Every finding on record at Salus Home Health and Hospice, Inc.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for three of three sampled patients (Patients 1, 2, and 3).  This failure had the potential for not evaluating the POC and providing appropriate care and services to these patients.Findings: --- The hospice's P&P titled The Plan of Care revised 3/2024, showed the written plan of care may contain, but will not be limited to the statement of treatment goals that are measurable and measurable outcomes anticipated from implementing and coordinating the plan of care. 1.  Review of Patient 1’s closed clinical record was initiated on 3/10/26.  The clinical record showed the SOC was 4/26/25.  The patient was certified for hospice services during the certification periods from 4/26/25 to 7/24/25, 7/25/25 to 10/22/25, 10/23/25 to 12/21/25 and 12/22/25 to 2/19/26.  The patient had expired on1/17/26. The POC/IDG Review dated 10/30, 11/13, 11/26, 12/24/25 and 1/7/26 showed the patient's identified problems with the established goal and interventions as follows:-Cardiovascular: to achieve and maintain peripheral circulation for patient comfort,-Nutrition: will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication, -Respiratory: oxygen treatment to achieve and maintain patient comfort.However, there was no documented evidence of measurable goals as to what adequate food and fluids, maintain peripheral circulation and maintain comfort was for the patients' goal.In addition, The POC/IDG Review dated 12/11/25, showed the identified problems with established interventions for gastro-intestinal.  The goal was to facilitate bowel elimination and comfort. However, there was no documented evidence of measurable goals as to what the comfort level was for the patient. On 3/13/26 at 1145 hours, an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the findings. 2.  Review of Patient 2’s clinical record was initiated on 3/12/26.  The clinical record showed the SOC was 10/8/25.  The patient was certified for hospice services during the certification periods from 10/8/25 to 12/6/25, 12/7/25 to 2/4/26 and 2/5/26 to 4/5/26.The POC/IDG Review dated 12/11, 12/24, 1/7,1/22, 2/5, 2/19, 3/5 and 3/12/26 showed the patient's identified problems with the established goal and interventions as follows:-Cardiovascular: to achieve and maintain peripheral circulation for patient comfort,-Nutrition: will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication.However, there was no documented evidence of measurable goals as to what adequate food and fluids and maintain peripheral circulation for the patients' goal.Further, the POC/IDG Review dated 2/5, 2/19, 3/5 and 3/12/26, showed the identified problems with established interventions for respiratory.  The goal was oxygen treatment to achieve and maintain patient comfort.However, there was no documented evidence of measurable goal as to what level of oxygen to maintain comfort or the patient.On 3/13/26 at 1327 hours, an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the findings. 3.  Review of Patient 3’s clinical record was initiated on 3/12/26.  The clinical record showed the SOC was 5/30/25.  The patient was certified for hospice services during the certification periods from 5/30/25 to 8/22/25, 8/23/25 to 11/25/25, 11/26/25 to 1/24/26, and 1/25/26 to 3/25/25. The POC/IDG Review dated 1/14, 1/29, 2/12, 2/22 and 3/12/26, showed the patient's identified problems with the established goal and interventions as follows:-Nutrition: will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication. -Respiratory: oxygen treatment to achieve and maintain patient comfort.However, there was no documented evidence of measurable goals as to what adequate food and fluids and maintain comfort for the patient.On 3/13/26 at 1411 hours, an interview and concurrent closed clinical record review was conducted with the  DPCS.  The DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients' POCs no less frequently than every 15 calendar days for two of three sampled patients (Patients 1 and 2).  This failure created the potential risk for not providing appropriate, consistent, and quality care to these patients. Findings: --- 1.  Review of Patient 1’s closed clinical record was initiated on 3/10/26.  The clinical record showed the SOC was 4/26/25.  The patient was certified for hospice services during the certification periods from 4/26/25 to 7/24/25, 7/25/25 to 10/22/25, 10/23/25 to 12/21/25 and 12/22/25 to 2/19/26.  The patient had expired on1/17/26. Review of the Visit Note MSW dated 12/12/25, showed the "an input request to volunteer haircut."However, the POC/IDG Review dated 12/24/25, failed to show documented evidence the IDG had discussed the patients' request for a Volunteer haircut.  In addition, there was no documented evidence the IDG had revised the care plan related for the need of a Volunteer service.On 3/13/26 at 1145 hours, an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was asked if the Volunteer services was ordered.  The DPCS reviewed the closed clinical record and replied, no.  The DPCS was also asked if there was a discussion for volunteer services on the 12/24/25 IDG.  The DPCS reviewed the closed clinical record and replied no and it should have been discussed.  The DPCS was informed and acknowledged the finding.     2.  Review of Patient 2’s clinical record was initiated on 3/12/26.  The clinical record showed the SOC was 10/8/25.  The patient was certified for hospice services during the certification periods from 10/8/25 to 12/6/25, 12/7/25 to 2/4/26, and 2/5/26 to 4/5/26.a.  Review of the Visit Note RN dated 1/9/26, showed the patient's medication "for both physicians (Physician 1 and 2) finasteride can be discontinued, however the patients' wife is still hesitant and deciding whether or not she will refill it." The POC/IDG Review dated 1/22/26, showed the IDG had discussed/updated the comprehensive assessment.   However, the POC/IDG failed to discuss the physician's plan for the discontinuation of the medication, finasteride. On 3/13/26 at 1414 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked if the physician's plan of discontinuing finasteride was discussed in the IDG on 1/22/26.  The DPCS reviewed the clinical record and replied, no.  The DPCS was also asked as to what should be discussed in the IDG.  The DPCS replied, " the patients' wife wants to continue the finasteride."  The DPCS was informed and acknowledged the findings.   b.  Review of the Volunteer Note dated 1/14 and 1/26/26, showed Volunteers 1 and 2 conducted a visit.However, the POC/IDG Review dated 1/22 and 2/5/26, failed to show documented evidence of the Volunteer visits discussed. In addition, the POC/IDG dated 1/22 and 2/2/26, was not revised to reflect the Volunteer visits. On 3/13/26 at 1414 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked if the volunteer visits were discussed in the IDG meeting.  The DPCS reviewed the clinical record and replied no documentation.  The DPCS was also asked if the POC/IDG was updated to reflect the volunteer visits.  The DPCS replied none was documented.  The DPCS was 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 provided for one of three  sampled patients (Patient 1).  This failure had the potential risk of not addressing the care needs for this patient. Findings: --- The hospice's P&P titled Interdisciplinary Group Coordination of Care revised 11/2020 showed documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting, and/or clinical note. The written evidence of care coordination will be found in the plan of care and/or interdisciplinary group meeting forms in the patient's clinical record, and will involve the hospice patient's attending physician.  1.  Review of Patient 1’s closed clinical record was initiated on 3/10/26.  The clinical record showed the SOC was 4/26/25.  The patient was certified for hospice services during the certification periods from 4/26/25 to 7/24/25, 7/25/25 to 10/22/25, 10/23/25 to 12/21/25, and 12/22/25 to 2/19/26.  The patient had expired on1/17/26. Review of the Visit Note MSW dated 12/12/25, showed the "an input request to volunteer haircut."However, there was no documented evidence the volunteer was notified of the request for a haircut.  In addition, there was no documented evidence the MSW had coordinated with the IDG regarding the patient’s request for a volunteer haircut. On 3/13/26 at 1145 hours, an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was asked if the request for a volunteer haircut was coordinated.  The DPCS replied yes, it should be documented somewhere.  The DPCS reviewed the closed clinical record and replied none was documented on the communication log.  The DPCS was informed and acknowledged the finding.2.  Review of Patient 2’s clinical record was initiated on 3/12/26.  The clinical record showed the SOC was 10/8/25.  The patient was certified for hospice services during the certification periods from 10/8/25 to 12/6/25, 12/7/25 to 2/4/26, and 2/5/26 to 4/5/26.Review of the Visit Note RN dated 1/9/26, showed the patient's medication " for both physicians (Physician 1 and 2) finasteride can be discontinued, however the patients wife is still hesitant and deciding whether or not she will refill it." On 3/11/26 at 1023 hours, a home visit with the MSW was conducted to Patient 2's home.  The Medication Profile showed the patient's medication included finasteride (for BPH) 5 mg one tablet PO Q HS.   However, review of the clinical record failed to show documented evidence of the IDG had coordinated with the physicians related to the continued use of finasteride. On 3/13/26 at 1414 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked if they coordinated with the physicians regarding the patient's continued use of finasteride.   The DPCS reviewed the clinical record and replied, no.  The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of one sampled patient (Patient 1).  This failure had to potential for not providing the appropriate, consistent, and quality care to this patient.  Findings: --- Review of the hospice's P&P titled Pain Assessment revised 3/2024 showed when the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible.  Pain intensity using a rating scale (e.g., on a pain scale of 0-10: 0 = no pain and 10 = severe pain). Pain intensity should include the current pain, worst pain and least pain using pain scale, pain location (s), pain quality, patterns of radiation, and character, onset, duration, variations, patterns, alleviating and aggravating factors. Review of Patient 1's closed clinical record was initiated on 4/22/25.  The clinical record showed the SOC was 2/27/24.  The patient was certified for hospice services during the certification period from  9/16/24 to 11/14/24 and 11/15/24 to 1/13/25.  The patient was transferred to a non contracted facility on 11/26/24.  a.  Review of the POC/IDG Review dated 9/19 and 10/3/24, cited SN visits 2 times per week plus 3 PRN visits for symptom management.  The POC included a care plan for pain and the interventions included to assess and monitor the pain severity every visit. Review of the SN notes showed the following:-on 10/1/24, the patient was assessed to have pain.  The section for the narrative notes showed the patient had increased pain despite the medications. -on 10/3/24, the patient was assessed to have pain.  The section for the narrative notes showed the patient seemed to only have pain to her fingers on both hands due to the contractures. However, review of the closed clinical record failed to show documented evidence if the severity of pain was assessed as ordered in the POC.  In addition, review of the verbal pain assessment dated 10/1 and 10/3/24, showed the pain was assessed verbally.  However, the pain assessments were incomplete as per the P&P.  On 4/24/25 at 1459 hours, an interview and concurrent closed clinical record review was conducted with the DPCS and Administrator.  The DPCS and Administrator were informed and acknowledged the findings.  b.  Review of the Current Treatment/Medication/DME List showed the physician's order for the pain medications.  The pain medications included the following:-acetaminophen (pain medication) 500 mg two tablets PO every eight hours PRN for mild pain,-morphine sulfate  (narcotic pain medication) 15 mg immediate release tablet one tablet PO every four hours PRN for pain,-Norco (narcotic pain medication) 5 mg-325 mg one tablet PO every four hours PRN for pain,-hydromorphone hydrochloride (narcotic pain medication) 2 mg one tablet one hour prior to changing the hydrocolloid patch for pain with wound care and -morphine sulfate (opioid) 20 mg/ml 20 mg PO prior to wound care for pain with wound care. However, the instructions for the pain medications were not specific as to what pain medication to administer based on the patient's level of pain.  On 4/24/25 at 1459 hours, an interview and concurrent closed clinical record review was conducted with the DPCS and Administrator.  They were asked if the instruction for pain medication needed to be specific as to what pain medication to administer based the patient's the level of pain.  They reviewed the clinical record and the DPCS replied "it was not specific."  The DPCS and Administrator were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the individualized care plan was developed for one of one sampled patient (Patient 1).  This failure had the potential for inconsistent delivery of care which can result in the decline or lack of improvement of the patients' health conditions. Findings: --- Review of the hospice’s P&P titled The Plan of Care revised 3/2024 showed the policy includes a written individualized patient and family/caregiver care plan will be established and maintained for each individual admitted to the hospice program.  Review of Patient 1's closed clinical record was initiated on 4/22/25.  The clinical record showed the SOC was 2/27/24.  The patient was certified for hospice services during the certification period from  9/16/24 to 11/14/24 and 11/15/24 to 1/13/25.  The patient was transferred to a non-contracted facility on 11/26/24. a.  Review of the Updated Assessment dated 9/5/24, showed the RN had performed the nutrition assessment.  The diet was puree with nectar thick liquids. The section for weight loss of more than 10% (6 month) showed "yes."  The assessment also included a “check mark” on the following:-appetite = poor;-swallowing =  aspiration precautions, history of aspirations and choking on liquids, and-hydration = inadequate fluid intake and poor skin turgor.  In addition, review of the Updated Assessment dated 11/14/24, showed the RN had performed nutrition assessment.  The diet was puree with nectar thick liquids. The section for weight loss more of than 10% (6 month) showed "yes."  The assessment also included a “check mark” on the following:-appetite = poor;-swallowing =  dysphagia, aspiration precautions, history of aspirations and choking on liquids, and-hydration = inadequate fluid intake and poor skin turgor.  However, review of the POC/IDG Review dated  9/5, 9/19, 10/3, 10/17, 10/31 and 11/14/24, failed to show documented evidence if an individualized POC was created to address the patient's nutrition status. On 4/24/25 at 1426 hours, an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was asked if the nutrition care plan was created on the POC/IDG.  The DPCS reviewed the clinical record and stated it should have been created.  The DPCS was informed and acknowledged the findings.  b.   Review of the Updated Assessment dated 11/14/24, showed the RN had performed vital signs assessment.  The assessment included the oxygen saturation level of 98% on 3 liters per minute of oxygen. Review of the POC/IDG Review dated  9/5, 9/19, 10/3, 10/17, 10/31, and 11/14/24, showed a care plan problem addressing the potential for altered respiratory status related to high risk for aspiration due to the disease process and oxygen therapy. The interventions included to check the oxygen saturation level PRN during the  SN visits. However, the documents failed to show the specific rate of the oxygen to be given PRN as the section was left blank. On 4/24/25 at 1426 hours an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the POCs included a measurable outcomes for one of one sampled patient (Patient 1).  This failure had the potential for inaccurate evaluation of the POC and provide inappropriate care and services to this patient.  Findings: --- Review of the hospice’s P&P titled The Plan of Care revised 3/2024 showed the procedure includes the written plan of care may contain but will not be limited to individualized interventions to assist with end-of-life care and statement of treatment goals that are measurable.  Review of Patient 1's closed clinical record was initiated on 4/22/25.  The clinical record showed the SOC was 2/27/24.  The patient was certified for hospice services during the certification period from  9/16/24 to 11/14/24 and 11/15/24 to 1/13/25.  The patient was transferred to a non-contracted facility on 11/26/24. The POC/IDG Review dated 9/5, 9/19, 10/3, 10/17 and 10/31 and 11/14/24, showed the patient's identified problems with the established goal and interventions.  The  POC failed to include a measurable outcomes for the patient's identified problems.  For example, the POC showed the following problems and goals:-  for Pain: alteration in physical comfort, the goal included the pain will remain in comfortable level during care.- for Respiratory: potential for altered respiratory status related to the risk of aspiration due to the disease process and oxygen therapy, the goal was to have an optimum level of oxygen as disease progress.- for Gastrointestinal: patient with constipation, the goal included patient will not have discomfort due to constipation.- for Sleep: patient not sleeping at night, the interventions included to identify the sleep pattern vs. normal sleep pattern. However, the document failed to show the measurable levels/parameters of the patient’s comfort level, optimum level of oxygen, and normal sleep pattern. On 4/24/25 at 1426 hours, an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was 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 frequently no less than every 15 calendar days related to the visits frequency for one of one sampled patient (Patient 1).  This failure had the potential for not providing the appropriate, consistent, and quality care to the patients. Findings: --- Review of the hospice's P&P titled Interdisciplinary Group Coordination of Care revised 11/2020 showed the Case Manager will be responsible for the coordination of services with the interdisciplinary group from referral to discharge.  The exact combination of services and the level of care will be unique to each patient and family/caregiver unit, and it change as the needs of the patient and family /caregiver evolve over the course of their involvement with hospice.  The procedure includes a written evidence of care coordination will be found in the plan of care and/or interdisciplinary group meeting forms in the patient's clinical record.  Review of Patient 1's closed clinical record was initiated on 4/22/25.  The clinical record showed the SOC was 2/27/24.  The patient was certified for hospice services during the certification period from  9/16/24 to 11/14/24 and 11/15/24 to 1/13/25.  The patient was transferred to a non-contracted facility on 11/26/24.  Review of the IDG/POC Review dated 9/5, 9/19, 10/3, 10/17, 10/31, 11/14 and 11/26/24, showed the Volunteer visit 1 time per month plus 1 PRN visit for socialization, companionship and emotional support. Review of the Volunteer Note dated 9/27/24, showed the volunteer visited the patient.   The comments section showed the patient’s family member wanted to pause the visit. However, review of the closed clinical record failed to show documented evidence if the IDG discussed the volunteer visit when the frequency was paused as requested by the PCG.  In addition, review of the History of Frequency of Visit showed the Volunteer was discontinued on 9/30/24. However, the IDG POC Review dated 10/3, 10/17, 10/31, 11/14 and 11/26/24, were not revised to reflect the discontinuation of the Volunteer visit.  On 4/24/25 at 1459 hours, an interview and concurrent closed clinical record review was conducted with the DPCS and Administrator.  They were asked if there was an IDG discussion related to the volunteer visit frequency.  The DPCS reviewed the POC/IDG and stated it should have been discussed.  They were also asked if the POC/IDG needed to be revised to show the volunteer visit was paused and discontinued.  The DPCS replied “yes,” it should have been revised.   The DPCS and Administrator were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the medications were coordinated with the physician for one of one sampled patient (Patient 1).  This failure posed the risk of not providing the appropriate, consistent, and quality care to the patient.  Findings: --- Review of Patient 1's closed clinical record was initiated on 4/22/25.  The clinical record showed the SOC was 2/27/24.  The patient was certified for hospice services during the certification period from 9/16/24 to 11/14/24 and 11/15/24 to 1/13/25.  The patient was transferred to a non-contracted facility on 11/26/24. a.  The POC/IDG Review dated 11/14/24, showed SN visits 2 times per week plus 3 PRN visits for symptom management.  The POC/IDG showed a care plan for the skin breakdown.   The intervention included to assess the alteration in skin integrity every visit and apply a moisture barrier cream as ordered. Review of the SN Notes dated 11/19/24, the narrative section, showed the patient was assessed to have a Stage 2 pressure injury to the coccyx and had a new order to apply a triple antibiotic to open area, and apply moisture barrier to the peri wound tissue. However, review of the closed clinical record failed to show documented evidenced if the new order for the triple antibiotic was coordinated with the physician to address the patient's Stage 2 pressure injury to the coccyx. On 4/24/25 at 1426 hours, an interview and concurrent closed clinical record review was conducted with the DPCS.  The DPCS was informed and acknowledged the findings. b.  The POC/IDG Review dated 9/19/24, showed SN visit 2 per week plus 3 PRN for symptom management.  The POC/IDG dated 10/3, 10/17, 10/31, 11/14 and 11/27/24 showed a care plan for pain. Review of the SN visit notes dated 10/1/24, the narrative section showed the patient was medicated with tramadol (narcotic pain medication) 50 mg. Review of the SN visit notes dated 10/10/24, the narrative section showed the PCG reported the tramadol was not effective. However, review of the closed clinical record failed to show documented evidence if the physician ordered the tramadol medication. In addition, there was no documented evidence the used of the tramadol medication was coordinated with the physician. On 4/24/25 at 1002 hours, an interview and concurrent closed clinical record review was conducted with the RN 1 and the DPCS.  RN 1 was asked if there was an order for the tramadol medication,  RN 1 reviewed the closed clinical record and replied “no”.   On 4/24/25 at 1459 hours,  a follow-up interview and concurrent closed clinical record review was conducted with the DPCS and Administrator.  They were asked if there was an order for the tramadol medication and if the used of tramadol medication was communicated with the physician.  They reviewed the clinical record and the DPCS replied, “will look for it”.  The DPCS and Administrator were informed and acknowledged the findings.

Observed in Emergency Management Session. In 3 of 12 HR files reviewed, During review of HR# 10, 11 and #12 there was lack of documentation of organization emergency management plan education at least every 2 years. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 17 patient records reviewed, During RR#2 it was noted lack of a description of the patient's G-tube site on the RN comprehensive assessment. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 17 patient records reviewed, During review of HV#1, RR#6 it was noted lack of documentation that a volunteer was offered at the initial assessments and subsequent reassessments. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 17 patient records reviewed, During RR#3 it was noted by the hospice surveyor the presence of a wound on the right buttock that was not added to the RN summary the next IDG meeting 3 days after the documentation of wound care orders. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 17 patient records reviewed, During HV#1 record review the hospice surveyor noted goals were not individualized or measurable. For example: Pt will have optimum level of oxygen. Pt will not develop any episodes of respiratory crisis as disease progresses. Altered skin will be free of infection as disease progresses. Comfort will be promoted as skin integrity changes throughout disease and dying process. Facilitate and maintain frequent bowel movements for pt comfort. During HV#2 record review it was noted goals that were not individualized or measurable, all with the same target date to be accomplished at the end of the certification period. They included: Hospice SN to monitor BP, Pt needs will be met on a day to day basis as communicated, [patient name] will be monitored by facility staff for changes in condition, Staff will report any changes in condition to Hospice. During RR#10 it was noted the following goals that were not individualized: Facilitate bowel movement for [pt. name], (wife) will verbalize having elimination needs met at an acceptable level. During RR#9 it was noted the following goal was not individualized or measurable: Pt will maintain optimum peripheral circulation through out this benefit period. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 17 patient records reviewed, During RR#2 it was noted by the hospice surveyor an order to Check Oxygen saturation PRN during SN visits. The order lacked the PRN reason to assess the oxygen saturation during SN visits. During RR#2 it was noted during an LVN visit in May 2024 the LVN provided a dressing change to the patient's G-Tube site without a physician order. Also during RR#2 it was noted the patient had a G-tube for feeding and medication administration. The POC lacked interventions related to care and instruction to the PCG on G-tube care, dressing changes, feedings, precautions, return demonstration of feeding procedure, medication administration and other related interventions. During D/C RR#2 it was noted the POC was not updated in January 2023 to reflect interventions and goals for mild redness noted bilaterally on heels. In March 2023 it was noted on the RN summary the presence of a small red spot on left heel. Barrier ointment applied and heel boot placed on left foot without additional interventions and goals added to the POC. In April 2023 it was documented the presence of groin irritation with an order for Nystatin topical twice a day for 7 days on the medication list however additional interventions and goals related to the groin irritation were not added to the POC. This was discussed with the organization leadership.

Observed in Record Review. In 8 of 17 patient records reviewed, During HV#1 record reivew it was noted by the hospice surveyor that assessments only were documented on the POC for cardiac and GI deficits. The identified deficits lacked interventions to accomplish the goals. During RR#4 it was noted the following deficits were assessed during the comprehensive assessment but not added to the POC: aspiration precautions interventions and goals, wound care on the right forearm arm interventions and goals, oxygen use and safety, and seizure precautions interventions and goals. During RR#3 it was noted an order the middle of February 2024 for wound care to the right buttock; cleanse with wound cleanser or NS, pat dry, cover with dry dressing daily. May change PRN, if soiled or falls off was not added to the POC to indicate who would do the wound care daily and other interventions and goals since at that time the SN visits were not daily. In addition in March 2024 an order for wound care to the left hip was not added to the POC with additional interventions and goals related to the new wound on the left hip. During RR#5 it was noted a new order for oxygen 2L/min PRN for comfort or SOB at the initial RN visit. The POC lacked interventions and goals for oxygen use and safety. During RR#6 it was noted assessments only were documented on the POC for cardiac deficits. The identified cardiac deficit lacked interventions to accomplish the goal. A bowel elimination deficit was documented on the POC with the goal to Facilitate bowel elimination and comfort with use of liquids and prescribed medications. There was lack of interventions added to the POC for the deficit. It was noted assessments only were added which included: Assess / monitor effectiveness of medications. Assess bowel status every visit. During RR#7 it was noted lack of interventions and goals on the POC related to the presence of a pressure injury on the coccyx and a high risk for skin breakdown assessed on the Braden scale. In addition the POC documented assessments but lacked interventions related to goals established that included: goal: Satisfactory comfort level achieved with no observable signs of presence of discomfort -Pain will remain in comfortable level during care. Pt will experience a comfortable, peaceful, and safe death in his/her environment of choice. current interventions: Assess / monitor pain and severity every visit -Assess and report non-verbal pain based on body language, moaning, restlessness and goal: Early detection of upper respiratory infection. -Pt will have decreased anxiety related to respiratory changes. -Pt will have optimum level of oxygen as disease progresses -Pt will not develop any episodes of respiratory crisis. -Pt/Family/PCG will verbalize understanding of safety measures re; oxygen use. Interventions included assessments only Check Oxygen saturation PRN during SN visits, Observe sign and symptoms of respiratory infection, Oxygen as ordered via ______ at ______L/min, Monitor/assess effectiveness of current and new medication/treatment. During RR#8 it was noted on an SN note the beginning of May 2024 the following:Coccyx areaOpen wound stage III 1cm x 1 cm and from February 2024 an open area on the right ear 0.5x0.5 cm caused by the oxygen tubing. These issues were not added to the POC. During RR#9 it was noted an altered Cardiac status on the POC with the goal: Pt will maintain optimum peripheral circulation through out this benefit period. There were no interventions identified to achieve the goal only Assess / monitor cardiac status every visit and Assess and monitor effectiveness of medications. it was noted at the initial RN assessment the patient was at a high risk for falls. Fall safety and fall prevention was not added to the POC during the comprehensive assessment. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 17 patient records reviewed, During HV#1 record reivew it was noted by the Hospice surveyor the aide assignment/POC at the SOC date indicated to shave the patient's face at each visit. The patient was receiving oxygen therapy with an order for continuous oxygen at 2L/min, however, the order lacked the type of razor and use with continuous oxygen therapy. In addition the aide applied barrier cream to the patient reddened coccyx and groin area during the visit without direction on the type of ointment to use other than to provide peri care every visit on the assignment form. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 1 patient records reviewed, who revoked the hospice benefit. During D/C RR#1 it was noted by the hospice surveyor lack of documentation that the organization sent the receiving hospital a hospice discharge summary after the patient revoked the hospice benefit. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 17 patient records reviewed, During D/C RR#1 it was noted by the hospice surveyor the patient's POC was not updated when the patient changed his POST in June 2023 to a DNR from a full code that was signed in December 2019. Both POSTs were part of the patient medical record. This was discussed with the organization leadership.

Observed in Record Review. In 10 of 17 patient records reviewed, During record review of D/CRR#1, D/CRR#2, HV#1, HV#2, RR#1-5, #7 it was noted by the hospice surveyor lack of the documented procedures in the medical record to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. This was discussed with the organization leadership.