Every finding on record at Reputable Hospice Care

Upon patient record review 2 of 14 (Patient #7,8) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. #7-Patient was admitted on 07/03/2024 but initial psychosocial assessment was not completed until 07/18/2024. #8-Patient was admitted on 07/01/2024 but initial psychosocial assessment was not completed until 07/18/2024.

Upon patient record review, 5 of 14 (Patient #3,4,6,9,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring #3-Medication profile indicated order for triamcinolone cream apply topically prn for itchiness without an indication of area for application. Corrected on-site. #4-At home visit it was noted that bottle with 50 mg trazadone tablets was labeled to take 1 tab po at bedtime for insomnia prn. This did not match medication profile order for trazadone 50 mg 1 tab po at bedtime for depression. Corrected on-site. #6-Medication profile listed two similar orders (dated 9/6/2024 and 9/9) for metoprolol. Corrected on-site. #9-Medication profile indicated order for diclofenac topical gel apply thin layer to affected area prn for arthritis without indication of area for application. Corrected on-site. #10-Medication profile listed two similar orders (dated 8/13/2024 and 9/12) for Vitamin D3. Corrected on-site.

Upon patient record review, 3 of 14 (Patient #3,7,8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. #3-Patient admitted on 09/30/2024. Initial bereavement assessment completed 10/16/2024. #7-Patient admitted on 07/03/2024. Initial bereavement assessment completed 07/18/2024. #8-Patient admitted on 07/01/2024. Initial bereavement assessment completed 07/18/2024.

Upon patient record review, 4 of 14 (Patient #2,3,6,8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. #2,3,8-Medical record indicates order for SN visits 1xweek and prn. Number of prn visits needed. Corrected on-site. #6-Medical record indicated order for SN visits 2xweek and prn. Number of prn visits needed. Corrected on-site. #8-Medical record indicated orders for MSW and SCP initial visit and prn. Number of prn visits needed. Corrected on-site.

Upon patient record review, 2 of 14 (Patient #3,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. #3-Plan of care indicated order for triamcinolone cream apply topically prn for itchiness without and indication of area for application. Corrected on-site. #9-Plan of care indicated order for diclofenac topical gel apply thin layer to affected area prn for arthritis without indication of area for application. Corrected on-site.

Upon patient record review, 2 of 14 (Patient #3,4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. #3-At home visit it was noted that patient was utilizing a wheel chair that was not included on the plan of care. At home visit it was noted that patient had half rails on bed, but full bed rails listed on plan of care. Both corrected on-site. #4-At home visit it was noted that patient had half rails on bed, but full bed rails listed on plan of care. Corrected on-site.

Upon patient record review, 2 of 14 (Patient #3,5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable #3-Current order dated 10/17/2024indicates aide frequency 2xweek. Aide care plan indicates frequency 3xweek. Corrected on-site. #5-Current order dated 09/19/2024 indicates aide frequency 3xweek. Aide care plan does not indicate a frequency of visits. Corrected on-site.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. #3-On CTI for benefit period #11, physician's narrative referenced F2F done for benefit period #10.

Based on interview and record review, the hospice failed to ensure the comprehensive assessment was completed no later than five calendar days for one of two sampled patients (Patients 1), creating the risk of not identifying the care needs for this patient. --- Findings: Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. The hospice election of benefit document dated 5/1/24, showed hospice care was elected. The initial spiritual assessment dated 5/10/24, showed the SC conducted the spiritual assessment. * However, the initial comprehensive spiritual assessment was completed nine calendar days after the election of hospice care. On 8/29/24 at 1330 hours, an interview and concurrent clinical record review was conducted with the Administrator, DPCS Designee, and Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to identify the patient's spiritual needs in the comprehensive assessments for one of two sampled (Patients 2), creating the risk of not providing necessary care and services to meet the care needs for this patient. --- Findings: Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification periods from 4/14/24 to 7/12/24 and 7/13/24 to 10/10/24. Review of the Spiritual Assessment dated 4/14/24, showed the sections to document the spiritual circumstances, patient faith community information, patient caregiver faith community information, spiritual and cultural influences, and spiritual support were left blank. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and Office Manager/Volunteer Coordinator. They were informed and acknowledged the finding.

Based on interview and record review, the hospice failed to include all current medications' potential drug interactions in the comprehensive assessment and failed to ensure the medication profile was reviewed and updated to reflect the current medications for two of two sampled patients (Patients 1 and 2), creating the risk for poor health outcomes for these patients. --- 2. . Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24 and 7/13/24 to 10/10/24. Review of Current Medication/treatment/DME list showed the patient's following medication: -a physician order dated 4/14/24 to administer Macrobid 100 milligram capsule oral twice a day for urinary tract infection with duration 10 days. -a physician order dated 5/16/24 to administer Flagyl 500 milligram tablet oral four times a day for stomach flu with duration 10 days. -a physician order dated 4/14/24, treatment to right heel: cleanse pressure injury (DTI) with NSS, pat dry, apply medihoney and cover with dry dressing daily and PRN for dislodgement and excessive soilage. Reevaluate for 30 days. Review of Skin assessment dated 7/2/24 showed right heel deep tissue deep tissue injury was resolved. Review of the POC/IDG Review dated 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed Medication Profile reviewed for contraindications, side effects, interactions, duplicate drug therapy and patient/patient caregiver compliance with meds and treatments therapy reviewed by IDG team. *However, there was no documented evidence the IDG had identified two medication and one treatment order should have been discontinue from medication profile. On 8/29/24 at 1430 hours, an interview and concurrent record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: The hospices P&P titled Medication Profile revised date 10/19, showed patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify: effectiveness, actual or potential side effects, toxic effects, allergic reactions, immediate desired effects, unusual and unexpected effects, changes in the patients condition that contraindicates continued administration of the medication, drug related laboratory results, actual and potential drug interactions, duplicate drug therapy, the need for pharmacological or non-pharmacological interventions for pain and other symptom management as applicable to the patient. The interdisciplinary group will confer with an individual with education in drug management to ensure the drugs and biologicals meet the patients needs. According to Lexi-Comp's pharmacology website, the US Boxed Warning for lorazepam included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Drug interactions for aspirin showed agents with antiplatelet properties may enhance the antiplatelet effect of other agents with antiplatelet properties. 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. The POC/IDG Review dated 5/1/, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed the patients medications included: - Ativan (antianxiety) 1 mg PO every two hours as needed for anxiety manifested by restlessness - morphine sulfate IR (opioid analgesic) 7.5 mg PO every two hours as needed for moderate pain - morphine IR 15 mg PO every two hours as needed for severe pain - Ultram (opioid analgesic) 50mg one tablet PO daily as needed for pain. - aspirin (antiplatelet agent) 81mg one tablet PO daily - Plavix (antiplatelet agent) 75mg one tablet PO Q HS * However, there was no documented evidence the RN/IDG had identified the potential drug interactions between morphine sulfate, Ativan and Ultram; and between aspirin and Plavix. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator, DPCS Designee, and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments were completed no less than every 15 days and included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses for two of two sampled patients (Patients 1 and 2 ), creating the risk of not addressing the care needs for these patients. --- 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24 and 7/13/24 to 10/10/24 A. Review of Physician progress notes for wound dated 5/16/24 showed Patient 1s right foot pressure ulcer was documented as stage 3, measuring 2.8 cm x 2.3 cm. The wound color was crusted, no drainage, no eschar, no slough, no undermining, and no tunneling. The surrounding skin was within normal limit. Review of Skin Assessment dated 5/17/24, showed under section list of current location was blank. Under section list of other impairments with opened dated 4/14/24 for the following location: moisture associated skin damage sacrum, right heel deep tissue injury, right malleolus deep tissue injury, right foot unstageable and suprapubic catheter. Review of Visit Notes-LVN dated 5/17/24 showed under integumentary-skin was documented wound right ankle stage one. However, there was no documented evidence the LVN had assessed the location, description, stage, size, color, drainage, odor, inflammation, tunneling/undermining, status, and treatment. Review of Skin Assessment dated 5/20/24, showed under section list of current location, skin assessment was documented right foot with unstageable Pressure Injury, measuring 4 cm x 4 cm. the wound color was black, serosanguinous drainage, and no odor. B. Review of Skin Assessment dated 7/2/24 showed right foot deep tissue injury malleolus and right heel deep tissue deep tissue injury was resolved. Review of Skin Assessment dated 7/9/24, 7/12/24, 7/15/24, 7/29/24, 8/10/24, 8/12/24 showed Under section list of other impairments added, the right foot malleolus and right heel deep tissue deep tissue injury dated 4/14/24 with status existing was documented. C. Review of Skin assessment dated 8/10/24 showed right dorsal ankle open wound and open wound between big toe and second toe for new wound. However, there was no documented evidence description of new wound such as stage, size, color, drainage, odor, and treatment. Review of Visit Notes-RN dated 8/10/24, showed under section integumentary-skin, the comments: right dorsal ankle open wound and open wound between big toe and 2nd toe with ulcer/bedsore severe. Review of the POC/IDG Review dated 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed a care plan addressing Integumentary skin for the following issues: moisture associated skin damage sacrum, right heel deep tissue injury, right foot unstageable open wound, and right malleolus deep tissue injury. The intervention for all skin impairment included assess alteration in skin integrity every visit, assess changes in wound status, check size, integrity, location, type/stage, signs and symptoms of infection, drainage, effectiveness of current treatment. *However, there was no documented the IDG identified the changes of the skin impairment status, resolved and new skin impairment. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. The Administrator stated they should have been updated the assessment for change of skin impairment, new wound and wound had been resolved. They were informed and acknowledged the findings. Findings: 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. a. The Visit Note RN dated 7/1/24, showed ecchymosis on the right hand and forearm possibly due to hitting the hand/arm against a table last night. * The POC/IDG Review dated 7/8/24, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to address ecchymosis on the right hand and forearm. b. The MSW Note dated 6/18/24 showed following information: - The MSW made a home visit for the patient at his house on this date, providing psychosocial support. - The patient was sitting on his bed upon arrival. The MSW greeted him and engaged in socialization. The patient was responsive and had no problem communicating with the MSW. The patient reported having no pain or discomfort at this time. - Due to the patients unsteady gait, the patient uses a walker for his safety. The MSW provided home safety precautions. - The MSW also provided emotional support for patient. The MSW assisted the patient in continuing to use existing coping skills to maintain his mental status appropriately as needed. - The MSW discussed the patient`s mortuary preparation, providing a couple of options and tips on how to prepare in advance. The patient asked for time to think about it. The MSW encouraged him to take enough time to consider it and to seek help from the MSW when he is ready. The MSW will continue to assist the patient in setting up the plan in advance through regular home visits once a month and as needed. The POC/IDG Review dated 6/24/24, showed the IDG had discussed and updated the comprehensive assessment including the MSW visit on 6/18/24. * Further review of the POC/IDG Review dated 7/8, 7/22, 8/5, and 8/19/24, showed the IDG met and updated the comprehensive assessment. However, the MSWs updated comprehensive assessment showed the same information on the POC/IDG Review dated 6/18/24, wherein IDG failed reflect the patients latest condition. c. The Visit Note SC dated 6/3/24, showed the following information: - SC conducted visit with the patient at his residence. Patient was accompanied by family member and resting comfortably in his room. - SC reintroduced self to the patient. SC asked if patient would like scripture reading or prayer and family member confirmed not this visit. The POC/IDG Review dated 6/10/24, showed the IDG had discussed and updated the comprehensive assessment including the SC visit on 6/3/24. * Further review of the POC/IDG Review dated 6/24 and 7/8/24, showed the IDG met and updated the comprehensive assessment. However, the SCs updated comprehensive assessment showed the same information on the POC/IDG Review dated 6/10/24, wherein IDG failed to reflect the patients latest condition. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator, DPCS Designee, and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24, and 7/30/24 to 10/27/24. a. The Visit Note RN dated 7/1/24, showed the patient had ecchymosis (bruise) on the right hand and forearm possibly due to hitting the hand/arm against a table last night. * The POC/IDG Review dated 7/8/24, showed no documented evidence the IDG had discussed and updated the comprehensive assessment to address ecchymosis on the right hand and forearm. b. The MSW Note dated 6/18/24 showed following information: - The MSW made a home visit for the patient at his house on this date, providing psychosocial support. - The patient was sitting on his bed upon arrival. The MSW greeted him and engaged in socialization. The patient was responsive and had no problem communicating with the MSW. The patient reported having no pain or discomfort at this time. - Due to the patients unsteady gait, the patient used a walker for his safety. The MSW provided home safety precautions. - The MSW also provided emotional support for the patient. The MSW assisted the patient in continuing to use existing coping skills to maintain his mental status appropriately as needed. - The MSW discussed the patient`s mortuary preparation, providing a couple of options and tips on how to prepare in advance. The patient asked for time to think about it. The MSW encouraged him to take enough time to consider it and to seek help from the MSW when he would be ready. The MSW wouldl continue to assist the patient in setting up the plan in advance through regular home visits once a month and as needed. The POC/IDG Review dated 6/24/24, showed the IDG had discussed and updated the comprehensive assessment including the MSW visit on 6/18/24. * Further review of the POC/IDG Review dated 7/8, 7/22, 8/5, and 8/19/24, showed the IDG met and updated the comprehensive assessment. However, the MSWs updated comprehensive assessment showed the same information on the POC/IDG Review dated 6/18/24, wherein the IDG failed to update to reflect the patients latest condition. c. The Visit Note SC dated 6/3/24, showed the following information: - The SC conducted visit with the patient at his residence. Patient 1 was accompanied by the family member and resting comfortably in his room. - The SC reintroduced self to the patient. The SC asked if the patient would like scripture reading or prayer and family member confirmed not this visit. The POC/IDG Review dated 6/10/24, showed the IDG had discussed and updated the comprehensive assessment including the SC visit on 6/3/24. * Further review of the POC/IDG Review dated 6/24 and 7/8/24, showed the IDG met and updated the comprehensive assessment. However, the SCs updated comprehensive assessment showed the same information on the POC/IDG Review dated 6/10/24, wherein the IDG failed to update to reflect the patients latest condition. On 8/29/24 at 1330 hours, an interview and concurrent clinical record review was conducted with the Administrator, DPCS Designee, and Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24, and 7/13/24 to 10/10/24 Review of the Physician progress notes for wound dated 5/16/24, showed Patient 1 had a Stage 3 pressure injury on the right foot, measured 2.8 cm (length) x 2.3 (width) cm. The wound color was crusted, no drainage, no eschar (dead tissue), no slough (yellow/white material in the wound bed), no undermining, and no tunneling. The surrounding skin was within normal limit. Review of the Skin Assessment dated 5/17/24, showed Patient 2 had the following skin issues: MASD on the sacrum, DTI on the right heel, DTI on the right malleolus, and unstageable pressure injury on the right foot. Review of the Visit Notes-LVN dated 5/17/24, showed Patient 2 had a Stage 1 pressure injury on the right ankle. However, there was no documentation for the description, size, color, drainage, odor, inflammation, tunneling/undermining, status, and treatment. Review of the Skin Assessment dated 5/20/24, showed Patient 2 had an unstageable pressure injury on the right foot, measuring 4 cm x 4 cm, wound color was black with serosanguinous drainage, and no odor. Review of the Skin Assessment dated 7/2/24, showed the DTIs on the right foot malleolus and right heel were resolved. Review of the Skin assessment dated 8/10/24, showed Patient 2 had open wounds on the right dorsal ankle and between big toe and second toe. However, there was no documentation for the description of new wound such as stage, size, color, drainage, odor, and treatment. Review of the Visit Notes-RN dated 8/10/24, showed Patient 2 had open wounds to the right dorsal ankle and between big toe and second toe with severe ulcer/bedsore. Review of the POC/IDG Review dated 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed a care plan addressing the following issues: MASD on the sacrum, DTI on the right heel, unstageable pressure injury on the right foot, and DTI on the right malleolus. The interventions for all skin impairment included to assess alteration in skin integrity every visit, assess changes in wound status, check size, integrity, location, type/stage, signs and symptoms of infection, drainage, effectiveness of current treatment. * However, there was no documented the IDG had identified the changes of the skin impairment status, resolved, and new skin impairment. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and Office Manager/Volunteer Coordinator. The Administrator stated they should have updated the assessment for the change of skin impairment, new wound, and wounds that had been resolved. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for two of two sampled patients (Patients 1 and 2), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24 and 7/13/24 to 10/10/24. a. Review of Comprehensive Nursing assessment dated 4/14/24 showed genitourinary reproductive suprapubic for indwelling catheter or suprapubic size was documented blank and last change 4/11/24. Review of Current Medication/treatment/DME list dated 4/14/24 showed Suprapubic Catheter Care: Assess signs and symptoms of UTI Q SN visit and educate caregiver for symptoms to report. Review of the POC/IDG Review dated 4/14/24, 4/15/24, 4/29/24, 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed a care plan addressing Patient has suprapubic catheter. The intervention included assess urinary status every visit and change suprapubic catheter monthly and as needed. Review of Visit Notes-RN dated 4/16/24 showed genitourinary reproductive urinary problem were occasionally incontinent. Under section comments timely peri care advised and suprapubic catheter in place. Under section visit checklist (comply every visit), check indwelling catheter if applicable) was documented non-applicable. Under section narrative, a suprapubic catheter is in place, which is intact, and the dressing was changed without any issues, we will continue to monitor for signs and symptoms of urinary tract infection. Review of Visit Notes- RN dated 5/10/24 showed genitourinary reproductive urinary problem were occasionally incontinent. Under section comments suprapubic catheter in place. Under section visit checklist (comply every visit), check indwelling catheter (if applicable) was documented non-applicable. Under narrative section, a suprapubic catheter is in place and is intact without any issues. Review of Visit Notes -LVN dated 5/10/24 showed genitourinary reproductive urinary problem were never, incontinent, and other symptoms: mild. Under narrative section, a suprapubic catheter is in place and is intact without any issues. Review of Visit Notes-RN dated 8/1/24 showed genitourinary reproductive urinary problem were occasionally incontinent. Under section comments suprapubic catheter in place. Under section visit checklist (comply every visit), check indwelling catheter if applicable) was documented non-applicable. Under narrative section, a suprapubic catheter is in place and is intact without any issues. Review of Visit Notes-RN dated 8/5/24 showed genitourinary reproductive urinary problem were occasionally incontinent. Under section comments suprapubic catheter in place. Under narrative section, Patient 2 was incontinent bowel and bladder elimination with last bowel movement yesterday. *However, further review of the clinical record showed there was no documentation of catheter was changed, catheter size and urine characteristics. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. b. Review of the POC/IDG Review dated 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed a care plan addressing Integumentary skin for the following issues: moisture associated skin damage sacrum, right heel deep tissue injury, right foot unstageable open wound, and right malleolus deep tissue injury. The intervention for all wound included assess alteration in skin integrity every visit, assess changes in wound status, check size, integrity, location, type/stage, signs and symptoms of infection, drainage, effectiveness of current treatment. Review of skin assessment dated 5/13/24 ,5/17/24, 7/12/24, 8/10/24, 8/12/24, 8/17/24, 8/20/24, 8/24/24, 8/26/24 showed under section list of current location, skin assessment was documented blank. *However, further review of the clinical record showed there was no documentation of description of wound such as stage, size, color, drainage, odor, and treatment. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: The hospices P&P titled Plan of Care revised date 10/19, showed the care provided to the patient must be in accordance with the plan of care. 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. a. The POC/IDG Review dated 5/1/24, showed HA visits 3 times per week for personal care and ADL assistance. On another part of the document showed HA visits 2 per week or personal care and ADL assistance. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator. He stated the HA visits 3 times per week was the correct plan of care for the patient. * However, further review of the clinical record showed there was no HA visits conducted during the week of Week 1 (5/1/24 to 5/4/24), instead of three visits as cited. b. The POC/IDG Review dated 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed SN visits 2 per Week and 3 PRN visits for pain and symptom management. * The SN notes during the certification period from 5/1/24 to 7/29/24, showed the SN conducted one visit during the week of Week 3 (5/12/24 to 5/18/24), Week 4 (5/19/24 to 5/25/24), Week 6 (6/2/24 to 6/8/24), Week 7 (6/9/24 to 6/15/24, Week 8 (6/16/24 to 6/22/24), Week 9 (6/23/24 to 6/29/24), Week 10 (6/30 to 7/6/24), Week 11 (7/7/24 to 7/13/24), and Week 12 (7/14 to 7/20), instead of two visits per week. * The SN notes during the certification period from 7/30/24 to 10/27/24, showed the SN conducted one visit during the week of Week 2 (8/4/24 to 8/10/24) and Week 3 (8/11/24 to 8/17/24), instead of two visits per week as cited. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator, DPCS Designee, and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: The hospices P&P titled Plan of Care revised date 10/19 showed the care provided to the patient must be in accordance with the plan of care. 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24, and 7/30/24 to 10/27/24. a. The POC/IDG Review dated 5/1/24, showed HA visits 3 times per week for personal care and ADL assistance; however, the other section of the document showed HA visits 2 times per week for personal care and ADL assistance. On 8/29/24 at 1330 hours, an interview and concurrent clinical record review was conducted with the Administrator. He stated the HA visits 3 times per week was the correct plan of care for the patient. * However, further review of the clinical record showed there was no HA visits conducted during Week 1 (5/1/24 to 5/4/24), instead of three visits as cited. b. The POC/IDG Review dated 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed SN visits 2 times per week and 3 PRN visits for pain and symptom management. * The SN notes for the certification period from 5/1/24 to 7/29/24, showed the SN had conducted one visit during Week 3 (5/12/24 to 5/18/24), Week 4 (5/19/24 to 5/25/24), Week 6 (6/2/24 to 6/8/24), Week 7 (6/9/24 to 6/15/24, Week 8 (6/16/24 to 6/22/24), Week 9 (6/23/24 to 6/29/24), Week 10 (6/30 to 7/6/24), Week 11 (7/7/24 to 7/13/24), and Week 12 (7/14 to 7/20), instead of two visits per week. * The SN notes for the certification period from 7/30/24 to 10/27/24, showed the SN had conducted one visit during Week 2 (8/4/24 to 8/10/24) and Week 3 (8/11/24 to 8/17/24), instead of two visits per week as cited in the POC. On 8/29/24 at 1330 hours, an interview and concurrent clinical record review was conducted with the Administrator, DPCS Designee, and Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification periods from 4/14/24 to 7/12/24, and 7/13/24 to 10/10/24. a. Review of the Comprehensive Nursing assessment dated 4/14/24, under the genitourinary section, showed the suprapubic size was left blank and last date the suprapubic catheter was changed on 4/11/24. Review of the Current Medication/treatment/DME list dated 4/14/24, showed to provide suprapubic catheter care, assess signs and symptoms of UTI Q SN visit and educate the caregiver for symptoms to report. Review of the POC/IDG Review dated 4/14, 4/15, 4/29, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed a care plan addressing the patient's suprapubic catheter. The interventions included to assess urinary status every visit and change suprapubic catheter monthly and as needed. Review of the Visit Notes-RN dated 4/16, 5/10, 8/1, and 8/5/24, showed the suprapubic catheter was in place. Review of the Visit Notes -LVN dated 5/10/24, showed the suprapubic catheter was in place, intact, and without any issues. * However, further review of the clinical record failed to show documented evidence the catheter was changed and urine characteristics was assessed. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. b. Review of the POC/IDG Review dated 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed a care plan addressing the following skin issues: MASD on the sacrum, DTI on the right heel, unstageable pressure injury on the right foot, and DTI on the right malleolus. The interventions included to assess for alteration in skin integrity every visit, assess changes in wound status, check size, integrity, location, type/stage, signs and symptoms of infection, drainage, and effectiveness of current treatment. Review of the skin assessment dated 5/13, 5/17, 7/12, 8/10, 8/12, 8/17, 8/20, 8/24, and 8/26/24, under the section list of current location, showed the skin assessment was left blank. In addition, there was no documented evidence of the description of wound such as stage, size, color, drainage, odor, and treatment; and the assessment of the effectiveness of the current treatment. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for two of two sampled patients (Patients 1 and 2 ), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. --- 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24 and 7/13/24 to 10/10/24. A. Review the POC/IDG Review dated 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed a care plan addressing the alteration in bowel elimination and Increasing episodes of loose stools with the following goals: - Facilitate bowel elimination and comfort. - Facilitate bowel movement - Patient/Family/Patient caregiver will verbalize understanding that symptom is a part of the disease process and the limitations of treatments. - Reduce discomfort with improved bowel elimination status. - Patient/ patients care giver will verbalize/express understanding of medication/treatment orders and side effects. In addition, a care plan addressing the bowel elimination with the following goals: -Patient will reduce discomfort with improved bowel elimination status with the help of proper diet in this certification period *However, there was no documented evidence of the measurable outcome as to when patient expected had decreased episodes of loose stools, and what was acceptable improved bowel elimination status (stool consistency) B. Review the POC/IDG Review dated 4/14/24, 4/15/24, 4/29/24, 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed a care plan addressing poor appetite with the following goal: - Patient will have adequate food and fluids as tolerated or desired with in hospice stay. *However, there was no documented evidence of the measurable outcome as to what the acceptable nutrition percentage and the volume of fluid intake. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: The hospices P&P titled Plan of Care revised date 10/19, showed written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The written plan of care will contain, but will not be limited to, the following: measurable outcomes anticipated from implementing and coordinating the plan of care. 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. The Plan of Care, for the certification period from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24, showed the patient's identified problems with the established goals and interventions. * However, some of the POCs failed to include measurable outcomes for the patient's identified problem. For example, the goal for bilateral lower edema was for the patient to prevent discomfort due to increasing edema and patient will maintain optimum peripheral circulation during hospice stay. However, there was no measurable outcome as to what optimum peripheral circulation for the patient would be. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator, DPCS Designee, and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to include the specific indication for the use of pain medication for one of two sampled patients (Patient 1), creating the risk for the patient not receiving the appropriate care and services necessary to improve the patient's health condition. --- Findings: Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24, and 7/30/24 to 10/27/24. The POC/IDG Review dated 5/1/, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed the patients following oral pain medications: - acetaminophen (analgesic) 650 mg PO every six hours as needed for mild pain - morphine sulfate IR (opioid analgesic) 7.5 mg PO every two hours as needed for moderate pain - morphine IR 15 mg PO every two hours as needed for severe pain - Ultram (opioid analgesic) 50 mg one tablet PO daily as needed for pain. * However, there was no documented evidence when Ultram would be administered for pain. On 8/29/24 at 1330 hours, an interview and concurrent clinical record review was conducted with the Administrator, DPCS Designee, and Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs at least every 15 days for two of two sampled patients (Patients 1 and 2), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24 and 7/13/24 to 10/10/24. a. Review of Physician progress notes for wound dated 5/16/24 showed Patient 1s right foot pressure ulcer was documented as stage 3, measuring 2.8 cm x 2.3 cm. The wound color was crusted, no drainage, no eschar, no slough, no undermining, and no tunneling. The surrounding skin was within normal limit. Review of skin assessment dated 5/17/24, showed under section list of current location, it was documented blank. Under section list of other impairments dated 4/14/24 for moisture associated skin damage sacrum, right heel, right malleolus deep tissue injury, right foot unstageable and suprapubic catheter. Review of Visit notes-LVN dated 5/17/24 showed under integumentary-skin, the wound documented right ankle stage one. However, there was no documented evidence the SN had assessed the location, description, stage, size, color, drainage, odor, inflammation, tunneling/undermining, status, and treatment. Review of skin assessment dated 5/20/24, showed under section list of current location was documented right foot with unstageable Pressure Injury, measuring 4 cm x 4 cm. the wound color was black, serosanguinous drainage, and no odor. b. Review of Skin assessment dated 7/2/24 showed right foot malleolus and right heel deep tissue deep tissue injury was resolved. Review of skin assessment dated 7/9/24, 7/12/24, 7/15/24, 7/29/24, 8/10/24, 8/12/24, 8/17/24, 8/20/24, 8/26/24 showed under section list of other impairments added, the right foot deep tissue injury malleolus and right heel deep tissue deep tissue injury dated 4/14/24 with status existing. c. Review of Current Medication/treatment/DME list showed the Patient 2s following treatment: - a physician order dated 4/14/24 for right foot: cleanse pressure injury (unstageable) with normal saline, pat dry, apply Medihoney and cover with dry dressing daily and as needed for dislodgement and excessive soilage. Re-evaluate for 30 days. -a physician order dated 4/14/24 for right heel: cleanse pressure injury (Deep Tissue Injury) with normal saline, pat dry, apply Medihoney and cover with dry dressing daily and PRN for dislodgement and excessive soilage. Re-evaluate for 30 days. -a physician order dated 4/14/24 for sacrum: cleanse moisture associated skin damage with soap and water, pat dry, apply calmoseptine daily and every diaper change, leave open to air. Re-evaluate for 30 days. *However, there was no documented evidence treatment order for right foot Deep tissue injury and new wound for right dorsal ankle and between big toe and second toe. Review of Skin Assessment dated 8/10/24 showed under section list of other impairment(s) added, right dorsal ankle open wound and open wound between big toe and second toe for new wound. However, there was no documented evidence of description of new wound such as stage, size, color, drainage, odor, and treatment. Review of the POC/IDG Review dated 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed a care plan addressing Integumentary-skin for the following issues: moisture associated skin damage sacrum, right heel deep tissue injury, right foot unstageable open wound, and right malleolus deep tissue injury. The intervention for all wound included assess alteration in skin integrity every visit, assess changes in wound status, check size, integrity, location, type/stage, signs and symptoms of infection, drainage, effectiveness of current treatment. *However, the IDG failed to review and revise the POC related to the care plan addressing integumentary skin issues which included wound assessment and treatment. d. Review of Current Medication/treatment/Device Medical Equipment list, showed a physician order dated 4/14/24 to administer oxygen 2 liter per minute via nasal cannula as needed for Shortness of breath, may titrate up to 5 liter/minutes as needed. Review the POC/IDG Review dated 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24 showed a care plan addressing respiratory for dyspnea upon exertion. *However, the IDG failed to review and revise the POC related to the care plan addressing respiratory for dyspnea which included the use of oxygen for shortness of breath. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. a. The Visit Note RN dated 7/1/24, showed ecchymosis on the right hand and forearm possibly due to hitting the hand/arm against a table last night. * The POC/IDG Review dated 7/8/24, showed a care plan problem addressing integumentary/skin with an issue of decreasing skin turgor. However, there was no documented evidence the POC was revised to include ecchymosis on the right hand and forearm. b. The Communication/Progress Log dated 5/14/24, showed a report was received from the HA the patient declined further services. The POC/IDG Review dated 5/27/24, showed under frequency of visit an order dated 5/14/24, HA declined with a start date of 5/14/24. The POC/IDG Review dated 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed under frequency of visit the HA was declined. The POC showed a care plan problem addressing ADL. Documentation included the patient will receive assistance from the aide to meet their activity needs within the certification period; and HA to visit patient 2 times a week. * However, the IDG failed to review and revise the POC related to the care plan addressing ADL which included the patient will receive assistance from the aide to meet their activity needs within the certification period; and HA to visit patient 2 times a week. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator, DPCS Designee, and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs for two of two patients (Patients 1 and 2) creating the risk of not identifying the care needs and providing necessary care and services to meet the care needs for these patients. --- 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24 and from 7/13/24 to 10/10/24. Review of the POC/IDG Review dated 5/13/24, 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24, showed the patient's identified problems included gastrointestinal, integumentary and nutrition. The goals were established for these identified problems. *Further review of the clinical record showed the IDG had reviewed the POCs Q 14 days. However, there was no documented evidence the POCs included the patient's progress toward goals. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. The POC/IDG Review dated 5/27/24, showed the patient's identified problems included ADL, low risk for complicated grieving, bilateral lower extremities edema, susceptibility to have increase BP related to hypertension, intermittent chest pain, glaucoma, potential for harm and increased risk related to poor coordination and weakness, risk of fall, gastroesophageal reflux disease, flatulence, bladder incontinence, decreasing skin turgor, ambulatory with fall risk, generalized body weakness, episodes of depression, drug allergy, burning sensation on soles of feet at night, knowledge deficit, patient/family may face emotional distress due to patient's illness and the challenges associated with end-of-life care, dyspnea upon exertion, and lack of sleep. The goals were established for these identified problems. * Further review of the clinical record showed documented evidence the IDG had reviewed the POCs Q 14 days. However, the updated POCs did not include the patient's progress toward goals as specified in the POCs. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator, DPCS Designee and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services related to HA assignment, IDG participation, and clinical records for two of two sampled patients (Patients 1 and 2), creating the risk of not addressing the care needs for these patients. --- 2. Review of Patient 2's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 4/14/24. The patient was certified for hospice services during the certification period from 4/14/24 to 7/12/24 and 7/13/24 to 10/10/24. a. Review of Hospice Aid Assignment dated 4/14/24 and 7/13/24 showed under section continence/toileting, Patient 2 was documented for completion colostomy care for bowel. Review of Comprehensive Nursing Assessment dated 4/14/24 showed Under section Gastro-Intestinal, Patient 2 had abdomen soft, bowel normal, and status incontinence 4 to 5 times per week. However, there was no documented evidence Patient 2 had colostomy. Review of Recert-Assessment dated 7/11/24 showed Under section Gastro-Intestinal, Patient 2 had abdomen soft, bowel normal, and status incontinence 4 to 5 times per week. However, there was no documented evidence Patient 2 had colostomy. Review of Hospice Aid Note dated 7/15/24, 7/17/24, 7/24/24, 7/26/24, 7/29/24, 7/31/24, 8/2/24, 8/5/24, 8/7/24, 8/9/24, 8/12/24, 8/16/24, 8/19/24, 8/21/24, 8/23/24, 8/26/24 showed under section continence/toileting, Patient 2 was documented for hospice aid completed colostomy care. *However, The IDG failed to supervise the care and services provided to the patient for hospice aid b. The POC/IDG Review dated 5/27/24, 6/10/24, 6/24/24, 7/8/24, 7/22/24, 8/5/24, and 8/19/24, showed no documented evidence of the SCs participation during the IDG meeting as there was no electronic signature during the IDG above meetings. On 8/29/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings. Findings: The hospices P&P titled Interdisciplinary Group (IDG) Roles and Responsibilities undated, showed roles and responsibilities include: -Assessment and Care Planning. Members Involved: Hospice Physician, Registered Nurse (RN), Social Worker, Spiritual Counselor, and other pertinent personnel. Responsibilities include conduct a comprehensive initial assessment of the patient and family; develop an individualized plan of care that addresses the physical, emotional, social, and spiritual needs of the patient; update the plan of care periodically based on the patient's condition and preferences; and ensure the plan of care is tailored to the patient's goals and the required frequency and type of services. - Interdisciplinary Collaboration. Members Involved: All IDG members. Responsibilities include participate in regular IDG meetings (minimum every 14 days) to review and update the patients plan of care; communicate effectively to ensure a unified approach to patient care; and share relevant observations, insights, and recommendations to enhance patient care. - Symptom Management and Palliative Care. Members Involved: Hospice Physician, RN. Responsibilities include oversee the management of symptoms, including pain, nausea, and respiratory distress; ensure medication and treatment plans are appropriate and adjusted as needed; focus on enhancing the patients quality of life through effective symptom management. - Emotional and Spiritual Support. Members Involved: Social Worker, Spiritual Counselor. Responsibilities included provide emotional and psychological support to the patient and family, addressing grief, anxiety, and social concerns; offer spiritual care consistent with the patient's beliefs and preferences; facilitate access to additional community resources as necessary; and provide bereavement support to the family as needed. - Patient and Family Education. Members involved: RN, Social Worker, and other IDG members.Responsibilities include educate the patient and family about the disease process, symptom management, and end-of-life care; ensure that the patient and family are informed about the care plan and their options; provide guidance on advance care planning, including advance directives and DNR orders. - Documentation and Compliance. Members Involved: All IDG members. Responsibilities include maintain accurate and timely documentation of assessments, care plans, and interventions; ensure compliance with ACHC standards, state, and federal regulations; and document all IDG meetings and updates to the plan of care. - Quality Improvement. Members Involved: All IDG members. Responsibilities include participate in the hospice's Quality Assessment and PerformanceImprovement (QAPI) program; review patient outcomes and identify areas for improvement. and implement changes to care practices based on performance data andfeedback. - Ethical and Legal Considerations. Members Involved: All IDG members. Responsibilities include ensure that care is provided ethically, respecting patient rights and autonomy; address any ethical issues that arise in the course of patient care; and ensure all care decisions comply with legal and regulatory requirements. The hospices P&P titled Interdisciplinary Group Meeting revised date10/19. showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. The meeting will be facilitated by the hospice Clinical Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The hospices P&P titled Contents of Clinical Record revised date 10/19, showed clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. 1. Review of Patient 1's clinical record was initiated on 8/27/24. The clinical record showed the SOC was 5/1/24. The patient was certified for hospice services during the certification periods from 5/1/24 to 7/29/24 and 7/30/24 to 10/27/24. a. The initial Comprehensive Nursing Assessment dated 5/1/24, showed a SN visit was conducted. However, there was no documented evidence the clinical note was dated and signed, including the title and credentials as per the hospices P&P. b. On 8/27/24 at 0945 hours, an entrance conference was conducted with the Administrator. He stated IDG meetings are conducted Q 14 days via online or office meeting. He stated the IDG meeting minutes and IDG participation were located in the patients electronic record. He stated the IDG members include the physician, DPCS, RN Case Manager, SC, MSW, and an LVN. * The POC/IDG Review dated 5/1, 5/13, 5/27, 6/10, 6/24, 7/8, 7/22, 8/5, and 8/19/24, showed no documented evidence of the SCs participation during the IDG meetings as there were no electronic signatures during the IDG above meetings. * The POC/IDG Review dated 8/19/24, showed no documented evidence of the MDs participation during the IDG meeting as there was no electronic signature during the IDG meeting on 8/19/24. On 8/29/24 at 1330 hours, an interview and concurrent record review was conducted with the Administrator and the Office Manager/Volunteer Coordinator. They were informed and acknowledged the findings.

Upon patient record review, 2 of 5 records (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 2: The medication profile contained a calcium/vitamin D3 supplement with no dosage or strength listed.

Upon patient record review, 2 of 5 records (Patients #2,#4) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #2,4: The space designated for the date of election was left blank.