Every finding on record at Prairie View Healthcare Inc

Based on observation, document review and interview, the hospice agency failed to ensure the organization, management, and administration of its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions for all patients.The cumulative effects of the Hospice’s failure to ensure necessary organization, management and administration of resources and services to patients, caregivers and families has the potential for provision of improper or inadequate palliative care services and/or management of terminal illnesses and related conditions. --- Findings Include:Observation on 04/22/25 at 3:00 PM showed, the hospice location was locked with no hospice personnel present. The hospice phone number posted on the signage was contacted, and an unidentified person confirmed contact would be made with the owner of the hospice.During an interview on 04/22/25 at 4:55 PM, Staff A, Administrator/Owner, confirmed the hospice had no current patients or staff. A plan to meet onsite with the survey team was established with Staff A for the following morning, 04/23/25 at 10:00 AM. Surveyors remained outside the office 2-3 hours with no staff entering the location of the hospice.Staff A arrived for the meeting at 10:42 AM and presented a document titled, "Description of Services," undated, to the survey team. The document failed to show provision of hospice care and services to patients, caregivers and families for the palliation and management of terminal illnesses and conditions.During an interview on 04/23/25 at 10:50 AM, Staff A, Administrator/Owner, confirmed the hospice was not currently operating with patients or staff; confirmed all patients had been discharged from services between December 2024-January 2025, having transferred patients to other hospices and one home health agency. During the same interview, Staff A confirmed the last date for employment for all staff was 02/07/25.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patients 1-5- There was no evidence of medication profile, only a list of medications upon admission, which was not a complete profile as it did not contain a purpose/indications for medications. The medication profile is not a part of the documented IDG/ update to the plan of care found in the patient records.

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

Upon client record review, 5 of 5 (Patient #1,2,3,4,5) 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. Patients 1,3,5 chose their PCP as attending MD on Election statement. There was no evidence found of including the individual's attending physician in the plan of care/ IDG. Administrator admits they have not been including the attending in IDG and they have not been faxing updates. No evidence of physician orders found in record. Patients 1-5 all IDG notes from December 2024 and January 2025 have section stating plan of care updated and discussed with family, left blank and patient /caregiver participation also is blank.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patients 1-5- The plan of care does not contain medications.

Upon client record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patients 1-5 all IDG notes from December 2024 and January 2025 have section stating plan of care updated and discussed with family, left blank and patient /caregiver participation also is blank.

Upon client record review, 4 of 5 (Patient #1,2,3,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. NOTE: Per Agency policy "Clinical / Service Data Collection" policy No.2-009.1: Procedure #6 "Entries into the Clinical/service record will be made on the day care/ service is provided to the patient. All documentation will be turned in to the office at the end of the workday." Patient 1 Last documented RN visit was 12/12/24 upon first review during survey. Administrator then reached out to RN whom emailed him a visit for 12/26/24 and another for 1/2/25. The date of survey was 1/16/25, the SN visit frequency is ordered as "1-4 every 15 days". Patient 2 had SN visit frequency of "1-4 every 15 days". documented visits 12/04/24, 12/10/24, 12/12/24, and 12/18/24. No further documentation of SN visits as of survey 1/16/25. Patient 3 SN visit frequency "1-4 every 15 days". Seen by RN, 11/29/24, LVN visits documented on 11/15/24, 11/20/24, 11/27/24,12/4/24, 12/09/24, 12/16/24, 12/26/24. No further SN visits documented on record on day of survey 1/16/25. Patient 5 SN visit frequency "1-4 every 15 days" last documented SN visit in record is dated 12/17/24 as of survey 1/16/25.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 3 of 5 (Patient #1,4,5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1 has documentation of aide visit frequency as "1-4 every 15 days". There are no frequencies with each task. Patient 4 has documentation of aide visit frequency as "1-3 every 15 days". There are no frequencies with each task. Patient 5 has documentation of aide visit frequency as "1-4 every 15 days". There are no frequencies with each task.

Upon patient record review 2 of 5 (Patient #1,4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1 has documentation of aide visit frequency as "1-4 every 15 days". The last documented aide visit in the record is dated 12/24/24 as of survey on 1/16/25. Per Agency policy "Clinical / Service Data Collection" policy No.2-009.1: Procedure #6 "Entries into the Clinical/service record will be made on the day care/ service is provided to the patient. All documentation will be turned in to the office at the end of the workday." Patient 4 has documentation of aide visit frequency as "1-3 every 15 days". The last documented aide visit in the record is dated 8/29/24 as of the day of survey 1/16/25. Per Agency policy "Clinical / Service Data Collection" policy No.2-009.1: Procedure #6 "Entries into the Clinical/service record will be made on the day care/ service is provided to the patient. All documentation will be turned in to the office at the end of the workday."

Upon patient record review 3 of 5 (Patient #1,4,5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1 had documented supervisory visits by the RN on 10/15/24 with the last documented RN visit 12/12/24 upon first review during survey. Administrator then reached out to RN whom emailed him a visit for 12/26/24 with supervisory visit and another for 1/2/25 with a supervisory visit. Patient 4 did not have evidence of a supervisory visit from 12/13/24 to day of survey, 1/16/25. Patient 5 has documentation of aide visit frequency as "1-4 every 15 days". The LVN documented a "Supervisory visit" for the aide on 12/17/24....there are no supervisory visits documented by the RN for the aide.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by the lack of oversight for ensuring patient visits are completed as ordered, documentation is in medical record per agency policy, supervision of aides and LVN's is being performed, physician orders are documented and signed accordingly, the patient's plan of care is complete as well as medication profiles and oversight of Administrator for management of the hospice.

Condition of Participation: Clinical Records.

Upon patient client record review, 5 of 5 (Patient #1,2,3,4,5) did not evidence that each patient record contains physician orders. Patients 1-5 only had the order for referral/ eval and treat for hospice. There was no evidence of any other physician orders. Surveyor inquired to Administrator, whom looked through the paper records/ charts, reached out to RN via phone/text. Administrator then stated, "I guess we don't have any". He further stated, "I know they call our medical director, do you want to talk to her?" Surveyor declined the offer as it would not abate this issue.

Upon patient record review, 5 of 5 (Patient # 1,2,3,4,5) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patients 1-5 showed no evidence that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient#2: Upon review the documentation indicates an RN visit on 10/9. The LPN documented visits on 10/15 and 10/21. There is no evidence of RN visit after 10/9.

Upon patient record review, 2 of 5 (Patient #4,#5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient#4,#5: No record for selected patient was provided. No evidence provided documenting aide plan of care, aide visits, or aide services provided.

Upon patient record review 2 of 5 (Patient #4,#5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#4,#5: No record for selected patient was provided. No evidence provided that documents aide services provided.

Upon patient record review 3 of 5 (Patient #2,#4,#5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient#2: Upon review the documentation indicates an RN did an aide supervisory visit on 10/9. The LPN documented an aide supervisory visit on 10/15 and 10/21. There is no evidence of RN completing an aide supervisory visit after 10/9. It has been greater than 14 days since RN supervisory visit completed. Patient#4,#5: No record for selected patient was provided. No evidence provided documenting appropriate aide supervisory visits were made.

Condition of Participation: Clinical Records.

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient#1: Hospice election signed 10/10/24 with the effective date left blank. Patient admitted 10/10/24. Corrected on site. Corrected documents obtain by team member.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Per conversation with Administrator, there have been no changes to this process since the previous survey. Records are kept at a storage facility and transported by Administrator in a plastic tote to the office as needed. Active and discharged records are kept off-site in what administrator described as a storage facility under his apartment complex. He couldn’t provide any proof that this facility was a secure facility. He transports the medical notes and medical records back and forth from his office to the storage facility in an unlocked tote.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Patient#3,#4,#5: Records for these patients were requested at 1030am. Record for Patient#3 was received at 2pm. Records for Patient #4 and #5 were not received.

Upon observation, there was no evidence the hospice complies with all applicable federal, state, and local emergency preparedness requirements by establishing and maintaining an emergency preparedness program that meets the requirements of 42 CFR 418.113.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. Most recent testing from 2021.

Upon patient record review, 4 of 14 (Patient #2, #5, #6, #9) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. #2-On consent for treatment form, certification of receipt of advance directive information section was left unmarked. #5-On consent for treatment form, certification of receipt of advance directive information section was left unmarked. #6-On consent for treatment form, certification of receipt of advance directive information section was left unmarked and no date of witness signature. #9-On consent for treatment form, certification of receipt of advance directive information section was left unmarked.

Upon patient record review 1 of 14 (Patient #8) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 #8-Hospice election signed 02/16/24 with effective date of 2/16/24. Patient admitted on 02/21/24.

Upon patient record review, 10 of 14 (Patient #1, #2, #3, 4, #5, #6, #7, #8, #9, #10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring #4-Drug profile review stated amlodipine 25 mg and atenolol 50mg, with no other information regarding drug order. #5-Drug profile review documents patient using Combivent inhaler and using albuterol with no other information or instructions. #6-No evidence of medication profile review since patient admission. As observed during home visit, patient had an order for Seroquel 50mg, take one tab in the morning and two in the evening. This medication was not on the medication list RN brought to home. #9-Patient has bottle with label for wife's Synthroid and patient states that Synthroid bottle contains his daily lisinopril. Lisinopril is not on medication list RN brought to home. Patient states he takes his oxycodone Q4 hours per prescription label. Medication on RN list reads oxycodone 30 mg po prn without frequency or indication. RN medication list has order for Vraylar 4.5 mg po daily, patient states he has not taken that medication "for a long time". Upon patient record review, patient has one medication profile from date of admission that list 5 medications with dosage, medications have no frequency or route. #10-Patient has a medication profile from date of admission listing 6 medications. Two topical medications (diclofenac and triamcinolone) are listed without directions for site of application. #1-10-Most recent medication profile reviews in patient record only include medication name and dose. Record does not contain date prescribed, route or frequency.

Upon patient record review, 10 of 14 (Patient #1-10) 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. #1-10 The plan of care does not include medications.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 3 of 14 (Patient #1, #4, #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 #1-Plan of care aide frequency is one visit every 15 days. There is no evidence of a hospice aide care plan in the patient record. #4 and #5-Plan of care aide frequency is 1-3 visits every 15 days. There is no evidence of a hospice aide care plan in the patient record.

Upon patient record review 5 of 14 (Patient #1, #4, #5, #6, #10) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group #1-Plan of care aide frequency is one visit every 15 days. There is no evidence of a hospice aide visits in the patient record. #4 and #5-Plan of care aide frequency is 1-3 visits every 15 days. There is no evidence of a hospice aide visits in the patient record. #6-Aide care plan dated 8/01 includes task of completing patient's laundry. Aide task list dated 08/13 does not include this task. #10-Aide care plan 08/15 includes task of showering patient and completing oral hygiene. Aide task list dated 08/16 checks off tub bath given and no check off for oral hygiene performed. No further comments from aide regarding why oral care task not completed.

Upon patient record review 10 of 14 (Patient #1-10) did not have evidence of documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. #1-10-No evidence of RN supervisory visits for the hospice aide.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon personnel record review, 1 of 14 (Personnel #9) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #9 is not an employee

Upon patient record review, 2 of 14 (Patient #5,6) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness

Upon patient record review, 2 of 14 (Patient #5, 6) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less.

Condition of Participation: Clinical Records.

Upon patient client record review, 7 of 14 (Patient #1, 2, 3, 4, 5, 6, 9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 #1-Hospice election signed 08/05/24 with effective date left blank. Patient admitted 08/07/24. #2-Hospice election signed 07/18/24 with effective date left blank. #3-Hospice election signed 07/18/24 with effective date left blank. Patient admitted 07/19/24. #4-Hospice election signed 03/28/24 and patient admitted 03/27/24. Choice for attending left blank. #4, #5-Election notice of non-covered items addendum requested at start of care. No evidence of addendum provided to patient/family. #6-Hospice election missing effective date. #9-Hospice election signed 05/14/24 with effective date blank.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains Advance Directives. Patients 8 was identified in RN initial assessment as DNR but did not have evidence if file.

Upon patient client record review, 2 of 14 (Patient #1, 6) 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. #1-Consent for treatment form also signed 8/5 by patient representative, with no reason given why patient unable to sign. #6-Patient Bill of rights not dated by hospice representative.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Administrator brought all agency record with him in boxes and binders.

Upon patient record review, 10 of 14 (Patient #1-10) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. #1-10 Did not contain any documented physician orders.

Based on interviews, record reviews, and agency policy review, it was determined the hospice agency failed to develop individualized plans of care that addressed the patient's goals and included interventions to guide staff in addressing problems identified during initial and subsequent assessments for 2 (Patients 4 and 6) of 6 patients reviewed. This failure had the potential to result in patients' health needs being unmet. Findings Included: --- Review of the hospice facility's undated policy titled, ";The Plan of Care," revealed, ";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 (15) days." The policy also indicated, ";The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions." Additionally, the policy revealed, ";The plan of care will identify the patients 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 patients and family/caregivers needs, goals and outcome achievement." 1. Review of Patient 4s ";Initial & Comprehensive Nursing Assessment," dated 04/13/22, showed that the agency admitted Patient 4 on 04/13/22 with a diagnosis of chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by long-term respiratory symptoms and airflow limitation). Patient 4's identified care needs were to maintain a normal blood pressure and relief of respiratory symptoms. Additionally, Patient 4 was at high risk for falls and was experiencing pain. Review of Patient 4s ";Hospice Plan of Care," dated 04/14/22, revealed the facility did not address the treatments or interventions that the agency would provide to help Patient 4 manage their blood pressure, respiratory symptoms, falls, or pain. During an interview on 10/24/22 at 9:10 AM, Registered Nurse (RN) C stated the agencys expectation was that a patients initial POC would be developed based on the patients needs identified during the initial comprehensive assessment and would include services, frequency of service visits, and treatments to be provided. During a concurrent record review and interview, conducted on 10/24/22 at 9:15 AM, RN C confirmed that Patient 4s initial POC did not contain services, supplies and equipment needed, or patient-specific interventions to meet the needs identified in Patient 4s initial comprehensive assessment. RN C acknowledged the agency was not following its policy. 2. Review of Patient 6s ";Initial & Comprehensive Nursing Assessment," dated 7/13/21, showed the agency admitted Patient 6 on 07/13/21 with a diagnosis of heart disease, a history of falls, and a recent surgical repair of the right hip. Further review showed that Patient 6s identified care needs were to receive physical therapy and occupational therapy to regain leg strength and avoid falling, to remain infection free, and for nursing services to provide wound care to Patient 6s right hip surgical wound and some small buttock wounds. Review of Patient 6s ";Hospice Plan of Care," dated 07/13/21, revealed the facility did not address the treatments or interventions that the agency would provide to help Patient 6 manage improving leg strength, fall avoidance, infection management, or wound care. During an interview on 10/24/22 at 9:10 AM, Registered Nurse (RN) C stated the agencys expectation was that a patients initial POC would be developed based on the patients needs identified during the initial comprehensive assessment and would include services, frequency of service visits, and treatments to be provided. During a concurrent record review and interview, conducted on 10/24/22 at 9:15 AM, RN C confirmed that Patient 6s initial POC did not contain services or patient-specific interventions to meet the needs identified in Patient 6s initial comprehensive assessment. RN C acknowledged the agency was not following its policy.

Based on interviews, record reviews, and agency policy review, it was determined the hospice agency failed to ensure the scope and frequency of services to be provided were included in individualized plans of care for 2 (Patients 4 and 6) of 6 patients reviewed. This failure had the potential to result in care providers not assessing or addressing patients health needs. Findings Included: --- Review of the hospice facility's undated policy titled, ";The Plan of Care," revealed, ";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 (15) days." The policy further indicated, ";It [the plan of care] must state in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs, goals and outcome achievement." 1. Review of Patient 4s ";Initial & Comprehensive Nursing Assessment," dated 04/13/22, showed the agency admitted Patient 4 on 04/13/22 with a diagnosis of chronic obstructive pulmonary disease (COPD – a progressive lung disease characterized by long-term respiratory symptoms and airflow limitation). Further review showed Patient 4's identified care needs were to maintain a normal blood pressure and relieve respiratory symptoms, and that Patient 4 had a high risk for falling and was experiencing pain. Review of Patient 4s ";Hospice Plan of Care," dated 04/14/22, revealed the facility did not address the type or frequency of visits that the agency would provide to Patient 4. During an interview on 10/24/22 at 9:10 AM, Registered Nurse (RN) C stated the agencys expectation was that a patients initial POCs and ongoing POCs would include services and the frequency of service visits to be provided. During a concurrent record review and interview, conducted on 10/24/22 at 9:15 AM, RN C confirmed that Patient 4s initial POC did not contain the services and frequency of service visits to meet Patient 4s needs identified in Patient 4s initial comprehensive assessment. RN C acknowledged the agency was not following its policy. 2. Review of Patient 6s ";Initial & Comprehensive Nursing Assessment," dated 7/13/21, showed the agency admitted Patient 6 on 07/13/21 with a diagnosis of heart disease, a history of falls, and a recent surgical repair of the right hip. Further review showed Patient 6s identified care needs were to receive physical therapy and occupational therapy to regain leg strength and avoid falling, to remain infection free, and for nursing services to provide wound care to Patient 6s right hip surgical wound and some small buttock wounds. Review of Patient 6s ";Hospice Plan of Care," dated 07/13/21, revealed the facility did not address the type or frequency of visits that the agency would provide to Patient 6. During an interview on 10/24/22 at 9:10 AM, Registered Nurse (RN) C stated the agencys expectation was that a patients initial POCs and ongoing POCs would include the services and frequency of service visits to be provided. During a concurrent record review and interview, conducted on 10/24/22 at 9:15 AM, RN C confirmed that Patient 6s initial POC did not contain services and frequency of service visits to meet Patient 6s needs identified in Patient 6s initial comprehensive assessment. RN C acknowledged the agency was not following its policy.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5 The 10/9/21 plan of care has been updated to include O2@3LPM continuous via NC however oxygen is not listed on the medication profile.

Upon patient record review, 3 of 3 applicable (Patient #2, 4, 5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2, 4, 5 The aide care plans do not contain frequencies for any of the assigned tasks.