Every finding on record at Southerncare, Inc.

Upon patient record review 2 of 23 (Patient #16,18) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #16: No evidence that a spiritual assessment was completed. Corrected during survey. Patient #18: No evidence that a spiritual assessment was completed. Corrected during survey.

Upon patient record review, 3 of 23 (Patient #3,12,18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3: DME indicated oxygen supplies and the nurse documentation indicated that the patient was on oxygen 2L/min. There was no evidence that oxygen was on the medication profile. Corrected on site. Patient #12: Duplicate drug therapy - the MAR has both Colace and Miralax listed as daily for constipation. No evidence that instructions were given to on which medication to give first for treating constipation. Corrected during survey. Patient #18: Duplicate drug therapy - the MAR has both Colace and Miralax listed as daily for constipation. No evidence that instructions were given to on which medication to give first for treating constipation. Corrected during survey.

Upon patient record review, 4 of 23 (Patient #3,8,16,21) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #3: No evidence that the bereavement risk assessment was completed within 5 days after the election. Completed during survey. Patient #8: No evidence that the bereavement risk assessment was completed within 5 days after the election. Completed on 05/06/2022. Patient admitted on 01/21/2022. Patient #16 : No evidence that the bereavement risk assessment was completed within 5 days after the election. Patient admitted on 01/06/2024. Patient #21 : No evidence that the bereavement risk assessment was completed within 5 days after the election. Completed on 07/10/2023. Patient admitted on 06/22/2022.

Upon patient record review, 2 of 23 (Patient #11,17) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #11: The record indicated that the patient is currently receiving Phyisical therapy. Order written on 04/08/2024. No evidence that the plan of care included goals and interventions related to therapy. Corrected during survey Patient #17: The patient was admitted with a diagnosis of major depressive disorder. Currently on 2 medications for depression. No evidence that the plan of care included goals and interventions related to depression. Corrected during survey.

Upon patient record review, 1 of 23 (Patient #13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #13: The initial visit frequency for the spiritual care counselor was 1 prn visit.

Upon patient record review, 2 of 23 (Patient #1,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated that the patient had oxygen at 2L/min continuously via nasal cannula. Current oxygen order was for 3L/min PRN for shortness of breath. No evidence of a titration order or an order to change the flow of oxygen. Corrected on site. Patient #3: DME indicated oxygen supplies and the nurse documentation indicated that the patient was on oxygen 2L/min. There was no evidence that oxygen was ordered on the POC. Corrected on site.

Upon patient record review, 6 of 23 (Patient #4,5,6,10,11,12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #4: The record shows that patient uses a walker and a wheelchair to help with mobility daily. Aide plan of care has orders for the aide to use the walker and wheelchair at every visit. No effective that a walker or a wheelchair was added to the medical supply list. Corrected during survey. Patient #5: The record indicated that the patient was using a wheelchair to help with mobility. Aide plan of care has orders for the aide to use the wheelchair at every visit. No evidence that a wheelchair was added to the supply list. Corrected during survey. Patient #6: Patient currently on PRN oxygen via nasal cannula. No evidence that oxygen was added to the current supply list. Corrected during survey. Patient #10: Wound care on supply list at the start of survey. No evidence that the patient ever had wound during time on service. Corrected during survey. Patient #11: Wound care on supply list at the start of survey. No evidence that the patient ever had wound during time on service. Corrected during survey. Patient #12: Wound care on supply list at the start of survey. No evidence that the patient ever had wound during time on service. Corrected during survey.

Upon client record review, 3 of 23 (Patient #3,16,#18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Order written on 04/10/2024 to start music therapy. No evidence that a follow up visit occurred. Patient 16: Volunteer services ordered as one weekly tuck in calls. No evidence that those calls were completed weekly pass 02/08/2024. No evidence of a physicians order to end those calls. Patient 18: Plan of care SN frequency as twice a week. No evidence that 2 visits occurred for the week of 03/24/2024, the record shows documentation for one visit that occurred on 03/26/2024.

Upon patient record review 2 of 23 (Patient #14,#15) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 14: Plan of care has aide visit frequency ordered as 2 times a week. No evidence that 2 visits occurred on the week of 05/26/2024. The record shows that one visit was completed that week on 05/30/2024. Patient 15: Plan of care has aide visit frequency ordered as 3 times a week. No evidence that 3 visits occurred on the week of 05/26/2024. The record shows that two visits were completed that week, on 05/29/2024 and 05/31/2024. Also, aide plan of care has nail care ordered as once a week, on the first visit of the week. The record shows that aide performed nail care on all visits from 04/15/2024 through 05/31/2024.

Upon patient record review 1 of 23 (Patient #8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 8: No evidence that on-site supervised visits occurred every 14 days between March 14th and March 29th then again between April 3rd and April 18th.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The documented annual usage for the year 2023 was 2.46%.

Upon patient client record review, 6 of 23 (Patient #4,7,12,13,14,15) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: The record contained a missed visit coordination note 5/17/24 with no information in the template to explain the reason for the frequency not met. The provided template in the note was empty except for a follow up completed by the RN reporting that she informed the aide that she needed to complete the note. Patient #7: The record contained a missed visit coordination note on 06/03/2024 that does not include indication if the aide notified the RN of the missed visit. Patient #12: The record contains a missed visit coordination note that listed the reason for missed visit as "Patient prefers her SW". No evidence of a visit date or who was notified that the visit did not occur. Patient #13: The record contains missed visit coordination notes entered on 04/11/2024, 4/16/2024, 4/24/2024, and 04/29/2024 with no visit dates. Also, the missed visits notes dated for 04/11/2024, 04/24/2024, and 04/29/2024 did not contain evidence pf a reason these visits were missed. Patient #14: Record shows the Consent to share information form was not signed or dated by the patient. Patient #15: Indiana POST and Indiana out of hospital DNR form missing MD license number.

Upon client record review, 1 of 23 (Patient #19) did not have evidence that the discharge summary includes all required information. Patient 19: No evidence that a discharge summary was completed.

Upon client record review, 1 of 23 (Patient #1) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: Volunteer referral entered on 02/21/2024. No evidence that a follow-up occurred.

Based on record review and interview, the agency failed to ensure staff followed the aide plan of care for 1 of 4 active record reviews (Patient #1) and 1 of 1 closed record review (Patient #5). Findings include: --- 1. A revised 08/30/2023 policy titled ";The Plan of Care" was provided by the Administrator on 01/10/2024. The policy indicated that care provided to the patient would follow the care plan. 2. A revised 06/15/2023 policy titled ";Hospice Aide Services" was provided by the Administrator on 01/11/2024. The policy indicated the services the aide would provide. Hospice aide duties include but are not limited to bathing, dressing, toileting, and transferring. Hospice aide duties may also include housekeeping, family/caregiver respite, and meal preparation. A Registered Nurse develops the aide plan of care. Hospice aides are to review the plan of care before providing care. 3. An undated Registered Nurse (RN) job description was provided by the Administrator on 01/10/2024. The policy indicates the RN maintains an accurate and updated medical record, including ongoing assessments and any other information pertinent to the patient's care. The RN was responsible for educating the patient and staff and communicating with the interdisciplinary team. 4. The clinical record for Patient #1 was reviewed and included Certified Nursing Assistant (CNA) visit notes from 10/10/2023. There was no documentation of CNA 1 providing shopping service for Patient #1, and no communication was made to the case manager about additional services needed to meet the needs of Patient #1. A review of the aide's plan of care did not include the task of using a patient credit card or money to purchase items on behalf of the patient. During a phone interview on 01/10/2024, Patient #1s spouse stated they gave 2 (two) Humana Flex cards to CNA 1 to use to buy them snacks and groceries. CNA 1 was allowed to keep the cards with them for convenience but the spouse could not recall the time frame during which CNA 1 had the cards. CNA 1 provided care for Patient #1 from September to November 2023. Social Worker (SW) 1 from the hospice agency also visited. The spouse stated they allowed a friend and two of Entity 1s personnel (Activity Director & Activity Assistant) to use the cards to purchase items for the patient and spouse. The spouse said another number would show up on the receipts or would not receive a receipt, and that was around the time CNA 1s new boyfriend moved in with CNA 1. The spouse stated if they did not use the money within the month, it would not roll over to the next month. The spouse stated they were having a hard time remembering but said they did not receive some of the receipts from October and November. The spouse could not recall which month but stated Patient #1 had $40.00 left on the card, but $120.00 should have been available. During an interview on 01/10/2024, CNA 1 stated they had bought Patient #1 milk, bread, and protein snacks using Patient #1 and their spouse's Human Flex cards weekly. CNA 1 stated they used both the spouse's and patient's Humana Flex cards because they would use the other if one card ran low on money. CNA 1 said the spouse allowed them to keep the cards with them for convenience but was unsure of the time frame. CNA 1 failed to follow the aide's plan of care. 5. The clinical record for Patient #5 was reviewed and included CNA visit notes from 01/04/2023 to 08/30/2023. There was no documentation of CNA 3 providing shopping service for Patient #5, and no communication was made to the case manager about additional services needed to meet the needs of Patient #5. A review of the aide's plan of care did not include the task of using a patient credit card or money to purchase items on behalf of the patient. During an interview on 01/10/2024, CNA 3 noted that about six months ago Patient #5 asked them to do shopping, which CNA 3 did. CNA 3 indicated Patient #5 would give CNA 3 cash or card, and they would purchase items and then return items, card/cash, and receipts to Patient #5. CNA 3 indicated they were not supposed to provide this service for the patient but were trying to help the patient. CNA 3 failed to follow the aide's plan of care. 6. During an interview on 01/10/2024, the Administrator stated no employee was to purchase items or run errands for the agencys patients. The Administrator stated the aides were to follow the aide plan of care.

Based on record reviews and interviews, the agency failed to provide in-service / education for staff regarding following the aide plan of care and handling patient money for 9 of 9 personnel record reviews, with the potential to affect all hospice aides. (CNAs 1, 2, 3, 6, 7, 8, 11, 13, 14) Findings include: --- 1. An undated Certified Nursing Aide (CNA) job description was provided by the Administrator on 01/10/2024. The job description indicated but was not limited to the duties the CNA may not do, including providing personnel care services or housekeeping services which have yet to be included in the hospice aide care plan developed by the Registered Nurse (RN). 2. A 04/2023 document titled ";Maintain Professional Relationships" education activity was reviewed and indicated staff should know the agencys policy on handling patients money and obtaining receipts for record keeping if shopping for the patient was part of their responsibility. 3. Personnel Record review evidenced the following: Personnel Record review for CNAs 1, 2, 3, 7, and 13 evidenced the Professional Boundaries and Ethics for Hospice Employees in-service / re-education were completed in December 2023 and January 2024. The material did not cover handling patients money, obtaining receipts for record-keeping, or following the aide plan of care. Personnel Record review for CNAs 6, 8, 11, and 14 evidenced that they did not complete any in-service or re-education for December 2023 or January 2024 about handling patients money, obtaining receipts for record-keeping, or following the aide plan of care. 4. A review of the Professional Boundaries and Ethics for Hospice Employees modules provided by the Administrator evidenced that they failed to address how to handle patients requesting shopping and handling patients money and receipts. No information in modules or other in-service was provided to CNAs regarding following the aide plan of care. 5. CNA phone interviews evidenced the following: During an interview on 01/10/2024, CNA 2 indicated they had completed an online in-service about professional boundaries. During an interview on 01/10.2024, CNA 1 stated they had bought Patient #1 milk, bread, and protein snacks using Patient #1 and their spouse's Human Flex cards weekly. CNA 1 stated they did not purchase items for other patients on their schedule. CNA 1 said they received education from the Administrator and the Patient Care Manager after the occurrence and completed Relias training regarding ";boundaries." During an interview on 01/10/2024, CNA 3 indicated they had completed an online in-service about professional boundaries in the last three months. They indicated that about six months ago, Patient #5 asked them to do shopping, which CNA 3 did. CNA 3 stated Patient #5 would give CNA 3 cash or card, and they would purchase items then return items, card/cash, and receipts to Patient #5. CNA 3 indicated they were not supposed to provide this service for the patient but were trying to help the patient. During an interview on 01/11/2024, CNA 13 indicated that a patient had never asked them to pick up items from a store or run errands but wouldnt have a problem with it. CNA 13 indicated they were unsure how the exchange of money would be handled and werent 100% sure they could provide that service. CNA 13 indicated online and in-person in-services are done monthly, and the last professional boundary in-service was during the summer. During an interview on 01/11/2024, CNA 11 indicated an in-service on 01-10-2024 on burnout and self-care. CNA 11 indicated they had been off from August 2023 to the start of December 2023 and are currently working as needed (PRN) but were not required to have all in-services assigned to them completed before returning to caring for patients. They indicated that the in-services assigned for September, October, and November have not been completed. During an interview on 01/11/2024, CNA 7 indicated that in-services are assigned monthly and must be completed within the month. They indicated that if a patient needed assistance with errands, CNA 7 would contact the office to inquire about volunteers providing that service. CNA 7 indicated there had been no education provided by the agency related to running errands or shopping for patients. During an interview on 01/11/2024, CNA 5 stated a patient had never asked them to pick up items from a store or run errands. CNA 5 could not recall any recent online training or in-services regarding following the plan of care. 6. During an interview on 01/11/2024, the Administrator stated the Professional Boundaries and Ethics for Hospice Employees in-service in December and January provided to the CNAs did not specifically talk about handling patients money and receipts when purchasing items on behalf of patients. The in-service did not discuss the importance of following the aide plan of care. The Administrator stated the in-service was isolated to the Bloomington parent office and not provided to the Terre Haute and New Albany branches.

Based on record review and interview, the agency failed to ensure the plan of care included frequency of visits for 3 of 3 record reviews, with the potential to affect all active patient records. (Patients #26, #27, #28) Findings include: --- 1. A revised 02/2020 policy titled The Plan of Care was provided by the Administrator on 05/30/2023 at 1:15 PM. The policy indicated, but was not limited to, ";9. The plan of care will be reviewed and revised ... not less often than every 15 days, by the interdisciplinary group ...12. The written plan of care will contain, ... m. Frequency/Amount of services, to include duration ... Indiana A. The plan of care includes the professional disciplines that will furnish the care to the patient and the frequency of visits proposed to be furnished ..." 2. The clinical record for Patient #26, election date 02/16/2023, benefit period 02/16/2023 to 05/16/2023, was reviewed on 05/30/2023. The agency failed to ensure the current frequency orders for each discipline were included in the Hospice IDG Comprehensive Assessment and Plan of Care Update Report document dated 04/26/2023 and 05/10/2023. 3. The clinical record for Patient #27, election date 03/13/2023, benefit period benefit period 03/13/2023 to 06/10/2023, was reviewed on 05/31/2023. The agency failed to ensure the current frequency orders for each discipline were included in the Hospice IDG Comprehensive Assessment and Plan of Care Update Report document dated 04/24/2023 and 05/24/2023. 4. The clinical record for Patient #28, election date 03/03/2023, benefit period 03/03/2023 to 05/31/2023, was reviewed on 05/31/2023. The agency failed to ensure the current frequency orders for each discipline were included in the Hospice IDG Comprehensive Assessment and Plan of Care Update Report document dated 05/10/2023 and 05/24/2023. 5. During an interview on 05/31/2023 at 3:15 PM the Administrator indicated if there were no changes to the frequency order of the visits, the frequency orders will not carry over on the Plan of Care that was reviewed every two weeks by the IDG. The Administrator indicated if a copy of the Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report was placed at a SNF facility it would not have the current frequency orders for the SNF facility.

Based on record review and interview, the agency failed to ensure staff implemented and coordinated the plan of care to achieve measurable outcomes for 2 of 3 active record reviews of patients residing in a skilled nursing facility (SNF), with the potential to affect all 169 patients residing in a SNF. (Patients #27, #28) Findings include: --- 1. A revised 02/2020 policy titled The Plan of Care was provided by the Administrator on 05/30/2023 at 1:115 PM. The policy indicated, but was not limited to, ";7. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals. ... 9. The plan of care will be reviewed and revised ... not less often than every 15 days, by the interdisciplinary group ... 12. ... w. Measurable outcomes anticipated from implementing and coordinating the plan of care." 2. A revised 11/2020 policy titled ";Provision of Care to Residents of SNF/NF ...", was provided by the Administrator on 05/30/2023 at 1:15 PM. The policy indicated, but was not limited to, ";a. The manner in which the parties will communicate with each other and document such communications to ensure the needs of patients are addressed ..." 3. The clinical record for Patient #27, election date 03/13/2023, benefit period 03/13/2023 to 06/10/2023, was reviewed on 05/30/2023. The record failed to evidence measurable outcomes and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family regarding anxiety. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cannot be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome regarding anxiety for the following dates: Visit Note Reports dates of 04/25/2023, 05/02/2023, 05/10/2023, 05/18/2023, 05/25/2023; and Hospice IDG Comprehensive Assessment and Plan of Care Update Report document dates 04/26/2023, 05/10/2023, and 05/24/2023. 4. The clinical record for Patient #28, election date 03/03/2023, benefit period 03/03/2023 to 05/31/2023, was reviewed on 05/31/2023. Review of the Visit Note Reports dated 05/04/2023, 05/10/2023, 05/18/2023, 05/22/2023, and 05/30/2023 failed to indicate measurable outcomes regarding Patients #28s left heel Deep Tissue Injury (DTI - discolored intact skin or blood‐filled blister due to damage of underlying soft tissue from pressure and/or shear). Each Visit Note Report failed to indicate measurable outcomes or any coordination of care with the SNF staff regarding the left heel DTI. Review of Patient #28s Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 04/26/2023, 5/10/2023, and 05/24/2023 failed to indicate measurable outcomes or any coordination of care with the SNF staff regarding the left heel DTI. 5. During an interview on 05/31/2023 at 3:15 PM the Administrator stated the IDG does not address each goal established on the plan of care at every IDG meeting. The Administrator stated the agency measures progress toward goals every two weeks in the Interdisciplinary Group (IDG) meetings. The Administrator acknowledge the inconsistent pattern of addressing measurable outcomes and goals.

Based on observation, record review, and interview, the agency failed to ensure contracted entities such as a skilled nursing facility (SNF), had access to the plan of care to ensure staff provided care accordingly for 3 of 3 record reviews of patients residing in a SNF (Patient #26, #27, #28) with the potential to affect all 169 patients residing in a SNF.; and failed to identify the management of a treatment and assessment of a potential wound for 1 of 1 home visit observation in a SNF (Patient #26); and failed to identify the management of a treatment and assessment of a deep tissue injury (DTI) for 1 of 1 record reviews of a patient residing in a SNF. (Patient #28) Findings include: --- 1. A revised 11/2020 policy titled ";Provision of Care to Residents of SNF/NF, ICF/IID or ALF" was provided by the Administrator on 05/30/2023 at 1:15 PM. The policy indicated, but was not limited to, ";a. The manner in which the parties will communicate with each other and document such communications to ensure the needs of patients are addressed ..." 2. A revised 05/11/2023 policy titled ";Wound Assessment, Documentation and Clinical Oversight" was provided by the Administrator on 05/31/2023 at 3:00 PM. The policy indicated, but was not limited to, ";Assessment ... 3. The RN will perform wound assessments as ordered by the physician but no less than once weekly ... will include wound measurements. ... 4. Assessment of wound should include the following: Every Dressing Change ... 5. Wound dressings will be removed in order to assess the wound ... Patients who Reside in Facilities ... 2. If facility staff are performing wound care, the hospice RN must assess the wound at least once per week, documenting a full assessment. This is not an option. ... Document wound in the narrative ..." 3. The clinical record for Patient #26, election date 02/16/2023, benefit period 02/16/2023 to 05/16/2023, was reviewed on 05/30/2023 and 05/31/2023 with orders for skilled nursing visits for 1 time a week for 1 week then 2 times a week for 12 weeks. During a home visit at Entity 4 on 05/30/2023 at 11:50 AM Licensed Practical Nurse (LPN) 1 raised the back of Patient #26s shirt to assess for skin issues and found a large Mepilex foam dressing applied to his/her mid-back. LPN 1 stated the dressing was new and was unaware of any new orders for the dressing. During the same home visit at Entity 4 on 05/30/2023 at 12:20 PM Patient #26s hospice binder was reviewed along with LPN 1. LPN 1 stated the plan of care was not in the hospice binder and was unsure why it was not there. The hospice binder did not indicate orders for a Mepilex foam dressing. At that time, LPN 1 asked Entity 4s nurse about the dressing. Entity 4s nurse stated the dressing was applied to the patients back for protection. No further discussion regarding when the dressing was applied, assessment of skin, or what agency was to manage dressing changes and care. The agency failed to ensure Entity 4s staff had access to and provided care according to Patient #26s plan of care and failed to identify who was managing the care and treatment of a potential wound. Review of Patient #26s Visit Note Report dated 05/31/2023 did not indicate documentation of Patient #26s foam dressing to mid-back or who was going to perform dressing changes and manage the care and treatment. During an interview on 05/31/2023 at 3:15 PM the Administrator stated the plan of care was to be placed in the hospice binder. The Administrator agreed the nurse failed to document the skin assessment and treatment applied to the patients mid-back. 4. The clinical record for Patient #28, election date 03/03/2023, benefit period 03/03/2023 to 05/31/2023, was reviewed on 05/31/2023. The record included Visit Note Reports for the following dates of 04/18/2023, 04/25/2023, 05/04/2023, 05/10/2023, 05/18/2023, 05/22/2023, and 05/30/2023. The Visit Note Reports failed to indicate details of collaboration with the SNF staff toward the established patient goals. Review of Patient #28s Visit Note Reports dated 05/04/2023, 05/10/2023, 05/18/2023, 05/22/2023, and 05/30/2023 failed to indicate an assessment or measurement for Patients #28s left heel Deep Tissue Injury (DTI - discolored intact skin or blood‐filled blister due to damage of underlying soft tissue from pressure and/or shear). Each visit indicated a skin prep was applied every shift but failed to indicate who was applying the skin prep. All Visit Note Reports failed to indicate the specific interventions, measurable outcome, and goal addressing the left heel DTI and which agency was responsible for the treatment and management of the left heel DTI. Review of Patient #28s Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 04/26/2023, 5/10/2023, and 05/24/2023 failed to indicate any problems, interventions, measurable outcomes, progress, and goals related to the left heel DTI or any communication with the SNF staff regarding the left heel DTI. During an interview on 05/30/2023 at 12:30 PM Patient #28s hospice binder was reviewed along with Entity 4s LPN. Entity 4s LPN indicated there was no plan of care. During an interview on 05/31/2023 at 3:00 PM the Administrator stated he/she reviewed Patient #28s record and agreed with the surveyor that the nurse was to assess and measure the left heel DTI and establish which agency was responsible for the management of the left heel DTI. The Administrator stated the agency charts by exception even though agency policy indicated documentation of a full wound assessment was not an option. 5. The clinical record for Patient #27, election date 03/13/2023, benefit period 03/13/2023 to 06/10/2023, was reviewed on 05/31/2023. The record included Visit Note Reports for the following dates of 04/18/2023, 04/22/2023, 05/02/2023, 05/04/2023, 05/16/2023, 05/18/2023, and 05/25/2023. The Visit Note Reports for each date indicated Entity 4s Skilled Nursing staff was knowledgeable of all durable medical equipment and the plan of care provided by the hospice agency even though there was no evidence of the patients plan of care in the hospice binder on 05/30/2023. During an interview on 05/30/2023 at 12:30 PM Patient #27s hospice binder was reviewed along with Entity 4s LPN. Entity 4s LPN indicated there was no plan of care. 6. During an interview on 05/30/2023 at 12:30 PM Patient #27s hospice binder was reviewed along with Entity 4s LPN. Entity 4s LPN stated there was no plan of care in the hospice binder nor in Entity 4s electronic medical record. At 12:47 PM Entity 4s Director of Nursing stated Entity 4 and the hospice agency communicate verbally and Entity 4s staff documents little as to what the hospice agency does while at Entity 4. Entity 4s Director of Nursing stated he/she was aware of the IDG meetings but does not attend.

Based on observation, record review, and interview, the agency failed to ensure standard infection control precautions regarding bag technique and hand hygiene were followed for 1 of 1 home visit observation. (LPN 1) Findings include: --- A revised 12/2020 policy titled Bag Technique was provided by the Administrator on 05/30/2023 at 4:15 PM. The policy indicated, but was not limited to, "; ... nothing inside the bag should be dirty ... patient care devices (e.g., blood pressure cuff, stethoscope) should be disinfected when visibly soiled, after each use [sic] patient use, and before placing in the nursing bag." During a home visit observation at a Skilled Nursing facility on 05/30/2023 at 11:45 AM Licensed Practical Nurse (LPN) 1 removed vital sign equipment (stethoscope, thermometer, oxygen saturation machine, blood pressure cuff) from a brown bag, cleaned off the vital sign equipment with a Santi-wipe (disinfectant), then obtained Patient #26s temperature, oxygen saturation, and blood pressure. LPN 1 returned all equipment into the brown bag without disinfecting. LPN 1 applied gloves and pulled up Patient #26s shirt to assess the buttocks and back. After assessing the areas, LPN 1 adjusted the bed and bedside table with the lunch tray on top (clean items) while still gloved. LPN 1 failed to remove gloves and perform hand hygiene before touching clean items. During an interview on 05/30/2023 at 4:17 PM the Administrator stated LPN 1 was to remove gloves and perform hand hygiene before touching clean items and disinfect vital sign equipment before placing the equipment back into the clean brown bag.

Based on record review and interview, the agency failed to ensure detailed documentation of communication between internal and external entities to ensure the needs of patients are addressed for 3 of 3 record reviews of patients residing at a skilled nursing facility (SNF). (Patients #26, #27, #28) Findings include: --- 1. A revised 11/2020 policy titled ";Provision of Care to Residents of SNF/NF ...", was provided by the Administrator on 05/30/2023 at 1:15 PM. The policy indicated, but was not limited to, ";a. The manner in which the parties will communicate with each other and document such communications to ensure the needs of patients are addressed ..." 2. The clinical record for Patient #26, election date 02/16/2023, benefit period 02/16/2023 to 05/16/2023, was reviewed on 05/30/2023 and 05/31/2023 with orders for skilled nursing visits for 1 time a week for 1 week then 2 times a week for 12 weeks. Review of Patient #26s Visit Note Report dated 05/31/2023 failed to indicate details of collaboration with Entity 4s staff regarding Patient #26s foam dressing to mid-back or who was going to perform dressing changes and manage the care and treatment. 3. The clinical record for Patient #27, election date 03/13/2023, benefit period 03/13/2023 to 06/10/2023, was reviewed on 05/31/2023. The record included orders for Skilled Nursing (SN) visits weekly for 13 weeks. A review of the Visit Note Reports for the following dates of 04/25/2023, 05/02/2023, 05/10/2023, 05/18/2023, and 05/25/2023 indicated Patient #27 was calm and confused. All Visit Note Reports failed to document an assessment, interventions, and progress regarding Patient #27s anxiety. Each Visit Note Report failed to indicate details of collaboration with Entity 4s staff and Registered Nurse (RN) 1 toward the established patient goals regarding anxiety. The Visit Note Report dated 04/21/2023 indicated Patient #27 was calm, confused, and forgetful. The Visit Note Report dated 04/25/2023 failed to indicate details of collaboration with Entity 4s staff and Registered Nurse (RN) 1 toward the established patient goals regarding anxiety. Review of Patient #27s Hospice IDG Comprehensive Assessment and Plan of Care Update Report document dated 04/26/2023 indicated anxiety and agitation/restlessness on the Care Plan. The record indicated in the next two weeks problems, interventions, and goals were to be addressed for anxiety. The Visit Note Report dated 05/02/2023 and 05/10/2023 failed to indicate interventions for anxiety and failed to document details of collaboration with Entity 4s staff and Registered Nurse (RN) 1 toward the established patient goals regarding anxiety. Review of Patient #27s Hospice IDG Comprehensive Assessment and Plan of Care Update Report document dated 05/10/2023 indicated the skilled nurse was to assess for anxiety and potential causes on the Care Plan. RN 1 failed to document any problems, interventions, measurable outcomes, progress, and goals related to anxiety. The Visit Note Report dated 05/16/2023 indicated Patient #27 was calm. The Visit Note Report failed to indicate details of collaboration with Entity 4s staff and caregiver toward the established patient goals regarding anxiety. The Visit Note Report dated 05/18/2023 indicated Patient #27 was calm but failed to indicate details of collaboration with Entity 4s staff and Registered Nurse (RN) 1 toward the established patient goals regarding anxiety. The Visit Note Report dated 05/22/2023 indicated Patient #27 was disoriented, forgetful, and emotional distress. The Visit Note Report failed to indicate details of collaboration with Entity 4s staff toward the established patient goals regarding anxiety. Review of Patient #27s Hospice IDG Comprehensive Assessment and Plan of Care Update Report document dated 05/24/2023 indicated Patient #27 anxiety control with Ativan (nerve medication). The agency failed to document a measurable outcome and progress toward the goal related to anxiety. The Visit Note Report dated 05/25/2023 failed to indicate interventions were provided for anxiety and failed to document details of collaboration with Entity 4s staff toward the established patient goals regarding anxiety. 4. The clinical record for Patient #28, election date 03/03/2023, benefit period 03/03/2023 to 05/31/2023, was reviewed on 05/31/2023. Review of the Visit Note Reports dated 05/04/2023, 05/10/2023, 05/18/2023, 05/22/2023, and 05/30/2023 failed to indicate measurable outcomes regarding Patients #28s left heel Deep Tissue Injury (DTI - discolored intact skin or blood‐filled blister due to damage of underlying soft tissue from pressure and/or shear). Each Visit Note Report failed to indicate measurable outcomes or any coordination of care with Entity 4s staff regarding the left heel DTI. Review of Patient #28s Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 04/26/2023, 5/10/2023, and 05/24/2023 failed to indicate measurable outcomes or any coordination of care with Entity 4s staff regarding the left heel DTI. 5. During an interview on 05/31/2023 at 3:15 PM the Administrator was asked how the agency measures outcomes that guide treatment decisions, needed education and training, to help patients recognize their own improvement, and progress toward goals when the details of collaboration with Entity 4s staff and agency RNs are not documented. The Administrator stated the nurse should document in the Visit Note Reports detailed interventions and collaborate with the RN who attends the IDG meetings. The Administrator stated the agency documents by exception and if there was nothing to document the goal would be met and removed from the care plan. The IDG meetings were how the agency measured progress toward the goals, but the agency does not address every goal at each IDG meeting. The agency failed to demonstrate a consistent documentation process on measuring outcomes and progress toward each goal identified on the plan of care and failed to evidence documentation of internal and external communication outside of the IDG meeting.

Based on record review and interview, the hospice failed to develop an individualized plan of care for each patient that reflected specific patient and family goals or interventions implemented for problems identified for 11 of 17 active record reviews. (Patient #11, 12, 13, 14, 16, 17, 19, 20, 22, 24, 26) Findings include: --- 1. A revised 11/2020 policy titled Care/Service Coordination was provided by the Administrator on 03/01/2023 at 4:07 PM. The policy indicated, but was not limited to, "PURPOSE To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services...PROCEDURE ... 4. Documentation of all communications will be included in the clinical record on a coordination note, IDG summary or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication ... 6. Written evidence of care coordination may be found in the plan of care, clinical notes in the patients clinical record or interdisciplinary group meeting notes ... " 2. A revised 02/2020 titled The Plan of Care was provided by the Administrator on 03/01/2023 at 4:07 PM. The policy indicated, but was not limited to, "PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues ... PROCEDURE ... 5. The individualized plan of care will be reviewed by the interdisciplinary group ... 7. Each patient will be monitored for his/her response to the care of services provided against established patient goals and patient outcomes to evaluate progress toward goals ... " 3. The complete clinical record for Patient #11, start of care date 02/20/2023, benefit period 02/20/2023 to 05/20/2023, was reviewed on 03/07/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 4. The complete clinical record for Patient #12, start of care date 01/28/2023, benefit period 01/28/2023 to 04/27/2023, was reviewed on 03/06/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 5. The complete clinical record for Patient #13, start of care date 07/23/2022, benefit period 01/2019/2023 to 03/19/2023, was reviewed on 03/07/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 6. The complete clinical record for Patient #14, start of care date 01/23/2023, benefit period 01/23/2023 to 04/22/2023, was reviewed on 03/07/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 7. The complete clinical record for Patient #16, start of care date 07/15/2020, benefit period 01/1/2023 to 03/1/2023, was reviewed on 03/09/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 8. The complete clinical record for Patient #17, start of care date 12/16/2021, benefit period 2/9/2023 to 4/9/2023, was reviewed on 03/08/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 9. The complete clinical record for Patient #19, start of care date 09/16/2022, benefit period 12/15/2022 to 03/15/2023, was reviewed on 03/08/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 10. The complete clinical record for Patient #20, start of care date 10/10/2022, benefit period 1/8/2023 to 4/7/2023, was reviewed on 03/08/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 11. The complete clinical record for Patient #22, start of care date 01/28/2022, benefit period 01/23/2023 to 03/20/2023, was reviewed on 03/07/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 12. The complete clinical record for Patient #24, start of care date 4/1/2022, benefit period 1/26/2023 to 3/26/2023, was reviewed on 03/09/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 13. The complete clinical record for Patient #26, start of care date 12/31/2022, benefit period 12/31/2023 to 3/30/2023, was reviewed on 03/09/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 14. During an interview on 3/8/2023 at 10:05 AM, the Administrator indicated goals should be updated when they are met. The Administrator indicated the Electronic Medical Record (EMR) is designed for charting by exception and if an intervention is used partially, then whatever what not done during the visit should be written in the narrative. If an intervention is listed then it was done in its entirety. The Administrator also indicated a goal listed as met on a visit note was actually completed during that visit alone so it may be on several visits because it is ongoing. The administrator indicated there is no way to write the intervention differently or change any part of the comments to reflect more accurately what is done by a provider with the patient.

Based on observation and interview, the agency failed to ensure the administrator assumed oversight, full authority and responsibility for the management, provision of all services, fiscal operations, and continuous quality assessment and performance improvement of the hospice parent and its branches overseen by the governing body in the organizational structure and practice (see L0651) and the administrator failed to ensure the parent location managed and maintained oversight of the two branch locations associated with the certification number (see L0660). --- The cumulative effect of these systemic problems resulted in the hospice's inability to be in compliance with the Condition of Participation 42 CFR 418.100 Organization / Administration of services.

Based on observation and interview, the agency failed to ensure the administrator assumed oversight, full authority and responsibility for the management, provision of all services, fiscal operations, and continuous quality assessment and performance improvement of the hospice parent and its branches overseen by the governing body in the organizational structure and practice for 1 of 1 hospice agency. Findings include: --- Review of the organizational chart on 03/07/2023 indicated ED 2 was to report to the Administrator of the parent office in Bloomington. The organizational chart indicated the Administrator reported to CS2 (Area Vice President of Operations - North). Review of the Governing Body Minutes dated 12/13/2022 indicated the Administrator was not in attendance nor was the CS10. The Governing Body minutes did not identify CS2 and CS10 as Governing Body members. During an interview on 03/03/2023 at 1:55 PM ED 2 (Executive Branch Director) indicated he/she reports to the CS10 (Area Vice President of Operations -South) who was not a Governing Body member. ED 2 indicated each branch keeps their own QAPI, Complaint log, and Emergency prep. During an interview on 3/7/2023 at 2:30 PM the Administrator indicated the branches as well as the parent location report directly to the Area Vice Presidents of Operations depending on their location within the state. The Administrator doesn't actually have any oversight responsibilities of the branches even though it indicates that on the organizational chart, line of authority, or within the job description. During an interview on 3/8/2023 at 4:25 PM the Administrator and CS 1 both indicated the hierarchy of the hospice are as follows: branches/parent reports to the area leadership, who reports to the regional leadership, who then reports to the division leadership, who then reports to the governing board.

Based on observation and interview, the administrator failed to ensure the parent location managed and maintained oversight of the two branch locations associated with the certification number for 1 of 1 hospice. Findings include: --- During Entrance conference on 3/1/2023 starting at 1:15 PM, the Emergency Preparedness Plan, QAPI exercises at each location, and Complaint/Grievance logs were requested from the Administrator. It was indicated that those programs and documents are kept at their respective branch, carried out and overseen by the executive directors of those branches. During an interview on 03/03/2023 at 1:55 PM ED 2 (Executive Branch Director) indicated he/she reports to the CS10 (Area Vice President of Operations -South) who was not a Governing Body member. ED 2 indicated each branch keeps their own QAPI, Complaint log, and Emergency prep. During an interview on 3/7/2023 at 2:30 PM the Administrator indicated the branches as well as the parent location report directly to the Area Vice Presidents of Operations depending on their location within the state. The Administrator doesn't actually have any oversight responsibilities of the branches even though it indicates that on the organizational chart, line of authority, or within the job description. During an interview on 3/8/2023 at 4:25 PM the Administrator and CS 1 both indicated the hierarchy of the hospice are as follows: branches/parent reports to the area leadership, who reports to the regional leadership, who then reports to the division leadership, who then reports to the governing board.

Based on record review and interview, the agency failed to ensure the volunteer orientation training verification was signed and dated by the volunteer for 3 of 5 Volunteer record reviews. (Volunteer 1, 2, 3) Findings include: --- 1. A 07/2019 Direct Care Volunteer Job Description provided by the Volunteer Coordinator 1 on 03/09/2023 at 12:00 pm. The job description indicated, by was not limited to, ";5. Successfully complete the Direct Care Volunteer orientation." 2. The personnel record for Volunteer 1 was reviewed on 03/09/2023 and included Volunteer Orientation Training Verification document that was not signed or dated by Volunteer 1 acknowledging completion of training. 3. The personnel record for Volunteer 2 was reviewed on 03/09/2023 and included Volunteer Orientation Training Verification document that was not signed or dated by Volunteer 2 acknowledging completion of training. 4. The personnel record for Volunteer 3 was reviewed on 03/09/2023 and included Volunteer Orientation Training Verification document that was not signed or dated by Volunteer 3 acknowledging completion of training. 5. During an interview on 03/09/2023 at 12:00 PM the Volunteer Coordinator 1 agreed the Volunteer Orientation Training Verification needed a signature and date by the Volunteers acknowledging completion of training.

Based on record review and interview, the agency failed to ensure Covid-19 (virus) screening was completed on all visitors to the agency for 5 of 7 survey days. (Parent & Branch Location) Findings include: --- 1. A 01/30/2023 policy titled Covid-19 Protocols and PPE Requirements was provided by the Administrator on 03/06/2023 at 4:25 PM. The policy indicated, but was not limited to, ";... 3. All associates, regardless of vaccination status, must continue to be monitored per the current COVID-19 protocols which includes daily screening upon entry to the branch or other work setting. ... 6. All federal, state, local government ... masking /PPE regulations and vaccination requirements must be followed." 2. Upon entrance at the Bloomington location the agency failed to screen the surveyors and visitors for signs and symptoms of Covid-19 for the following dates: 03/01/2023, 03/02/2023, 03/03/2023, 03/06/2023, and 03/07/2023. 3. Upon entrance at the New Albany branch location on 03/03/2023 at 1:00 PM the agency failed to screen the surveyor for signs and symptoms of Covid-19. 4. During an interview on 03/07/2023 at 4:30 PM the CS1 (Regional Director of Clinical Operations) agreed that all visitors should be screened for Covid-19 at all agency locations.

Based on observation, record review, and interview, the hospice failed to ensure quality of care for the patient and family through continuity of communication and easy access to ongoing information with documentation in both respective entities clinical records for 2 of 7 home visits with record reviews of patients who lived in an assisted living facility (ALF), skilled nursing facility (SNF) or nursing facility (NF-Long-term care), with the potential to affect all patients living in facilities. (Patients #11, 12) Findings include: --- 1. A revised 11/02/2022 policy titled Interdisciplinary Group Plan of Care was provided by the Administrator on 03/07/2023 at 10:19 AM. The policy indicated, but was not limited to, "6. Written evidence of care coordination will be found in the plan of care and / or interdisciplinary team meeting documentation, coordination notes and / or visit notes in the patient's clinical record ... 9. All interdisciplinary group members, including contracted services, will have access to the plan of care to ensure coordination and continuity." 2. The complete clinical record for Patient #12, start of care date 01/28/2023, benefit period 01/28/2023 to 04/27/2023, was reviewed on 03/06/2023, and included a plan of care (POC), IDG Comprehensive Assessment and Plan of Care Update Reports, Communication Notes, and Visit Note Reports. The documentation failed to evidence specific communication that occurred between the hospice and Entity 2s staff. 3. During an observation at Entity 2 (skilled nursing / assisted living facility) of Patient #12 on 03/03/2023 at 11:00 AM Chaplin 1 provided spiritual services and emotional support for Patient #12. Chaplin 1 indicated he/she reports off to Entity 2s nurse before leaving. A review of Patient #12s hospice binder located in a separate room at Entity 2 failed to evidence documentation of collaboration or interaction regarding the care of the patient and response to that care by Entity 2s staff when hospice staff were not in the building. 4. During an interview on 03/03/2023 at 11:45 AM Entity 2s social worker indicated he/she are invited to attend hospice IDG meetings and go if there were issues. At that time, Entity 2s Administrator indicated he/she does not attend the hospice IDG meetings. 5. The complete clinical record for Patient #11, start of care date 02/20/2023, benefit period 02/20/2023 to 05/20/2023, was reviewed on 03/07/2023, and included a POC, IDG Comprehensive Assessment and Plan of Care Update Reports, Communication Notes, and Visit Note Reports. The documentation failed to evidence specific communication that occurred between the hospice and Entity 1s staff. 6. During an observation at Entity 1 (assisted living facility) of Patient #11 on 03/03/2023 at 10:00 AM RN 1 (Registered Nurse) provided direct patient care for Patient #11. A review of Patient #11s hospice binder located in his/her room at Entity 1 failed to evidence documentation of collaboration or interaction regarding the care of the patient and response to that care by Entity 1s staff when hospice staff were not in the building. At that time, RN 1 reviewed the contents of the hospice binder and agreed there was no documentation supporting collaboration or interaction regarding the care of the patient and response to that care by Entity 1s staff when hospice staff were not in the building. RN 1 indicated he/she gives a verbal report to the Entity 1s Wellness nurse before leaving. 7. During an interview on 03/06/2023 at 12:50 PM Entity 1s Executive Director indicated that he/she gets invited to hospice IDG meetings but does not attend.