Every finding on record at Pristine Hospice and Palliative Care

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan was reviewed and updated at least every two years. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Operations Plan (undated) was initiated on 3/26/24. The Emergency Management Plan showed the strategies for addressing emergency events based on the hospices risk assessments. Review of the Governing Body minutes on 1/4/23 and 1/23/24, showed the Emergency Operations Plan was reviewed and updated. However, there was no documented evidence when the plan was reviewed and updated for the years of 2022 and 2021. On 3/27/24 at 1025 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness risk assessment plan included specific information for the facility based and community-based risk assessment, creating the increased risk of not utilizing an all-hazard approach for addressing the care needs of the patients during an emergency. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 3/26/24. Review of the Hazard Vulnerability Assessment (undated) showed a list of different events such as fire, flooding, earthquake, electrical failure, and hostage situation. However, there was no documented evidence the hazard Vulnerability Assessment included a facility based and a community-based risk assessment. On 3/27/24 at 1025 hours, an interview and concurrent document review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan addressed the patient population including, but not limited to, persons at-risk. This failure created the risk not providing appropriate, consistent and quality care to the patients. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 11/16/23. The documents did not address the patient population including, but not limited to, persons at-risk. On 3/27/24 at 1025 hours, an interview and concurrent documents review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan based on the risk assessment and communication plan was reviewed and updated at least every two years. This failure created the risk of not providing the necessary care and services to the patients during an emergency. --- Findings: Review of the hospices Emergency Operations Plan was initiated on 3/26/24. The Emergency Operations Plan showed the hospice analyzed the type of emergencies most likely to occur in their geographical area. It also included the contact information of the local agencies and officials. Review of the Governing Body minutes on 1/4/23 and 1/23/24, showed the Emergency Operations Plan was reviewed and updated. However, there was no documented evidence when the communication plan was reviewed and updated in the years of 2022 or 2021. On 3/27/24 at 1025 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan maintained a communication plan that was reviewed and updated at least every two years. This failure created the risk for the patients not receiving adequate and timely assistance during an emergency crisis. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Operations Plan (undated) was initiated on 3/26/24. Review of the Governing Body minutes on 1/4/23 and 1/23/24, showed the Emergency Operations Plan was reviewed and updated. However, there was no documented evidence when the plan was reviewed and updated during the years of 2022 or 2021. On 3/27/24 at 1025 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness communication plan included the names and contact information of the patients physicians. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices Emergency Operations Plan (undated) was initiated on 3/26/24. The Operations Plan showed the contact information for the local and regional agencies. However, it did not include the names and contact information of the patients physicians. On 3/26/24 at 1025 hours, an interview and concurrent hospice document review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness plan maintained an emergency preparedness training and testing program that was reviewed and updated at least every two years. This failure created the risk of not providing the necessary care and services to the patients. --- Findings: Review of the hospices emergency preparedness P&P titled Emergency Operations Plan (undated) was initiated on 3/26/24. The Emergency Operations Plan and employee files review showed the hospice provided the initial emergency preparedness trainings and testing to the staff. Review of the hospice documents dated 4/22 and 10/20/22, 4/11 and 10/19/23, showed the hospice conducted an earthquake and fire drills. However, there was no documented evidence the emergency preparedness training and testing program was reviewed and updated at least every two years. On 3/27/24 at 1025 hours, an interview and concurrent record review was conducted with the DPCS and Administrator/MSW/Bereavement Coordinator. They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the initial training in the emergency preparedness P&P was provided for the Volunteer. In addition, the hospice failed to ensure the trainings and testing were recorded and maintained. These failures created the risk of the hospice's staff not knowing what to do in case of an emergency. --- Findings: Review of the hospices emergency preparedness program documents was initiated on 3/26/24. a. Review of the personnel file for Volunteer was initiated on 3/26/24. The Volunteers start date was 4/3/23. However, there was no documented evidence the Volunteer had an initial training in the emergency preparedness P&P. b. The Earthquake Drill Evaluation form dated 10/19/23, showed the hospice conducted an earthquake drill. However, there was no documented evidence of a staff sign-in sheet or testing of knowledge for the drill. The Fire Drill Evaluation form dated 4/11/23, showed the hospice conducted a fire drill. However, there was no documented evidence of a staff sign-in sheet or testing of knowledge for the drill. The Earthquake Drill Evaluation form dated 10/20/22, showed the hospice conducted an earthquake drill. However, there was no documented evidence of a staff sign-in sheet or testing of knowledge for the drill. The Fire Drill Evaluation form dated 4/20/22, showed the hospice conducted a fire drill. However, there was no documented evidence of a staff sign-in sheet or testing of knowledge for the drill. The hospice failed to show documented evidence of any trainings or testing for the year of 2021. On 3/27/24 at 1025 hours, an interview and concurrent record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessment was completed no later than five calendar days for one of 15 sampled patients (Patient 8), creating the risk of not identifying the care needs for this patient. --- Findings: Review of Patient 8's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 10/21/23. The patient was certified for hospice services during the certification period from 1/19/24 to 4/17/24. The initial comprehensive nursing and psychosocial assessments were conducted on 10/21 and 10/24/23, respectively. The Spiritual Assessment dated 10/25/23, showed the Chaplain reached out to the family/PCG for spiritual assessment and support. Documentation showed the PCG or the patient did not respond nor returned the call for any need of spiritual support. Documentation showed the Chaplain would offer services to the next recertification period. Documentation showed the Chaplain would make a follow-up call and would be available whenever needed in person or would be available on the phone for telehealth support. Documentation showed the IDG report would be included for the telehealth attempt calls. There was no documented evidence the Chaplain attempted to make follow-up calls to the family/PCG. Further review of the clinical record showed no documented evidence the hospice had completed the comprehensive spiritual assessment timely for the patient. On 3/27/24 at 1209 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessment had identified the spiritual needs for one of 15 sampled patients (Patient 8). This failure created the risk of not identifying the care needs for this patient. --- Findings: Review of Patient 8's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 10/21/23. The patient was certified for hospice services during the certification period from 1/19/24 to 4/17/24. Further review of the clinical record showed no documented evidence the hospice had completed the initial comprehensive spiritual assessment for the patient. On 3/27/24 at 1209 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments had identified the imminence of death for 15 of 15 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15). This failure created the risk of not appropriately addressing the patients' needs. --- 3. Review of Patient 2's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 10/29/23. The patient was certified for hospice services during the certification period from 1/27/24 to 4/25/24. Review of the initial comprehensive nursing assessment dated 10/29/23, showed no documented evidence the patients imminence of death was identified. On 3/27/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. Review of the initial comprehensive nursing assessment dated 12/5/23, showed no documented evidence the patients imminence of death was identified. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 showed no documented evidence the patients' imminence of death were assessed during the initial comprehensive assessment. For example: 1. Review of Patient 4's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. Review of the initial comprehensive nursing assessment dated 1/4/24 showed no documented evidence the patients imminence of death was identified. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 2. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification periods from 11/30/23 to 2/27/24 and 2/28/24 to 4/27/24. Review of the initial comprehensive nursing assessment dated 9/1/23 showed no documented evidence the patients imminence of death was identified. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding.

Based on observation, interview, and record review, the hospice failed to include all current medications' side effects, and actual or potential drug interaction in the comprehensive assessments and failed to ensure the medication profile was reviewed and updated to reflect the current medications and include specific indications and parameters for its use for eight of 15 sampled patients (Patients 1, 3, 5, 8, 11, 12, 13, and 15). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve these patients' health conditions. --- 6. Review of Patient 1s clinical record was initiated on 3/18/24. The clinical record showed the SOC was 3/15/24. The patient was certified for hospice services during the certification period from 3/15/24 to 6/12/24. The Current Treatment/Medication/DME List showed the patient was taking Ativan (antianxiety) 0.5 mg PO Q four hours PRN for anxiety/agitation and morphine sulfate (opioid analgesic) 0.25 ml SL Q two hours PRN for severe pain/shortness of breath. According to Lexi-Comp's pharmacology website, the US Boxed Warning for Ativan included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the patients current medication list showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence showing the IDG had assessed and identified the potential drug interactions between the medications. On 3/27/24 at 1040 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 7. Review of Patient 5's clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 1/5/24 to 3/4/24. The Current Treatment/Medication/DME List showed the patient was taking Ativan (antianxiety) 0.5 mg PO Q six hours PRN for anxiety/agitation and trazodone (antidepressant) 200 mg PO QD. According to Lexi-Comp's pharmacology website, the concomitant use of these medications may depress the function of the CNS. Effects may include, but are not limited to, ataxia (impaired coordination), confusion, drowsiness, respiratory depression, and weakness. Further review of the patients current medication list showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence showing the IDG had assessed and identified the potential drug interactions between the medications. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 8. Review of Patient 12's clinical record was initiated on 3/20/24. The closed clinical record showed the SOC was 5/18/23. The patient was certified for hospice services during the certification period from 5/18/23 to 8/15/23. The Current Treatment/Medication/DME List showed the patient was taking amlodipine (antihypertensive) 10 mg PO QD and nitroglycerin (used to treat chest pain) 0.4 mg SL PRN for angina (chest pain), heart failure, and hypertension (high blood pressure). According to Lexi-Comp's pharmacology website, the concomitant use of these medications increases the risk for hypotension. Further review of the patients current medication list showed all medications have been reviewed for effectiveness of drug therapy, drug side effects, actual or potential drug/food interactions, duplicate drug therapy and drug currently associated with laboratory monitoring. However, there was no documented evidence showing the IDG had assessed and identified the potential drug interactions between the medications.In addition, there was no specific parameter documented for when to give nitroglycerin if the patient was experiencing hypertension as indicated in the medication profile. On 3/27/24 at 1108 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 1. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. The Current Treatment/Medication List/DME List showed the patient was on Multi-Day Plus Iron multivitamin (supplement) tablet one tablet PO QD, aspirin (non-steroidal anti-inflammatory drug) 81 mg one tablet PO daily, and stool softener 100 mg one tablet PO BID. A joint home visit with HA 1 to the patient's SNF was conducted on 3/20/24 at 1110 hours. Review of the patients SNF March 2024 MAR showed the following information: - Senokot (laxative) 8.6 mg tablet PO BID, instead of stool softener 100 mg one tablet PO BID. - multivitamin with minerals (supplement) one tablet PO daily, instead of Multi-Day Plus Iron multivitamin tablet one tablet PO QD - chewable aspirin 81 mg one tablet PO daily, instead of aspirin 81 mg one tablet PO daily. In addition, the patient was on Vitamin C (supplement) 500 mg tablet PO daily, which was not included in the hospices Current Treatment/Medication List/DME List. * The hospice failed to update patients medication profile. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 8's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 10/21/23. The patient was certified for hospice services during the certification period from 1/19/24 to 4/17/24. The Current Treatment/Medication/DME List showed the patients medication included lorazepam (antianxiety) 0.5 mg one tablet PO Q four hours PRN for anxiety/agitation and morphine sulfate (opioid analgesic) 20 mg 0.25 ml SL Q two hours PRN for severe pain/SOB. According to Lexi-Comp's pharmacology website, the US Boxed Warning for lorazepam included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. * However, there was no documented evidence the IDG had identified the potential drug interactions between lorazepam and morphine sulfate. On 3/27/24 at 1209 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 11's clinical record was initiated on 3/25/24. The clinical record showed the SOC was 4/24/23. The patient was certified for hospice services during the certification periods from 12/20/23 to 2/17/24 and 2/18/24 to 4/17/24. The Current Treatment/Medication/DME List showed the patients medication included lorazepam (antianxiety) 0.5 mg PO Q four hours PRN for anxiety/agitation and Norco (opioid analgesic) 5 mg-235 mg one tablet PO once a day PRN for pain. According to Lexi-Comp's pharmacology website, the US Boxed Warning for lorazepam included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. * However, there was no documented evidence the IDG had identified the potential drug interactions between lorazepam and Norco. On 3/27/24 at 1217 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 13's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 9/15/23. The patient was certified for hospice services during the certification period from 9/15/23 to 12/13/23. The Current Treatment/Medication/DME List showed the patients medication included ibuprofen (non-steroidal anti-inflammatory drug) 800 mg one tablet TID PRN for pain. According to Lexi-Comp's pharmacology website, the US Boxed Warning for ibuprofen included NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events. * However, there was no documented evidence the IDG had identified the potential adverse effect of ibuprofen. On 3/27/24 at 1225 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 5. Review of Patient 15's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification period from 10/8/23 to 1/5/24. The Current Treatment/Medication/DME List showed the patients medication included lorazepam (antianxiety) 0.5 mg one tablet PO Q four hours PRN for anxiety/agitation and morphine sulfate (opioid analgesic) 20 mg 0.25 ml SL Q eight hours routinely and Q two hours PRN for severe pain/SOB. According to Lexi-Comp's pharmacology website, the US Boxed Warning for lorazepam included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. * However, there was no documented evidence the IDG had identified the potential drug interactions between lorazepam and morphine sulfate. On 3/27/24 at 1295 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments were completed and included the changes that had occurred since the initial assessment, information on the patients' progress, and reassessment of the patients' responses for two of 15 sampled patients (Patients 4 and 10). This failure created the risk of not addressing the care needs for these patients. --- Findings: 1. Review of Patient 4's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. The Physician Order dated 1/4/24, showed the following wound treatment orders: - for the right buttock wound: to cleanse with normal saline, pat dry, apply Medi Honey (antimicrobial gel), then cover with a foam dressing Q two to three days and PRN if soiled or dislodged; - for the right foot and right first metatarsal wound: to cleanse with normal saline, pat dry, apply A&D ointment, and leave open to air; - for the right heel wound: to cleanse with normal saline, pat dry, apply Medi Honey, then cover with a foam dressing Q two to three days and PRN if soiled or dislodged; - for the left buttock wound: to cleanse with normal saline, pat dry, apply Medi Honey, then cover with a foam dressing Q two to three days and PRN if soiled or dislodged; and - for the left heel wound: to cleanse with normal saline, pat dry, apply Medi Honey, then cover with a foam dressing Q two to three days and PRN if soiled or dislodged; Review of the RN Visit Note dated 1/8/24, showed the patients skin and wounds were assessed. The wounds were measured and treatment was completed as ordered. The POC/IDG Review dated 1/15/24, showed a care plan problem was developed for the patients integumentary/skin. However, it was not updated to include each of the patients wounds and treatments. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings. 2. Review of Patient 10's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 1/22/24. The patient was certified for hospice services during the certification period from 2/9/24 to 5/8/24. Review of the RN Visit Note dated 2/16/24, showed the patients skin was assessed. The nurse noted inflammation with abscess on the bilateral toenails. Documentation showed the office scheduled an appointment for a podiatrist visit. The POC/IDG Review dated 2/26/24, showed a care plan problem was developed for the patients integumentary/skin. However, it was not updated to include the patients issue related to the abscess on the bilateral toenails. There was also no documented evidence showing the IDG had discussed the problem. On 3/27/24 at 1104 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for two of 15 sampled patients (Patients 9 and 10). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- Findings: Review of Patient 9's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 3/28/23. The patient was certified for hospice services during the certification period from 1/22/24 to 3/21/24. The SN note dated 2/6 and 3/5/24, showed the SN inserted a new indwelling catheter aseptically. Documentation showed the new indwelling catheter was intact and draining well. Further review of the clinical record showed no documented evidence of a physicians order for the insertion of an indwelling catheter. On 3/27/24 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 10's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 1/22/24. The patient was certified for hospice services during the certification period from 2/9/24 to 5/8/24. The POC/IDG Review dated 2/12/24, cited SN visit once per week. A care plan problem for the patients respiratory system was developed. The interventions included checking the patients oxygen saturation during SN visits. Review of the RN Visit Note dated 2/21/24 showed no documented evidence the patients oxygen saturation level was assessed. On 3/27/24 at 1104 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. Findings: 1. Review of Patient 9's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 3/28/23. The patient was certified for hospice services during the certification period from 1/22/24 to 3/21/24. The SN notes dated 2/6 and 3/5/24, showed the SN inserted a new indwelling urinary catheter aseptically. Documentation showed the new indwelling urinary catheter was intact and draining well. Further review of the clinical record showed no documented evidence of a physician's order for the insertion of indwelling urinary catheter. On 3/27/24 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 10's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 1/22/24. The patient was certified for hospice services during the certification period from 2/9/24 to 5/8/24. The POC/IDG Review dated 2/12/24, cited SN visit once per week. A care plan problem for the patients respiratory system was developed. The interventions included checking the patients oxygen saturation during SN visits. Review of the RN Visit Note dated 2/21/24, showed no documented evidence the patients oxygen saturation level was assessed. On 3/27/24 at 1104 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for two of 15 sampled patients (Patients 7 and 9). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health conditions. --- 2. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 11/30/23 to 2/27/24. Review of the RN Visit Note dated 1/3/24 showed the PCG reported the patient had episodes of depression and poor appetite. The POC/IDG Review dated 1/15/24 showed the care plan problems were developed for ADLs, bereavement, environment/safety, pain, sleep, spiritual, respiratory, musculoskeletal, gastrointestinal, endocrine, and cardiovascular systems. However, there was no documented evidence showing an individualized POC was developed to address the patients episodes of depression. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. Review of Patient 9's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 3/28/23. The patient was certified for hospice services during the certification period from 1/22/24 to 3/21/24. The Recertification Assessment dated 1/16/24, showed the patient had an indwelling catheter intact and draining well. Documentation showed catheter care rendered. * However, there was no documented evidence the IDG had developed an individualized POC to address the patients use of indwelling catheter. On 3/27/24 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 14 of 15 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). This failure created the risk of not evaluating the POC and providing appropriate care and services to these patients. --- 3. Review of Patient 2's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 10/29/23. The patient was certified for hospice services during the certification period from 1/27/24 to 4/25/24. The POC/IDG Review dated 1/29, 2/12, 2/26, and 3/11/24, showed the patient's identified problems with the established goal and interventions. However, the POC failed to include measurable outcome for the patient's identified problem. For example, the goal for altered neurological status related to seizure disorder was to minimize episodes of seizure attack. There was no documented evidence to specify as to what minimize episodes of seizure attack was. On 3/27/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the finding. 4. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. The POC/IDG Review dated 2/12, 2/19, 2/26, and 3/11/24, showed the patient's identified problems with the established goal and interventions. However, the POC failed to include measurable outcome for the patient's identified problem. For example, the goal for altered cardiac status related to hyperlipidemia was to maintain optimum peripheral circulation. There was no documented evidence as to what optimum peripheral circulation was. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the finding. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 showed no documented evidence the POCs included measurable outcomes. For example: 1. Review of Patient 4's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. The POC/IDG Review dated 1/15/24 showed a care plan problem was developed for altered cardiac status related to stroke, heart attack, and other heart problems. The goal listed was for the patient to maintain optimum peripheral circulation which was not measurable. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 2. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 2/28/24 to 4/27/24. The POC/IDG Review dated 3/11/24 showed a care plan problem was developed for the musculoskeletal system. The goals listed were for the patient to perform activities as tolerated or desired and maintain or have increased strength/energy for functional activities which were not measurable. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days for eight of 15 sampled patients (Patients 2, 3, 6, 7, 9, 13, 14, and 15), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- 7. Review of Patient 14s closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 6/18/23. The patient was certified for hospice services during the certification period from 6/18/23 to 9/15/23. Review of the Physicians Order dated 6/18/23 showed the patients family declined HA visits once per week. The POC/IDG Review dated 7/3/23, 7/17/23, 7/31/23, 8/14/23, and 8/28/23 cited HA visits twice per week for personal care and to assist with ADLs. Further review of the clinical record showed no documented evidence the HA visited the patients home as cited in the POC. On 3/27/24 at 1110 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the patients family declined HA services, and the IDG did not revise the frequency of visits. 8. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification periods from 11/30/23 to 2/27/24 and 2/28/24 to 4/27/24. The Physicians Orders dated 9/6/23 cited Chaplain visit once every recertification period and PRN for spiritual needs and support, and SW once every recertification period and PRN for psychosocial needs and support. Further review of the clinical record showed the Chaplain completed a Spiritual Assessment on 11/27/23 and 2/25/24. The MSW completed the Psychosocial Assessments on 11/18/23 and 2/15/24. However, the POC/IDG Review dated 12/4/23, 12/18/23, 1/1/24, 1/15/24, 1/29/24, 2/12/24, and 3/11/34 cited MSW visit once on admission to evaluate for psychosocial and emotional support and needs within five days of admission, and Chaplain visit once on initial admission to assess for spiritual needs and concern within five days of admission. The IDG did not revise the frequency of visits to include MSW and Chaplain visits every benefit period. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee stated the staff completed recertification assessments a week prior to the new benefit period. The Administrator Designee verified the IDG should have revised the POC to reflect the frequency of visits. 1. Review of Patient 2's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 10/29/23. The patient was certified for hospice services during the certification periods from 10/29/23 to 1/26/24 and 1/27/24 to 4/25/24. The POC/IDG Review dated 1/15/24, showed the visit frequency included "MSW ";1-x1 visit on admission to evaluate for psychosocial and emotional support and needs within 5 days of admission" and Chaplain ";1-x1 visit on initial to assess for spiritual needs and concern within 5 days of admission." The Psychosocial and Spiritual Assessment dated 1/16 and 1/25/24, respectively showed the MSW and Chaplain conducted telehealth visits On 3/27/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. He stated the MSW and Chaplain visits were conducted every recertification period which was a week prior to the beginning of the new benefit period. The Administrator Designee was informed and acknowledged the findings. * The POC/IDG Review was not updated with the MSW and Chaplains visit frequency. 2. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification periods from 12/5/23 to 2/2/24 and 2/3/24 to 4/2/24. The patient was residing in a SNF. The physicians order dated 12/5/23, showed HA visit 2W for personal care and assist on ADLs. The POC/IDG review dated 2/12 and 2/26/23showed HA 1W for personal care and to assist ADLs. The HA notes showed the HA conducted visits 2W from 2/4/23 to 3/9/23. However, the POC/IDG Review was not updated with the HA frequency visit of 2W for personal care and to assist ADLs. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 6's clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/18/23. The patient was certified for hospice services during the certification periods from 12/14/23 to 2/11/24 and 2/12/24 to 4/11/24. The physicians order dated 5/18/23, showed MSW x 1 visit on admission to evaluate for psychosocial and emotional support and needs within 5 days of admission; and Chaplain x 1 visit to assess for spiritual needs and concerns within 5 days of admission. The physicians order dated 5/21/23, showed MSW and Chaplain x 1 every recertification period and PRN for spiritual/ psychosocial needs and support. The POC/IDG Review dated 1/29/24, showed the visit frequency included "MSW 1- 1 visit on admission to evaluate for psychosocial and emotional support and needs within 5 days of admission" and Chaplain ";1- x1 visit on initial to assess for spiritual needs and concern within 5 days of admission." The Psychosocial and Spiritual Assessment dated 2/8 and 2/11/24, respectively showed the MSW and Chaplain conducted home and telehealth visits However, the POC/IDG Review was not updated with the MSW and Chaplains visit frequency. On 3/27/24 at 1159 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 9's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 3/28/23. The patient was certified for hospice services during the certification period from 1/22/24 to 3/21/24. The physicians order dated 3/28/23, showed MSW x 1 every recertification period PRN for spiritual/ psychosocial needs and support. The POC/IDG Review dated 3/11/24, showed the visit frequency included "MSW 1- on admission to evaluate for psychosocial and emotional support and needs within five days of admission." The Psychosocial Assessment dated 3/14/24, showed the MSW conducted a home visit. However, the POC/IDG Review was not updated with the MSWs visit frequency. On 3/27/24 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 5. Review of Patient 13's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 9/15/23. The patient was certified for hospice services during the certification period from 9/15/23 to 12/13/23. The physicians order dated 9/20/23, showed MSW x1 every recertification period and PRN for psychosocial needs and support. The POC/IDG Review dated 12/4/23, showed the visit frequency included "MSW 1- 1x on admission to evaluate for psychosocial and emotional support and needs within five days of admission." The Psychosocial Assessment dated 12/7/23, showed the MSW conducted a visit. However, the POC/IDG Review was not updated with the MSWs visit frequency. On 3/27/24 at 1215 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 6. Review of Patient 15's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification period from 10/8/23 to 1/5/24. The physicians order dated 10/8/23, showed Chaplain "x 1 visit on initial to assess for spiritual needs and concern within five days of admission." The POC/IDG Review dated 10/8, and 10/23/23, showed Chaplain "1-1 x week for personal care and to assist with ADLs." On 3/27/24 at 1215 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. He stated the visit frequency for the Chaplain in the POC/IDG Review was not correct and should have been updated. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patients' progress toward goals specified in the POCs for 15 of 15 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15). This failure created the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. --- #. Review of Patient 2's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 10/29/23. The patient was certified for hospice services during the certification period from 1/27/24 to 4/25/24. The POC/IDG Review dated 2/12/24, showed the hospice identified patient care problems included self-care deficit; fall risk; potential for harm and increased risk related to oxygen use; patient with history of skin rashes; generalized body weakness; altered neurological status related to episode of anxiety; disturbed thought process related to disease process; altered neurological status related to seizure disorder; and altered sleep pattern related to insomnia. The goals were established for these identified problems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 3/27/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. #. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. The POC/IDG Review dated 2/26/24, showed the hospice identified patient care problems included self-care deficit; bereavement; altered cardiac status related to stroke, heart attack and other heart problems, history of hypertension, and hyperlipidemia; history of falls in the last three months; potential for harm and increased risk related to oxygen use; occasional constipation with bowel frequency of 2-3x per week; bladder incontinence; disturbed thought process related to disease process; altered neurological status related to seizure disorder; reduced portion consumption; potential for altered respiratory status related to asthma; altered sleep pattern related to insomnia; and spiritual (fear of the unknown at this time). The goals were established for these identified problems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 showed no documented evidence the revised POCs included the patients progress towards goals. For example:1. Review of Patient 4's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. The POC/IDG Review for the certification period showed the hospice identified multiple patient care problems related to ADLs, pain, environment/safety, and cardiovascular system. The goals were established for these identified problems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 2. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 2/28/24 to 4/27/24. The POC/IDG Review dated 3/11/24 showed the hospice identified multiple patient care problems related to ADLs, bereavement, cardiovascular, endocrine, and gastrointestinal systems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. The goals were established for these identified problems. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. Findings: Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 showed no documented evidence the revised POCs included the patients progress towards goals. For example: 1. Review of Patient 4's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. The POC/IDG Review for the certification period showed the hospice identified multiple patient care problems related to ADL cares, pain, environment/safety, and cardiovascular system. The goals were established for these identified problems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings. 2. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 2/28/24 to 4/27/24. The POC/IDG Review dated 3/11/24, showed the hospice identified multiple patient care problems related to ADL cares, bereavement, cardiovascular, endocrine, and gastrointestinal systems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. The goals were established for these identified problems. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings. 3. Review of Patient 2's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 10/29/23. The patient was certified for hospice services during the certification period from 1/27/24 to 4/25/24. The POC/IDG Review dated 2/12/24, showed the hospice identified patient care problems included self-care deficit; fall risk; potential for harm and increased risk related to oxygen use; patient with history of skin rashes; generalized body weakness; altered neurological status related to episode of anxiety; disturbed thought process related to disease process; altered neurological status related to seizure disorder; and altered sleep pattern related to insomnia. The goals were established for these identified problems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 3/27/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. The POC/IDG Review dated 2/26/24, showed the hospice identified patient care problems included self-care deficit; bereavement; altered cardiac status related to stroke, heart attack and other heart problems, history of hypertension, and hyperlipidemia; history of falls in the last three months; potential for harm and increased risk related to oxygen use; occasional constipation with bowel frequency of 2-3 times per week; bladder incontinence; disturbed thought process related to disease process; altered neurological status related to seizure disorder; reduced portion consumption; potential for altered respiratory status related to asthma; altered sleep pattern related to insomnia; and spiritual (fear of the unknown at this time). The goals were established for these identified problems. However, there was no documented evidence the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG had maintained the responsibility for directing, coordinating, and supervising the care and services provided for 14 of 15 sampled patients (Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15). This failure created the risk of not addressing the care needs for these patients. --- c. Review of Patient 2's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 10/29/23. The patient was certified for hospice services during the certification periods from 10/29/23 to 1/26/24 and 1/27/24 to 4/25/24. The initial Spiritual Assessment dated 10/31/23 and the Spiritual Assessment dated 1/25/24, showed the Chaplain completing telehealth visit with the patient. Documentation showed report to IDG will be given with the telehealth assessment. * However, there was no documented evidence on the reason telehealth was conducted. The initial Psychosocial Assessment dated 11/1/23, showed the MSW called the B&C, ";staff report that she can be visited at the facility will be fine but patient is unable to participate on any assessment due to her cognitive impairment." The Psychosocial Assessment dated 1/16/24, showed PCG requested telehealth visit for this patient. However, there was no documented evidence on the reason why the PCG requested for a telehealth visit. * The IDG failed to supervise the use of telehealth with the Chaplain and MSW. On 3/27/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. c. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification periods from 12/5/23 to 2/2/24 and 2/3/24 to 4/2/24. The patient was residing in a SNF. The initial Spiritual Assessment dated 12/8/23 and the Spiritual Assessment dated 2/1/24, showed the Chaplain completing telehealth visit with the patient. Documentation showed report to IDG will be given with the telehealth assessment. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. d. Review of Patient 8's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 10/21/23. The patient was certified for hospice services during the certification period from 1/19/24 to 4/17/24. The Spiritual Assessment dated 10/25/23 and 1/19/24, showed the Chaplain reached out to the family/PCG for spiritual assessment and support. Documentation showed the PCG nor the patient did not respond nor returned the call for any need of spiritual support. Documentation showed the Chaplain will offer services to the next recertification period. Documentation showed the Chaplain will make a follow-up call and will be available whenever needed in person or will be available on the phone for telehealth support. Documentation showed IDG report will be included for the telehealth attempt calls. * There was no documented evidence the Chaplain attempted to make other calls to the family/PCG. The POC/IDG Review dated 11/26/23 and 1/29/24, showed the IDG discussed about the documentation on the Spiritual Assessment dated 10/25/23 and 1/19/24. * There was no documented evidence the IDG supervised the spiritual service as there was no plan of care developed to address the patient/family/PCG not responding; and there was no documented evidence on the attempts to make other calls by the Chaplain. On 3/27/24 at 1209 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. #. Review of Patient 8's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 10/21/23. The patient was certified for hospice services during the certification period from 1/19/24 to 4/17/24. The SN note dated 1/28/24 showed the patients BP was 175/76 mm Hg. Documentation showed the case manager or the physician was updated on the patients status. However, there was no documented evidence on what the Case Manager or physicians response was. The IDG dated 1/29/24, showed a care plan problem addressing altered cardiac status related to hypertension. The goal was to maintain BP within individually acceptable range of SBP 91-159 mm Hg and DPB 61-100 mm Hg until the end of the benefit period. Documentation showed the status was controlled. However, there was no documented evidence the IDG supervised the patients BP as there was no discussion about the patients BP and the goal for the care plan problem addressing altered cardiac status related to hypertension was not met. On 3/27/24 at 1209 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 1. Review of the clinical records for Patients 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, and 15 showed no documented evidence the IDG supervised the use of telehealth with the MSW and Chaplain. For example: a. Review of Patient 4's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/23. The patient was certified for hospice services during the certification period from 1/4/23 to 4/3/23. The initial Spiritual Assessment dated 1/8/24, showed the Chaplain conducted the initial assessment via telehealth with the patients daughter. There was no documented evidence showing the reason why a telehealth visit was conducted. The IDG failed to supervise, coordinate, and ensure the Chaplain conducted the initial assessment at the patients home. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. b. Review of Patient 5's clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 1/5/24 to 3/4/24. The initial Spiritual Assessment dated 5/12/23, showed the Chaplain conducted the initial assessment via telehealth with the patients son. There was no documented evidence showing the reason why a telehealth visit was conducted. The IDG failed to supervise, coordinate, and ensure the Chaplain conducted the initial assessment at the patients home. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. #### 3. Review of Patient 10's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 1/22/24. The patient was certified for hospice services during the certification period from 2/9/24 to 5/8/24. Review of the RN Visit Note dated 2/16/24 showed the patients skin was assessed. The nurse noted inflammation with abscess on the bilateral toenails. Documentation showed the office scheduled an appointment for a podiatrist visit. Review of the RN Visit Note dated 3/6/24 showed the nurse requested a follow up regarding the podiatrist visit. The POC/IDG Reviews dated 2/26/24 and 3/11/24 showed no documented evidence the patients need for a podiatrist was discussed. Further review of the clinical record showed no documented evidence of the podiatrists assessments, visit notes, and recommendations. On 3/27/24 at 1104 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding and stated he was unable to find the podiatrists assessments and notes.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for two of 15 sampled patients (Patients 9 and 10). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- Findings: 1. Review of Patient 9's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 3/28/23. The patient was certified for hospice services during the certification period from 1/22/24 to 3/21/24. The SN notes dated 2/6 and 3/5/24, showed the SN inserted a new indwelling urinary catheter aseptically. Documentation showed the new indwelling urinary catheter was intact and draining well. Further review of the clinical record showed no documented evidence of a physician's order for the insertion of indwelling urinary catheter. On 3/27/24 at 1215 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 10's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 1/22/24. The patient was certified for hospice services during the certification period from 2/9/24 to 5/8/24. The POC/IDG Review dated 2/12/24, cited SN visit once per week. A care plan problem for the patients respiratory system was developed. The interventions included checking the patients oxygen saturation during SN visits. Review of the RN Visit Note dated 2/21/24, showed no documented evidence the patients oxygen saturation level was assessed. On 3/27/24 at 1104 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on interview and record review, the hospice failed to measure, analyze, and track quality indicators including the adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations for their QAPI program for the years of 2021 and 2022. This created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. --- Findings: The hospices P&P titled Improving Organizational Performance (undated) showed the following: - Senior Management will have the responsibility to guide the organization's effort in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan end processes the organization will utilize to assess, improve and maintain quality of care and services. - Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. - All personnel will be active participant in the organization's quality assessment and performance improvement (QAPI) activities. - The Governing Body is responsible for ensuring that the QAPI program is defined, implemented, and maintained and is evaluated annually. - Trends identified through quality assessment and performance improvement measurement and a last analysis will be reported to the governing body on a quarterly basis. 1. Review of the QAPI documents failed to show documented evidence of an ongoing quality assessment for the 4th quarter of 2021. There was no documented evidence of measuring, analyzing, and tracking of quality indicators including adverse events and infection control which would enable the hospice to assess processes of care, hospice services, and operation for the 4th quarter of 2021. 2. Review of the 2022 QAPI documents showed a QAPI Plan dated 1/7/22, which included the following indicators to be monitored for 2022: - Hospice Item Set Compliance - Pain assessment - fall - infection occurrence - unwanted hospitalization - sentinel event - admission trends - complaints - discharge trend Review of the QAPI documents for the year of 2022 showed the data collected on the above indicators. However, there was no documented evidence of data analysis of the infection control for the 3rd and 4th quarters and QAPI recommendations. There was no documented evidence of a quarterly meeting minutes for 2022. On 3/27/24 at 1245 hours, an interview and concurrent record review was conducted with the Administrator Designee. He stated the QAPI members included the Administrator, Administrator Designee, DPCS, IDG members, HR person, and Medical Director. He stated the QAPI data collection was done monthly and reported quarterly. He stated there was an annual QAPI meeting in the beginning of the year discussing the goal/target for the whole year. He stated the QAPI meeting was conducted also quarterly to discuss if the goals were met, if there were any issues to address and any performance improvement plan. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to maintain a coordinated agency-wide program for the surveillance identification, prevention, control, and investigation of infections that included a method of identifying the infections and a plan for implementing the appropriate actions that were expected to result in improvement and infection prevention. This created the risk of spread of infections. --- Findings: The hospice's P&P titled Evaluating and Maintaining Records of Infections Among Patients dated 4/2021 showed: - All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery. - The Infection Identification-Patient Report Form is completed when any of the following occur: a. A new, actual, or suspected infection is clinically observed by personnel. b. A Culture is ordered and performed, and the results are positive. c. A new antibiotic is ordered. d. A patient is admitted to a hospital due to an actual or suspected infection. e. An unanticipated death due to an actual or suspected infection. f. A major permanent loss of function associated with an actual or suspected infection g. a reportable communicable infection is identified h. Patient has temperatures greater than 101 degrees Fahrenheit i. Patient has conjunctivitis. - The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection. - Each section of the report should be completed in its entirety. - If patient was admitted to home care from a hospital and a new infection was identified by the clinician within the first 48 hours of service, the source of the suspected infection may be nosocomial. - After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up. - The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The break down and summary may include, but will not be limited to: a. Number of infection types b. Sources of infection c. Diagnoses d. Age/sex of patients e. Family/caregiver f. Pathogens, if identified g. Follow-up taken - The Performance Improvement Coordinator, in conjunction with the Clinical Supervisor, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations. - A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the Professional Advisory Committee - Information from the summary, analysis, and discussion will be used as part of the organizations risk analysis and annual evaluation of the organizations infection prevention and control activities. a. Review of the QAPI and infection control documents showed no documented evidence of the infection control data/information for the 4th quarter of 2021. b. Review of the 2nd Quarter 2022 QAPI and infection control documents showed two infection cases which were UTI (urinary tract infection). Review of the 3rd Quarter 2022 QAPI and infection control documents showed three infection cases. There was one infection case of UTI, one infection case of URI (upper respiratory infection), and one case of ear infection. However, there was no documented evidence an Infection Identification-Patient Report Form was completed as per the hospices P&P. There was no documented evidence of the summary and analysis of data, and a plan for implementing the appropriate action. There was no documented evidence the hospice had investigated to identify the cause of each type of infection to develop appropriate plans to improve and prevent infections for the infection control cases. On 3/27/24 at 1245 hours, an interview and concurrent record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to implement the bereavement program as per the hospices P&P to address the needs of the bereaved family members for two of two sampled deceased patients (Patients 14 and 15). This failure created the risk of not addressing the bereavement needs of the bereaved family members of these patients. --- 2. Review of Patient 14's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 6/18/23. The patient was certified for hospice service during the certification period from 6/18/23 to 9/15/23. The Discharge Summary dated 9/9/23, showed the patient had passed away. Review of the Bereavement Letters showed the letters were sent to the bereaved on 10/9/23, 12/9/23, and 3/9/24. Review of the Comprehensive Bereavement Assessment dated 9/27/24 showed the Chaplain reached out to the family, and the bereavement standard mailing letters will be sent out.The Bereavement POC dated 9/12/23, showed the interventions included post death sympathy card, post death bereavement assessment, provide post death bereavement mailings, and encourage/support expression of grief. However, there was no documented evidence a sympathy card was sent within two weeks of the patients death as per the hospice's P&P. On 3/27/24 at 1110 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. Findings: The hospices P&P titled Bereavement Services (undated), showed the following: - The hospice will provide an organized bereavement program supervised buy a qualified Bereavement Coordinator for up to one year following the death of the patient. - Within two weeks after the death of a patient, a sympathy card will be sent to the bereaved. 1. Review of Patient 15's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 10/8/23. The patient was certified for hospice services during the certification period from 10/8/23 to 1/5/24. The patient expired on 11/6/23. The Bereavement POC dated 11/10/23, showed the interventions included post death sympathy card, post death bereavement assessment, provide post death bereavement mailings, and encourage/support expression of grief. Further review of the clinical record showed no documented evidence a sympathy card was sent to the bereaved two weeks after the patients death as per the hospice's P&P. On 3/27/24 at 1229 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on observation, interview, and record review, the hospice failed to ensure the written patient care instructions for the HAs were developed by the RN who was responsible for the supervision of the HA for five of 15 sampled patients (Patients 3, 5, 6, 7, and 11), creating the risk of not addressing the care needs for these patients. --- Findings: 1. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. a. A joint home visit with HA 1 to the patient's SNF was conducted on 3/20/24 at 1110 hours. HA 1 transferred the patient from chair to the bed, from bed to shower chair, from shower chair to bed, and from bed to chair using a mechanical lift with the assistance of the SNFs CNA. However, there was no documented evidence on the information on how the patient will be transferred in the HA Assignment. b. The physicians order dated 12/5/23, showed mechanical soft diet. The HA Assignment dated 12/5/23 and 2/3/24, showed the diet was as tolerated, which was not consistent. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 6's clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/18/23. The patient was certified for hospice services during the certification periods from 12/14/23 to 2/11/24 and 2/12/24 to 4/11/24. The HA Assignment dated 11/30/23 and 2/8/24, showed to notify RN if blood pressure was above 160/90 or below 90/60, pulse above 100 or below 60, and respirations above 20 or below 10. However, there was no documented evidence on how the HA will obtain the information related BP, pulse, and respiration. On 3/27/24 at 1159 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 11's clinical record was initiated on 3/25/24. The clinical record showed the SOC was 4/24/23. The patient was certified for hospice services during the certification periods from 12/20/23 to 2/17/24 and 2/18/24 to 4/17/24. The HA Assignment dated 4/24/23, showed to notify RN if blood pressure was above 160/90 or below 90/60, pulse above 100 or below 60, and respirations above 20 or below 10. However, there was no documented evidence on how the HA will obtain the information related BP, pulse, and respiration. On 3/27/24 at 1217 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 5s clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 3/5/24 to 5/3/24. The HA Assignment dated 3/5/24 showed to notify RN if blood pressure was above 160/90 or below 90/60, pulse above 100 or below 60, and respirations above 20 or below 10. However, the HA Assignment did not provide instructions to check the patients vital signs every visit. There was no documented evidence showing how the HA will obtain the information related BP, pulse, and respirations. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 5. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 11/30/23 to 2/27/24. The HA Assignment dated 11/29/23 showed to notify RN if blood pressure was above 160/90 or below 90/60, pulse above 100 or below 60, and respirations above 20 or below 10. However, the HA Assignment did not provide instructions to check the patients vital signs every visit. There was no documented evidence showing how the HA will obtain the information related BP, pulse, and respirations. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. Findings: 1. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. a. A joint home visit with HA 1 to the patient's SNF was conducted on 3/20/24 at 1110 hours. HA 1 transferred the patient from the chair to bed, from the bed to shower chair, from the shower chair to bed, and from the bed to chair using a mechanical lift with the assistance of the SNFs CNA. However, there was no documented evidence on the information on how the patient would be transferred in the HA Assignment. b. The physicians order dated 12/5/23, showed an order for mechanical soft diet. The HA Assignment dated 12/5/23 and 2/3/24, showed the diet was as tolerated, which was not consistent with the physician's order. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 6's clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/18/23. The patient was certified for hospice services during the certification periods from 12/14/23 to 2/11/24, and 2/12/24 to 4/11/24. The HA Assignment dated 11/30/23 and 2/8/24, showed to notify the RN if the blood pressure was above 160/90 mmHg or below 90/60 mmHg, pulse above 100 beats per minute or below 60 beats per minute, and respirations above 20 per minute or below 10 per minute. However, there was no instructions on for the HA to obtain the BP, pulse, and respiration. On 3/27/24 at 1159 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 11's clinical record was initiated on 3/25/24. The clinical record showed the SOC was 4/24/23. The patient was certified for hospice services during the certification periods from 12/20/23 to 2/17/24, and 2/18/24 to 4/17/24. The HA Assignment dated 4/24/23, showed to notify RN if blood pressure was above 160/90 mmHg or below 90/60 mmHg, pulse above 100 beats per minute or below 60 beats per minute, and respirations above 20 per minute or below 10 per minute. However, there was no instructions for the HA to obtain the BP, pulse, and respiration. On 3/27/24 at 1217 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 5s clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 3/5/24 to 5/3/24. The HA Assignment dated 3/5/24, showed to notify RN if blood pressure was above 160/90 mmHg or below 90/60 mmHg, pulse above 100 beats per minute or below 60 beats per minute, and respirations above 20 per minute or below 10 per minute. However, the HA Assignment did not provide instructions to check the patients vital signs every visit, or how the HA would obtain the information related to the BP, pulse, and respirations. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings. 5. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 11/30/23 to 2/27/24. The HA Assignment dated 11/29/23, showed to notify RN if blood pressure was above 160/90 mmHg or below 90/60 mmHg, pulse above 100 beats per minute or below 60 beats per minute, and respirations above 20 per minute or below 10 per minute. However, the HA Assignment did not provide instructions to check the patients vital signs every visit, or how the HA would obtain the information related to the BP, pulse, and respirations. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on interview and record review, the hospice failed to ensure the HAs provided services in accordance with the POC for four of 15 sampled patients (Patients 3, 5, 7, and 11). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- 3. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. A joint home visit with HA 1 to the patient's SNF was conducted on 3/20/24 at 1110 hours. HA 1 provided shower to the patient. HA applied A&D ointment to patient's buttocks. Further review of the patients clinical record showed the HA Assignment dated 2/3/24, showed HA to provide bed bath. * However, HA 1 failed to ensure the HA assignment was followed as HA provided a shower instead of bed bath and did not include the use of A&D ointment. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 11's clinical record was initiated on 3/25/23. The clinical record showed the SOC was 4/24/23. The patient was certified for hospice services during the certification periods from 12/20/23 to 2/17/24 and 2/18/24 to 4/17/24. The POC/IDG Review dated 2/26/24, showed HA visits 2W. The HA note showed the HA conducted one visit on Week 2 (2/25/24 to 3/2/24), instead of two visit per week as cited in the POC. In addition, there was no documented evidence the HA conducted a visit on Week 3 (3/3/24 to 3/9/24), instead of two visit per week as cited in the POC. On 3/27/24 at 1217 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. Review of the hospices P&P titled Hospice Aide Services dated 2009, showed hospice aides will document care provided in accordance with the hospice aide assignment. 1. Review of Patient 5s clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 1/5/24 to 3/4/24. The POC/IDG Review dated 2/12/24, cited HA visits two times per week. Review of the HA Visit Notes showed the HA visited the patients home once on 3/2/24 for Week 9 (2/25/24 to 3/2/24). There was no documented evidence showing the HA visited another time during the week as cited in the POC. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 2. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 11/30/23 to 2/27/24. The POC/IDG Review dated 1/1/24, cited HA visits two times per week. Review of the HA Visit Notes showed the HA visited the patients home once on 1/9/24 for Week 7 (1/7/24 to 1/13/24). There was no documented evidence showing the HA visited another time during the week as cited in the POC. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding.

Based on interview and record review, the hospice failed to ensure the RN provided timely supervision to the HAs to assess the quality of care and services provided for four of 15 sampled patients (Patients 4, 5, 7, and 11). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- 4. Review of Patient 11's clinical record was initiated on 3/25/24. The clinical record showed the SOC was 4/24/23. The patient was certified for hospice services during the certification periods from 12/20/23 to 2/17/24 and 2/18/24 to 4/17/24. The clinical record for Patient 11 showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, example --. The Visit Note RN dated 3/12/24, showed the RN conducted a supervisory visit and the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 3/27/24 at 1217 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. Review of the hospices P&P titled Hospice Aide Supervisory Visits dated April 2021, showed the frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days. 1. Review of Patient 4s clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. Review of the HA Visit Notes showed the HA provided services to the patient as cited in the POC. However, the RN did not perform timely supervisions to the HAs every 14 days as per the hospices P&P. Review of the RN Visit Note dated 1/29/24 showed the RN conducted a supervisory visit for the HA. However, the next supervisory visit was conducted on 2/17/24 which was five days late. In addition, the following supervisory visit was conducted on 3/6/24 which was four days late.On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 2. Review of Patient 5s clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 1/5/24 to 3/4/24. Further review of the clinical record showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example 1. The RN Visit Note dated 3/6/24, showed the RN conducted a supervisory visit and documented the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 3. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 11/30/23 to 2/27/24. Further review of the clinical record showed the HA did not provide HA services in accordance with the POC for this patient. Cross reference L626, Example 2. The RN Visit Notes dated 1/10/24 and 1/24/24, showed the RN conducted supervisory visits and documented the HA services met the patients needs. However, the RN failed to identify the HA did not provide HA services in accordance with the POC. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding.

Based on interview and record review, the hospice's Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all the care provided as follows: - The Administrator failed to ensure the written agreements for two of nine contractors (Contractors 1 and 3) included the required elements related to bereavement follow-up, adhering to applicable policies, and procedure for charge and reimbursement as per Title 22. - The Administrator failed to ensure a health examination and TB screening was completed for LVN 1 prior to employment. These failures had the potential to negatively impact the hospice's operational performance. --- ** The hospice failed to ensure a health examination and TB screening was completed for LVN 1 prior to employment. X. According to Standards of Quality Hospice Care, 2005 under Section 6.3 A(1) and 6.3 A(2), all persons providing physician, nursing, or home health aide services shall have a health examination by a physician, nurse practitioner or physicians assistant six months prior to employment or within 14 days of the date of employment. The initial health examination shall include a tuberculosis screening. Review of the employee file for LVN 1 showed the date of hire was 9/28/23. However, there was no documented evidence a health examination was completed six months prior or within 14 days of employment. In addition, there were no documented evidence TB screening was completed. On 3/26/24 at 1400 hours, an interview and concurrent record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the finding. Review of the hospices job description titled Executive Director/Administrator (undated) showed the Executive Director/Administrator is responsible for the overall direction of the day-to-day operation of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; and is responsible for establishing standards of care to comply with federal and state regulations and guidelines. 1a. According to the Hospice Standards Article 6, Section 6.2 B Contractual Services, when program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to bereavement follow-up; responsibility of the contracted individual or organization to adhere to applicable policies, including personnel qualification; and procedure for charge and reimbursement. Review of the written agreement between the hospice and Contractor 1 providing PT, OT, ST, and RD services was initiated on 3/25/24. The written agreement with Contractor 1 did not include a statement regarding the roles and responsibilities of the contractor regarding patient bereavement follow-up. b. Review of the written agreement between the hospice and Contractor 3 providing medical equipment and supplies was initiated on 3/25/24. The written agreement with Contractor 3 did not include a statement regarding the responsibility of the contractor to adhere to applicable policies, including personnel qualification. It also did not include the procedures for charge and reimbursement. In addition, the written agreement showed another hospice agencys name. On 3/27/24 at 1118 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings. The Administrator Designee verified the hospice was currently contracted with Contractor 3, and they must have forgotten to change the hospices name on the document.

Based on interview and record review, the hospice failed to ensure the patients' clinical records were complete and accurate for two of 15 sampled patients (Patients 4 and 5). This failure created the risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete and inaccurate documentation. --- Findings: 1a. Review of Patient 4s clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. The Physicians Order dated 1/4/24 showed for the patient to be NPO. Another physicians order dated 1/4/24 showed to change the patients diet to mechanical soft. The POC/IDG Review dated 1/15/24 still showed both NPO and mechanical soft as the patients diet which was inconsistent. In addition, review of the gastrointestinal POC showed one of the interventions was to provide an enteral feeding as ordered to meet the patients nutritional needs. However, there was no documented evidence showing what type of enteral feeding the patient was receiving. b. Review of the RN Visit Note dated 1/29/24 under the narrative section, showed the patients skin was intact at the time of visit and no skin breakdown were noted. However, review of the Skin Impairment Assessment form dated 1/29/24, showed the RN had documented the patient had wounds to the right buttock, left heel, right heel, left buttock, and right foot which was inconsistent with what was written in the narrative. Documentation showed the wounds were measured and treatment was done as ordered. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings. 2. Review of Patient 5s clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 1/5/24 to 3/4/24. Review of the clinical record showed the initial Comprehensive Nursing Assessment was completed on 5/10/23. However, there was no documented evidence showing the RN assessed the patients height and weight. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on clinical record review, hospice P&P review, and interview, the hospice failed to authenticate entries made into the clinical record for nine of 15 patients (Patients 4, 5, 6, 7, 8, 9, 11, 12, and 13), creating the risk of not having a complete and accurate information. --- 6. Review of Patient 4s clinical record was initiated on 3/19/24. The clinical record showed the SOC was 1/4/24. The patient was certified for hospice services during the certification period from 1/4/24 to 4/2/24. Further review of the clinical record showed the HA visited the patients home on 3/2, 3/6, 3/9, and 3/13/24. However, there was no documented evidence showing the HA had electronically signed and/or dated the visit notes. On 3/27/24 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 7. Review of Patient 5s clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/10/23. The patient was certified for hospice services during the certification period from 1/5/24 to 3/4/24. Further review of the clinical record showed the SN visited the patients home on 1/15, 1/29, 2/12, and 2/26/24. The HA visited the patients home on 2/6, 2/8, 2/13, 2/15, 2/20, 2/22, and 3/2/24. However, there was no documented evidence showing the SN and HA had electronically signed and/or dated the visit notes. On 3/27/24 at 1055 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 8. Review of Patient 7s clinical record was initiated on 3/21/24. The clinical record showed the SOC was 9/1/23. The patient was certified for hospice services during the certification period from 11/30/23 to 2/27/24. Further review of the clinical record showed the HA visited the patients home from 12/1/23 to 1/5/24 twice a week as cited in the POC. However, there was no documented evidence showing the HA had electronically signed and/or dated the visit notes. On 3/27/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. 9. Review of Patient 12s closed clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/18/23. The patient was certified for hospice services during the certification period from 5/18/23 to 8/15/23. Further review of the clinical record showed the HA visited the patients home on 7/11, 7/18, and 7/25/23. However, there was no documented evidence showing the HA had electronically signed and/or dated the visit notes. On 3/27/24 at 1108 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding. The P&P titled Clinical/Services Data Collection dated 4/21, showed documentation in the clinical/ service record will be timely, detailed, accurate, an reflect the care or services provided. A clinical/service record will be initiated for each patient receiving care or services according to organization policies found in this manual and will include at a minimum: date, times, and types of interventions, assessments, and coordination of care/service. Entries to the clinical/service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. The clinical service note will include the date the service was provided and the signature of clinician/technician and his/her credentials. All entries will reflect the date care was provided including the month, day, and year. 1. Review of Patient 6's clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/18/23. The patient was certified for hospice services during the certification periods from 12/14/23 to 2/11/24 and 2/12/24 to 4/11/24. The SN note dated 12/5, 12/19, 1/3, 1/16, 2/13, and 2/27/24, showed the clinician electronically signed the note. However, the date was not completed. On 3/27/24 at 1159 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 8's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 10/21/23. The patient was certified for hospice services during the certification period from 1/19/24 to 4/17/24. a. The POC/IDG Review dated 2/26/24 and 3/11/24 , showed no documented evidence of the physicians electronic signature. b. The SN note dated 2/3, 2/10, 2/17, and 2/24/24, showed the clinician electronically signed the note. However, the date was not completed. On 3/27/24 at 1209 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 3. Review of Patient 9's clinical record was initiated on 3/21/24. The clinical record showed the SOC was 3/28/23. The patient was certified for hospice services during the certification period from 1/22/24 to 3/21/24. The SN note dated 1/23, 2/6, and 2/20/24, showed the clinician electronically signed the note. However, the date was not completed. On 3/27/24 at 1215 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 4. Review of Patient 11's clinical record was initiated on 3/25/24. The clinical record showed the SOC was 4/24/23. The patient was certified for hospice services during the certification periods from 12/20/23 to 2/17/24 and 2/18/24 to 4/17/24. The HA note dated 2/6, 2/15, and 3/18/24, showed the DPCS signed to close the note on behalf of the staff assigned, which was not consistent with the P&P On 3/27/24 at 1217 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. 5. Review of Patient 13's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 9/15/23. The patient was certified for hospice services during the certification period from 9/15/23 to 12/13/23. The SN note dated 9/27/23, showed the DPCS signed to close the note on behalf of the staff assigned, which was not consistent with the P&P. The SN note dated 11/9 and 12/5/23, showed the clinician electronically signed the note. However, the date was not completed. On 3/27/24 at 1225 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the discharge summaries were complete for two of two sampled discharged patients (Patients 12 and 13). This failure created the risk of not identifying the patients needs to ensure continuity of care after being discharged from the hospice services. --- 2. Review of Patient 13's closed clinical record was initiated on 3/25/24. The clinical record showed the SOC was 9/15/23. The patient was certified for hospice services during the certification period from 9/15/23 to 12/13/23. The Discharge Summary dated 12/13/23, showed hospice services were rendered. However, it was incomplete as there was no documented evidence of the extent to which goals were/ and were not met and the resolution of the identified problems as per the hospices P&P. On 3/27/24 at 1225 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the finding. Review of the hospices P&P titled Discharge Summary dated 2009, showed the hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: significant health history; discharge orders, instructions, medication profile, and allergies; the status of problems identified at admission and during the provision of care the resolution of identified problems; continuing pain and symptom management needs; the overall status of the patient at discharge; a summary of care or services provided and ongoing needs that cannot be met; and end of life decisions. 1. Review of Patient 12's closed clinical record was initiated on 3/20/24. The clinical record showed the SOC was 5/18/23. The patient was certified for hospice services during the certification period from 5/18/23 to 8/15/23. The patient was discharged on 7/28/23. Review of the closed clinical record showed a discharge summary was completed on 7/28/23. However, it was incomplete and did not include information regarding the status of problems identified; the resolution of identified problems and the extent to which goals were and/or were not met; and the overall status of the patient at discharge as per the hospices P&P. On 3/27/24 at 1108 hours, an interview and concurrent closed clinical record review was conducted with the Administrator Designee. The Administrator Designee verified the finding.

Based on interview and record review, the hospice failed to ensure the written agreements for three of three contracted SNFs (Contractors 7, 8, and 9) included a provision that the SNF would immediately notify the hospice regarding significant changes in patients' condition, plan of care, need for transfer, and patient death. This failure created the risk of not coordinating care and services timely for the patients. --- Findings: Review of the written agreements between the hospice and Contractors 7, 8, and 9 was initiated on 3/25/24. The written agreements failed to include a provision that the SNFs will immediately notify the hospice of any significant changes in a patient's physical, mental, social, or emotional status; clinical complications suggesting the need to alter the POC; need to transfer the patient; and patient death. On 3/27/24 at 1118 hours, an interview and concurrent record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on interview and record review, the hospice failed to ensure the written agreements for three of three contracted SNFs (Contractors 7, 8, and 9) included the hospices responsibility to provide services at the same level and to the same extent as those services would be provided if the patients were in their own home. This failure created the risk of not providing consistent care and services to the patients. --- Findings: Review of the written agreements between the hospice and Contractors 7, 8, and 9 was initiated on 3/25/24. The written agreements failed to include the hospices responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF patients were in their own home. On 3/27/24 at 1118 hours, an interview and concurrent record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on interview and record review, the hospice failed to ensure the written agreements for three of three contracted SNFs (Contractors 7, 8, and 9) included a provision stating the hospice must report all alleged violations to the SNF within 24 hours of becoming aware of the alleged violation. This failure created the risk for the patients to become exposed to further mistreatment. --- Findings: Review of the written agreements between the hospice and Contractors 7, 8, and 9 was initiated on 3/25/24. The written agreements failed to include a provision stating the hospice must report all the alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF Administrator within 24 hours of the hospice becoming aware of the alleged violation. On 3/27/24 at 1118 hours, an interview and concurrent record review was conducted with the Administrator Designee. The Administrator Designee verified the findings.

Based on interview and record review, the hospice failed to ensure the IDG had provided overall coordination of hospice care with the SNF for one of 15 sampled patients (Patient 3), creating the risk for not providing necessary and quality of care to this patient. --- Findings: 1. Review of Patient 3's clinical record was initiated on 3/19/24. The clinical record showed the SOC was 12/5/23. The patient was certified for hospice services during the certification period from 2/3/24 to 4/2/24. The patient was residing in a SNF. a. The POC/IDG Review dated 2/12/24, showed the patient's identified problems included self-care deficit; bereavement; altered cardiac status related to stroke, heart attack and other heart problems, history of hypertension, and hyperlipidemia; history of falls in the last three months; potential for harm and increased risk related to oxygen use; occasional constipation with bowel frequency of 2-3x per week; bladder incontinence; disturbed thought process related to disease process; altered neurological status related to seizure disorder; reduced portion consumption; potential for altered respiratory status; altered sleep pattern related to insomnia; and spiritual (fear of the unknown at this time). However, review of the SNF POC showed the patient's current identified problems included potential for pain related to hemorrhoids, s/p fall, and asthma; ";decub" risk; and at risk for dehydration, which was not consistent with the above identified problems in the hospice's POC identified by the IDG. * The IDG failed to coordinate with the SNF to consistently address the identified problems in the POC at the SNF. b. The POC Summary dated 3/11/24, showed an order date of 12/5/23, for a mechanical soft diet. Review of the March 2024 MAR showed an order date of 12/6/23, for puree NAS diet with nectar thick liquid (may deviate therapeutic diet on special occasions and/or when resident so desires). * The IDG failed to coordinate with the SNF to consistently address the patients diet. c. On 3/20/24 at 1110 hours, a joint home visit with HA 1 to the patient's SNF was conducted. On 3/20/24 at 1204 hours, an observation was conducted with HA 1 and the SNFs LVN regarding the patients right heel. The SNFs LVN stated the patients right heel had an open red skin and there was a necrotic tissue. The SNFs LVN stated the SNF's LVN showed the patients right heel to the hospice RN on 3/17/24. The SNF's LVN stated the hospice RN stated it was a Stage 1 pressure injury and the hospice RN would call the physician. The SNF's LVN stated the patient received heel protectors from the hospice on 3/18/24. The SNFs Nurses Notes dated 3/17/24 at 1030 hours, showed the patient noted with bilateral heels pinkish in color and blanchable. Documentation showed the hospice nurse was in the facility, reassessed the bilateral heels and "stated to notify the physician and will place an order for heel protector". The hospice Sign In Sheet in the SNF showed the hospice RN conducted a visit on 3/18/24. The physicians orders dated 3/18/24, showed an order for heel protector. The SN note dated 3/18/24, showed the patient did not have rash, wounds, and ulcers/bedsores. Documentation showed the skin was intact at the time of visit and no skin breakdown. Documentation showed the PCG was advised to check the patient's skin. Documentation showed the SN had educated the patient and PCG about proper skin care. * There was no documented evidence showing the reason for the heel protectors were ordered on 3/18/24. The RN who documented in the hospice Sign In Sheet in the SNF was not the same RN who documented in the SN visit note dated 3/18/24. The date when the RN visited in the Sign In Sheet and hospice note was not consistent with the SNF nurses notes. The SN note dated 3/26/24, showed the patient did not have rash, wounds, and ulcers/bedsores. Documentation showed the skin was clean, dry, and intact. Documentation showed no pressure injury was noted. Documentation showed the family/PCG was updated on the patient's condition. On 3/27/24 at 1149 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee was informed and acknowledged the findings. When asked for the reason on the inconsistency on the clinician who documented in the Sign In Sheet and the SN note dated 3/18/24. He stated he did not know.