Every finding on record at Physicians Preferred Hospice Inc

Based on interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process of the Patient) was met as follows. --- The HA failed to maintain an accurate, current medication profile by ensuring that License Vocational Nurse 1 (LVN 1) performed medication reconciliation and have checked all prescribed medications to ensure Triamterene medication (to treat fluid retention and high blood pressure) and Methimazole medication (treats high thyroid levels in the body) were available and administered as prescribed for Patient 1. As a result, the non-compliance resulted in Patient 1 did not received the Triamterene and Methimazole medications for six days and Patient 1 was transferred to General Acute Care Hospital (GACH) due to shortness of breath. (Refer to L530). The cumulative effect of these systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits. the HA failed to ensure the Interdisciplinary Group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for two of 19 sampled patients ( Patient 6, and Patient 7). (refer to L523) the HA failed to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/familys needs for one of 19 sampled patients (Patient 7). (refer to L531)

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Interdisciplinary Group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for two of 19 sampled patients ( Patient 6, and Patient 7). This failure had the potential to result in patient and caregiver/family not receiving appropriate assessment and support of their needs identified on the plan of care. --- a A review of Patient 6s medical record Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #2, indicated a Start Of Care (SOC) date of 11/15/2024 with a primary diagnosis of malignant neoplasm of pancreas (a cancerous tumor that develops in the pancreas), and an order for the Medical Social Worker (MSW) to evaluate and assess patient within five days of admission for psychosocial counseling and support assessment. During a joint home visit on 11/19/1024 at 1:15 p.m., with Licensed Vocational Nurse 2 (LVN 2) at Patient 6s home, LVN 2 stated Patient 6 was a new patient to the HA and the comprehensive assessment was to be submitted within 48 hours of admission. During a concurrent interview and record review on 11/22/2024 at 2:30 p.m., with the Administrator/Director of Patient Care Services (DPCS), Patient 6s Electronic Medical Record (EMR) was reviewed. Patient 6s EMR indicated there was no documented evidence of a psychosocial assessment submitted since the SOC of 11/15/024 by the MSW. The DPCS stated there was no psychosocial assessment submitted by MSW. The DPCS stated each discipline has five days to complete their assessments from the patient's SOC date. The DPCS further stated Patient 6s SOC was 11/15/2024 and it has been seven days since Patient 6 was admitted to the HA. b A review of Patient 7s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 indicated a Start of Care (SOC) date of 11/14/2024 with a primary diagnosis of malignant neoplasm of stomach (a cancerous tumor that develops in the stomach when cells grow and divide abnormally), an order for the Medical Social Worker (MSW) to evaluate and assess patient within five days of admission for a psychosocial assessment and an order the Spiritual Care Coordinator (SC) to evaluate and assess patient within 5 days of admission for a spiritual needs/support assessment. During a concurrent interview and record review on 11/22/2024 at 2:30 p.m., with the Administrator/Director of Patient Care Services (DPCS), Patient 7s Electronic Medical Record (EMR) was reviewed. Patient 7s EMR indicated there was no documented evidence of a psychosocial assessment submitted since the SOC by the MSW. There was no spiritual assessment submitted since the SOC by the SC. The DPCS stated there was no psychosocial assessment submitted by MSW, and no spiritual assessment submitted by the SC. The DPCS stated each discipline has five days from admission to complete their assessments. The DPCS further stated Patient 7s SOC was 11/14/2024 and it has been eight days since Patient 7 was admitted to the HA. During a review of the HAs Policy and Procedure (P&P) titled, Initial Assessment/Comprehensive Assessment, with a revised date of February 2024, indicated, ";2. Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patients need for Hospice care and service and identify the patients need for; physical care, psychosocial and emotional care, spiritual care, all areas of hospice care related to palliation and management of the terminal illness and related conditions, and support with activities of daily living. 4. The Hospice IDG, in consultation with the patients attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the patients election of Hospice care."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill (patients who have six months or less to live) failed to maintain an accurate and current medication profiles for two of 19 sampled patients (Patient 1 and Patient 13). For Patient 1, License Vocational Nurse 1 (LVN 1) failed to perform medication reconciliation and failed to check all prescribed medications taken by Patient 1 to ensure Triamterene medication (to treat fluid retention and high blood pressure) and Methimazole medication (treats high thyroid levels in the body) were available and administered as prescribed. The non-compliance resulted in Patient 1 did not received the medications for six days and Patient 1 was transferred to General Acute Care Hospital (GACH) due to shortness of breath. On 11/20/2024 at 11:36 am., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agencys Director of Patient Care Services (DPCS), related to the hospice agency failure to maintain an accurate medication profile for Patient 1 by failing to ensure that the Licensed Vocational Nurse 1 (LVN1) performed medication reconciliation and have checked all prescribed medications to ensure Patient 1 has medication available as prescribed. On 11/21/2024, at 11:49 a.m., the HA submitted an IJ removal plan (IJRP-includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) was reviewed on 11/21/2024, at 4 p.m., the IJRP was not accepted. On 11/22/2024, at 4 p.m., the survey team completed the survey tasks and conducted an exit conference, in the presence of the DPCS with the IJ situations not removed. On 12/12/2024 the Department received an IJ removal plan from the agency, reviewed and accepted. The IJ removal Plan was as follow: From 11/20/2024 to 11/27/2024, the hospice agency visited all active patients and completed the medication reconciliation. On 11/20/2024 the consultant conducted in services for all clinical staff including LVN 1 on medication management and reconciliation. Patient 1 remained discharged. On 12/12/2024 the survey team conducted an onsite verification of the IJ removal plan. The IJ removal plan was implemented during an onsite visit. The IJ was removed on 12/12/2024 at 11:33 am., in the presence of the agencys Administrator/DPCS. --- During a review of Patient 1s admission record indicated a start of care (SOC) date of 3/24/2023, with a terminal diagnosis of Alzheimer's disease (destroys memory and other important mental functions). During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 9/14/2024, the POC/IDG indicated the frequency of visits of Licensed Vocational Nurse (LVN, in general) to one visit per week plus one prn (as needed) visits to administer and monitor the effectiveness of medication, and to instruct the patient caregiver (PCG) regarding prescribed medication and side effects (are unwanted undesirable effects). On 11/18/2024, at 11 a.m., a complaint validation survey was conducted at the HA that included a complaint allegation that Patient 1 had ran out of two medications for six days, the agency was contacted four times but failed to deliver the medications. On the sixth day, (4/7/2024), Patient 1 developed symptoms of difficulty of breathing and left leg swelling and was transferred to a general acute care hospital (GACH), for further treatment. During an phone interview with Family member 1 (FM1) on 11/18/2024, FM 1 stated that Medication Technician (MT) called her to inform that Patient 1s Triamterene medication (to treat fluid retention and high blood pressure) and Methimazole medication (treats high thyroid levels in the body) had ran out on 4/1/2024, and that MT kept calling LVN 1 over the phone from 4/1/2024, 4/2/2024, and 4/4/2024, to let LVN 1 know that the Triamterene and Methimazole medications had ran out since 4/1/2024, so LVN 1 could notify the HA to call the pharmacy for a refill. FM 1 also stated that the HA did not deliver the medications, and on the sixth day, Patient 1 experienced episodes of hard of breathing and left leg swelling that led to Patient 11 being taken to the nearest GACH via ambulance transport. During a phone interview with Pharmacist 1 on 11/19/2024, at 11 a.m., Pharmacist 1 stated, there was a refill order on 2/28/2024, to administer Triamterene 37.5-25 milligrams (mg) (30 tabs) ½ tab daily for diuretic and Methimazole 5 mg (30 tabs) ½ tab daily for hyperthyroidism with confirmed delivery on 2/28/2024, for Patient 1. Pharmacist 1 also stated the next refill order for Patient 1 was on 4/12/2024, for Triamterene 37.5-25 milligrams (mg) (30 tabs) one tab daily and Methimazole 5 mg (30 tabs) 1 tab daily with confirmed delivery on 4/12/2024. Pharmacist 1 further stated the Triamterene and Methimazole medications with a refill dated of 2/28/2024, would run out by 4/1/2024, and the next refill order received for both medications was on 4/12/24. During a phone interview with MT on 11/19/2024, at 1 p.m., MT stated she was assigned to administer medications to Patient 1 on dates 4/1/2024 to 4/6/2024. MT also stated she called LVN 1 over the phone on 4/1/2024, but could not remember the time and spoke with her, on 4/2/2024, and 4/4/2024, left a message to let her know that Patient 1 ran out of her Triamterene and Methimazole medications since 4/1/2024. When MT was asked if LVN 1 was checking Patient 1s actual medications during her visits, MT stated that every hospice nurses from different agencies would see her during their visits because she has the access to get in the medication room and reconcile the patients medication with them however, MT have not seen LVN 1 at all. MT further stated HA should be the one contacting the patients pharmacy for medication refill as per the HAs contract agreement with the pharmacy. A review of Patient 1s Visit Note LVN indicated that LVN 1 provided visits on dates 3/27/2024, 4/3, and 4/7/2024. However, there was no documented evidence Patient 1s Triamterene and Methimazole medications had ran out and if LVN 1 notified the HA and the physician for a refill order. During a phone interview with LVN 1 on 11/19/2024, at 2 p.m., stated she was not aware that Patient 1 ran out of her Triamterene and Methimazole medications on 4/1/2024. LVN 1 also stated she has not spoken with MT nor have received phone messages at all. When LVN 1 was asked if she checked Patient 1s medications during her visits, LVN 1 stated the medical technicians at the boarding care facility knew her phone number and the HAs emergency number to call if ever Patient 1s medications runs out, LVN 1 also stated she does not check Patient 1s actual medications because the medication technicians will let her know if Patient 1s medication runs out or if there are any new medication orders during her visits. LVN 1 further stated that she had no access at the medication room and when she needed to see the medication technicians to reconcile medications, the medication technicians were always busy attending to other patients, so she ended up not checking the patients medications. During a phone interview with the Director of Patient Care Services (DPCS) on 11/19/2024, at 2:30 p.m., when asked what the DPCS expectations was for the HA's visiting nurse regarding checking patients medications during their visits, the DPCS stated usually the visiting nurse checked the patients actual medication bottle or bubble pack with the assigned medication technician for medication reconciliation. The DPCS also stated the visiting nurse had no access of the patients medication room and if the medication technicians are occupied with other patients, the visiting nurse would just check the patients medications on their next visits. A review of Patient 1s GACH History and Physical report dated 4/7/2024, indicated Patient 1 was diagnosed having acute exacerbation of congestive heart failure (CHF- chronic condition in which the heart does not pump blood as well as it should), presenting with symptoms of increased work of breathing and lower leg swelling. The Chest Xray results dated 4/7/2024, indicated the patient had cardiomegaly with increased interstitial opacities and small left pleural effusion correlated for signs of fluid overload. A review of the agency's undated policy "Medication Administration and Reconciliation" indicated medication reconciliation will be conducted at each skilled visit, and to compare the medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies. b. During a review of Patient 13s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 1/29/2024 with a terminal diagnosis of cerebral infarction affecting right dominant side (a serious condition that occurs when brain tissues die due to a lack of blood flow to the brain). During a review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) dated 11/6/2024, the indicated the frequency of visits of the skilled nurse (SN) to one visit per week plus 1 prn (or pro re nata, which means ";as needed") visit, Social worker (MSW) prn and recertification and the chaplain (SC) service was declined. There was a physician's order included on the POC as follows: a. to administer Gabapentin 100 milligrams (mg) one capsule three times a day for neuropathy (weakness, numbness and pain from nerve damage). b. Sevelamer Carbonate 800 mg 2 tabs three times daily for phosphorous reducer. During a joint home visit, on 11/21/2024 at 1 p.m., with the LVN 4 at Patient 13s residence, Patient 13 was observed lying in a hospital bed, asleep but arousable, and had an AV (arterio-venous - used for vascular access for long term dialysis) shunt on left upper arm. During a review of Patient 13's current medication at home on 11/21/2024, at 1:45 p.m., with LVN 4, noted a bottle of Gabapentin 100 milligrams (mg) to take one to two capsules daily and a bottle of Sevelamer Carbonate 800 mg 2 tabs three times daily. During an interview on 11/21/2024, at 1:15 p.m., with Family Member 2 (family member), FM 2 stated she administers Gabapentin one capsule daily and Sevelamer 2 tabs twice a day for Patient 13. When FM 2 was asked if the visiting nurse checked Patient 13's medication during their visits, she stated the visiting nurse would only ask if there were new medications but seldom checks the patient's actual medication bottles.

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/familys needs for one of 19 sampled patients (Patient 7). This failure had the potential to result in the patient/family member not being provided the social, spiritual, and cultural support that could impact the patient's family members ability to cope with the patient's impending death. --- A review of Patient 7s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 with a Start of Care (SOC) date of 11/14/2024 indicated a primary diagnosis of malignant neoplasm of stomach (a cancerous tumor that develops in the stomach when cells grow and divide abnormally), and an order for Bereavement Coordination to assess and evaluate the patients bereavement and grieving risk factor within 5 days of admission. A review of Patient 7s record titled, POC/IDG Review for certification period #1 with SOC date of 11/14/2024, indicated ";Plan of Care (Problems/Interventions/Goals/Status)-Bereavement- Goal: Bereavement Coordinator will assess for Bereavement risk factors within 5 days of admission. Intervention: Bereavement Coordinator will complete assessment within 5 days of admission for risks of grieving- Assist primary bereaved in coping with the dying process and death. Target Date: 11/19/2024". During a concurrent interview and record review on 11/22/2024 at 2:30 p.m., with the Administrator/Director of Patient Care Services (DPCS), Patient 7s Electronic Medical Record (EMR) was reviewed. Patient 7s EMR indicated there was no documented evidence of an Initial Bereavement Assessment was submitted since the SOC of 11/14/024 by the Bereavement Coordinator. The DPCS stated there was no submission of an initial bereavement assessment by the bereavement coordinator. The DPCS stated the HA staff follow a patients POC/IDG which states each discipline has five days from admission to complete their assessment. The DPCS further stated Patient 7s SOC was on 11/14/2024 and it has been eight days since Patient 7 was admitted to the HA. During a review of the HAs Policy and Procedure (P&P) titled, Bereavement Services, with a revised date of February 2022, indicated, ";2. An initial Bereavement Risk Assessment will be performed as part of the Comprehensive Assessment." During a review of the HAs Policy and Procedure (P&P) titled, Initial Assessment/Comprehensive Assessment, with a revised date of February 2024, indicated, ";2. Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patients need for Hospice care and service and identify the patients need for; physical care, psychosocial and emotional care, spiritual care, all areas of hospice care related to palliation and management of the terminal illness and related conditions, and support with activities of daily living. 3. The comprehensive assessment will take into consideration the following factors: An initial bereavement risk assessment of the needs of the patients family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patients death. 4. The Hospice IDG, in consultation with the patients attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the patients election of Hospice care."

Based on observation, interview, and record review, the hospice agency (HA) failed to develop a care plan for hemodialysis care (medical treatment that filters waste and excess fluid from the blood when kidneys are no longer functioning properly) management for one out of 19 sampled patients (Patient 13) with an atrio-ventricular (AV shunt- a surgical procedure that creates a connection between the heart's atrium and the inferior vena cava) located at left upper arm. This deficient practice has the potential to result in the buildup of toxins (bacterial infection spreading through the bloodstream) in the blood due to failing kidneys. --- During a review of Patient 13s face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 1/29/2024 with a terminal diagnosis of cerebral infarction affecting right dominant side (a serious condition that occurs when brain tissues die due to a lack of blood flow to the brain). During a review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) dated 11/6/2024, indicated the frequency of visits of the skilled nurse (SN) to one visit per week plus 1 prn (or pro re nata, which means ";as needed") visit, Social worker (MSW) prn and recertification and the chaplain (SC) service was declined. During a joint home visit, on 11/21/2024 at 1 p.m., with the LVN 4 at Patient 13s residence, Patient 13 was observed lying in a hospital bed, asleep but arousable, and had an AV shunt on left upper arm. During a further review of Patient13's clinical record indicated no documented evidence the HA had developed a care plan for hemodialysis care management. During an interview on 11/22/2024 at 1:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated and confirmed there was no care plan done for hemodialysis care management for Patient 13. During a review of the agency's undated policy and procedure (P&P) titled, The Plan of Care, indicated 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.

Based on interview and record review, the hospice failed to ensure the Conditions of Participation for Quality Assessment & Performance Improvement was met as follows: --- 1. The hospice agency (HA-healthcare organization that provides specialized care focused on comfort and symptom management for terminally ill patients) failed to provide documented evidence of the hospice program data being collected to monitor effectiveness and safety services and quality of patient care. This deficient practice resulted in the failure of the hospice to monitor and identify significant issues, health and safety, and implementation of the highest quality of care provided to all patients receiving the hospice benefits. (Refer to L564). 2. The HA failed to provide evidence its governing body is responsible in ensuring an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. (Refer to L574). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the Federal regulations for Quality Assessment & Performance Improvement to ensure provision of the highest quality of care to all certified hospice patients receiving the benefits.

Based on interview and record review, the hospice agency (HA-healthcare organization that provides specialized care focused on comfort and symptom management for terminally ill patients) failed to provide documented evidence of the hospice program data being collected to monitor effectiveness and safety services and quality of patient care. This deficient practice resulted in the failure of the hospice to monitor and identify significant issues, health and safety, and implementation of the highest quality of care provided to all patients receiving the hospice benefits. --- On 11/22/2024 at 11 a.m., the hospice QAPI program was requested from the Administrator/Director of Patient Care Services (Admin/DPCS) to be reviewed. The QAPI program revealed the hospice program was gathered from a software called QAPIPLUS (a quality management software solution created specifically for home health, hospice, behavioral health, home care, and long-term care organizations that digitizes and automates the QAPI). During an interview on 11/22/2024 at 1:51 p.m., with the Admin/DPCS stated, the data gathered by the software were gathered from the patients' charts in the electronic medical record. Admin/DPCS could not interpret the data presented to the survey team for their QAPI program. Admin/DPCS stated ";I am not sure; I would ask the software company first." A review of the agencys document titled ";QAPI Plan" generated from the software company revised 1/5/2024, indicated data collection is based on the organizations setting, scope and services. The organization selects measures that are meaningful to the organization and that addresses the needs of the patients it serves. The QAPI committee will meet quarterly. QAPI activities and outcomes will be on the agenda of every staff meeting. The minutes of the meetings will be available online. The QAPI committee will report all activities to the governing board. The QAPI committee will have responsibility for reviewing data, suggestions and input from patients, staff, family members, and other stakeholders. The QAPI committee will prioritize opportunities for improvement and determine which performance improvement projects will be initiated. When an issue or problem is identified that is not systemic and does not require a performance improvement project, the QAPI committee will decide how to correct the issue or problem. These corrections may include an easy decision, corrective action plan, or rapid improvement cycle. The committee will solicit individuals from the organization to participate in performance improvement projects. The committee will monitor progress, provide input and ensure the individuals involved in the project have the resources they need. The hospice agency will develop, implement, evaluate and maintain an effective, ongoing, agency wide, data driven QAPI program. The organized hospice wide QAPI program \􀍑will be ongoing and have a written plan of implementation.

Based on interview and record review, the hospice agency (HA- a healthcare organization that provides specialized care focused on comfort and symptom management for terminally ill patients) failed to provide evidence the governing body is responsible in ensuring an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality of care. --- A review of the hospice agencys Governing Body Minutes (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement) was requested on 11/22/2024 at 11 a.m., from the Administrator/Director of Patient Care Services (Admin/DPCS). During a concurrent record review and interview with the Admin/DPCS on 11/22/2024 at 1:51 p.m., confirmed that they conducted their governing body meeting on 1/5/2024 with the agencys chief executive officer (CEO) at 9 a.m. to 10 a.m., that was generated by a software titled QAPIPLUS (a quality management software solution created specifically for home health, hospice, behavioral health, home care, and long-term care organizations that digitizes and automates the QAPI). Admin/DPCS confirmed that there was only one governing body meeting conducted that discussed and approved the QAPI program, QI (quality improvement) outcomes, infection control program, flu program, hand hygiene program , emergency management plan, Volunteer program, bereavement program, budget and capital expenditure plan, human resources , administrative, clinical and Covid-19 policies and procedures, on-call schedule, ethics committee, Tuberculosis program, IDT schedule, PI plan, Covid-19 plan and medication management plan. There was no documented evidence of the governing body meeting was held for the year 2024. A review of the hospice agencys document titled ";Administrator" indicated Job Summary: The Administrator ensures quality and safe delivery of Hospice services; coordinates services that reflect Hospice's philosophy and standards of care; and plans, develops, implements and evaluates Hospice services, programs and activities. Responsibilities: 1. Organizes and directs hospices ongoing liaison among the governing body and staff 2. Employs qualified personnel and ensures adequate staff education and evaluations. 19. Maintains compliance with applicable federal, state and local rules and regulations and accreditation standards. A review of the hospice agencys document titled ";Medical Director" MEd pass 2009, indicated Job Summary: Directs the medical aspects of the Hospice's patient care program. Serves as consultant and advisor to the Director, offering his/her expertise to assess and interpret medical problems. The Hospice physician serves as consultant to the primary physician of Hospice patients but does not take over the medical direction of the patient's care. Serves as consultant to the Interdisciplinary Group. A review of the hospice agencys document titled ";Job Description: Manager of Patient Services" indicated Job Summary: Responsible as a member of the interdisciplinary and clinical management teams to the Director for the implementation, delivery, coordination and supervision of Hospice services delivered by respective team consistent with Hospice policies and procedures

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Volunteer Services was met as follows: --- The Hospice Agency (HA) failed to ensure volunteers were provided training and orientation consistent with the specific tasks to perform under the supervision of the volunteer coordinator. This deficient practice resulted in the failure of the volunteers not performing according to their specific tasks that will contribute to the improvement of the hospice patients' care and services. (Refer to L643). The Hospice Agency (HA) failed to document the cost savings achieved through the use of volunteers. (refer to L646) The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with the Federal regulations for Volunteers to ensure this required core services are provided to certified hospice patients during their end of life experience.

Based on interview and record review the Hospice Agency (HA) failed to ensure volunteers were provided training and orientation consistent with the specific tasks to perform under the supervision of the volunteer coordinator. This deficient practice resulted in the failure of the volunteers not performing according to their specific tasks that will contribute to the improvement of the hospice patients' care and services. --- On 11/22/2024 at 2:15pm, a request was made to the HA Administrator/Director of Patient Care Services (DPCS) to review their hospice volunteer training program. During a concurrent interview and record review on 11/22/2024 at 3 p.m., with the DPCS, the Hospice Volunteer Training Program was reviewed. The Volunteer Training program indicated volunteer hours recorded for the year of 2024 for the months of January to October. The Volunteer Training Program also indicated there was no specifications documented for the cost savings plan, volunteer duties utilized and specified name of volunteers and the training completed and how often. The DPCS stated he would input the HAs volunteer work data into Qapiplus (quality management software solution purpose-built for home health and) and produced the Volunteer Training Program. The DPCS further stated the HA has many volunteers, and did not have documented evidence of a log of the volunteer hours done per month that would include the volunteers name and what type of volunteer work was performed, and any training the volunteers completed with dates. During a review of the HAs Volunteer training program, with a revised date of 1/5/2024, indicated that volunteers will maintain a record of their volunteer hours by completing the volunteer hours log in order to calculate total number of volunteer hours and all volunteer hours documented are added up for the month and used to determine the volunteer cost savings ratio and percentage. During a review of the facilitys Policy and Procedure (P&P) titled, Volunteer Services with a revised date of April 2020, indicated, the hospice agency will provide volunteer services under the direction of a volunteer coordinator who will track use of volunteers and costs savings achieved, and will develop and implement a specialized volunteer orientation and training program to meet needs of patients and families. The P&P also indicated volunteers may work in a variety of roles including: ";1. patient care volunteers: provide personal care or emotional support and practical assistance, which enhance the comfort and quality of life for patients and families/caregivers. These services include being available for companionship, listening, simply ";being there," and preparing meals. Patient care volunteers may also provide relief for caregivers or assist them with household chores. 2. Bereavement volunteers: provide anticipatory counseling and bereavement support to families/caregivers. 3. errands and transportation volunteers: offer a type of practical support often needed by hospice patients and families/caregivers. These duties may include picking up needed prescriptions or supplies, or grocery shopping. and office duties. 4. Office volunteers: lend their services working in hospice's administrative offices. These activities may include assembling information packets, filing, photocopying, and assisting with mailings."

Based on interview and record review, the Hospice Agency (HA) failed to document the cost savings achieved through the use of volunteers. This deficient practice resulted in the agencys failure to ensure proper utilization of volunteers through the volunteer program and that patients will receive other benefit services that will contribute to the improvement of patient care and services. --- On 11/22/2024 at 2:15pm, a request was made to the HA Administrator/Director of Patient Care Services (DPCS) to review their hospice volunteer training program During a concurrent interview and record review on 11/22/2024 at 3pm with the DPCS, the Hospice Volunteer Training Program was reviewed. The Volunteer Training program indicated volunteer hours recorded for the year of 2024 for the months of January to October. The Volunteer Training Program also indicated there was no specifications documented for the cost savings plan, volunteer duties utilized and specified name of volunteers and the training completed and how often. The DPCS stated he inputs the HAs volunteer work data into Qapiplus and Qapiplus produced the Volunteer Training Program. The DPCS further stated he the HA has many volunteers and did not have documented evidence of a log of the volunteer hours done per month that would include the volunteers name and what type of volunteer work was performed, and any training the volunteers completed with dates. During a review of the HAs Volunteer training program, with a revised date of 1/5/2024, indicated that volunteers will maintain a record of their volunteer hours by completing the volunteer hours log in order to calculate total number of volunteer hours and all volunteer hours documented are added up for the month and used to determine the volunteer cost savings ratio and percentage. During a review of the HAs Policy and Procedure (P&P) titled, Volunteer Services, with a revised date of April 2020, indicated, ";5. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved".

Based on interview, and record review, the hospice agency (HA- a healthcare organization that provides specialized care focused on comfort and symptom management for terminally ill patients) failed to ensure the Condition of Participation for Clinical Records was met as follows: --- Failed to ensure the members of the IDG (IDG (Interdisciplinary Group- which is a team of healthcare professionals who work together to provide comprehensive care for hospice patients. IDGs are responsible for developing and reviewing a patient's plan of care, and they meet regularly to discuss care plans, communicate updates, and more. IDGs typically include members from the following professions: Doctor of medicine or osteopathy, Registered nurse, social worker, and Pastoral or other counselor) signed patient care orders, plan of care, and interdisciplinary group team meetings for 1 of 19 sampled patients (Patients 16). Refer to L678. Failed to ensure clinical records were authenticated by a staff employed by the agency for 5 of 19 sampled patients (Patient 2, Patient 9, Patient 10, Patient 16, and Patient 17) during their IDG (Interdisciplinary Group- which is a team of healthcare professionals who work together to provide comprehensive care for hospice patients. IDGs are responsible for developing and reviewing a patient's plan of care, and they meet regularly to discuss care plans, communicate updates, and more. IDGs typically include members from the following professions: Doctor of medicine or osteopathy, Registered nurse, social worker, and Pastoral or other counselor) meetings. This failure resulted in an unauthorized access and inaccurate patient information, or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. Refer to L679. The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal regulations for Clinical Records to ensure authorized access and accurate patient information or assessments were entered in the clinical records for patients certified to receive hospice care benefits.

Based on interview and record review, the hospice agency (HA- healthcare organization that provides specialized care focused on comfort and symptom management for terminally ill patients) failed to ensure the members of the IDG (IDG (Interdisciplinary Group- which is a team of healthcare professionals who work together to provide comprehensive care for hospice patients. IDGs are responsible for developing and reviewing a patient's plan of care, and they meet regularly to discuss care plans, communicate updates, and more. IDGs typically include members from the following professions: Doctor of medicine or osteopathy, Registered nurse, social worker, and Pastoral or other counselor) signed patient care orders, plan of care, and interdisciplinary group team meetings for 1 of 19 sampled patients (Patients 16). This deficient practice resulted in patients provided care and services without the physicians and the members of the IDGs approval of Patient 16s plan of care. --- During a record review on 11/21/2024 at 1:40 p.m., of Patient 16s ";Personal Information" sheet indicated an SOC date of 8/21/2024 with the primary diagnosis of cerebral infarction (most common type of stroke). During a review of Patient 16s document titled ";Comprehensive Nursing Assessment" dated 8/21/2024 on 11/21/2024 at 1:40 p.m., indicated Patient 16 was admitted to the hospice agency under routine level of care, presents with generalized weakness, KPS score of 30 percent (the Karnofsky Performance Status scale, meaning they are likely to require hospitalization although death is not imminent; essentially, they are significantly impaired in their ability to perform daily activities and need considerable medical support) and a PPS score of 30 percent (Palliative Performance Scale (PPS), meaning they are unable to perform any activity and require complete care, severely bedbound, signifying a very severe illness often considered near the end of life). Patient had past medical history of Hypertension (high blood pressure), Diabetes Mellitus (a chronic disease that occurs when the body can't produce or use insulin properly, resulting in high blood sugar levels) Constipation(infrequent or uncomfortable bowel movements), Gastro-esophageal reflux (a digestive disorder that occurs when stomach contents leak into the esophagus) disease, Dysphagia( trouble swallowing), Depression (a mental health condition that involves a persistent low mood or loss of interest in activities) and Benign Prostatic Hyperplasia (enlargement of the prostate making it difficult to urinate). During a review of Patient 16s document titled ";History of IDG" on 11/21/2024 at 1:40 p.m., upon review, the IDG meeting was conducted on 11/20/2024 at 6 p.m. There were no documented signatures found on the medical director, registered nurse, social worker and chaplain that they attended the IDG meeting in the electronic medical record. During a concurrent interview and record review with the Administrator/Director of Patient Care Services Designee (Admin/DPCSD) on 11/22/2024 at 12:41 p.m., Admin/DPCSD stated that the office hours are from 9 a.m. to 5 p.m. Admin/DPCSD stated that he comes in the absence of the Administrator/Director of Patient Care Services (Admin/DPCS) or if there are emergencies. Admin/DPCSD stated that the agency conducts IDG every two weeks and is attended by the medical director (MD) social worker (SW), registered nurse (RN), licensed vocational nurse (LVN), volunteers, hospice aides (HA) and other persons included in the patients care. Admin/DPCSD stated he was currently studying to become a nurse practitioner and the last IDG meeting he attended was three months ago. During an interview with the registered nurse case manager (RNCM) o11/22/2024 at 1:21 p.m., RNCM stated that she participated in the IDG meetings over the phone because they do not fit in the office and some nurses are located far away from the office. RNCM stated that they do conduct their IDGs sometimes after office hours due to availability of staff present and is usually presided by the Administrator, DPCS or Registered Nurse. On concurrent record review with the RNCM, RNCM stated that the employee recorded in the IDG who initiates the documentation is a staff of the agency. On concurrent record review with the RNCM of the hospice agencys employee list on 11/22/2024, the name of the staff listed in the electronic medical record is not listed. RNCM stated she does not work in the office, she was outside. RNCM stated that this person helps us with our paperwork. During an interview on 11/22/2024 at 1:51 p.m., with the Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated that it was unlikely that the agency conducts their IDGs that late as 7 p.m., 10 p.m., or at 10:45 p.m. Admin/DPCS and IDG members do not sign in on a sign in sheet. Admin/DPCS stated that because of the availability of the IDG members are different, the form is opened in the electronic medical record and the IDG members sign the next day or when the IDG member is available to sign the document. Admin/DPCS confirmed that this unknown person who creates the IDG in the electronic medical record is not a nurse, but a QA (Quality Assurance) person and she works outside and not in the office. A review of the hospice agencys document titled ";Coordination of Patient Care" revised 6/2019, indicated that Hospice staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the IDG plan of care. To ensure that quality services are being provided to patients and to provide a mechanism for representatives from various disciplines to discuss patient care in IDG meeting. Ensures that the IDG maintains responsibility for directing, coordinating, and supervising care and service provided. A review of the hospice agencys document ";IDG Care Planning Process" revised 2/2024, indicated Hospice has designated an interdisciplinary group which, in consultation with the patient's attending physician, prepares a written plan of care for each patient. The group consists of a physician member who is the hospice medical director or another hospice physician who is employed by or under contract with the hospice, a registered nurse, social worker or marriage family therapist or mental health counselor, a pastoral or another counselor. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of the hospice patients and families facing terminal illness and bereavement A review of the hospice agencys document titled ";Job Description: Manager of Patient Services" indicated Job Summary: Responsible as a member of the interdisciplinary and clinical management teams to the Director for the implementation, delivery, coordination and supervision of Hospice services delivered by respective team consistent with Hospice policies and procedures. A review of the hospice agencys document titled "; Administrator" indicated Job Summary: The Administrator ensures quality and safe delivery of Hospice services; coordinates services that reflect Hospice's philosophy and standards of care; and plans, develops, implements and evaluates Hospice services, programs and activities. Responsibilities: 2. Employs qualified personnel and ensures adequate staff education and evaluations. 19. Maintains compliance with applicable federal, state and local rules and regulations and accreditation standards. A review of the hospice agencys document titled ";Patient Record Entries: Authentication" revised 6/2019, indicated all patient record entries will be dated and authenticated. Only authorized individuals make entries in the patients record. The purpose of this policy indicates to establish a method to identify authors of entries and how individuals will authenticate patient record entries. All entries in the patient record will be authenticated by staff by signing first name or initial, last name an, title. By authenticating entries in the patient's record, staff is validating the correctness of the information. If automated clinical record system is used, authentication includes a signature and title, or a secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry, in accordance with state law.

Based on interview and record review the hospice agency (HA) failed to ensure clinical records were authenticated by a staff employed by the agency for 5 of 19 sampled patients (Patient 2, Patient 9, Patient 10, Patient 16, and Patient 17) during their IDG (Interdisciplinary Group- which is a team of healthcare professionals who work together to provide comprehensive care for hospice patients. IDGs are responsible for developing and reviewing a patient's plan of care, and they meet regularly to discuss care plans, communicate updates, and more. IDGs typically include members from the following professions: Doctor of medicine or osteopathy, Registered nurse, Social worker, and Pastoral or other counselor) meetings. This failure resulted in an unauthorized access and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being --- 1. During a record review on 11/21/2024 at 11:05 a.m., of Patient 2s ";Personal Information" sheet indicated a start of care (SOC- the initial phase when a patient begins receiving hospice services) on 11/17/2024, with a primary diagnosis of malignant neoplasm ( an abnormal mass of tissue, also known as a tumor) of head, face and neck. During a record review on 11/21/2024 at 11:05 a.m., of Patient 2s ";History of IDG" notes indicated that on 11/20/2024 at 10:00 p.m., an IDG was conducted y the hospice agency. 2. During a record review on 11/21/2024 at 11:30 a.m., of Patient 9s ";Personal Information" sheet indicated an SOC of 8/20/2024 with the primary diagnosis of malignant neoplasm of the rectum (lower part of the large intestine that collects waste). During a record review of Patient 9s ";History of IDG" notes on 11/21/2024 at :30 a.m., indicated that the hospice agency conducted their IDGs for Patient 9 on 11/5/2024, 10/23/2024,10/9/2024, 9/25/2024, 9/11/2024, 8/28/2024 at 6:00 p.m. and 8/20/2024 at 7:45 p.m. 3. During a record review on 11/21/2024 at 1:02 p.m., of Patient 10s "; Personal Information" sheet indicated an SOC date of 10/23/2023 with the primary diagnosis of chronic obstructive pulmonary disease ( COPD- a group of serious lung diseases that make it difficult to breathe) with a certification period (refers to the initial 90-day period of hospice care, followed by subsequent 60-day periods, where a patient's terminal illness must be recertified by a hospice physician to continue receiving hospice benefits; essentially, it's the timeframe during which a patient is considered eligible for hospice care based on their medical prognosis). During a record review on 11/21/2024 at 1:02 p.m., indicated that the hospice agency conducted their IDGs for Patient 10 on 10/24/2024 Saturday at 1:15 p.m., 10/24/2024, 10/9/2024, 9/25/2024, 9/11/2024, 8/28/2024, 8/14/2024, 7/31/2024, 7/17/2024 at 6:00 p.m. 4. During a record review on 11/21/2024 at 1:40 p.m., of Patient 16s "; Personal Information" sheet indicated an SOC date of 8/21/2024 with the primary diagnosis of cerebral infarction ( most common type of stroke). During a record review on 11/21/2024 at 1:40 p.m., indicated that the hospice agency conducted their IDGs for Patient 16 on 11/6/2024, 10/23/2024, 10/9/2024, 9/25/2024, 9/11/2024, 8/28/2024 at 6:00 p.m. 5. During a record review on 11/21/2024 at 3:00 p.m., of Patient 17s "; Personal Information" sheet indicated an SOC date of 2/7/2024 with the primary diagnosis of atherosclerotic heart disease (a condition where plaque (a build-up of sticky substances usually made up of fat, cholesterol and other substances) builds up in the arteries of the heart, reducing blood flow and oxygen supply to the heart). During a record review on 11/21/2024 at 3:00 p.m., indicated that the hospice agency conducted their IDGs for Patient 17 on 11/20/2024, 11/6/2024, 10/23/2024, 10/9/2024, 9/25/2024, 9/11/2024, 8/28/2024, 8/14/2024, 7/31/2024, 7/17/2024, 7/3/2024 at 6:00 p.m. and 2/7/2 at 7:00 p.m. During a concurrent interview and record review with the Administrator/Director of Patient Care Services Designee (Admin/DPCSD) on 11/22/2024 at 12:41 p.m., Admin/DPCSD stated that the office hours are from 9:00 a.m. to 5:00 p.m. Admin/DPCSD stated that he comes in the absence of the Administrator/Director of Patient Care Services (Admin/DPCS) or if there are emergencies. Admin/DPCSD stated that the agency conducts IDG every two weeks and is attended by the medical director (MD) social worker (SW), registered nurse (RN), licensed vocational nurse (LVN), volunteers, hospice aides (HA) and other persons included in the patients care. Admin/DPCSD stated he is currently studying to become a nurse practitioner and the last IDG meeting he attended was three months ago. During an interview with the registered nurse case manager (RNCM) o11/22/2024 at 1:21 p.m., RNCM stated that she participates in the IDG meetings over the phone because they do not fit in the office and some nurses are located far away from the office. RNCM stated that they do conduct their IDGs sometimes after office hours due to availability of staff present and is usually presided by the Administrator, DPCS or Registered Nurse. On concurrent record review with the RNCM, RNCM stated that the employee recorded in the IDG who initiates the documentation is a staff of the agency. On concurrent record review with the RNCM of the hospice agencys employee list on 11/22/2024, the name of the staff listed in the electronic medical record is not listed. RNCM stated she does not work in the office , she is outside. RNCM stated that this person helps us with our paperwork. During an interview on 11/22/2024 at 1:51 p.m., with the Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated that it is unlikely that the agency conducts their IDGs that late as 7:00 p.m., 10:00 p.m., or at 10:45 p.m. Admin/DPCS and IDG members do not sign in on a sign in sheet. Admin/DPCS stated that because of the availability of the IDG members are different, the form is opened in the electronic medical record and members sign the document the next day or when the IDG member is available to sign the document. Admin/DPCS confirmed that this unknown person who creates the IDG in the electronic medical record is not a nurse, but a QA (Quality Assurance) person and she works outside and not in the office. A request was made to the hospice agency to provide the employee file for this unknown staff that was not listed in the employee list on 11/22/2024 at 1:30 p.m. There was no employee file provided to the survey team upon exit at 3:30 p.m. A review of the hospice agencys document titled "; Patient Record Entries: Authentication" revised 6/2019, indicated all patient record entries will be dated and authenticated. Only authorized individuals make entries in the patients record. The purpose of this policy indicates to establish a method to identify authors of entries and how individuals will authenticate patient record entries. All entries in the patient record will be authenticated by staff by signing first name or initial, last name an, title. By authenticating entries in the patient's record, staff is validating the correctness of the information. If automated clinical record system is used, authentication includes a signature and title, or a secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry, in accordance with state law. A review of the hospice agencys document titled "; Administrator" indicated Job Summary: The Administrator ensures quality and safe delivery of Hospice services; coordinates services that reflect Hospice's philosophy and standards of care; and plans, develops, implements and evaluates Hospice services, programs and activities. Responsibilities: 2. Employs qualified personnel and ensures adequate staff education and evaluations. 19. Maintains compliance with applicable federal, state and local rules and regulations and accreditation standards. A review of the hospice agencys document titled "; Medical Director" Medpass 2009, indicated Job Summary: Directs the medical aspects of the Hospice's patient care program. Serves as consultant and advisor to the Director, offering his/her expertise to assess and interpret medical problems. The Hospice physician serves as consultant to the primary physician of Hospice patients, but does not take over the medical direction of the patient's care. Serves as consultant to the Interdisciplinary Group.

Upon patient record review 1 of 19 (Patient #8) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 8: The psychosocial comprehensive assessment was not completed until 5/21/24, pt admitted 2/25/2024.

Upon patient record review, 3 of 19 (Patient #1,3,9) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,3,9: Did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon client record review, 1 of 19 (Patient #4) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 4: There is no evidence the the hospice follows the individualized plan of care developed in in collaboration with the attending physician. There is no signature by the attending physician on the POC.

Upon patient record review, 6 of 19 (Patient #1,2,4,6,7,10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: The POC 6/4/24 contains an order for MSW and SC for 1 per month and upon patient request with no frequency. Corrected on site. Patient 2: The POC 6/21/24 contains an order for MSW 1 recert and upon request with no frequency. Corrected on site. Patient 4: The POC 5/9/24 contains an order for MSW 1 per month and upon request and SC 1 per recert and upon request with no frequency. Corrected on site. Patient 6: The POC 6/4/24 contains an order for MSW at recert, every month and PRN with no frequency. Corrected on site. Patient 7: The POC 7/15/24 contains an order "Send MSW per PCG request". There is no frequency. Corrected on site. Patient 10: The 7/19/24 POC contains and order MSW to visit per pt request. There is no frequency. Corrected on site.

Upon patient record review, 1 of 19 (Patient #14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 14: The POC 7/15/24 contains an order "draw up approximately 30ml of irritant in syringe and instill in catheter". Irritant is a typo but the order does not state what type of irrigation fluid they are to use to irrigate the foley. Corrected on site.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: The SN documented on 6/4/24 "SN recommended using ice pack for discomfort". There is no evidence of an order for this modality. The MSW saw patient on 6/5/24,6/18/24,7/9/24,7/22/24 the orders on POC are for every month, and at recertification.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel 5: The aide competency did not include: Sponge bath or Shampoo, sink, tub, and bed.

Upon personnel record review, 3 of 13 (Personnel #6,7,8) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 6,7,8,: The contracted personnel did not have evidence they have received orientation on the hospice philosophy.

Upon patient client record review, 1 of 19 (Patient #4) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 4: The elections of benefits indicated pt had chosen an attending physician that was not one of the hospice medical directors. There is no evidence of a CTI completed by the chosen attending physician. The hospice medical directors completed both CTI's.

Upon patient client record review, 10 of 19 (Patient #3,4,5,6,7,8,10,11,13,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 3: The SN documented aide supervisory visits on 7/21/23 and 8/4/23, there is evidence the aide did not see the pt past 7/5/23. The SN documented wound care on 7/12/24 as "wound care provided aseptically as ordered" and 7/18/24 documented the wound care by restating the order. There is no evidence the nurse performed the wound care as the documentation is not in past tense or clear and complete to show that the SN followed the POC. Patient 4: The SN completed supervisory visits on 7/4/24,7/18/24,8/1/24 but left the box blank where the aide's name is placed to show who was supervised. The SN documented on 7/3/24,7/10/24,7/15/24 "wound treatment done on pressure ulcer and coccyx, pt tolerated well". There is no evidence the SN followed the POC as documentation is not clear and complete. Patient 5: The SN documented wound care in the comprehensive assessment 6/25/24, 7/20/24,7/22/24, and 8/1/24 by restating the order. There is no evidence the SN completed the wound care as the documentation is not in past tense, clear, and complete. SN documented 6/25/24 "LROM" This is not an approved abbreviation. Patient 6: The SN documented wound care on 6/11/24 "SN/PCG observing aseptic technique to perform treatment for pressure ulcer right buttocks as follows" The nurse then documents the order though not in past tense, clear, and complete to indicate the treatment was actually completed. The SN documented on 2/25/24"PT" for patient this is not an approved abbreviation and "PCG" is also no approved. Patient 7: The SN documented on 8/3/24,8/6/24,8/9/24 "SN to perform treatment for pressure ulcer as follows"...The SN then documents the order though not in past tense, clear, and complete to indicate the treatment was completed. Patient 8: The SN documented on 8/1/24 and 8/5/24 "wound care done per orders". There is no evidence the SN followed the POC as documentation is not clear and complete. The SN documented on 2/25/24 "cap refill <3 s". This is not an approved abbreviation. Patient 10: The SN documented on the comprehensive assessment 6/27/24 "Consents signed by patient". There is evidenced the POA signed all consents. The SC documented on 7/27/24 "PCG" this is not an approved abbreviation. Patient 11: The SN documented on 8/4/24 "cont" and "s/s" these are not approved abbreviations. Patient 13: The SN documented on 7/28/24,8/7/24,8/8/24 "continue" and then documented the wound order. There is no evidence the wound care was completed as the documentation is not in past tense, clear, and complete. Patient 14: The SN documented on 7/6/24 "foley care done" and on 7/18/24,7/23/24,7/29/24 the SN documented "foley care done and flushed per orders". On 8/8/24 the SN documented "Foley catheter care done SN changed out per orders". There is no evidence the orders were followed as documentation is not clear and complete. The SN documented 7/15/24 "F/C" this is not an approved abbreviation. On 7/19/24 the SN documented "sn and cont". These are not approved abbreviations.

Upon client record review, 2 of 19 (Patient #15,16) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patients 15 and 16: There is no evidence a copy of the hospice discharge summary was sent to the attending physician.