Every finding on record at Sanford Health Network

Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure emergency preparedness training every two years to all current staff members.  Lack of emergency preparedness training for staff put patients at risk should an emergency situation arise and staff be needed to assist patients to ensure patient safety.    Findings include: --- According to the agency policy titled Emergency Preparedness, dated 5/27/25, the agency must develop and maintain an emergency preparedness training and testing program based on the Emergency Management Plan (EMP).  Staff training includes: initial training training on emergency preparedness policies and procedures to all new and existing staff, including those who provide services under contract; training must be provided every 2 years; the agency must maintain documentation of the training; and staff must demonstrate knowledge of the training procedures.    1.Review of the agency's Emergency Preparedness trainings lacked documentation of training since 8/24/2019 for contracted Staff G, Massage Therapist.  2. Review of the agency's Emergency Preparedness trainings lacked documentation of training since 10/13/2016 for contracted Staff H, Music Therapist.    During an interview on 7/2/25 at 10:50 AM, the Administrator stated no additional training had been done for contracted Staff G and contracted Staff H and they do not participate in Emergency Preparedness drills.    The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.

Based on clinical record review, hospice policy review, hospice admission packet review, patient interview, family interview and staff interview, the hospice failed to:Ensure hospice staff protected and promoted the right of the patient to exercise his/her rights (see L0512)

Based on clinical record review, hospice policy review, patient representative interview and staff interview, the hospice failed to ensure hospice staff honored the right of the patient to receive effective pain management and symptom control while the patient received hospice services for 1 of 5 sampled hospice patients (Patient #14), while residing in a nursing home and deceased.  Failure to ensure hospice staff ensured the patient received effective pain management and symptom control from the hospice for conditions related to the patient's terminal illness, the patient did not have their rights honored in regard to pain management. Findings include: --- According to the hospice policy titled Patient Rights, dated 7/30/24, patients have the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #14 had a hospice admission date of 7/11/23, a death date of 7/18/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 7/11/23 to 10/8/23, identified the patient had diagnoses that included myelodysplastic syndrome (a group of disorders caused by blood cells that don't work properly),  chronic diastolic heart failure, emphysema, pulmonary fibrosis, thrombocytopenia, atrial fibrillation and dependence on supplemental oxygen.  The POC included orders for skilled nursing services to collaborate with facility/agency staff to discuss/review POC, provide certificate of terminal illness (CTI), Plan of Care and future updates to facility/agency. Instruct how to order/obtain hospice covered medications, instruct on the role of hospice at the facility/agency, and discuss schedule of facility/agency Interdisciplinary Group (IDG).  The POC also included intervention the patient/caregiver will demonstrate/verbalize medication needs, side effects and correct use/care of medications: Acetaminophen 500 milligrams (mg) 2 tablets by mouth 3 times a day as needed (prn) for mild pain or headache, Lorazepam (Ativan) 0.5 mg 1 tablet by mouth every 4 hours prn for anxiety, Oxycodone 5 mg 1 tablet by mouth 4 times daily for pain, Oxygen therapy 3 to 4 liters per minute (LPM) per nasal cannula, Eliquis 2.5 mg by mouth 2 times a day (blood thinner). b. The medication update, dated 7/18/23, revealed a physician's order for Roxanol (Morphine) 20 mg/ml, give 10 mg (0.5 ml) sublingual every 1 hour prn shortness of breath, restlessness or pain. c. The (as needed) skilled nurse visit note, dated 7/17/23 from 7:00 PM to 8:30 PM, Staff M, Registered Nurse (RN), revealed, skilled nurse visit was made due to request of the nursing home to evaluate the patient due to oxygen saturation (the measure of how much oxygen is carried in blood) readings in the 60's, even with oxygen at 5 liters per minute (LPM). The nursing home staff had just given an Ativan prn (as needed) and family present. The nursing home nurse had placed the patient's portable oxygen concentrator on the patient at 3 LPM via nasal cannula and also had the oxygen concentrator on at 5 LPM via mask. Patient's  oxygen saturation (O2 Sat) varied between 75% and 80%, heart rate 96 to 104 beats per minute and respirations rapid and shallow, 24 to 30 breaths per minute and the patient denied distress during the skilled nurse visit.  Patient also had a positive Homan's (pain or discomfort in the calf when pointing the foot upwards) on the left leg. Patient alert and speaking with family with mild confusion noted. Staff M, RN documented she advised the family the patient should be given the prescribed Ativan, oxycodone and Eliquis if no other medications were given, which would help the most if patient had an embolism (sudden blockage of a blood vessel by a traveling clot or other substance, such as air or fat). The nursing home nurse informed of medications to be given. d. The hospice case communication note, dated 7/18/23 at 4:00 AM, Staff M, RN included documentation after phone calls at 2:21 AM, 2:47 AM and 3:25 AM, Staff M, RN, called the on call physician and got a telephone order for roxanol 20 mg/milliliter (ml), give 10 mg (0.5 ml) sublingual every hour as needed for shortness of breath, restlessness or pain. The nursing home nurse stated the medication available in the emergency kit. e. The hospice skilled nurse note, dated 7/18/23 at 6:25 AM, Staff M, RN revealed the hospice nurse received a call from the nursing home nurse who reported the patient passed away at 4:55 AM with family at the bedside. The body released to the funeral home at 6:15 AM. f. The nursing home document, titled Medication Administration Record, dated 7/1/23 to 7/30/23, included the following medications administered: Oxycodone 5 mg administered on 7/18/23 at 2:50 AM-ineffective, Lorazepam (Ativan) 0.5 mg administered on 7/17/23 at 7:00 PM-effective, 11:00 PM-ineffective and 2:25 AM-ineffective. g.  The nursing home progress note, dated 7/17/23 at 5:45 PM, documented the patient's family informed the nurse the resident's O2 Sat registering 65%. The nursing home nurse measured the O2 Sat at 64%. The oxygen concentrator tubing changed to shorter tubing and oxygen delivered at 5 LMP via the nasal cannula. The O2 Sat remained at 64% to 65%. Hospice contacted to request a as needed (prn) visit. The patient's respirations at 28 breaths per minute and skin warm and dry. The patient's O2 Sat rose to 76% to 77 % on 5 LPM, and the patient noted to be alert and responded appropriately. h. The nursing home progress notes, dated 7/18/23 at 1:55 AM, documented the hospice nurse arrived at approximately 7:00 PM and informed the nursing home nurse the patient had a positive Homan's sign in the left leg that could be causing the shortness of breath and low oxygen saturation. Family at the bedside and request to keep the patient comfortable at this time. The O2 Sat ranged from 74% to 77% on 5 LPM oxygen mask and 3 LPM portable oxygen per nasal cannula. When the patient repositioned, oxygen saturation ranged form 61% to 64%. Family request both the oxygen mask and nasal cannula remain in place. The patient received Ativan at 7:00 PM and 11:00 PM for increased restlessness and seemed to help the patient calm down. Oxycodone administered as scheduled per family request.  i. The nursing home progress note, dated 7/18/23 at 2:30 AM, documented a call placed to the hospice nurse at 2:20 AM due to the patient's family reported the patient had shortness of breath and just can't catch their breath. The hospice nurse (Staff M, RN) instructed the nurse to administer Ativan dose of 0.5 mg. The nursing home nurse requested hospice change the frequency of the Ativan to be less than every 4 hours between doses or to increase the Ativan dose. The hospice nurse (Staff M, RN) reported she will get the patient something in the morning and instructed the nursing home staff to give the as needed Ativan dosage at this time. The patient continued to gasp for breath and still unable to rest due to shortness of breath. The patient's oxygen saturation dropped to 35% during repositioning at 1:30 AM, oxygen continued to be on at 5 LPM per oxygen mask and 3 Liters per nasal cannula on portable oxygen. At 2:50 AM the patient's family reported the Ativan not working and the patient gasping for air. A telephone call was placed to the hospice nurse (Staff M, RN) again and hospice nurse (Staff M, RN) instructed nursing home staff to give oxycodone now for relief as the combination of oxycodone and Ativan should help. Nursing Home staff administered Oxycodone as ordered.  At 3:25 AM, the patient's family requested morphine ordered as the combination of oxycodone and Ativan did not help the patient at all. The patient continued to be extremely short of breath, continued to be gasping for air and cannot get any rest with ongoing shortness of breath present. A telephone call placed to hospice nurse (Staff M, RN) and discussed the family request.  At 4:00 AM the nursing home nurse received a call back from the hospice nurse (Staff M, RN) for an order for morphine sulfate 10 mg, give 0.5 ml every 1 hour as needed for shortness of breath/anxiety or pain. Morphine 0.5 ml administered and tolerated well. The patient continued to gasp for air. j.  The nursing home progress note, dated 7/18/23 at 4:55 AM, documented the patient had passed away with no blood pressure, pulse or respirations. At 5:25 AM telephone call to hospice nurse (staff M, RN) to report of the patient's death. Unable to leave message, no call or voicemail on, will continue to try calling.  At 6:35 AM, the hospice nurse (Staff M, RN) notified of the patient death at 4:55 AM. k. The hospice untitled document, dated 7/17, 7/18 and 7/24/23, revealed the hospice received a complaint from the nursing home. The complaint included pain/comfort not addressed appropriately, hospice only suggestion to give Ativan and oxycodone that were already ordered and the patient "gasping" for air and roxanol not brought up as a medication option. On 7/24/23 an investigation of the complaint completed. Education on end of life signs and symptoms and interventions with Staff  M, RN occurred. During an interview on 7/7/25 at 10:15 AM, Staff M, RN stated she did not have any memory of patient #14. She did, however remember an instance getting calls from the nursing home. Staff M further stated she did not remember any complaint made concerning her and did not remember any re-education or training regarding end of life signs and symptoms and interventions provided by hospice Administrator or Clinical Manager. During an interview on 7/7/25 at 10:40 AM, the Administrator stated the hospice received a complaint and had reported they felt the patient's pain and comfort not addressed appropriately by the on-call hospice nurse. She also stated she completed education/counseling with Staff M, RN. The expectation is to ensure the patient is comfortable. The above findings were reviewed with the agency Administrator, Clinical Manager and Clinical Quality Specialist.

Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to perform an initial bereavement assessment within 5 days of the patient's election of the hospice benefit as part of the initial comprehensive assessment in order to determine patient and/or family bereavement needs, goals and interventions to be identified on the Plan of Care for 4 of 13 sampled patients (Patients #2, #4, #5 and #6) receiving hospice services for more than 5 days.    Failure to complete an initial bereavement assessment increased the risk that patient's or family's/caregiver's grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors.    Findings include: --- 2. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed:  a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Skilled nurse initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment.  c. Social work initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment.  The hospice failed to complete an initial bereavement risk assessment.  3. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Skilled nurse initial comprehensive assessment, dated 9/18/24, lacked an initial bereavement risk assessment.  c. Social work initial comprehensive assessment, dated 10/10/24, lacked an initial bereavement risk assessment.  d. Bereavement risk assessment, dated 12/12/24, completed.  The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation.   4. Patient #2 had a hospice admission date of 12/12/24 and received services while residing in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 6/10/25 to 8/8/25, identified the patient had a diagnosis of Huntington's disease and included orders for skilled nurse, social work, hospice aide and volunteer services.    b. Skilled nurse initial comprehensive assessment, dated 12/12/24, lacked an initial bereavement risk assessment.  c. Social work initial comprehensive assessment, dated 12/23/24, included a bereavement risk assessment. (6 days after the 5 day post election of benefits)  The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation. The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality  Specialist.  According to the hospice policy titled Assessments: Initial, Comprehensive and Ongoing, dated 1/27/25, the initial assessment will assess the patient's need for hospice care/services and gather critical information necessary to treat the patient/family's immediate physical, psychosocial, emotional and spiritual needs as related to the terminal illness and related conditions.  The comprehensive assessment is completed within 5 calendar days after the election of hospice care by the Interdisciplinary Group (IDG), in consultation with the patient's attending physician.  This may be completed at the same time as the initial assessment.  The assessments should guide: patient problems and needs related to the terminal illness, patient goals related to the terminal illness, patient/caregiver goals related to pain management and anticipated discharge needs, including bereavement and funeral needs.    During an interview on 7/1/25 at 9:25 AM, the Social Worker identified agency Registered Nurses (RN) complete the initial bereavement assessment within 5 days of admission.    1.Patient #5 had a hospice admission date of 6/28/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 6/28/25 to 9/25/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Skilled nurse initial comprehensive assessment, dated 6/28/25, lacked an initial bereavement risk assessment.    c. Social work initial comprehensive assessment, dated 7/1/25, lacked an initial bereavement risk assessment.   The hospice failed to complete an initial bereavement risk assessment.   2. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed:  a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Skilled nurse initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment.  c. Social work initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment.  The hospice failed to complete an initial bereavement risk assessment.  3. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Skilled nurse initial comprehensive assessment, dated 9/18/24, lacked an initial bereavement risk assessment.  c. Social work initial comprehensive assessment, dated 10/10/24, lacked an initial bereavement risk assessment.  d. Bereavement risk assessment, dated 12/12/24, completed.  The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation.  4. Patient #2 had a hospice admission date of 12/12/24 and received services while residing in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 6/10/25 to 8/8/25, identified the patient had a diagnosis of Huntington's disease and included orders for skilled nurse, social work, hospice aide and volunteer services.    b. Skilled nurse initial comprehensive assessment, dated 12/12/24, lacked an initial bereavement risk assessment.  c. Social work initial comprehensive assessment, dated 12/23/24, included a bereavement risk assessment. (6 days after the 5 day post election of benefits)  The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation.  The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.

Based on hospice interview, clinical record review and hospice policy review, the hospice failed to perform comprehensive patient assessments for patient's identified wounds for 1 of 2 patients with wounds receiving services in the home (Patient #1).  Failure of the hospice staff to perform comprehensive wound assessments placed the patient at risk for ineffective staff collaboration and communication regarding the patient’s hospice care and care of the patient’s wound including effectiveness of treatments and interventions. Findings include: --- According to hospice policy titled, Wound Care, dated 7/30/24, the wounds will be measured in centimeters (length x width x depth) at least weekly unless covered with a non-removable dressing during the nurse visit. Wound and peri-wound appearance will be assessed each visit unless covered with a non-removable dressing. Wound assessment will include, but is not limited to; color, odor, drainage, tunneling/undermining, and character of wound bed tissue. During an interview on 7/7/25 at 10:55 AM, the Clinical Manager stated the expectation for staff to assess the wound every visit. Measurements are to be completed every week and include length, width and depth. 1.Patient #1 had a hospice admission date of 6/19/25, and received hospice services in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 6/19/25 to 9/16/25, identified the patient had diagnoses of cirrhosis of the liver, lymphedema and non-pressure chronic ulcer of the right heel and midfoot. The POC included orders for skilled nursing visits 3 times a week and wound dressing changes to the right heel and right knee surgical incision. b. The skilled nurse visit note, dated 6/19/25, included the following wound measurements: right heel:1.2 centimeters (cm) length by 1.2 cm width by 1 cm depth. Right knee #1: 2 cm by 2 cm by 0.1 cm and right knee #2: 2 cm by 2 cm by 0.1 cm. c. The skilled nurse visit notes, dated 6/25/25, included the following wound measurements: right heel: 2 cm by 2 cm by 1 cm. Right knee #1: 2 cm by 2 cm by 0.1 cm and right knee #2: 2 cm by 2 cm by 0.1 cm. During a home observation visit on 7/1/25 at 3:30 PM with the Administrator and ,Staff C, Registered nurse (RN) stated the patient had an open wound noted beneath the current 2 wounds on the right knee 1 week ago. Staff C pointed to area on the right knee that she placed a dressing for a total of 3 wound dressings. She stated the wound is now closed.  During the same home visit the Administrator stated the patient had a wound on the right shin area that is now closed. Review of the clinical record lacked documentation of an assessment or treatment of wound #3 to the right knee or the right shin. The hospice failed to complete wound assessments on all identified wounds. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.

Based on home observation visits, interviews, clinical record reviews and agency policy reviews, the hospice failed to ensure the Plans of Care (POC) for 2 of 3 sampled patients with home observation visits (Patient #1 and #3) identified all medical equipment and supplies necessary to meet identified patient needs.    Failure to include all needed items of medical equipment and supplies the patient used on the POC placed the patients at risk of unanticipated decline or injury and of needs not met.    Findings include: --- 2. Patient #1 had a hospice admission date of 6/19/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 6/19/25 to 9/16/25, identified the patient had a diagnosis of cirrhosis of the liver and used the following medical equipment and supplies: hospital bed, Foley catheter and supplies, wheelchair, wheelchair cushion, walker, Hoyer, mediset, incontinence supplies and urinal.  b. During a home observation visit on 7/1/25 at 3:30 PM, with the Administrator and Staff C, RN, the surveyor observed the patient had a reacher. During an interview with the patient's spouse during the same home visit, he/she stated the patient does use the reacher although does not use it as often as he/she used to. c. During an interview on 7/9/25 at 9:25 AM, the Clinical Manger stated the reacher not added to the POC due to the patient did not have the dexterity to use it anymore. The hospice failed to include all medical equipment and supplies utilized by the patient including the reacher. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.   According to the hospice policy titled Plan of Care, dated 1/27/25, hospice care follows a written Plan of Care (POC) established and reviewed by the Interdisciplinary Group (IDG) in collaboration with the patient's attending physician.  The content of the POC includes but is not limited to: Interventions to manage pain and symptoms, drugs and treatments necessary to meet the needs of the patient, medical supplies and appliances necessary to meet the needs of the patient and a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.   1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 6/11/25 to 8/9/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and used the following medical equipment and supplies: bedrails, hospital bed, oxygen supplies and concentrator, incontinence supplies, bedside table, high back wheelchair, gait belt, gloves, grab bars and walker.  b. During a home observation visit on 7/1/25 at 10:20 AM, with the Administrator and Staff C, Registered Nurse (RN), the surveyor observed the patient utilized a lift chair, a wheelchair cushion and a high rise toilet seat.    c. During an interview on 7/1/25, the Administrator confirmed the medical equipment and supplies had been utilized since prior to the most recent recertification.    d. The IDG meeting notes, dated 7/2/25, failed to identify the lift chair, wheelchair cushion and high rise toilet seat utilized by the patient.    The hospice failed to include all medical equipment and supplies utilized by the patient.

Based on staff communication and clinical record reviews, the hospice agency failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the Plan of Care for 5 of 14 sampled patients (Patients #2, #3, #8, #10 and #13).    Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care, increased the risk that patients did not receive services to meet assessed needs.    Findings include: --- 3. Patient #2 had a hospice admission date of 12/12/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POCs, dated 4/11/25 to 6/9/25 and 6/10/25 to 8/8/25, identified the patient had a diagnosis of Huntington's disease and included orders for skiled nurse visits, social worker, hospice aide visits 5 days per week and volunteer visits.   b. The clinical record included documentation of 4 hospice aide visits the week of 4/27/25 through 5/3/25.   c. The IDG meeting notes, dated 5/7/25, lacked documentation the IDG was notified of the missed hospice aide visit for the week of 4/27/25 through 5/3/25.   The hospice failed to provide hospice aide visits as ordered per the POC.   4. Patient #8 had a hospice admission date of 2/19/25, a date of death of 2/25/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 6/11/25 to 8/9/25, identified the patient had a diagnosis of chronic kidney disease and included orders for skilled nurse, social worker, hospice aide, music therapy 1 time a week, massage therapy and volunteer visits.   b. The clinical record lacked documentation of a music therapy visit the week of 2/19/25 through 2/22/25.   c. The IDG meeting notes, dated 2/26/25, lacked documentation the IDG was notified of the missed music therapy visit for the week of 2/19/25 through 2/22/25.   The hospice failed to provide music therapy visits as ordered per the POC.   5. Patient #3 had a hospice admission date of 10/4/24, a date of death of 10/24/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 10/4/24 to 1/1/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social worker, hospice aide, music therapy, massage therapy and volunteer visits.   b. The clinical record lacked documentation of a massage therapy visit the weeks of 10/6/24 and 10/12/24 and 10/13/24 to 10/19/24.   c. The IDG meeting notes, dated 10/23/25, lacked documentation the IDG was notified of the missed massage therapy visit for the weeks of 10/6/24 and 10/12/24 and 10/13/24 to 10/19/24.    The hospice failed to provide massage therapy visits as ordered per the POC.  They above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy for missed visits.  Missed visits are reported to the IDG team at each IDG meeting and included in the IDG notes.    1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 6/11/25 to 8/9/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse visits 1 time weekly, social worker, hospice aide, music therapy, massage therapy and volunteer visits.    b. The clinical record lacked documentation of a skilled nurse visit the week of 6/15/25.    c. The IDG meeting notes to update the POC, dated 7/2/25 lacked documentation the IDG was notified of the missed skilled nurse visit for the week of 6/15/25.    The hospice failed to provide skilled nurse visits as ordered per the POC.    2. Patient #10 had a hospice admission date of 1/22/25, a death date of 2/10/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 1/22/25 to 4/21/25, identified the patient had a diagnosis of Atherosclerotic heart disease and included orders for skilled nurse, social worker, hospice aide, music therapy and massage therapy 1 time a week effective 1/22/25.    b. The clinical record lacked documentation of a massage therapy visit the week of 1/22/25.    c. The IDG meeting notes to update the POC, dated 1/29/25 lacked documentation the IDG was notified of the missed massage therapy visit for the week of 1/22/25.  The hospice failed to provide massage therapy visits as ordered per the POC.

Based on review of written hospice agreements for services under arrangement, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 3 sampled services (Pharmacy provider).    Failure to include this provision within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care.    Findings include: --- Review of the contract between the hospice and sampled pharmacy provider, date amended 9/27/24, identified the contract lacked the following required component:   The hospice retains oversight of staff and services.  The hospice failed to ensure contractual agreements contained all required components for safe and effective patient care.    The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.

Based on hospice staff communication and clinical record review, the hospice failed to ensure all required components of physician initial certification of the terminal illness (CTI) were completed, appropriately authenticated and included in the patient's clinical record for 4 of 14 sampled patients (Patients #4, #7, #11 and #12).   Failure to obtain the physician's certification of terminal illness put the patients at risk of receiving hospice care inappropriately and/or without a funding source.   Findings include: --- 5. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed:  a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. CTI form, dated 6/5/25 to 9/2/25, included a verbal CTI, dated 6/4/25, but lacked the written attestation statement and physician electronic signature.  The hospice failed to obtain the written CTI.  6. Patient #7 had a hospice admission date of 6/20/25 and received services while residing in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 6/20/25 to 9/17/25, identified the patient had a diagnosis of Dementia of the Alzheimer’s type with late onset without behavioral disturbance and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. CTI form, dated 6/20/25 to 9/17/25, included a verbal CTI, dated 6/20/25, but lacked the written attestation statement and physician electronic signature.  The hospice failed to obtain the written CTI.  Findings were given to the Administrator, Clinical Manager and Clinical Quality Specialist.   1.Patient #11 had a hospice admission date of 3/28/25 and received services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/28/25 to 6/25/25, identified the patient had a diagnosis of metastatic melanoma and included orders for skilled nurse and social work services.   b. CTI form, dated 3/28/25 to 6/25/25, included a verbal CTI, dated 3/28/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 3/28/25 to 6/25/25, dated 7/8/25, by the Medical Director. The hospice failed to obtain the written CTI in the electronic record. 2. Patient #12 had a hospice admission date of 5/23/25 and revoked services on 5/28/25 and received services while residing in a private residence. Clinical record review revealed: a. The POC, dated 5/23/25 to 8/20/25, identified the patient had a diagnosis of chronic kidnew disease and included orders for skilled nurse and social work services.   b. CTI form, dated 5/23/25 to 8/20/25, included a verbal CTI, dated 5/23/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI in the electronic record.  According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy on Certification of Terminal Illness.  The email noted the agency follows regulatory requirements.

Based on staff communication and clinical record reviews, the hospice failed to ensure the hospice medical director reviewed clinical documentation and completed a recertification of terminal illness for 3 of 4 sampled patients receiving services longer than the initial certification period at the time of the survey (Patients #2, #3 and #6).    Failure to obtain the physician's certification of terminal illness put the patients at risk of receiving hospice care inappropriately and/or without a funding source.    Findings include: --- 3. Patient #6 had a hospice admission date of 9/18/24 and received services in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. CTI form, dated 3/17/25 to 5/15/25, included a verbal CTI, dated 3/11/25, but lacked the written attestation statement and physician electronic signature.  c. CTI form, dated 5/16/25 to 7/14/25, included a verbal CTI, dated 5/7/25, but lacked the written attestation statement and physician electronic signature.  The hospice failed to obtain the written CTI.  Findings were given to the Administrator, Clinical Manager and Clinical Quality Specialist.   2. Patient #2 had a hospice admission date of 6/5/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 4/11/25 to 6/9/25 and 6/10/25 to 8/8/24, identified the patient had a diagnosis of Huntinton's disease and included orders for skilled nurse, social work, hospice aide and volunteer services.   b. CTI form, dated 4/11/25 to 6/9/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 4/11/25 to 6/9/25, dated 7/8/25 by the Medical Director. d. CTI form, dated 6/10/25 to 8/8/25, included a verbal CTI, dated 6/3/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for both, 4/11/25 to 6/9/25, and 6/10/25 to 8/8/25, dated 7/8/25 with attestation statement and physician electronic signature by the Medical Director. The hospice failed to complete a CTI.    According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy on Certification of Terminal Illness.  The email noted the agency follows regulatory requirements.    1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 4/12/25 to 6/10/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy and music therapy services.    b. The Certification of Terminal Illness (CTI) form, dated 4/12/25 to 6/10/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature.  c. On 7/9/25, the Administrator and Clinical Quality Specialist gave Surveyor a CTI dated 4/12/25 to 6/10/25, signed completed by the Medical Director on 7/8/25 at 2:02 PM, 87 days after the start of the benefit period.    The hospice failed to obtain the written CTI at the time of recertification.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 3 of 14 sampled patients (Patients #2, #3 and #6).  Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up-to-date information related to the patient's condition and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care.    Findings include: --- 3. Patient #2 had a hospice admission date of 12/12/24 and received services while residing in a nursing home.  Clinical record review revealed:  a. The IDG update to the POC, dated 5/7/25, identified the patient had a diagnosis of Huntington's disease and included orders for skilled nurse, social work, hospice aide and volunteer services.   b. IDG update to the POC, dated 6/4/25, identified a finalization date of 7/2/25, 28 days after the meeting date and 27 days late per agency policy.  The hospice failed to have all documentation completed timely.   The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. 2. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed:  a. The IDG update to the Plan of Care, dated 4/23/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Massage therapy visit notes, dated 4/29/25 and 5/5/25, identified being scanned into the electronic medical record on 6/10/25, 42 and 35 days after the visits, and 41 and 34 days late per agency policy.  c. IDG update to the Plan of Care, dated 6/4/25, identified a finalization date of 7/2/25, 28 days after the meeting date, and 27 days late per agency policy.  The hospice failed to have all documentation completed timely.   According to the hospice policy titled Documentation in the Electronic Medical Record (EMR), dated 10/18/24, hospice clinical records are a combination of paper based and electronic medical records.  Documentation in the clinical record is timely, detailed, accurate and reflects the care and services provided.  Entries are made for all care, services, observations and assessments, communication and are signed by the person providing services no longer than 24 hours after the contact.  All written entries are legible, complete and scanned into the EMR.   1.Patient #3 had a hospice admission date of 6/22/23 and received services while residing in a nursing home.  Clinical record review revealed:   a. The Interdisciplinary Group (IDG) update to the Plan of Care (POC), dated 5/21/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. IDG update to the POC, dated 6/4/25, identified a finalization date of 7/2/25, 28 days after the meeting date and 27 days late per agency policy.   The hospice failed to have all documentation completed timely.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 5 of 14 sampled patients (Patients #3, #4, #5, #6 and #7).    Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients.    Findings include: --- 3. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed:  a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Hospice aide visit note, dated 6/6/25, signed and closed on 6/12/25, 6 days after the visit and 5 days late.  c. Skilled nurse visit note, dated 6/13/25, signed and closed on 6/17/24, 4 days after the visit and 3 days late.  d. Hospice aide visit note, dated 6/9/25, signed and closed on 6/11/25, 2 days after the visit and 1 day late.  e. Hospice aide visit note, dated 6/13/25, signed and closed on 6/15/25, 2 days after the visit and 1 day late.  f. Volunteer visit note, dated 6/9/25, signed and dated 6/15/25, 6 days after the visit.  g. Music therapy visit notes, dated 6/12, 6/19 and 6/26/25, lacked handwritten or electronic signature, title and date completed.  During an interview on 7/2/25 at 3:00 PM, Staff J, Lead Administrative Assistant, reported music therapist usually provides the hospice with visit notes at the end of the month.  They will contact music therapist regarding missing visit notes.  On 7/2/25 at 3:55 PM, Staff J, Lead Administrative Assistant, provided music therapy notes, dated 6/12, 6/19 and 6/26/25, to surveyor and reported they were just emailed to hospice staff.  On 7/8/25 at 3:00 PM, Staff L, Clinical Quality Specialist, provided music therapy notes, dated 6/12/25, 6/19/25 and 6/26/25, to surveyor with handwritten signature and dated the date of visit.  The agency failed to ensure timely completion of routine visit documentation.    4. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed:  a. The IDG update to the Plan of Care, dated 4/23/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Hospice aide visit note, dated 5/6/25, signed and closed on 5/9/25, 3 days after the visit and 2 days late.  c. Volunteer visit note, dated 6/16/25, lacked a signature or date of signature.  The agency failed to ensure timely completion of routine visit documentation.    5. Patient #7 had a hospice admission date of 6/20/25 and received services while residing in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 6/20/25 to 9/17/25, identified the patient had a diagnosis of Dementia of the Alzheimer’s type with late onset without behavioral disturbance and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Hospice aide visit note, dated 6/24/25, signed and closed on 6/27/25, 3 days after the visit and 2 days late.  The agency failed to ensure timely completion of routine visit documentation.   Findings were given to the Administrator, Clinical Manager and Clinical Quality Specialist.   According to the hospice policy titled Documentation in the Electronic Medical Record (EMR), dated 10/18/24, hospice clinical records are a combination of paper based and electronic medical records.  Documentation in the clinical record is timely, detailed, accurate and reflects the care and services provided.  Entries are made for all care, services, observations and assessments, communication and are signed by the person providing services no longer than 24 hours after the contact.  All entries reflect the date care, treatment and/or service was provided, including the month, date and year, time and authentication.  All written entries are are legible, complete and scanned into the EMR.   1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plans of Care (POC), dated 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. Hospice aide visit note, dated 5/6/25, signed completed 5/9/25, 3 days after the visit and 2 days late per agency policy.    c. Hospice aide visit note, dated 5/7/25, signed completed 5/9/25, 2 days after the visit and 1 day late per agency policy.    d. Hospice aide visit note, dated 6/12/25, signed competed 6/15/25, 3 days after the visit and 2 days late per agency policy.   The agency failed to ensure timely completion of routine visit documentation.    2.Patient #5 had a hospice admission date of 6/28/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 6/28/25 to 9/25/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social work, hospice aide, massage therapy and music therapy.    b. Skilled nurse visit note, dated 6/30/25, signed completed 7/2/25, 2 days after the visit and 1 day late per agency policy.    The agency failed to ensure timely completion of routine visit documentation.

Based on review of the written agreements between the hospice and hospitals providing short-term inpatient care or respite care, the hospice failed to ensure the written agreements identified the hospitals would send a copy of the hospice patient's discharge summary to the hospice at the time of discharge from the facility for 2 of 2 sampled written agreements (Hospital A and Hospital B).    Failure to ensure the hospitals provided the hospice with a discharge summary upon hospital discharge of a hospice patient decreased the possibility of continuity of care when the patient returned home.    Findings include: --- 1.The hospice had a contractual agreement with Hospital A, dated 8/28/2022.  The contractual agreement failed to specify the hospital would provide the hospice agency with a copy of the discharge summary at the time of discharge.    2.The hospice had a contractual agreement with Hospital B, dated 8/22/2022.  The contractual agreement failed to specify the hospital would provide the hospice agency with a copy of the discharge summary at the time of discharge.    The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.

Based on staff interview, clinical record reviews and review of nursing home medication administration records, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient's medications with the nursing home for 2 of 2 sampled patients (Patients #2 and #3) with a nursing home medication review.  Failure to ensure the hospice staff provided overall coordination of the patient's medications with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient.    Findings include: --- 2. Patient #2 had a hospice admission date of 12/12/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 6/10/25 to 8/8/25, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 time per week and included physician orders for medications.   b. Review of the patient's nursing home MAR, dated 7/1/25 through 7/30/25, identified the following medication discrepancy with the hospice's POC and Medication Profile for the patient: The hospice POC had an order for atropine sulfate ophthalmic solution 1%, give 2 drop every 4 hours as needed for increased secretions. The nursing home MAR included the order for atropine sulfate ophthalmic solution 1%, give 1 drop every 4 hours as needed for increased secretions. The nursing home identified a start datd of 8/16/2024. Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home.   The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. During an interview on 7/1/25 at 12:22 PM, Staff C, Registered Nurse (RN), identified anytime an update or change to the patient's plan of care occurs, the facility is notified via telephone call or in person regarding the update or change.     1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 6/11/25 to 8/9/25, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 time per week and included physician orders for medications.    b. Review of the patient's nursing home Medication Administration Record (MAR), dated 7/1/25, identified the following medication discrepancy with the hospice's POC and Medication Profile for the patient: The hospice POC had an order for Lorazepam (Ativan) 0.5 milligram (mg) tablet with instructions to take 0.5mg by mouth every 2 hours as needed for agitation or anxiety.  The hospice's Medication Profile identified a start date for the medication, dated 3/6/25.  The nursing home's MAR had an order for Ativan (Lorazepam) 1 mg oral tablet with instructions to give 0.5 mg by mouth every 4 hours as needed for repetitive "help me", "we gotta go".  The nursing home MAR identified a start date for the medication, dated 4/2/25.    Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home.

Based on staff interviews, clinical record reviews and agency policy review, the hospice failed to ensure the substantial provision of a core hospice service, medical social services, complied with the educational and supervisory requirements for personnel providing medical social services for 12 of 14 sampled hospice patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #13) who received social worker services.    Failure of the hospice to ensure a qualified social worker provided and documented regular and timely supervision of the delivery of medical social services increased the risk the delivery of this core service may not have adequately or safely met the needs of hospice patients and/or families.    Findings include: --- According to the agency policy titled Social Services, dated 10/1/2024, social services are provided by qualified social workers (Master of Social Work or Baccalaureate of Social Work), licensed in the state in which they practice, under the direction of a physician and in accordance with the plan of care.  A social worker with a baccalaureate degree will be supervised by a Master of Social Work (MSW) who is employed or contracted by the hospice.   The clinical records of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #13 included documentation the patients received social work services by Staff F, Social Worker.   During an interview on 7/1/2025 at 9:25 AM, Staff F, Social Worker, reported having a Baccalaureate degree in Social Work (BSW) and several years of experience working in a healthcare setting.   Staff F stated he has not received supervision from an MSW since he was hired on 9/3/24.   During an interview on 7/8/2025 at 10:02 AM, Staff L, Clinical Quality Specialist, reported Staff F, BSW had not had supervision since he was hired on 9/3/24.   The agency failed to ensure a qualified Master of Social Work provided and documented regular supervision of the baccalaureate level hospice social worker.    The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks.  The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor.  Based on review of employee personnel files, the hospice failed to ensure completion of a criminal background check for 1 of 5 sampled employees who began serving hospice patients since their last survey, dated 7/27/22.  The hospice reported hiring 12 employees since the last survey.    Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice volunteers and/or employees who had direct patient contact. --- Findings include:  Staff I, Chaplain, had a hire date of 5/5/25.  Staff I's personnel file included documentation of a completed criminal history background check, dated 4/2/25, 33 days prior to Staff I’s hire date.   Hospice staff failed to complete a criminal history background check within 30 days prior to the date of hire on all staff prior to hiring.  The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.

The Iowa Administrative Code, Chapter 78, identifies the hospice must obtain certification that an individual is terminally ill in accordance with the following procedures: (        1) The hospice may obtain verbal orders to initiate hospice services from the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician.  The verbal order shall be noted in the patient’s record.  The verbal order must be given within two days of the start of care and be followed up in writing no later than eight calendar days after hospice care is initiated.  The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course.  (     2) When verbal orders are not secured, the hospice must obtain, no later than two calendar days after hospice care is initiated, written certification signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician. (     3)  Hospice care benefit periods consist of up to two periods of 90 days each and an unlimited number of subsequent 60-day periods as elected by the individual.  The medical director or a physician must recertify at the beginning of each benefit period that the individual is terminally ill.    Based on review of clinical records, the hospice failed to ensure timely completion of the Certification of Terminal Illness for 7 of 14 sampled patients (Patients#2, #3, #4, #6, #7, #11 and #12).    Failure to obtain the physician’s certification of terminal illness put the patient’s at risk of receiving hospice care inappropriately and/or without a funding source.    The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks.  The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor.  Based on review of employee personnel files, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 1 of 5 sampled employees who began serving hospice patients since their last survey, dated 7/27/22.  The hospice reported hiring 12 employees since the last survey.   Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from employees who had direct patient contact. --- 5. Patient #2 had a hospice admission date of 6/5/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 4/11/25 to 6/9/25 and 6/10/25 to 8/8/24, identified the patient had a diagnosis of Huntington's disease and included orders for skilled nurse, social work, hospice aide and volunteer services.   b. CTI form, dated 4/11/25 to 6/9/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 4/11/25 to 6/9/25, dated 7/8/25 by the Medical Director. d. CTI form, dated 6/10/25 to 8/8/25, included a verbal CTI, dated 6/3/25, but lacked the written attestation statement and physician electronic signature. e. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for both, 4/11/25 to 6/9/25, and 6/10/25 to 8/8/25, dated 7/8/25 with attestation statement and physician electronic signature by the Medical Director. The hospice failed to complete a CTI within 8 calendar days after the care initiated. 6. Patient #11 had a hospice admission date of 3/28/25 and revoked services on 5/23/25 and received services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/28/25 to 6/25/25, identified the patient had a diagnosis of metastatic melanoma and included orders for skilled nurse and social work services.   b. CTI form, dated 3/28/25 to 6/25/25, included a verbal CTI, dated 3/28/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 3/28/25 to 6/25/25, dated 7/8/25, by the Medical Director. The hospice failed to obtain the written CTI within 8 calendar days after the care initiated.. 7. Patient #12 had a hospice admission date of 5/23/25 and revoked services on 5/28/25 and received services while residing in a private residence. Clinical record review revealed: a. The POC, dated 5/23/25 to 8/20/25, identified the patient had a diagnosis of chronic kidney disease and included orders for skilled nurse and social work services.   b. CTI form, dated 5/23/25 to 8/20/25, included a verbal CTI, dated 5/23/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI in the electronic record within 8 days after the care initiated.  They above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. 4.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 4/12/25 to 6/10/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy and music therapy services.    b. The Certification of Terminal Illness (CTI) form, dated 4/12/25 to 6/10/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature.  c. On 7/9/25, the Administrator and Clinical Quality Specialist gave Surveyor a CTI dated 4/12/25 to 6/10/25, signed completed by the Medical Director on 7/8/25 at 2:02 PM, 87 days after the start of the benefit period.    According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy on Certification of Terminal Illness.  The email noted the agency follows regulatory requirements.    The hospice failed to obtain the written CTI at the time of recertification. Findings include:  According to the hospice policy titled Hiring and Screening, last reviewed 3/28/25, Human Resources will conduct background checks on all new employees and transfers prior to beginning employment or transferring to a new position.  All offers of employment are contingent upon successful completion of the background check and state-specific background check.  Background checks and verification checks may include but are not limited to: Criminal background check(s) and Local and state-specific background and/or registry checks.  These checks can include, but are not limited to: abuse registry, sexual misconduct registry and nurse aide registry.   Staff I, Chaplain, had a hire date of 5/5/25.  Staff I's personnel file included documentation of completed dependent adult and child abuse record checks, dated 4/2/25, 33 days prior to Staff I’s hire date.  Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  The surveyor reviewed the above findings with the Administrator, Clinical Manager and Clinical Quality Specialist.  1. Patient #6 had a hospice admission date of 9/18/24 and received services in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. CTI form, dated 3/17/25 to 5/15/25, included a verbal CTI, dated 3/11/25, but lacked the written attestation statement and physician electronic signature.  c. CTI form, dated 5/16/25 to 7/14/25, included a verbal CTI, dated 5/7/25, but lacked the written attestation statement and physician electronic signature.  The hospice failed to obtain the written CTI within the required time frame of 8 days.  2. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed:  a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. CTI form, dated 6/5/25 to 9/2/25, included a verbal CTI, dated 6/4/25, but lacked the written attestation statement and physician electronic signature.  The hospice failed to obtain the written CTI within the required time frame of 8 days.  3. Patient #7 had a hospice admission date of 6/20/25 and received services while residing in a nursing home. Clinical record review revealed:  a. The Plan of Care, dated 6/20/25 to 9/17/25, identified the patient had a diagnosis of Dementia of the Alzheimer’s type with late onset without behavioral disturbance and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services.    b. CTI form, dated 6/20/25 to 9/17/25, included a verbal CTI, dated 6/20/25, but lacked the written attestation statement and physician electronic signature.  The hospice failed to obtain the written CTI within the required time frame of 8 days.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the drug regimen review (DRR) included a complete review of all the required components at the start of care and at least every 15 days with the update to the comprehensive assessment for 6 of 11 sampled patients (Patients #2, #3, #6, #8, #10 and #11). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed all components of the drug regimen review with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. Findings include: Review of the hospice policy, titled Drug Regimen Review, Hospice, dated 4/28/22, revealed the DRR comprehensive review of medication will include a review of all medication prescribed, herbal remedies, over the counter medications and other alternative treatments that could affect drug therapy the patient is currently using. The following should be reviewed: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with laboratory monitoring. The initial drug regimen review is performed by the pharmacist and a Registered Nurse (RN) during the initial comprehensive assessment. The IDG will complete a DRR at least every 15 days with the update to the comprehensive assessment. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported hospice staff completed the DRR at admit to hospice, with each recertification and at each IDG meeting. The DRR includes a review of medication side effects, duplicate drug therapy, drug therapy associated with laboratory monitoring, drug interactions and adverse reactions. 1. Patient #3 had a hospice admission date of 6/22/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/22/22 to 9/19/22, included orders for medications. The physician ordered the following medications associated with laboratory testing: Losartan, Amlodipine, Atorvastatin and Potassium. b. The initial IDG meeting, dated 6/29/22, and subsequent IDG meetings, dated 7/6 and 7/13/22, included a DRR which identified the patient did not have any lab testing ordered at the time of the review, but failed to identify if the patient was taking any medications associated with laboratory monitoring. 2. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included orders for medications. The physician ordered the following medications associated with laboratory testing: Levothyroxine, Metoprolol and Potassium. b. The initial IDG meeting, dated 5/25/22, and subsequent IDG meetings, dated 6/1, 6/8, 6/15, 6/22, 6/29, 7/6 and 7/13/22, included a DRR which identified the patient did not take any medications associated with lab monitoring. 3. Patient #8 had a hospice admission date of 7/8/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included orders for medications. The physician ordered the following medications associated with laboratory monitoring: Lasix, Levothyroxine, Metoprolol and Potassium. b. The comprehensive assessment completed by a RN, dated 7/8/22, and the initial IDG meeting, dated 7/13/22, included a DRR which identified the patient did not have any lab testing ordered at the time of the review, but failed to identify if the patient was taking any medications associated with laboratory monitoring. 4. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record revealed the following: a. The POC, dated 5/19/22 to 8/16/22, included orders for medications. The physician ordered the following medications associated with laboratory monitoring: Lasix. b. The comprehensive assessment completed by a RN, dated 5/19/22, included a DRR which identified the patient did not take any medications associated with laboratory monitoring. 5. Patient #11 had a hospice admission date of 5/24/22, received hospice services while residing in a private residence and died on 6/4/22. Review of the clinical record revealed the following: a. The POC, dated 5/24/22 to 6/4/22, included orders for medications. The physician ordered the following medications associated with laboratory monitoring: Metolazone, Bumex, Atorvastatin, Carvedilol, Isosorbide Mononitrate, Hydralazine and Levothyroxine. b. The comprehensive assessment completed by a RN, dated 5/24/22, and the initial IDG meeting, dated 6/1/22, included a DRR which identified the patient did not have any lab testing ordered at the time of the review, but failed to identify if the patient was taking any medications associated with laboratory monitoring. 6. Patient #2 had a hospice admission date of 7/7/22 and received hospice services while residing in a nursing home. a. The IDG update to the POC DRR, dated 7/14/22, identified the patient was using Isosorbide and Carvedilol (both medications used for heart), Plavix and Aspirin (both used to thin the blood), Glipizide and Metformin (both used for diabetes) and Spironolactone and Furosemide (both used for fluid retention). The IDG update to the Plan of Care (POC), dated 7/14/22, included documentation of a DRR. The DRR identified duplicate drug therapy included medications for the bowels and eyes. The DRR lacked identification of duplicate drug therapy for the heart, blood thinning, diabetes, and fluid retention. b. The nursing home's medication list for July 2022, included orders for fasting blood sugars weekly on Mondays. The IDG update to the Plan of Care (POC), dated 7/14/22, included documentation of a DRR. The DRR identified no drug therapy was currently associated with laboratory monitoring. The DRR lacked the laboratory monitoring associated with the patient's diabetes medications. c. The nursing home's medication list for July 2022, included orders for levothyroxine (a thyroid medication that is associated with laboratory monitoring). The IDG update to the Plan of Care (POC), dated 7/14/22, included documentation of a DRR. The DRR lacked identification of the patient's use of Levothyroxine and identified no drug therapy was currently associated with laboratory monitoring. The DRR lacked the laboratory monitoring associated with the patient's thyroid medication. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient /patient representative interview and hospice staff interview, the hospice failed to: 1) ensure the hospice provided care and services to patients and their families that followed an individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the patient/patient representative (see L543); 2) ensure the hospice IDG developed a Plan of Care (POC) for each patient which included goals and interventions for all services ordered based on the assessed needs of the patient and caregiver (see L545); 2) ensure the hospice IDG developed a POC which included all necessary drugs and treatments to meet the needs of the patient (see L549); 3) ensure the hospice IDG developed a POC which included all medical supplies and appliances necessary to meet the needs of the patient (see L550); 4) ensure the hospice IDG reviewed and revised the patient's plan of care based on updates to the comprehensive assessment and included the patient's progress towards outcomes and goals for care and services specified in the plan of care (see L553); and, 5) ensure the hospice Interdisciplinary Group members collaborated and communicated to ensure hospice staff provided care and services in accordance with the Plan of Care (see L555). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.

Based on clinical record review, hospice policy review and patient representative interview, the hospice failed to ensure hospice Interdisciplinary Group members collaborated with the patient's representative prior to implementing changes to the Plan of Care for 1 of 11 sampled (Patient #10). Failure to collaborate with the patient's representative prior to making changes to the patient's Plan of Care put the patient at risk of inconsistent care that may not meet the desired needs of the patient. Findings include: Review of the hospice's policy, titled Patient Plan of Care (POC), Hospice, dated 4/28/22, identified the hospice IDG develops a POC with a physician and the involvement and agreement of the patient or patient's representative. Hospice staff are to keep the patient and family involved and informed of any changes to the patient's care and treatment. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record revealed the following: a. Hospice admission documents, including the Statement of Financial Responsibility, release of information, informed consent and Hospice Medicare/Medicaid Benefit Election, dated 5/19/22, included documentation of a signature by the patient's representative. The initial hospice consent and hospice plan of care, signed by the patient's representative, dated 5/19/22, included a plan for the patient/family to receive skilled nursing, social worker and chaplain services. The patient representative signed agreement with the plan of care and planned visit schedule. b. The POC, dated 5/19/22 to 8/16/22, identified the patient had a known severe allergy to Morphine Sulfate which caused hives since 1/12/2008. c. A skilled nursing visit note, dated 5/23/22, included documentation the patient reported pain at a 7 out of 10. d. A skilled nursing communication note, dated 5/24/22, included documentation the hospice nurse had been trying to get a hold of the patient's attending physician in relation to medication changes needed. The hospice nurse documented the physician's nurse reported the physician would be signing orders over lunch that day. e. A skilled nursing communication note, dated 5/25/22, included documentation the hospice nurse received the following physician orders at 9:00 AM: Morphine Sulfate 20 milligrams (mg) per milliliter (ml), give 0.25 ml to 1 ml (5 to 20 mg) every hours as needed for pain and Ativan 0.5 mg 1 to 2 tabs every 4 hours as needed for anxiety and oxygen 2 liters per nasal cannula or mask as needed for dyspnea (difficulty breathing). The hospice nurse documented she called and spoke with a facility (nursing home) nurse to ensure they had the orders as well. The facility nurse voiced concerns about the ranges for the medications and reported she had already contacted the physician about this concern. The facility and hospice nurse developed a plan to start with the lower doses initially for the medications. According to the hospice nurse, both she and the facility nurse noted the patient had an allergy to Morphine use in the past which caused hives. The hospice nurse documented the patient's allergy to Morphine was brought to the attention of the "MD", and the "MD" stated it was okay to use the medication. The hospice nurse reported the pharmacy was made aware of the new medication orders. The facility nurse reported the patient did not need oxygen at this time. The hospice nurse documented the facility nurse asked for hospice aide services and asked about a Foley (urinary) catheter. The facility planned on contacting the "MD" again for the Foley catheter order and clarification of orders. f. The clinical record included documentation of verbal orders, dated 5/25/22 for Ativan 0.5 mg 1 to 2 tabs every 4 hours as needed for anxiety, starting with one tab initially, and Morphine 0.25 ml to 1 ml every hour as needed for pain, starting with 0.25 ml initially, oxygen and hospice aide services 1 to 2 times per week starting on 5/27/22. g. A skilled nursing communication note, dated 5/26/22 at 3:22 PM, included documentation the hospice nurse reported the patient had increased pain. She documented the discussion of adding a long-acting pain medication to supplement the Roxanol (Morphine Sulfate). The hospice nurse documented she contacted the patient's attending physician for an order for MS Contin ER. The physician's nurse left a message stating the physician gave a verbal order for this medication. The hospice nurse confirmed the pharmacy received the order. h. A skilled nursing communication note, dated 5/26/22 at 3:53 PM, included documentation the hospice nurse contacted the patient's representative to give an update. The hospice nurse let the patient representative know the patient had an increase in pain, and she had obtained an order for MS Contin ER in addition to the Roxanol. She also informed the patient's representative that they had started the patient on oxygen which was helping and put a hospice aide to help the patient with bathing twice per week. She documented the patient representative acknowledged the information. On 7/27/22 at 1:13 PM, during a phone interview, the patient's representative reported not being aware the patient had an allergy to Morphine. The patient representative reported this was not explained; however, the main concern for the patient representative was the patient's comfort. Hospice staff failed to ensure they included the patient's representative in the care planning process prior to implementing changes to the Plan of Care. Hospice nursing staff failed to adequately explain the risk of the patient using Morphine with a known allergy in order for the hospice representative to make an informed decision on behalf of the patient. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed an individualized plan of care which included goals and interventions of all services ordered based on the assessed needs of the patient and caregiver for 8 of 8 sampled patients (Patients #2, #3, #4, #5, #6, #8, #9 and #11) who had massage and/or music therapy services. Failure to develop a plan of care with goals and interventions for all services ordered by the IDG placed patients and families at risk for not having their assessed needs met. Findings include: Review of the hospice's policy, titled Patient Plan of Care (POC), Hospice, dated 4/28/22, identified the hospice IDG develops a POC in collaboration with the physician and patient/patient representative which includes measurable outcomes and interventions related to services necessary to meet the needs of the patient and family. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported the electronic computer system generated an auto statement on the POC which identified the massage and/or music therapist would provide interventions to meet individualized goals established by the respective therapist. 1. Patient #3 had a hospice admission date of 6/22/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/22/22 to 9/19/22, included IDG orders for music and massage therapy 1 time per week. The POC included a statement which identified the massage and/or music therapist would provide interventions to meet individualized goals established by the respective therapist. The POC lacked any interventions or outcomes/goals specific to the patient's identified needs/wishes. b. The IDG meetings, dated 6/29, 7/6 and 7/13/22, lacked documentation the IDG established any interventions and goals/outcomes related to massage and music therapy specific to the patient. 2. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for music and massage therapy 1 to 2 times per week. The POC included a statement which identified the massage and/or music therapist would provide interventions to meet individualized goals established by the respective therapist. The POC lacked any interventions or outcomes/goals specific to the patient's identified needs/wishes. b. The initial IDG meeting, dated 5/25/22, and subsequent IDG meetings, dated 6/1, 6/8, 6/15, 6/22, 6/29, 7/6 and 7/13/22, lacked documentation the IDG established any interventions and goals/outcomes related to massage and music therapy specific to the patient. 3. Patient #8 had a hospice admission date of 7/8/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for music and massage therapy 2 to 4 times per month. The POC included a statement which identified the massage and/or music therapist would provide interventions to meet individualized goals established by the respective therapist. The POC lacked any interventions or outcomes/goals specific to the patient's identified needs/wishes. b. The IDG meeting, dated 7/13/22, lacked documentation the IDG established any interventions and goals/outcomes related to massage and music therapy specific to the patient. 4. Patient #11 had a hospice admission date of 5/24/22, received hospice services while residing in a private residence and died on 6/4/22. Review of the clinical record revealed the following: a. The POC, dated 5/24/22 to 6/4/22, included orders for music and massage therapy 2 to 4 times per month. The POC included a statement which identified the massage and/or music therapist would provide interventions to meet individualized goals established by the respective therapist. The POC lacked any interventions or outcomes/goals specific to the patient's identified needs/wishes. b. The IDG meeting, dated 6/1/22, lacked documentation the IDG established any interventions and goals/outcomes related to massage and music therapy specific to the patient. 5. Patient #5 had a hospice admission date of 4/29/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 4/29/22 to 7/27/22, included IDG orders as follows: a. Massage therapy 1 to 2 times a week. b. Music therapy 1 to 2 times a week. d. The IDG meeting notes, dated 5/25, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6 and 7/13/22, lacked documentation of the music therapy and massage therapy goals and interventions. 6. Patient #9 had a hospice admission date of 5/17/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC, dated 5/17/22 to 8/14/22, included IDG orders as follows: a. Massage therapy 1 to 2 times a week. b. Music therapy 1 to 2 times a week. d. The IDG meeting notes, dated 5/25, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6 and 7/13/22, lacked documentation of the music therapy and massage therapy goals and interventions. 7. Patient #2 had a hospice admission date of 7/7/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 7/7/22 to 10/4/22, included IDG orders as follows: a. Massage therapy 2 to 4 times a month. b. Music therapy 2 to 4 times a month. c. The IDG meeting notes, dated 7/13/22, lacked documentation of the music therapy and massage therapy goals and interventions. 8. Patient #4 had a hospice admission date of 1/25/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POCs, dated 3/26/22 to 5/24/22 and 5/25/22 to 7/23/22, included IDG orders as follows: a. Massage therapy 2 to 4 times a month. b. Music therapy 2 to 4 times a month. c. The IDG meeting notes, dated 5/25, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6 and 7/13/22, lacked documentation of the music therapy and massage therapy goals and interventions. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice plan of care included a complete order for all medications and treatments to meet the needs of the patient for 2 of 11 sampled patients (Patients #10 and #11). Failure to ensure the plan of care included physician orders for all necessary medications and treatments placed patients at risk to not receive needed or appropriate treatment of symptoms. Findings include: Review of the hospice's policy, titled Patient Plan of Care (POC), Hospice, dated 4/28/22, identified the POC will include drugs and treatments necessary to meet the needs of the patient. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported the RN Case Manager, Patient Care Coordinator and Admission Coordinator ensures the clinical record includes all physician orders. 1. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record revealed the following: a. The POC, dated 5/19/22 to 8/16/22, identified a diagnosis of hypertensive heart disease with chronic kidney disease and heart failure and included IDG orders for skilled nursing services. The POC identified the patient used Ace Wraps for medical equipment and supplies. b. The comprehensive assessment completed by a registered nurse at the start of care, dated 5/19/22, included documentation the nurse assessed the patient had 2 plus pitting edema (extreme retention of fluid) in the lower extremities and edema in the arms and hands. The nurse documented the patient had extensive edema with weeping of fluid to the lower legs (a symptom associated with heart failure and chronic kidney disease). The nurse documented a Telfa and Kerlix dressing with edema netting covered the lower extremities. c. The subsequent skilled nursing visit, dated 5/23/22, identified the patient continued to have extensive edema to the lower extremities and an ABD (abdominal wound pad), Kerlix and Ace bandage. The POC and clinical record failed to include any type of treatment order to treat edema and weeping of fluid from the lower extremities. 2. Patient #11 had a hospice admission date of 5/24/22, received hospice services while residing in a private residence and died on 6/4/22. Review of the clinical record revealed the following: a. The POC, dated 5/24/22 to 6/4/22, included a physician order for oxygen 4 liters orally every night via inhalation. The order failed to specify the specific route of delivery (such as nasal cannula or mask). b. The comprehensive assessment completed at the start of care by a registered nurse, dated 5/24/22, and subsequent skilled nursing visits, dated 5/27, 5/31, 6/3 and 6/4/22, identified the patient used oxygen at 2 liters per minute via nasal cannula. The POC failed to include an order for oxygen that accurately reflected the patient's use. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, home visit observation, nursing home record review and assisted living staff interview, the hospice failed to ensure the Plan of Care included all medical equipment and supplies necessary to meet identified patient needs for 3 of 3 sampled patients (Patients #1, #2 and #5) with a home visit observation. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: Review of the hospice's policy, titled Patient Plan of Care (POC), Hospice, dated 4/28/22, identified the POC will include medical equipment and supplies used by the patient. 1. Patient #1 had a hospice admission date of 6/23/22 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 6/23/22 to 9/20/22, identified the patient had the following medical equipment and supplies: wheelchair, hand held shower, bath bench and incontinent supplies. b. The IDG meeting, dated 6/29/22, 7/6 and 7/13/22, identified no additional medical equipment and supplies used by the patient. On 7/27/22 at 10:08 AM, during a home visit observation with Staff J, Registered Nurse (RN) the surveyor observed the patient had a walker. In an interview, during the same nursing home visit observation, the Assisted Living staff stated the patient continues to use the walker and has been using the walker prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. 2. Patient #5 had a hospice admission date of 4/29/22 and received hospice services in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 7/27/22, identified the patient had the following medical equipment and supplies: wheelchair, walker, wheelchair cushion. b. The IDG meeting note, dated 7/20/22, included the addition of supplies including incontinent supplies. c. The IDG meeting, dated 5/25/22, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6 and 7/13/22, identified no additional medical equipment and supplies used by the patient. d. On 7/26/22 at 10:30 AM, during a home visit observation with Staff B, Patient Care Coordinator, the surveyor identified the patient also used rooke boots and a gait belt. e. The massage therapist note, dated 5/31/22, documented the patient had rooke boots on. f. The nursing home care plan dated 6/29/22, identified the patient utilized a gait belt for 2 person transfers. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. 3. Patient #2 had a hospice admission date of 7/7/22 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/7/22 to 10/4/22, lacked identification of any medical equipment and/or supplies. b. The IDG meeting, dated 7/14/22, identified no additional medical equipment and supplies used by the patient. On 7/26/22 at 11:40 AM, during a home visit observation with Staff C, Registered Nurse (RN) the surveyor identified the following: a. A hospital bed located in the patient's bedroom b. An air mattress on the patient's hospital bed c. A broda wheelchair the patient was sitting in during the entire visit. d. A hoyer lift in the patient's room next to the hospital bed. e. Tubagrip stockings on the the patient's bilateral lower extremities. f. Incontinence supplies, including a pad on the patient's bed and depends in the patient's bathroom. In an interview, during the same nursing home visit observation, the Charge Nurse at the nursing home stated he/she has used the equipment since admission to the hospice. The POC, and IDG meeting to update the POC, failed to identify all medical equipment and supplies used by the patient. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group reviewed and revised the patient's plan of care based on updates to the comprehensive assessment and included the patient's progress towards outcomes and goals for care and services specified in the plan of care for 9 of 11 sampled patients (Patients #1, #2, #3, #4, #5, #6, #8, #9 and #11). Failure of the hospice to ensure the Interdisciplinary Group (IDG) reviewed and revised the patient's plan of care based on updates to the comprehensive assessment and included patients' progress towards outcomes and goals for care and services provided by the hospice placed patients at risk to not receive care and services based on their current assessed needs. Findings include: Review of the hospice's policy, titled Patient Plan of Care (POC), Hospice, dated 4/28/22, identified the hospice IDG develops a POC in collaboration with the physician and patient/patient representative which includes measurable outcomes and interventions related to services necessary to meet the needs of the patient and family. Review of the hospice's policy, titled Interdisciplinary Team, Hospice, dated 4/28/22, revealed the IDG is responsible for establishing, reviewing and updating the POC at least every 15 days and providing supervision of hospice care and services. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported she was responsible to obtain updates from massage and music therapy and report this to the IDG. The Aide Coordinator or Registered Nurse Case Manager were responsible to provide updates to the IDG on hospice aide services and the Volunteer Coordinator provides updates on volunteer services. 1. Patient #3 had a hospice admission date of 6/22/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/22/22 to 9/19/22, included IDG orders for skilled nursing, social worker, hospice aide, volunteer, music and massage therapy services. b. The IDG meetings, dated 6/29 and 7/13/22, included documentation of interventions and outcome progress for skilled nursing and social worker services, but lacked any documentation of updates regarding music, massage, volunteer and hospice aide services. c. The IDG meeting, dated 7/6/22, included documentation of interventions and outcome progress for skilled nursing services, but lacked any documentation of updates regarding social worker, music, massage, volunteer and hospice aide services. 2. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for skilled nursing, social worker 2 to 4 times per month, hospice aide services 1 to 2 times per week, volunteer services 2 times per week, music and massage therapy 1 to 2 times per week. b. The IDG meetings, dated 5/25 and 6/15/22, included documentation of interventions and outcome progress for skilled nursing services, but lacked any documentation of updates regarding social worker, music, massage, volunteer and hospice aide services. c. The IDG meetings, dated 6/1, 6/8, 6/22, 6/29, 7/6 and 7/13/22, included documentation of interventions and outcome progress for skilled nursing and social worker services, but lacked any documentation of updates regarding music, massage, volunteer and hospice aide services. 3. Patient #8 had a hospice admission date of 7/8/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for music and massage therapy 2 to 4 times per month. b. The IDG meeting, dated 7/13/22, included documentation of interventions and outcome progress for skilled nursing and social worker services, but lacked any documentation of updates regarding music and massage therapy services. 4. Patient #11 had a hospice admission date of 5/24/22, received hospice services while residing in a private residence and died on 6/4/22. Review of the clinical record revealed the following: a. The POC, dated 5/24/22 to 6/4/22, included IDG orders for music and massage therapy 2 to 4 times per month. b. The IDG meeting, dated 7/13/22, included documentation of interventions and outcome progress for skilled nursing and social worker services, but lacked any documentation of updates regarding music and massage therapy services. 5. Patient #1 had a hospice admission date of 6/23/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/23/22 to 9/20/22, included IDG orders for volunteer services 1 to 2 times a week. b. The IDG meeting, dated 6/29/22, 7/6/22 and 7/13/22, , lacked documentation of progress towards interventions and the goal related to volunteer services. The hospice failed to include updates to the POC for volunteer services. 6. Patient #5 had a hospice admission date of 4/29/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 7/27/22, included IDG orders for music therapy services 1 to 2 times a week, massage therapy services 1 to 2 times a week and volunteer services 1 to 2 times a week. b. The IDG meeting, dated 5/25/22, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6/22 and 7/13/22, lacked documentation of progress towards interventions and the goal related to music therapy, massage therapy and volunteer services. The hospice failed to include updates to the POC for music therapy, massage therapy and volunteer services. 7. Patient #1 had a hospice admission date of 5/17/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 5/17/22 to 8/14/22, included IDG orders for music therapy 1 to 2 times a week and massage therapy 1 to 2 times a week. b. The IDG meeting, dated 5/25/22, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6/22 and 7/13/22, lacked documentation of progress towards interventions and the goal related to music therapy and massage therapy services. The hospice failed to include updates to the POC for music therapy and massage therapy services. 8. Patient #2 had a hospice admission date of 7/7/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 7/7/22 to 10/4/22, included IDG orders for aide services 3 to 5 times per wee, volunteer services 2 to 3 times a week, music therapy 2 to 4 times per month, and massage therapy 2 to 4 times per month. b. The IDG meeting, dated 7/14/22, , lacked documentation of progress towards interventions and the goal related to volunteer, music services. The hospice failed to include updates to the POC for aide, volunteer, music, and massage therapy services. 9. Patient #4 had a hospice admission date of 1/25/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 3/26/22 to 5/24/22 and 5/25/22 to 7/23/22, included IDG orders for volunteer services 1 to 2 times per week, music therapy services 2 to 4 times a month, and massage therapy services 2 to 4 times a month. b. The IDG meetings, dated 5/25/22, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6/22 and 7/13/22, lacked documentation of progress towards interventions and the goal related to music therapy, massage therapy and volunteer services. The hospice failed to include updates to the POC for music therapy, massage therapy and volunteer services. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff did not provide any additional information prior to the end of the survey.

Based on hospice policy review, clinical record review, and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the Plan of Care for 6 of 11 sampled patients (Patients #2, #3, #5, #6, #7 and #11). Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice's policy, titled Interdisciplinary Team, Hospice, dated 4/28/22, revealed the IDG is responsible for establishing, reviewing and updating the POC at least every 15 days and providing supervision of hospice care and services. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported she was responsible to obtain updates from massage and music therapy and report this to the IDG. The Aide Coordinator or Registered Nurse Case Manager were responsible to provide updates to the IDG on hospice aide services and the Volunteer Coordinator provides updates on volunteer services. 1. Patient #3 had a hospice admission date of 6/22/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/22/22 to 9/19/22, included IDG orders for volunteer 1 to 2 times per week, music and massage therapy services 1 time per week. b. On 7/26/22, review of the clinical record revealed a lack of visit notes for music, massage and volunteer services. On 7/26/22 at 9:35 AM, the surveyor notified the Patient Care Coordinator of an inability to find the massage, music and volunteer therapy visit notes in the clinical record. She reported they were waiting for the music and massage therapists to bring the visit notes to the office, but could get the volunteer visit notes. On 7/27/22, the Patient Care Coordinator provided a copy of the massage therapy visit notes, dated 6/28, 7/6, 7/12 and 7/26/22, but not any visit notes for music therapy or volunteer services. c. The IDG meeting notes, dated 6/29, 7/6 and 7/13/22, lacked documentation of IDG member awareness of missed visits for music or volunteer services. 2. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for volunteer services 2 times per week, music and massage therapy services 1 to 2 times per week. b. On 7/26/22, review of the clinical record revealed documentation of a volunteer services care plan, dated 5/19/22, 2 additional volunteer visit notes, dated 5/23 and 5/30/22, and 2 music therapy visit notes, dated 5/19 and 5/26/22. The clinical record lacked documentation of any massage therapy visit notes and any other volunteer and music therapy visit notes. On 7/26/22 at 4:14 PM, the Administrator provided copies of massage therapy visit notes, dated 6/27, 7/5, 7/11 and 7/26/22. She also provided copies of music therapy visit notes, dated 6/2, 6/9 and 7/7/22. She did not provide copies of any other volunteer visit notes. c. The IDG meetings, dated 5/25, 6/1, 6/8, 6/15, 6/22, 6/29, 7/6 and 7/13/22, lacked documentation of IDG awareness of any missed visits for volunteer, music or massage therapy services. 3. Patient #11 had a hospice admission date of 5/24/22, received hospice services while residing in a private residence and died on 6/4/22. Review of the clinical record revealed the following: a. The POC, dated 5/24/22 to 6/4/22, included IDG orders for music and massage therapy 2 to 4 times per month. b. On 7/26/22, review of the clinical record revealed a lack of music and massage therapy visit notes. c. The IDG meeting note, dated 6/1/22, lacked documentation of IDG member awareness of any missed visits for music or massage therapy services. 4. Patient #5 had a hospice admission date of 4/29/22 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 4/29/22 to 7/27/22, included physician orders for music therapy services 1 to 2 times a week and massage therapy services 1 to 2 times a week. b. The clinical record lacked documentation massage therapy services were completed the weeks of 6/12/22 through 6/18/22 and 6/19/22 through 6/25/22. c. The clinical record lacked documentation music therapy services were completed the weeks of 5/22/22 through 5/28/22 6/12/22 through 6/18/22 and 7/10/22 through 7/16/22. d. The IDG update to the POC, dated 5/25/22, 6/1, 6/8, 6/15, 6/22, 6/29/22, 7/6 and 7/13/22, lacked documentation of the missed music therapy and massage therapy services. 5. Patient #2 had a hospice admission date of 7/7/22 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 7/7/22/22 to 10/4/22, included physician orders for volunteer services 2 to 3 times a week. b. The clinical record documented a volunteer visit was made on 7/14/22 and 7/21/22. c. The clinical record lacked documentation of a second volunteer visit was made as ordered for the weeks of 7/10/22 and 7/17/22. d. The IDG update to the POC, dated 7/14/22, lacked documentation of the missed volunteer visits. 6. Patient #7 had a hospice admission date of 2/24/22 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 5/24/22 to 8/22/22, included physician orders for social work services 2 to 4 times a week. b. The clinical record documented a social worker visit was made on 5/26/22, 6/9/22, 6/24/22, 6/30/22, 7/14/22 and 7/19/22. c. The clinical record lacked documentation of missed social work visits for the weeks of 5/22, 5/29, 6/5, 6/12, 6/19, 6/26, 7/3, 7/10, and 7/17/22. d. The IDG updates to the POC, dated 6/1/22, 6/8/22, 6/15/22, 6/22/22, 6/29/22, 7/6/22, 7/13/22, and 7/20/22, lacked documentation of the missed volunteer visits. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and staff interview, the hospice failed to ensure 4 of 5 sampled hospice aides (Staff D, E, F and G) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a RN with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 5 sampled patients who requires the task be performed (Patients #5 and #7). The hospice employed 5 hospice aides at the time of the survey. The hospice reported a total of 5 patients received hospice aide services at the time of the survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation require hospices direct that the hospice aide may not independently provide any patient cares beyond the basic skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. 1. Patient #5 had an admission to hospice on 4/29/22, received services while residing in a nursing home. The Plan of Care, dated 4/29/22 to 7/27/22, included orders for hospice aide services. The nursing home care plan dated 6/29/22, identified the patient utilized a gait belt for 2 person transfers: a. Staff E, Hospice Aide, had a hire date of 5/24/21. Staff E's personnel file lacked documentation a RN had observed Staff E competently demonstrate the tasks of use of a gait belt. b. Staff F, Hospice Aide, had a hire date of 5/18/01. Staff F's personnel file lacked documentation a RN had observed Staff F competently demonstrate the tasks of use of a gait belt. c. Staff G, Hospice Aide, had a hire date of 8/22/12. Staff G's personnel file lacked documentation a RN had observed Staff G competently demonstrate the tasks of use of a gait belt. 2. Patient #7 had an admission to hospice on 2/24/22 and received services while residing in a nursing home. The Plans of Care, dated 5/25/22 to 8/22/22, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills charting refusal of gait belt with assistance with bathroom elimination. Staff D, Hospice Aide, had a hire date of 5/20/2014. Staff D's personnel file lacked documentation a RN had observed Staff D competently demonstrate the tasks of use of a gait belt. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 7 of 7 sampled patients receiving hospice aide services (Patients #2, #3, #5, #6, #7, #9 and #10). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Group (IDG) Care Plan to meet each patient's needs. Findings include: Review of the hospice's policy, titled Interdisciplinary Team, Hospice, dated 4/28/22, revealed the IDG is responsible for establishing, reviewing and updating the POC at least every 15 days and providing supervision of hospice care and services. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported the admission RN or RN Case Manager created the hospice aide care plan. 1. Patient #3 had a hospice admission date of 6/22/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/22/22 to 9/19/22, included IDG orders for skilled nursing and hospice aide services. The POC included directions to the hospice aide to complete the task of partial/complete bed bath as needed each visit. The directions allowed the hospice aide to determine independently when the patient needed a partial or complete bed bath which is above the scope of the hospice aide's ability to determine. The directions included 2 bath types, partial and complete bed bath, on the same line without any separation between the 2 directives. b. The hospice aide visit notes, dated 6/27, 6/29 through 7/8, 7/11, 7/13, 7/15, 7/18, 7/20 and 7/22/22, included documentation the hospice aide completed the directive to provide either a partial or complete bed bath, but failed to specify which type of the bath the hospice aide provided. 2. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for skilled nursing and hospice aide services. The POC included directions to the hospice aide to complete the task of partial/complete bed bath as needed each visit. The directions allowed the hospice aide to determine independently when the patient needed a partial or complete bed bath which is above the scope of the hospice aide's ability to determine. The directions included 2 bath types, partial and complete bed bath, on the same line without any separation between the directives. The POC also included directions for the hospice aide to complete "foot care" without any specific direction on what the hospice aide needed to do to complete the assigned task. The POC included additional tasks of feeding assist, lotion to the skin, dressing assist, combing the patient's hair, oral care, ambulation, assist to bathroom, incontinence care and fingernail filing. b. The hospice aide visit notes, dated 5/27, 6/17, 6/28, 7/1 and 7/5/22, included documentation the hospice aide completed the directive to provide either a partial or complete bed bath, but failed to specify which type of the bath the hospice aide provided. On 7/26/22 at 1:50 PM, during an interview, Staff I, Hospice Aide, reported providing hospice aide services to the patient. She explained she typically provided care around mealtime to assist the patient with feeding. The facility staff usually had the patient bathed and dressed by the time she got there. She reported foot care was different for every patient, but was typically lotion to the feet, and reporting to the nurse if the patient had sores and if the toenails were too long. On 7/26/22 at 2:02 PM, during an interview, Staff H, RN, reported hospice aides do a partial bed bath if the patient needs it after lunch. She reported foot care for the patient is the application of lotion to the feet. On 7/26/22 at 3:23 PM, during an interview, Staff F, Hospice Aide, reported providing hospice aide services to the patient. She explained she usually sees the patient close to noon and the facility staff have already completed the tasks of bed bath, oral care, foot care, filing of fingernails, dressing and applying lotion to the skin. She assists with feeding the patient, toileting and incontinence care and assists with ambulation. She reported foot care means she should either soak the feet or apply lotion. On 7/26/22 at 4:28 PM, during an interview, Staff G, Hospice Aide, reported providing hospice aide services to the patient. She going at mealtime to assist with feeding the patient, ambulation and toileting. She described foot care as applying lotion to the patient's feet. 3. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record revealed the following: a. The POC, dated 5/19/22 to 8/16/22, included IDG orders for skilled nursing services. b. The clinical record included documentation of verbal orders, dated 5/25/22, for hospice aide services 1 to 2 times per week starting on 5/27/22. c. The hospice aide visit note, dated 5/27/22, included direction to the hospice aide to complete catheter (urinary) cares as needed. The assignment failed to include specific direction to the hospice aide on when the the hospice aide needed to complete the task. 4. Patient #5 had a hospice admission date of 4/29/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. Clinical record review revealed hospice aide care plan, dated 4/29/22, included tasks assigned by the registered nurse for the aide to complete. The tasks included assist with transfers using 1 assist and walker, provide complete/partial bath and tub/shower bath.. b. The nursing home care plan dated 6/29/22, identified the patient utilized a gait belt for 2 person transfers. The hospice aide care plan failed to identify the patient required a gait belt and 2 person transfer and failed to identify whether the aide to provide a complete or partial bath and a tub bath or shower.. 5. Patient #9 had a hospice admission date of 5/17/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. Clinical record review revealed hospice aide care plan, dated 5/17/22, included tasks assigned by the registered nurse for the aide to complete. The tasks included provide complete/partial bath and tub/shower bath. The hospice aide care plan failed to identify whether the aide to provide a complete or partial bath and a tub bath or shower. 6. Patient #2 had a hospice admission date of 7/7/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. Clinical record review revealed hospice aide care plan, dated 7/7/22 to 10/4/22,, included tasks assigned by the registered nurse for the aide to complete. The tasks included assist with partial/complete bed bath as needed. The hospice aide care plan failed to identify whether the aide was to provide a complete or partial bath. 7. Patient #7 had a hospice admission date of 2/24/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. Clinical record review revealed hospice aide care plan, dated 7/7/22 to 10/4/22,, included tasks assigned by the registered nurse for the aide to complete. The tasks included assist patient with bathroom elimination using 1-2 person assist, dependent on amount of weakness and document refusal of gait belt. The plan failed to identify the specific assistance the aide was to provide. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Group according to an individualized plan of care for 5 of 7 sampled patients who received hospice aide services. (Patients #2, #5, #6, #7 and #10). Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients' personal care needs were not met. Findings include: Review of the hospice's policy, titled Interdisciplinary Team, Hospice, dated 4/28/22, revealed the IDG is responsible for establishing, reviewing and updating the POC at least every 15 days and providing supervision of hospice care and services. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported the hospice aide is responsible for documenting the reason the hospice aide is unable to complete an assigned task. 1. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for skilled nursing and hospice aide services. The POC included directions to the hospice aide to complete the tasks of partial/complete bed bath as needed each visit, lotion to the skin every visit and foot care every visit. b. The hospice aide visit note completed by Staff I, Hospice Aide, dated 5/24/22, included documentation the hospice aide did not complete the assigned tasks of bed bath, foot care and lotion to the skin due to the tasks not being scheduled. c. The hospice aide visit note completed by Staff I, Hospice Aide, dated 6/3/22, included documentation the hospice aide did not complete the assigned task of bed bath due to the task not being scheduled. She documented the assigned tasks of oral care, dressing assist, finger nail filing, and lotion to the skin were "previously done". The hospice aide failed to complete the assigned tasks and did not provide a reason, as the RN had scheduled the tasks. On 7/26/22 at 1:50 PM, during an interview, Staff I, Hospice Aide, reported she assumed she put not scheduled, because she went to provide cares to the patient later in the day. She reported the facility staff would have done the tasks already. 2. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record revealed the following: a. The POC, dated 5/19/22 to 8/16/22, included IDG orders for skilled nursing services. b. The clinical record included documentation of verbal orders, dated 5/25/22, for hospice aide services 1 to 2 times per week starting on 5/27/22. c. The hospice aide visit note, dated 5/27/22, included direction to the hospice aide to complete the task of assisting with repositioning the patient. The visit note lacked documentation the hospice aide completed the assigned task and failed to include a reason why the hospice aide did not complete the task. 3. Patient #5 had a hospice admission date of 4/29/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 7/27/22, included orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Care, dated 4/29/22, included the following assignments to occur: assist with bath shower, assist with transfer and ambulation. c. The aide visit notes, dated 6/2/22, failed to include documentation the following tasks completed or addressed as the reason for omission: assist with bath shower and ambulation. d. The aide visit notes, dated 6/9/22, failed to include documentation the following tasks completed or addressed as the reason for omission: assist with transfer. The aide failed to follow the care plan as written. 4. Patient #2 had a hospice admission date of 7/7/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 7/27/22, included orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Care, dated 7/7/22 to 10/4/22, included the following assignments to occur: aide to assist with eating/feeding as needed, assist with partial/complete bed bath as needed, and provide whirlpool bath for patient on Mondays and Thursdays. c. The aide visit note, dated 7/18/22, failed to include documented the aide completed a partial/complete bath as needed and assisted with the whirlpool bath. The aide did not specify which bath was performed a partial, complete, or whirlpool bath. The aide failed to follow the care plan as written. 5. Patient #7 had a hospice admission date of 2/24/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 2/24/22 to 5/24/22 and 5/25/22 to 8/22/22, included orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Cares, dated 2/24/22 to 5/24/22 and 5/25/22 to 8/22/22, included the following assignments to occur: assist patient to bathroom using 1-2 person assist, dependent on amount of weakness and document refusal of gait belt. c. The aide visit notes, dated 6/21/22, 6/23/22, 7/5/22, 7/7/22, 7/12/22, 7/19/22 and 7/26/22, failed to include documentation the aide assisted the patient to bathroom using 1-2 person assist, dependent on amount of weakness and document refusal of gait belt. The aide did not specify why the task was not completed. The aide failed to follow the care plan as written. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff provided no additional information prior to the end of the survey.

Based on review of written contractual agreements, the hospice failed to ensure the written agreement between the hospice and 1 of 3 sampled services under arrangement included all of the required contract components. The hospice reported a total of 10 written agreements for services under arrangement with individuals/companies at the time of the survey. Failure to include the required contract components within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: A hospice pharmacy contract, dated 8/23/19, failed to include the following contractual language: the hospice retains financial management, oversight of staff and services; all services are authorized by the hospice and delivered in accordance with the patient's plan of care. The above findings were reviewed with the Administrator and hospice staff provided no further evidence prior to the end of the survey.

Based on patient clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure patient's with an attending physician signed the initial written certification of terminal illness, for 2 of 5 sampled patients (Patients #6 and #10) who had chosen a attending physician to provide primary hospice care and was not identified as the hospice's Medical Director or physician designee. Failure of the hospice to ensure the medical director or designee signed the Certificate of Terminal Illness placed patients at risk for not meeting the eligibility requirements for hospice and have unexpected medical expenses. Findings include: Review of the hospice's policy, titled Certificate of Terminal Illness, dated 10/2012, identified, at the time of admission, the hospice Medical Director and the patient's attending physician will sign the certification of terminal illness. Review of the hospice's policy, titled Admission Criteria and Process, Hospice, dated 2/22/22, identified the patient's physician orders and approves care by hospice. The patient's physician and hospice Medical Director determine the patient's eligibility for hospice by identifying the patient has a life-threatening illness with a life expectancy of 6 months or less. Review of the hospice's policy, titled Clinical Record Content, Hospice, dated 4/28/22, identified the clinical record will include the Certification of Terminal Illness. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported both the Medical Director and the patient's attending physician sign the initial Certificate of Terminal Illness (CTI). 1. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record on 7/26/22 revealed the following: a. The Medicare Benefit Election form, dated 5/19/22, included documentation the patient's representative chose an attending physician for the patient other than the hospice Medical Director. b. The clinical record included documentation of a signed CTI by the hospice's Medical Director and a verbal attestation of the initial CTI by the patient's attending physician per a hospice nurse. The clinical record lacked documentation of a signed initial CTI by the patient's attending physician. On 7/27/22 at 11:00 AM, during an interview, the Administrator confirmed the hospice's policy to obtain a signed initial CTI from the patient's attending physician. 2. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record on 7/26/22 revealed the following: a. The Medicare Benefit Election form, dated 5/19/22, included documentation the patient's representative chose an attending physician for the patient other than the hospice Medical Director. b. The clinical record included documentation of a signed CTI by the hospice's Medical Director and a verbal attestation of the initial CTI by the patient's attending physician per a hospice nurse. The clinical record lacked documentation of a signed initial CTI by the patient's attending physician. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 7 of 11 sampled patients (#3, #4, #5, #6, #8, #9 and #10). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up to date information related to the patient's condition, and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: Review of the hospice's policy, titled Clinical Record Content, Hospice, dated 4/28/22, identified the patient clinical record will include all progress and clinical notes. Review of the hospice's policy, titled Completion of Clinical Documentation, Hospice, dated 4/13/21, revealed clinical documentation occurs typically during the visit or immediately afterwards and is typically entered into the computer clinical record within 48 hours after the visit. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported they were in the process of trying to get the massage and music therapist to submit visit notes weekly. 1. Patient #3 had a hospice admission date of 6/22/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/22/22 to 9/19/22, included IDG orders for volunteer 1 to 2 times per week, music and massage therapy services 1 time per week. b. On 7/26/22, review of the clinical record revealed a lack of visit notes for music, massage and volunteer services. On 7/26/22 at 9:35 AM, the surveyor notified the Patient Care Coordinator of an inability to find the massage, music and volunteer therapy visit notes in the clinical record. She reported they were waiting for the music and massage therapists to bring the visit notes to the office, but could get the volunteer visit notes. On 7/27/22, the Patient Care Coordinator provided a copy of the massage therapy visit notes, dated 6/28, 7/6, 7/12 and 7/26/22, but not any visit notes for music therapy or volunteer services. c. The IDG meeting notes, dated 6/29, 7/6 and 7/13/22, lacked documentation of IDG member awareness of missed visits for music or volunteer services. The hospice staff failed to include documentation of massage therapy notes into the clinical record in a timely manner. The clinical record was unclear on whether the patient had received music therapy and volunteer services per IDG orders. 2. Patient #6 had a hospice admission date of 5/19/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for volunteer services 2 times per week, music and massage therapy services 1 to 2 times per week. b. On 7/26/22, review of the clinical record revealed documentation of a volunteer services care plan, dated 5/19/22, 2 additional volunteer visit notes, dated 5/23 and 5/30/22, and 2 music therapy visit notes, dated 5/19 and 5/26/22. The clinical record lacked documentation of any massage therapy visit notes and any other volunteer and music therapy visit notes. On 7/26/22 at 4:14 PM, the Administrator provided copies of massage therapy visit notes, dated 6/27, 7/5, 7/11 and 7/26/22. She also provided copies of music therapy visit notes, dated 6/2, 6/9 and 7/7/22. She did not provide copies of any other volunteer visit notes. The hospice staff failed to include documentation of music and massage therapy notes into the clinical record in a timely manner. The clinical record was unclear on whether the patient had received volunteer services per IDG orders. 3. Patient #8 had a hospice admission date of 7/8/22 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 7/8/22 to 10/5/22, included IDG orders for music and massage therapy 2 to 4 times per month. b. On 7/26/22 at 2:46 PM, review of the clinical record revealed a lack of any massage or music therapy visit notes in the clinical record. The surveyor requested hospice staff provide a copy of all music and massage therapy visit notes. Hospice staff failed to provide copies of any completed visits related to these services prior to the end of the survey (7/28/22). The clinical record was unclear on whether the patient had received any massage or music therapy services per IDG orders. 4. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record on 7/26/22 revealed the following: a. The POC, dated 5/19/22 to 8/16/22, included IDG orders for volunteer services 2 to 4 times per month. b. The clinical record included documentation of one volunteer visit note, dated 5/25/22. Hospice staff did not scan the volunteer visit note into the patient's clinical record until 7/13/22. 5. Patient #5 had an admission to hospice on 4/29/22. The patient received hospice services while residing in a nursing home. a. The POC, dated 4/29/22 to 7/27/22, documented the patient received skilled nursing 1 to 2 visits a week, social worker 4 to 6 times a month, hospice aide 2 to 3 times a week, volunteer 1 to 2 times a week, massage therapy 1 to 2 times a week and music therapy services 1 to 2 times a week. Clinical record review revealed: b. Massage therapy service notes, dated 5/24,5/27, 5/31/22, 6/7, 7/1, 7/5, 7/8 and 7/12/22 were not scanned into the patients electronic record until 7/26/22. c. Music therapy service notes, dated 6/2, 6/9/22 and 7/7/22 were not scanned into the patients electronic record until 7/26/22. The hospice staff failed to include documentation of music and massage therapy notes into the clinical record in a timely manner. 6. Patient #9 had an admission to hospice on 5/17/22. The patient received hospice services while residing in a private residence. a. The POC, dated 5/17/22 to 8/14/22, documented the patient received skilled nursing 1 to 2 visits a week, social worker 4 to 6 times a month, hospice aide 2 to 3 times a week, massage therapy 1 to 2 times a week and music therapy services 1 to 2 times a week. Clinical record review revealed: b. Massage therapy service notes, dated 5/23/22, 6/1, 6/6, 6/13, 6/20, 6/27/22, 7/5 and 7/11/22 were not scanned into the patients electronic record until 7/26/22. c. Music therapy service note, dated 5/25/22, present in the electronic record. The hospice identified remaining music therapy notes were not received in the office and were in the mail. The hospice staff failed to include documentation of music and massage therapy notes into the clinical record in a timely manner. 7. Patient #4 had an admission to hospice on 1/25/22. The patient received hospice services while residing in a nursing home. a. The POCs, dated 3/26/22 to 5/24/22 and 5/25/22 to 7/23/22, documented the patient received skilled nursing 1 to 2 visits a week, social worker 3-5 times every 30 days, volunteer visits 1 to 2 times a week, massage therapy 2 to 4 times a month and music therapy services 2 to 4 times a month. Clinical record review revealed: b. Massage therapy service notes, dated 5/16/22, 5/23/22, 6/1/22, 6/6/22, 6/13/22, 6/20/22, 6/27/22, 7/5/22 and 7/11/22 were not scanned into the patients electronic record until 7/26/22. c. Music therapy service notes, dated 6/1/22 and 6/8/22 were not scanned into the patients electronic record until 7/26/22. The hospice staff failed to include documentation of music and massage therapy notes into the clinical record in a timely manner. The above findings were reviewed with the Hospice Administrator and Staff B, Patient Care Coordinator. Hospice Staff provided no additional information prior to the end of the survey.

Based on clinical record review, policy review and staff interview, the hospice failed to ensure patient clinical records included a physician order for all treatments for 2 of 11 sampled patients (Patients #10 and #11). Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings include: Review of the hospice's policy, titled Patient Plan of Care (POC), Hospice, dated 4/28/22, identified the registered nurse (RN) receives oral and telephone orders, records and obtains the physician counter signature on the order as soon as possible. Hospice staff will include orders obtained after the initial POC in the patient record. On 7/27/22 at 2:00 PM, during an interview, the Patient Care Coordinator reported the RN Case Manager, Patient Care Coordinator and Admission Coordinator ensures the clinical record includes all physician orders. She also reported the hospice used standing orders. She explained when a nurse enacts a standing order, the nurse writes a separate order to send to the physician to notify the physician of the implementation of the order. 1. Patient #10 had a hospice admission date of 5/19/22, received hospice services while residing in a nursing home and died on 5/30/22. Review of the clinical record on 7/26/22 revealed the following: a. The POC, dated 5/19/22 to 8/16/22, identified a diagnosis of hypertensive heart disease with chronic kidney disease and heart failure and included IDG orders for skilled nursing services. b. The clinical record included documentation of hospice standing orders, titled Hospice Comfort Protocol, dated 5/20/22, with a variety of medications and treatments to treat pain, anxiety, agitation, dyspnea, secretions, constipation, diarrhea, nausea/vomiting, indigestion, fever, itching, dry eyes, dry mouth, dry nares, urinary difficulties, hiccups, insomnia and nutrition, as well as orders to apply a barrier cream, to hold medications if the patient can not swallow, activity as tolerated and release the patient's body to the funeral home. The standing orders included a signature by the patient's attending physician, dated 5/24/22. The standing orders specifically have an order to insert a 16 French urinary catheter with a 10 cubic centimeter (cc) balloon filled with 10 cc of sterile water as needed for urinary retention or incontinence, may discontinue the urinary catheter as needed per patient or family request, may irrigate with 60 milliliters of Saline as needed if not patent, and may replace catheter if irrigation does not resolve non-patency. c. A skilled nursing communication note, dated 5/25/22, included documentation the hospice nurse spoke with the facility (nursing home) nurse. The facility nurse asked about a Foley (urinary) catheter. The facility nurse planned on contacting the "MD" for the Foley catheter order. d. A skilled nursing visit note, dated 5/27/22, included documentation the patient had a urinary catheter in place. The clinical record lacked documentation of the order the facility staff obtained for the use of a urinary catheter. The clinical record was unclear on which, if any, of the standing orders in relation to urinary difficulties the facility or hospice staff implemented. 2. Patient #11 had a hospice admission date of 5/24/22, received hospice services while residing in a private residence and died on 6/4/22. Review of the clinical record revealed the following: a. The POC, dated 5/24/22 to 6/4/22, included IDG orders for skilled nursing services. b. An interim physician order, dated 6/3/22, included an order for a Scopolamine patch, 1 patch to the skin every 3 days. The order failed to include a dosage amount for the medication. On 7/27/22 at 4:15 PM, during an interview, the Patient Care Coordinator confirmed the Scopolamine patch order lacked a dosage amount. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to maintain documentation in the patient clinical records as evidence that patients received a copy of the hospice policy concerning the disposition of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 1 sampled patients (Patient #11) who received routine home care while living in a private home and had physician ordered controlled medications, not on admission, but some time after the patient's admission to hospice. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: Review of the hospice policy, titled Controlled Medication Home Management and Disposal, Hospice, dated 11/22/21, identified the hospice staff would provide the policy and instruct the patient/ caregiver on disposal of controlled medications (medications which distribution and use are controlled by the government) based on Federal guidelines. The policy identified hospice staff would provide the written information and instruction to the patient/family/caregiver upon admission and when a physician orders a controlled medication. Patient #11 had a hospice admission date of 5/24/22, received hospice services while residing in a private residence and died on 6/4/22. Review of the clinical record revealed the following: a. The POC, dated 5/24/22 to 6/4/22, included IDG orders for skilled nursing services. The POC included orders for medications, but lacked any orders for a controlled medication. b. An interim physician order, dated 6/3/22, included orders for hospice comfort medications. c. A skilled nursing visit note, dated 6/4/22, identified the patient was taking Roxanol and Ativan (both controlled medications). The clinical record lacked documentation the hospice nurse reviewed the hospice's controlled drug disposal policy with the patient/family/caregiver at the time the physician first ordered a controlled medication. On 7/27/22 at 11:00 AM, during an interview, the Patient Care Coordinator reported hospice nursing staff provide education on the hospice's drug disposal policy every time the patient starts a new controlled medication. She agreed to look for this documentation. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on review of written contracts, the hospice failed to ensure written contractual agreements between the hospice and nursing homes included a provision which specified the hospice would provide services at the same level and extent as if the patient was in his/her own home for 1 of 3 sampled contracts the hospice maintained with nursing homes. The hospice had separate written agreements contracts with a total of 11 nursing homes and provided services to 6 patients who received hospice care while residing in a nursing home at the time of the survey. Failure to include this provision within the contractual agreement increased the potential of hospice and nursing home staff not meeting patient needs. Findings include: The written agreement with a nursing home in Rock Rapids, IA, dated 5/18/12, lacked a provision which specified the hospice would provide services at the same level and extent as if the patient was in his/her own home. The above findings were reviewed with the Administrator. The hospice provided no further information prior to the end of the survey.

Based on review of written contracts, the hospice failed to ensure written contractual agreements between the hospice and nursing homes included a provision which specified the hospice would delineate hospice responsibilities for 1 of 3 sampled contracts the hospice maintained with nursing homes. The hospice had separate written agreements contracts with a total of 11 nursing homes and provided services to 6 patients who received hospice care while residing in a nursing home at the time of the survey. Failure to include this provision within the contractual agreement increased the potential of hospice and nursing home staff not meeting patient needs. Findings include: The written agreement with a nursing home in, Rock Rapids, IA, dated 5/18/12, lacked a provision which specified the hospice would allow delineation of hospice responsibilities. The above findings were reviewed with the Administrator. The hospice provided no further information prior to the end of the survey.

Based on review of written contracts, the hospice failed to maintain a written contractual agreement with nursing homes which included a provision for hospice staff to report, to the nursing home administrator, within 24 hours, of any knowledge of alleged mistreatment, neglect or abuse perpetrated by non-hospice staff against nursing facility residents. The survey identified this deficient practice with 2 of 3 sampled contracted nursing homes. The hospice had separate written agreements contracts with a total of 11 nursing homes and provided services to 6 patients who received hospice care while residing in a nursing home at the time of the survey. Failure to include this provision within the contractual agreement increased the potential of unreported acts and/ or failure to investigate allegations of abuse, mistreatment or neglect against residents in a nursing homes. Findings include: The written agreement with a nursing home in Rock Rapids, IA, dated 5/18/12, lacked a provision to address the need for the hospice to report all allegations of abuse by non hospice staff within 24 hours to the facility administrator. The written agreement with a nursing home in Sutherland, IA, dated 11/16/07, lacked a provision to address the need for the hospice to report all allegations of abuse by non hospice staff within 24 hours to the facility administrator. The above stated findings were reviewed with the Administrator. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, nursing home medication and treatment administration records, hospice policy review, nursing home staff interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 1 of 2 sampled patients (Patient #2) with an on-site visit to the patient's nursing home residence. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for not receiving care and/or treatment according to the hospice philosophy. Findings Include: Review of the hospice's policy, titled Interdisciplinary Team, Hospice, dated 4/28/22, revealed the IDG is responsible for establishing, reviewing and updating the POC at least every 15 days and providing supervision of hospice care and services. Patient #2 had a hospice admission date of 7/7/22 and received hospice services while residing in a nursing home. The Plan of Care (POC), dated 7/7/22 to 10/4/22, included IDG orders for skilled nursing services. On 7/26/22 at 11:40 AM, during an on-site visit to the patient's nursing home, the nursing home receptionist provided a copy of the patient's medication and treatment administration records for July 2022. Review of the nursing home's medication administration record (MAR) and treatment administration record (TAR) for July 2022 compared to the hospice's medication status sheet, dated 10/31/18, identified the following medication and treatment discrepancies: a. The nursing home's MAR and TAR included an order for a Claritin 10 milligrams (mg) daily for allergies. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. b. The hospice's medication status sheet included an order for cranberry 250 mg daily. The nursing home's MAR included an order for cranberry 500 mg daily. c. The nursing home's MAR and TAR included an order for fasting blood sugars weekly every Monday. The hospice's plan of care lacked the order. d. The nursing home's MAR and TAR included an order for Levemir 25 units daily. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. e. The nursing home's MAR and TAR included an order for Levothyroxine 88 micrograms (mcg). The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. f. The nursing home's MAR and TAR included an order for Sodium Chloride 1 gram (g). The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. g. The nursing home's MAR and TAR included an order for Bactroban ointment 2% as needed daily apply topically to the ear canal. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. h. The nursing home's MAR and TAR included an order for Benzocaine gel 20 % to be applied topically every 6 hours as needed for pain to sore on the left side of the mouth. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. i. The nursing home's MAR and TAR included an order for Biofreeze gel 4 % to be applied to affected areas topically for pain/soreness. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. j. The hospice's medication status sheet included an order for hydrocortisone 1% ointment to be applied topically two time per day. The nursing home's MAR/TAR lacked documentation of a physician order for the medication. k. The hospice's medication status sheet included an order for prochlorperazine 5 mg every 6-8 hours for nausea/vomiting. The nursing home's MAR/TAR lacked documentation of a physician order for the medication. The hospice RN case manager failed to coordinate medications and treatment with the hospice. The above findings were reviewed with the hospice Administrator and Staff B, Patient Care Coordinator. Hospice staff provided no additional information prior to the end of the survey.

Based on hospice clinical record review, long term care (nursing home) clinical record review, nursing home staff and hospice staff interview, the hospice failed to ensure the nursing home where hospice patients resided received all required hospice documentation for 1 of 2 sampled patients who received an on-site record review at the facility (Patient #2). Failure to communicate hospice information to nursing home staff placed patients at risk to not receiving necessary care and services. Findings include: Patient #2 had an admission to hospice on 7/7/22 and received services while residing in a nursing home. During an onsite visit on 7/26/22 at 11:40 AM, the nursing home Charge Nurse and Administrator assisted the surveyor in the review of the patient's nursing home record. The patient's nursing home clinical record lacked a copy of the hospice benefit election form. The nursing home Administrator checked in papers waiting to be filed and with business office staff and reported not finding the election benefit form or a current medication list. While surveyor provided findings on 7/27/22 at 10:26 AM with the hospice Administrator and Staff B, Patient Care Coordinator, the Hospice Administrator reported that the hospice election benefit form is usually faxed to the nursing home and bring all other paperwork to the nursing home the next visit day after the 5 day of services. The agency does not maintain proof of what was faxed to the nursing home. The hospice provided no further information prior to the end of the survey.