Every finding on record at Shelby County Chris A.Myrtue Memorial Hospital

Based on review of the emergency preparedness plan and policies and staff interview, the hospice failed to ensure the policy contained verbiage to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.  Failure to include this verbiage in the emergency preparedness policy placed hospice patients at risk should an emergency situation arise. --- Findings include:  During an interview on 3/10/26 at 3:45 PM, Staff I, Public Health Nurse, confirmed information regarding evacuation was missing from emergency preparedness policy and would be added at next revision of the policy.  The above findings were reviewed with the Administrator/Clinical Manager.

Based on review of emergency preparedness training rosters, review of the emergency preparedness plan and policies and staff interview, the hospice failed to ensure training in emergency preparedness for all staff, including individuals providing services under arrangement (contracted staff) and volunteers, consistent with their expected roles for the calendar years of 2024 and 2025. The agency currently employed a total of 9 directly hired staff, utilized a total of 1 contracted staff (Music Therapist) and had a total of 18 volunteers to provide services to patients. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. --- Findings include:  During an interview on 3/10/26 at 11:30 AM, the Administrator/Clinical Manager, reported Staff E, Music Therapist, did not receive emergency preparedness training.  During an interview on 3/10/26 at 2:15 PM, Staff I, Public Health Nurse, reported nursing staff are involved in annual drills and this is their annual education of emergency preparedness policy.   Staff C, Registered Nurse, was not included in drills completed in 2024 and 2025.  Staff I had no additional educational information for Staff C. During an interview on 3/10/26 at 4:00 PM, the Administrator/Clinical Manager, reported the social worker provided volunteer training and had retired.  The Administrator/Clinical Manager and Volunteer Coordinator have looked through files for documentation of emergency preparedness training for Staff F, Volunteer and Staff G, Volunteer, but were unable to locate any documentation.  The above findings were reviewed with the Administrator/Clinical Manager.

Based on clinical record review, hospice policy review, hospice admission packet review, patient interview, family interview and staff interview, the hospice failed to:1) Ensure hospice staff inform and distribute written information to the patient concerning its policies on advance directives, including a description of applicable State law. (see L0503)2) Ensure patients receive information about the services covered under the hospice benefit. (see L0518) Findings include: --- The cumulative effects of this systemic practice resulted in the failure to ensure the organizational framework of the hospice, promoted and supported the coordination of safe and effective delivery of care according to patient's rights and responsibilities.

Based on hospice staff Interview, hospice clinical record reviews, and hospice policу review,  the hospice failed to ensure the the documentation and correct Identification, in a prominent part of the patient's record, any advance directives executed by the patient or patient's representative for 5 of 14 sampled patients (Patients #3, #4, #7, #8,  and #13) with a record review.  Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: --- 5. Patient # 4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and conflicting advanced directive information including the patient did not want resuscition, dated 10/25/25 and also identified the patient a full code, dated 2/21/25.    b. The admission consent forms, signed by the patient on 12/10/25 identified the patient does not want CPR.    The hospice agency failed to include accurate advance directive information on the patient's plan of care at the time of admission to hospice services.   The above findings were reviewed with the Administrator/Clinical Manager.  2. Patient # 3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and identified no active advance directives exist for the patient.    b. The admission consent forms, signed by the patient's authorized representative on 1/26/26 identified the patient does not want cardiopulmonary resuscitation (CPR).    The hospice agency failed to include accurate advance directive information on the patient's plan of care at the time of admission to hospice services.    3. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and identified no active advance directives exist for the patient.    b. The admission consent forms, signed by the patient's authorized representative on 1/22/26 identified the patient does not want CPR.    The hospice agency failed to include accurate advance directive information on the patient's plan of care at the time of admission to hospice services.    4. Patient #13 had a hospice admission date of 6/13/25, a death date of 9/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 6/13/25 to 9/10/25, identified the patient had a primary diagnosis of panlobular emphysema and identified patient's advance directive as a full code (wants resuscitative measures).    b. The admission consent forms, signed by the patient on 6/13/25 identified the patient as a DNR (do not attempt resuscitation).      The hospice agency failed to include accurate advance directive information on the patient's plan of care at the time of admission to hospice services.   According to the hospice policy titled Advance Directives Procedure, last revised November 2008, the agency recognizes that all persons have the fundamental right to make decisions about their own medical treatment, including the right to accept or refuse medical treatment. The individual has the right to revoke or change an advance directive at any time and will need to notify the agency of any changes. In an interview on 3/17/26 at 3:47 PM, the Administrator reported the process used for the advanced directive form used at admission.  When the patient/patient representative chooses resuscitate or do not resuscitate (DNR) this form content is then entered into the Plan of Care (POC).  The nurses may not be doing this or the nurses may not be updating the POC to reflect patient’s advanced directive.   1. Patient #7 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home.  Clinical record review revealed the following: a.The Plan of Care (POC), dated 2/12/26 to 5/12/26, identified the patient had a primary diagnosis of hepatic encephalopathy and  identified no active advance directives exist for the patient.    b. The admission consent forms, signed by the patient's authorized representative on 1/26/26 identified the patient does not want cardiopulmonary resuscitation (CPR).   Review of the clinical record included conflicting code  status information in a situation the patient had no pulse and was not breathing.

Based on staff interview, clinical record reviews, and policy review, the hospice failed to ensure patients received information about the services covered under the hospice benefit for 14 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14).  Failure of the hospice to ensure the patient received information about the services covered under the hospice benefit increased the risk that patients did not receive appropriate services to meet assessed needs.  Findings include: --- Review of patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14 clinical record revealed a Medicare Hospice Election Statement form completed at the time of admission to hospice services.  The clinical record failed to contain notification of a right to request patient notification of hospice non-covered items, services and drugs.  The hospice failed to notify the patients of their rights to receive notification of services not covered by the hospice benefit.  The above findings were reviewed with the Administrator/Clinical Manager   According to the agency document titled Patient Notification of Hospice Non-Covered Items, Services, and Drugs, dated July 2023, the purpose of this addendum is to notify the requesting Medicare beneficiary (or representative), in writing, of those conditions, items, services, and drugs not covered by the hospice because the hospice has determined they are unrelated to your terminal illness and related conditions.  If you request this notification on the effective date of the hospice election (that is, on the start date of hospice care), the hospice must provide you this form within 5 days.  If you request this form at any point after the start date of hospice care, the hospice must provide you this form within 3 days.    In an interview on 3/11/26 at 8:27 AM, the Administrator reported the nursing staff are verbally notifying patient and family of the Medicare benefit election addendum that explains what the hospice did not cover for medications, services and treatment; but nothing is documented in the patient chart.  A form was created in the past, but not used.

Based on staff interview, clinical record reviews, and agency policy review, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements for 3 of 4 sampled patients (#1, #10, and #12) with wounds.  Failure to complete wound assessments increased the risk that patients’ needs would not be identified and/or addressed appropriately.  Findings include: --- According to the agency policy titled Wound Assessment, last revised December 2023, clients will receive comprehensive assessment and ongoing treatment of wounds in compliance with physician orders and evidence based practice in order to provide continuity in wound care, assess outcomes, and provide documentation of actions implemented by departmental staff.  A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing.  Comprehensive wound assessment is necessary during every dressing change and includes data on wound type, location, drainage, color, size and shape, presence of tunneling, condition of the wound edges, and condition of the surrounding tissue.    In an interview on 3/10/26 at 10:27 AM, the Administrator reported that full wound assessments are performed weekly or with any changes and include length, width, depth, description, if there is drainage, and skin color around the wound.  1.Patient #1 had a start of care date of 10/16/25 and received hospice services in a nursing home.  a.The Plan of Care (POC), dated 1/14/26 to 4/13/26, included a primary diagnosis of Alzheimer’s disease and orders for skilled nursing.  b.Skilled nurse visit note on 2/17/26 by Staff C, Registered Nurse (RN), identified a skin tear to the patient’s right lower forearm skin tear with no assessment of the wound performed.     c.Skilled nurse visit note on 2/24/26, by Staff C, identified a wound assessment of the patient’s left heel stage 2 pressure ulcer with length measuring 2 cm (centimeters) and 1.3 cm in width.  The wound measurement did not include the wound's depth.  The hospice failed to accurately assess the patient’s wounds.   2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POCs, dated 3/31/25 to 6/28/25 and 6/29/25 to 9/26/25 identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse to assess integrity of skin.    b. The skilled nurse initial assessment, dated 3/31/25, completed by Staff B, RN identified the patient had an open, unstageable pressure ulcer to the left gluteal fold and described the wound bed as pink/red with no drainage or odor.  The wound measures 0.6 cm length by 0.4 cm width by 0 depth.  The measurements lacked an accurate depth measurement for the open wound.    c. The skilled nurse visit note, dated 9/8/25, completed by Staff B, RN, identified a new wound to the left gluteal fold with a small amount of serous drainage and described the wound bed as pink/red.  The wound measures 1 cm length by 0.7 cm width by 0 depth.  The measurements lacked an accurate depth measurement for the open wound.    The clinical record lacked accurate wound measurements including length, width and depth.   3. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse to assess integrity of skin.    b. The skilled nurse note, dated 1/5/26, completed by Staff C, RN identified the patient had a small abrasion to the back of the right leg due to the wheelchair pedal. The wound lacked assessment of wound bed and surrounding skin and measured 0.5 length by 0.5 width with no depth measured.  c. The skilled nurse visit note, dated 2/26/26, completed by Staff A, Administrator/Clinical Manager, identified the patient had a dressing to the inner part of the left lower leg. The documentation failed to include an assessment of the skin integrity of the left lower leg.  The clinical record lacked accurate wound assessment or measurements including length, width and depth.    The above findings reviewed with the Administrator/Clinical Manager According to the agency policy titled Wound Assessment, last revised December 2023, clients will receive comprehensive assessment and ongoing treatment of wounds in compliance with physician orders and evidence based practice in order to provide continuity in wound care, assess outcomes and provide documentation of actions implemented by departmental staff.  A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing.  Comprehensive wound assessment is necessary during every dressing change and includes data on wound type, location, drainage, color, size and shape, presence of tunneling, condition of the wound edges and condition of the surrounding tissue.    In an interview on 3/10/26 at 10:27 AM, the Administrator reported that full wound assessments are performed weekly or with any changes. The assessment includes length, width, depth, description, if there is drainage, and skin color around the wound.  1.Patient #1 had a start of care date of 10/16/25 and received hospice services in a nursing home.  a.The Plan of Care (POC), dated 1/14/26 to 4/13/26, included a primary diagnosis of Alzheimer’s disease and orders for skilled nursing.  b.Skilled nurse visit note on 2/17/26 by Staff C, Registered Nurse (RN), identified a skin tear to the patient’s right lower forearm skin tear with no assessment of the wound performed.     c.Skilled nurse visit note on 2/24/26, by Staff C, identified a wound assessment of the patient’s left heel stage 2 pressure ulcer with length measuring 2 cm (centimeters) and 1.3 cm in width.  The wound measurement did not include the wound's depth.  The hospice failed to accurately assess the patient’s wounds.  2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POCs, dated 3/31/25 to 6/28/25 and 6/29/25 to 9/26/25 identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse to assess integrity of skin.    b. The skilled nurse initial assessment, dated 3/31/25, completed by Staff B, RN identified the patient had an open, unstageable pressure ulcer to the left gluteal fold and described the wound bed as pink/red with no drainage or odor.  The wound measures 0.6 cm length by 0.4 cm width by 0 depth.  The measurements lacked an accurate depth measurement for the open wound.    c. The skilled nurse visit note, dated 9/8/25, completed by Staff B, RN, identified a new wound to the left gluteal fold with a small amount of serous drainage and described the wound bed as pink/red.  The wound measures 1 cm length by 0.7 cm width by 0 depth.  The measurements lacked an accurate depth measurement for the open wound.    The clinical record lacked accurate wound measurements including length, width and depth.    3. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse to assess integrity of skin.    b. The skilled nurse note, dated 1/5/26, completed by Staff C, RN identified the patient had a small abrasion to the back of the right leg due to the wheelchair pedal. The woundmeasured 0.5 length by 0.5 width with no depth measured. lacked assessment of wound bed and surrounding skin and measured 0.5 length by 0.5 width with no depth measured.  c. The skilled nurse visit note, dated 2/26/26, completed by Staff A, Administrator/Clinical Manager, identified the patient had a dressing to the inner part of the left lower leg. The documentation failed to include an assessment of the skin integrity of the left lower leg.  The clinical record lacked accurate wound assessment or measurements including length, width and depth.    The above findings reviewed with the Administrator/Clinical Manager

Based on clinical record reviews, hospice policy review and staff interview, the hospice failed to ensure hospice staff used routine and standing orders that were Individualized and specific to the needs of the patients for 14 of 14 patients sampled (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) with a record review.   Failure to establish the use of individualized routine and standing orders rather than generalized, non-specific standing orders, placed patients for potential risk of receiving or not receiving medications, treatments, and services that did not adequately meet the needs of hospice patients.   Findings include: --- According to the agency policy titled Interdisciplinary Team (IDT) Guidelines, last revised September 2020, the primary responsibility of the IDT is to provide and supervise care and services delivered in the patient’s home or on an inpatient or respite basis.  The role of IDT includes participation in establishment of an interdisciplinary, individualized plan of care for each patient/family.  In an interview on 3/10/26 at 10:27 AM, the Administrator reported that on admission, standing orders are created and sent to the physician. If the patient starts a medication listed on standing orders, it is then added to the patient’s medication list. Nurses should be able to remove a standing order that does not apply, such as ostomy, so that the order should not be present on the Plan of Care (POC).    The routine standing orders signed off by a physician contained the following patient non-specific orders for Patients #1 through #14, on the patients’ POC.  a.Incisional/wound cares as appropriate as needed. The standing order failed to include wound care specific to the needs of the patients. Every patient had the same non-specific order regardless whether or not the patient had a wound and/or incision.  b.Calmoseptine topical ointment as needed. The standing order failed to specify what the topical ointment should be used to treat.   c.Silvadene 3% topical cream to affected area 1-2 times power day and as needed.   The standing order failed to specify what the topical cream should be used to treat.  d.Suction as needed.  The standing order failed to specify under what circumstances suctioning would be needed.  e.Oxygen at 2 liters per minute and may increase as needed. The standing order failed to include a route for delivery of the oxygen, failed to specify under what circumstances the patient would increase the oxygen rate per minute and at what rate the patient could or should increase the oxygen rate per minute to above the 2 liters per minute.  f.Placement of external/indwelling or suprapublic urinary catheter straight catheterization as needed.  If indwelling, change the catheter every 4 weeks and as needed.   May irrigate catheter as needed with sterile water/saline 100 mL (milliliters) as needed. The standing order failed to specify under what circumstances a catheter would need to be placed and failed to specify a catheter size or type specific to the individual needs of the patient and under what circumstances irrigation of the catheter would be needed.  g.Ostomy care and maintenance (includes gastrostomy) as indicated. None of the patients sampled (Patients #1 through #14 had an ostomy of any type.   h. The standing orders included the following medications:  1)Colace 100 mg 1-2 twice daily as needed. The order lacked a route and failed to specify the reason why the as needed medication should be taken.   2)Milk of Magnesia 30-60 cc (cubic centimeter) as needed. The order lacked a frequency and route and failed to specify the reason why the as needed medication should be taken.  3)Senokot or Senokot S 1-2 tablets by mouth daily and as needed. The order falled to specify the reason why the as needed medication should be taken.  4)Miralax 17 gm(grams) by mouth daily or daily as needed. The order failed to specify the reason why the as needed medication should be taken.  5)Lactulose 10 gm/15 mL 15-30 mL by mouth as needed. The order failed to specify a frequency and the reason why the as needed medication should be taken.  6)Dulcolax 10 mg rectal suppository daily as needed. The order lacked a route and failed to specify the reason why the as needed medication should be taken.   7)Fleets enema as needed. The order failed to specify a frequency and the reason why the as needed medication should be taken.   The above medications are used to treat/prevent constipation. The standing orders failed to identify how the nurse and/or patient would know in what order the medications should be implemented or if they should all be implemented at once.   8)Lasix 20 mg 1-2 tablets by mouth daily and as needed. The order failed to specify the reason why the as needed medication should be taken. 9)Maalox 30 mL daily as needed. The order lacked a route and failed to specify the reason why the as needed medication should be taken. 10)Zofran 4-8 mg by mouth every 4-6 hours as needed.  The order failed to specify the reason why the as needed medication should be taken. 11)Simethicone 80 mg by mouth twice per day as needed. The order failed to specify the reason why the as needed medication should be taken. 12)Benadryl cream 1 application to the affected area 2-3 times per day as needed. The standing order failed to specify what the topical cream should be used to treat.  13)Scopolamine transdermal patch 1 mg every 72 hours. The order failed to specify the reason why the as needed medication should be taken. 14)Mucinex 600 mg by mouth twice per day as needed. The order failed to specify the reason why the as needed medication should be taken. 15)Miracle mouthwash/swish and swallow mouthwash equal parts Benadryl, lidocaine, viscus, Mylanta 10 mL by mouth twice per day and as needed. The order failed to specify the reason why the as needed medication should be taken. 16)Ocean spray 1 spray each nostril as needed. The order failed to specify the reason why the as needed medication should be used. 17)Albuterol 2.5 mg/3 mL nebulized every 4 hours as needed. The order failed to specify the reason why the as needed medication should be used. The above findings were reviewed with the Administrator/Clinical Manager.

Based on staff interviews, clinical record reviews and agency policy review, the hospice failed to ensure the hospice plan of care included complete orders for all necessary medications and treatments to meet the needs of the patients for 4 of 14 sampled patients (Patients #2, #10, #8 and #12).    Failure to ensure the plan of care included complete orders for medications and treatments placed the patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients.    Findings include: --- 3. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included physician orders for skilled nurse visits, medications and treatments.    b. The POC included standing orders for placement of an external/indwelling or suprapubic urinary catheter or straight catheterization as needed.  c. During an observation home visit on 3/10/26 at 9:30 AM with Staff D, RN the surveyor observed the skilled nurse change the patinets existing suprapubic catheter.  The hospice failed to include complete physician orders for the patients specific urinary catheter to meet the patients needs. 4. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included physician orders for skilled nurse visits, medications and treatments.    b. The skilled nurse visit note, dated 2/26/26, completed by Staff D, RN, identified the patient had a dressing to the inner part of the left lower leg.   c. Review of the clinical record lacked orders for the dressing to the patient's inner left lower leg.  The hospice failed to include complete physician orders for necessary treatment on the patient's plan of care. The above findings were reviewed with the Administrator/Clinical Manager.   According to the agency policy titled Plan of Care, last revised July 2017, the Plan of Care (POC) is established by the Interdisciplinary Group (IDG) in collaboration with the patient's attending physician, the patient and the primary caregiver.  The POC includes patient diagnosis, a complete assessment of patient and family needs including medical, nursing psychosocial and spiritual status and frequency of services, treatments and medications.   The POC is reviewed and updated at least every two weeks.    During an interview on 3/10/26 at 10:27 AM, the Administrator stated the agency does use standing orders for some medications and treatment; however, the orders are individualized prior to being put on the POC.    1.Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included physician orders for skilled nurse visits, medications and treatments.    b. The IDG update to the POC, dated 1/29/26, identified the patient had a foley catheter but lacked complete orders with French size and balloon volume.    c. The skilled nurse visit note, dated 2/12/26, completed by Staff B, Registered Nurse (RN), identified she covered a reddened area to the patient's buttocks with a foam wound dressing for protection.    d. The IDG update to the POC, dated 2/26/26, lacked orders for the foam wound dressing.     The hospice failed to include complete physician orders for necessary treatment on the patient's plan of care.  2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 3/31/25 to 6/28/25 identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse visits, medication and treatments.    b. The skilled nurse initial comprehensive assessment, dated 3/31/25, completed by Staff B, RN identified the patient had an open, unstageable pressure ulcer to the left gluteal fold and noted it covered with a foam wound dressing.   c. The plan of care lacked wound care orders.    The hospice failed to include physician orders for necessary treatment on the patient's plan of care.

Based on home observation visits, staff interview, 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 #2 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: --- According to the hospice policy titled Interdisciplinary Group (IDG) Guidelines, last revised September 2020, the role of the IDG includes reviewing the plan of care for hospice patients at least every two weeks, conduct ongoing assessments of patient and family needs, present patient/family assessments at the IDG meeting and document care plan revisions on the IDG patient review record.    In an interview on 3/10/26 at 10:27 AM, the Administrator reported supplies and equipment are part of the comprehensive assessment and are assessed by talking with the patient, family members/caregivers and reviewing physician notes.    1.Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and used the following medical equipment and supplies: grab bars, hand held shower, lift chair, raised toilet seat, wheeled walker and shower chair and motion alarm.     b. The IDG meeting note, dated 2/12/26, identified additional medical equipment and supplies needed by the patient: incontinence products, hospital bed, side rails and motion alarm.    c. During a home observation visit on 3/12/26 at 2:00 PM, with Staff B, Registered Nurse (RN), the surveyor observed the RN to use patient's pill cutter to cut a medication prior to putting the medication in the medication planner.  The pill cutter has been utilized since the start of care.    The hospice failed to include all medical equipment and supplies utilized by the patient.   2. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and failed to identify any medical equipment or supplies used by the patient.  c. During a home observation visit on 3/10/26 at 9:30 AM, with Staff D, RN, the surveyor observed the patient utilized the following medical equipment and supplies: lift chair, suprapubic catheter and supplies, incontinence supplies.   The hospice failed to include all medical equipment and supplies utilized by the patient.    The above findings reviewed with the Administrator/Clinical Manager

Based on review of a written hospice agreement for services under arrangement and staff interview, the hospice failed to ensure the hospice provided orientation on the hospice's philosophy for 1 of 1 sampled contracted staff (Staff E).   The hospice reported working with a total of 1 contracted individual at the time of the survey.  Failure to provide orientation on hospice's philosophy increased the potential for provision of services in a manner contradictory to the hospice's philosophy. --- Findings include:  A contract, dated 11/2/22, identified the hospice contracted for music therapy services.   During an interview on 3/11/26 at 8:50 AM, the Administrator/Clinical Manager reported the hospice verbally provided Staff E, Music Therapist, with education on hospice philosophy but does not have any documentation in writing that this occurred.  The above findings were reviewed with the Administrator/Clinical Manager.

Based on hospice staff interviews, clinical record reviews and agency policy reviews, the hospice failed to: --- 1)Ensure the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments and clinical notes are included in the patient's medical record (L0672),  2) Ensure all entries in the clinical record are appropriately authenticated in accordance with hospice policy and currently accepted standards of practice (L0679) and   3) Ensure all revoked or discharged patients have a discharge summary completed and forwarded to the patient's attending physician (L0683).   The cumulative effects of these systemic practices resulted in the failure of the agency to ensure the accuracy and integrity of clinical records and increased the risk that hospice staff provided services without current and/or accurate information for its patients.

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 8 of 14 sampled patients (Patients #2, #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: --- According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion.  In an interview on 3/10/26 at 10:27 AM, the Administrator stated admission visits are expected to be completed in the electronic record within 5 days of the visit and routine visits are to be completed within 48 hours.  1.Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included physician orders for skilled nurse to visit the patient 2-3 times per week.    b. The Interdisciplinary Group (IDG) meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week.  c. At the time of the clinical record review on 3/9/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026.    The agency failed to ensure the patients clinical record included all clinical notes.    2. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included physician orders for skilled nurse to visit the patient 1-2 times per week.    b. The IDG meeting note, dated 2/19/26, identified the skilled nurse visits the patient 1-2 times per week.  c. The IDG meeting note, dated 3/5/26, identified no missed visits.    d. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026.    The agency failed to ensure the patients clinical record included all clinical notes.   3. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included physician orders for skilled nurse to visit the patient 2-3 times per week.    b. The IDG meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week.  c. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026.    The agency failed to ensure the patients clinical record included all clinical notes.   4.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed:   a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nurse to visit the patient 2-3 times per week.      b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 and 2/22/26.     The agency failed to ensure the patients clinical record included all clinical notes.       4.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed:   a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nurse to visit the patient 2-3 times per week.      b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 and 2/22/26.     The agency failed to ensure the patients clinical record included all clinical notes.      According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion.  In an interview on 3/10/26 at 10:27 AM, the Administrator stated admission visits are expected to be completed in the electronic record within 5 days of the visit and routine visits are to be completed within 48 hours.  1.Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included physician orders for skilled nurse to visit the patient 2-3 times per week.    b. The Interdisciplinary Group (IDG) meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week.  c. At the time of the clinical record review on 3/9/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026.    The agency failed to ensure the patients clinical record included all clinical notes.    2. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included physician orders for skilled nurse to visit the patient 1-2 times per week.    b. The IDG meeting note, dated 2/19/26, identified the skilled nurse visits the patient 1-2 times per week.  c. The IDG meeting note, dated 3/5/26, identified no missed visits.    d. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026.    The agency failed to ensure the patients clinical record included all clinical notes.   3. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included physician orders for skilled nurse to visit the patient 2-3 times per week.    b. The IDG meeting note, dated 2/26/26, identified the skilled nurse visits the patient 2-3 times per week.  c. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026.        The agency failed to ensure the patients clinical record included all clinical notes.    4. Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed:   a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nurse to visit the patient 2-3 times per week.      b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 and 2/22/26.     The agency failed to ensure the patients clinical record included all clinical notes.    he agency failed to ensure the patients clinical record included all clinical notes.    5. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included physician orders for skilled nurse to visit the patient 1-2 times per week.    b. At the time of the clinical record review on 3/9/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/2026 to 3/7/26.    The agency failed to ensure the patients clinical record included all clinical notes.    6. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic obstructive lung disease and included physician orders for skilled nurse to visit the patient 2-3 times per week.    b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 2/15/2026 to 2/21/26, 2/22/26 to 2/28/26 and 3/1/26 to 3/7/26.  c. The IDG note, dated 2/26/26, failed to identify missed skilled nurse visits.    The agency failed to ensure the patients clinical record included all clinical notes.    7. Patient #9 had a hospice admission date of 10/23/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 1/21/26 to 4/20/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included physician orders for skilled nurse to visit the patient 1-2 times per week.    b. At the time of the clinical record review on 3/10/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/26 to 3/7/26.  The agency failed to ensure the patients clinical record included all clinical notes.      c. The IDG note, dated 2/26/26, failed to identify missed skilled nurse visits.    The agency failed to ensure the patients clinical record included all clinical notes.    8. Patient #10 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included physician orders for skilled nurse to visit the patient 1-2 times per week.    b. At the time of the clinical record review on 3/11/26, the clinical record lacked documentation of completed skilled nurse visits the week of 3/1/26 to 3/7/26.  c. The IDG note, dated 2/26/26, failed to identify missed skilled nurse visits.    The agency failed to ensure the patients clinical record included all clinical notes.    The above findings were reviewed with the Administrator/Clinical Manager

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely in accordance with accepted standards of practice and agency standards for 12 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12 and #13). 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: --- 4. Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide and social work services.    b. Skilled nurse visit note, dated 2/9/26, signed completed 2/24/26 by Staff C, RN, 15 days after the visit and 13 days late per agency expectation.    c. Skilled nurse visit note, dated 2/12/26, signed completed 3/4/26 by Staff B, RN, 20 days after the visit and 18 days late per agency expectation.    d. Skilled nurse visit note, dated 2/19/26, signed completed 3/4/26 by Staff B, RN, 13 days after the visit and 11 days late per agency expectation.    e. Skilled nurse visit note, dated 2/24/26, signed completed 3/4/26 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.    5. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included orders for skilled nurse and social work services.    b. Skilled nurse visit note, dated 2/10/26, signed completed 3/5/26 by Staff B, RN, 23 days after the visit and 21 days late per agency expectation.    c. Skilled nurse visit note, dated 2/24/26, signed completed 3/5/26 by Staff B, RN, 9 days after the visit and 7 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.    6. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included orders for skilled nurse, hospice aide and social work services.    b. Skilled nurse visit note, dated 1/23/26, signed completed 2/9/26 by Staff B, RN, 17 days after the visit and 15 days late per agency expectation.    c. Skilled nurse visit note, dated 1/26/26, signed completed 2/9/26 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation.    d. Skilled nurse visit note, dated 2/12/26, signed completed 3/3/26 by Staff B, RN, 19 days after the visit and 17 days late per agency expectation.   The agency failed to ensure timely completion of routine visit documentation.    7. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 6/29/25 to 9/26/25, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide, social work and music therapy services.    b. Skilled nurse visit note, dated 8/12/25, signed completed 8/25/25 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation.    c. Skilled nurse visit note, dated 8/22/25, signed completed 8/29/25 by Staff B, RN, 7 days after the visit and 5 days late per agency expectation.    d. Skilled nurse visit note, dated 8/25/25, signed completed 9/4/25 by Staff B, RN, 10 days after the visit and 8 days late per agency expectation.    e. Skilled nurse visit note, dated 9/11/25, signed completed 9/25/25 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation.    f. Skilled nurse visit note, dated 9/17/25, signed completed 9/25/25 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.    8. Patient #13 had a hospice admission date of 6/13/25, a discharge date of 9/19/25 and received hospice services in a nursing home.  Clinical record review revealed:   a. The POC, dated 6/13/25 to 9/10/25, identified the patient had a diagnosis of panlobular emphysema and included orders for skilled nurse, hospice aide and social work services.    b. Skilled nurse visit note, dated 8/22/25, signed completed 9/3/25 by Staff D, RN, 12 days after the visit and 10 days late per agency expectation.    c. Skilled nurse visit note, dated 9/3/25, signed completed 9/19/25 by Staff D, RN, 16 days after the visit and 14 days late per agency expectation.    d. Skilled nurse visit note, dated 9/5/25, signed completed 9/18/25 by Staff D, RN, 13 days after the visit and 11 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.     According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion.  In an interview on 3/10/26 at 10:27 AM, the Administrator reported that the expectation for admission visits to be completed in the electronic record is 5 days and daily visits are to be completed within 48 hours.  1.Patient #1 had a hospice admission date of 10/16/25 and received hospice services while residing in a nursing home. Clinical record review revealed:  a. The Plans of Care (POC), dated 10/16/25 to 1/13/26 and 1/14/26 to 4/13/26, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nursing.  b. Skilled nurse visit note, dated 1/5/26, was signed completed on 1/16/26 by Staff C, Registered Nurse (RN), 11 days after the visit and 9 days late per agency expectation.  c. Skilled nurse visit note, dated 1/20/26, was signed completed on 1/27/26 by Staff C, 7 days after the visit and 5 days late per agency expectation.  d. Skilled nurse visit note, dated 1/27/26, was signed completed on 2/9/26 by Staff C, 14 days after the visit and 12 days late per agency expectation.   e. Skilled nurse visit note, dated 2/3/26, was signed completed on 2/16/26 by Staff C, 13 days after the visit and 11 days late per agency expectation.   f. Skilled nurse visit note, dated 2/10/26, was signed completed on 3/1/26 by Staff C, 20 days after the visit and 18 days late per agency expectation.   The agency failed to ensure timely completion of routine visit documentation.   2.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed:  a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nursing.  b. Skilled nurse visit note, dated 3/2/26 and completed 3/13/26 by Staff B, 18 days after the visit and 18 days late per agency policy.  The agency failed to ensure timely completion of routine visit documentation.   3.Patient #7 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed:  a. The POC, dated 2/12/26 to 4/12/26, identified the patient had a diagnosis of hepatic encephalopathy and included orders for skilled nursing. b. Skilled nurse visit note, dated 2/12/26, signed completed 3/17/26 by Staff D, Registered Nurse (RN), 27 days after the visit and 27 days late per agency policy. c. Skilled nurse visit note, dated 2/25/26, signed completed 3/17/26 by Staff D,  21 days after the visit and 21 days late per agency policy. The agency failed to ensure timely completion of routine visit documentation.  9. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included orders for skilled nurse, hospice aide and social work services.    b. Skilled nurse comprehensive assessment visit note at start of care, dated 2/9/26, signed completed 3/9/26 by Staff D, RN, 11 days after the visit and 6 days late per agency expectation.   The agency failed to ensure timely completion of start of care visit documentation.    10. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic pulmonary disease and included orders for skilled nurse, hospice aide and social work services.    b. Skilled nurse visit note, dated 1/26/26, signed completed 2/4/26 by Staff D, RN, 9 days after the visit and 7 days late per agency expectation.    c. Skilled nurse visit note, dated 2/3/26, signed completed 3/5/26 by Staff D, RN, 30 days after the visit and 28 days late per agency expectation.    d. Skilled nurse visit note, dated 2/11/26, signed completed 3/5/26 by Staff D, RN, 12 days after the visit and 20 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.   11. Patient #9 had a hospice admission date of 10/23/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 1/21/26 to 4/20/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included orders for skilled nurse, chaplain and social work services.    b. Skilled nurse visit note, dated 2/3/26, signed completed 2/16/26 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation.    c. Skilled nurse visit note, dated 2/10/26, signed completed 3/4/26 by Staff C, RN, 22 days after the visit and 20 days late per agency expectation.    d. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 19 days late per agency expectation.    e. Skilled nurse visit note, dated 2/24/26, by Staff C, RN, not signed completed.   The agency failed to ensure timely completion of routine visit documentation.   12. Patient #11 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse, chaplain and social work services.    b. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 9 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.    The above findings reviewed with the Administrator/Clinical Manager.   According to the hospice policy titled Clinical Record/Medical Record Retention, last revised April 2011, required documentation for each service or care provided shall be completed on the day the service is rendered if possible and computer generated assessments, visit notes, and plans of treatment shall be locked by the nurse author upon completion. In an interview on 3/10/26 at 10:27 AM, the Administrator clarified that the expectation for admission visits to be completed in the electronic record is 5 days and daily visits are to be completed within 48 hours. 1.Patient #1 had a hospice admission date of 10/16/25 and received hospice services while residing in a nursing home. Clinical record review revealed:a. The Plans of Care (POC), dated 10/16/25 to 1/13/26 and 1/14/26 to 4/13/26, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nursing.b. Skilled nurse visit note, dated 1/5/26, was signed completed on 1/16/26 by Staff C, Registered Nurse (RN), 11 days after the visit and 9 days late per agency expectation.c. Skilled nurse visit note, dated 1/20/26, was signed completed on 1/27/26 by Staff C, 7 days after the visit and 5 days late per agency expectation.d. Skilled nurse visit note, dated 1/27/26, was signed completed on 2/9/26 by Staff C, 14 days after the visit and 12 days late per agency expectation. e. Skilled nurse visit note, dated 2/3/26, was signed completed on 2/16/26 by Staff C, 13 days after the visit and 11 days late per agency expectation. f. Skilled nurse visit note, dated 2/10/26, was signed completed on 3/1/26 by Staff C, 20 days after the visit and 18 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation.  2.Patient #6 had a hospice admission date of 2/16/26 and received hospice services while residing in a private home. Clinical record review revealed:a. The POC, dated 2/16/26 to 4/16/26, identified the patient had a diagnosis of acute and chronic respiratory failure with hypoxia and included orders for skilled nursing. b. Skilled nurse visit note, dated 3/2/26 and completed 3/13/26 by Staff B, 18 days after the visit and 16 days late per agency expectation.   The agency failed to ensure timely completion of routine visit documentation.   3.Patient #7 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed:a. The POC, dated 2/12/26 to 4/12/26, identified the patient had a diagnosis of hepatic encephalopathy and included orders for skilled nursing.b. Skilled nurse visit note, dated 2/12/26, signed completed 3/17/26 by Staff D, Registered Nurse (RN), 27 days after the visit and 25  days late per agency expectation.  c. Skilled nurse visit note, dated 2/25/26, signed completed 3/17/26 by Staff D,  21 days after the visit and 19  days late per agency expectation.  The agency failed to ensure timely completion of routine visit documentation. 4. Patient #3 had a hospice admission date of 1/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The POC, dated 1/26/26 to 4/25/26, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide and social work services.  b. Skilled nurse visit note, dated 2/9/26, signed completed 2/24/26 by Staff C, RN, 15 days after the visit and 13 days late per agency expectation.  c. Skilled nurse visit note, dated 2/12/26, signed completed 3/4/26 by Staff B, RN, 20 days after the visit and 18 days late per agency expectation.  d. Skilled nurse visit note, dated 2/19/26, signed completed 3/4/26 by Staff B, RN, 13 days after the visit and 11 days late per agency expectation.  e. Skilled nurse visit note, dated 2/24/26, signed completed 3/4/26 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation.  The agency failed to ensure timely completion of routine visit documentation.   5. Patient #5 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The POC, dated 1/20/26 to 4/19/26, identified the patient had a primary diagnosis of amyotrophic neurodegenerative disease and included orders for skilled nurse and social work services.  b. Skilled nurse visit note, dated 2/10/26, signed completed 3/5/26 by Staff B, RN, 23 days after the visit and 21 days late per agency expectation.  c. Skilled nurse visit note, dated 2/24/26, signed completed 3/5/26 by Staff B, RN, 9 days after the visit and 7 days late per agency expectation.  The agency failed to ensure timely completion of routine visit documentation.   6. Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The POC, dated 1/22/26 to 4/21/26, identified the patient had a primary diagnosis of sepsis and included orders for skilled nurse, hospice aide and social work services.  b. Skilled nurse visit note, dated 1/23/26, signed completed 2/9/26 by Staff B, RN, 17 days after the visit and 15 days late per agency expectation.  c. Skilled nurse visit note, dated 1/26/26, signed completed 2/9/26 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation.  d. Skilled nurse visit note, dated 2/12/26, signed completed 3/3/26 by Staff B, RN, 19 days after the visit and 17 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation.   7. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 and received hospice services while residing in a nursing home.  Clinical record review revealed: a. The POC, dated 6/29/25 to 9/26/25, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis and included orders for skilled nurse, hospice aide, social work and music therapy services.  b. Skilled nurse visit note, dated 8/12/25, signed completed 8/25/25 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation.  c. Skilled nurse visit note, dated 8/22/25, signed completed 8/29/25 by Staff B, RN, 7 days after the visit and 5 days late per agency expectation.  d. Skilled nurse visit note, dated 8/25/25, signed completed 9/4/25 by Staff B, RN, 10 days after the visit and 8 days late per agency expectation.  e. Skilled nurse visit note, dated 9/11/25, signed completed 9/25/25 by Staff B, RN, 14 days after the visit and 12 days late per agency expectation.  f. Skilled nurse visit note, dated 9/17/25, signed completed 9/25/25 by Staff B, RN, 8 days after the visit and 6 days late per agency expectation.  The agency failed to ensure timely completion of routine visit documentation.   8. Patient #13 had a hospice admission date of 6/13/25, a discharge date of 9/19/25 and received hospice services in a nursing home.  Clinical record review revealed: a. The POC, dated 6/13/25 to 9/10/25, identified the patient had a diagnosis of panlobular emphysema and included orders for skilled nurse, hospice aide and social work services.  b. Skilled nurse visit note, dated 8/22/25, signed completed 9/3/25 by Staff D, RN, 12 days after the visit and 10 days late per agency expectation.  c. Skilled nurse visit note, dated 9/3/25, signed completed 9/19/25 by Staff D, RN, 16 days after the visit and 14 days late per agency expectation.  d. Skilled nurse visit note, dated 9/5/25, signed completed 9/18/25 by Staff D, RN, 13 days after the visit and 11 days late per agency expectation.  The agency failed to ensure timely completion of routine visit documentation.     9. Patient #2 had a hospice admission date of 2/26/26 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The POC, dated 2/26/26 to 5/26/26, identified the patient had a primary diagnosis of senile degeneration and included orders for skilled nurse, hospice aide and social work services.  b. Skilled nurse comprehensive assessment visit note at start of care, dated 2/9/26, signed completed 3/9/26 by Staff D, RN, 11 days after the visit and 9 days late per agency expectation.  The agency failed to ensure timely completion of start of care visit documentation.   10. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The POC, dated 12/10/25 to 3/9/26, identified the patient had a primary diagnosis of chronic pulmonary disease and included orders for skilled nurse, hospice aide and social work services.  b. Skilled nurse visit note, dated 1/26/26, signed completed 2/4/26 by Staff D, RN, 9 days after the visit and 7 days late per agency expectation.  c. Skilled nurse visit note, dated 2/3/26, signed completed 3/5/26 by Staff D, RN, 30 days after the visit and 28 days late per agency expectation.  d. Skilled nurse visit note, dated 2/11/26, signed completed 3/5/26 by Staff D, RN, 12 days after the visit and 10 days late per agency expectation.  The agency failed to ensure timely completion of routine visit documentation.   11. Patient #9 had a hospice admission date of 10/23/25 and received hospice services while residing in a nursing home.  Clinical record review revealed: a. The POC, dated 1/21/26 to 4/20/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included orders for skilled nurse, chaplain and social work services.  b. Skilled nurse visit note, dated 2/3/26, signed completed 2/16/26 by Staff C, RN, 13 days after the visit and 11 days late per agency expectation.  c. Skilled nurse visit note, dated 2/10/26, signed completed 3/4/26 by Staff C, RN, 22 days after the visit and 20 days late per agency expectation.  d. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 19 days late per agency expectation.  e. Skilled nurse visit note, dated 2/24/26, by Staff C, RN, not signed completed as of date of clinical record review on 3/12/26, 16 days after the visit and 14 days  late per agency expectation.The agency failed to ensure timely completion of routine visit documentation.   12. Patient #11 had a hospice admission date of 12/19/25 and received hospice services while residing in a nursing home.  Clinical record review revealed: a. The POC, dated 12/19/25 to 3/18/26, identified the patient had a primary diagnosis of dementia and included orders for skilled nurse, chaplain and social work services.  b. Skilled nurse visit note, dated 2/17/26, signed completed 3/10/26 by Staff C, RN, 21 days after the visit and 19 days late per agency expectation.  The agency failed to ensure timely completion of routine visit documentation.  The above findings reviewed with the Administrator/Clinical Manager.

Based on hospice staff interview, clinical record reviews, and agency policy review the hospice failed to ensure the hospice staff sent a copy of the patient's discharge summary to the attending physician for 2 of 2 sampled, live discharged patients (Patients #11 and #12).   Failure to ensure the hospice staff included the attending physician in the process of discharge placed the patients at risk for not receiving ongoing medical care and services to meet the needs of the patient.   Findings include: --- 2. Patient #12 had a hospice admission date of 3/31/25, a discharge date of 9/26/25 (no longer terminally ill) and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 6/29/25 to 9/26/25, identified the patient had a primary diagnosis of non-rheumatic aortic valve stenosis.  The POC included orders for skilled nursing services.    b. Clinical record review lacked documentation the discharge summary was forwarded to the patient's attending physician.    The above findings were reviewed with the Administrator/Clinical Manager.   According to the hospice policy, titled Discharge for Reasons Other than Death, dated November 2008, when the patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient's attending physician.  1. Patient #11 had a start of care date of 4/25/25, a discharge date of 5/22/25 (revoked hospice services) and received hospice services while residing in a nursing home.   a. The Plan of Care (POC), dated 4/25/25 to 7/23/25, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nursing services.  b. The discharge summary, dated 5/22/25, included a summary of hospice services and a list of the patient's current medications.   c. Clinical record review lacked documentation of the discharge summary forwarded to the patient's attending physician.   During an interview on 3/17/26 at 3:47 PM, the Administrator reported they could not find in the clinical record that the discharge summary was faxed to the patient’s attending physician.    The hospice failed to forward a copy of the discharge summary to the patient's attending physician.

Based on clinical record review and agency policy review, the hospice failed to maintain documentation in the patient clinical records as evidence patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 2 sampled patients who received routine home care while living in a private residence and received orders for controlled medications after the start of care (Patients #4 and #8).    Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances 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: --- 2. Patient #4 had a hospice admission date of 12/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a.  The POC, dated 12/10/25 to 3/9/26, included physician orders for medications, but no controlled medications.  The POC identified the patient had a primary diagnosis of chronic obstructive pulmonary disease.   b. A physician's order, dated 12/29/25, revealed a new order for Hydrocodone (controlled medication) 5 mg/Acetaminophen 325 mg every 4 hours as needed for pain or air hunger. c. The skilled nurse visit note, dated 12/30/25, lacked documentation of education for the disposal of controlled medications. The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medication. The above findings reviewed with the Administrator/Clinical Manager. According to the agency policy titled Labeling, Disposing and Storing of Drugs and Biologicals, last revised July 2018, when controlled substances are first ordered the Interdisciplinary Group (IDG) provides a copy of the hospice's written policies and procedures on the management of and disposal of controlled drugs to the patient or patient representative and family, the IDG discusses the hospice's policies and procedures for managing the safe use and disposal of controlled drugs with the patient or patient representative and family and the IDG documents in the patient's clinical record the written policies and procedures related to disposal of controlled substances were provided and discussed.    1.Patient #8 had a hospice admission date of 1/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a.  The Plan of Care (POC), dated 1/22/26 to 4/21/26, included physician orders for medications, but no controlled medications.  The POC identified the patient had a primary diagnosis of sepsis.    b. A skilled nurse visit note, dated 1/29/26, completed by Staff B, Registered Nurse (RN), identified the patient's primary physician ordered Lorazepam (controlled medication) as needed and the RN educated the patient on how to take the medication and potential side effects of the medication.  The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medication.

Based on hospice clinical record review, hospice policy review, nursing home record review, patient and patient representative interview and hospice staff interview, the hospice failed to ensure the the documentation and correct identification, in a prominent part of the patient's record, any advance directives executed by the patient or patient's representative for 4 of 14 sampled patients (Patients #6, #8, #10 and #12) with a record review. Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: --- 4. Patient #12 had a hospice admission date of 3/29/23, received routine home care hospice services while residing in a private residence and revoked the hospice Medicare benefit. Review of the clinical record revealed the following: a. An advance directive related to whether or not the patient wanted CPR in the event the patient stopped breathing and/or the patient's heart stopped beating, dated 3/29/23, included documentation the patient's representative chose for the patient to not receive CPR. b. The POC, dated 3/29/23 to 6/26/23, identified the patient was a "full code" (wanted CPR) since 6/1/21. c. An advance directive, dated 4/13/23, included documentation the patient signed a form stating they wanted CPR. The clinical record failed to reflect the time frame (3/29/23 to 4/12/23), the patient had an advance directive of no CPR (do not resuscitate). On 6/14/23 at 3:31 PM, during an interview, the Administrator reported the patient had been receiving home health services through their agency prior to hospice. The full code status transferred over to the hospice POC and staff did not get this updated to reflect the wishes of the patient/patient's representative. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. 2. Patient #6 had a hospice admission date of 4/27/23 and received routine home care hospice services while residing in a private home. Clinical record review revealed: a. The POC dated 4/27/23 to 7/25/23, identified no active advance directives exist. b. The Advance Directives/CPR Information form was marked as I do not wish CPR and dated 4/27/23. Review of the clinical record included conflicting code status information in a situation the patient had no pulse and not breathing. 3. Patient #8 had a hospice admission date of 5/31/23 and received routine home care hospice services while residing in a private home. Clinical record review revealed: a. The POC dated 5/31/23 to 8/28/23, identified no active advance directives exist. b. The Advance Directives/CPR Information form was marked as I do not wish CPR and dated 5/31/23. Review of the clinical record included conflicting code status information in a situation the patient had no pulse and not breathing. According to the undated hospice policy titled Advance Directives Policy, dated 8/2008, identified the agency recognizes that all persons have the fundamental right to make decisions about their own medical treatment including the right to accept or refuse medical treatment. The individual has the right to revoke or change an advance directive at anytime and will need to notify the agency of any changes. 1. Patient #10 had a hospice admission date of 5/5/18 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The plans of care (POC), dated 2/17/23 to 4/17/23 and 4/18/23 to 6/16/23, identified the patient had orders to do not resuscitate. b. The Iowa Physician Order for scope of treatment, dated 9/28/22, identified the patient, if has no pulse and is not breathing to attempt resuscitation, CPR (cardiopulmonary resuscitation). Review of the clinical record included conflicting code status information in a situation the patient had no pulse and not breathing.

Based on clinical record review and staff interview, the hospice failed to ensure the patient received information about the services covered under the hospice benefit for 14 of 14 sampled patients (Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15). Failure of the hospice to ensure the patient received information about the services covered under the hospice benefit increased the risk that patients did not receive appropriate services to meet assessed needs. --- 12. Patient #5 had a hospice admission date of 4/4/23 and received routine home care hospice services while residing in a group home for Medicaid waiver participants. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 4/4/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 13. Patient #12 had a hospice admission date of 3/29/23, received routine home care hospice services while residing in a private residence and revoked the hospice Medicare benefit. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 3/29/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 14. Patient #15 had a hospice admission date of 4/28/23 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 4/28/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. 6. Patient #1 had a hospice admission date of 1/20/23 and received hospice services while residing in a nursing home. Clinical record review revealed the following: A Medicare Benefit Election form, dated 1/20/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 7. Patient #4 had a hospice admission date of 5/23/23 and received hospice services while residing in a private home. Clinical record review revealed the following: A Medicare Benefit Election form, dated 5/23/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 8. Patient #7 had a hospice admission date of 5/16/23 and received hospice services while residing in a private home. Clinical record review revealed the following: A Medicare Benefit Election form, dated 5/16/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 9. Patient #9 had a hospice admission date of 5/5/23 and received hospice services while residing in a nursing home. Clinical record review revealed the following: A Medicare Benefit Election form, dated 5/5/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 10. Patient #10 had a hospice admission date of 5/14/18 and received hospice services while residing in a private home. Clinical record review revealed the following: A Medicare Benefit Election form, dated 5/14/18, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 11. Patient #13 had a hospice admission date of 5/16/23 and date of death of 5/28/23 and received hospice services while residing in a private home. Clinical record review revealed the following: A Medicare Benefit Election form, dated 4516/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. Findings include: During an interview on 6/14/23 at 9:13 AM, the Administrator reported the nursing staff are verbally notifying patient and family of the medicare benefit election addendum that explains what the hospice did not cover for medications, services and treatment; but nothing is documented in the patient chart. 1. Patient #3 had a hospice admission date of 4/20/23 and received hospice services while residing in a private home. Clinical record review revealed a Medicare Benefit Election form, dated 4/20/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 2. Patient #6 had a hospice admission date of 4/27/23 and received hospice services while residing in a nursing home. Clinical record review revealed a Medicare Benefit Election form, dated 4/27/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 3. Patient #8 had a hospice admission date of 5/31/23 and received hospice services while residing in a nursing home. Clinical record review revealed a Medicare Benefit Election form, dated 5/31/23, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 4. Patient #11 had a hospice admission date of 11/30/22, a discharge date of 4/2/23 and received hospice services while residing in a private home. Clinical record review revealed a Medicare Benefit Election form, dated 11/30/22, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form. 5. Patient #14 had a hospice admission date of 8/5/22, a death date of 8/13/22 and received hospice services while residing in a nursing home. Clinical record review revealed a Medicare Benefit Election form, dated 8/5/22, included documentation the patient had elected to receive hospice services. The Medicare Benefit Election form and clinical record lacked documentation on whether or not the hospice staff offered to provide information verbally and in writing that explained what items (treatment, medications and services) the hospice would not cover under the benefit and whether or not the patient accepted or denied to receive this information via an addendum to the Medicare Benefit Election form.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound measurements for 4 of 5 sampled patients with an open wound (Patients #1, #3, #8 and #13). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- 3. Patient #1 had a hospice admission date of 1/20/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The skilled nurse visit note, dated 4/11/23, included documentation of a stasis ulcer wound on the left lower extremity. The nurse completed a dressing change and applied chamosy and allevyn dressing. The documentation failed to include wound length, width and depth. b. The skilled nurse visit note, dated 4/18/23, included documentation of a stasis ulcer wound on the left lower extremity. The nurse completed a dressing change and applied chamosy and allevyn dressing. The documentation include wound measurements of 0.3 cm (centimeters) length by 0.3 cm width and failed to document wound depth measurement. c. The skilled nurse visit note, dated 4/20/23, included documentation of a stasis ulcer wound on the left lower extremity. The nurse completed a dressing change and applied chamosy and manuka honey dressing. The documentation failed to include wound length, width and depth. d. The skilled nurse visit note, dated 5/11/23, included documentation of a stasis ulcer wound on the left lower extremity. The nurse completed a dressing change and applied chamosy and allevyn dressing. The documentation include wound measurements of 0.2 cm (centimeters) length by 0.4 cm width and failed to document wound depth measurement. e. The skilled nurse visit note, dated 5/25/23, included documentation of a wound on right inside lower leg, included no open area. The area covered with a bandaid. f. The skilled nurse visit note, dated 5/30/23, included documentation of a stasis ulcer wound on the left lower extremity. The nurse completed a dressing change and applied chamosy and allevyn dressing. The documentation include wound measurements of 0.4 cm (centimeters) length by 0.3 cm width and failed to document wound depth measurement. The skilled nurse failed to document complete wound measurements. 4. Patient #13 had a hospice admission date of 5/16/23 and date of death of 5/28/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The skilled nurse visit note, dated 5/16/23, included documentation of a large open abdominal wound between 2 ostomies that is packed with a wet to dry dressing and covered with an abdominal (ABD) dressing. The documentation failed to include wound assessment or measurements of length, width and depth. b. The skilled nurse visit note, dated 7/17/23, included documentation of a dressing change to wound on abdomen, she has a large gaping open wound where he/she reports was once a closed incision and they did another surgery and were not able to get it closed up due to the skin being fragile and not having anything to use to close it up. It has been open and dressed with a wet to dry dressing using sterile water and a roll of kerlix. The documentation failed to include wound assessment or measurements of length, width and depth. c. The skilled nurse visit note, dated 5/18/23, included documentation of wound care completed to wound on abdomen and jejunostomy tube emptied.The documentation failed to include wound assessment or measurements of length, width and depth. d. The skilled nurse visit note, dated 5/16/23, included documentation of a large open abdominal wound between 2 ostomies that is packed with a wet to dry dressing and covered with an ABD dressing. The documentation failed to include wound assessment or measurements of length, width and depth. c. The skilled nurse visit note, dated 5/19/23, included documentation wound care completed to abdomen and the patient tolerates well. The documentation failed to include wound assessment or measurements of length, width and depth. d. The skilled nurse visit note, dated 5/21/23, included documentation of wound that appeared to have opened even farther. Did not measure. Cleansed with sterile water and wiped with sterile 4 by 4 gauze. Wet to dry dressing reapplied. The documentation failed to include wound assessment or measurements of length, width and depth. e. The skilled nurse visit note, dated 5/23/23, included documentation the abdominal dressing removed and wound cleansed with sterile water and cleaned with sterile 4 by 4 gauze. Abdominal wound redressed with sterile kerlix dampened with sterile water. Gauze layered gently over the open wound and covered with an ABD and secured with tape. The documentation failed to include wound assessment or measurements of length, width and depth. f. The skilled nurse visit note, dated 5/26/23, included documentation the abdominal dressing removed, wound cleansed and new dressing applied with kerlix moistened in sterile water, layed in the wound and covered with sterile ABD dressing. The documentation failed to include wound assessment or measurements of length, width and depth. The skilled nurse failed to document complete wound assessments including measurements. The above stated findings were presented to the Administrator/Clinical Manager. No further information was provided prior to the end of the survey. Findings include: According to the hospice policy, titled Wound Assessment, dated 01/2011, document wound assessment findings and treatment on the Initial Comprehensive Assessment and on the wound/ostomy care section of the visit note. Measure wound as needed or per physician order. During an interview on 6/12/23 at 11:01 AM, the Administrator reported the agency expectation is for wounds to be measured weekly, including length by width by depth. 1. Patient #3 had a hospice admission date of 4/20/23 and received hospice services while residing in a private home. Clinical record review revealed: a. The skilled nurse visit note, dated 5/4/23, included documentation of a wound on right inside lower leg with open scab, old dressing removed, wound cleansed, applied antibiotic ointment, nonadherent dressing and coban. The documentation failed to include wound length, width and depth. b. The skilled nurse visit note, dated 5/8/23, included documentation of a wound on right inside lower leg with open scab, old dressing removed, applied antibiotic ointment and allevyn dressing. The documentation failed to include wound length, width and depth. c. The skilled nurse visit note, dated 5/12/23, included documentation of a wound on right inside lower leg, old dressing removed, wound cleansed, applied antibiotic ointment and allevyn dressing; and a wound on the left shin with open scab, old dressing removed, wound cleansed and large bandaid applied. The documentation failed to include wound length, width and depth. d. The skilled nurse visit note, dated 5/15/23, included documentation of a wound on right inside lower leg, old dressing removed, wound cleansed with soap and water and applied allevyn dressing. The documentation failed to include wound length, width and depth. e. The skilled nurse visit note, dated 5/22/23, included documentation of a wound on right inside lower leg, open wound measured 1 centimeter (cm) by 1 cm and nurse changed allevyn dressing. The documentation failed to include a wound depth. f. The skilled nurse visit note, dated 5/30/23, included documentation of a wound on right inside lower leg measuring 1.5 cm circle, wound cleansed with soap and water and allevyn dressing placed. The documentation failed to include a wound depth. g. The skilled nurse visit note, dated 6/1/23, included documentation of a wound on right inside lower leg measuring 1.5 cm circle, wound cleansed with soap and water and allevyn dressing placed. The documentation failed to include a wound depth. 2. Patient #8 had a hospice admission date of 8/5/22, a death date of 8/13/22 and received services while residing in a nursing home. Clinical record review revealed: a. The initial comprehensive assessment, dated 5/31/23, included documentation of a wound on the tip of the right great toe with black eschar. The documentation failed to include wound length, width and depth. b. The skilled nurse visit, dated 6/6/23 included documentation of a wound on the end of the right great toe with hard black eschar that is open to air. The documentation failed to include wound length, width and depth. c. The skilled nurse visit, dated 6/9/23 included documentation of a wound on the end of the right great toe with hard black eschar. The documentation failed to include wound length, width and depth.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice staff used routine and standing orders that were individualized and specific to the needs of the patients for 14 of 14 patients sampled (Patients #1, #3, #4, #5, #6, #7, #8, #8, #10, #11, #12, #13, #14 and #15) with a record review. Failure to establish the use of individualized routine and standing orders rather than generalized, non-specific standing orders, placed patients for potential risk of receiving or not receiving medications, treatments and services that did not adequately meet the needs of hospice patients. --- Review of the hospice policy, titled Interdisciplinary Group (IDG) Coordination of Care, dated 1/2019, identified the IDG is responsible for establishing, implementing, reviewing and revising the patient's plan of care as frequently as the patient's condition requires. The IDG will develop an individualized plan of care (POC) for each patient/family. The IDG members will document status of the patient and updates to the POC in the IDG meeting notes. Review of the hospice policy, titled Plan of Care (POC), dated 7/2017, identified hospice staff provide care and services to patients and their family in accordance with a POC in collaboration with the attending physician. The POC reflects care and interventions based on the identified needs of the patient and family. Hospice staff will review, document and communicate changes in the POC to members of the IDG. The IDG will update the POC no less than every 15 days. 1. The most current routine standing orders signed off by a physician contained the following patient non-specific orders for Patients #1 and #3 through #15 on the patients" Plan of Care (POC): a. Silvadene topical cream to affected area 1 to 2 times per day and as needed. The standing order failed to specify what the topical cream should be used to treat. b. Incisional/ wound cares as appropriate as needed. The standing order failed to include wound care specific to the needs of the patients. Every patient had the same non-specific order regardless whether or not the patient had a wound and/or incision. c. Calmoseptine ointment (a type of barrier ointment used to protect or treat the skin from break down due to moisture) topical as needed. The standing order failed to specify what the topical ointment should be used to treat. d. Oxygen at 2 liters per minute and may increase as needed. The standing order failed to include a route for delivery of the oxygen, failed to specify under what circumstances the patient would increase the oxygen rate per minute and at what rate the patient could or should increase the oxygen rate per minute to above the 2 liters per minute. e. Ostomy care and maintenance, including a gastrostomy, as indicated. None of the patients sampled (Patients #1 and #3 through #15) had a ostomy of any type. f. Placement of an external or indwelling, suprapubic urinary catheter or straight catheter as needed. The standing order failed to specify under what circumstances a catheter wound need to be placed and failed to specify a catheter size or type specific to the individual needs of the patient. g. The standing orders included the following medications: 1) Colace 100 milligrams (mg) 1 to 2 tablets as needed. The order lacked a frequency and route and failed to specify the reason why the as needed medication should be taken. 2) Milk of Magnesia 30 to 60 cubic centimeters (cc) as needed. The order lacked a frequency and route and failed to specify the reason why the as needed medication should be taken. 3) Miralax 17 grams by mouth daily or daily as needed. The order failed to specify the reason why the as needed medication should be taken. 4) Lactulose 10 grams per 15 milliliters (ml) 15 to 30 ml by mouth as needed. The order failed to specify a frequency (such as daily) and the reason why the as needed medication should be taken. 5) Senokot or Senokot S 1 to 2 tabs by mouth daily and as needed. The order failed to specify the reason why the as needed medication should be taken. 6) Fleets Enema as needed. The order failed to specify a frequency (such as daily) and the reason why the as needed medication should be taken. The above medications are used to treat/prevent constipation. The standing orders failed to identify how the nurse and/or patient would know in what order the medications should be implemented or if they should all be implemented at once. 2. Patient #12 had a hospice admission date of 3/29/23, received routine home care hospice services while residing in a private residence and revoked the hospice Medicare benefit. Review of the clinical record revealed the following: a. The POC, dated 3/29/23 to 6/26/23, included IDG orders for skilled nursing services, a physician order for oxygen 3.5 liters (per minute) continuously via nasal cannula and a conflicting standing order for oxygen 2 liters (per minute) per nasal cannula as needed and may increase as needed. b. The comprehensive assessment completed by Staff D, Registered Nurse (RN), at the start of care, dated 3/29/23, included documentation the nurse assessed the patient used oxygen at a rate of 6 liters per minute continuously via nasal cannula. c. The subsequent skilled nursing visits, dated 3/31, 4/4, 4/6, 4/11 and 4/13/23, included documentation the patient used oxygen at 6 liters per minute. On 6/14/23 at 1:48 PM, during an interview, Staff D, RN, confirmed the patient was on oxygen at 6 liters per minute when they admitted the patient to hospice services. Staff D, RN, explained the patient got the order from the patient's Pulmonologist to use oxygen at a rate of 6 liters per minute continuously, so the patient continued to use oxygen at this rate. The POC included 2 orders for oxygen that conflicted and did not reflect the patient's actual need/use of oxygen. On 6/14/23 at 11:25 AM, during an interview, the Administrator reported that for standing orders, the nurse individualizes the standing order list for each patient, but generally the same ones roll over to the POC for the patients. If the nurse enacts a standing order for a medication, the nurses will add the medication to the patient's medication list in the electronic record. To notify the physician of patient condition changes which warranted the enactment of a standing order, the nurse may send a note in a separate electronic system for communication purposes with healthcare practitioners, or send a fax if a healthcare practitioner does not have access to the electronic communication system. The nurse, should document in the nurses visit note that they notified the physician. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview, patient interview and hospice staff interview, the hospice failed to ensure the Plans of Care for 2 of 2 home visits (Patients #1 and #3) and 2 of 12 other patients with a record review (Patients #5 and #12) 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 Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: --- 3. Patient #5 had a hospice admission date of 4/4/23 and received routine home care hospice services while residing in a group home for Medicaid waiver participants. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/4/23 to 7/2/23, identified the patient used the following medical equipment and supplies: wheelchair, mechanical lift, hospital bed and oxygen. b. The skilled nursing visit, dated 4/21/23, included documentation which identified the patient also used a bedside commode and hand held urinal. c. The subsequent IDG meeting notes, dated 4/20, 5/4, 5/18 and 6/1/23, failed to identify the patient used a bedside commode and hand held urinal for medical equipment and supplies. On 6/14/23 at 3:31 PM, during an interview, the Administrator confirmed hospice staff had not added the bedside commode and hand held urinal to the patient's list of medical equipment/supplies. 4. Patient #12 had a hospice admission date of 3/29/23, received routine home care hospice services while residing in a private residence and revoked the hospice Medicare benefit. Review of the clinical record revealed the following: a. The POC, dated 3/29/23 to 6/26/23, identified the patient used the following medical equipment and supplies: commode, gait belt, hand held shower, hospital bed, trilogy machine, wheelchair, nebulizer, oxygen supplies, Bi-Pap machine and grab bars. b. A skilled nursing visit, dated 4/6/23, identified the patient had been using compression stockings. c. The IDG meeting, dated 4/13/23, failed to identify the patient's use of compression stockings. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. 2. Patient #3 had a hospice admission date of 4/20/23 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 4/20/23 to 7/18/23, identified the patient used the following medical equipment and supplies: grab bars (toilet/shower/tub), raised toilet seat, 3 prong cane, scale and edema wear. b. The IDG meeting note, dated 5/11/23, identified the patient use of lifeline. c. The IDG meeting note, dated 6/8/23, identified the patient use of oxygen and a nebulizer machine. On 6/13/23 at 1:00 PM, during a home visit observation with Staff C, RN, reported the patient used the equipment in the bathroom, including shower chair, raised toilet seat, and grab bars on the toilet and tub. The POC and IDG meeting notes failed to identify all necessary medical equipment and supplies used by the patient, including the shower chair. According to the hospice policy titled The Plan of Care, dated April 2018, the written plan of care will contain, but will not be limited to the following: durable medical equipment and supplies to meet patient needs. 1. Patient #1 had a hospice admission date of 1/20/23 and received hospice services in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/20/23 to 7/18/23, identified the patient had the following medical equipment and supplies: grab bars, hospital bed, lift chair, overbed table, raised toilet seat, side rails, walker and wheelchair. b. The Interdisciplinary Group (IDG) meeting, dated 4/27/23, 5/11/23, 5/25/23 and 6/8/23, identified no additional medical equipment and supplies used by the patient. c. On 6/15/23 at 9:30 AM, during a home visit observation with Staff D, Registered Nurse (RN), the surveyor identified the patient also utilized a reacher, wheelchair cushion and edema wear. e. In an interview, during the same nursing home visit observation, the nursing home staff stated he/she has used the equipment 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.

Based on hospice policy review, clinical record review, and staff interview, the hospice failed to ensure registered nurses performed a hospice aide supervisory visit, at least once every 14 days, for 2 of 4 sampled patients (Patients #1 and #5) that required supervision. Failure to supervise hospice aides at least every 14 days placed patient's at risk for a delay in identification of potential problems and/or patient needs and placed the patient's at risk for not receiving the services needed to meet the assessed patient needs. Findings include: --- 2. Patient #5 had a hospice admission date of 4/4/23 and received routine home care hospice services while residing in a group home for Medicaid waiver participants. Review of the clinical record revealed the following: a. The Plan of Care, dated 4/4/23 to 7/2/23, included Interdisciplinary Group orders for skilled nursing services 2 to 3 times per week and hospice aide services two times per week. b. The skilled nursing visits, dated 5/12, 5/16, 5/19, 5/23, 5/26, 5/30, 6/2, 6/6 and 6/8/23, lacked documentation the hospice RN supervised the hospice aide during any of the visits. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. Review of hospice policy, titled Hospice Aide Supervision, dated 3/2012, supervisory visits of Hospice Aides shall be according to the following frequency: when skilled nursing care is being furnished to a client, a Registered Nurse must make a supervisory visit to the client's residence at least every 2 weeks, either when the Hospice Aide is present to observe and assess care delivery, or when the Hospice Aide is absent, to assess relationships and determine whether goals are being met. 1. Patient #1 had an admission to hospice on 1/20/23, received services while residing in a nursing home. Clinical record review revealed: a. The plan of care (POC), dated 4/20/23 to 7/18/23, included orders for skilled nursing and hospice aide services. b. The skilled nursing visit notes, dated 5/11/23, 5/16/23, 5/18/23, 5/23/23, 5/30/23, 6/1/23, 6/6/23 and 6/8/23, failed to include hospice aide supervision. c. During an interview on 6/13/23 at 10:00 AM, Staff D, Registered Nurse (RN) stated she had not been aware aide supervision required every 14 days. The registered nurse failed to supervise the hospice aide services every 14 days.

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 4 of 14 sampled patients (Patients #1, #3, #12 and #13) with a record review. 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: --- 4. Patient #12 had a hospice admission date of 3/29/23, received routine home care hospice services while residing in a private residence and revoked the hospice Medicare benefit. Review of the clinical record revealed the following: a. The POC, dated 3/29/23 to 6/26/23, included Interdisciplinary Group (IDG) orders for skilled nursing services and the following standing order: incisional/ wound cares as appropriate as needed and Calmoseptine ointment (a type of barrier ointment) topically as needed. The standing orders failed to include orders specific to the needs of the patient and failed to include a frequency and reason for the use of the Calmoseptine. 1) A skilled nursing visit, dated 3/31/23, included documentation the nurse assessed the patient had a reddened area on the patient's coccyx (buttocks area) and a wound on the patient's nose that had a pink wound bed with "eschar" (a scab). The nurse documented they applied Chamosyn (a type of barrier cream) to both wounds and left Chamosyn in the home for the patient to use. 2) A skilled nursing visit, dated 4/4/23, included documentation the nurse assessed the eschar for the wound on the patient's nose had improved and the nurse applied Chamosyn to the nose wound. The nurse documented the patient had a red spot on the coccyx and they applied barrier cream to the coccyx. 3) A skilled nursing as needed visit, dated 4/13/23, included documentation the nurse dropped off Allevyn (a type of wound dressing) and "ointment" for the patient's gluteal folds. The visit note did not specify what ointment the nurse dropped off for the patient. 4) The clinical record lacked documentation of a specific physician order for the use of Chamosyn to treat the nose and coccyx wound, the Allevyn wound dressing to treat the gluteal folds and a specific order for an ointment to treat the gluteal folds. The clinical records lacked documentation of physician and IDG notification of the patient's need or use of the Chamosyn, Allevyn and an ointment to treat the gluteal folds. b. A skilled nursing visit, dated 4/4/23, included documentation the nurse had delivered Lorazepam (a controlled medication used to treat anxiety) to the patient's home. 1) An IDG meeting, dated 4/13/23, included documentation the nurse reported they had delivered Lorazepam to the patient's home and the patient had used one dose. The IDG meeting lacked documentation of a dose, frequency or route of delivery for the medication. 2) The clinical record lacked documentation of a physician order for the Lorazepam or identification of the dose, frequency and route of the medication. c. A skilled nursing visit, dated 4/6/23, included documentation the patient was taking Levaquin 250 milligrams for 3 days. The clinical record lacked documentation of a physician order for the medication. d. A skilled nursing visit, dated 4/13/23, included documentation the patient was taking Metalazone 5 milligrams daily. The clinical record lacked documentation of a physician order for the medication. On 6/14/23 at 11:25 AM, during an interview, the Administrator reported that for standing orders, the nurse tweaks the standing order list for each patient, but generally the same ones roll over to the POC for the patients. If the nurse enacts a standing order for a medication, the nurses will add the medication to the patient's medication list in the electronic record. The electronic record will then generate a an order to the physician. If the nurse adds a wound care treatment, the electronic record will not automatically create an order and notification to the physician. To notify the physician of patient condition changes which warranted the enactment of a standing order, the nurse may send a note in a separate electronic system for communication purposes with healthcare practitioners, or send a fax if a healthcare practitioner does not have access to the electronic communication system. The nurse should document in the nurses visit note that they notified the physician. On 6/14/23 at 1:38 PM, during an interview, Staff D, RN, explained they got an order from the patient's attending physician for the Lorazepam via telehealth. Staff D, RN, reported that if they need a medication order change, they order put request through the electronic system used for communication with the healthcare practitioners. When asked how Staff D, RN, knew to use Chamosyn to treat the nose and coccyx wound, Staff D, RN, responded that they used Chamosyn when they worked at a nursing home and the Chamosyn worked great. Staff D, RN, thought the Chamosyn would work well for this patient. Staff D, RN, reported the patient never used the Allevyn, because the patient did not want it. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. 3. Patient #3 had a hospice admission date of 4/20/23 and received hospice services while residing in a private home. Clinical record review revealed: a. The skilled nurse visit note, dated 5/4/23, included documentation of a wound on right inside lower leg with open scab, old dressing removed, wound cleansed, applied antibiotic ointment, nonadherent dressing and coban (self-adherent wrap). The clinical record lacked documentation of interim physician orders for what to cleanse wound with, antibiotic ointment, nonadherent dressing and coban. b. The skilled nurse visit note, dated 5/8/23, included documentation of a wound on right inside lower leg with open scab, old dressing removed, applied antibiotic ointment and allevyn dressing. The clinical record lacked documentation of interim physician orders for antibiotic ointment and allevyn dressing. c. The skilled nurse visit note, dated 5/12/23, included documentation of a wound on right inside lower leg, old dressing removed, wound cleansed, applied antibiotic ointment and allevyn dressing; and a wound on the left shin with open scab, old dressing removed, wound cleansed and large bandaid applied. The clinical record lacked documentation of interim physician orders for what to cleanse wound with, antibiotic ointment and allevyn dressing. d. The skilled nurse visit note, dated 5/15/23, 5/30/23 and 6/1/23, included documentation of a wound on right inside lower leg, wound cleansed with soap and water and applied allevyn dressing. The clinical record lacked documentation of interim physician orders for soap and water to cleanse wound and allevyn dressing. e. The skilled nurse visit note, dated 5/22/23, included documentation of a wound on right inside lower leg and nurse changed allevyn dressing. The clinical record lacked documentation of interim physician orders for allevyn dressing. According to the hospice policy titled Verbal Orders, dated 2/2018, all treatments and medical care must be ordered, dated and signed by the physician. The orders may be initiated per telephone or in writing, and must be counter-signed by the physician. The verbal order will be sent to the physician for signature and must be returned to the agency for incorporation into the record within 30 days and prior to billing. All orders shall be maintained in the clinical record. 1. Patient #1 had a hospice admission date of 1/20/23 and received hospice services while residing in a nursing home. The POC, dated 4/20/23 to 7/18/23, included non patient specific standing orders. a. The skilled nurse visit note, dated 4/11/23 included documentation the patient had a stasis ulcer wound on the left lower extremity. The treatment provided included chamosy and allevyn dressing. The clinical record lacked orders for chamosy and allevyn dressing. b. The skilled nurse visit note, dated 4/20/23 included documentation the patient had a stasis ulcer wound on the left lower extremity. The treatment provided included chamosy and manuka honey. The clinical record lacked orders for chamosy and manuka honey. The hospice failed to notify the physician of wound care treatments and receive specific orders for patient care. 2. Patient #13 had a hospice admission date of 5/16/23 and date of death of 5/28/23 and received hospice services while residing in a private home. The POC, dated 5/16/23 to 7/14/23, included non patient specific standing orders. a. The skilled nurse visit note, dated 5/16/23, included documentation the patient had a peripherally inserted central catheter (PICC) line with 2 lumens that required daily flushing. The note included documentation the patient had a Foley catheter and abdominal wound that is packed with a wet to dry dressing and covered with an abdominal dressing. The Standing orders, dated 5/16/23, included an order as follows: placement of external/indwelling or suprapubic urinary catheter or straight catheterization as needed. If indwelling, change catheter every 4 weeks and as needed. The order lacked a specific catheter size, a specific bulb inflation size/amount .of the catheter. The standing order also included incisional/wound cares as appropriate as needed. b. The skilled nurse note, dated 5/28/23, included documentation family giving the patient lorazepam about every 2 hours and feels it wears off after about an hour and a half. Will increase dose from 1 mg to 1.5 mg to maintain comfort and family is in agreement with this. During an interview on 6/14/23 at 1:30 PM the Administrator stated the physician wrote the order in the clinic electronic system and filled by the pharmacy. She further stated the order should have been also noted in the patient's hospice medical record. Review of the clinical record lacked physician order for Foley catheter, wound care, PICC line flush or lorazepam 1 mg (milligram) or an order to increase the dosage of lorazepam to 1.5 mg.

Based on clinical record review, policy review and staff interview, the hospice failed to ensure the hospice staff sent a copy of a discharge summary to the attending physician for 2 of 2 sampled (live) discharged patients (Patients #11 and #12). The hospice reported a total of 3 live discharge in the past 12 months. Failure to ensure the hospice staff included the attending physician in the process for imminent discharge placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patients. --- 2. Patient #12 had a hospice admission date of 3/29/23, received routine home care hospice services while residing in a private residence and revoked the hospice Medicare benefit. Review of the clinical record revealed the following: Clinical record review revealed the lack of a discharge summary and lacked documentation hospice staff sent any information on the patient to the patient's attending physician. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey. Findings: According to the hospice policy, titled Discharge for Reasons Other than Death, dated 11/2008, when the patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patients attending physician. During an interview on 6/14/23 at 10:38 AM, the Administrator reported hospice nurses may not be completing discharge summaries but she will look in the records and let us know. During an interview on 6/14/23 at 10:40 AM, the Administrator reported she reviewed the clinical records and was unable to find a discharge summary completed for Patients #11 and #12. 1. Patient #11 was admitted to hospice on 11/30/22, received services while residing in a private home and had a discharge date of 4/2/23. Clinical record review lacked documentation the discharge summary was completed or forwarded to the patient's attending physician.

Based on clinical record review, nursing home clinical record review, nursing home staff interview and hospice staff interview, the hospice failed to ensure the nursing home received copies of all required documents including physician certification of terminal illness specific to the patient and hospice benefit election form for 1 of 1 sampled patients (Patient #1) with home observation visits in nursing homes. Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: --- According to the hospice policy titled Coordination of Hospice Care For Nursing Facility Residents, dated 10/2011, instructed hospice staff the following information is provided to the facility: the most recent hospice plan of care specific to each patient, hospice election form and any advance directives specific to each patient, physician certification and recertification of the terminal illness specific to each patient, names and contact information for hospice personnel involved in hospice care of each patient, instructions on how to access the hospice's 24 hour on call system, hospice medication information specific to each patient and hospice physician and attending physician orders specific to each patient. Patient #1 had a hospice admission date of 1/20/23 and received routine home care hospice services while residing in a nursing facility (nursing home). Review of the hospice clinical record revealed the following documents: a. An initial CTI, dated 1/20/23 to 4/19/23, and subsequent CTI, dated 4/20/23 to 7/8/23. b. A Medicare Benefit Election form, dated 1/20/23. On 6/13/23 at 10:00 AM, during an interview with Staff D, RN (Registered Nurse), she stated she had been unaware the hospice required to provide the nursing facility with the patients documents. She reported she did not believe the patient had the required documents in the nursing facility. On 6/13/23 at 10:15 AM, during an interview and record review with nursing facility staff, the nursing facility staff stated they were not aware of any documentation provided by the hospice that related to the patient. On 3/29/23 at 3:24 PM, during an interview, the Administrator/Clinical Manager stated the hospice faxed all required information but did not provide a copy of the benefit election form for any hospice patients that resided in a nursing facility. She concurred staff education not provided to identify the location of the documents, but identified the CTI, Advanced directive and plan of care, IDG notes were located in the patient's facility electronic record.. The hospice staff failed to provide a copy of the patient's Medicare Benefit Election form to the nursing home. The above findings were shared with the Administrator/Clinical Manager. No further information provided prior to the end of the survey.

Based on patient clinical record review and review of hospice documentation in nursing facilities, hospice policy review and nursing home staff interview the hospice failed to assess the education and training needs for staff of a long term care facility where 1 of 1 sampled patient (Patient #1) residing in a long term care facility at the time of the survey. Failure to educate and train the long term care (LTC) facility staff where a patient resides potentially puts the patient as risk for receiving substandard hospice philosophy based care. Findings include: --- According to the hospice policy titled Hospice Levels of Care, Nursing Facility Residents, dated 3/2012, hospice staff assures that facility staff providing care to hospice patients is oriented to the hospice philosophy of care, pain control, symptom management, principles about death and dying, patients rights and documentation requirements. Inservices are offered to facilities at frequent intervals by the hospice department. Patient #1 had a hospice admission date of 1/20/23 and received care at a nursing home. The patient's terminal diagnosis was heart failure. During an interview on 6/13/23 at 10:15 AM, the surveyor discussed Patient #1 with nursing home Staff Registered Nurse, who reported to the surveyor that the hospice had not provided any education or training to nursing home staff regarding hospice philosophy, including policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements. During an interview on 6/14/23 at 11:30 AM, the Administrator/Clinical Manager concurred education or training to nursing home staff not completed. She further stated she had been unaware of the requirement for hospice. The above information was provided to Hospice Administrator/Clinical Manager. Hospice staff provided no further information prior to the end of the survey.