Every finding on record at Pruitthealth Hospice Inc

Based on agency policy, clinical record review, and staff interviews, the agency failed to document patient falls in the agency’s Incident/Occurrence Report for 2 of 2 patients reporting falls (patient #1 & 3).Findings included: --- A policy, Opportunity Occurrence Program for Hospice (revised 11/22/2021), received on 02/17/2026 at 11:58 AM from the administrator stated, “Mandatory Reportable Accidents/Incidents: All falls witnessed and not witnessed by a staff member…”1. Patient #1 was admitted on 12/12/2025 with a diagnosis of Alzheimer’s disease (brain degeneration). Patient #1 was a facility resident. The plan of care for 12/12/2025-03/11/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 12 weeks, 1 time a week for 1 week, and 3 PRN (as needed). Review of the clinical record revealed that on 12/16/2025 registered nurse (RN) #3 documented a Late Entry note for 12/12/2025 stating, “Received a call from _______  [facility medication tech’s name] regarding patient having a fall after admission visit…” Review of the agency incident/occurrence report revealed that the fall was not documented.An interview conducted on 02/17/2026 at 11:38 AM 02/17 RN #3 revealed that they could not remember if they completed an incident report. Review of the agency incident/occurrence report revealed that the fall was not documented. 2. Patient #3 was admitted on 01/09/2026 with a diagnosis of Parkinson’s disease (degenerative disorder effecting the central nervous system). Patient #3 was a facility resident. The plan of care for 01/09/2026-04/08/2026 included orders for skilled nurse visits 2 times a week for 12 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 02/03/2026 RN#5 documented, “Received a call from ______ [spouse’s name] that ______ [patient’s name] had fallen…” Review of the agency incident/occurrence report revealed that the fall was not documented.During an interview conducted on 02/17/2026 at 3:06 PM RN #5 stated, “I did not [complete an incident report] ________  [software system for documentation] didn’t allow me to do it. It [incident report] should have been completed the next day” During an interview conducted on 02/17/2026 at 11:48 the administrator stated, “My expectation is that an incident report is completed.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide an after-hours skilled nurse visit after a reported fall for 1 of 2 patients with a documented fall.Findings included: --- A policy, Patient Rights and Responsibilities for Hospice (reviewed 06/07/2021), received on 02/17/2026 at 9:55 AM from the administrator stated, “Patient, Legal Representative, and Caregiver Have the Right to… Expect twenty-four-hour, seven days a week, on-call services.”Patient #1 was admitted on 12/12/2025 with a diagnosis of Alzheimer’s disease (brain degeneration). Patient #1 was a facility resident. The plan of care for 12/12/2025-03/11/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 12 weeks, 1 time a week for 1 week, and 3 PRN (as needed). Review of the clinical record revealed that on 12/16/2025 registered nurse (RN) #3 documented a Late Entry note for 12/12/2025 stating, “Received a call from_________  [facility medication tech’s name], regarding patient having a fall after admission visit…” Further review revealed that a PRN visit to assess for injuries after the fall was not documented.During an interview conducted on 02/17/2026 at 11:38 AM 02/17 RN #3 stated, “The policy states that we need to make a visit if the patient does fall.”During an interview conducted on 02/17/2026 at 3:50 PM the area vice president stated, “The Hospice nurse should have contacted the DHS [director of health services] and make a visit.”

Based on agency policy, clinical record review, and staff interviews, the agency assigned interventions in the plan of care to disciplines who were not qualified to perform them for 3 of 23 patients. (#4, 7, 22)Findings included: --- 3. Patient #4 was admitted on 09/09/2025 with a diagnosis of chronic kidney disease stage 5 (kidney failure). The plan of care for 09/09/2025 - 12/07/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 12 weeks, “patient declined volunteer services…”,  “patient declined  social work…”, and “Teach [patient nickname] regarding medications and medication management: SN, MSW [medical social worker], Volunteer, Chaplain”, “Assess for signs/symptoms of urinary tract infection: SN, MSW, Volunteer, Chaplain”, “Assess for presence of peripheral edema: SN, MSW, Volunteer, Chaplain”, “Assess [patient’s nickname] risk for developing pressure ulcers: SN, MSW, Volunteer, Chaplain”, “Assess pressure ulcer status including s/s [signs/symptoms] of healing and complications: SN, MSW, Volunteer, Chaplain”.During an interview conducted on 10/07/2025 at 11:52 AM the area vice president stated, “Chaplain’s and social workers should not be doing education on skilled nurse care” and confirmed that volunteers cannot assess or teach on skilled nursing care. A policy, Plan of Care for Hospice (revised 03/11/2022) received on 10/06/2025 at 12:57PM from the agency director stated, “Each patient and his or her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care.”1. Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN, medical social worker (MSW) visits 1 time a month for 2 months with 4 PRN (as needed), Chaplain to assess and evaluate, and “Teach tracheostomy [artificial opening in the neck for breathing] care, cleaning (site assessment/cleaning, care of inner cannula, dressings, coughing/suctioning) during each visit document education and response: SN, MSW, Chaplain.”An interview conducted on 10/07/2025 at 11:38 AM with registered nurse #10 revealed that they believe that it is appropriate for the MSW and Chaplain to provide education on tracheostomy care.2. Patient # 22 was admitted on 07/11/2025 with a diagnosis of liver cell carcinoma (liver cancer). The plan of care for 07/11/2025-07/08/2025 included orders for skilled nurse (SN) visits 2 times a week for 12 weeks with 3 PRN (as needed), medical social worker (MSW) visits 2 times a month for 2 months with 3 PRN, “patient declined Chaplain services…”, and “Teach [patient nickname] regarding the contents and use of the comfort pack including morphine [narcotic medication] for pain and shortness of breath, as well as Zofran [treats nausea] for nausea related to liver cancer.: SN, MSW, Chaplain.”During an interview conducted on 10/07/2025 at 11:52 AM the area vice president stated, “Chaplain’s and social workers should not be doing education on skilled nurse care.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to include orders for suctioning for 1 of 1 patient requiring suctioning (patient #7), a CPAP (continuous positive airway pressure machine used to keep the airway open during sleep) for 2 of 2 patients with a CPAP (patients #’s 6 &10), complete orders for urinary catheters (tube that drains urine from the bladder) for 2 of 4 patients with urinary catheters (patient #’s 3 & 18), and failed to include oxygen orders for 4 of 7 patients with oxygen (patient #s 3, 6, 8, & 23).Findings included: --- 7. Patient #12 was admitted on 6/20/2025 with a diagnosis of Malignant carcinoid tumor of the transverse colon (colon cancer). The plan of care for 9/18/25– 12/16/25 included orders for skilled nursing 2 times a week for 12 weeks, and 5 PRN (as needed) visits for symptom management and “O2 [oxygen] @2L [liters per minute] prn [as needed] for shortness of breath”.A review of the clinical record revealed that oxygen was not listed as a medication on the patient’s plan of care. On 10/9/25 at approximately 11:00 AM, the area vice president confirmed that oxygen should be on the plan of care medication list. A policy, Plan of Care for Hospice (revised 03/11/2022) received on 10:06 AM at 12:57 PM from the administrator stated, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient.”1. Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN. Review of the clinical record revealed that on 09/11/2025 registered nurse (RN) #10 documented, “Patient denies offer for suction…” Further review revealed that there was no order for suctioning in the plan of care.During an interview conducted on 10/07/2025 at 11:38 AM RN #10 stated that they did offer to suction the patient and confirmed that they did not have an order to suction.An interview conducted on 10/07/2025 at 11:40 AM with the area vice president revealed that the expectation is to have an order.2. Patient #6 was admitted on 09/02/2025 with a diagnosis of chronic obstructive pulmonary disease (lung disease restricting air flow). The plan of care for 08/22/2025-11/19/2025 included orders for skilled nurse visits 1 time a week for 11 weeks with 3 PRN (as needed). Review of the clinical record revealed that during the registered nurse (RN) visit on 09/03/2025 RN #17 documented, “SOB [shortness of breath] treatment O2 [oxygen] 2Lmin [liters per minute] NC [nasal cannula]” and on 09/29/2025 RN #17 documented, “Wears c-pap (continuous positive airway pressure machine used to keep the airway open during sleep) when sleeping.” Further review revealed that there were no orders for oxygen or a CPAP in the plan of care.3. Patient #10 was admitted on 10/02/2025 with a diagnosis of “Traum subdr hem with LOC status unknown, sequela” (head injury with internal bleeding). The plan of care for 10/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 12 weeks with 5 PRN (as needed). During the registered nurse (RN) visit on 10/02/2025 RN #18 documented, “Findings/Treatments CPAP/BiPAP [Bilevel positive airway pressure, assist with respirations while sleeping].” Further review revealed that there was no order for a CPAP/BiPAP in the plan of care.An interview conducted on 10/08/2025 at 9:52 AM with the area vice president revealed that there were no orders in the plan of care for a CPAP/BiPap and should be.4. Patient #3 was admitted on 08/28/2025 with a diagnosis of chronic systolic (congestive) heart failure (heart can not pump enough blood through the body). The plan of care for 08/28/2025-10/26/2025 included orders for skilled nurse visits 1 time a week for 1 week, 3 times a week for 8 weeks with 3 PRN (as needed), “SP cath [suprapubic catheter, tube inserted through the abdomen into the bladder] should be changed every 4-6 weeks…” and “Change foley [catheter brand] catheter as ordered: on the first of each month” and  “Oxygen.” Review of the clinical record reveal that there were no orders that included the size of the catheter or the dose of the oxygen.5. Patient #18 was admitted on 08/22/2025 with a diagnosis of Parkinson’s disease (progressive neurological disorder). The plan of care for 08/22/2025-11/18/2025 included orders for skilled nurse visits 1 time a week for 13 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 09/01/2025 registered nurse (RN) #19 documented, “Urinary catheter.” Further review revealed that were no orders for a urinary catheter.During an interview conducted on 10/08/2025 at 4:27 PM the administrator stated, “There should always be an order for a catheter if the patient has one.”6. Patient #8 was admitted on 09/03/2025 with a diagnosis of malignant neoplasm of right breast (breast cancer). The plan of care for 09/03/2025-12/01/2025 included orders for skilled nurse visits 1 time a week for 12 weeks. Review of the clinical record revealed that on 09/03/2025 registered nurse (RN) #23 documented, “Oxygen 100% at rest with oxygen.” Further review revealed that there was no order for oxygen.During an interview conducted on 10/09/2025 at 11:18 AM RN #23 stated, “She should have an order [for oxygen] … I don’t see it… it [oxygen order] would go on medications.”An interview conducted on 10/08/2025 at approximately 11:00 AM with the area vice president revealed that the expectation is for the oxygen orders to be included in the medication profile.

Based on agency policy, clinical records review, and staff interviews, the agency failed to provide services as ordered in the plan of care for 2 of 18 active patients. (patients #7 & 11)Findings included: --- 2. Patient #11 was admitted on 08/20/2025 with a diagnosis of hemiplegia (a condition that causes paralysis or weakness on one side of the body). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 13 weeks with 5 prn (as needed) visits, hospice aide 1 time a week for 1 week, 2 times a week for 13 weeks.A review of the clinical record revealed that the patient was only seen 1 time a week by the hospice aide during the week of 9/1/25 and 9/15/25 and no missed visit notes were documented.An interview conducted on 10/08/2025 at 2:48 PM with the area vice president confirmed that 2 hospice aide visits were missed. A policy, Plan of Care for Hospice (revised 03/11/2022) received on 10/06/2025 at 12:57 PM from the administrator stated, “It is the policy of [agency name] to make certain that the care and services provided to patients and their families are in accordance with an individualized, written plan of care…”Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN and “Volunteer to Assess and Evaluate.”Review of the clinical record revealed that on 09/29/2025 the volunteer coordinator documented that they were unable to contact the patient and, “volunteer declined.”An interview conducted on 10/08/2025 at 12:43 PM with the volunteer coordinator revealed that the volunteer coordinator had not spoken to the patient to offer volunteer services.During an interview conducted on 10/08/2025 at 12:50 PM the area vice president stated, “They should continue to follow-up [attempt to contact and offer services].”

Based on agency policy, direct observation, and staff interviews, the skilled nurse and chaplain failed to follow acceptable infection control practices for 2 of 6 patients receiving home visits (#12 and #15).Findings included: --- A policy, Hand Hygiene for Hospice (reviewed 8/7/2024), received from the administrator on 10/06/2025 at 1:23 PM stated, “Indications for handwashing: … before and after direct patient skin contact”. A policy, Bag Technique for Home Health and Hospice (reviewed 9/18/2025) was received from the administrator on 10/06/2025 at 1:23 PM. The policy stated, “Perform hand hygiene before accessing the bag… If additional equipment or supplies are needed from the bag during the visit, the handwashing procedure must be repeated… Rewash hands before patient contact… perform hand hygiene after equipment use…Clean equipment and allow the equipment to dry… return the equipment to the clean side of the bag.” 1. Patient #12 was admitted on 6/20/2025 with a diagnosis of Malignant carcinoid tumor of the transverse colon (colon cancer). The plan of care for 9/18/25 – 12/16/25 included orders for skilled nursing 2 times a week for 12 weeks, and 5 PRN (as needed) visits for symptom management. During a home visit at a skilled nursing facility conducted on 10/7/2025 at approximately 10:30 AM with registered nurse (RN) # 4, RN #4 washed hands with soap and water upon entering patient’s room. She removed the thermometer from the clinical bag, assessed the patient’s temperature, and placed thermometer back into the bag. RN #4 removed the stethoscope and the blood pressure cuff from clinical bag, assessed the patient’s blood pressure, and returned the stethoscope and blood pressure cuff to bag. RN #4 removed the pulse oximeter from clinical bag, assessed the oxygen saturation, then returned pulse oximeter to bag. Hand hygiene nor disinfection of the equipment occured prior to entering and reentering bag. An interview was conducted with RN #4 on 10/8/2025 at 11:51 AM. RN #4 stated “I disinfect the equipment after each patient use at least 10-15 minutes before I see the next patient…”2. Patient #15 was admitted on 6/12/2025 with a diagnosis of Alzheimer’s disease (a progressive disorder that affects memory, thinking, and behavior). The plan of care for 8/11/25 -10/09/25 included orders for Chaplain visits 1 time a month for 2 months and 3 PRN (as needed) visits.During a joint visit with Chaplain #6 on 10/7/25 at approximately 12:10 PM (patient resided in a skilled nursing facility), Chaplain #6 was observed placing his documentation device directly on the floor without any type of barrier. The chaplain used the device during the visit and did not disinfect at any time during the visit. After the visit, Chaplain #6 carried the documentation device to the facility nurse’s desk and placed it on the desk without a barrier. He then proceeded to clean only the screen of the documentation device with a disinfecting wipe. An interview was conducted on 10/9/2025 at 12:10 PM with Chaplain #6 and the area vice president. Chaplain #6 revealed that while he was trying to accommodate seating for everyone, he placed the tablet on the floor and would not normally do that.

Based on agency policy, clinical record review, and staff interviews, the agency documented licensed practical nurse (LPN) supervisory visits prior to the LPN visiting the patient for 1 of 10 patients with LPN supervisory visits. (patient #2)  Finding included: --- A policy, Clinical Records for Hospice (revised 09/18/2024) received on 10/06/2025 at 1:32 PM from the administrator stated, “It is the policy of [agency name] to establish and maintain a clinical record for every patient receiving care and services and that record is to be complete, promptly, and accurately documented…”Patient #2 was admitted on 09/06/2025 with a diagnosis of Alzheimer’s disease (progressive brain disorder). The plan of care for 09/06/2025-12/04/2025 included orders for skilled nurse visits 1 time a week for 12 weeks. Review of the clinical record revealed the following documentation:On 09/15/2025 registered nurse (RN) #24 documented, “LPN Supervisory Visit Details [LPN #24’s name] … Client Satisfied Yes.”On 09/29/2025 registered nurse #24 documented, “LPN Supervisory Visit Details [LPN #24’s name] … Client Satisfied Yes.”Further review revealed that LPN #24 had not conducted a visit for patient #2.During an interview conducted on 10/08/2025 at 1:00 PM RN #23 stated, “It is in fact not possible [to document a supervisory visit prior to the LPN seeing the patient].”

Based on agency policy, clinical record review, and staff interviews, the registered nurse failed to perform hospice aide supervisory visits every 14 days on 1 out of 15 patients with hospice aide orders. Findings included: --- A policy, Hospice Aide Assignments and Duties (reviewed 8/07/2024) was received from the administrator on 10/06/2025 at 1:26 PM. The policy stated “A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to assure that the services ordered by IDG and provided by the hospice aide are meeting the patient’s need.”Patient #1 was admitted on 8/28/2025 with a diagnosis of malignant neoplasm of unspecified bronchus or lung (lung cancer). The plan of care dated 8/28/25 – 11/25/25 included orders for skilled nursing 2 times a week for 13 weeks, and 5 PRN (as needed) visits for symptom management and hospice aide 2 times a week for 13 weeks. A review of the clinical record revealed that hospice aide supervisory visits were due by 9/15/25 and again by 9/29/25 in order to follow policy.An interview was conducted on 10/07/2025 at 9:30 AM with the area vice president, who confirmed that the hospice aide supervisory visits were not completed.

Based on agency policy, clinical record review, and staff interviews, the agency documented an advance directive as do not resuscitate for 1 of 2 patients that had requested to remain a full code. (patient #7)Findings included: --- A policy, Advanced Directives for Hospice, (09/09/2025) received on 10/06/2025 at 12:44 PM from the agency director stated, “The hospice nurse or social worker documents in the patient’s clinical record that written information was provided and whether the patient has executed an advance directive.”Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN and “Advanced Directives/Healthcare Proxy Full resuscitation.” Review of the clinical record revealed the following documentation:On 09/11/2025 RN (registered nurse) #10 documented, “Does the patient want CPR [cardiopulmonary resuscitation] if heart or lungs stop working? No… DNR [do not resuscitate] order.”For the interdisciplinary group meeting on 09/18/2025 RN #10 documented, “DNR.”On 09/17/2025 RN #9 documented, “DNR.”On 09/19/2025 RN #9 documented, “DNR.”On 09/26/2025 RN #9 documented, “DNR.”On 10/01/2025 RN #9 documented, “DNR.”On 10/03/2025 RN #9 documented, “DNR.”Further review revealed that there was no documentation of patient #7 having a DNR order.During an interview conducted on 10/07/2025 at 11:38 RN #10 stated, “We did talk about code status, he did not want chest compressions. I made team aware that he would need a golden rod [DNR form]. I put in the order for a DNR… I am not seeing the DNR order either…”During an interview conducted on 10/07/2025 at 11:55 AM RN #9 stated, “His code status is a full code. I do be forgetting that he’s a full code.”During an interview conducted on 10/07/2025 at 12:00 PM the area vice president stated, “That it [code status] should be reviewed at every visit and documented accurately.”

Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to communicate a change in condition with the provider for 1 out of 18 active patient records reviewed.Findings included: --- A policy, Coordination of Hospice Services (reviewed 8/21/2024), was received from the administrator on 10/06/2025 at 1:26 PM. The policy stated “An assigned hospice RN [registered nurse] coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities…”Patient #14, who resides at a skilled nursing facility, was admitted on 9/23/2025 with a diagnosis of Senile degeneration of brain (a progressive decline in cognitive abilities that occurs with aging). The plan of care dated 9/23/25 – 12/21/25 included orders for skilled nursing 2 times a week for 13 weeks, and 5 PRN (as needed) visits for symptom management. A review of the clinical record revealed that on 10/6/25, licensed practical nurse (LPN) #15 documented  “CNA [certified nursing assistant] reported that the patient had bright red blood in his stool….RN case manager (RN #4) was updated regarding findings…” LPN #15 documented that an attempt was made to inform the facility nurse practitioner but was unable to reach by phone. An interview was conducted on 10/08/2025 at 11:45 AM with RN #4, who confirmed that LPN #15 had notified her of the blood in the patient’s stool and she did not notify the hospice physician, facility physician, or patient’s family. An interview was conducted with LPN #15 on 10/09/25 at 10:34 AM, who confirmed that she had tried to notify the facility nurse practitioner, but was not able to reach her by phone. She passed this information on to RN #4, presuming RN #4 would notify the Hospice physician.During an interview conducted on 10/08/2025, the area vice president stated that the expectation is that the physician and family should be notified in the case of a change in patient condition.

Based on agency policy, clinical record review, and staff interviews, the agency failed to obtain consent from the patients representatives/power of attorneys prior to adding volunteer services to the plan of care for 2 of 2 patients with orders for volunteers. (patients #1 and 2)Findings Included: --- A policy Patient Rights and Responsibilities for Hospice (reviewed 06/07/2021) received on 07/08/2025 at 11:30 AM from the administrator stated, “Patient, Legal Representative, and Caregiver Have the Right to: Be fully informed of hospice services in advance so that decisions concerning your care can be made… Receive only the care and services to which you have consented.”Patient #1 was admitted on 12/03/2024 with a diagnosis of Unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for volunteer visits 1 time a month. Review of the clinical record revealed that on 12/04/2025 the volunteer coordinator documented, “I introduced myself and explained that we had some volunteers who would like to come out and see her. At first, she did not seem to understand… She said okay. Sometimes she would put her hand up in a confused gesture… At one point, she tried to point to me and communicate something but seemed to get frustrated and gave up… Frequency will be 1x [time] a month…” Volunteer visits were added to the plan of care. Further review revealed no documentation that the patient’s representative/caregiver were notified.Patient #2 was admitted on 09/25/2025 with a diagnosis of malignant neoplasm of the rectum. The plan of care for 09/25/2024-12/23/2024 included orders for volunteer visits 1 time a month beginning 09/30/2024. Review of the clinical record revealed that on 09/26/2024 the volunteer coordinator documented, “He said that if they [volunteers] want to come visit they can.” Review of the Notice of Election/Informed Consent document revealed that the patient’s son signed the consents as the legal representative because the patient was, “confused due to disease process” and could not provide consent. Further review revealed that there was no documentation of the patient’s legal representative being contacted prior to adding volunteers to the plan of care.The volunteer coordinator was not available for an interview.During an interview conducted on 07/08/25 at 10:57 AM the administrator confirmed that there was no documentation of the responsible party being notified of a volunteer being added to the plan of care and stated, “If the patient is unable to consent, they need to discuss it [changes to the plan of care] with the family member.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to develop an individualized plan of care for 1 of 3 patients with record reviews. (# 1, 2, 3).Findings included: --- A policy, Plan of Care for Hospice (reviewed 03/11/2022), received on 07/07/2025 at 3:19 PM from the administrator stated, “It is the policy of [agency name] to make certain that the care and services provided to patients and their families are in accordance with an individualized, written plan of care…”Patient #2 was admitted on 09/25/2024 with diagnoses of malignant neoplasm of the rectum (rectal cancer) and dysphagia (difficulty swallowing). The plan of care for 09/25/2024-12/23/2024 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 10 PRN (as needed). Review of the plan of care revealed that there were no interventions included related to dysphagia.      2. Patient #3 was admitted on 08/22/2024 with diagnoses of Parkinsonism (a collection of movement symptoms) and vascular dementia (confusion caused by reduced blood                flow). The plan of care for 02/18/2025-04/18/2025 included orders for skilled nurse visits 2 times a week for 8 weeks with 5 PRN and “dietary order: Regular puree.” Review              of the clinical record revealed that on 02/24/2025 RN #10 documented, “severe dysphagia.” Review of the plan of care revealed that there were no interventions included                  related to dysphagia.An interview conducted on 07/08/2025 at 9:42 AM with RN #4 revealed that a patient with dysphagia should have a disease specific plan of care.An interview on 07/08/2025 at 10:36 AM with the administrator revealed that the expectation is for the plan of care to be updated with interventions related to dysphagia should be documented on the plan of care.

Based on agency policy, clinical record review, and staff interviews, the agency failed to communicate changes of condition/symptoms between all disciplines providing care and/or services for 1 of 3 patients with record reviews (1).Findings included: --- A policy, Coordination of Hospice Services (reviewed 08/21/2024), received on 07/08/2025 at 11:43 AM from the administrator stated, “It is the policy of [agency name] Interdisciplinary Group (IDG) to make certain that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines…”Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks, with 6 PRN (as needed), Medical Social Worker (MSW) 1 times a month for 3 months with 6 PRN (as needed), and volunteer visits 1 time a month. Review of the clinical record revealed that on 12/04/2024 the volunteer coordinator documented, “Pt [patient] also seemed to have a cough.” On 12/16/2024 MSW #5 documented, “Pt [patient] was coughing and kept adjusting the pads underneath her as if she was uncomfortable. Further review revealed that there was no documentation in the clinical record of the volunteer coordinator or MSW #5 notifying the registered nurse.The volunteer coordinator was not available for an interview.MSW #5 was not available for an interview.An interview conducted on 07/08/2025 at 10:25AM with the administrator revealed that the expectation is for all agency staff to report symptoms to the registered nurse case manager.

Based on agency policy, clinical record review and staff interviews, the agency failed to obtain wound measurements for 1 of 2 patients with wounds. (#1)Findings included: --- A policy, Wound Documentation for Hospice (effective 10/01/2018), received on 07/07/2025 at 3:42 PM from the administrator stated, “All wounds will be measured weekly by the hospice nurse…”Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 6 PRN (as needed). Review of the clinical record revealed that on 12/04/2024 licensed practical nurse (LPN) #6 documented, “Diffuse stage II pressure areas [shallow open wounds] to bilateral sacrum spanning to lower buttocks…” Further review revealed that 6 of 6 SN visits had no documentation of wound measurements.LPN #6 was not available for an interview.An interview conducted on 07/07/2025 at 1:30 PM with the agency administrator confirmed that there was no evidence that the wound was ever measured. The agency administrator stated, “The registered nurse completes the wound measurements at every visit, at least once a week.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide an alternating pressure pad and pump [pressure relieving mattress] as ordered for 1 of 1 patient. (#1)Findings included: --- A policy, Durable Medical Equipment for Hospice (reviewed 07/31/2024), received on 07/08/2025 at 11:30 AM from the administrator stated, “It is the policy for [agency name] to provide for safe and effective use of medical equipment including delivery, setup, maintenance and training of staff, patients, family members and other caregivers.”Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks, with 6 PRN (as needed) and “DME: Alternating pressure pad and pump…. Start 12/04/2025.” Review of the clinical record revealed that on 12/18/2024 registered nurse (RN) #8 documented, “Son reiterated concerns about the oral care at the facility and delayed medical equipment. Son stated that hospital mattress was supposed to be delivered on 12/06 and had not yet arrived.”An interview conducted on 07/08/2025 at 10:09 AM with RN #8 confirmed that the patient did not have the mattress.An interview conducted on 07/08/2025 at approximately 10:20 AM with the administrator revealed that the mattress was ordered and it is the expectation for the nurse to confirm delivery. The administrator could not state when patient #1 received the mattress.

Based on agency policy, clinical record review, and staff interviews, the agency failed to accurately document physician’s orders for 2 of 3 patients with record reviews conducted. (patients #1, & 2)Findings included: --- A policy, Documentation requirements for Hospice (reviewed 08/07/2024) received on 07/08/2025 at 11:32 AM from the administrator stated, “Documentation must be legible, grammatically correct, accurate, and timely.”Patient #1 was admitted on 12/03/2024 with a diagnosis of Unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 6PRN (as needed) and NPO (nil per os, Latin for nothing by mouth). Patient #1 had a gastrostomy tube (surgically placed device to access the stomach]. Review of the clinical record found the following medication orders:“Acetaminophen [treats pain] 325mg oral tablet; Take 2 tab(s) orally every 4 hours as needed for mild pain”“Gabapentin [treats nerve pain] 300mg oral capsule; Take 1 cap(s) orally 2 times a day.”“Geri-tussin expectorant [treats cough] 100mg/5mL oral liquid; Take 2.5 mL orally 3 times a day”“Hyoscyamine [dries secretions] 0.125 mg oral tablet; Take 1 tablet orally every 6 hours”“Levothyroxine [treats low thyroid hormone] 50 mcg oral capsule; Take 1 cap(s) orally once a day”“Lorazepam [treats anxiety] 0.5 mg oral tablet; Take 1 tab(s) orally every 6 hours”During an interview conducted on 07/08/2025 at 9:42 AM with registered nurse (RN) #4 stated, “Normally those medications should be order by tube [gastrostomy tube; surgically placed device to access the stomach]. I guess I made a mistake and ordered them by mouth.”During an interview conducted on 07/08/2025 at 9:48 AM the administrator stated, “The orders need to be clarified with a physician and changed as needed.”     2. Patient #2 was admitted on 09/25/2025 with diagnoses of malignant neoplasm of the rectum and retention of urine. Patient #2 was a resident of a skilled nursing facility. The              plan of care for 09/25/2024-12/23/2024 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 10 PRN (as needed) and “Catheter:          Catheter care as needed. Change PRN per facility protocol for leakage, dislodgement, obstruction As Needed Indwelling urinary catheter #16F 10cc bulb.”During an interview conducted on 07/08/2025 at 9:45 AM RN #4 stated, “I know that the facility protocol is on the first on the month, I should have put that order in with a specific day to be changed.”An interview conducted on 07/08/2025 at 9:50 AM with the agency administrator revealed that the expectation is for the order to be entered with a specific frequency.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to develop an individualized plan of care for 3 of 3 patients with record reviews. (#1, 2, 3)Findings included: --- A policy, Plan of Care for Hospice (reviewed 03/11/2022), received on 07/07/2025 at 3:19 PM from the administrator stated, “It is the policy of [agency name] to make certain that the care and services provided to patients and their families are in accordance with an individualized, written plan of care…” Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 6 PRN (as needed), Aide visits 1 time a week for 1 week, 2 times a week for 12 weeks, NPO (nil per os, Latin for nothing by mouth), and “discontinue-effective 12/13/2024: NPO Puree diet with thin liquids.” A review of the clinical record revealed that on 12/12/2024 licensed practical nurse (LPN) #6 documented, “New order for pureed diet…” Further review revealed that the aide plan of care was not updated to include the new diet order.LPN #6 was not available for an interview.An interview on 07/08/2025 at 10:36 AM with the administrator revealed that the expectation is for the plan of care to be updated with a new diet order.

Based on agency policy, clinical record review, complaint log review, and staff interviews, the agency failed to document and investigate a complaint that was reported to the agency for 1 of 1 patient with a complaint. (patient #2) Findings included: --- A policy, Complaint Resolution for Hospice (reviewed 07/31/2024), received on 02/24/2025 at 5:11 PM from the agency administrator stated, ";All complaints are documented in a complaint log by the Director of Health Services or Administrator no more than 5 (five) business days from the date that the complaint was first received. Appropriate personnel conduct a documented investigation..." Patient #2 was admitted on 10/07/2024 with a diagnosis of neurocognitive disorder with Lewy bodies (condition causing changes in thinking, movement, behavior, and mood). The plan of care for 10/07/2024-01/04/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, with 13 PRN (as needed) visits. A review of the clinical record revealed that the patients daughter revoked hospice services on 02/07/2025. A review of the agencys Complaint and Grievance Record Form for Hospice revealed that no complaint was documented for patient #2. An interview conducted on 02/25/2025 at approximately 4:40 PM with the agency director revealed that the patients daughter entered the agency and spoke with the office manager. During an interview conducted on 02/25/2025 at approximately 4:45 PM the office manager stated, ";She [patients daughter] said that we [hospice agency] were trying to kill her mother. I didnt log it as a complaint because she was revoking services." During an interview conducted on 02/25/2025 at approximately 4:50 PM the agency director stated, ";We [hospice agency] should have documented a complaint, investigated, and reported it to compliance operations."

Based on agency policy, clinical record review, and staff interviews, the agency failed to manage symptoms related to the terminal diagnosis for 1 of 1 patient with unmanaged symptoms. (patients #2) Findings included: --- A policy, Patient Rights and Responsibilities for Hospice (reviewed 06/07/2021), received on 02/24/2025 at 5:11 PM from the agency director stated, ";Patient, Legal Representative, and Caregiver Have the Right to: ... Receive effective pain management and symptom control for conditions related to your terminal illness." Patient #2 was admitted on 10/07/2024 with a diagnosis of neurocognitive disorder with Lewy bodies (a condition causing changes in thinking, movement, behavior, and mood). The plan of care for 10/07/2024-01/04/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, with 13 PRN (as needed) visits. A review of the clinical record revealed the following documentation: During the registered nurse (RN) visit of 12/23/2024 RN #3 documented, ";She is no5 [sic] eating or drinking... she is throwing up what she has eaten... now she is throwing up ensure [supplement drink]." Further review revealed that there was no physicians order for medication to treat nausea or vomiting and the physician was not notified. During the RN visit of 01/03/2025 RN #5 documented, ";[Daughters name] reported watery stools for about a week..." Further review revealed that there was no physicians order for medication to treat liquid stools and the physician was not notified. During the RN visit of 01/06/2025 RN #3 documented, ";Patient rejects food most of the time but is unable to hold it down when she eats." Further review revealed that the physician was not notified. During the RN visit of 01/08/2025 RN #3 documented, ";Patients daughter says that she started throwing up what she is drinking..." Further review revealed that the physician was not notified. An interview conducted on 02/24/2025 at approximately 4:00 PM with RN #3 revealed that the physician was not notified about unmanaged vomiting. An interview conducted on 02/24/2025 at approximately 3:18 PM with RN #5 revealed that the physician was not notified about the patients unmanaged diarrhea. An interview with the agency administrator on 02/24/2025 at 3:44 PM revealed that the expectation is for all unmanaged symptoms to be treated.

Based on clinical record review and staff interviews, the agency failed to include accurate medication orders for 1 of 3 patients. (patient #2) Findings included: --- Patient #2 was admitted on 10/07/2024 with a diagnosis of neurocognitive disorder with Lewy bodies (condition causing changes in thinking, movement, behavior, and mood). The plan of care for 10/07/2024-01/04/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, with 13 PRN (as needed) visits, and an order dated 10/29/2024 for, ";Lorazepam [anxiety medication] 0.5 mg [milligrams] oral tablet; Take 0.50 milliliter(s) [measurement for liquid medications] oral every 4 to 6 hours as need for anxiety." During an interview conducted on 02/24/2025 at 3:55 PM registered nurse #3 stated, ";The 0.5 [dose] should be in milligrams." An interview conducted on 02/24/2025 at 4:15 PM with the agency administrator revealed that the expectation is for all medication doses to be documented accurately.

Based on agency policy, clinical record review and staff interviews the agency failed to update the comprehensive assessment no less than every 15 days 1 of 5 patients [#4]. The findings included: --- The policy, Interdisciplinary Group Meetings for Hospice [revised date of 11/21], was provided by the director of nursing on 2/28/23 at 1 pm. The policy stated, ";...The Interdisciplinary Group reviews each patients plan of care every two weeks, or more frequently if needed, to continually monitor the care and services provided to the patient and his or her continued eligibility for hospice care...plan of care is reviewed and updated, and changes are communicated to the patients attending physician with requests for new orders when needed..." Patient # 4 had a Start of Care date of 1/20/23 and a terminal diagnosis of Alzheimers disease. The Plan of Care [POC] for the certification period 1/20/23 to 3/20/23 included orders for Medical Social Worker [MSW] 1 time a month for 2 months; volunteer 1 time a month for 2 months. Review of the medical record revealed interdisciplinary group [IDG] meetings were conducted on 1/25/23, 2/8/23 and 2/22/23. Review of the IDG meeting minutes dated 2/8/22 included no entry from the MSW. During an interview with RN # 2 on 2/28/23 at approximately 3:45 pm, RN # 2 confirmed there was IDG entry from the MSW.

Based on agency policy review, clinical record review and staff interviews the Plan of Care [POC] failed to included all medications the patient was takings for 1 for 5 patients [#1] and the POC failed to include an order to place an indwelling catheter for 1 of 1 patient with an indwelling catheter [#2]. The findings included: --- The policy, Physician Narratives, Orders and Services for Hospice [revised 11/4/19] was provided by the director of nursing on 2/28/23 at 1 pm. The policy stated, ";...Some of the reasons orders are obtained from physicians include, but are not limited to...Care, treatment and services. Dressing changes/wound care..." Patient # 1 had a Start of Care date of 1/31/23 and terminal diagnosis of thoracic aortic aneurysm [ weakened area in the bodys main artery in the chest]. The Plan of Care [POC] for the certification period 1/31/23 to 4/30/23 included orders for Skilled nursing [SN] 1 time a week for 1 week, 3 times a week for 12 weeks; hospice aide 1 time a week for 1 week, 2 times a week for 11 weeks; Medical Social Worker [MSW] 1 time a month for 3 months; Chaplain 2 times a month for 3 months. Further review of the POC revealed no medications listed. A review of the medication profile revealed the patient was prescribed the following medications at the time of admission on 1/31/23: Aspiring 81 mg. Take 1 tablet daily. Diltiazem 120 mg [high blood pressure]. Take 1 capsule each day. Lasix 20 mg [fluid medication]. Take 1 tablet daily. Levothyroxine Sodium [thyroid] 75 mcg. Take 1 tablet each day. MiraLAX [stool softener] 17 grams. Take 1 dose each day. Montelukast Sodium [asthma] 10 mg. Take 1 tablet each day. During an interview with the director of nursing on 2/28/23 at approximately 3:30 pm, the director confirmed the POC should have included the current medications. 2. Patient # 2 had a Start of Care date of 1/21/23 and a terminal diagnosis of unspecified severe protein-calorie malnutrition. Review of the Plan of Care for the certification period 1/21/23 to 4/20/23 included orders for Skilled nursing [SN] 3 times a week for 13 weeks. Review of the clinical record revealed the RN inserted a foley catheter on 2/3/23. RN # 4 documented the following information, ";...No signs of infections so a 16 french foley was inserted..."Further review of the clinical record revealed no order for insertion of a foley catheter. An interview was conducted with the director of nursing on 2/28/23 at 3:30 pm. During the interview, the director confirmed there was no order to insert a foley catheter.

Based on agency policy, clinical record review and staff interviews the agency failed to update the plan of care with visit frequency projections for 4 of 5 records reviewed [#1, 3, 4, 5]. The findings included: --- The policy, ";Interdisciplinary Group Meetings for Hospice [revised 11/23/21], was presented by the director of nursing on 2/28/23 at approximately 1 pm. The policy stated, ";...The focus of the IDG [interdisciplinary group] meeting is reviewing the patients plan of care and revising it as needed to develop a comprehensive plan for the next 2 weeks, based on the updated comprehensive assessments." 1. Patient # 1 had a Start of Care date of 1/31/23 and terminal diagnosis of thoracic aortic aneurysm [ weakened area in the bodys main artery in the chest]. The Plan of Care [POC] for the certification period 1/31/23 to 4/30/23 included orders for Skilled nursing [SN] 1 time a week for 1 week, 3 times a week for 12 weeks; hospice aide 1 time a week for 1 week, 2 times a week for 11 weeks; Medical Social Worker [MSW] 1 time a month for 3 months; Chaplain 2 times a month for 3 months. Review of the medical record revealed the IDG [interdisciplinary group] meetings were conducted on 2/8/23 and 2/22/23. Further review of the clinical record revealed no visit projections for the next 15 days by the chaplain or the MSW during either of the IDG meetings [2/8/23 or 2/22/23]. An interview with the director of nursing on 2/28/23 at approximately 4:15 pm. During the interview, the director confirmed the POC was not updated with visit projections for the next 15 days during the 2/8/23 or 2/22/23 IDG meetings. 2. Patient # 3 had a Start of Care date of 2/9/23 and terminal diagnoses of unspecified neoplasm of skin of breast [cancer] and malignant neoplasm of upper outer quadrant of right female breast. The Plan of Care [POC] for the certification period 2/9/23 to 5/9/23 included orders for Skilled nursing [SN] 1 time a week for 13 weeks; Chaplain to assess and evaluate 2/9/23-2/13/23; Medical Social Worker [MSW] to assess and evaluate 2/9/23-2/13/23; Volunteer Coordinator to assess and evaluate 2/9/23-2/13/23. The patient refused volunteer services on 2/10/23 and the family requested the MSW not visit until 2/16/23. A supplementary order for the chaplain was written on 2/10/23 for 1 time a month. Review of the medical record revealed an IDG [interdisciplinary group] meeting was conducted on 2/16/23. Review of the IDG meeting minutes revealed no visit projections related to chaplain visits for the next 15 days. During an interview with the director of nursing on 2/28/23 at approximately 3:15 pm, the director confirmed the chaplain failed to update the POC with visit projections. 3. Patient # 4 had a Start of Care date of 1/20/23 and a terminal diagnosis of Alzheimers disease. The Plan of Care [POC] for the certification period 1/20/23 to 3/20/23 included orders for Skilled nursing [SN] 1 time a week for 1 week, 2 times a week for 8 weeks; hospice aide 5 times a week for 8 weeks; chaplain 2 times a month for 2 months; Medical Social Worker [MSW] 1 time a month for 2 months; volunteer 1 time a month for 2 months. Review of the medical record revealed interdisciplinary group [IDG] meetings were conducted on 1/25/23, 2/8/23 and 2/22/23. Review of the IDG meeting minutes dated 2/8/22 revealed no visit projections related to the chaplain or the volunteer for the next 15 days. During an interview with the director of nursing on 2/28/23 at approximately 3:45 pm, it was confirmed the POC lacked updates related to visit projections for the next 15 days from the chaplain or volunteer . 4. Patient # 5 had a Start of Care date of 1/13/23 and terminal diagnoses of malignant neoplasm of unspecified part of bronchus or lung [lung cancer], secondary malignant neoplasm of bone [bone cancer] and malignant neoplasm of brain [brain cancer]. The Plan of Care for the certification period 1/13/23 to 4/12/23 included orders for Skilled nursing [SN] 1 time a week for 1 week, 2 times a week for 13 weeks, 3 PRN [as needed] pain and symptom management; hospice aide 2 times a week for 13 weeks; Chaplain to assessment and evaluate 1/13/23-1/18/23; Medical Social Worker [MSW] to assessment and evaluate 1/13/23-18/23. The medical record included supplementary orders dated 1/19/23 for chaplain visits 2 times a month for 3 months, 1 time a month for 1 month and 3 PRN for spiritual concerns and MSW 1 time a month for 3 months and 3 PRN for social concerns. Review of the medical record revealed the interdisciplinary group [IDG] meetings were conducted on 1/18/22 and 2/1/22. The IDG group meetings [1/18/22 and 2/1/23] revealed no visit projections for the next 15 days from the chaplain or the MSW. An interview was conducted with the director of nursing on 2/28/23. During the interview, the director confirmed the POC was not updated by the chaplain or the MSW at least every 15 days.

Based on agency policy, clinical record review and staff interviews the RN failed assess/measure wounds in accordance with the agency policy for 2 of 2 patients with wounds [#1 and 2]. The findings included: --- The policy, Documentation of Skin and Wound Care [revised 3/18/21], was provided by the agency administrator on 2/28/23 at 5:25 pm. The policy stated, ";...Documentation regarding wound observations and care should be completed...On pressure ulcers, venous insufficiency/stasis ulcers, arterial ischemic ulcers, diabetic wounds and any other chronic or complex wounds weekly..." 1. Patient # 4 had a Start of Care [SOC] date of 1/20/23 and a terminal diagnosis of Alzheimers disease. The Plan of Care [POC] for the certification period 1/20/23 to 3/20/23 included orders for Skilled nursing [SN] 1 time a week for 1 week, 2 times a week for 8 weeks and ";Cleanse stage II [skin breaks open, wears away or creates an ulcer] to the sacrum [bony area at the base of the spine] with wound cleanser..."Review of the medical record revealed the stage II was identified at the SOC by the RN. The patient received SN visits on 1/23/23, 1/30/23, 2/1/23 [wound measurements 1.6 x 0.3 cm x 0.1], 2/7/23, 2/9/23, 2/14/23, 2/16/23, 2/21/23 and 2/23/23. Review of the SN visits notes from 2/14/23-2/23/23 revealed no wound measurements. During an interview with the agency administrator on 2/28/23 at approximately 4 pm, the administrator confirmed the nursing staff failed to measure the wound in accordance with the agency policy. 2. Patient # 2 had a Start of Care date of 1/21/23 and a terminal diagnosis of unspecified severe protein-calorie malnutrition. Review of the Plan of Care for the certification period 1/21/23 to 4/20/23 included orders for Skilled nursing [SN] 3 times a week for 13 weeks. Review of the clinical record revealed the RN identified skin breakdown at the time of admission. RN # 4 documented the following information, ";..._______ [patient name] has a stage 2/3 [sic] pressure ulcer on his bottom and is experiencing some pain because of it..." The clinical record revealed no treatment, no wound assessment or measurements at the time of this documentation. Patient # 2 received SN visits on 1/22/23, 1/24/23, 1/26/23, 1/31/23, 2/2/23, 2/3/23, 2/6/23, 2/9/23, 2/13/23, 2/15/23,2/20/23 and 2/24/23. Review of the clinical documentation revealed no wound assessment/treatment order or wound measurements for the skin breakdown identified on 1/21/23.

Based on agency policy, clinical record review and staff interviews, the agency failed to provide pain management for 1 of 1 patients [#13] with a PCA [patient control analgesia] pump. The findings included: --- A policy, ";Pain and symptom management for hospice", revised 11/04/19 stated, ";(agency) to make certain that patients receive effective pain management and symptom control from the hospice for the terminal illness and its related conditions." Patient #13 had a Start of Care of 10/18/22 which included diagnoses of Malignant neoplasm of appendix and colon [cancer]; plural effusion [excess fluid around the lungs]; and ascites [abnormal buildup of fluid in the abdomen]. The Plan of Care [ POC] for the certification period of 10/18/22 to 01/05/23 included orders for skilled nursing [SN] 3 times per week for 1 week; 3 times per week for 12 weeks with 3 PRN [as needed]. Assess and evaluate patients pain, CADD pump [ambulatory infusion pump], PCA [ patient control analgesic] settings and troubleshooting. An order for Hydromorphone [pain medication] infusion... 0.2 mg/ hour [milligrams] continuous with 0.6 mg every 15 minutes as needed for pain, intravenously via CADD pump [a small battery-operated pump used to deliver medications] was listed on the medication profile. Documentation of SN #3 initial assessment on 10/18/22 reported patient rated abdominal pain as sharp and an ";8 of 10" on the numerical pain scale, [pain screening tool used to assess pain severity ... 0-10 with zero meaning no pain and 10 meaning the worst pain]. SN #3 visit on 10/26/22 revealed patient #13 complained of left axilla pain [under arm] as ";8 of 10". Blood pressures were elevated - 149/100, 152/97, 152/88, 148/88 and 161/90. SN #3 reported, ";...today she did a lot of moaning and slightly touching abdomen with facial grimacing and winching and even yelling out when the pain hit ... left axilla." Documentation reveals patient stated use of the PCA ";at least 3 times within an hour" for additional breakthrough pain. SN #3 documented the physician was notified. There was no evidence of follow up. Patient reported sharp, tender abdominal pain as ";12/10" to SN #3 on 10/28/22. On 10/31/22 SN visit, documentation showed patients spouse had stopped the PCA pump for approximately 45 minutes due to condensation [water] in part of the tubing. SN#3 reported, "; patient in a great deal of pain... scored pain 12 out of 10... did a lot of moaning... anxiety is elevated to the pain... application of cool compresses applied to forehead, wrist and the top of her thighs... received two PCA boluses to help with pain control and pain score drop to 9 out of 10...receiving targeted therapy for pain Dilaudid [Hydromorphone] at 0.2 mg/ hour with 0.6 mg every 15 minutes... states uses every 15 minutes or four times in the hour..." There was no evidence SN #3 had notified the physician about patients pain crisis.

Based on policy and procedure, clinical record review and staff interview the agency failed to conduct initial bereavement assessments for 5 of 16 records reviewed (#2,1, 6, 12, and 16). Findings included: --- 2. Patient # 1 had a Start of Care date of 10/7/22 and a terminal diagnosis of Unspecified Protein-Calorie Malnutrition. Review of the Plan of Care for the Certification period 10/7/22 to 1/4/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 12 weeks, 3 PRN [as needed] pain/symptom management; hospice aide 2 times a week for 12 weeks, 1 time a week for 1 week; Chaplain to assess and evaluate; MSW [medical social worker] to assess and evaluate. A review of the clinical record revealed the RN completed the initial assessment on 10/7/22. No initial bereavement assessment was included. On 10/12/22, the MSW documented, ";Call to niece. Declines MSW visit or services..." No initial bereavement assessment was conducted. During an interview with the agency director on 11/9/22 at 1 pm, the director confirmed no initial bereavement assessment was conducted. 3. Patient # 6 had a Start of Care date of 9/21/22 and terminal diagnoses of Alzheimers Disease and Parkinsons Disease. Review of the Plan of Care for the certification period 9/21/22 to 11/19/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 3 PRN [as needed] for pain and symptom control and for MSW [medical social work] 2 times a month for 1 month, 1 time a month for 1 month, 2 PRN for emotional support. The SN completed the initial assessment visit on 9/21/22. The SN did not conduct the initial bereavement assessment during this visit. The MSW conducted the initial MSW assessment on 9/26/22. There was no bereavement assessment completed during this visit. An interview was conducted with the agency director on 11/9/22 at 9 am. During the interview, the director confirmed there was no initial bereavement assessment completed for the patient 4. Patient # 12 had a Start of Care date of 10/19/22 and a terminal diagnosis of Alzheimers Disease. A review of the Plan of Care for the certification period 10/19/22 to 1/16/23 included orders for Medical Social Worker [MSW] to assess and evaluate. On 10/25/22, a supplemental order for MSW visit frequency was written for 1 time a week for 11 weeks and 4 PRN [no reason]. The MSW conducted the initial assessment on 10/20/22 and completed the spiritual assessment. There was no evidence an initial bereavement assessment was conducted. On 11/9/22 at approximately 2:30 pm an interview was conducted with the agency director. During the interview, the director confirmed there was no evidence an initial bereavement assessment was conducted for the patient. 5. Patient # 16 had a Start of Care [SOC] date of 9/28/22 and terminal diagnoses of Protein Calorie Malnutrition and Failure to Thrive. Review of the Plan of Care for the certification period 9/28/22 to 11/26/22 included orders for Medical Social Worker [MSW] 1 week 1. A supplemental order for MSW was written on 10/3/22 with the frequency of 1 time a week for 2 months and 3 PRN [as needed] for psychosocial support. Review of the clinical record revealed the MSW completed the initial assessment on 10/3/22. Review of the MSW initial assessment revealed no evidence the initial Bereavement Assessment was conducted. An interview was conducted with the agency director on 11/9/22 at 9:30 am. During the interview, the director confirmed there was no evidence the Bereavement assessment was conducted. Review of a policy ";Bereavement Care Planning for Hospice", revised 11/29/21 was received from the director of nursing on 11/09/22 at 2:02 p.m. The policy stated," ...during the initial bereavement assessment, which as per regulations must be completed within the first 5 days of a patients care by hospice...". 1.Patient #2 was admitted on 10/08/22 with obstructive hypertrophic cardiomyopathy (heart muscle is too thick), cardiac murmur (blood flow creates abnormal heart sounds), and essential hypertension (high blood pressure). The Plan of Care for 10/08/22 -01/05/23 included orders for skilled nursing to visit 2 times a week for 13 weeks, social work to assess and evaluate and chaplain to assess and evaluate and aide 3 times a week for 13 weeks. No evidence of an initial bereavement assessment was in the record. Interview with the director of nursing on 11/9/22 at 9:52 a.m. confirmed no initial bereavement was in the record.

Based on agency policy, clinical record review and staff interviews the agency failed to update the comprehensive assessment no less than every 15 days 2 of 16 patients [#12 and 15]. The findings included: --- The policy ";Interdisciplinary group meetings for Hospice" revised 11/23/21 was provided by Director of nursing [DON] #1 on 11/7/22 at approximately 3:30 pm. The policy stated, ";the interdisciplinary group reviews each patients plan of care every two weeks, or more frequently if needed, to continually monitor the care and services provided to the patient and his or her continued eligibility for hospice care." 3-Patient #13 had a Start of Care date of 10/18/22 which included diagnoses of malignant neoplasm of appendix and colon [cancer]; pleural effusion [fluid in the lungs]; and ascites [excess fluid in abdomen]. The Plan of Care for certification period 10/18/22 through 1/15/23 included orders for skilled nursing [ 3 times per week for 1 week; 3 times per week for 12 weeks with 3 PRN [as needed]; Hospice health aide 3 times per week 13 weeks; Chaplain 1 time per week for 11 weeks with 2 PRN; MSS [medical social worker] 1 time week for 12 weeks with 4 PRN. A review of clinical record revealed there was no evidence that patient #13 was discussed in IDG [interdisciplinary group] meetings from 10/18/22 to 11/9/22. An interview with DON #1 on 11/9/22 at approximately 9:45am confirmed there was no evidence of patient #13 being discussed in IDG since the Start of Care on 10/18/22. The policy, Interdisciplinary Group Meetings for Hospice [revised date of 11/21], was provided by RN # 1 on 11/7/22 at approximately 3:30 pm. The policy stated, ";...The Interdisciplinary Group reviews each patients plan of care every two weeks, or more frequently if needed, to continually monitor the care and services provided to the patient and his or her continued eligibility for hospice care...plan of care is reviewed and updated, and changes are communicated to the patients attending physician with requests for new orders when needed..." 1. Patient # 12 had a Start of Care date of 10/19/22 and a terminal diagnosis of Alzheimers Disease. A review of the Plan of Care for the certification period 10/19/22 to 1/16/23 included orders for Skilled nurse 1 time a week for 1 week, 3 PRN [as needed] for pain and symptom management, 2 times a week for 12 weeks, 2 PRN for pain and symptom management; hospice aide 3 times a week for 12 weeks, 1 time a week for 1 week; Chaplain to assess and evaluate; Medical Social Worker [MSW] to assess and evaluate. On 10/25/22, a supplemental order for MSW visit frequency was written for 1 time a week for 11 weeks and 4 PRN [no reason]. A review of the clinical record revealed no IDT [interdisciplinary team] minutes from 10/19/22 to 11/9/22. An interview was conducted with RN # 1 on 11/9/22. During the interview the RN confirmed there was no evidence patient # 12 was discussed in IDT. 2. Patient # 15 had a Start of Care date of 9/10/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care for the certification period 9/10/22 to 12/8/22 included orders for SN [skilled nurse] to assess and evaluate; Chaplain to assess and evaluate; MSW [medical social work] to assess and evaluate. The following supplemental orders were noted: 9/10/22- SN 1 time a week for 10 weeks; 3 PRN [as needed] for symptom management; 9/10/22-hospice aide 2 times a week for 14 weeks; 9/13/22- Chaplain 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month and 3 PRN for spiritual support; 9/14/22- MSW 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month, 3 PRN for unexpected psychosocial support. Review of the clinical record revealed IDT [interdisciplinary team] meetings were conducted on 9/14/22, 9/28/22, 10/12/22. There was no evidence of the patient being discussed in IDT on 10/26/22. During an interview with RN # 1 on 11/9/22 at approximately 3 pm, she confirmed there was no evidence of the IDT meeting on 10/26/22.

Based on policy and procedure, clinical record review and staff interview the agency failed to have indications for prn (as needed) visit frequencies on the plan of care for 3 of 16 records reviewed (#7, 8, and 12), failed to include all medications on the plan of care for 1 of 16 records reviewed (#7), and failed to include oxygen on the medications on the plan of care for 1 of 16 records reviewed with oxygen dependence (#14), failed to include frequency/indication for foley catheter change for 1 of 1 charts reviewed with a foley (#1), failed to have an order for foam dressing for 1 of 4 patients with wound (#1) and failed to obtain order for nectar thickened liquids for 1 of 1 patients with a speech therapy consult (#1). Findings included: --- 2. Patient # 7 had a Start of Care date of 9/22/22 and terminal diagnoses of Unspecified Severe Protein-Calorie Malnutrition and Alzheimers Disease. Review of the Plan of Care for the certification period 9/22/22 to 12/20/22 revealed orders for Medical Social Worker [MSW] to assess and evaluate. A supplemental order for MSW visits was written on 10/3/22 for MSW 1 time a month for 3 months and 2 PRN [as needed]. Another supplemental order was written on 10/31/22 to discontinue the previous order for MSW services and effective 11/1/22 MSW to see patient 2 times a month for 2 months and 2 PRN visits. Both orders for the MSW failed to include indications for the PRN visits. An interview was conducted with the agency director on 11/9/22 at 9:15 am. During the interview, the director confirmed the orders for the MSW failed to include indications for the PRN visits. 3. Patient # 12 had a Start of Care date of 10/19/22 and a terminal diagnosis of Alzheimers Disease. A review of the Plan of Care for the certification period 10/19/22 to 1/16/23 included orders for Medical Social Worker [MSW] to assess and evaluate. On 10/25/22, a supplemental order for MSW visit frequency was written for 1 time a week for 11 weeks and 4 PRN [no reason]. There was no indication written for the PRN visits. An interview was conducted with the agency director on 11/9/22 at approximately 2:30 pm. During the interview, the director confirmed there were no indications included for the PRN visits for the MSW. 4A. Patient # 1 had a Start of Care date of 10/7/22 and a terminal diagnosis of Unspecified Protein-Calorie Malnutrition. Review of the Plan of Care [POC] for the Certification period 10/7/22 to 1/4/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 12 weeks, 3 PRN [as needed] pain/symptom management. Review of the ";Intervention" section of the POC included ";Change foley [indwelling urinary catheter] as ordered". There was no frequency or catheter size included with the intervention. During an interview with RN # 1 on 11/9/22 at 1:30 pm, RN # 1 confirmed the order/intervention related to the indwelling catheter was incomplete. 4B. Patient # 1 had a Start of Care date of 10/7/22 and a terminal diagnosis of Unspecified Protein-Calorie Malnutrition. Review of the Plan of Care [POC] for the Certification period 10/7/22 to 1/4/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 12 weeks, 3 PRN [as needed] pain/symptom management. Review of the clinical record revealed LPN # 11 made a routine visit on 10/13/22. Review of the visit note dated 10/13/22 revealed the following information, ";...Foam dressing to sacrum [triangle bone at the base of the spine] and upper back x 2..." Further review of the clinical record revealed no order for the foam dressing. During an interview with RN # 1 on 11/9/22 at 1 pm, RN # 1 stated, ";I am sure she didnt think an order would be required for a foam dressing if it was preventative." 4C. Patient # 1 had a Start of Care date of 10/7/22 and a terminal diagnosis of Unspecified Protein-Calorie Malnutrition. Review of the Plan of Care [POC] for the Certification period 10/7/22 to 1/4/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 12 weeks, 3 PRN [as needed] pain/symptom management. Review of the clinical record revealed RN # 12 made a routine visit on 10/22/22 and documented, ";...diet is puree with nectar thickening [sic] due to Dysphagia [difficulty in swallowing] ..." Further review of the clinical record revealed no order for nectar thickened liquids. An interview was conducted with RN # 1 on 11/9/22 at 1 pm. During the interview, the RN confirmed there was not order for the nectar thickened liquids. Review of a policy ";Plan of Care for Hospice", revised 03/11/22 was received from the director of nursing on 11/09/22 at 2:38 p.m. The policy stated," ...the plan of care includes, but is not limited to interventions to manage pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the plan of care, drugs and treatments, medical supplies, equipment, and appliances...". 1a. Patient #7 was admitted on 10/24/22 with unspecified protein calorie malnutrition, essential hypertension, vitamin B12 deficiency, and vitamin D deficiency. The Plan of Care for 10/24/22 -01/24/22 included orders for skilled nursing to visit 2 times a week for 13 weeks, aide 2 time a wee for 1 week, and 3 times a week for 12 weeks, chaplin to assess and evaluate and medical social work to assess and evaluate. Review of the plan of care revealed the nursing frequency was 2 times a week for 13 weeks with 4 prn (as needed) visits. The indication was not included on the plan of care for the prn visits. Interview with the director of nursing on 11/9/22 at 9:10 a.m. confirmed as needed reasons should be listed on the plan of care, and the plan of care should be individualized. 1b. Patient #7 was admitted on 10/24/22 with unspecified protein calorie malnutrition, essential hypertension, vitamin B12 deficiency, and vitamin D deficiency. The Plan of Care for 10/24/22 -01/24/22 included orders for skilled nursing to visit 2 times a week for 13 weeks, aide 2 time a wee for 1 week, and 3 times a week for 12 weeks, chaplin to assess and evaluate and medical social work to assess and evaluate. Review of the plan of care revealed the medications were blank. Interview with the director of nursing on 11/9/22 at 9:10 a.m. confirmed as needed reasons should be listed on the plan of care, and the plan of care should be individualized. 1c. Patient #14 was admitted on 10/22/22 with chronic obstructive pulmonary disease (lung disease). The Plan of Care for 10/22/22 to 01/19/2023 included orders for skilled nursing to assess and evaluate, medical social work to assess and evaluate and the chaplin to assess and evaluate. Review of the skilled nurse start of care visit on 10/22/22 revealed the patient was on 2 liters of oxygen per nasal cannula continuously but was not listed on the medications of the plan of care. Oxygen was listed as a safety precaution on the plan of care. Interview with the director of nursing on 11/9/22 at 9:10 a.m. confirmed as needed reasons should be listed on the plan of care, and the plan of care should be individualized.

Based on policy and procedure, clinical record review and staff interview the agency failed to have visit frequency projections for the chaplin IDG (interdisciplinary group) for 10 of 16 records reviewed (#2,7,10,14,1,6, 8, 11, 15, and 16) and frequency projections for the social work IDG for 10 of 16 records reviewed (#2,7,10,14,1, 6, 8, 11, 15, and 16). Findings included: --- 5. Patient # 1 had a Start of Care date of 10/7/22 and a terminal diagnosis of Unspecified Protein-Calorie Malnutrition. Review of the Plan of Care for the Certification period 10/7/22 to 1/4/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 12 weeks, 3 PRN [as needed] pain/symptom management; hospice aide 2 times a week for 12 weeks, 1 time a week for 1 week; Chaplain to assess and evaluate; MSW [medical social worker] to assess and evaluate. On 10/12/22, the patient/caregiver declined MSW services. A supplemental order was written on 10/14/22 for chaplain orders 1 time a month for 1 month. Review of the clinical record revealed IDT [interdisciplinary team] meetings were conducted on 10/12/22 and 10/26/22. Review of the IDT minutes revealed no update to the individualized plan of care related to visit frequencies by the chaplain. On 11/9/22 at 9:30 am an interview was conducted with the agency director. During the interview, the director confirmed no update to the individualized plan of care related to chaplain visit frequencies was included. 6. Patient # 6 had a Start of Care [SOC] date of 9/21/22 and terminal diagnoses of Alzheimers Disease and Parkinsons Disease. Review of the Plan of Care for the certification period 9/21/22 to 11/19/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 3 PRN [as needed] for pain and symptom control; hospice aide 2 times a week for 8 weeks; MSW [medical social work] 2 times a month for 1 month, 1 time a month for 1 month, 2 PRN for emotional support. Review of the clinical record revealed IDT [interdisciplinary team] meetings were conducted on 9/28/22, 10/12/22 and 10/26/22. Review of the 3 IDT minutes revealed no update to the individualized plan of care related to MSW visit frequencies. An interview was conducted with the agency director on 11/9/22 at 9 am. During the meeting, the director confirmed no update to the MSW plan of care related to visit frequencies were noted. 7. Patient # 8 had a Start of Care date of 9/22/22 and terminal diagnoses of Unspecified Severe Protein-Calorie Malnutrition and Alzheimers Disease. Review of the Plan of Care for the certification period 9/22/22 to 12/20/22 included orders for SN [skilled nursing] to assess and evaluate; Chaplain to assess and evaluate; Medical Social Worker [MSW] to assess and evaluate. A supplemental order was written on 9/22/22 for SN visits 2 times per week for 13 weeks and hospice aide 2 times a week for 12 weeks. Supplemental orders for the chaplain and MSW were written on 10/3/22. MSW 1 time a month for 3 months and 3 PRN [as needed] [no reason for PRN] and chaplain 2 times a month for 3 months and 2 PRN visits for spiritual support. Review of the clinical record revealed IDT [interdisciplinary team] meetings were conducted on 9/28/22, 10/12/22 and 10/26/22. Further review of the clinical record revealed no update to the individualized plan of care related to visit frequencies for the chaplain or MSW. An interview was conducted with the agency director on 11/9/22 at 9:30 am. During the meeting, the director confirmed there were no visit projections for the next 15 days related to chaplain or MSW services. 8. Patient # 11 had a Start of Care date of 10/15/22 with a terminal diagnosis of Malignant Neoplasm of Frontal Lobe [brain cancer]. Review of the Plan of Care for the certification period 10/15/22 to 1/12/23 included orders for SN [skilled nursing] 3 times a week for 13 weeks, 3 PRN [as needed] for pain/symptom management; hospice aide 5 times a week for 12 weeks, 4 times a week for 1 week; Chaplain to assess and evaluate; Medical Social worker to assess and evaluate. The following supplemental orders were written on 10/19/22: Chaplain-patient/caregiver declined chaplain services at this time and MSW 1 time a month for 2 months. Review of the clinical record revealed IDT [interdisciplinary] minutes for the IDT meeting on 10/19/22. Review of the IDT minutes revealed no update to the individualized plan of care related to visit projections for the MSW. During an interview with the agency director on 11/9/22 at 9 am, the director confirmed there were no visit projections related to the MSW. 9. Patient # 15 had a Start of Care date of 9/10/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care for the certification period 9/10/22 to 12/8/22 included orders for SN [skilled nurse] to assess and evaluate; Chaplain to assess and evaluate; MSW [medical social work] to assess and evaluate. The following supplemental orders were noted: 9/10/22- SN 1 time a week for 10 weeks; 3 PRN [as needed] for symptom management; 9/10/22-hospice aide 2 times a week for 14 weeks; 9/13/22- Chaplain 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month and 3 PRN for spiritual support; 9/14/22- MSW 1 time a month for 1 month, 2 times a month for 2 months, 1 time a month for 1 month, 3 PRN for unexpected psychosocial support. Review of the clinical record revealed IDT [interdisciplinary team] meetings were conducted on 9/14/22, 9/28/22, 10/12/22. Review of the minutes for these meetings revealed no update to the individualized plan of care related to visit projections from the chaplain or MSW. An interview was conducted with the agency director on 11/9/22 at approximately 1 pm. During the interview, the director confirmed there were no visit projections. 10. Patient # 16 had a Start of Care [SOC] date of 9/28/22 and terminal diagnoses of Protein Calorie Malnutrition and Failure to Thrive. Review of the Plan of Care for the certification period 9/28/22 to 11/26/22 included orders for SN [skilled nursing] 1 day 1; Chaplain 1 week 1; Medical Social Worker [MSW] 1 day 1; Volunteer 1 week 1. Supplemental orders for SN were written on 9/28/22 for 1 time a week for 7 weeks, 3 PRN [as needed] for changes in condition and hospice aide 3 times per week for 13 weeks. A supplemental order for the MSW was written on 10/3/22 with the frequency of 1 time a week for 2 months and 3 PRN [as needed] for psychosocial support. A supplemental order for the chaplain was written on 10/3/22 with the frequency of 2 times a month for 2 months, 3 PRN for spiritual support. Review of the clinical record revealed Patient # 16 was discussed in the IDT [interdisciplinary team] meeting on 10/5/22. Further review of the clinical record revealed no update to the individualized plan of care related to visit projections for the next 15 days by the MSW or the chaplain. During an interview with the agency director on 11/9/22 at approximately 9 am, it was confirmed there were no visit projections for visit frequencies related to MSW and chaplain visits for the next 15 days. Review of a policy ";Interdisciplinary Group Meetings for Hospice", revised 11/23/21 was received from the director of nursing on 11/09/22 at 2:02 p.m. The policy stated," ...the focus of the IDG meeting is reviewing the patients plan of care and revising it as needed to develop a comprehensive plan for the next 2 weeks, based on the updated comprehensive assessment...". 1.Patient #2 was admitted on 10/08/22 with obstructive hypertrophic cardiomyopathy (heart muscle is too thick), cardiac murmur (blood flow creates abnormal heart sounds), and essential hypertension (high blood pressure). The Plan of Care for 10/08/22 -01/05/23 included orders for skilled nursing to visit 2 times a week for 13 weeks, social work to assess and evaluate and chaplain to assess and evaluate and aide 3 times a week for 13 weeks. The IDG meeting on 10/27/22 did not include a projected individualized plan for the next 2 weeks for the medical social work or the chaplin. 2.Patient #7 was admitted on 10/24/22 with unspecified protein calorie malnutrition, essential hypertension, vitamin B12 deficiency, and vitamin D deficiency. The Plan of Care for 10/24/22 -01/24/22 included orders for skilled nursing to visit 2 times a week for 13 weeks, aide 2 time a wee for 1 week, and 3 times a week for 12 weeks, chaplin to assess and evaluate and medical social work to assess and evaluate. There was no evidence of an IDG meeting in the record from the start of care on 10/24/22 with projected visit frequencies for the medical social work, or the chaplin. 3.Patient #10 was admitted on 09/21/22 with unspecified heart failure, alzheimers disease, abnormalities of gait and mobility and muscle weakness. The Plan of Care for 09/21/22 to 12/19/22 included orders for skilled nursing to 2 times a week for 13 weeks, home care aide 3 times a week for 13 weeks, medical social work to assess and evaluate, and chaplin assess and evaluate. There was no evidence in the record of the IDG meetings having projected visit frequencies for the medical social work or the chaplin. 4.Patient #14 was admitted on 10/22/22 with chronic obstructive pulmonary disease (lung disease). The Plan of Care for 10/22/22 to 01/19/2023 included orders for skilled nursing to assess and evaluate, medical social work to assess and evaluate and the chaplin to assess and evaluate. There was no evidence of an IDG meeting in the record from the start of care on 10/22/22 with projected visit frequencies for the medical social work, or the chaplin. Interview with the director of nursing on 11/9/22 at 9:40 a.m. revealed, we just put the orders in for the next 2 weeks, we discuss the next 2 weeks, its not listed specifically for the next 15 days in the IDG notes".

Based on policy, clinical record review and staff interviews, the agency failed to notify the physician of anxiety for 1 of 1 patient [#13] with anxiety. The findings included: --- A policy, ";Coordination of Hospice Services" revised 11/4/19 was provided by Director of Nursing on 11/9/22 at 2:02 pm stated, ";[agency] Interdisciplinary Group to make certain that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines..." Patient #13 had a Start of Care date of 10/18/22 which included diagnoses of malignant neoplasm of appendix and colon [cancer]; pleural effusion [fluid in the lungs]; ascites [excess fluid in abdomen] and anxiety (documented on the referral). The Plan of Care for certification period 10/18/22 through 1/15/23 included orders for skilled nursing [ 3 times per week for 1 week; 3 times per week for 12 weeks with 3 PRN [as needed]; Hospice health aide 3 times per week 13 weeks; Chaplain 1 time per week for 11 weeks with 2 PRN; MSS [medical social worker] 1 time week for 12 weeks with 4 PRN. A review of SN #13 visit on 10/19/22 revealed patient reported mood and emotions were severely affected by pain. There is no evidence that SN #13 had communicated with the physician. SN #3 made a visit on 10/19/22 and documented patient was taking ";Xanax 0.5 mg [milligram] 1 BID [twice daily] sleep and anxiety from 9/24/22" in the narrative note. SN #3 stated in an interview on 11/9/22 at 9:15 am that the patient had recently taken Xanax that was ordered by another physician in September 2022. SN #3 reported the patient had shown the bottle of Xanax for verification. Documentation from SN #3 visit on 10/20/22 reveals patient had rated her anxiety at a 10 [moderate to severe; scale used for self report of anxiety]. There is no evidence that SN #3 had communicated with the physician. SN #3 confirmed in an interview on 11/9/22 at approximately 9:15 am, that Xanax had not been added to the Plan of Care, and there was no evidence of communication with the physician that the patient had taken Xanax.

Review of a policy ";Hospice Aide Assignments and Duties", revised 11/04/19 was received from the director of nursing on 11/09/22 at 2:38 p.m. The policy stated," ...the hospice RN (registered nurse) develops a hospice aide plan of care that provides instructions to the hospice aide of the patient-specific care to be provided...". Patient #14 was admitted on 10/22/22 with chronic obstructive pulmonary disease (lung disease). The Plan of Care for 10/22/22 to 01/19/2023 included orders for skilled nursing to assess and evaluate, medical social work to assess and evaluate, and chaplin to assess and evaluate, Review of the hospice aide notes for 10/27/22 and 11/01/22 on 11/08/22 revealed the aide provided care without having a care plan on the tablet. Documentation in the record for 10/27/22 on the aide note revealed the following care was provided: provided chair bath, shampoo hair, oral care, peri care, nail care, foot care, applied lotion, barrier cream to sacrum, caring hand, and compassionate care. ADL (activies of daily living) care plan not on hha (home health aide) tablet. Documentation in the record for 11/01/22 on the aide note revealed the following care was provided: ADL care plan not on tablet. Patient did not want a bath today, dropped off bladder pads and provided companionship. Interview with the agency director on 11/09/22 at approximately 9:25 a.m. confirmed the aide care plan was not in the medical record.

Based on agency policy, clinical record review and staff interviews the clinical record failed to include all required items for 3 of 16 patients [#6, 11 and 16]. The findings included: --- The policy, Documentation Requirements for Hospice [revised 11/19], was provided by the agency director on 11/9/22 at approximately 2 pm. The policy stated, ";...Documentation should be completed in the EMR [electronic medical record] ...Documentation must be...correct, accurate and timely...No blank spaces are left on any forms or tools..." 1. Patient # 6 had a Start of Care [SOC] date of 9/21/22 and terminal diagnoses of Alzheimers Disease and Parkinsons Disease. Review of the Plan of Care for the certification period 9/21/22 to 11/19/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks, 3 PRN [as needed] for pain and symptom control and hospice aide 2 times a week for 8 weeks. Review of the clinical record revealed a hospice aide visit note dated 9/30/22. Further review of the visit note revealed the note was blank [did not include any information related to the visit on 9/30/22]. An interview was conducted with RN # 1 on 11/9/22 at approximately 9:30 am. During the interview, the RN confirmed the aide visit note was incomplete. 2A. Patient # 11 had a Start of Care date of 10/15/22 with a terminal diagnosis of Malignant Neoplasm of Frontal Lobe [brain cancer]. Review of the Plan of Care for the certification period 10/15/22 to 1/12/23 an order for the MSW [medical social work] to assess and evaluate. A supplemental order was written on 10/19/22 for the MSW to see the patient 1 time a month for 2 months. Review of the clinical record revealed a MSW visit for 11/2/22. However, the visit note was blank [did not include any visit information] During an interview with RN # 1 on 11/9/22 at 1:30 pm, RN # 1 stated, ";I guess it is where she didnt sync her computer." The RN confirmed the MSW visit for 11/2/22 was not included in the clinical record. 2B. Patient # 11 had a Start of Care date of 10/15/22 with a terminal diagnosis of Malignant Neoplasm of Frontal Lobe [brain cancer]. Review of the Plan of Care for the certification period 10/15/22 to 1/12/23 included orders for SN [skilled nursing] 3 times a week for 13 weeks, 3 PRN [as needed] for pain/symptom management; hospice aide 5 times a week for 12 weeks, 4 times a week for 1 week; Chaplain to assess and evaluate; Medical Social worker to assess and evaluate. Supplemental orders were written on 10/19/22: Chaplain-patient/caregiver declined chaplain services at this time and MSW 1 time a month for 2 months. Review of the clinical record revealed IDT [interdisciplinary] minutes for the IDT meeting on 10/19/22. Further review of the clinical record revealed no evidence of the IDT meeting conducted on 11/2/22. RN # 1 provided the surveyor with the minutes from the 11/2/22 meeting on 11/9/22 at 3pm. During an interview with RN # 1 on 11/9/22 at 3 pm, the RN confirmed the IDT minutes for 11/2/22 were not included in the clinical record. 3A. Patient # 16 had a Start of Care [SOC] date of 9/28/22 and terminal diagnoses of Protein Calorie Malnutrition and Failure to Thrive. Review of the Plan of Care for the certification period 9/28/22 to 11/26/22 included orders for SN [skilled nursing] 1 day 1; Chaplain 1 week 1; Medical Social Worker [MSW] 1 day 1, Volunteer 1 week 1. Supplemental orders for SN were written on 9/28/22 for 1 time a week for 7 weeks, 3 PRN [as needed] for change in condition and aide 3 times per week for 13 weeks. A supplemental order for MSW was written on 10/3/22 with the frequency of 1 time a week for 2 months and 3 PRN [as needed] for psychosocial support and a supplemental order for the chaplain was written on 10/3/22 with the frequency of 2 times a month for 2 months, 3 PRN for spiritual support. Review of the clinical record revealed no IDT [interdisciplinary team] minutes were included for the IDT meetings on 10/12/22 and 10/26/22 until 3:30 pm on 11/9/22. During an interview with RN # 1 on 11/9/22 at approximately 3:45 pm, the RN confirmed the meetings were not in the clinical record until 11/9/22. 3B. Patient # 16 had a Start of Care [SOC] date of 9/28/22 and terminal diagnoses of Protein Calorie Malnutrition and Failure to Thrive. Review of the Plan of Care for the certification period 9/28/22 to 11/26/22 included orders for Medical Social Worker [MSW] 1 week 1. A supplemental order for MSW was written on 10/3/22 with the frequency of 1 time a week for 2 months and 3 PRN [as needed] for psychosocial support. Review of the clinical record revealed the MSW entered a visit for 10/21/22 and 10/28/22. Further review of the clinical record revealed no visit information was visible. During an interview with the RN # 1 on 11/9/22 at approximately 12:30 pm, the RN stated, ";that happens when the clinician does not sync the visits that day". Further review of the clinical record revealed the visits were not visible until 11/9/22.

Based on clinical record review and staff interviews, the agency failed to show evidence of an order for urinalysis for 1 of 1 patients with symptoms of urinary tract infection. [#9] The findings included: --- Patient #9 had a Start of Care 10/18/22 with diagnoses of heart disease, Dementia with agitation, cardiac pacemaker, Atrial fibrilation. The Plan of Care for certification period of 10/18/22 to 1/15/23 included orders for Skilled nursing [SN] 1 time week 1; 2 times per week for 12 weeks with 4 PRN [as needed] [no reason listed]. SN #9 documented on 11/5/22 a PRN visit was made due to the facility had reported patient #9 with hematuria [ blood in urine]. SN #9 documented, ";order written to obtain urine sample/ CNS [culture and sensitivity lab test] and to hold Eliquis..." An interview with SN #9 on 11/9/22 at 10:10 am, confirmed the facility had obtained the urine specimen and at this time the results were pending. An interview with SN #9 on 11/9/22 at approximatley 10:10 am, confirmed that an order was given by the hospice physician and given to the facility staff, but SN #9 did not add the order to patient #9 care plan.

Based on contract review and staff interview the agency failed to have the provision stating that hospice must report all alleged violations for abuse and neglect 1 of 3 contracts reviewed (#2). Findings included: --- Review of Contract #2 on 11/8/22 revealed the contract did not include the provision stating that the hospice must report all 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 (skilled nursing facility) administrator within 24 hours of the hospice becoming aware of the alleged violation. Interview with the director of nursing on 11/8/22 at approximately 1:02 p.m. confirmed the contract did not have the provision per the regulation.