the QA Coordinator verified the hospice conducted the same emergency drills annually.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments included the assessments for the needs of volunteer services for 10 of 13 sampled patients (Patients 1, 2, 3, 5, 6, 7, 8, 10, 11, and 12), creating the risk of not identifying the care needs for these patients. --- Findings: Review of the clinical records for Patients 1, 2, 3, 5, 6, 7, 8, 10, 11, and 12 showed no documented evidence the patients' needs for volunteer services were assessed during their initial comprehensive assessments for these patients. For example: 1. Patient 2's clinical record showed the SOC was 9/8/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The initial comprehensive nursing, psychosocial, and spiritual assessments dated 7/19 and 7/21/22, showed no documented evidence of the assessment of the patient's need for volunteer services. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Patient 3's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The initial comprehensive nursing, psychosocial, and spiritual assessments dated 12/4 and 12/7/21, showed no documented evidence of the assessment of the patient's need for volunteer services. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 3. Review of Patient 11's closed clinical record was initiated on 9/13/22. The closed clinical record showed the SOC was 8/19/21. The patient was certified for hospice services during the certification period from 8/19/21 to 11/16/21. Review of the initial comprehensive nursing, spiritual, and psychosocial assessments dated 8/19 and 8/23/21, showed no documented evidence the patient's need for volunteer services was assessed. On 9/19/22 at 1100 hours, an interview and concurrent closed clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the initial comprehensive assessments identified the imminence of death for two of 13 sampled patients (Patients 10 and 13). This failure created the risk of not appropriately addressing the care needs of the patients. --- Findings: 1. Review of Patient 13's closed clinical record was initiated on 9/13/22. The clinical record showed the SOC was 11/12/21. The patient was certified for hospice services during the certification period from 11/12/21 to 2/9/22 Review of the initial comprehensive nursing, spiritual, and psychosocial assessments dated 11/12/21, showed no documented evidence the patient's imminence of death was identified. On 9/19/22 at 1130 hours, an interview and concurrent closed clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. Review of the initial comprehensive nursing, spiritual, and psychosocial assessments dated 4/15 and 4/19/22, showed no documented evidence the patient's imminence of death was identified. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use for five of 13 sampled patients (Patients 3, 4, 6, 7, and 12). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. --- Findings: Review of the hospice's P&P titled Medication Profile dated 5/10/02, showed the Case Manager will accurately document new orders, changes in orders and patient/family teaching as they occur. The RN Case Manager will update the medication list as they occur.1. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22.On 9/12/22 at 0900 hours, a joint home visit was conducted with LVN 1 and RN 1 to Patient 4's home. Review of the patient's medications with RN 1 showed the patient was taking Ativan (anti-anxiety medication) one tablet PO Q six hours PRN for anxiety instead of Ativan one tablet PO Q 24 hours PRN for anxiety as listed in the patient's medication profile. On 9/12/22 at 1005 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the findings.2. Review of Patient 6's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 3/29/21. The patient was certified for hospice services during the certification period from 7/22/22 to 9/19/22. On 9/12/22 at 0900 hours, a joint home visit was conducted with LVN 1 and RN 1 to Patient 6's home. Review of the patient's medications with RN 1 showed the patient was taking Senna (used to treat constipation) 8.6 mg two tablets PO QD instead of Senna 8.6 mg one tablet PO QD as listed in the patient's medication profile.On 9/12/22 at 1011 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the findings. 3. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The medication profile dated 9/6/22, showed the patient's medication included hydralazine (antihypertensive) 25 mg one tablet PO Q eight hours PRN. * However, there was no documented evidence of the indication for when to administer hydralazine 25 mg one tablet PO Q eight hours PRN. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The medication profile for the certification period from 8/11/22 to 11/8/22, showed the patient's medication included lorazepam (anxiolytic medication) 1 mg one to two tablets Q four hours PRN for agitation/restlessness, morphine sulfate (opioid analgesic) 20 mg/ml 1-2 mg Q one hour PRN for pain/SOB, and atropine sulfate (used for excessive secretions) 1% one to two "solution" ophthalmic Q four hours PRN. However, there was no documented evidence of the instructions for when to administer lorazepam 1 mg one tablet or two tablets; morphine sulfate 20 mg/ml 1 mg or 2 mg; and atropine sulfate 1% one drop or two drops. On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2. They were informed and acknowledged the findings. 5. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. The medication profile for the certification period from 1/24/22 to 4/23/22, showed the patient's medication included morphine sulfate 20 mg/ml 1-2 mg Q one hour PRN for pain/SOB, oxycodone (opioid analgesic) 10 mg one tablet PO Q eight hours PRN for pain, and Senna (laxative) 8.6 mg one to two tablets QD PRN for constipation. However, there was no direction for which pain medication to be administered first. In addition, there was no documented evidence of the instruction showing when to administer one or two tablets of Senna. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator, RNs 2, and 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG, care planning, and coordination of services were provided to meet the patients' care needs. --- Findings: 1. The hospice failed to ensure the participation of the Chaplain/Spiritual Counselor during the review and revision of the POCs every 14 days. Cross reference to L541. 2. The hospice failed to ensure the care and services were provided in accordance with the POCs. Cross reference to L543. 3. The hospice failed to ensure the patient and PCG were provided education/training to meet the care needs. Cross reference to L544. 4. The hospice failed to develop an individualized written POCs that reflected goals and interventions based on the problems identified in the comprehensive assessments. Cross reference to L545. 5. The hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN visits. Cross reference to L547. 6. The hospice failed to develop an individualized written POCs with measurable outcomes. Cross reference to L548. 7. The hospice failed to develop the individualized POC included the medications and treatments necessary to meet the patients' needs. Cross reference to L549. 8. The hospice failed to ensure the IDG had reviewed and revised the POCs no less than every 15 calendar days. Cross reference to L552. 9. The hospice failed to ensure the revised POCs included progress toward the outcomes and goals specified in the POCs. Cross reference to L553. 10. The hospice failed to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided. Cross reference to L554. 11. The hospice failed to communicate with the physician regarding the patients' care needs. Cross reference to L557. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with the interdisciplinary team, care planning and coordination of services to meet the patients' care needs.

Based on interview and record review, the hospice failed to ensure the participation of the Chaplain/Spiritual Counselor during the review and revision of the POCs every 14 days for 11 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, and 12), creating the risk of not providing appropriate, consistent and quality care to there patients. --- Findings: The hospice's P&P titled Interdisciplinary Meeting dated 5/10/02, showed it is the policy of the hospice to conduct an interdisciplinary care plan development, review, and update for every hospice patient at least every 15 days. The interdisciplinary team includes the patient and family, hospice and attending physicians, RN Case Manager, Spiritual Counselor, Social Worker, Home Health Aide, Volunteer, Volunteer Coordinator, Bereavement Coordinator, Dietary Counselor, other team members may include the facility staff if the patient resides in a nursing facility or other members of the hospice staff. A record of attendance is kept on file in the Medical Records Department. On 9/7/22 at 0930 hours, an entrance conference was conducted with the Administrator. The Administrator stated the members of the IDG group included the Medical Director, various attending physicians, MSW, Chaplain, DPCS, Bereavement Counselor, QA Coordinator, and RN 1. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, and 12, showed the Chaplain/Spiritual Counselor failed to participate in the review and revision of the POCs every 14 days. For example: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The IDG Comprehensive Assessment Details dated 7/26, 8/9, 8/23, and 9/6/22, showed the IDG had reviewed and revised the POCs. However, there was no documented evidence the Chaplain/Spiritual Counselor had participated in these IDG meetings On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. The Administrator stated the Chaplain/Spiritual Counselor only attended the meeting if the Chaplain would have a case. They were informed and acknowledged the findings. 2. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. The IDG Comprehensive Assessment Details dated 1/25/22 and 2/8/22, showed the IDG had reviewed and revised the POCs. However, there was no documented evidence the Chaplain/Spiritual Counselor had participated in these IDG meetings On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator, RNs 2, and 3. They were informed and acknowledged the findings. 3. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The IDG Comprehensive Assessment Details dated 4/19, 5/3, and 5/17/22, showed the IDG had reviewed and revised the POCs. However, there was no documented evidence the Chaplain/Spiritual Counselor had participated in these IDG meetings. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings. 4. Review of Patient 1's clinical record was initiated on 9/8/22. The clinical record showed the SOC was 3/9/20. The patient was certified for hospice services during the certification periods from 6/27/22 to 8/25/22, and 8/26/22 to 10/24/22. Review of the IDG Comprehensive Assessment Details dated 7/26, 8/9, 8/23, and 9/6/22, showed the IDG had reviewed and revised the patient's POCs. However, there was no documented evidence showing the Chaplain/Spiritual Counselor participated in these IDG meetings. On 9/19/22 at 0925 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 5. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the IDG Comprehensive Assessment Details dated 7/26, 8/9, 8/23, and 9/6/22, showed the IDG had reviewed and revised the patient's POCs. However, there was no documented evidence showing the Chaplain/Spiritual Counselor participated in these IDG meetings. On 9/19/22 at 0950 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the care and services were provided in accordance with the POC for three of 13 sampled patients (Patients 2, 8, and 13), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/21/22, showed the patient had redness to the coccyx. Documentation showed Calmoseptine cream (moisture barrier) was applied routinely. However, there was no documented evidence in the patient's POC for the use of Calmoseptine cream not until 8/19/22. The physician's order dated 8/19/22, showed an order to apply Calmoseptine to the coccyx and buttocks PRN for skin protection. b. The physician's order dated 7/18/22, showed an order for peritoneal drainage with sterile technique once a week, not to exceed one liter. The SN note dated 7/19/22, showed the patient had a drain on the right side of the abdomen and 1500 ml of clear fluid was drained with sterile technique. The SN note dated 7/21/22, showed the patient's peritoneal catheter drained 1600 ml of yellow fluid. The SN note dated 7/25/22, showed the patient's peritoneal catheter drained 1100 ml of yellow fluid. The SN note dated 7/28/22, showed the SN drained 1100 ml of yellow fluid from the patient's peritoneal catheter. The SN note dated 8/1/22 at 1230 hours, showed the peritoneal drain in place and drained approximately 1100 ml yellow fluid. The SN note dated 8/5/22, showed 1750 ml of peritoneal cavity was drained. The SN note dated 8/8/22, showed the SN drained 1400 ml of clear liquid with aseptic technique. The SN note dated 8/15/22, showed using aseptic technique, the SN drained 1.25 liters of abdominal fluid. The SN note dated 8/24/22, showed the patient's peritoneal catheter drained 1200 ml yellow fluid. * However, the amount of fluid drained during the patient's peritoneal drainage procedure was more than one liter during these visits, which was not consistent with the POC. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1, and LVN 1. RN 1 stated the family member wanted to draw more fluid. c. The physician's order dated 7/18/22, showed SN visits 3W (three times a week) and three PRN visits. * The SN notes showed the SN conducted two visits during Week 2 (7/24/22 to 7/30/22), instead of three visits a week as ordered. The IDG Comprehensive Assessment Details dated 8/23/22, showed SN visits 3W. * The SN notes showed the SN conducted two visits during Week 7 (8/28/22 to 9/3/22), instead of three visits a week as ordered. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1, and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 8's clinical record was initiated on 9/7/22. The clinical record showed the SOC was 9/3/21. The patient was certified for hospice services during the certification period from 6/30/22 to 8/28/22. Review of the Physician/Provider Order dated 6/28/22, cited SN visits 1W1 (one visit a week for one week), 2W8 with five PRN visits for pain, safety, medication, recertification, and changes of condition. Review of the patient's clinical record showed the SN only made a visit to the patient's home one time on 7/21/22, for the week of 7/17/22 to 7/23/22, instead of two visits a week as cited in the POC. On 9/19/22 at 1035 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 3. Review of Patient 13's closed clinical record was initiated on 9/13/22. The closed clinical record showed the SOC was 11/12/21. The patient was certified for hospice services during the certification period from 11/12/21 to 2/9/22. Review of the Physician/Provider Order dated 11/12/21, cited SN visits twice a week. Review of Patient 13's closed clinical record showed the SN only made a visit to the patient's home one time a week for the weeks of 11/14/22 to 11/20/22, 11/28/22 to 12/4/22, 12/5/22 to 12/11/22, 12/12/22 to 12/18/22, and 12/19/22 to 12/25/22, instead of two visits a week as cited in the POC On 9/19/22 at 1130 hours, an interview and concurrent closed clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the patient and PCG was provided education/training as per the patient's POC for two of 13 sampled patients (Patients 2 and 10). the creating the risk of not providing appropriate instructions to address the care needs for these patients. --- Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 7/18/22, showed the SN instructed the family member to use A&D ointment (protective barrier ointment) and Calmoseptine cream with each diaper change as skin barrier. The physician's order dated 8/19/22, showed Calmoseptine cream to the coccyx and buttocks PRN for skin protection. * However, there was no documented evidence the use of A&D ointment and Calmoseptine cream was included in the patient's POC until 8/19/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 5/19/22, showed the family member had concerns about a small healing bed sore at the patient's right buttock. Documentation showed the family member was advised to "continuing with A&D ointment and cover with dry dressing with no paper tape." * However, there was no documented evidence the above treatment was not included in the patient's POC. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for eight of 13 sampled patients (Patients 2, 3, 4, 5, 6, 7, 10, and 12). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health condition. --- Findings: Review of the clinical records for Patients 2, 3, 4, 5, 6, 7, 10, and 12 showed no documented evidence the individualized care plans were developed to address the identified problems and care needs for these patients. For example: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/18/22, showed the patient had a "Foley catheter" which was last changed on 7/15/22. Review of the patient's care plan showed a care plan problem addressing the patient's "Foley/Supra-pubic catheter/Renal issues and or Incontinence." * However, the patient's care plan was not individualized as to what the patient had. b. The physician's order dated 7/18/22, showed an order for peritoneal drainage with sterile technique once a week, not to exceed one liter. The SN note dated 7/21/22, showed the peritoneal catheter drained 1600 ml of yellow fluid. The SN note dated 7/21/22, showed the patient had redness to the coccyx. Documentation showed Calmoseptine was applied routinely. The SN note dated 8/8/22, showed the patient's penis had a small amount of yellow drainage. Documentation showed the patient's family member was educated to use soap and water to clean the penis as the solution she used causing irritation. The SN note dated 8/29/22, showed the patient had slight throat pain due to thrush which was being treated with Nystatin (anti-fungal) oral suspension. The SN note dated 9/5/22, showed the patient had hiccups all night long. Documentation showed the physician was notified with new order for Thorazine (antipsychotic). * However, review of the patient's plan of care showed no documented evidence the care plan problems were developed to address the identified problems such as peritoneal drainage, coccyx redness, yellow drainage on the penis, thrush, hiccups, and the use of Thorazine medication. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. Further review of the clinical record showed the following; - The physician's order dated 12/4/21, showed lorazepam 0.5 mg one tablet PO PRN for anxiety/agitation/SOB. - The physician's order dated 7/8/22, showed an order for Nystatin (antifungal) 100,000 u/gm one application Q 12 hours. - The PT notes dated 8/12, 8/22, and 8/29/22, showed the patient had received PT services. * However, review of the patient's plan of care showed no documented evidence the care plan problems were developed to address the use of the lorazepam medication, Nystatin ointment, and PT services. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 3. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the Medication Profile showed the patient's medications included Ativan, Seroquel (antipsychotic), and temazepam (sedative). However, review of the plan of care showed no documented evidence the care plan problems were developed to address the use of each medication, their interactions, and side effects. On 9/19/22 at 0950 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN discipline visits for 12 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12), creating the risk of not providing necessary services for these patients. --- Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 showed the initial and revised POCs did not include the discipline visit frequencies and the indication for the PRN visits. For example: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed SN visits 3W and 3 PRN visits; HA 2W; MSW initial visit within five days from the SOC, then 1M (once a month) and 1 PRN visit; and the patient did not wish for Chaplain services at this time. However, there was no documented evidence the indication for the PRN visits in the physician's order. The IDG Comprehensive Details dated 7/26/22, cited MSW visits 1M and 1 PRN visits. Review of the IDG Comprehensive Details dated 7/26/22, showed no documented evidence of the visit frequency for the SN and HA and indication for the PRN visits for the MSW in the POC. In addition, there was documented evidence of the indication for the PRN visits of the SN and MSW on the physician's order dated 7/18/21. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the Physician/Provider Order dated 4/11/22, cited SN visits once a week and three PRN visits; and MSW visit within five days from the SOC, then one visit every month, and one PRN visit every 30 days. However, there was no documented evidence showing the indication for the PRN visits in the physician's order. On 9/19/22 at 0950 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 3. Review of Patient 11's closed clinical record was initiated on 9/13/22. The closed clinical record showed the SOC was 8/9/21. The patient was certified for hospice services during the certification period from 8/19/21 to 11/16/21. Review of the Physician/Provider Orders dated 8/19/22, cited SN visits two times per week, HA visits two times per week, and MSW visit within five days from the SOC then one visit every month. Review of the IDG Comprehensive Assessment Detail dated 8/24/21, showed an IDG meeting was conducted. However, there was no documented evidence the SN, HA, and MSW visit frequencies were discussed during the IDG meeting. On 9/19/22 at 1100 hours, an interview and closed clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed of the findings.

Based on record review and interview, the hospice failed to ensure the POCs included measurable outcomes for six of 13 sampled patients (Patients 1, 4, 5, 7, 11, and 12 ), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. --- Findings: Review of the clinical records for Patients 1, 4, 5, 7, 11, and 12 showed the POCs did not include the measurable outcomes anticipated to evaluate the effectiveness of the plan of care to meet the patients' needs. For example: 1. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The POC, for the certification period from 8/11/22 to 11/8/22, showed the patient's identified problems with the established goals and interventions. However, the POC failed to include the measurable outcomes for the patient's identified problems. For example, the expected outcome for disease/diagnosis progression or other specified etiology was for the patient to achieve and maintain optimal/acceptable pain/discomfort relief as evidenced by assessed pain level with each SN visit and/or report from the patient/family/caregivers However, there was no measurable outcome as to what the patient's optimal/acceptable pain/discomfort relief would be. On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2. They were informed and acknowledged the findings. 2. Review of Patient 1's clinical record was initiated on 9/8/22. The clinical record showed the SOC was 3/9/20. The patient was certified for hospice services during the certification periods from 6/27/22 to 8/25/22 and 8/26/22 to 10/24/22. Review of the care plan showed the patient's identified problems included problems related to the disease process and decreased appetite. The goal listed was for the patient to have adequate nutrition and fluid intake. There was no documented evidence showing the measurable nutritional needs for the patient. On 9/19/22 at 0925 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 3. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the care plan showed the patient's identified problems included problems related to the disease process and decreased appetite. The goal listed was for the patient to receive adequate nutrition and hydration. There was no documented evidence showing the measurable nutritional needs for the patient. On 9/19/22 at 0950 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the individualized POC included medication and treatments necessary to meet the care needs for two of 13 sampled patients (Patients 2 and 4), creating the risk of not addressing the care needs of these patient. --- Findings: 1. Review of the Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The physician's order dated 7/18/22, showed the provided DME was oxygen concentrator. The order included "Foley Catheter" bladder irrigation with sterile technique weekly PRN. The SN note dated 7/28/22, showed the family member reported the patient had decreased of oxygen saturation level at 84% overnight. The family member was advised may administer oxygen overnight at 2 liters per minute if patient agreed. * However, the POC did not include the oxygen administration and indication for the PRN bladder irrigation. b. The physician's order dated 7/18/22, showed an order for peritoneal drainage with sterile technique once a week, not to exceed one liter; and dressing changes with sterile technique weekly and PRN for soilage. The SN note dated 8/1/22 at 1130 hours, showed the patient had been having moderate ascites with order for peritoneal drain two times a week. Documentation showed "Drainage to not exceed 1 liter." Documentation showed drainage site clean and free from infection; and slight oozing from the abdomen. Xeroform (wound dressing) and dry dressing applied. * However, the physician's order did not include Xeroform to be used. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the Physician/Provider Order dated 4/11/22, showed an oxygen concentrator was ordered for the patient. However, the physician's order did not include the oxygen administration including administration rate. On 9/19/22 at 0950 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator and RN 1. The QA Coordinator and RN 1 were informed of the findings. The QA Coordinator stated they ordered an oxygen concentrator for all of their patients because it was difficult to obtain an oxygen concentrator from the supplier in a timely manner. They placed an order in case the patient needed oxygen; however, this patient did not use oxygen. However, further review of the clinical record showed numerous documentations from the SN showing the patient recevied oxygen without physician's order. For example, the SN notes dated 7/28/22, showed the patient received 2-5 liters/min of oxygen PRN.

Based on record review and interview, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs at least every 15 days for three of 13 sampled patients (Patients 2, 3, and 10), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed an order for peritoneal drainage with sterile technique once a week, not to exceed one liter. The SN note dated 8/1/22, showed the patient had been having "moderated ascites with order for peritoneal drainage 2 times a week. Drainage not to exceed 1 liter." On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator, RN 1, and LVN 1. The Administrator stated the physician's order for the peritoneal drainage should be done twice a week and should never have been once a week. They were informed and acknowledged the findings. * The IDG failed to update the POC to address the frequency of the peritoneal drainage. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The IDG Comprehensive Assessment Details dated 8/23/22, showed HA visits 3W. The HA notes showed the HA conducted four visits starting 8/23/22, during Week 5 (8/28/22 to 9/3/22) On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. The Administrator stated the HA visit frequency should have been increased in the POC. However, the POC was not revised to reflect the increased of HA visits. They were informed and acknowledged the findings. 3. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The patient was transferred to another hospice on 5/23/22. The SOC-Recertification-Continuation of Service Order dated 4/15/22, showed HA visit frequency was 3W for the first week, then for the next eight weeks to "Re evaluation for hospice criteria." The HA notes showed the HA conducted two visits during Week 1 (4/15/22 to 4/16/22; and three visits during Week 2 (4/17/22 to 4/23/22), Week 3 (4/24/22 to 4/30/22), Week 4 (5/1/22 to 5/7/22), Week 5 (4/8/22 to 4/14/22), and Week 6 (4/15/22 to 4/21/22). However, the POC was not revised to show the HA visit frequency after Week 1. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. The Administrator stated the POC related to the HA visit frequency should have been revised. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs for 13 of 13 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13), creating the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. --- Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13 was conducted from 9/7/22 to 9/19/22. The clinical records showed the IDG had reviewed and revised the POCs every 14 days. However, the revised POCs did not include the patients' progress toward the goals as specified in the POCs. For example: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. Patient 2's plan of care dated 7/19/22, showed the patient's identified problems included deficit related to fall, related to "Foley/Supra-pubic catheter/Renal Issues and or Incontinence," enterocolitis due to Clostridium difficile and/or disease process; COVID-19 precautions; initial plan of care prior to service provision; family/patient /PCG needing assistance with burial /funeral arrangements; and grieving anticipatory related to expected loss of physio-psychosocial well being of the patient. The goals were established for these identified problems. Further review of the clinical record showed the IDG had reviewed the POCs Q 14 days. However, there was no documented evidence the POCs included the patient's progress toward goals. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the plan of care for the certification period showed the hospice identified multiple patient care problems such as related to disease process/decreased appetite and deficit related to risk for injury related to falls. Further review of the clinical record showed documented evidence the IDG reviewed the POCs Q 14 days. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 9/19/22 at 0950 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 3. Review of Patient 8's clinical record was initiated on 9/7/22. The clinical record showed the SOC was 9/3/21. The patient was certified for hospice services during the certification periods from 6/30/22 to 8/28/22, and 8/29/22 to 10/27/22. Review of the plan of care for both certification periods showed the hospice identified multiple patient care problems such as grieving, anticipatory related to expected loss of physio-psychosocial well-being of the patient, and deficit related to risk for injury related to falls. The goals were established for the identified problems. Further review of the clinical record showed documented evidence the IDG reviewed the POCs Q 14 days. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 9/19/22 at 1035 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for two of 13 sampled patients (Patient 2 and 10), creating the risk of not addressing the care needs for this patient. --- Findings: 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 7/21/22, showed the patient had redness to the coccyx, and Calmoseptine (moisture barrier) was applied routinely. * However, there was no documented evidence the SN had assessed for the size of the redness on the coccyx. The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 2. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 5/19/22, showed the family member had concerns about a small healing bed sore at the patient's right buttock. The family member was advised "continuing with A&D ointment and cover with a dry dressing with no paper tape." * However, there was no documented evidence the SN had assessed the size and wound bed of the small healing bedsore. The IDG failed to supervise the care and services provided to the patient. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to communicate with the physician regarding the patients' care needs for two of 13 sampled patients (Patients 1 and 9). This failure created the risk of not providing the necessary care and services to these patients. --- Findings: 1. Review of Patient 9's closed clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/4/22. The patient was certified for hospice services during the certification period from 4/4/22 to 7/2/22. Review of the Physician/Provider Order dated 4/5/22, cited SN visits two times per week and three PRN visits. The order also showed the patient had an order for oxygen to titrate, ranging from one to five liters per minute continuously, PRN for shortness of breath. Review of the closed clinical record showed both the LVN and RN visited the patient's home on 5/3/22. Their assessments showed the patient's oxygen saturation level was 88% on room air and the respiratory rate was 32 breaths per minute. The assessments showed the patient had a tracheostomy tube and used oxygen intermittently. Further review of the closed clinical record showed no documented evidence the SNs had reassessed the patient's oxygen saturation level, provided intervention to increase the oxygen saturation level as per the order, or notified the physician regarding the patient's decreased oxygen saturation level. On 9/19/22 at 1015 hours, an interview and concurrent closed clinical record review was conducted with the QA Coordinator and RN 1. The QA Coordinator and RN 1 were informed of the findings. RN 1 explained the patient's oxygen saturation level was low because it was assessed on room air. When asked if the patient's oxygen saturation level was reassessed after providing oxygen, RN 1 stated yes. However, they were unable to provide documented evidence showing the oxygen saturation level was reassessed and that intervention was provided. 2. Review of Patient 1's clinical record was initiated on 9/8/22. The clinical record showed the SOC was 3/9/20. The patient was certified for hospice services during the certification period from 6/27/22 to 8/25/22. Review of the Physician/Provider Orders dated 3/9/20, cited SN visits three times per week for one week then two times per week and three PRN visits for any complication, pain, symptom management or recertification. Review of the SN Note dated 7/28/22, showed the patient's blood pressure was 96/50 mmHg and heart rate was 58 beats per minute. The SN documented she was unable to obtain the patient's oxygen saturation level. The notes showed the PCG reported the patient had signs and symptoms of TIA in the morning with decreased responsiveness, low blood pressure, and low oxygen saturation level. The note showed upon the SN's arrival, the patient's vital signs were within normal limits and had a regular heart rate. Further review of the clinical record showed no documented evidence of the reassessment of the patient's vital signs nor was there any documentation showing the physician was informed about the patient's TIA episode. On 9/19/22 at 0925 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator and RN 1. They were informed of the findings and was unable to provide documented evidence of the reassessment and communication with the physician.

Based on record review and interview, the hospice failed to develop an effective, on-going, hospice-wide date-driven QAPI program. --- Findings: 1. The hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven QAPI program. Cross reference to L560. 2. The hospice failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas. Cross reference to L566. 3. The hospice failed to ensure the PI project for the year of 2022 was conducted. Cross reference to L571. 4. The hospice failed to document the reasons for conducting the 2021 PI project and measurable progress achieved on this project. Cross reference to L573. 5. The hospice failed to maintain the coordinated agency-wide program for surveillance, identification, prevention control, and investigation of infectious and communicable disease. Cross reference to L580. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with continuous QAPI to ensure the provision of quality healthcare in a safe environment for the patients.

Based on document review and interview, the hospice failed to develop, implement, and maintain an effective, on-going, and hospice-wide data-driven QAPI program. The hospice failed to ensure the QAPI program reflected the complexity of its organization; involved all hospice services; focused on indicators related to improved outcomes; and taken actions to demonstrate improvement in hospice performance. The hospice failed to maintain documentary evidence of its QAPI program. These failures created the increased risk of not identifying areas for performance improvement to improve care and services provided to the patients. --- Findings: The hospice's P&P titled QAPI Program dated 03/02 showed the hospice will accomplish QAPI review work performed by department supervisors. All departments and services will be involved in QAPI activities and the organization's efforts to continuously improve services. The organization will identify and use data to monitor the performance; establish goals and thresholds for the performance measurements; utilize patient and staff input; identify and prioritize problems and opportunities for improvement; systematically analyze underlying causes of systemic problems and adverse events; and develop corrective action or performance improvement activities. Review of the hospice's QAPI programs for 2021 and 2022, was conducted on 9/15/22. The following were identified: 1. Review of the QAPI meeting minutes for the 1st, 2nd, 3rd, and 4th quarters of 2021 and 1st and 2nd quarters of 2022 showed the QAPI members met and reviewed the hospice's admissions, pain follow-up, falls, discharges, continuous care, and infection control. The QAPI meeting minutes for the 1st, 2nd, 3rd, and 4th quarters of 2021 showed the new issues were "timely charting: must chart same day as visit" and COVID-19 related items such as changes and updates, teaching, and guideline. The QAPI meeting minutes for the 1st quarter 2021 showed the new issues included recognizing the patients needing continuous care. * However, the topics related to the hospice's admissions, pain follow-up, falls, discharges, continuous care, infection control were discussed repeatedly during the QAPI meetings for the 1st, 2nd, 3rd, and 4th quarters of 2021 and 1st and 2nd quarters of 2022. There was no documented evidence other aspects of the hospice program was included such as the patient/family satisfaction levels. 2. The hospice failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas. Cross reference to L566. 3. The QAPI program for 2022 failed to show documented evidence the QAPI committee had developed any PIP for 2022. Cross reference to L571. 4. The hospice failed to document the reason for conducting the project and measurable progress achieved on the PI project for 2020 and 2021. The PIP for 2020 and 2021 failed to show documented evidence the action plan and recommendations were reevaluated to ensure the effectiveness of implemented plan to improve patient care and performance. Cross reference to L573. 5. The hospice's infection control data were inconsistent. The action plans failed to address and revise the identified problems. Cross reference to L580. On 9/15/22 at 1430 hours, an interview and document review was conducted with the Administrator. She was informed and acknowledged the findings. 6. Review of the hospice's QAPI program for 2020 was initiated on 9/15/22. Review of the QAPI Meeting minutes showed the committee met quarterly. The QAPI Meeting agenda showed the committee discussed the following same six topics quarterly: - Admissions;- Pain;- Falls; - Discharges;- Continuous care; and - Infection control. For each quarter, the committee also identified the same issues related to timely charting. Documentation showed the chart audits would be completed by the QA as part of the solution to improve the issues concerning timely charting. However, there was no documented evidence showing the chart audits were completed. On 9/19/22 at 1209 hours, an interview and concurrent record review was conducted with the QA Coordinator. The QA Coordinator was asked about the topics discussed and issues identified by the QAPI committee in 2020. The QA Coordinator verified they always discussed the same six topics. They also identified that timely charting was an ongoing concern and that was why it was included in the agenda for each quarter. When asked what the actions were taken to resolve the issue, the QA Coordinator stated she performed the chart audits. When asked to show the evidence of the chart audits, the QA Coordinator verified she did not document the chart audits performed.

Based on interview and record review, the hospice failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas. This failure had the potential to adversely affect the quality of care provided to the patients. --- Findings: Review of the QAPI meeting minutes for 1st, 2nd, 3rd, and 4th quarters of 2021 and 1st and 2nd quarters of 2022 showed the QAPI members met and reviewed the hospice's admissions, pain follow-up, falls, discharges, continuous care, and infection control. The QAPI meeting minutes for the 1st, 2nd, 3rd, and 4th quarters of 2021 showed the new issues included "timely charting: must chart same day as visit" and COVID-19 related topics such as changes and updates, teaching, and guideline. The QAPI meeting minutes for 1st quarter of 2021 showed the new issues included recognizing the patients needing continuous care. On 9/15/22 at 1430 hours, an interview and concurrent document review was conducted with the Administrator. She stated the PIPs for the 1st, 2nd, 3rd, and 4th quarters of 2021 were about "documentation." When asked what specific about the PIP for documentation. She stated it was about late documentation. She stated it had always been a problem. She stated documentation was the hospice's chronic problem. * However, there was no documented evidence to show if the late documentation was the high risk, high volume, or problem area of the hospice. On 9/15/22 at 1430 hours, an interview and concurrent document review was conducted with the Administrator. She was informed of the findings.

Based on document review and interview, the hospice failed to ensure the PI project for the year of2022 was conducted, created the risk of not improving the care and services provided to the patients. --- Findings: Review of the hospice's QAPI programs for 2022 showed no documented evidence the hospice had conducted the PI project for this year. On 9/15/22 at 1430 hours, an interview and document review was conducted with the Administrator. The Administrator was asked what was the hospice's PIP for 2022. She stated they had not done it yet.

Based on interview and record review, the hospice failed to document the reasons for conducting the 2021 PI project and measurable progress achieved on this project. This created the risk of not identifying the opportunity for improvement for care and services provided the patients. --- Findings: Review of the QAPI meeting minutes for the 1st, 2nd, 3rd, and 4th quarters of 2020 showed the new issues included improvement in timely charting/timely charting, must chart same day as visit/continuous care charting, and must chart as same day as visit with hourly logs. Review of the QAPI meeting minutes for the 1st, 2nd, 3rd, and 4th quarters of 2021 showed the new issues included "timely charting: must chart same day as visit." Documentation showed the updates/solutions/trends for the QAPI programs for the 1st, 2nd, and 3rd quarters of 2020 and 2021 were the chart audits to be completed by the QA, all new admissions to be completed within 72 hours, and real time charting to be completed in home. The QAPI for the 4th quarter of 2020 included all continuous care charts to be obtained and submitted after discharge of continuous care, chart audits to be completed by the QA, and real time charting to be completed in home. However, the documentation showed the updates/solutions/trends for the QAPI programs for the 1st, 2nd, and 4th quarters of 2020 and all four quarters of 2021 were the same. The QAPI program for the 3rd quarter of 2020 included one different intervention; however the rest of the updates/solutions/trends were the same as the 1st, 2nd, and 4th quarters of 2020 and 2021. On 9/15/22 at 1430 hours, an interview and concurrent document review was conducted with the Administrator. She stated the PIPs for the 1st, 2nd, 3rd, and 4th quarters of 2020 and 2021 were the "documentation." When asked what specific for the PIP on documentation, she stated it was about late documentation. She stated it had always been a problem. She stated documentation was the hospice's chronic problem. * However, there was no documentation of the reason why the hospice had decided to conduct this performance improvement project. There was no documented evidence of the result and progress of the performance improvement project conducted for 2020 and 2021. There was no documented evidence the action plan and recommendations were reevaluated to ensure the effectiveness of implemented plan to improve patient care and performance. In addition, there was no documented evidence of a clinical record review/audit was conducted. On 9/15/22 at 1430 hours, an interview and concurrent document review was conducted with the Administrator. She was informed of the findings.

Based on record review and interview, the hospice failed to maintain the coordinated agency-wide program for surveillance, identification, prevention control, and investigation of infectious and communicable disease, creating the risk of the spread of infections and not improving the infection control program. --- Findings: Review of the infection control data for 2021 and 2022 was conducted on 9/15/22. a. The 1st quarter of QAPI 2021 meeting minutes, under the infection control section, showed there were high number of infections found in the patients with diagnosis of Alzheimer's. Documentation showed the highest infection rate was related to UTI. The plan was to increase education among caregivers regarding skin care and skin integrity to prevent infection. The 2nd quarter of QAPI 2021 meeting minutes, under the infection control section, showed, "identified patient with COVID-19." Documentation showed "increase staff awareness, continued with all required PPE to prevent spread of infection." The highest infection rate was related to UTIs. The plan was to increase education among caregivers regarding skin care and skin integrity to prevent infection. * However, the action plan for the 1st and 2nd quarters QAPI 2021 was the same information after the hospice had identified the highest infection rate was related to UTIs. The action plan, which was to to increase education among caregivers regarding skin care and skin integrity to prevent infection, failed to address UTI. Cross reference to L 560. a. However, the infection control data was inconsistent. For example: - The 1st quarter of the 2022 infection control graph showed five cases of respiratory infection; one case of urinary infection; one case of skin/wound infection and one case of other infection. However, the infection control log included two cases of infection for the 1st quarter of 2022. One case was listed as urinary infection and one case had no information as to the symptom or infection, which was not consistent with the 1st quarter of 2022 infection control graph. b. The 3rd quarter of the 2021 infection control graph showed one case of urinary tract infection; two cases of skin/wound infection; three cases of respiratory infection; one case of GI infection; and one case of other infection. However, the infection control log for the 3rd quarter of 2021 included four cases of infection. Two cases were listed as urinary infection; one case was listed as respiratory infection; and one case was related to eye infection, which was not consistent with the 3rd quarter of 2021 infection control graph. On 9/19/22 at 1430 hours, and interview and concurrent document review was conducted with the Administrator and RN 3. The Administrator stated one of the staff member collected the data. The Administrator stated she and one of the staff member made the graph, analyzed the data, and presented during the QAPI committee. They were informed of the findings.

Based on interview and record review, the hospice failed to implement the bereavement program to address the needs of the bereaved family members for two of three sampled patients (Patients 11 and 12). This failure created the increased risk of not addressing the bereavement needs of the bereaved family members. --- Findings: Review of the hospice's P&P titled Bereavement Program dated 5/10/2002, showed the hospice offers a comprehensive bereavement program to families/significant others for up to one year after the patient's death. An ongoing bereavement record will be kept to track all patient deaths and bereavement activity. This record will include the date of birth, start of care, medical record number, patient name, name of bereaved, counselor assignment, and date of condolence call/four week follow-up/closing of care and the reason for closure. Assessment forms as well as other documentation regarding bereavement activity will be placed in the patient's medical record chart. 1. Review of Patient 11's closed clinical record was initiated on 9/13/22. The clinical record showed the SOC was 8/9/21. The patient was certified for hospice services during the certification period from 8/19/21 to 11/16/21. The patient had expired on 10/30/21. Review of the Bereavement Care Plan dated 8/23/21, showed the following interventions:- Bereavement counseling for one year after death as needed/requested;- Initial bereavement telephone call and sympathy card mailed within 0-5 days of death;- Bereavement mailings and follow-up telephone calls within 0-1 month, 2-4 months, 5-7 months, 8-10 months, 11-13 months; and- One holiday mailing in December. Further review of the closed clinical record showed documented evidence the letter mailing services were completed as written in the care plan. Documentation showed the initial telephone call was completed on 11/2/21. However, there was no documented evidence showing the second and third follow-up phone calls were made to the bereaved family as cited in the bereavement care plan. On 9/19/22 at 1100 hours, an interview and concurrent closed clinical record review was conducted with the QA Coordinator and MSW 1. The QA Coordinator and MSW 1 were informed and acknowledged the findings. 2. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. The patient had expired on 2/12/22. The Bereavement Care Plan dated 1/26/22, included the following interventions:- Bereavement counseling for one year after death as needed/requested;- Initial bereavement telephone call and sympathy card mailed within 0-5 days of death;- Bereavement mailings and follow-up telephone calls within 0-1 month, 2-4 months, 5-7 months, 8-10 months, 11-13 months; and- One holiday mailing in December. Review of the Bereavement File Checklist showed the initial telephone call was completed on 2/15/22; and the first follow-up call was completed on 3/31/22. However, there was no documented evidence of a second follow-up call was conducted to the bereaved. On 9/14/22 at 1400 hours, an interview was conducted with Administrator and MSW 2. MSW 2 stated the staff would document in the patient's clinical record when bereavement telephone calls were conducted. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the HAs provided services in accordance with the POC for eight of 13 sampled patients (Patients 2, 3, 4, 5, 9, 11, 12, and 13). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- Findings: Review of the clinical records for Patients 2, 3, 4, 5, 9, 11, 12, and 13 showed the HAs failed to provide services in accordance with the POC. The HAs also failed to document the temperature, pain, and last bowel movement as per the POC. For example: 1.a. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the Physician/Provider Order dated 4/11/22, cited HA visits three times per week. Review of the patient's clinical record showed the HA only visited two times during the weeks of 7/17/22 to 7/23/22 and 9/4/22 to 9/10/22, instead of three visits as ordered. b. Review of the HA Assignment History showed for the HA to check the patient's temperature and report to CM if abnormal (temperature above 100.2 F). Review of the HA note dated 7/12/22, showed the HA visited the patient's home. However, there was no documented evidence showing the HA had checked the patient's temperature as per the POC. On 9/19/22 at 0950 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 2. Review of Patient 9's closed clinical record was initiated on 9/12/22. The closed clinical record showed the SOC was 4/4/22. The patient was certified for hospice services during the certification period from 4/4/22 to 7/2/22. Review of the HA Assignment History showed HA to assess the patient's pain level and temperature. Review of the HA Notes for certification period from 4/4/22 to 7/2/22, showed the HA visited the patient's home as cited in the POC. However, the HA failed to provide services in accordance with the POC. There were multiple days when the HA did not document the patient's pain level or temperature as per the POC. For example, on 4/29/22, the HA marked the boxes showing he assessed the patient's pain and temperature. However, there was no documented evidence showing the patient's pain level and temperature. On 9/19/22 at 1015 hours, an interview and concurrent closed clinical record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings. 3. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The physician's order dated 7/18/22, showed HA visits two times a week. * The HA notes showed the HA conducted one visit during Week 1 (7/18/22 to 7/23/22), instead of two visits as ordered. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 4. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The IDG Comprehensive Assessment dated 8/9/22, showed the HA's assigned tasks included to check if the patient had any pain; and if there was pain, on a pain scale from 0-10 (0 = no pain and 10 = worst pain) what the pain was. The HA note dated 8/16/22, showed an area to mark if the patient had any pain. Documentation showed the HA acknowledged and completed the task. However, there was no documented evidence showing if the patient had pain. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 5. Review of Patient 5's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 9/3/21. The patient was certified for hospice services during the certification periods from 6/30/22 to 8/28/22, and 8/29/22 to 10/27/22. Review of the HA Assignment History showed the HA's assigned tasks included to document the patient's last BM and output. * The HA notes dated 6/30, 7/2, 7/5, 7/7, 7/9, 7/12, 7/14, 7/17, 7/19, 7/21, 7/26, 7/28, 7/31, 8/2, 8/4, 8/9, 8/13, 8/16, 8/18, 8/20, 8/21, 8/23, and 8/25/22, during the certification periods, 6/30/22 to 8/28/22, showed the HA acknowledged and completed the task. However, there was no documented evidence the HA documented the patient's patient's last BM and output. On 9/19/22 at 1100 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 6. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. Review of the HA Assignment History showed the HA's assigned tasks included to check if the patient had any pain; and if there was pain, on a pain scale from 0-10, what the pain was; and to check temperature, report to the Case Manager if abnormal. The HA note dated 1/27/22, showed an area to mark if the patient had any pain, to check the temperature, and report to the Case Manager if abnormal. Documentation showed the HA acknowledged and completed the task. * However, there was no documented evidence showing if the the patient had pain and what the patient's temperature was. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2 and RN 3. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the type of services provided by the volunteer was documented, creating the risk of not thoroughly evaluating the volunteer program. --- Findings: Review of the hospice's volunteer documents for 2020, 2021, and 2022 was conducted on 9/15/22. Review of the August 2020 route sheet, showed the following information for Volunteer 1:- On 8/1/20, the volunteer hours was 2 hours and 30 minutes.- On 8/2/20, the volunteer hours was 2 hours and 30 minutes.- On 8/3/20, the volunteer hours was 2 hours and 30 minutes.- On 8/4/20, the volunteer hours was 3 hours and 45 minutes.- On 8/6/20, the volunteer hours was 2 hours and 15 minutes.- On 8/11/20, the volunteer hours was 4 hours and 35 minutes.- On 8/13/20, the volunteer hours was 4 hours.- On 8/18/20, the volunteer hours was 4 hours and 30 minutes.- On 8/20/20, the volunteer hours was 4 hours. - On 8/25/20, the volunteer hours was 4 hours. - On 8/27/20, the volunteer hours was 3 hours and 20 minutes. * However, there was no documented evidence of the type of service that Volunteer 1 had provided. On 9/19/22 at 1330 hours, a concurrent record review and interview was conducted with the Administrator.She was informed of the findings.

Based on record review and interview, the hospice failed to ensure the work time spent by the volunteers were consistently summarized, creating the risk of over/underestimating the cost savings the hospice obtained with the use of volunteers. --- Findings: Review of the hospice's volunteer documents for 2020, 2021, and 2022 was conducted on 9/15/22. However, the monthly volunteer hours were not consistent with the volunteer log and the hospice's volunteer documents. For example: a. Review of the volunteer log for January 2021 showed the volunteer hours were 56 hours and cost savings of $ 728.00 Review of the volunteer route sheets and documents for January 2021 showed the volunteer hours were 39 hours and 50 minutes. b. Review of the volunteer log for February 2021 showed the volunteer hours were 64 hours and cost saving of $800.00 Review of the volunteer route sheets and documents for February 2021 showed the volunteer hours were 44 hours. c. Review of the volunteer log for March 2021, showed the volunteer hours were 41 hours and cost saving of $512.50 Review of the volunteer route sheets and documents for March 2021 showed the volunteer hours were 42 hours. d. Review of the volunteer log for April 2021 showed the volunteer hours were 37 hours and cost saving of $462.50 Review of the volunteer route sheets and documents for April 2021 showed the volunteer hours were 26 hours. On 9/19/22 at 1330 hours, a concurrent record review and interview was conducted with the Administrator. The Administrator stated the cost savings were calculated by multiplying the volunteer hours and $15.00. The cost savings documented on the volunteer logs were not accurately calcultated for $15.00 per hour. For example, for volunteer hours of 64, the cost savings should be $960 (64 x 15 = 960), not $800 for February 2021. She was informed of the findings.

Based on record review and interview, the hospice failed to ensure the COP regarding Organization and Administration of Services was met. --- Findings: The GB failed to assume full legal authority and responsibility for the management of the hospice, provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with all COPs. Cross reference to L651. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Organization and Administration of Services.

Based on interview and record review, the hospice's GB failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operation, and continuous QAPI. The Administrator failed to perform day-to-day operation to ensure compliance with the COPs under 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418:58 (Quality Assessment & Performance Improvement); and 418.100 (Organization and Administration of Services). --- Findings: The hospice's P&P titled Governing Body - Authority/Responsibility dated 11/03 showed the Governing Body assumes full legal authority and responsibility for the overall operation of the hospice. 1. The hospice failed to ensure the COPs under 418.56 (Interdisciplinary Group, Care Planning, and Coordination of Services); 418.58 (Quality Assessment & Performance Improvement); and 418.100 (Organization and Administration of Services) were met. Cross references to L536, L559, and L648. 2. Review of the hospice's P&P titled Staff Performance Evaluations, Volunteers, Employees and Independent Contractor dated 5/10/22 showed staff will receive a performance evaluation annually, using skill competency assessment, etc. Review of the Chaplain's employee file was initiated on 9/14/22. The employee file showed no documented evidence of the performance evaluation or skill competency for the year of 2021. On 9/19/22 at 1310 hours, an interview and concurrent record review was conducted with the HR Coordinator. The HR Coordinator was informed and acknowledged the findings. 3. According to the Hospice Standards Article 6, Section 6.2 B Contractual Services, when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to the roles and responsibilities of the program and contracted individual or organization in the patient/family admission process, patient/family assessment, the development, review, and revision of POCs, interdisciplinary team conferences, scheduling of visits or hours, discharge planning, bereavement, and submission of documentation of services provided to the agency. a. Review of the written agreements between the hospice and Contractor 1 providing physician services was initiated on 9/15/22. The written agreement with Contractor 1 did not include the roles and responsibilities of the hospice and the contractor in the patient/family admission process, patient/family assessment, the development, review, and revision of POCs, interdisciplinary team conferences, scheduling of visits or hours, discharge planning, bereavement, and submission of documentation of services provided to the agency. b. Review of the written agreements between the hospice and Contractors 2 and 3 providing SN services was initiated on 9/15/22. The written agreement with Contractors 2 and 3 did not include the roles and responsibilities of the program and the contractor in the interdisciplinary team conferences, discharge planning, and bereavement follow-up. c. Review of the written agreements between the hospice and Contractor 4 providing PT/OT/ST services was initiated on 9/15/22. The written agreement with Contractor 4 did not include the roles and responsibilities of the program and the contractor in the bereavement follow-up. On 9/19/22 at 1140 hours, an interview and concurrent record review was conducted with the HR Coordinator. The HR Coordinator was informed and acknowledged the findings. 4. The hospice's P&P titled General Wound Care Guideline dated 03/12 showed RN to visit wound care patient at least once a week for wound assessment and measurement. The RN is to make at least once a week visit to assess and measure the wound dimension and status. Wound condition is to record. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The SN note dated 8/15/22, showed the RN initiated the wound care to the patient's Stage 2 coccyx pressure injury. Documentation showed the coccyx pressure injury had a size of 1 cm (length) x 1 cm (width) x 0.2 cm (depth). * Further review of the clinical record showed no documented evidence of the coccyx's wound measurements for Week 3 (8/21/22 to 8/27/22) and Week 4 (8/28/22 to 9/3/22) as per the P&P. On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 2. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the clinical records were complete and accurate for eight of 13 sampled patients (Patients 1, 2, 3, 4, 6, 7, 9 and 10). This failure created the risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete and inaccurate documentation. --- Findings: 1. Review of Patient 4's clinical record was initiated on 9/12/22. The clinical record showed the SOC was 4/11/22. The patient was certified for hospice services during the certification period from 7/10/22 to 10/7/22. Review of the Physician/Provider Order dated 4/11/22, cited SN visits once a week and three PRN visits. Review of the SN notes showed the SN visited the patient's home on 7/19/22. The SN assessed the patient's cardiovascular system and noted the patient had slight pitting edema; however, the SN documented under the Nursing Summary Notes section of the same document that "the patient had no edema observed at this visit" which was inconsistent. On 9/19/22 at 0959 hours, an interview and concurrent clinical record review was conducted with the QA Coordinator and RN 1. The QA Coordinator and RN 1 were informed of the findings. 2. Review of Patient 9's closed clinical record was initiated on 9/12/22. The closed clinical record showed the SOC was 4/4/22. The patient was certified for hospice services during the certification period from 4/4/22 to 7/2/22. Review of the Physician/Provider Order dated 4/5/22, cited SN visits two times per week and three PRN visits. Review of the SN notes showed the SN visited the patient's home on 4/5/22, and assessed the patient's blood pressure; however, the documentation showed the blood pressure measurement was "1224/88" mmHg. On 9/19/22 at 1015 hours, an interview and concurrent closed clinical record review was conducted with the QA Coordinator and RN 1. The QA Coordinator and RN 1 were informed and acknowledged the findings. 3. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. a. The SN note dated 7/19/22, showed the patient had a drain site on the "right side of the abdomen." The SN note dated 8/1/22, showed the patient had a hospitalization for a peritoneal drain was placed in the "left abdomen." * However, the location of the peritoneal drain was not consistently documented. b. The IDG Comprehensive Assessment dated 7/26/22, included PT visit notes dated 8/3 and 8/8/22; SN visit notes 8/5 and 8/15/22; and MSW note dated 8/15/22, instead of the visit notes that were conducted prior to the IDG Comprehensive Assessment dated 7/26/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. LVN 1 stated the peritoneal drain was located on the right side of the abdomen. They were informed and acknowledged the findings. 4. Review of Patient 7's clinical record was initiated on 9/8/22. The patient's clinical record showed the SOC was 8/11/22. The patient was certified for hospice services during the certification period from 8/11/22 to 11/8/22. The IDG Comprehensive Assessment Details dated 9/6/22, showed SN visits 3W. Further review of the clinical record showed no documented evidence of SN visits during Week 4 (8/28/22 to 9/3/22). On 9/19/22 at 1120 hours, a concurrent clinical record review and interview was conducted with the Administrator. The Administrator stated the patient had a SN visit during Week 4. She stated the SN who visited the patient was a substitute nurse. She was informed and acknowledged the findings. 5. Review of the clinical records for Patients 1, 2, 3, 6, 7, and 10 showed the medications as pending instead of current on the IDG Comprehensive Assessment. For example: a. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The IDG Comprehensive Assessment dated 8/23/22, showed patient's pending medications included the following: - an order dated 7/18/22, showed diclofenac sodium (NSAID) gel 1% 4 gm QID topical PRN- an order dated 7/18/22, showed ertapenem sodium (antibiotic) 500 mg one time a day- an order dated 7/18/22, showed lactobacillus (probiotic) one package one time a day- an order dated 7/18/22, showed midodrine (antihypotensive) 5 mg one tablet TID- an order dated 7/18/22, showed octreotide acaetate (synthetic hormone) 50 mcg/ml Q eight hours SC- an order dated 7/18/22, showed pantoprazole (used to treat GERD) 40 mg Q 24 hours- an order dated 7/22/22, showed Actos (anti-diabetic) 30 mg one tablet Q 24 hours- an order dated 7/22/22, showed cholecalciferol (supplement) 2000 u one tablet Q 24 hours- an order dated 7/22/22, showed finasteride (urinary retention medication) 5 mg one tablet Q 24 hours- an order dated 7/22/22, showed sodium bicarbonate (antacid) 650 mg one tablet Q 12 hours- an order dated 7/22/22, showed tamsulosin (urinary retention medication) 0.4 mg two tablet Q 24 hours- an order dated 7/22/22, showed Vitamin B plus C Complex (supplement) one tablet Q 24 hours - an order dated 8/2/22, showed Norco (opioid analgesic) 5-325 mg one tablet one times a day On 9/20/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator. The Administrator stated the above medications were all current and not pending. She stated the nurse needed to click the "software" to remove the medications listed as pending and become current.

Based on record review and interview, the hospice failed to timely authenticate entries made into the clinical record for four of 13 patients (Patients 2, 3, 10, and 12), creating the risk of not having a complete and accurate information. --- Findings: The hospice's P&P titled Entries into Medical Records and Authentication revised date 3/1/15, showed hospice personnel providing direct patient care and supervisory functions will have access to make entries into the electronic record database. Those who are not fully trained to use the electronic medical record software/database may use manual paper documentation. These records will be scanned into the electronic software attached to patient's file. Documentation shall be placed in the patient's medical record within 7 days except for the initial start of care for "HIS" is within 5 days. The entries will be authenticated by user name and credential. All entries will reflect the date care/service was provided. The software requires these entries. The electronic software records the date and time of the entries. QA personnel might access the record for review and correction as necessary. Each entry is recorded by the software the time, date, and name of the user. 1. Review of Patient 2's clinical record was initiated on 9/8/22. Patient 2's clinical record showed the SOC was 7/18/22. The patient was certified for hospice services during the certification period from 7/18/22 to 10/15/22. The SN note dated 8/1/22, showed the SN had electronically signed the SN note on 9/5/22. The HA note dated 7/21/22, showed the HA had electronically signed the HA note on 8/3/22. On 9/19/22 at 0930 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. The Administrator stated the clinical record should be electronically signed within 48 hours from the discipline's visit. The Administrator stated sometimes the staff have to go back to correct the clinical record after the QA staff opened the clinical record. They were informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 9/12/22. The patient's clinical record showed the SOC was 12/3/21. The patient was certified for hospice services during the certification period from 7/31/22 to 9/28/22. The HA notes dated 8/1 and 8/2/22, showed the HA had electronically signed the HA notes on 8/12/22. The HA notes dated 8/16, 8/17, 8/18/22, showed the HA had electronically signed the HA notes on 8/28/22 The HA notes dated 8/29, 8/30, and 8/31/22, showed the HA had electronically signed the HA notes on 9/11/22. On 9/19/22 at 1010 hours, a concurrent clinical record review and interview was conducted with the Administrator and LVN 1. They were informed and acknowledged the findings. 3. Review of Patient 12's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 1/24/22. The patient was certified for hospice services during the certification period from 1/24/22 to 4/23/22. The HA notes dated 1/27 and 1/31/22, showed the HA had electronically signed the HA notes on 6/26/22. The HA notes dated 2/2, 2/4, 2/7, 2/9, and 2/11/22, showed the HA had electronically signed the HA notes on 6/27/22. On 9/19/22 at 1150 hours, a concurrent clinical record review and interview was conducted with the Administrator and RNs 2 and 3. They were informed and acknowledged the findings. 4. Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The SN note dated 4/15/22, showed the SN had electronically signed the SN note on 5/29/22. The SN note dated 4/19/22, showed the SN had electronically signed the SN note on 5/30/22. The SN note dated 4/28/22, showed the SN had electronically signed the SN note on 5/13/22. The SN note dated 5/12/22, showed the SN had electronically signed the SN note on 5/24/22. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the discharge summary was completed for one of 13 sampled patients (Patient 10), creating the risk of of not providing the necessary information for aftercare. --- Findings: Review of Patient 10's closed clinical record was initiated on 9/13/22. The patient's clinical record showed the SOC was 4/15/22. The patient was certified for hospice services during the certification period from 4/15/22 to 6/13/22. The patient was transferred to another hospice on 5/23/22. Further review of the clinical record showed no documented evidence of a discharge summary to include summary of the patient's hospice services, including treatments, symptoms, and pain management. On 9/19/22 at 1230 hours, a concurrent clinical record review and interview was conducted with the Administrator and RN 3. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure their P&P for COVID-19 Vaccination included the process by which staff may request an exemption from the COVID-19 vaccination requirements and the process for ensuring the implementation of additional precautions and contingency plans intended to mitigate the transmission and spread of the COVID-19 infection for staff who were not fully vaccinated. This failure created the risk of not meeting the health and safety needs of the staff and patient population. --- Findings: Review of the QSO-22-07 showed the hospice's P&Ps must include the process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for all staff who were not fully vaccinated for COVID-19, the process by which staff may request an exemption from the COVID-19 vaccination requirements based on applicable Federal laws, and the contingency plans for staff who were not fully vaccinated for COVID-19. Review of the hospice's P&P titled Infection Control and Safety Overview - COVID 19 revised 4/1/20, showed the procedures on what to do if the staff was experiencing signs and symptoms of COVID-19 or was exposed to COVID-19 infection. However, the P&P did not include the specific procedures and contingency plans to ensure additional precautions were in place in order to mitigate the transmission of COVID-19 for all unvaccinated staff. In addition, the P&P did not address the process by which staff may request an exemption from the COVID-19 vaccination requirements. On 9/19/22 at 1150 hours, an interview and concurrent record review was conducted with the QA Coordinator. The QA Coordinator was informed and acknowledged the findings.