Every finding on record at Skagit Hospice Services LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. 2 of 6 (33%) observed home visits revealed that the agency did not ensure the drug profiles included the patients' current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. HOME VISIT 5: The patient elected the hospice benefit on 12/09/2025 with a diagnosis of Huntington's disease. The patient resided in a skilled nursing facility (SNF). During the observed home visit with the Registered Nurse (RN - Personnel Record 4) on 03/03/2026 the hospice medication profile (printed on 03/02/2026) was compared to the SNF medication profile (printed on 03/03/2026). The hospice medication profile included the following medications not listed on the SNF list: "Lorazepam 2 mg, 1 tablet daily (ordered 01/15/2026); Clonazepam 2 mg,1-2 tablets every 4 hours as needed (ordered 12/09/2025); Lorazepam 2 mg, 1 tablet every 2 hours as needed (ordered 12/23/2025). The SNF medication profile contained the following medications not listed on the hospice list: "Milk of Magnesia 30 ml, daily as needed (ordered 12/09/2025); Fleet enema, daily as needed (ordered 12/09/2025). The following discrepancies were noted: The hospice medication profile included Depakote 250 mg, 1 tablet 3 times a day (ordered 12/23/2025); and the SNF list included Depakote 250 mg/5 ml, give 5 ml twice daily; Additionally the hospice medication profile included Lactulose 15-60 ml daily as needed (ordered 12/09/2025); and the SNF medication list documented Lactulose 15 ml daily as needed (ordered 12/09/2025). The last comprehensive nursing visit was on 02/23/2026. HOME VISIT 6: The patient elected the hospice benefit on 01/27/2026 with a diagnosis of heart failure. The patient resided in an adult family home (AFH). During the observed home visit with the Hospice Aide (HA - Personnel Record 8) on 03/04/2026 the hospice medication profile (printed on 03/02/2026) was compared to the AFH medication profile (printed on 03/04/2026). The AFH medication profile included the following medications not listed on the hospice list: Nystatin 100000units/ml, four times daily (ordered 01/26/2026); Omeprazole 20 mg, 1 capsule daily (ordered 01/26/2026); Olanzapine 5 mg, twice daily as needed (ordered 01/26/2026). The following discrepancies were noted: the Hospice medication profile documented Olanzapine 5 mg, 2 times a day (ordered 02/02/2026); and the AFH medication list documented Olanzapine 5 mg tablet ,1 time daily (ordered 01/26/2026). Additionally, the Hospice medication profile documented Ipratropium-Albuterol every 4 hours as needed (ordered 01/27/2026); and the AFH medication list documented Ipratropium-Albuterol daily as needed (ordered 01/27/2026)." The last comprehensive nursing visit was on 02/23/2026 A joint clinical record review and interview was conducted with the Clinical Manager on 03/04/2026 during which time it was stated that "medication reconciliations were expected to be completed with every nursing visit."

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 23 (9%) clinical records reviewed revealed the agency did not ensure the comprehensive assessments included an initial bereavement assessment of the needs of the patient's family and other individuals. Agency policy, titled "Bereavement Program", PFC:B10, Original effective date 11/02/2010, current effective date 10/10/2025, stated in relevant part(s): "On admission to hospice: 1. Hospice social workers will complete a pre-death bereavement assessment for each primary bereaved. If the hospice social worker is declined, the pre-death bereavement assessment will be completed by the spiritual counselor or nurse. 2. The interdisciplinary group (IDG) will continue to gather pertinent information regarding the identified primary bereaved. This information is recorded in the patient's clinical record...." CLINICAL RECORD 21: A clinical record review was performed on 03/05/2026 for a patient who elected the hospice benefit on 10/17/2025 and died on 11/25/2025. The only information documented for the initial bereavement risk assessment was the name of the primary bereaved. The clinical record did not include documentation of a full risk assessment that focused on the bereaved's ability to cope with the patient's death. CLINICAL RECORD 22: A clinical record review was performed on 03/05/2026 for a patient who elected the hospice benefit on 05/09/2025 and died on 06/20/2025. The only information documented for the initial bereavement risk assessment was the name of the primary bereaved. The clinical record did not include documentation of a full risk assessment that focused on the bereaved's ability to cope with the patient's death. An interview and joint clinical record review was conducted on 03/05/2026 with the Manager of Integrative Services regarding the lack of documentation of a bereavement risk assessment. She replied that it was "currently non standardized and inconsistent in where to document the bereavement risk assessment. Probably captured in IDG (interdisciplinary group) discussion as opposed to EMR (electronic medical record)."

It is required that each patient’s individualized written plan of care Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 1 of 23 (4%) clinical records reviewed revealed the agency did not ensure the patient’s individualized written plan of care Identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 18: The plan of care (POC) for the benefit period dated 11/03/2025 to 01/19/2026 included a problem, dated 11/04/2025, titled "Risk for skin impairment" and "Intervention: skilled observation and assessment of integumentary status."  The patient resided in a skilled nursing facility (SNF). A nursing visit dated 12/19/2025 documented the following: "Dressings (foam 4x4) to bilateral LE (lower extremity) peeled back to view wounds then reinforced. RLE (shin) almost healed. Approximately 2 mm x 2 mm small pink open area. LLE (anterior shin) approximately 5 mm x 5 mmm pink open area with scant tan drainage. LLE (lateral shin): almost healed approx 2mm x 2mm small pink open area." A nursing visit dated 01/02/2026 documented the following: "Dressings to LE 1 to RLE, 2 to LLE are CDI (clean, dry and intact), due to be changed tomorrow. He reports the small wounds are improving." A nursing visit dated 01/09/2026 documented the following: "No changes to small 3 wounds on LE. Facility applying Medihoney to wound beds, covering with foam dressing." The POC was not updated to specifically reflect the wounds identified during these nursing visits or coordination between the hospice and facility staff of the SNF for care of the wounds. A joint clinical record review and interview was conducted with the Clinical Manager on 03/06/2026 during which time it was stated that the "facility staff are doing the wound dressings but we should have captured it for our care plan."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aides provided services included in the plans of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/27/2026. The HA care plan dated 02/10/2026 included the following tasks: "Adult brief change, apply lotion, apply silicone barrier, assist with personal care, assist with dressing, change bed linens, clean and file fingernails, toenails, comb or brush hair, document last BM (bowel movement), shampoo hair, trim fingernails and toenails on the first visit on the month, seated shower, perineal care, shampoo hair, transfer to or from shower/tub." All tasks were to be completed every visit unless otherwise noted with an aide visit frequency of twice weekly. The hospice aide visit dated 02/23/2026 noted the following tasks were completed: "trim fingernails and toenails." These were not scheduled as it was the last visit of the month and they had been completed on the hospice aide visit on 02/11/2026. CLINICAL RECORD 22: The patient elected the hospice benefit on 05/09/2025 and died on 06/20/2025. The HA care plan dated 05/09/2025 included the following tasks: "Adult brief change, apply lotion, apply silicone barrier, assist with personal care, assist with dressing, change bed linens, clean and file fingernails, toenails, comb or brush hair, document last BM, shampoo hair, trim toenails, seated shower, perineal care, shampoo hair, transfer to or from shower/tub." All tasks were to be completed every visit unless otherwise noted with an aide visit frequency of twice weekly. The hospice aide visit dated 06/03/2025 noted the following: "Seated shower: No. Bed bath given." Bed bath was not an assigned task on the HA care plan. A joint clinical record review and interview was conducted with the Clinical Manager on 03/05/2026 during which time it was agreed the "aides should not vary from the plan of care without specific direction from a registered nurse."

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care, or to the patient’s community attending physician upon hospice discharge, (and) includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 2 (50%) clinical records reviewed, in which a discharge summary was required, revealed the agency did not ensure the patient's discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Agency policy, titled "Discharge From Hospice Care", Policy CES:D15, Original effective date 11/17/2010, current effective date 07/11/2025, stated in relevant parts, "6. The discharge summary includes: a. The reason for discharge; b. The attendings physician's (if any) support of and/or concerns with the planned discharge; c. A summary of the patient's stay including treatments, symptoms and pain management; d. The patient's most recent comprehensive assessment; e. The patient's latest physician orders; and f. Any other documentation that will assist in post-discharge continuity of care." CLINICAL RECORD 20: The patient elected the hospice benefit on 06/08/2025 and chose to revoke the hospice benefit on 07/04/2025. The discharge summary dated 07/04/2025 included the following note: "PRN (as needed) visit at hospital due to patient seeking treatment and requesting revocation. Visit patient in his room and discussed revocation. Patient reports his symptoms were too much to handle and he has not eaten in 4-5 days. He states he may have surgery. He is interested in coming back to hospice services after treatment. He is aware the referral process may take several days. Revocation paperwork signed and emailed to medical records." The discharge summary did not include at least a summary of the patient's hospice stay including treatments, symptoms and pain management. An interview and joint clinical record review was conducted with the Director of Quality and the Clinical Manager on 03/06/2026 during which time it was agreed that the discharge summary narrative note written by the nurse "did not meet the requirements, although a verbal report was most likely given to the hospital staff receiving the patient."

It is required that the comprehensive assessment includes consideration of the following factors: Symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) records reviewed in which the patient had an active wound it was revealed the agency did not consistently ensure the comprehensive assessments included a full and accurate assessment of the patients' skin integrity. The agency's policy, "72913, Skin Care Protocol (revised 12/27/2021)", stated in part at sub-section one (1): "An RN completes a comprehensive skin assessment on the initial and comprehensive assessment visit. The assessment includes general skin health history and an examination. Specific identified risks such as incontinence, poor nutrition, and immobility shall be included in the comprehensive skin assessment." The skin status is recorded in the visit workflow in the patient's electronic medical record." Sub-section two (2) stated in part: "If indicated by the skin assessment, a skin treatment regimen (Plan of Care) that is specific to end-of-life care, will be established by the hospice physician and the hospice RN." Clinical Record 8: The clinical record for this patient with a hospice benefit election date of 1/23/2023, contained documentation that described the presence of altered skin integrity. The initial Registered Nurse (RN) assessment dated 1/23/23 stated: "Superficial open area abdominal fold left breast. Son reported that they are applying calaseptine daily"; and documentation on the certificate of terminal illness (CTI), signed by the Medical Director on 1/24/2023, stated: "Patient coccyx. has open areas on coccyx from bedbound status." The patient's plan of care dated 1/23/2023 - 4/22/2023 also described the presence of, "Multiple scattered stage two (2) pressure ulcer". Review of the comprehensive RN assessment dated 2/6/2023 stated: "PU (pull-up adult brief) on Unable to see. Told it is a superficial open, and they continue to turn". There was no documented evidence on the visit note that the nurse completed an observation and description of the patient's altered skin integrity. In a joint record review and interview on 4/27/2023 with the QAPI Manager it was confirmed the RN did not perform a comprehensive skin assessment on the visit dated 2/6/2023.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) records reviewed the hospice did not ensure that all problems identified on the initial comprehensive assessment were written into the care plan. The agency's policy, "66733, Symptom Management (revised 12/27/2021)", stated in part at sub-section one (1): "The hospice nurse assesses the patient's symptoms as part of the initial assessment. Based on the findings from the initial assessment, the hospice nurse ensures that the patient's immediate needs are met". Sub-section five (5) stated in part: "If the patient is not receiving relief from the prescribed medication or dosage, the nurse notifies the Hospice Medical Director and carries out recommended actions(s) as ordered by the physician." Clinical Record 16: The clinical record of this patient with a hospice benefit election date of 8/29/2022 had an initial RN assessment dated 8/29/2022 which stated that patient pain was an active problem. The plan of care dated 8/29/2022 - 11/26/2022 did not include documentation of the patient's pain as an active problem and did not include a description of intervention(s), or goal(s) that focused on pain control. The clinical record did contain a note which stated, "Acetaminophen changed from nightly to TID (three (3) times daily)". A joint record review and interview on 4/25/2023 with the QAPI Manager confirmed the care plan did not contain documentation of an active problem, intervention, or goals to address the patient's pain. Clinical Record 10: The clinical record of this patient with a hospice benefit election date of 11/17/2021 had a certification of terminal illness (CTI) dated 3/20/2023 that stated the patient "... has bilateral unstageable deep tissue injury to the heels." The comprehensive assessment completed during the skilled nurse visit on 4/12/2023 stated in part: "Sore on chest spouse states patient has had for a long time. Currently open to the air. She is applying calazinc to coccyx". The patient's care plan dated 3/12/2023 - 5/10/2023 stated in part, "Skin Integrity teach early treatment guidelines and optimal skin care" and did not include documentation of orders for the interventions provided and goals for wound management of the bilateral heel and coccyx wounds. Clinical Record 21: The clinical record of this patient with a hospice benefit election date of 9/21/2022 had an initial RN assessment that documented the presence of skin breakdown. The initial RN assessment dated 9/21/2022 stated, "Skin non-healing pressure wound to the sacrum." The CTI dated and signed on 10/1/2022 stated, "... has additional conditions of sacral pressure wound." The plan of care dated 9/21/2022 - 12/19/2022 did not contain orders for wound care interventions being provided or goals related to sacral wound. In a joint record review and interview with the QAPI Manager on 4/27/2023 it was confirmed the care plans did not include orders for all patient needs, specifically the wounds, identified on the RN assessments and the Certificate of Terminal Illness (CTI's).

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 4 of 23 (17%) records reviewed the agency did not ensure the plans of care included documentation of all medical supplies and equipment necessary to meet the patient's needs. The agency's policy, "PFC.P15, Plan of Care (revised 6/3/2022)", stated in part in the sub-section, "Personal Care": "Personal Care items are also itemized on the POC (Plan of Care) and if it is not on the POC a hospice aide will not provide unless verbal permission from an RN is received first." Clinical Record 18: The care plan dated 4/8/2023 - 7/6/2023 included documentation of Durable Medical Equipment (DME) and supplies ordered to be provided "as needed". During a home visit (Home Visit 1) conducted on 4/25/23 with the hospice Social Worker (Staff 5), the patient reported using oxygen every night at bedtime and a full-sized electric O2 concentrator was observed in the patient's bedroom. The patient also had an active physician order for administration of Albuterol-Ipratropium nebulizer solution, 3ml, and the patient reported he had a nebulizer provided by the hospice. He also stated the hospice supplied him with adult pull-up briefs. The Social Worker was present during the interview with the patient when the DME and supplies were discussed. Clinical Record 14: The care plan dated 3/8/2023 - 6/5/2023 included documentation of Durable Medical Equipment (DME) and supplies ordered to be provided as: "over bed table; wheelchair; portable oxygen system; oxygen concentrator; commode." During a home visit (Home Visit 2) conducted with the Hospice Aide (Staff1) on 4/25/2023, the aide reported during interview that she brings "gloves, briefs, wipes, and chux" to the patient's home that are supplied by the hospice. Observation revealed the patient had gloves, briefs, and wipes present in the home, however there was no documented evidence that these additional supplies were present on the patient's plan of care. The Director of Nursing was present during the home visit and interview when the Aide reported the additional supplies provided to the patient. Clinical Record 7: The clinical record for this patient with a hospice benefit election date of 4/10/2023, included an initial RN assessment dated 4/10/2023, which stated the patient was "incontinent of bowel/bladder." The plan of care dated 4/10/2023 - 7/8/2023 included an entry of, "declined upon admission", in the area designated for listing supplies and equipment provided to the patient by the hospice. During a joint record review and interview with the QAPI Manager, it was reported that the patient has received incontinence supplies from the hospice, however there was no documentation on the plan of care that described adult briefs or wipes listed as supplies provided to the patient by the hospice. Clinical Record 10: The clinical record for this patient with a hospice benefit election date of 11/17/2021, included an initial RN assessment dated 11/17/2021 which stated the patient was "incontinent of bowel and bladder", and "bedbound". The plan of care dated 3/12/2023 - 5/10/2023 listed the following Durable Medical Equipment (DME) and supplies ordered and provided to the patient as: "over bed table; alternating pressure pump (APP) mattress; half rails; power wheelchair." During a joint record review and interview with the QAPI Manager, it was reported that the patient has received adult briefs and wipes from the hospice, however there was no documentation on the plan of care that described briefs and wipes listed as supplies provided to the patient by the hospice. In a joint record review and interview on 4/26/2023 with the QAPI Manager, it was confirmed that the agency did not document all the supplies and equipment provided to patients on the plans of care. The QAPI Manager stated, "That is not something the staff typically does on the plan of care or IDT notes."

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 15 (13%) records reviewed in which hospice aide services were provided, it was revealed that the agency did not ensure all hospice aide services were provided in accordance with the visits ordered on the patient's plan of care. The agency's policy, "PFC.P15, Plan of Care (revised 6/3/2022)", stated at sub-section seven (7), in part: "The services provided are linked to the assessed needs of the patient related to the patient's terminal illness and related conditions." Sub-section eight (8) stated in part: "Services that are not able to be provided as scheduled will be managed as follows: (a). An alternate staff member with the same credentials will be arranged if possible". Sub-section fifteen (15) stated in part: "Reviews of changes to the plan of care are documented and communicated to members of the IDG." Clinical Record 14: This patient with a Hospice benefit election date of 12/8/2022, had a care plan dated 12/8/2022 - 3/7/2023 with hospice aide visit frequency orders that stated: "hospice aide one (1) time (X) weekly". The patient also had a subsequent care plan for continued services, dated 3/8/2023 - 6/5/2023, that stated orders for aide services as: "hospice aide one (1) time (X) weekly". Review of the record revealed the patient did not receive a hospice aide visit as ordered during the weeks of 3/12/2023 - 3/18/2023, 3/19/2023 - 3/25/2023, 4/2/2023 - 4/8/2023, and 4/9/2023 - 4/15/2023. There was no documented evidence that the Registered Nurse (RN) or Interdisciplinary Team (IDT) was notified of the missed hospice aide visits. A joint record review and interview with the QAPI Manager on 4/24/2023 confirmed the clinical record did not contain documentation for the missed aide visits from the week of 3/12/2023 - 3/18/2023, 3/19/2023 - 3/25/2023, 4/2/2023 - 4/8/2023, and 4/9/2023 - 4/15/2023. Clinical Record 8: The clinical record for this patient with a hospice benefit election date of 1/23/2023 contained an aide plan of care that assigned the aide to complete the following interventions during each aide visit: "Hoyer transfer to and from WC/Bed; order supplies' transfer to bed; transfer to chair". Documentation on the aide visit note dated 2/14/2023 did not include evidence that the assigned task to "transfer to chair" was not completed by the aide. The chart did not contain evidence or documentation that the RN was notified of the intervention not performed by the hospice aide during the visit. A joint record review and interview with the QAPI Manager on 4/27/2023 confirmed the clinical record did not contain documentation the RN was notified of the hospice aide intervention not performed during the visit dated 2/14/2023.