Every finding on record at Selah Hospice Care, Inc.

Based on record review and interview, the Hospice failed to follow an individualized written plan of care (POC) that included all services necessary for the palliation and management of the terminal illness and related conditions for 2 (Patient #2 and Patient #4) of 5 Hospice patients, whose records were reviewed in that: Colostomy (a surgical opening or stoma in the abdomen that allows stool to exit the body without passing through the anus) care and interventions were not included in the POC for Patient #2 or for Patient #4. This deficient practice placed patients at risk of receiving inadequate care required to meet their needs if patient-specific information was not included in the plan of care. --- The findings included: Record review of Patient #2’s electronic medical record (EMR) included a “Patient Face Sheet” that documented an admission date of 09/17/25 with a current “admitted (hospice)” status. Further record review of the patient face sheet revealed a primary diagnosis of “athscl (atherosclerosis) heart disease of native coronary artery w/o (without) ang (angina) pctrs (pectoris)”, hardening and narrowing of the coronary arteries in the native (non-graft) coronary arteries, but without the presence of chest pain. Record review of the Patient Face Sheet revealed Patient #2 was receiving routine come care (RHC), at an “assisted living facility” Further review of Patient #2’s EMR included a “Hospice Physician Recertification of Terminal Illness” that was signed and dated 12/05/25, and that documented a “certification period” of 12/16/25 to 03/05/26 comorbid conditions “contributing to overall decline including acute kidney injury (sudden decline in kidney function), prior myocardial infarction (heart attack) and recurrent syncope (fainting)” and a “colostomy in place. Record review of Patient #2’s EMR revealed skilled nurse visits were conducted on: 12/17/25, 12/18/25, 12/22/25, 12/26/25, 12/29/25, 01/01/26, 01/05/26, 01/07/26, 01/08/26, 01/12/26, 01/15/26, 01/19/26, 01/22/26, 01/26/26, 01/29/26, 01/30/26, 01/31/26, 02/02/26, 02/04/26, 02/05/26, 02/07/26, 02/09/26, 02/12/26, 02/17/26, 02/18/26, 02/19/26, 02/23/26, 02/25/26, 02/26/26, 03/02/26, 03/05/26. Record review of Patient #2’s EMR revealed colostomy assessment and care or interventions were provided by skilled nurses during skilled nurse visits through certification period 12/16/25 to 03/05/26. Record review of Patient #2’s EMR failed to include a plan of care for certification period of 12/16/25 to 03/05/26 that addressed care and interventions for colostomy to left lower quadrant. Record review of Patient #2’s EMR revealed no additional physician orders for colostomy care were obtained for this certification period. Record review of Patient #4’s EMR included a “Patient Face Sheet” that documented an admission date of 03/24/25 with a current “expired (Hospice)” status. Further record review of the patient face sheet revealed a primary diagnosis of “end stage renal disease”, final stage of chronic kidney disease where the kidneys function at less than 15% of their normal capacity and can no longer effectively filter waste products to maintain the body’s fluid and electrolyte balance. Record review of the “Patient Face Sheet revealed Patient #4 was receiving RHC at a “skilled nursing facility”. Record review of Patient #4’s EMR included a “Combined Physician Initial Certification of Terminal Illness” signed and dated 03/24/25 that documented a “certification period” of 03/24/25 to 06/21/25. Record review of Patient #4’s EMR included an “Initial Plan of Care/Admission Orders” signed and dated 03/24/25 that documented the following orders for care: Skilled nurse frequency: (low/high) 7/week. Nursing facility representative confirms he/she has reviewed and participated in the development of this patient’s Hospice POC…Nursing facility representative understands that hospice is responsible for the professional management of this patient care… Assess bowel status with each visit Record review of Patient #4’s EMR revealed skilled nurse visits were conducted on 03/24/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25, 03/31/25, 04/01/25, 04/02/25, 04/03/25, 04/04/25, 04/05/25 and 04/07/25. Further review of Patient’s EMR revealed skilled nurses documented colostomy assessment and care or interventions during skilled nurse visits through certification 03/24/25 to 04/08/25 (discharge). Record review of Client #4’s EMR failed to include a plan of care that addressed care and interventions for colostomy to the left upper quadrant. Record review of Client #4’s EMR revealed no additional orders for colostomy care were obtained for this certification period. In a simultaneous interview and record review on 05/07/26 at 02:15 p.m., the DON confirmed had oversight of the clinical department. The DON confirmed Client #2’s start of care (SOC) as 09/17/25 and a certification period of 12/16/25 through 03/05/26. The DON confirmed Client #2 had a colostomy to the left lower quadrant and that Client #2 did not have a care plan for colostomy care and interventions included in the plan of care. The DON stated that colostomy care and interventions should be part of the care plan for Patient #2. The DON stated the clinical manager [she] had oversight of the nurses and they did not initiate a plan of care for Patient #2. The DON confirmed Patient #4’s SOC as 03/24/25 and a certification period of 03/24/25 through 06/21/25. The DON confirmed Patient #4 had a colostomy to the left upper quadrant and that Patient #4 did not have a care plan for colostomy care and interventions included in the plan of care. The DON confirmed there were no additional physician orders obtained from the nurses for colostomy care for Patient #2 and Patient #4. The DON stated the nurse should have obtained orders and care planned colostomy care and interventions. The DON stated she did not know why the nurses did not obtain orders or care planned colostomy care. The DON stated she was responsible for ensuring these were care planned. The DON stated the nurses did not follow agency policy regarding plan of care and that more education and training needed to occur for the nurses regarding this. The DON stated not having a care plan for colostomy in the plan of care could negatively affect the patient because if “something happened, there would be no order and that we [nurses] could not do anything without physician orders. In an interview on 05/07/26 at 03:25 p.m., the Adm stated the DON had clinical oversight of the patients. The Adm stated she was not aware of problems with the plan of care orders for Patient #2 or Patient #4 prior to this survey. The Adm stated she was not “qualified” to explain how the patient could negatively be affected but acknowledged the patient could negatively be affected. Record review of Agency policies titled “Plan of Care, C-580”, revision 1024 and no revision date noted, quoted in part, “Hospice services are furnished under the supervision and direction of the patient’s physician. The Plan of Care is based on a comprehensive assessment and information provided by the patient/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that patient needs are met, and will be updated as necessary, but at least every fifteen (15) days. The update of the Plan of Care is based on changes that have taken place since the initial assessment and includes information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care and needs. For hospice care provided to a resident of a Skilled Nursing Facility (SNF), Nursing Facility (NF), or Intermediate Care Facility for the Mentally Retarded (ICF/MR), the hospice plan of care identifies the care and services that are needed and identifies which provider is responsible for performing the functions that have been agreed upon and included in the plan of care… 2.The Plan of Care shall be completed in full to include…a. All pertinent diagnosis(es), principle and secondary… e. Medications and treatment necessary to meet the patient’s needs… 9. Verbal/telephone orders shall be obtained from the patient’s physician for changes in the Plan of Care…”No further information was provided by the Agency prior to exit conference on 05/07/26 for Patient #2 or Patient #4.

Based on record review and interview, the Hospice failed to develop an individualized written plan of care that reflected the clients and family’s goals and interventions based on the problems identified in the comprehensive and updated comprehensive assessments for 1 (Patient #2) of 5 patients whose records were reviewed. This failure placed active Hospice patients at risk of negative patient outcomes related to not receiving adequate patient care or services. --- The findings included: Record review of a “Hospice Active Patient Report” dated 05/05/26 provided to the surveyor upon entrance, documented Patient #2 as an active patient with a “start of care (SOC) date 09/17/25”. Record review of Patient #2’s electronic medical record (EMR) included a “Patient Face Sheet” that documented an admission date of 09/17/25 with a current “admitted (hospice)” status. Further record review of the patient face sheet revealed a a primary diagnosis of “athscl (atherosclerosis) heart disease of native coronary artery w/o (without) ang (angina) pctrs (pectoris)”, hardening and narrowing of the coronary arteries in the native (non-graft) coronary arteries, but without the presence of chest pain. Further review of the Patient Face Sheet revealed Patient #2 was receiving routine come care (RHC), at an “assisted living facility” Further review of Patient #2’s EMR included a “Hospice Physician Recertification of Terminal Illness” signed and dated 12/05/25 that documented a “certification period” of 12/16/25 to 03/05/26. Record review of Patient #2’s EMR revealed skilled nurse visits conducted on: 12/17/25, 12/18/25, 12/22/25, 12/26/25, 12/29/25, 01/01/26, 01/05/26, 01/07/26, 01/08/26, 01/12/26, 01/15/26, 01/19/26, 01/22/26, 01/26/26, 01/29/26, 01/30/26, 01/31/26, 02/02/26, 02/04/26, 02/05/26, 02/07/26, 02/09/26, 02/12/26, 02/17/26, 02/18/26, 02/19/26, 02/23/26, 02/25/26, 02/26/26, 03/02/26, 03/05/26. Record review of Patient #2’s EMR revealed hospice aide visits conducted on: 12/20/25/12/21/25, 12/24/25, 12/25/25, 12/27/25, 12/28/25, 12/30/25, 01/03/26, 01/04/26, 01/14/26, 01/15/26, 01/16/26, 01/17/26, 01/18/26, 01/23/26, 01/24/26, 01/25/26, 01/26/26, 01/18/26, 01/29/26, 01/31/26, 02/01/26, 02/02/26, 02/05/26, 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/18/26, 02/19/26, 02/20/26, 02/21/26, 02/22/26, 02/23/26, 02/24/26/ 02/25/26, 02/26/26, 02/27/26, 02/28/26, 03/01/26, 03/03/26, 03/04/26, 03/05/26. Record review of Patient #2’s EMR revealed social worker visits conducted on: 12/17/25, 01/13/26 and 02/01/26. Record review of Patient #2’s EMR revealed care was provided by skilled nurses, hospice aid and the social worker during these visits. Record review of Patient #2 failed to include an individualized written plan of care for certification period 12/16/25 through 03/05/26 that included orders for care, services and frequencies to be provided by skilled nurse, hospice aide and social worker. In a simultaneous interview and record review on 05/07/26 at 02:15 p.m., the DON confirmed had oversight of the clinical department. The DON explained that during the recertification visit the nurse will update the physician of any changes in assessment, updated physician orders and those changes would be “put in the system, in a note or recertification note that would then be signed by the physician for the certification period as the plan of care. The DON stated the Agency had 14 days to update the plan of care before the next interdisciplinary team meeting. The DON confirmed a start of care date of 09/17/25 for Patient #2 and a re-certification period of 12/16/25 through 03/05/26. The DON stated Patient #2 was on her 3rd certification period. The DON stated the discrepancy in dates was because the physician had made an “error in typing the certification date correctly” and that the certification was from 03/06/26 to 05/14/26. The DON stated the nurse conducted a recertification note on 03/02/26 that reflected new orders and medication review changes. The DON stated the plan of care process did not get completed and that Patient #2 did not have a plan of care for certification period 12/16/25 through 03/05/26. The DON stated there was a lack of education of nurses to complete the plan of care process. The DON stated the Clinical Manager [she] had the oversight to ensure the plan of care for each patient was completed. The DON stated she did not know there was a problem and that this could negatively affect the patient because there was no order for the care the nurses were providing for the patient. In an interview on 05/07/26 at 03:25 p.m., the Adm stated the DON had clinical oversight of the patients. The Adm stated she was not aware of problems with the plan of care orders for the patient prior to this survey. The Adm stated she was not “qualified” to explain how the patient could negatively be affected but acknowledged the patient could negatively be affected. Record review of Agency policies titled “Plan of Care, C-580”, revision 1024 and no revision date noted, quoted in part, “Hospice services are furnished under the supervision and direction of the patient’s physician. The Plan of Care is based on a comprehensive assessment and information provided by the patient/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that patient needs are met, and will be updated as necessary, but at least every fifteen (15) days. The update of the Plan of Care is based on changes that have taken place since the initial assessment and includes information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care and needs. For hospice care provided to a resident of a Skilled Nursing Facility (SNF), Nursing Facility (NF), or Intermediate Care Facility for the Mentally Retarded (ICF/MR), the hospice plan of care identifies the care and services that are needed and identifies which provider is responsible for performing the functions that have been agreed upon and included in the plan of care… 7. The interdisciplinary group documents its review and revision of the patient’s total plan of care as often as the severity of the patient’s condition requires, but at least one time every fifteen (15) days… 12. Plan of Care will be developed by the Interdisciplinary team in consultation with the patient’s attending physician and all team members will have access to the plan of care.No further information was provided by the Agency prior to exit conference on 05/07/26 for Patient #2.

Based on record review and interview, the Hospice interdisciplinary group/team (IDG/IDT) failed to review, revise and document the individualized plan of care as frequently as the patient’s condition required, but no less frequently than every 15 calendar days for 2 (Patient #2 and Patient #3) of 5 patients whose records were reviewed. This failed practice to review, revise and document the individualized plan of care placed patients at risk of negative patient care outcomes related to physical, medical, emotional and spiritual needs or changes not identified and addressed at this interval. --- The findings included: Record review of Patient #2’s electronic medical record (EMR) included a “Patient Face Sheet” that documented an admission date of 09/17/25 with a current “admitted (hospice)” status. Further record review of the patient face sheet revealed a primary diagnosis of “athscl (atherosclerosis) heart disease of native coronary artery w/o (without) ang (angina) pctrs (pectoris)”, hardening and narrowing of the coronary arteries in the native (non-graft) coronary arteries, but without the presence of chest pain. Further review of the patient face sheet revealed Patient #2 was receiving routine come care (RHC), at an “assisted living facility” Further review of Patient #2’s EMR included a “Hospice Physician Recertification of Terminal Illness” signed and dated 12/05/25 that documented a “certification period” of 12/16/25 to 03/05/26. Record review of Patient #2’s EMR did not contain IDG/IDT meetings documented through certification period of 12/16/25 to 03/05/26. The IDG/IDT should have met 12/18/25, 01/06/26, 01/15/26, 01/29/26, 02/12/26, 02/26/26, 03/12/26. Further review revealed no evidence that the IDG/IGT meet every 14 days for 12/18/25, 01/06/26, 01/15/26, 01/29/26, 02/12/26, 02/26/26, 03/12/26.Record review of Patient #3 EMR included a “Patient Face Sheet” that documented an admission date of 04/28/25 with a current “discharged (hospice)” status. Further record review of the patient face sheet revealed a primary diagnosis of “heart failure”, heart condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen. Further review of the patient face sheet revealed Patient #3 was receiving routine home care (RHC) in the patient’s home. Further review of Patient #3’s EMR included a “Combined Physician Initial Certification of Terminal Illness” signed and dated 05/02/25 that documented a “certification period” of 04/28/25 to 07/26/25. Record review of Patient #3’s EMR included an “Initial Plan of Care/Admission Orders” signed and dated 04/28/25. Record review of Patient #3’s EMR did not contain IDG/IDT meetings documented through certification period of 04/28/25 to 05/20/25 (patient discharge). The IDG/IDT should have met 05/08/25. Further review revealed no evidence that the IDG/IDT met every 14 days for 05/08/25.  In a simultaneous interview and record review on 05/07/26 at 02:15 p.m., the DON confirmed had oversight of the clinical department. The DON confirmed Patient #2’s start of care (SOC) as 09/17/25 and a certification period of 12/16/25 through 03/05/26. The DON confirmed Patient #2 was not included in the interdisciplinary meetings for certification period 12/16/25 through 03/05/26. The DON stated she did not “see any [completed IDT] notes on this patient”. The DON stated she would ensure there were none completed on “paper but doubted there would be”. The DON stated IDT meetings were held every 14 days. The DON stated she did not know why Patient #2 was not included. The DON confirmed Patient #3’s SOC as 04/28/25 and a certification period of 04/28/25 through 07/26/25. The DON stated she did not see any complete IDG notes on this patient either. The DON stated she was “sure the meeting was completed in person but not in the notes”. The DON stated the nurses needed “more education” regarding interdisciplinary team/group meetings. The DON stated she was “sure the nurses were giving report to the doctor [during the IDT meeting] but were not writing anything down”. The DON stated the agency did not follow Agency policy regarding interdisciplinary team plan of care updates and that more education and training needed to occur for the nurses regarding this. In an interview on 05/07/26 at 03:25 p.m., the Adm stated the DON had clinical oversight of the patients. The Adm stated she was not aware of problems with the interdisciplinary team plan of care updates for Patient #2 or Patient #3 prior to this survey. The Adm stated she was not “qualified” to explain how “missing paperwork” could negatively affect the patient but acknowledged the patient could negatively be affected. The Adm stated, “I suppose the nurses are reporting to the doctor”. Record review of Agency policies titled “Plan of Care, C-580”, revision 1024 and no revision date noted, quoted in part, “Hospice services are furnished under the supervision and direction of the patient’s physician. The Plan of Care is based on a comprehensive assessment and information provided by the patient/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that patient needs are met, and will be updated as necessary, but at least every fifteen (15) days. The update of the Plan of Care is based on changes that have taken place since the initial assessment and includes information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care and needs. For hospice care provided to a resident of a Skilled Nursing Facility (SNF), Nursing Facility (NF), or Intermediate Care Facility for the Mentally Retarded (ICF/MR), the hospice plan of care identifies the care and services that are needed and identifies which provider is responsible for performing the functions that have been agreed upon and included in the plan of care… 7. The interdisciplinary group documents its review and revision of the patient’s total plan of care as often as the severity of the patient’s condition requires, but at least one time every fifteen (15) days…” No additional information was provided by the Agency prior to exit conference on 05/07/26 for Patient #2 or Patient #3

Based on record review and interview, the Hospice failed to provide infection control education to 4 (Adm, Alt Adm, DON and RN A) of 9 employees whose records were reviewed for 2026. This failure could place staff and the Hospice’s current patients at risk for exposure for communicable and/or infectious diseases. --- The findings included: Record review of the Hospice’s policy titled, “Infection Control Education, D-168”, revision 1024 and employer manual 2017, quoted in part, “For each twelve (12) months of employment, all employees and contractors who have contact with the patients in the patient’s residence shall complete in-service training about infection control practices to be used in the home… 2. Employee education shall occur at the time of employment, within thirty (30) days when changes occur, and annually… 3. Annual infection control training will focus on changes in policy or regulation and topics pertinent to position in the agency…” Record review of employee roster provided by the HR Director on 05/05/26 documented the following active personnel: Adm with a date of hire 09/01/08 Alt Adm with a date of hire 03/03/25 DON with a hire date 02/17/25 RN A with a hire date 02/17/25 Record review of Adm personnel file included a “Job Application Form” signed and dated 08/01/24. Further record review of Adm personnel file included a “Personnel Orientation Checklist” signed and dated 08/16/24 and a “Job Description: Administrator/Alternate Administrator” that was signed and dated 12/01/23. Record review of Adm personnel file included an “Annual In-Service Training for All Staff” signed and dated 04/01/25 that documented in-service hours completed for the OSHA and Infectious Disease Control in-service. Record review of the Adm personnel file failed to include an updated Hepatitis B or Bloodborne pathogen, microorganisms including viruses, bacteria, or parasites that circulate in the bloodstream and can cause systemic infections, in-service for 2026. Record review of Alt Adm personnel file included a “Job Application form” signed and dated 03/03/25. Further review of Alt Adm personnel file included a “Personnel Orientation Checklist” signed and dated 03/17/25 and a “Job Description: Administrator/Alternate Administrator” that was signed and dated 03/03/25. Record review of the Alt Adm personnel file included an “Occupational Exposure to Bloodborne Pathogens” that documented acknowledgment and receipt of “Universal Precautions and Hepatitis B” information and was signed/dated 03/03/25. Record review of Alt Adm personnel file included an “Annual In-service Training for All Staff” signed and dated 03/17/25 that documented in-service hours completed for the OSHA and Infectious Disease Control in-service. Record review of the Alt Adm personnel file failed to include an updated Hepatitis B or Bloodborne pathogen in-service for 2026. Record review of the DON personnel file included a “Job Application Form” signed and dated 02/15/25. Further review of the DON personnel file included an “Orientation” form signed and dated 02/17/25 and a “Job Description” that was signed and dated 05/12/25. Record review of the DON personnel file included an “Occupational Exposure to Bloodborne Pathogens” that documented acknowledgment and receipt of “Universal Precautions and Hepatitis B” information and was signed and dated 02/17/25. Record review of the DON personnel file included an “Initial competency assessment skills checklist registered nurse” that was signed and dated 02/18/25 and documented competency in “Infection control, personal protective equipment (PPE), Exposure control plan, Tuberculosis (TB) exposure control plan and standard precautions. Record review of the DON personnel file included an “Annual In-Service Training for All Staff” signed and dated 02/17/25 that documented in-service hours completed for the OSHA and Infectious Disease Control in-service. Record review of the DON personnel file failed to include an updated Hepatitis B or Bloodborne pathogen in-service for 2026. Record review of RN A personnel file included a “Job Application Form” signed and dated 02/17/25. Further review of RN A personnel file included an “Orientation” form signed and dated 02/17/25 and a “Job Description Summary” that was signed and dated 02/17/25. Record review of RN A personnel file included an “Occupational Exposure to Bloodborne Pathogens” that documented acknowledgment and receipt of “Universal Precautions and Hepatitis B” information and was signed and dated 02/17/25. Record review of RN A personnel file included an “Initial competency assessment skills checklist registered nurse” that was signed and dated 02/19/25 and documented competency in “Infection control, PPE, Exposure control plan, TB exposure control plan and Standard precautions”. Record review of RN A personnel file included an “Annual In-Service training for All Staff” signed and dated 02/17/25 that documented in-service hours completed for the OSHA and Infectious Disease Control in-service. Record review of RN A personnel file failed to include an updated Hepatitis B or Bloodborne pathogen in-service for 2026. In a telephone interview on 05/07/26 at 13:10, the HR Director was asked to provide Hepatitis B, Bloodborne pathogen or any OSHA in-service related to bloodborne pathogen and infection control for Adm, Alt Adm, DON, and RN A for record review. In a follow up interview and simultaneous record review on 05/07/26 at approximately 01:45 p.m., the HR Director confirmed she was head of human resources department and had oversight of maintaining personnel records including in-services and performance evaluation schedules. The HR Director stated the Agency tried to “group” in-services in June. The HR Director stated in-services had not been performed for 2026. The HR Director stated in-service documentation was kept in each employees personnel file. The HR Director confirmed Adm with a date of hire (DOH) 09/01/08 and stated in-services for Hepatitis B or Bloodborne pathogens for 2025 and 2026 had not been completed. The HR Director confirmed a DOH of 02/04/25 for the Alt Adm and stated the in-service for Hepatitis B or Bloodborne pathogen for 2026 had not been completed. The HR director confirmed a DOH of 02/17/25 for the DON and stated the in-service for Hepatitis B or Bloodborne pathogen for 2026 had not been completed. The HR Director confirmed a DOH of 03/04/25 for RN A and stated the in-service Hepatitis B or Bloodborne pathogen for 2026 had not been completed. The HR director stated Hepatits B and Bloodborne pathogen in-services were performed upon hire and annually. The HR Director stated each department was notified of what in-service was needed for each employee. The HR director stated the Agency had not followed their policy for infection control and personnel records. The HR director stated not conducting required in-services for infection control and bloodborne pathogens negatively affected Hospice patients in that the Agency was “not following their internal policy”. In an interview on 05/07/26 at 02:00 p.m., the Alt Adm stated he was unaware required hepatitis B and bloodborne pathogen in-services had not been completed for the Adm, Alt Adm, DON and RN A. The Alt Adm stated it was the responsibility of the HR department to maintain personnel records and in-service schedules. The Alt Adm stated he was not sure why the in-services had not been completed. The Alt Adm stated not maintaining in-service for hepatitis B and bloodborne pathogen could negatively affect patient care in “every way” The Alt Adm continued by stating that if staff were not “properly trained with polices and procedures, the lack of understanding could affect the patient”. In a telephone interview on 05/07/26 at 03:25 p.m., the Adm stated she was not in the office and in front of her computer due to an emergency to be able to confirm the lack of in-services conducted for the staff in question. The Adm stated she had ultimate oversight of the HR department including ensuring in-services were completed. The Adm stated in-services for hepatitis B and bloodborne pathogens were conducted annually but they “had a lot of new staff”.  The Adm stated not conducting in-services could have a negative effect on the Hospice due to them not following policies and procedures. Record review of Code of Federal Regulations (CFR), Chapter XVII, Part 1910.1030, accessed 05/07/26, related to Bloodborne pathogens, and quoted in part, “Bloodborne pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV)… (g)(2)(i) The employer shall train each employee with occupational exposure in accordance with the requirements of this section. Such training must be provided at no cost to the employee and during working hours. The employer shall institute a training program and ensure employee participation in the program… (ii) Training shall be provided as follows… (A) At the time of initial assignment to tasks where occupational exposure may take place… (B) At least annually thereafter… (iv) Annual training for all employees shall be provided within one year of their previous training… (v) Employers shall provide additional training when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee's occupational exposure. The additional training may be limited to addressing the new exposures created….” No further information was provided by Hospice upon exit on 05/07/26 at 05:20 p.m.

Observed in Record Review. In 3 of 14 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RR#7 the documentation noted that the patient had a G-tube and was receiving tube feedings. There were no physicians orders for the tube feedings and the G-tube and feedings were not reflected on the care plan. Additionally, the documentation noted skin care treatments to the G-tube site, but there were no treatment orders, nor were they reflected on the care plan. On review of RR#10 the documentation showed the patient to be diabetic with orders for sliding scale insulin, yet there were no orders for blood glucose monitoring, nor was management of diabetes reflected on the care plans. On review of RR#13 the patient had a wound with orders for dressing changes, however the issues were not reflected on the care plan, as there was no skin integrity care plan open. Further, the care plan for risk for infection has a goal, but no interventions. These observations were reviewed with the Administrator, Alt. Administrator, and the Director of Nursing.

Observed in Individual Tracer. In 1 of 10 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the registered nurse member of the interdisciplinary team, had not visited the patient to update the assessment for a period of 21 days since mid-February. This was confirmed with the director of nursing.

Observed in Record Review. In 5 of 10 patient records reviewed, The hospice nurse surveyor noted (RR#1) that the patient was admitted and assessed six (6) days ago; however, there was no plan of care developed that that included all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Interventions to manage pain and symptoms - A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs - Measurable outcomes anticipated from implementing and coordinating the plan of care - Medications and treatment necessary to meet the patient’s needs - Medical supplies and appliances necessary to meet the patient’s needs. Also, in (RR#2), there was no plan of care established since the patient was admitted nine (9) days ago. The surveyor noted that the assessment indicated that the patient was experiencing dyspnea, fatigue and anxiety and there were no goals or interventions to manage the symptoms. Also, in (RR#3), there was no plan of care established for this patient admitted thirteen (13) days ago. The surveyor noted that the assessment indicated that the patient was experiencing hallucinations, was wandering, had anxiety and was at risk for falls and aspiration; and there were no goals or interventions to manage the patient needs. Also, in (RR#4), there was no plan of care established for this patient admitted fourteen (14) days ago. The surveyor noted that the patient assessment indicated that the patient had a gastrostomy tube and was receiving enteral nutrition with Jevity via pump. since there was no plan of care there were no orders on file for either oral or enteral nutrition, G-tube care and maintenance, oxygen use, care for a skin rash identified and goals and interventions to manage dyspnea, aspiration risk and falls risk. This was discussed with the alternate administrator and director of nursing who confirmed that the plan of care was not being completed until after the next interdisciplinary group discussion in 14 days. The surveyor noted that there were some orders for services and frequency and medications, but no written plan of care in the interim. In (RR#6), the surveyor noted that the medication orders were incomplete. The order for Novolog Insulin 100 units/ml 1 day as directed did not include a dose or frequency of administration. Also, there were no goals or interventions to manage the patient's nutrition, blood glucose monitoring and insulin use. This was confirmed with the director of nursing.

Observed in Individual Tracer. In 2 of 7 patient records with home health aide services, The hospice nurse surveyor noted (HV#1) that the hospice aide had not been supervised by an on-site nursing visit for a period of 21 days since mid-February. Also, in (RR#5) the aide supervision had not been completed since mid-February for a period of 22 days. This was confirmed with the director of nursing.

Observed in Tracer Activities. The hospice nurse surveyor noted that the organizations leadership and the governing body should have reasonably known about COP 418.56 and 418.100.

Observed in Tracer Activities. the organization did not identify in writing the potential emergencies that could affect its ability to provide services and the likely consequences of those emergencies. During EM tracer activities, the hospice nurse surveyor observed the EM plan did not contain an HVA. Upon discussion with the Clinical Supervisor who manages the plan, they did not currently have one. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to provide emergency preparedness training to volunteers. During tracer activities for the volunteer program, the hospice nurse surveyor observed the volunteer training manual did not include training for new or on-going education related to the organization's emergency operations plan. This was discussed and reviewed with the Volunteer Coordinator.

Observed in Tracer Activities. the organization failed to evaluate the effectiveness of its Emergency Operation Plan. During tracer activities for Emergency Management, the hospice nurse surveyor observed the organizational policy states they will have two drills a year. With no HVA in place, there was no focus on relevant emergency situations and the only emergency drill they had documented for 2022 was a table top exercise related to review and implementation of the new Emergency Operations Plan. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Record Review. In 2 of 12 patient records reviewed, the organization failed to assess and reassess its patient. During HV#2, the hospice nurse surveyor observed the RN did not visit the hospice patient at least every 15 days to conduct an assessment. There were no documented nursing visits from 11/15 to 12/9. During record review for RR#9, the hospice nurse surveyor observed the patient had no nursing visits from 11/15 until discharge on 12/6. This was confirmed with the Alternate Administrator. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Record Review. In 12 of 12 patient records reviewed, the organization failed to plan the patients care. During record review for all records, the hospice nurse surveyor observed missing or incorrect issues in the Plan of Care. For example: During HV#1, the hospice nurse surveyor observed the POC did not contain wound care orders for an injury related to a fall or goals and interventions related to the wound and sleep issues. In HV#2, the SN documented performing an enema on at least two occasions but there was no documentation of an order for the enema. In HV#3, the patient had a UTI on 10/24 and was placed on Bactrim but the POC was not updated. In RR#1, the patient nursing notes stated aggressive behavior with biting and yelling but there were no interventions and goals for these issues on the POC. In RR#9, the patient was discharged on 12/6 for extended prognosis but there had been no interventions on the POC. In HV#3, the patient was taking both Tramadol and Tylenol PRN for pain but no indication was given on which medication to give first. In RR#2, Naproxen and Tramadol were both listed for moderate pain but there was no direction on which medication to give first. In RR#3, Tylenol with Codeine PRN was ordered for pain with no instructions on when to take and Children's liquid Tylenol for pain was ordered with no instructions. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Record Review. In 12 of 12 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the hospice nurse surveyor observed the written plan of care did not contain measurable, individualized time frames to meet the patients goals. For example in HV#2, the SN goals were all beyond the target date and the SC/ SW goals were all to be achieved on the last day of certification. For HV#3, all SN/ SW/ SC goals are to be met on 12/22. For RR#1, had a goal of caregiver becoming compliant with removal of safety hazards began on 9/15 with a target date of 12/15 and the patient lived in a SNF. For RR#2, the goal written was patient will have decreased signs of depression added 3/23 with target date of 12/27/22. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Record Review. In 1 of 12 patient records reviewed, the organization failed to provide patient education and training based on each patient's needs and abilities. During record review for RR#9, the hospice nurse surveyor observed the patient was discharged on 12/6 for extended prognosis and there had not been education on the discharge process. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Record Review. In 3 of 12 patient records reviewed, the organization did not provide interdisciplinary, collaborative care, treatment, or services. During HV#1, the hospice nurse surveyor observed the patient had a fall with injury and the RN did not document collaboration or communication with the provider in charge of the patient's care. The RN was providing wound care without coordination or communication. The physician was notified two days later during IDG. During record review for RR#9, the hospice nurse surveyor observed the patient had been discharged on 12/6 and was discussed for MD approval at IDG on 12/14 , with hospice nurse surveyor present. There had been no discharge order or discussion documented prior and the patient was discharged for extended prognosis. For RR#3, the caregiver was providing wound care using Hydrofera Blue and there was no documentation of an order or collaboration with the provider. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to establish a quality assessment and improvement program. During tracer activities for Data Management, the hospice nurse surveyor observed the organization had been tracking and reporting on some data but had no written QAPI plan in place to prioritize or evaluate the effectiveness of their activities. This was discussed and reviewed with the Hospice Administrator and DON. Observed in Tracer Activities. the organization failed to have a quality assessment and performance improvement program (QAPI) that met all required criteria. The organization did not have a written QAPI plan in place and the activities there were performing did not include DME, pharmacy, bereavement or volunteer services. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to establish a quality assessment and performance improvement program demonstrates improvement in the indicators related to improved palliative outcomes and hospice services. During tracer activities for Data Management, the hospice nurse surveyor observed there was no documentation of an organizational wide plan therefore the HCO was unable to show measurable improvement in indicators. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to establish a QAPI plan that used quality indicator data, including patient care and other relevant data, in the design of its quality assessment and improvement program. During tracer activities for Data Management, the hospice nurse surveyor observed the organization had been tracking and reporting on some data but had no written QAPI plan in place to prioritize or evaluate the effectiveness of their activities. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to select performance improvement activities that affect palliative outcomes. During tracer activities for Data Management, the hospice nurse surveyor observed had been tracking and reporting on some data but had no written QAPI plan in place to prioritize or evaluate the effectiveness of their activities and the data they had been collecting did not include palliative outcomes. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to reprioritize performance improvement activities in response to changes in the internal or external environment. During tracer activities for Data Management, the hospice nurse surveyor observed there was no documentation of an organizational wide plan ,and with recent changes in loss of staffing, there was no reprioritization of data collection focus. During conversation with the leadership team, they mentioned the loss of several full time nurses, including the DON, 2 weeks before survey related to attempting to hold staff accountable for documentation. But there was no documented focus in the QAPI activities on process improvement related to those events. This was discussed and reviewed with the Hospice Administrator and DON. Observed in Tracer Activities. the organization failed to establish priorities for performance improvement organizational wide. During tracer activities for Data Management, the hospice nurse surveyor observed there was no documentation of an organizational wide plan. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During HV#3, the hospice nurse surveyor observed the HHA re-enter her bag multiple times with gloves on and she did not perform hand hygiene in between, per organizational policy. This was discussed and reviewed with the Hospice Administrator and the DON. Observed in Patient Home. In 2 of 3 patient records reviewed, for HV#2 and HV#3, the hospice nurse surveyor observed diagnosis of urinary tract infection with ordered antibiotics. There was no documentation of the infections for data management tracking per organizational policy. Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1, the hospice nurse surveyor observed the RN clean her equipment with some disinfectant wipes. Upon conversation and review of the package, it was noted that the wipes are to have a ten minute wet time for disinfection. The organizational policy states to follow manufacture guidelines. When questioning the RN, she was unaware of the wet time requirements. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During HV#3, the hospice nurse surveyor observed the HHA did not perform hand hygiene consistent with policy. She did not perform hand hygiene when removing her gloves and she did not perform hand hygiene when going from dirty ( washing patient genitals) to clean ( putting on clean clothes and applying lotion). This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to have written infection prevention and control goals based on their prioritized risks. During tracer activities for Data Management, the hospice nurse surveyor observed the infection control program was collection of data but did not include goals for addressing prioritized risks. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Record Review. In 1 of 12 patient records reviewed, the organization failed to provide care, treatment or services according to the POC. During record review for HV#2, the hospice nurse surveyor observed the patient had orders for SN 2x weekly. There had been no visits from 11/15- 12/9. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to supervise effectively. During record review for RR#1, the hospice nurse surveyor observed no documentation of aide supervision performed at least every 14 days. The patient began aide services on 7/21/22 and there was no documentation of aide supervision until 12/8/22. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization failed to supervise staff effectively. During tracer activities for HR competence, the hospice nurse surveyor observed HR file #5 did not contain documentation of an annual on-site visit by an RN in order to observe and assess each aide while the aide is providing care. There was no documentation of an on-site competency performed for 2020 and 2021. After discussion with the Alternate Administrator, it was noted the organization had been performing them once every three years. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. Leadership and the governing body failed to understand the degree of risk in 428.226, 418.114, 418.76, 418.54, 418.56, 418.58, 418.70, and 418.60. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in HR File Review. In 1 of 6 HR files reviewed, the organization failed to provide orientation to staff. During HR file review for HR file #6, the hospice nurse surveyor observed there was no documentation of orientation for the Medical Director. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in HR File Review. In 1 of 6 HR files reviewed, the organization failed to provide orientation to staff. During HR file review for HR file #6, the hospice nurse surveyor observed there was no documentation of competence at least every three years, as required by policy. The MD had been employed since 4.12.2019. This was discussed and reviewed with the Hospice Administrator and DON. Observed in HR File Review. In 1 of 6 HR files reviewed, the organization failed to provide orientation to staff. During HR file review for HR file #6, the hospice nurse surveyor observed there was no documentation of initial staff competence as part of orientation. The MD had been employed since 4.12.2019. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Patient Home. In 2 of 12 patient records reviewed, the patient record did not contain information that reflected the patient's care, treatment, or services. During HV#1, the medication list was discovered to be inaccurate. The hospice nurse surveyor observed the RN perform a medication reconciliation with multiple previous errors. The medication list in the home and in the Electronic Medical Record reflected Meclizine for dizziness but the daughter stated that had been stopped several months previous. The Tylenol with Codeine was still in the home and expired over 6 months, and was reflected on both lists but the daughter stated it had not been used. He was no longer taking Centrum Silver or Remeron but both were still on the medication list. And the patient was taking Lorazepam but the daughter had not been educated to put it in the refrigerator, as listed on the label. The family also had a medication they were giving that had no label, and they stated it is for constipation. The medical record stated the medications were reviewed on 11/30/22. During record review for HV#1, the hospice nurse surveyor observed the patient had a fall on 11/28 with a skin tear to the right forearm and a laceration to the right eyelid but there was no documentation of the wounds per the organizational policy. During record review for RR#3, the hospice nurse surveyor observed an active wound but no description or wound measurements documented. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to provide education and training based on each patient's needs and abilities. During HV#1, the hospice nurse surveyor observed the patient did not have an oxygen sign on the door and was on intermittent oxygen. Also noted, the RN asked the daughter to show her the concentrator and asked probing questions about the use of the machine. The daughter stated I just turn the machine on, I don't mess with anything. The concentrator was set at 4Liters and the patient orders stated 2 Liters. During HV#2, the hospice nurse surveyor observed no oxygen sign on the door as required by policy. This was discussed and reviewed with the Hospice Administrator and DON.

Observed in Tracer Activities. the organization did not comply with law and regulation. During record review and conversation with the Alternate Administrator it was noted the organization did not have a process in place for managing or implementing the NOMNC. This was discussed and reviewed with the Hospice Administrator and DON.