Every finding on record at Southerncare Inc

Based on record review and interview, hospice failed to assume responsibility for professional management of the resident’s hospice services provided, in accordance with the hospice plan of care to ensure availability of pain medication in 1 of 1 discharged clinical records reviewed of a patient residing in a skilled nursing facility (Patient #4), and in 1 of 1 active clinical records reviewed of a patient residing in entity C, a skilled nursing facility (Patient #3).   Findings include: --- 1.  A revised policy dated 08/03/2024 titled, “Pharmacy Services,”  indicated pharmacy services needed by hospice patients would be available 24 hours a day, drugs related to the palliation and management of the terminal illness and related conditions would be provided by hospice while the patient was under hospice care and all medications are ordered for each individual patient based upon actual or anticipated need.  2. A revised policy dated 11/15/2023, titled, “Provision of Care to Residents of a Skilled Nursing Facility,” indicated the hospice would assume responsibility for professional management of the resident’s hospice services provided, a delineation of the hospice’s responsibilities to included but not limited to providing medical direction and management and providing nursing ongoing assessments.  3.  A revised policy dated 12/11/2024, titled, “On-Call/Weekend Services,” indicated on call staff would be expected to perform visits on an as-needed basis, including weekends, the on call nurse would provide follow up appropriate to the call to include call the patient/family/caregiver, visit the patient if necessary, obtain physician orders as needed, the on call nurse would document each patient/family interaction in a coordination note, and guidelines that may require a visit from the hospice nurse would include but not limited to patient/family/caregiver/facility perceived a problem and requested a visit, duplicate calls regarding the same problem, unusual, severe or uncontrolled pain and new or changed medication orders.4. A revised policy, dated 11/15/2023, titled, “Pain Assessment,” indicated pain assessments would be appropriate to patient’s cognitive status, the patient’s/family’s pain goal, satisfaction with goal, including pain intensity. 5. The clinical record for Patient #4 included a POC for the initial benefit period 06/20/2025 to 09/17/2025, with diagnosis of end stage renal disease, intellectual disability, and cerebral palsy (condition with difficulty with movement, coordination, speech and development). The POC indicated the skilled nurse was to assess for agitation/restlessness and potential causes, assess for pain and potential causes, and to assess effectiveness of treatment regimen.The Triage On-Call Log, dated 06/22/2025, indicated at 2:55 PM, Family Member (FM) I of Patient #4 and indicated Patient was not able to swallow and was requesting liquid morphine (pain medication), indicated Patient was in pain, had not received pain medications, and message was forwarded to RN 3.The Triage On-Call Log indicated at 3:27 PM, caregiver at skilled nursing facility [SNF] from Entity A, reported Patient 4 had difficulty swallowing, Tylenol was given, though was difficult to administer, Patient unable to take regular medication and comfort medications had not been delivered yet; the  Triage RN recommended an in-person visit and the STAT (urgent) message was forwarded to RN 3.  A Hospice Physician Order, dated 06/22/2025, at 7:08 PM, indicated to discontinue all oral medication and start Morphine every 4 hours as needed for pain and Lorazepam (anxiety medication) every 4 hours as needed for anxiety.A RN Visit Note Report, dated 06/23/2025, indicated Patient had shallow/labored breathing with coarse lung sounds and moist crackles in throat, indicated current pain management was not effective, Patient required higher level of pain management, and no opioid medication was prescribed, Patient was minimally verbally responsive, heart rate elevated at 127, and received new orders for Atropine (used for secretions), Morphine, Tylenol Suppository, and Lorazepam (anxiety medication), and Entity A's nurse was provided with written orders and nursing visits would be changed to daily due to imminent status.During an interview, on 08/01/2025, beginning at 10:55 AM, FM I of Patient #4 indicated Patient was mentally disabled, resided at entity A, a skilled nursing facility, and pain medications was not delivered for 3 days from hospice. FM 1 indicated Patient was partially verbal on Friday 06/20/2025 and could say hello and eyes were open.   FM I indicated a hospice RN indicated on Saturday 06/21/2025 pain medication would be delivered 06/21/2025.  FM I indicated Patient had signs of pain on Sunday 06/22/2025 with Patient moaning and groaning and on 06/23/2025 Patient was not awake, eyes were not open, Patient was moaning, groaning and face was grimacing.  FM I indicated he/she and entity A had called hospice on 06/22/2025 to see about hospice medication delivery.   FM I indicated on Monday 06/23/2025 Patient’s hospice medications were delivered and Patient received medications from the skilled nursing facility’s staff.During an interview on 08/04/2025, beginning at 9:20 AM, Patient Care Manager [PCM] indicated Patient did not have a hospice visit completed on 06/22/2025.  The PCM indicated the hospice nurse on call should have gone to the SNF/Entity A when the triage call was received from the SNF and FM I; indicated the hospice nurse should have contacted the physician to obtain medication orders, should have written the medication orders, and discussed with the SNF if the hospice pharmacy or the SNF pharmacy would order medications. The PCM indicated pain medications would be ordered when Patient indicated they were having pain.  The PCM indicated the hospice was responsible for terminal illness pain medications and should ensure pain medications were available when needed.A SNF [Entity A] Progress Note, dated 06/22/2025 at 3:40 PM, indicated Patient was unable to swallow, called hospice and was notified a hospice nurse would come to facility to deliver comfort medications.  A SNF Progress Note, dated 06/22/2025 at 8:18 PM, indicated hospice nurse called facility and indicated she was getting orders for Patient’s comfort medications, and she would send orders to the facility and indicated the hospice nurse informed the author the pain medications would have to be filled by Entity A's pharmacy.A SNF Progress Note, dated 06/23/2025, 4:34 PM, indicated Person B, supervising LPN at facility administered dose of morphine due to Patient had signs and symptoms of pain.A SNF Shift Pain Scale Note indicated Patient’s pain level 06/22/2025 day shift was 0, evening shift pain level was 4, night shift pain level was 0.   On 06/23/2025, day shift pain level was 2, and the evening shift pain level was 5. During an interview on 08/01/2025, beginning at 12:45 PM, Person B, LPN nursing supervisor at entity A, indicated she administered Patient’s morphine on 06/23/2025, after it was delivered by the hospice executive director.  Person B indicated Patient looked uncomfortable when at time of dosing.   During an interview on 08/04/2025, beginning at 3:00 PM, Person K, a pharmacist at Entity, J, a pharmacy, indicated he received a prescription for morphine, Ativan, and atropine on 06/23/2025 at 12:37 PM for Patient #4, and was picked up by hospice staff on 06/23/2025, at 3:39 PM.During an interview on 08/04/2025, beginning at 4:30 PM, RN 3 indicated she did attempt to give verbal medication orders to the SNF staff for Patient #4, was reeducated on the hospice’s protocol that verbal orders cannot be given to another nurse at a SNF and that hospice was responsible for ordering pain medication.6. The POC for the benefit period 07/19/2025 to 10/16/2025, indicated Patient #3’s diagnosis included cerebral atherosclerosis (plaque buildup in brain reduces blood flow), and functional quadriplegia (weakness limbs).  A Coordination Note, completed by RN 3, dated Saturday 07/19/2025, indicated Patient #3 was admitted to hospice on 07/19/2025 with a diagnosis of dementia (cognitive impairment), was disoriented x3, and new medications ordered would include but not limited to Ultram (also known as tramadol pain medication) every 8 hours as needed for pain greater than 4. An entity C, a SNF, Controlled Drug Receipt Form, indicated Tramadol was received on 07/21/2025. During an interview, on 08/04/2025, beginning at 4:30 PM, RN 3 indicated Patient #3 complained of shoulder pain and only had Tylenol ordered upon admission and RN 3 indicated she thought entity C would order the Tramadol however, she indicated she was reeducated that hospice should be responsible to order Tramadol. During an interview, on 08/04/2025 beginning at 6:00 PM, Patient #3’s hospice physician, Other Physician 2, indicated she would order Tramadol as needed for pain when a nurse would notify of a patient’s moderate pain level. During an interview on 08/04/2025, beginning at 3:00 PM, Person K, pharmacist at pharmacy J indicated Patient #3’s tramadol order was received on 07/21/2025, and delivered to the SNF on 07/21/2025 at 5:02 PM by the pharmacy. During an interview on 08/04/2025, beginning at 1:00 PM, MSW L, at entity C  indicated she was notified by the nurse at the facility that Patient #3 did not have the Tramadol that was ordered by hospice, and she reached out to the executive director of the hospice on 07/21/2025, to inform that Tramadol was ordered on 07/19/2025 by hospice had not been received at the SNF. During an interview, on 08/04/2025 beginning at 1:00 PM, Person M, a facility nurse indicated Patient #3 was not able to verbalize pain, had osteoporosis and she notified the MSW the Tramadol was not delivered from hospice to ensure was available if needed by Patient.  Person M indicated due to a 08/01/2025 altercation initiated by another patient, Patient was started on scheduled Tylenol every 6 hours, and the Tramadol was destroyed on 08/01/2025.

Based on record review and interview, the hospice POC failed to identify the care and services that were needed and specifically identify which provide would be responsible for performing the respective functions in 3 of 6 active clinical records reviewed of a patient that resided in a skilled nursing facility (SNF) (Patient #1, Patient #2, and Patient #8), and in 1 of 1 discharged clinical records reviewed of a patient that resided in a SNF (Patient #4).  Findings include: --- 1. A revised policy, dated 11/15/2023, titled, “Provision of Care to Residents of Skilled Nursing Facility, ICF/IID or ALF,” indicated a written plan of care established and maintained in consultation with the SNF would identify the care and services that were needed and specifically identify which provide was responsible for performing the respective functions.   2. A POC Update for Patient #1’s benefit period 06/21/2025 to 08/19/2025, indicated the hospice skilled nurse to instruct facility staff on responsibilities related to patient care needs as delineated on the hospice POC.  A Recertification Assessment Visit Note, dated 07/31/2025, indicated Patient required assistance for feeding, bathing, dressing, grooming, and toileting.  The Visit Note indicated the SNF staff to administer medications.  The POC failed to evidence the delineation of care between the hospice and the SNF.During a visit at the SNF, the hospice binder failed to evidence a POC with delineation of Patients’ care. 3. The clinical record for Patient #2 included a POC for the benefit period 02/18/2025 to 05/18/2025 which indicated skilled nurse to instruct facility staff on hospice responsibilities and facility staff responsibilities related to patient care needs as delineated on the hospice POC.   The POC failed to include the delineation of hospice and SNF services provided by each provider.A Visit Note Report, dated 07/22/2025, indicated Patient resided at Entity O, a SNF, was incontinent of bowl and bladder, had intermittent confusion, and had oxygen as needed.   A clinical record review failed to evidence a delineation of care identifying specific hospice responsibilities and skilled nursing facility responsibilities.  4. The POC for the initial benefit period for Patient #8, dated 7/29/2025 to 08/27/2025, indicated skilled nurse to coordinate patient care needs with the facility staff.  A Start of Care Visit Note Report, dated 07/29/2025, indicated Patient resided at entity N, a SNF, had diagnosis of traumatic brain injury, required Hoyer lift to transfer, was bedbound, needed 1 person assist with all activities of daily living and had increased choking episodes.  During a review of the hospice binder at entity N, on 08/04/2025, failed to evidence a POC with delineation of patients care.  5. A POC for Patient #4’s initial benefit period dated 06/20/2025 to 09/17/2025, indicated skilled nurse to instruct facility staff on hospice responsibilities, and facility staff responsibilities related to patient care needs as delineated on the hospice POC.  A Start of Care Visit Note, dated 06/20/2025, indicated Patient was bedbound, required total care and resided in a SNF.  6. During an interview, on 08/04/2025, beginning at 10:40 AM, RN 1 indicated the delineation of care should be in the hospice binder at the SNF and the delineation of care should be completed by the RN upon admission to hospice.  7. During an interview, on 08/04/2025, beginning at 3:45 PM, the Patient Care Manager indicated Patient #1, Patient #2, Patient #4, and Patient #8 did not have a delineation of care with patients’ SNF.

Based on record review and interview, the interdisciplinary group failed to ensure the plan of care (POC) was individualized (see L543), failed to ensure the agency provided patient/caregiver education regarding oxygen safety when smoking or vaping (see L544), failed to ensure it developed individualized plans of care which included measurable outcomes (L548), failed to ensure the plan of care (POC) included the correct route of administration of medications (L549) --- The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment and resulted in the agency being found out of compliance with the condition 42 CFR 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services

Based on record review and interview, the interdisciplinary group failed to ensure the plan of care (POC) was individualized for 1 of 1 patient with a home visit (Patient #3). Findings include: --- 1. A policy dated 8/30/2023 indicated the interdisciplinary group was responsible for creating an individualized plan of care. 2. During a home visit observation on 7/26/2024 at 10 AM with registered nurse (RN) 2, Patient #3 indicated they did not receive aide services at this time. RN 2s assessment of Patient #3 indicated Patient #3 had no wounds. Patient #3s POC dated 7/4/2024 identified goals of developing an aide care plan to meet the patient's personal care needs and achieve optimal wound healing. During an interview on 7/29/2024 at 10:41 AM, RN 2 indicated Patient #3 did not have an aide or a wound. When asked, RN 3 indicated they forgot to remove the goal regarding the aide meeting personal care needs. RN 3 indicated they included the wound healing goal in case Patient #3 developed a wound. RN 3 indicated goals could be changed or removed at any time. RN 2 indicated the plan of care was not specific to Patient #3.

Based on clinical record review and interview, the hospice failed to ensure the agency provided patient/caregiver education regarding oxygen safety when smoking or vaping in 3 of 4 active clinical records reviewed (Patient #1, 4, 5). --- Findings include: 1. Review of an agency document titled ";Oxygen Safety Agreement" indicated that by signing the document the patient/caregiver acknowledged they had received education regarding the risks of oxygen use while smoking or vaping. The agreement indicated the hospice will not be held responsible for injury or damage resulting from using oxygen improperly in the home, do not smoke or vape or allow others to smoke or vape around you when oxygen is in use 2. Review of Patient #1s clinical record indicated he/she was hospitalized due to burns sustained while vaping on O2. Patient #4 had a signed Oxygen use agreement on 4/29/24 and signed the same agreement on 7/18/24. Review Patient #1s clinical record evidenced a Plan of care dated 4/29/29/24 to 7/27/24 with an order to assess for safe and appropriate use of oxygen. Review of a visit note dated 6/28/24 indicated the patient was a former smoker and was using oxygen. The note failed to evidence education on oxygen safety. The Patient had been up to the bathroom on 02 4 liters and oxygen saturation was 92%. Patient needed a 5-minute rest period to recover from being up and out of bed. Review of a coordination note dated 7/9/24 indicated the Patient #1was hospitalized on 7/8/24 due to patient wearing oxygen and using her vape causing the oxygen to explode. Review of a compliance investigation evidenced an interview with RN 5 which indicated she was not aware vaping was something the agency should be educating on. A visit note dated 7/18/24 indicated Patient #1 quit vaping 2 weeks ago. This note failed to evidence what safety education was completed and the Patients response to the education. A coordination note dated 7/9/24 indicated the Patient was hospitalized on 7/28/24 due to patient wearing oxygen and using her vape causing the oxygen to explode. During an interview on 7/29/24 at 2:56 PM RN 4 indicated she had become aware that vaping should be part of the oxygen safety education after Patient #1 vaping accident. During an interview on 7/29/24 at 12:50 PM LPN 1 indicated the training had just recently in the last month been updated to include vaping and the use of oxygen. LPN 1 indicated that after a short time of seeing Patient #1 she noticed a vape on the side table. 3. The medication profile for Patient #4 indicated they used oxygen for shortness of breath. A review of the medical record failed to evidence an oxygen safety agreement. Review of Patient #4s clinical record evidenced a recertification assessment date 5/24/24. This assessment indicated the patient is on oxygen and continues to smoke 10-12 cigarettes per day. Review of the record failed to evidence an oxygen safety agreement was complimented and signed by Patient #4. The record also failed to evidence what education was provided on oxygen safety and what the Patient response to the education was. During an interview on 7/29/24 at 1:32 PM, RN 4 indicated Patient #4 knows he/she should not smoke, but the educaton was not documented in the record. During an interview on 7/26/2024 at 3:05 PM, the Administrator indicated Patient #4 did not have an oxygen safety agreement but should have had one. 4. Review of the clinical record for Patient #5 indicated an election of benefit date on 06/27/2024. The plan of care (POC) included orders for oxygen to be used as needed. The record failed to evidence an oxygen safety agreement and failed to evidence what education was provided about oxygen safety and the Patients response to the education. During an interview on 07/26/2024 at 12:55 PM, when asked when the Oxygen Safety Agreement had been reviewed and signed with Patient #5, Registered Nurse (RN) 3 indicated had completed the admission and had been told the patient was not going to smoke, but the family did smoke. When queried as to where the signed oxygen safety agreement could be found RN 3 indicated she did not have the Oxygen Safety Agreement form with him/her at this admission.

Based on record review and interview, the agency failed to ensure it developed individualized plans of care which included measurable outcomes for 3 of 4 active clinical records reviewed (Patient #1, 3, and 4). Findings include: --- 1. The plan of care (POC) policy dated 8/30/2024 indicated the established goals/ outcomes would be used to monitor patient progress. 2. The POC for Patient #3, dated 7/4/2024, included a goal of ";Patient will achieve optimal respiratory function and comfort within disease process." During an interview on 7/29/2024 at 10:41 AM, registered nurse (RN) 2 indicated they measured the goal based on the patient assessment. RN 2 indicated someone unfamiliar with Patient #3 would not know the goal or outcome of the respiratory goal. 3. The POC for Patient #4 dated 5/28/2024 included a goal of ";Patient will achieve optimal respiratory function and comfort within disease process." During an interview on 7/29/2024 at 1:32 PM, RN 4 indicated the respiratory functioning goal was too broad to determine progress. Review of the clinical record of Patient #1 included a plan of care (POC) for benefit period 04/29/2024 – 07/27/2024 that indicated diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and chronic respiratory failure with hypercapnia (build up of carbon dioxide in the bloodstream). The POC included a goal ";Patient will achieve optimal respiratory function and comfort within disease process". The POC failed to evidence the goal had a measurable outcome. During an interview on 07/29/2024 at 10:22 AM, when asked how to measure the goal, patient will achieve optimal respiratory function and comfort within disease process, for Patient #1, Registered Nurse (RN) 1 indicated comments could be entered for the goal. When asked what comments had been entered for this goal, RN 1 indicated nothing had been entered.

Based on record review and interview, the agency failed to ensure the plan of care (POC) included the correct route of administration of medications in 1 of 4 active records reviewed (Patient #1). Findings include: --- 1. Review of an agency policy titled ";The Plan of Care" indicated the written plan of care will include drugs necessary to meet the needs of the patient. 2. Review of the clinical record for Patient #1 indicated an election of benefit date on 04/29/2024 and readmission on 07/18/2024. Review included a POC for certification periods 04/29/2024 – 07/27/2024, and 07/18/2024 – 10/15/2024 with the following medication orders: Albuterol Sulfate (used by inhalation to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness caused by lung diseases) solution for nebulizer by mouth, and Proventil HFA (same use as Albuterol Sulfate) aerosol by mouth. Documentation failed to evidence inhalation as the route of administration. During an interview on 07/29/2024 at 10:22 AM, when asked what the route of administration should be entered for inhaled medications, Registered Nurse 1 indicated the route should have been entered as inhalation.

Based on record review and interview, the agency failed to ensure the documentation of a sentinel event included a completed root cause analysis and an action plan (see L562) --- The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment and resulted in the agency being found out of compliance with 42 CFR 418.58 Condition of Participation: Quality Assessment and Performance Improvement

Based on record review and interview, the agency failed to ensure the documentation of a sentinel event included a completed root cause analysis and an action plan for 1 of 1 record reviewed that included a sentinel event that resulted in a patients death (Patient #2) out of a total of 2 patients involved in house fires related to smoking/vaping. Findings include: --- 1. Review of an agency policy titled ";Incident Reporting" indicated a sentinel event is an unexpected occurrence involving death and a root cause analysis (process of discovering the root cause of a problem to identify appropriate solutions) of the sentinel event will be conducted. 2. Review of an agency policy titled ";Sentinel Events" indicated a sentinel event could be a death of a patient directly related to agency involvement or equipment supplied by the agency or fires in the home where oxygen is in use. Indicated the administrator or executive director will initiate the root cause analysis process within 48 hours and begin interviews with all parties to the event, determine the root cause and determine potential improvements in processes or systems that would decrease the likelihood of such events in the future. 3. Review of an agency policy titled ";Root Cause Analysis Action Plan" indicated when a sentinel event is discovered, a root cause analysis will be conducted to identify underlying causes and an action plan will be implemented to identify the strategies the hospice is to implement to reduce the risk of similar events occurring in the future. 4. Review of the clinical record of Patient #2 included a Visit Note Report for a routine visit completed by Licensed Practical Nurse 2 on 07/02/2024 that indicated Patient #2 was alert and oriented to self, situation and place with confusion at times. Review indicated Patient #2 had labored breathing and used continuous oxygen and was a current smoker. Review included a Visit Note Report for a non-attended death completed by Registered Nurse 1 on 07/04/2024 that indicated Patient #2 died on 07/02/2024 in an unexpected house fire. Review of an agency document titled ";Client Occurrence Report" completed by Branch Executive Director on 07/03/2024 indicated Patient #2 had house fire on 07/02/2024 with no further information regarding the time and cause of death. Review on 07/26/2024 of an agency document titled ";Incident/Occurrence Root Cause Analysis" completed by Branch Executive Director on 07/03/2024 included documentation in a section identified as, what happened, that indicated family member of Patient #2 notified Registered Nurse 1 about a house fire and that Patient #2 did not survive. The agency document failed to evidence documentation of the why questions and findings of the incident and failed to evidence documentation of an action plan. During an interview on 07/29/2024 at 3:12 PM, when asked where the documentation for the rest of the root cause analysis and action plan was for Patient #2, the administrator and director of compliance indicated the documentation had not been done.

Based on record review and interview, the agency failed to ensure the registered nurse (RN) coordinated with the attending physician regarding the updated assessment and plan of care for 1 of 2 patient records reviewed with a non – hospice physician (#5), with the potential to affect all patients with a non – hospice attending physician. Findings include: --- 1. A review of a letter for non – hospice physicians regarding the expectations of the attending physician included ";... participation in the development, revisions, and approval of the ... plan of care." A review of a policy on the attending physicians role indicated the physician will participate in the development of the plan of care. The policy indicated the hospice interdisciplinary group would collaborate with the attending physician on updates of the patient's plan of care. 2. A review of the clinical record for Patient #5s evidenced interdisciplinary group meeting notes for 12/11, 12/26/2023, 1/8, 1/22, 2/5, and 2/19/2024. The notes included a section titled ";Communication and coordination of services with non – hospice providers." The meeting notes failed to include communication or coordination with Physician E, Patient #5s attending physician. During an interview on 2/19/2023 at 2:45 PM, the Administrator indicated the agency faxed the updated plan of care to Physician E. During an interview on 2/20/2023 at 3:30 PM, the Administrator indicated the coordination with the physician occurs when the nurse communicates with the physician for new orders (when needed) but not specific coordination regarding the plan of care prior to the update.

Based on observation, record review, and interview, the Registered Nurse (RN) failed to ensure written patient-specific care instructions were provided to the Hospice Aide (HA) for 1 of 1 active clinical record reviewed with a home visit in a skilled nursing facility (Patient #29) and 2 of 2 active clinical records reviewed with patients who resided in an assisted living facility (ALF) (Patients #28 and 30). The findings include: --- 1. During a home visit observation on 01/17/2024 beginning at 1:00 PM, at Entity 15 a skilled nursing facility, Registered Nurse (RN) 7 indicated, prior to entering Patient #29s room, that Patient tested positive for COVID-19 within the previous hour and was placed on droplet precautions and would remain bedbound until resolved. During the visit, noted Patient was wearing heel protectors in bed. The clinical record for Patient #29 included a hospice aide (HA) care plan (written patient care instructions for the HA) with effective date 11/22/2023, that included but was not limited to the following instructions, to offer fluids (consistency not specified), Patient with aspiration precautions (practices to reduce/prevent risk of food/fluids or other foreign objects from entering the lungs), use of a mechanical lift to transfer Patient from surface to surface, shower Patient with each visit, and to remove compression stockings prior to showering. The HA care plan failed to evidence the use of heel protectors while the patient was in bed, or patient-specific aspiration precautions. The clinical record failed to evidence the HA care plan was updated between 11/22/2023 - 01/16/2024. An updated hospice plan of care dated 01/16/2024 included, but was not limited to the following interventions: The nurse would create a HA care plan and revise as needed to meet the patients needs was added on 7/23/2023. The patient would wear heel protectors while in bed was added on 7/23/2023. The patients diet of pureed consistency with nectar thick liquids was added on 1/16/2024. Documentation within Patient's clinical record at Entity 15 indicated Patients fluid consistency was downgraded to nectar thick (aspiration precautions) on 11/29/2023 and a physicians order that revealed Patients diet was downgraded to puree (pudding) consistency (aspiration precautions) on 11/29/2023. A HA care plan with effective date 1/18/2024, created and approved by the Administrator, indicated tasks included but not limited to the use of a mechanical lift and wheelchair every visit, use of compression stockings, and failed to include droplet precautions were initiated for COVID-19, that Patient to wear heel protectors and Patient was to remain bedbound, and therefore unable to shower. During an interview on 1/18/2024 at 1:48 PM, RN 7 indicated the hospices Medical Director downgraded Patients diet/fluid consistencies in late November or early December (2023), the compression stockings were discontinued but he/she was behind on charting, he/she updated the HA care plan yesterday (1/17/2024) and the HA care plan should have included diet/fluid consistencies so the HA would know how to care for Patient, and the updated HA care plan still indicated showers were to be given. 2. The clinical record for Patient #28 evidenced the patient resided at Entity 18 (an ALF), and a HA care plan with effective date 7/24/2023 indicated tasks included but not limited to the patient required assistance of 1 person for transfers, and failed to include the use of a mechanical lift for transfers. A nursing visit note dated 1/04/2024 indicated the patient required the use of a mechanical lift for transfers. A nursing visit note dated 1/14/2024 indicated the patient required the use of a mechanical lift for transfers, it was present in the patient's room but wasn't used to transfer the patient (by staff at Entity 18), and the patient sustained 2 lacerations to the left lower leg, which required emergent care. A nursing visit note dated 1/15/2024 indicated the patient received sutures and wound care orders to the left lower leg. During an interview on 1/18/2024 at 3:45 PM, HA 9 indicated Patient required the use of a mechanical lift and 2 people for transfers, and staff at Entity 18 helped them.During an interview on 1/19/2024 at 11:48 AM, the Administrator indicated she believed they updated the HA care plan and it was "fixed" this morning, and dependent on how Patient was that day, the transfer could be done with the mechanical lift or by 2 person assist. 3. The clinical record for Patient #30 evidenced Patient resided at Entity 17 (an ALF), and a nursing visit note dated 01/13/2024 indicated Patient sustained a fall on 01/12/2024 which resulted in a laceration to the left temporal (side of scull near/above the ear) that required stitches. The clinical record failed to evidence the HA care plan was updated with patient-specific instructions for showering/hair care after the fall occurred; the record evidenced the most recent aide care plan update was 10/27/23. A physician's order dated 01/13/2024 included orders for wound care to laceration with sutures as follows: Entity 17 or hospice nurse to cleanse daily with wound wash, pat dry with gauze, apply antibiotic ointment, and leave open to air. During an interview on 1/18/2024 at 3:36 PM, HA10 indicated Entity 17 was laying the patient down more frequently, staff at Entity 17 told him/her it was okay to shower Patient, but to give a bed bath if Patient was already in bed, he/she believed he/she had to wash around the stitches, the facility said dont wash the stitched area, and dont get it wet. HA10 also indicated he/she has not spoken with hospice nurse about the head laceration. During an interview on 01/18/2024 at 4:03 PM, RN 23 indicated the only change in Patient's care after the fall was the care to the sutures (stitches) and the HA care plan was fine.During an interview on 01/18/2024 at 4:40 PM, RN 26 indicated the main thing was to not get the sutures wet during personal care and Patient was supposed to receive bed baths. During an interview on 01/19/2024 at 11:55 AM, the Administrator indicated the HA care plan should be updated, but if the sutures were left open to air with no treatment, then the HA would just continue with the current care plan.

Based on observation, record review, and interview, the hospice agency's interdisciplinary group (IDG) failed to ensure the written instructions for hospice aide (HA) care was updated as often as necessary to reflect updated and or change in care in 1 of 1 clinical record reviewed with a home visit of a patient who resided in a skilled nursing facility (Patient #29). The findings include: --- The clinical record for Patient #29 was reviewed on 1/16/2023, which contained a HA care plan (written patient care instructions), effective date 11/22/2023, included but not limited to offer fluids, and the patient had aspiration precautions (practices to reduce/prevent risk of food/fluids or other foreign objects from entering the lungs.) The record from Entity 15, a skilled nurse facility, indicated Patients fluid consistency was downgraded to nectar thick (aspiration precautions) on 11/29/2023 and included a physicians order that indicated Patients diet was downgraded to puree (pudding) consistency (aspiration precautions) on 11/29/2023. A hospice nurse visit note dated 01/10/2024 indicated the aide care plan was reviewed and was not updated. The clinical record failed to evidence the hospice aide care plan was updated after 11/22/2023 through 01/16/2024. On 1/16/2024 beginning at 12:05 PM, during the hospices IDG meeting, Patient #29 was discussed regarding their increased difficulty swallowing and a recent downgrade in dietary requirements. During an interview on 01/18/2024 at 1:48 PM, RN 7 indicated the hospice agencys Medical Director downgraded the patients diet / fluid consistencies in late November or early December (2023), they were behind on their charting and relayed the HA care plan should have included diet/fluid consistencies so the HA would know how to care for the patient, and indicated he/she did call the HA to provide a verbal update on the patient's current status.

Based on record review and interview, the agency failed to ensure patients have the right to receive effective pain management in 1 of 1 (Patient #11) active clinical record of a patient with a respite stay for pain management and failed to ensure patients have the right to have medications related to terminal illness, paid for by the hospice provider for 1 of 1 (Patient #6) active clinical record of a patient who had to pay for medications related to terminal illness in a sample of 21. Findings include: --- 1. The hospices' Patient Bill of Rights indicates patients have the right to effective pain management. 2. The clinical record for Patient #11, with Election date 9/28/2023, identified diagnoses that included but were not limited to, lung cancer with metastasis to the bones. The record contained a plan of care for the benefit period 9/28/2023 - 12/26/2023 indicating Patient #11 identified a pain goal of 4 out of 10. A review of nursing visit notes documented Patient #11s pain level did not meet their pain goal on the following dates: On 9/29 Patient reported a verbal pain level of 5 with a revised goal of 3. On 10/3 their pain level was reported at a level 6 with a goal of goal 4. On 10/6 their pain level was 4, and their revised pain goal was 2. On 10/9 Patient reported ";constant moderate" 7/10 with no goal noted. On 10/19 Patient reported verbal pain level was 9, with a goal of 6. On 10/20 ";constant severe" (no goal noted); on 10/26/23 pain level 7, with a goal of 4. On 10/31/23 patient reported verbally their pain level was 6, with a goal of 5. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated the pain management regimen was identified as effective on the visit notes. When asked if 9 was considered an acceptable pain level, the Administrator indicated it was not. 3. A review of the clinical record for Patient #6 evidenced an interdisciplinary group (IDG) comprehensive assessment and plan of care update dated 10/31/2023. The document indicated Patient #6 had a terminal diagnosis of Parkinsons disease (a degenerative movement disorder). The document contained a medication list with the medication name, dosage, reason if the medication was on the hospice formulary, and whether it was paid for by the hospice or the patient. Patient #6's medication list on this updated plan of care evidenced that a medication called Entacapone (treats end-of-dose "wearing off" effect in patients with Parkinsons disease) was not covered and indicated the patient was responsible for paying for it. Gabapentin (improves rigidity, and tremors of parkinsonism) and Pramipexole (works on the nervous system to help treat the symptoms of Parkison's) were listed and also indicated it was the patients responsibility to pay as they were not related to the hospice diagnosis. A review of the agencys medication formulary, provided on 11/17/2023 at 1:28 PM, indicated Entacapone, Gabapentin, and Pramipexole were all covered medications on the formulary. A report on medications paid for by the hospice for all patients of the multiple location 2 branch was provided and included all medications paid for by the hospice since 10/1/2023. A review of the report failed to include Patient #6's Parkinson's medications. During an interview on 11/17/2023 at 1:15 PM, the branch manager indicated Hospice Physician 2 would only pay for medications that made a meaningful improvement in the patients condition. The branch manager further indicated they often argued with Hospice Physician 2 about paying for all medications related to the terminal diagnosis.

Based on observation, record review, and interview, the agency failed to ensure a Registered Nurse's initial comprehensive assessments contained an accurate assessment of equipment in a patient's home, an assessment of risk for falls, and an assessment of skin impairments (seeL524) and failed to ensure a Registered Nurse's updated comprehensive assessments contained a complete and accurate skin assessment and an assessment for risk of falls. An Immediate Jeopardy related to 42 CFR §418.54: Initial and Comprehensive Assessment of the Patient was identified and announced on 11/20/2023 at 10:00 AM. The agency's immediate jeopardy removal of the immediacy plan and actions were determined to have removed the immediacy component of the Immediate Jeopardy on 11/28/2023 at 1:42 PM. --- The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate care and services, which could result in the agency not providing quality health care, thus being out of compliance with the Conditions of Participation 42 CFR §418.54 Initial and Comprehensive Assessment of the Patient for all patients who receive care and services with this provider. The findings include:

Based on observation, record review, and interview, the agency failed to ensure a Registered Nurse's initial comprehensive assessments contained an accurate assessment of equipment in a patient's home, an assessment of risk for falls, and an assessment of skin impairments for 4 of 4 active records reviewed of patients with an initial RN comprehensive assessments in a sample of 21. (Patient #1, 5, 8, 12) The findings include: --- A review of an agency policy on the comprehensive assessment indicated the comprehensive assessment should include the condition of the skin, medical equipment in the home, fall risk assessment, and individualized problems and needs. A review of an agency policy on wound assessment indicated the nurse must assess open wounds and surgical incisions at the time of admission. The wound assessment was to identify the location, size, odor, drainage, wound bed characteristics, condition of the surrounding skin, and pain. The policy indicated the details of the wound must be completed in the Integumentary Command Center (ICC), which was used to track the number and status of wounds. A review of the clinical record for Patient #1 identified diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and congestive heart failure, both of which caused breathing problems. The comprehensive assessment, completed on 9/18/2023 by registered nurse (RN) 8, indicated Patient #1 had medical equipment that was safe and in good working order. In the narrative section of the note, RN 8 indicated Patient #1 had a portable oxygen concentrator that needed repairs. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated the assessment incorrectly identified the medical equipment was in good working order and they should have ensured the portable concentrator worked properly or was replaced. A review of the clinical record for Patient #5, benefit election date 9/9/2023, included a comprehensive assessment which indicated the patient had no skin issues. Registered nurse (RN) 3 completed the assessment on 9/9/2023. A nurse visit for Patient #5 occurred with RN 3 on 9/11/2023, two days after RN 3 completed the comprehensive assessment. The visit note for 9/11/2023 indicated patient had a surgical wound with staples from a procedure completed approximately one month prior to the hospice admission. At that time, RN 3 spoke with Physician #7 about the removal of the staples. RN 3 identified the wound but failed to complete the ICC. RN 3 failed identify and document an existing surgical wound on the comprehensive assessment. During an interview on 11/21/2023 at 4:30 PM, the Administrator indicated the surgical wound with staples should have been included on the comprehensive assessment and on the ICC. During an interview on 11/28/2023 at 9 AM, RN 3 indicated the wound was present at the time of the comprehensive assessment and included the discussion with Physician #7 regarding the removal of the staples. When told that documentation was on the note for 9/11/2023 and not the comprehensive assessment, RN 3 indicated they were sure they included it on the comprehensive assessment. RN 3 indicated the wound should have been included on the ICC. A narrative note for a nurse visit on 9/21/2023, completed by RN 3, identified scratches on Patient #5s right lower leg. The visit note for 9/28/2023, completed by RN 3, identified the scratches on the ICC, which included skin characteristics and size. The ICC indicated the onset date of the scratches was 9/28/2023, though they were first observed on 9/21/2023. During an interview on 11/28/2023 at 9 AM, RN 3 indicated the scratches should have been noted on the ICC on 9/21/23. A record review for Patient #6 evidenced a comprehensive assessment completed by RN 24, dated 10/25/2023 for the benefit period 11/7/2023 – 1/5/2024. The comprehensive assessment indicated Patient #6 frequently had wounds but the comprehensive assessment lacked documentation of a full skin assessment. The assessment indicated Patient #6 had a recent fall which caused scratches on their face but the wound was not included on the ICC. A review of the recertification of the terminal illness (a summary of the patients terminal diagnosis and status which the physician completed) identified Patient #6 had a ";significant laceration and went to the ER [emergency room] for stitches." The comprehensive assessment failed to evidence a ";significant laceration" on the ICC, however, a skin tear was noted on the ICC. During an interview on 11/20/2023 at 9:45 AM, the Administrator indicated the wound was wound #18 and was classified as a skin tear, not a laceration. When requested, the Administrator provided the wound documentation for wound #18, which was included on the comprehensive assessment as a skin tear. The Administrator indicated the identification of the wound was inconsistent. A record review for Patient #9 evidenced a comprehensive assessment completed by RN 14, dated 9/14/2023 for the benefit period 9/28/2023 – 11/26/2023. The comprehensive assessment indicated Patient #9 had new conditions which included falls; however, the assessment lacked a complete fall risk assessment. During an interview on 11/21/2023 at 11 AM, the Administrator indicated the fall risk assessments should be completed with every comprehensive assessment for all patients. 7. The clinical record for Patient #8 (election of benefit [EOB] date 10/28/2023) included the initial comprehensive assessment, which evidenced the patient had nutritional deficits, decreased appetite, malnutrition; Patient was confused, high risk for falls, unable to ambulate without assistance, had a foam dressing on the coccyx (tailbone) and right hip for preservation of skin integrity, was incontinent of bowel and bladder, wore adult briefs, and had a recent UTI; no environmental or safety issues were identified. The initial Social Worker (SW) evaluation, also dated 10/28/2023, indicated caregiver was inadequate/unreliable, safety hazards included unsafe floor coverings, unsafe electrical cords/devices, cluttered/soiled living area, and respite placement was needed. During an interview on 11/28/2023 at 11:44 AM, MSW 3 indicated they were waiting for patient's Medicaid insurance to get approved before he could go to respite, and he/she was present with the RN during the admission visit. 8. The clinical record for Patient #12 (EOB date 10/04/2023) included the initial comprehensive assessment, which evidenced the patient was confused, unable to ambulate, was incontinent of bowel and bladder, had heavy bladder incontinence, wore adult briefs, and had no skin concerns. The comprehensive assessment evidence RN 3 declined to perform a standardized risk assessment to determine risk for skin breakdown, or a completed a full head to toe skin assessment. A Skilled Nurse (SN) visit note dated 10/05/2023 evidenced RN 3 performed incontinence care, and during care, a stage 2 (a shallow open wound, or intact or open/ruptured serum- filled blister) was identified. During an interview on 11/16/2023 at 2:48 PM, with RN3 indicated they didn't routinely assess for wounds, they relied on aides and caregivers to report new wounds, and once a wound was identified, then they would assess the patient. 9. A home visit was observed on 11/16/2023 at 11:00 AM with Patient #13, RN 3, and Person 9 (group home caregiver). Prior to providing any care, RN 3 indicated the patient had but not limited to 1 wound on the buttocks, RN 1 measured it yesterday, patient wore a colostomy bag (a surgical opening diverting a portion of intestine out through the abdomen to drain feces), and she just checked to ensure it was sealed during her visits. RN 3 indicated all wounds developed after admission to hospice, and there was a glitch with group home staff with turning and re-positioning the patient. RN 3 and Person 9 transferred the patient from chair to bed without difficulty. Assessment of the patient's buttocks, revealed multiple open wounds, with some areas having full thickness skin loss. The clinical record for Patient #13 (EOB date 7/26/2022) included comprehensive reassessments for recertification of services dated 8/23/2023 and 10/24/2023, which both evidenced the patient was confused, RN 3 declined to perform a standardized risk assessment to determine risk for skin breakdown, completed full head to toe skin assessments, or completed standardized comprehensive pain assessments. The assessments indicated pain was determined by "staff observation". The clinical record evidenced RN 1 provided SN visits 10/27/2023, 11/02/2023, 11/09/2023, and 11/15/2023. During an interview on 11/16/2023 at 2:38 PM, RN 1 assessed the patients wounds to both heels and 1 on buttocks on 11/15/2023, per the nurse practitioner's request, he/she just took over caring for the patient, 11/15/2023 was the first time she assessed patient's "rear end", he/she couldn't always transfer the patient by him/herself, staff at group home didn't speak English very well, and the patient was a very, very heavy lift. 1. A review of a policy on the comprehensive assessment indicated the comprehensive assessment should include the condition of the skin, medical equipment in the home, fall risk assessment, and individualized problems and needs (psychosocial needs). 2. A review of a policy on wound assessment indicated the nurse must assess open wounds and surgical incisions at the time of admission. The wound assessment was to identify the location, size, odor, drainage, wound bed characteristics, condition of the surrounding skin, and pain. 3. A review of the clinical record for Patient #1 identified diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and congestive heart failure, both of which caused breathing problems. The initial comprehensive assessment dated 9/18/2023 indicated Patient #1 had medical equipment that was safe and in good working order. In the narrative section of the note, RN 8 indicated Patient #1 had a portable oxygen concentrator that needed repairs. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated the initial comprehensive assessment incorrectly identified the medical equipment was in good working order and they should have ensured the portable concentrator worked properly or was replaced 4. A review of clinical record #5,completed by Registered nurse (RN) 3, indicated the patient had no skin issues. A nurse visit for Patient #5 occurred with RN 3 on 9/11/2023, two days after RN 3 completed the comprehensive assessment. The visit note for 9/11/2023 indicated patient had a surgical wound with staples from a procedure completed approximately one month prior to the hospice admission. At that time, RN 3 spoke with Physician #7 about the removal of the staples. RN 3 failed to identify and document the existing surgical wound on the initial comprehensive assessment. During an interview on 11/21/2023 at 4:30 PM, the Administrator indicated the surgical wound with staples should have been included on the initial comprehensive assessment. During an interview on 11/28/2023 at 9 AM, RN 3 indicated the wound was present at the time of the initial comprehensive assessment. 5. The clinical record for Patient #8 included the initial comprehensive assessment dated 10/28/2023, which evidenced the patient had nutritional deficits, decreased appetite, and malnutrition. The patient was confused, a high risk for falls, unable to ambulate without assistance, had a foam dressing on the coccyx (tailbone) and right hip for preservation of skin integrity, was incontinent of bowel and bladder, and wore adult briefs. The assessment failed to evidence a complete head to toe assessment to include skin integrity under the dressings, or identification of psychosocial needs. The initial Medical Social Worker (MSW) evaluation, also dated 10/28/2023, indicated psychosocial needs included the following: the caregiver was inadequate/unreliable, safety hazards included unsafe floor coverings, unsafe electrical cords/devices, a cluttered/soiled living area, and respite placement was needed (to meet psychosocial needs). During an interview on 11/28/2023 at 11:44 AM, MSW 3 indicated he/she was present with the RN during the admission visit, when psychosocial needs were identified. 6. The clinical record for Patient #12 included the initial comprehensive assessment dated 10/04/2023, which evidenced the patient was confused, unable to ambulate, was incontinent of bowel and bladder, had heavy bladder incontinence, wore adult briefs, and had no skin concerns. The comprehensive assessment evidence RN 3 declined to perform a standardized risk assessment to determine risk for skin breakdown, or completed a full head to toe skin assessment. A Skilled Nurse (SN) visit note dated 10/05/2023 (1 day after the initial comprehensive assessment) evidenced RN 3 performed incontinence care, and during care, a stage 2 (a shallow open wound, or intact or open/ruptured serum- filled blister) was identified. During an interview on 11/16/2023 at 2:48 PM, RN 3 indicated they didn't routinely assess for wounds, they relied on aides and caregivers to report new wounds, and once a wound was identified, then they would assess the patient.

Based on observation, record review, and interview, the agency failed to ensure a Registered Nurse's updated comprehensive assessments contained a complete assessment for skin impairments in 2 of 2 patient records reviewed of patients with wounds (#13, 6) and 1 of 1 active records reviewed of a patient with a new condition that includes falls (Patient #9), in a sample of 21. --- 1. A review of an agency policy on the comprehensive assessment indicated the comprehensive assessment should include the condition of the skin, medical equipment in the home, fall risk assessment, and individualized problems and needs. 2. A review of an agency policy on wound assessment indicated the nurse must assess open wounds and surgical incisions at the time of admission. The wound assessment was to identify the location, size, odor, drainage, wound bed characteristics, condition of the surrounding skin, and pain. The policy indicated the details of the wound must be completed in the Integumentary Command Center (ICC), which was used to track the number and status of wounds. 3. The Immediate Jeopardy began on 10/24/2023 when the nurse completed the recertification assessment for the benefit period 11/18/2023 - 1/16/2024. Patient #13 was immobile and dependent on others for position changes and was incontinent of bowel and bladder. On 9/06/23, a Skilled Nursing Visit (SNV) evidenced the (L) buttock wound was inactivated as healed. The clinical record for Patient #13 included an updated comprehensive assessment for recertification of services dated 8/23/2023 and 10/24/2023, which failed to evidence a full head-to-toe skin assessment, including a standardized risk assessment to determine the patient's risk for skin breakdown. SNV notes after 10/24/23 to 11/14/23 failed to evidence the patients buttocks were assessed. The clinical record evidenced RN 1 conducted SN visits on 10/27/2023, 11/02/2023, 11/09/2023, and 11/15/2023. SNV note dated 11/15/23 revealed (1) stage 2 wound on the (L) gluteal cleft, a wound on the (R) heel, without the presence of necrotic (black/brown tissue), and a necrotic wound on the (L) heel. During a home visit on 11/16/23, both of the patients heels were observed to be black. RN3 relayed patient had (2) new stage 3 wounds and (2) unstageable wounds, all located on the gluteal cleft/buttocks. RN 3 relayed patient was without wounds on the buttocks on 10/24/23, per documentation. RN3 relayed they had not assessed the patient for skin breakdown between 10/24/23 and 11/14/23. RN3 relayed patient was dependent on the privately hired staff in their home (not agency employees) and/or Hospice aides to report any skin issues, then once a wound was identified and reported, a hospice nurse would do an assessment. Hospice aide 2 relayed they last provided incontinent care to the patient on 11/10/23 and relayed they did not look at the patient's skin during the visit when they changed the incontinence brief. During an interview on 11/16/2023 at 2:38 PM, RN 1 indicated he/she assessed the patient's wounds to both heels and 1 on the buttocks on 11/15/2023. Per the Nurse Practitioner's request, he/she just took over caring for the patient and 11/15/2023 was the first time she assessed the patient's buttocks. RN1 indicated he/she couldn't always transfer the patient by him/herself, the staff at the group home didn't speak English very well, and the patient was a very, very heavy lift. 4. A record review for Patient #6 evidenced an updated comprehensive assessment dated 10/25/2023 for the benefit period 11/7/2023 – 1/5/2024. The updated comprehensive assessment indicated Patient #6 frequently had wounds but lacked documentation of a full skin assessment. The assessment indicated Patient #6 had a recent fall which caused scratches on their face but the wound was not included on the ICC. A review of the certificate of terminal illness (a summary of the patients terminal diagnosis and status which the physician completed) dated 10/31/23, identified Patient #6 had a ";significant laceration and went to the ER [emergency room] for stitches." The updated comprehensive assessment failed to evidence a ";significant laceration" on the ICC, however, a skin tear was noted on the ICC. During an interview on 11/20/2023 at 9:45 AM, the Administrator indicated the wound was classified as a skin tear, not a laceration. The Administrator provided the wound documentation, which was included in the updated comprehensive assessment as a skin tear. The Administrator indicated the identification of the wound was inconsistent. 5. A record review for Patient #9 evidenced an updated comprehensive assessment dated 9/14/2023 for the benefit period 9/28/2023 – 11/26/2023. The comprehensive assessment indicated Patient #9 had new conditions which included falls; however, the assessment lacked a complete fall risk assessment. During an interview on 11/21/2023 at 11 AM, the Administrator indicated the fall risk assessments should be completed with every comprehensive assessment for all patients.

Based on record review and interview, the hospice agency failed to ensure the patient and/or the primary caregiver (s) received education and training for 1 of 1 active clinical records reviewed with a patient who had an indwelling urinary catheter (a tube to drain urine from the bladder) in a sample of 21. (Patient #17). The findings include: --- The clinical record of Patient #17 was reviewed and evidenced the nurse inserted a Foley catheter (a tube inserted through the urethra to drain the bladder) on 10/21/2023. A review of all skilled nurse visit notes from 10/21/2023 to 11/13/2023 failed to evidence the patient and/or caregiver were instructed on foley catheter care. A review of the plan of care for the certification period 10/17/2023 to 1/14/2024 failed to evidence educating the patient and/or caregiver about foley catheter care. During an interview on 11/16/2023 at 1:01 PM, Administrative Staff 2 indicated the nurse should educate the patient and/or family about Foley catheter care and document the education in the nurses visit notes.

Based on record review and interview, the hospice agency failed to ensure the patient's plan of care (POC) was individualized for 1 of 21 active clinical records reviewed in a sample of 24 (Patient #8). The findings include: --- 1. An agency policy dated 8/30/2023, titled "The Plan of Care", evidenced an individualized POC would be established and maintained for each patient, based on the initial, comprehensive, and ongoing assessments, and focused on identified problems, goals, and interventions. 2. The clinical record for Patient #8 (election of benefit [EOB] date 10/28/2023) included the initial comprehensive assessment, which evidenced the patient was confused, high risk for falls, unable to ambulate without assistance, was incontinent of bowel and bladder, wore adult briefs, and had a recent urinary tract infection (UTI). The initial Medical Social Worker (MSW) evaluation, dated 10/28/2023, indicated caregiver was inadequate/unreliable, safety hazards included unsafe floor coverings, unsafe electrical cords/devices, cluttered/soiled living area, respite placement was needed, once Medicaid was approved, Patient would be placed at Entity 7 (long term care facility), and MSW 3 would set up a respite stay toward the end of the week to assist in meeting patient care until Medicaid was approved. The initial POC for certification period 10/28/2023 - 1/25/2024, failed to be individualized to include any education provided would be only to caregiver, as patient was confused; patient-specific interventions/education to prevent falls, frequency to check/change adult briefs, or signs/symptoms of UTI and when to contact hospice; activities required human assistance to ambulate; interventions to address inadequate/unreliable caregiver or patient-specific safety hazards, or interventions to initiate the needed respite placement. During an interview on 11/28/2023 at 11:28 AM, MSW 3 indicated once respite was determined to be needed immediately, they tried to have it done within 24 hours or sooner; interventions for signs of potential neglect of caregivers to a patient who was cognitively impaired included an assessment of home for safety, ensure pathways were clear, have access to food/water, ability to make own food or someone who will, and ensure caregiver was willing to provide care. 3. The clinical record for Patient #12 (EOB date 10/04/2023) included the initial comprehensive assessment, which evidenced other conditions contributing to terminal diagnosis included colitis (inflammation of the lining of the intestines), anemia (decreased red blood cells, which inhibits ability for blood to carry oxygen throughout the body), and hypertension (HTN) (high blood pressure); patient had pitting edema (swelling caused by fluid retention) to lower legs, was confused, 3 or more falls within the past 3 months, high risk for falls, and unable to ambulate. The initial POC for certification period 10/04/2023 - 1/01/2024, failed to be individualized to include any education provided would be only to caregiver, as patient was confused; patient-specific interventions/education for the following: to prevent falls with a confused, non-ambulatory patient, colitis, anemia, HTN, or pitting edema. 4. The clinical record for Patient #13 (EOB date 7/26/2022) included a comprehensive reassessment for recertification of services dated 8/23/2023 (for certification period 9/19/2023 - 11/17/2023), which evidenced the patient experienced increased anxiety over past certification period, was disoriented, was chair bound, transfer with assist of sit to stand equipment, high risk for falls, presence of a stage 2 pressure injury (onset date 8/02/2023), and unable to verbalize any discomforts. The updated POC dated 10/02/2023, for certification period 9/19/2023 - 11/17/2023, evidenced a nursing summary entry which indicated the patient continued to decline, no longer ambulatory or able to use sit to stand mechanical lift, coughed hard with mechanical soft (chopped foods) diet/nectar thick liquids, and recommended alteration of diet to prevent aspiration (ingestion of food into lungs). The POC failed to be individualized to include but not limited to any education provided would be only to caregiver, as patient was confused; patient-specific interventions/education for the following: increased anxiety, no longer able to use sit to stand, or patient-specific fall prevention plan. 5. The clinical record for Patient #14 (EOB date 6/02/2023) included an updated POC dated 10/23/2023, for certification period 8/31/2023 - 11/28/2023, evidenced the patient recently started taking morphine (10/06/2023) (a narcotic medication to treat severe pain) to assist with pain control, staff at Entity 11 (long term care facility) reported that since starting taking morphine, patient has become more agitated and mean; ativan (to treat anxiety, and acts as a sedative) was then prescribed (10/13/2023); patient has become mostly bedbound, and almost never got up to sit in wheelchair anymore, and a number of new problems were identified (not further specified). The POC evidenced problem and interventions for pain were added 6/02/2023 and 6/29/2023, and a pain goal of "be comfortable" was added 9/06/2023. The POC failed to be individualized to address increased pain, agitation and "meanness", change in mobility status, or specific "new problems" identified. 6. The clinical record for Patient #15 (EOB date 8/24/2023) included an initial comprehensive assessment, which indicated patient transferred from another hospice agency (Entity 13) in August, was oriented to person and place, abnormal recent memory recall, inability to recall recent events, had 2 UTIs in the past 6 months, with most recent 8/09/2023, patient had constipation, family open to volunteer visits, high risk falls, and patient/representative did not select an attending physician. The initial POC for certification period 8/24/2023 - 11/21/2023 failed to be individualized to include any education provided would be only to caregiver, as patient had impaired mental status; patient-specific interventions/education for the following: recurrent UTIs, constipation, or fall prevention specific to patient. A review of the clinical record for Patient #4 included an updated comprehensive assessment for the benefit period 10/7/2023 – 12/5/2023, which evidenced caregiver resistance to perform medical tasks. A review of the interdisciplinary group (IDG) plan of care update dated 10/18/2023 failed to evidence interventions to address the caregivers resistance to perform medical tasks. A review of the clinical record for Patient #6 included an updated comprehensive assessment for the benefit period 11/7/2023 – 1/5/2024. The assessment identified Patient #6 has greater fatigue and weakness, which resulted in more frequent falls. A review of the IDG plan of care update dated 10/31/2023 failed to evidence any new or changed interventions to address the physical decline. A review of the clinical record for Patient #18 included a comprehensive assessment completed on the benefit election date 10/27/2023. The assessment identified numerous problems which included, but were not limited to adult failure to thrive, weakness, pressure ulcers, and pain. The initial plan of care failed to include any interventions related to the problems and goals identified. 1. A policy dated 8/30/2023, titled "The Plan of Care", evidenced an individualized plan of care would be established and maintained for each patient, based on the initial, comprehensive, and ongoing assessments, and focused on identified problems, goals, and interventions. 2. The clinical record for Patient #8 included the initial comprehensive assessment dated 10/28/2023, which evidenced the patient was confused, was a high risk for falls, unable to ambulate without assistance, was incontinent of bowel and bladder, wore adult briefs, and had a recent urinary tract infection (UTI). The initial Medical Social Worker (MSW) evaluation, dated 10/28/2023, indicated the caregiver was inadequate/unreliable, safety hazards included unsafe floor coverings, unsafe electrical cords/devices, cluttered/soiled living area, and respite placement was needed. The initial plan of care for the certification period 10/28/2023 - 1/25/2024, failed to be individualized to include any education provided only to the caregiver, as the patient was confused, patient-specific interventions/education to prevent falls, frequency to check/change adult briefs, or signs/symptoms of urinary tract infection and when to contact hospice. The POC failed to evidence activities included the patient requiring human assistance to ambulate, interventions to address inadequate/unreliable caregiver or patient-specific safety hazards, or interventions to initiate the needed respite placement. During an interview on 11/28/2023 at 11:28 AM, MSW 3 indicated once respite was determined to be needed immediately, they tried to have it done within 24 hours or sooner; interventions for signs of potential neglect of caregivers to a patient who was cognitively impaired included an assessment of home for safety, ensure pathways were clear, have access to food/water, ability to make own food or someone who will, and ensure caregiver was willing to provide care. 3. The clinical record for Patient #12 included the initial comprehensive assessment dated 10/04/2023, which evidenced other conditions contributing to terminal diagnosis included colitis (inflammation of the lining of the intestines), anemia (decreased red blood cells, which inhibits ability for blood to carry oxygen throughout the body), and hypertension (HTN) (high blood pressure); patient had pitting edema (swelling caused by fluid retention) to lower legs, was confused, 3 or more falls within the past 3 months, high risk for falls, and unable to ambulate. The initial POC failed to be individualized to include any education provided would be only to caregiver, as patient was confused; patient-specific interventions/education for the following: to prevent falls with a confused, non-ambulatory patient, colitis, anemia, or pitting edema. 4. The clinical record for Patient #13 included a comprehensive reassessment dated 8/23/2023, which evidenced the patient experienced increased anxiety over past certification period, was disoriented, was chair bound, transfer with assist of sit to stand equipment, high risk for falls, presence of a stage 2 pressure injury (onset date 8/02/2023), and unable to verbalize any discomforts. The updated POC dated 10/02/2023, for certification period 9/19/2023 - 11/17/2023, evidenced a nursing summary entry which indicated the patient continued to decline, no longer ambulatory or able to use sit to stand mechanical lift, coughed hard with mechanical soft (chopped foods) diet/nectar thick liquids, and recommended alteration of diet to prevent aspiration (ingestion of food into lungs). The POC failed to be individualized to include but not limited to any education provided would be only to caregiver, as patient was confused; patient-specific interventions/education for the following: increased anxiety, no longer able to use sit to stand, or patient-specific fall prevention plan. 5. The clinical record for Patient #14 included an updated POC dated 10/23/2023, which evidenced the patient recently started taking morphine (10/06/2023) (a narcotic medication to treat severe pain) to assist with pain control, staff at Entity 11 (long term care facility) reported that since starting taking morphine, patient has become more agitated and mean; ativan (to treat anxiety, and acts as a sedative) was then prescribed (10/13/2023); patient has become mostly bedbound, and almost never got up to sit in wheelchair anymore, and a number of new problems were identified (not further specified). The POC evidenced problem and interventions for pain were added 6/02/2023 and 6/29/2023, and a pain goal of "be comfortable" was added 9/06/2023. The POC failed to be individualized to address increased pain, agitation and "meanness", change in mobility status, or specific "new problems" identified. 6. The clinical record for Patient #15 included an initial comprehensive assessment dated 8/24/2023, which indicated patient transferred from another hospice agency (Entity 13) in August, was oriented to person and place, abnormal recent memory recall, inability to recall recent events, had 2 UTIs in the past 6 months, with most recent 8/09/2023, patient had constipation, family open to volunteer visits, high risk falls, and patient/representative did not select an attending physician. The initial POC failed to be individualized to include any education provided would be only to caregiver, as patient had impaired mental status; patient-specific interventions/education for the following: recurrent UTIs, constipation, or fall prevention specific to patient. 7. A review of the clinical record for Patient #4 included an updated comprehensive assessment for the benefit period 10/7/2023 – 12/5/2023, which evidenced caregiver resistance to perform medical tasks. A review of the interdisciplinary group (IDG) plan of care update dated 10/18/2023 failed to evidence interventions to address the caregivers resistance to perform medical tasks. 8. A review of the clinical record for Patient #6 included an updated comprehensive assessment for the benefit period 11/7/2023 – 1/5/2024. The assessment identified Patient #6 has greater fatigue and weakness, which resulted in more frequent falls. A review of the IDG plan of care update dated 10/31/2023 failed to evidence any new or changed interventions to address the physical decline. 9. A review of the clinical record for Patient #18 included a comprehensive assessment completed on the benefit election date 10/27/2023. The assessment identified numerous problems which included, but were not limited to adult failure to thrive, weakness, pressure ulcers, and pain. The initial plan of care failed to include any interventions related to the problems and goals identified.

Based on observation, record review, and interview, the hospice agency failed to ensure the patient's plan of care (POC) included interventions for 1 of 1 active clinical record review of a patient with a Foley catheter in a sample of 21. (Patient #17). The findings include: --- During a home visit on 11/15/2023 at 1:00 PM, Patient #17 was observed to have a foley catheter (a tube inserted through the urethra to drain the bladder). A review of the plan of care for certification period 10/17/2023 to 1/14/2024 failed to evidence when the catheter was to be changed and foley catheter care. During an interview on 11/16/2023 at 12:59 PM, Administrative Staff 2 indicated the plan of care should include the type and size of catheter used, instruction on when to replace the catheter, and foley catheter care. 1. An agency policy dated 8/30/2023, titled "The Plan of Care", evidenced an individualized POC would be established and maintained for each patient, and would include medications and treatments. 2. The clinical record for Patient #8 (election of benefit [EOB] date 10/28/2023) included the initial comprehensive assessment, which evidenced the patient had a foam dressing on the coccyx (tailbone) and right hip for preservation of skin integrity. The initial POC for certification period 10/28/2023 - 1/25/2024, failed to evidence treatment orders for the use of the dressings. 3. The clinical record for Patient #12 (EOB date 10/04/2023) included the initial POC for certification period 10/04/2023 - 1/01/2024, which evidenced interventions to mitigate skin breakdown included use of "skin barriers". The POC failed to include treatment orders for the type or frequency for the use of skin barrier(s). 4. A home visit was observed on 11/16/2023 at 11:00 AM with Patient #13, Registered Nurse (RN) 3, and Person 9 (group home caregiver). Person 9 indicated the patient was on a pureed diet with honey thick liquids (downgrade, thicker than nectar thick), indicated Person 8 authorized that change, and RN 3 indicated she was not aware the change was made, or who made it. RN 3 indicated the only routine medications the patient currently took included tylenol for pain, aspirin (blood thinner), bumetanide (to treat fluid retention), and potassium (supplement), due to the difficulty swallowing. Morphine was not observed in the home. The clinical record for Patient #13 (EOB date 7/26/2022) included A Skilled Nurse (SN) visit note dated 11/15/2023, which evidenced the patient was prescribed morphine (narcotic pain relief), it was dispensed 9/28/2023, and the RN performed a count of the medication. The clinical record failed to evidence morphine was prescribed or dispensed to the patient on 9/28/2023. An updated plan of care dated 11/27/2023, which evidenced morphine was not prescribed until 11/16/2023, and failed to evidence the patient's diet was pureed with now honey thick liquids, or the medications included use of bumetanide or potassium. 5. A home visit was observed on 11/15/2023 at 9:30 AM with Patient #14 and Home Health Aide (HHA) 9 at Entity 11 (long term care facility). Patient had a pain patch on the left hip and right front chest, wore oxygen which delivered 3.5 liters per minute (LPM), Person 12 (Licensed Practical Nurse [LPN] at Entity 11) indicated wound care to the right inner hip/groin area was application of silicone cream and cover with a dry dressing. After the home visit occurred, Entity 11 submitted medication and treatment administration records (date range 11/01/2023 - 11/15/2023) for Patient #14, which evidenced but not limited to blood sugar levels were checked/monitored weekly, and notify physician for readings below 60 or greater than 360; blood sugar levels were checked as needed for signs/symptoms of high/low blood sugar as needed, and notify physician for readings below 60 or greater than 400; Percocet (narcotic pain relief medication) every 4 hours as needed, gabapentin (to treat nerve pain) 900 mg 3 times daily, and lidocaine topical patch (pain relief) to right shoulder and left thigh. The clinical record for Patient #14 (EOB date 6/02/2023) included an updated POC dated 11/06/2023, for certification period 8/31/2023 - 11/28/2023, which evidenced Percocet every 4 hours scheduled (not as needed), gabapentin 300 mg (not 900 mg) 3 times daily, lidocaine topical patch (pain relief) to right shoulder (not also left thigh), and parameters to call physician for weekly blood sugar monitoring was less than 70 or greater than 250 (not below 60 or greater than 360). The updated POC also failed to evidence treatment orders for the right inner hip. 6. A home visit was observed on 11/15/2023 at 12:00 PM with Patient #15 and RN 2. Family indicated they were soaking the patient's feet and using an "electronic pulser" to help with ingrown toenail on left great toe, and reddened right 5th toe. Family indicated the patient's only routine (scheduled) medications were valsartan (to treat high blood pressure), loperamide (anti-diarrheal), and oxybutynin (to control overactive bladder). Family indicated they haven't given the other medications because patient can't swallow them, and medications were crushed and administered in yogurt. The clinical record for Patient #15 (EOB date 8/24/2023) included an updated POC dated 11/13/2023 for certification period 8/24/2023 - 11/21/2023. The medication list failed to evidence the patient no longer took scheduled aspirin, multivitamin, or pantoprazole (to reduce acid reflux), medications were crushed and administered in yogurt, or treatments included soaking of the feet or use of "electronic pulser." 1. An agency policy dated 8/30/2023, titled "The Plan of Care", evidenced an individualized POC would be established and maintained for each patient, and would include medications and treatments. 2. 5. A home visit was observed on 11/15/2023 at 9:30 AM with Patient #14 and Home Health Aide (HHA) 9 at Entity 11 (long-term care facility). Patient had a pain patch on the left hip and right front chest, wore oxygen which delivered 3.5 liters per minute (LPM), Person 12 (Licensed Practical Nurse [LPN] at Entity 11) indicated wound care to the right inner hip/groin area was application of silicone cream and cover with a dry dressing. After the home visit occurred, Entity 11 submitted medication and treatment administration records (date range 11/01/2023 - 11/15/2023) for Patient #14, which evidenced but not limited to blood sugar levels were checked/monitored weekly, and notify physician for readings below 60 or greater than 360; blood sugar levels were checked as needed for signs/symptoms of high/low blood sugar as needed, and notify physician for readings below 60 or greater than 400; Percocet (narcotic pain relief medication) every 4 hours as needed, gabapentin (to treat nerve pain) 900 mg 3 times daily, and lidocaine topical patch (pain relief) to right shoulder and left thigh. The clinical record for Patient #14 (EOB date 6/02/2023) included an updated POC dated 11/06/2023, for certification period 8/31/2023 - 11/28/2023, which evidenced Percocet every 4 hours scheduled (not as needed), gabapentin 300 mg (not 900 mg) 3 times daily, lidocaine topical patch (pain relief) to right shoulder (not also left thigh), and parameters to call physician for weekly blood sugar monitoring was less than 70 or greater than 250 (not below 60 or greater than 360). The updated POC also failed to evidence treatment orders for the right inner hip. 6. A home visit was observed on 11/15/2023 at 12:00 PM with Patient #15 and RN 2. Family indicated they were soaking the patient's feet and using an "electronic pulser" to help with ingrown toenail on left great toe, and reddened right 5th toe. Family indicated the patient's only routine (scheduled) medications were valsartan (to treat high blood pressure), loperamide (anti-diarrheal), and oxybutynin (to control overactive bladder). Family indicated they haven't given the other medications because patient can't swallow them, and medications were crushed and administered in yogurt. The clinical record for Patient #15 (EOB date 8/24/2023) included an updated POC dated 11/13/2023 for certification period 8/24/2023 - 11/21/2023. The medication list failed to evidence the patient no longer took scheduled aspirin, multivitamin, or pantoprazole (to reduce acid reflux), medications were crushed and administered in yogurt, or treatments included soaking of the feet or use of "electronic pulser." During a home visit on 11/15/2023 at 1:00 PM, Patient #17 was observed to have a foley catheter (a tube inserted through the urethra to drain the bladder). A review of the plan of care for certification period 10/17/2023 to 1/14/2024 failed to evidence when the catheter was to be changed and foley catheter care. During an interview on 11/16/2023 at 12:59 PM, Administrative Staff 2 indicated the plan of care should include the type and size of catheter used, instruction on when to replace the catheter, and foley catheter care.

Based on observation, record review, and interview, the hospice agency failed to ensure the patient's plan of care (POC) included all medical supplies and/or equipment necessary for 2 of 21 active clinical records reviewed (Patient #8, 14). The findings include: --- 1. An agency policy dated 8/30/2023, titled "The Plan of Care", evidenced an individualized POC would be established and maintained for each patient, and would include equipment and medical supplies. 2. The clinical record for Patient #8, Election date 10/28/2023, included an initial comprehensive assessment dated 10/28/23, which evidenced the patient had a foam dressing on the coccyx (tailbone) and right hip for preservation of skin integrity. The initial POC for the certification period 10/28/2023 - 1/25/2024, failed to evidence foam dressing supplies. 3. A visit was conducted on 11/15/2023 at 9:30 AM at Patient #14's home. The patient wore oxygen which delivered 3.5 liters per minute (LPM), a small superficial wound was noted to the right inner hip, and Person 12 (Licensed Practical Nurse [LPN] at Entity 11) indicated wound care to the right inner hip/groin area was an application of silicone cream and cover with a dry dressing. A review of Patient #14's updated plan of care for the certification period 8/31/2023 - 11/28/2023, failed to evidence supplies/equipment needed for administration of oxygen and supplies for wound care.

Based on record review and interview, the hospice agency failed to ensure the patient's plan of care (POC) included interventions for a patient who had increased difficulty swallowing for 1 of 21 active clinical records reviewed in a sample of 24. The findings include: --- A policy dated 8/30/2023, titled "The Plan of Care", evidenced an individualized POC would be established and maintained for each patient, based on the initial, comprehensive, and ongoing assessments, discomfort, and symptom relief. The clinical record for Patient #15 (Election date 8/24/2023) included an initial POC for the certification period 8/24/2023 - 11/21/2023, which evidenced that the patient's primary diagnosis for hospice services was Other Cerebral Infarction due to occlusion or stenosis of small artery (stroke). A coordination note dated 10/11/2023 indicated an RN visit was made, the family reported the patient had increased difficulty swallowing and reported he/she was thickening the patients liquids. A coordination note dated 10/25/2023 indicated an RN visit was made, and the patient experienced coughing while eating a regular diet. A coordination note dated 11/01/2023 indicated an RN visit was made, the family reported patient was having trouble swallowing food. RN suggested giving soft foods. A coordination note dated 11/09/2023 indicated an RN visit was made, the patient had difficulty swallowing. A coordination note dated 11/22/2023 indicated an RN visit was made, the family reports increased difficulty swallowing medications and is crushing most medications at this time. A review of the IDG plan of care update report dated 10/23/23 failed to evidence discussion and interventions regarding the patient's increase in difficulty swallowing. A review of the IDG plan of care update report dated 11/6/23 and 11/13/23 evidenced the patient having trouble swallowing but failed to evidence interventions. During an interview on 11/15/2023 at 2:36 PM, RN 2 indicated family just mentioned the patients trouble swallowing during the past couple of visits, and if it continued, he/she could consult with the supervisor for a dietary consult, and didnt know if they could do that or not. RN 2 indicated he/she thought the family crushed medications and gave them something soft.

Based on observation, record review, and interview, the hospice agency failed to ensure all patients received the care and/or services needed for 6 of 6 active clinical records reviewed for patients and/or caregivers with identified additional needs (Patient #5, 8, 11, 12, 13, 15), which had the potential to affect all agency patients. The findings include: --- A review of the clinical record for Patient #5 included a triage note dated 11/18/2023. The note indicated a nurse from Patient #5s nursing home called to report the patients urine was dark brown. The triage note continued indicated ";... nurse visit advised for change in condition." A note from the on-call nurse also dated 11/18/2023, indicated they called the nursing home and spoke to a nurse. The on-call nurse advised Patient #5s urine was dark as they were not drinking enough fluids, and they should encourage the patient to drink more fluids. The next nursing visit with Patient #5 occurred on 11/20/2023, two days after the triage call. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated a visit should occur if recommended by triage to address the concerns. A review of the clinical record for Patient #11, benefit election date 9/28/2023, identified diagnoses which included, but not limited to, lung cancer with metastasis to the bones. The record identified triage coordination notes for problems after hours. A nurse visit note for 10/4/2023 at 8:54 PM, completed by licensed practical nurse (LPN) 5, indicated Patient #11 had a bloody nose that continued to bleed. According to the note, Patient #11 removed the cotton ball the nurse used to staunch the blood flow. LPN 5 then inserted a tampon into Patient 11s nostril and told patient to keep it there until morning. The LPN left 3 additional tampons to be used if nose continued to bleed. A triage note dated 10/5/2023 at 1:33 AM, indicated Patient #11s nose continued to bleed. The caller indicated they had used a total of 6 tampons in approximately 4 hours and Patient #11s nose continued to bleed. The triage note indicated a visit was advised. The clinical record failed to evidence a note for a nursing visit on 10/5/2023. A triage note dated 10/8/2023 at 11:20 AM indicated Patient #11 was short of breath and had already taken all the routine and PRN (taken as needed) medications. The triage note indicated a visit was advised. The clinical record failed to evidence a note for a nursing visit on 10/8/2023. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated visits should have occurred since the triage nurse advised it. A review of an agency policy on nursing care indicated the registered nurse case manager (RNCM) was responsible to determine the care needs of the patient and / or caregivers needs. The policy also indicates the RN was responsible to facilitate changes to the level of care based on the patient and / or caregiver's needs. A review of the clinical record for Patient #11 evidenced a nursing visit note dated 10/6/2023 indicated Patient #11s spouse was interested in respite care ";... for better pain management and time to locate additional paid PCG [patient care giver] ..." A nursing visit note for 10/20/2023 indicated Patient #11 was in a facility for a respite stay. Respite stay began 10/19/2023, 13 days after the spouse requested respite. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated there is no specific time frame required to put someone into respite. When asked, the Administrator indicated they do not place patients in respite for pain management. When documentation of a discussion of general inpatient care (used for pain and symptom management), the Administrator was unable to provide any. When documentation of social work involvement to assist with finding caregiver options was requested, the Administrator indicated the family had declined social work services at the time of admission. When asked if the family was educated about the assistance a social worker could provide, at the time the family expressed the need, the Administrator indicated there was no documentation of the education. 1. The clinical record for Patient #8 (election of benefit [EOB] date 10/28/2023) included the initial comprehensive assessment, which evidenced the patient was confused, high risk for falls, unable to ambulate without assistance, had a foam dressing on the coccyx (tailbone) and right hip for preservation of skin integrity, was incontinent of bowel and bladder, wore adult briefs, and had a recent UTI. The initial Medical Social Worker (MSW) evaluation, dated 10/28/2023, indicated caregiver was inadequate/unreliable, safety hazards included unsafe floor coverings, unsafe electrical cords/devices, cluttered/soiled living area, respite placement was needed, Patient would be placed at Entity 7 (long term care facility), and MSW 3 would set up a respite stay toward the end of the week to assist in meeting patient care until Medicaid was approved. During an interview on 11/28/2023 at 11:28 AM, MSW 3 indicated if respite was determined to be needed immediately, they tried to have it done within 24 hours or sooner; interventions for signs of potential neglect of caregivers to a patient who was cognitively impaired included an assessment of home for safety, ensure pathways were clear, have access to food/water, ability to make own food or someone who will, and ensure caregiver was willing to provide care. 2. The clinical record for Patient #12 (EOB date 10/04/2023) included the initial comprehensive assessment, which evidenced other conditions contributing to terminal diagnosis included but not limited to colitis (inflammation of the lining of the intestines, requiring special nutritional considerations); patient required a mechanical soft diet (chopped consistency) due to observed pocketing (food remains in the mouth between taking bites or after a meal is done), diet was quite restrictive and patient was unable to tolerate many food choices provided by Entity 10 (a locked memory care facility), patient fed himself/herself, and family was open to all disciplines. The initial POC for certification period 10/04/2023 - 1/01/2024, failed to evidence referral for dietician or speech language pathology (SLP) services to determine dietary or swallowing needs/interventions to meet the patient's needs. During an interview on 11/29/2023 at 11:10 AM, the Administrator indicated they don't use SLP for every patient, and she didn't find documentation in the clinical record history and physical to verify if a SLP evaluated the patient prior to hospice admission. 3. A home visit was observed on 11/16/2023 at 11:00 AM with Patient #13, RN 3, and Person 9 (group home caregiver). Person 9 indicated the patient was on a pureed diet with honey thick liquids (downgrade to thicker than nectar thick), indicated Person 8 (owner of group home, nurse practitioner, not the patient's physician, family, or power of attorney) authorized that change, and RN 3 indicated she was not aware the change was made, or who made it. RN 3 indicated the patient developed dysphagia (difficulty swallowing) after admission to hospice, there had been no referral to dietician or SLP made for assessment/management of dysphagia or diet recommendations, and the patient couldn't take a trip outside the home for the evaluation. The clinical record for Patient #13 (EOB date 7/26/2022) included the initial plan of care for certification period 7/26/2022 - 10/23/2022, which evidenced diet as tolerated. The updated plan of care dated 8/08/2022 indicated a regular diet with thin liquids. A coordination note dated and entered by Registered Nurse (RN) 3 on 9/27/2023, evidenced patient was observed eating mechanical soft lunch, but then began coughing very loudly (sign of aspiration/ingestion of food into lungs). The updated POC dated 10/02/2023, for certification period 9/19/2023 - 11/17/2023, evidenced a nursing summary entry which indicated the patient continued to decline, coughed hard with mechanical soft (chopped foods) diet/nectar thick liquids, and recommended alteration of diet to prevent aspiration (ingestion of food into lungs). The POC failed to evidence dietician or SLP was ordered. A coordination note dated and entered by RN 3 on 10/04/2023, evidenced patient still experienced cough with meals. A coordination note dated and entered by RN 3 on 10/17/2023, evidenced RN 3 sent a message to Person 8 to request a change in diet to pureed (pudding/blended consistency), and was awaiting a response. A coordination note dated and entered by RN 3 on 10/24/2023, evidenced RN 3 observed patient consume a mechanical soft meal, the patient coughed repeatedly during, and well after meal was completed. An undated comprehensive care plan report received on 11/20/2023 evidenced the patient's diet was changed to puree with nectar thick liquids on 10/24/2023 (27 days after documented sign of aspiration). 4. A home visit was observed on 11/15/2023 at 12:00 PM with Patient #15 and RN 2. Family indicated she was very overwhelmed with everything, and she has been since the whole hospice process started; the patient never had any type of therapy after the stroke, patient developed trouble swallowing well over a month ago, and patient's diarrhea was ongoing and very hard to deal with; family was never offered SLP services, but would like patient to have it; family wanted to see the MSW more often, and were very overwhelmed; RN 2 asked family about the difficulty swallowing. During a confidential interview after the home visit, at 2:27 PM, family indicated they had to hire a private nurse who came twice weekly for 5 hours each visit, so family could go to dentist, get a massage, and "stuff like that". Family indicated RN 2 was aware of the hiring and indicated MSW 1 could help, but that was the end of that. The clinical record for Patient #15 (EOB date 8/24/2023) included an initial comprehensive assessment, which indicated family was open to volunteer visits. The clinical record failed to evidence volunteer service visits occurred. A "Coordination Notes Report" for date range 8/25/2023 - 11/22/2023 evidenced the following entries: 8/31/2023: RN visit made and family very anxious in regard to many issues. 9/22/2023: MSW visit made and family not feeling well because he/she was somewhat overwhelmed with caregiving, and was not sleeping well. 9/25/2023: Licensed Practical Nurse (LPN) visit made and family indicated they were anxious about several things. 9/30/2023: Family indicated patient just sustained a fall, and emergency medical services (EMS) came to help get the patient up. 10/03/2023: RN visit made, and family informed RN about recent fall, patient was walking and right leg went out from under her. Family thought patient had a transient ischemic attack (TIA, or mini-stroke), and speech was garbled for several minutes, but returned to normal after several hours. 10/11/2023: RN visit made, and family reported patient had signs of pain in right leg while walking, reported increased difficulty swallowing, and reported she was thickening liquids. The clinical record failed to evidence SLP was ordered. 10/18/2023: RN made visit, and family reported they were fatigued, had questions about respite care, and RN made referral for MSW to follow up with respite and volunteer to provide caregiver with some free time. The clinical record failed to evidence respite or volunteer services was provided. 10/25/2023: RN visit made, and patient experienced coughing with eating regular diet. The clinical record failed to evidence SLP was ordered. 10/27/2023: MSW made, family tearful upon arrival, family will be in from out of town, many going out to dinner, but family just too overwhelmed to go out with them. Family reported they hired a private pay nurse ten hours per week starting next week to give family relief. The clinical record failed to evidence respite or volunteer services was provided. 11/01/2023: RN visit made, family reported patient continued to have diarrhea most days, and having trouble swallowing foods. RN suggested to give soft foods. The clinical record failed to evidence SLP was ordered. 11/09/2023 RN visit made, patient had 2 falls since admission to hospice, and has difficulty swallowing. The clinical record failed to evidence SLP was ordered. 11/22/2023: RN visit made, family reports increased difficulty swallowing medications and is crushing most medications at this time. The clinical record failed to evidence SLP was ordered. During an interview on 11/15/2023 at 2:36 PM, RN 2 indicated family just mentioned the patient's trouble swallowing during the past couple visits, he/she guessed if it continued, he/she could talk to the supervisor for a dietary consult, and didn't know if they could do that or not; services provided included but not limited to SLP and dietician; he/she thought family crushed medications and gave with something soft, and wasn't sure if the patient's issues were discussed in IDG. 1. The clinical record for Patient #8 Election date 10/28/2023 included the initial comprehensive assessment, which evidenced the patient was confused, high risk for falls, unable to ambulate without assistance, had a foam dressing on the coccyx (tailbone) and right hip for preservation of skin integrity, was incontinent of bowel and bladder, wore adult briefs, and had a recent UTI. The initial Medical Social Worker (MSW) evaluation, dated 10/28/2023, indicated caregiver was inadequate/unreliable, safety hazards included unsafe floor coverings, unsafe electrical cords/devices, cluttered/soiled living area, respite placement was needed, Patient would be placed at Entity 7 (long term care facility), and MSW 3 would set up a respite stay toward the end of the week to assist in meeting patient care until Medicaid was approved. During an interview on 11/28/2023 at 11:28 AM, MSW 3 indicated if respite was determined to be needed immediately, they tried to have it done within 24 hours or sooner; interventions for signs of potential neglect of caregivers to a patient who was cognitively impaired included an assessment of home for safety, ensure pathways were clear, have access to food/water, ability to make own food or someone who will, and ensure caregiver was willing to provide care. 2. The clinical record for Patient #12 Election date 10/04/2023 included the initial comprehensive assessment, which evidenced other conditions contributing to terminal diagnosis including but not limited to colitis (inflammation of the lining of the intestines, requiring special nutritional considerations); patient required a mechanical soft diet (chopped consistency) due to observed pocketing (food remains in the mouth between taking bites or after a meal is done), diet was quite restrictive and patient was unable to tolerate many food choices provided by Entity 10 (a locked memory care facility), patient fed himself/herself, and family was open to all disciplines. The initial POC for benefit period 10/04/2023 - 1/01/2024, failed to evidence referral for a dietician or speech-language pathology (SLP) services to determine dietary or swallowing needs/interventions to meet the patient's needs. During an interview on 11/29/2023 at 11:10 AM, the Administrator indicated they don't use SLP for every patient, and she didn't find documentation in the clinical record history and physical to verify if a SLP evaluated the patient prior to hospice admission. 3. A home visit was conducted on 11/16/2023 at 11:00 AM with Patient #13, RN 3, and Person 9 (group home caregiver). Person 9 indicated the patient was on a pureed diet with honey thick liquids (downgrade to thicker than nectar thick), and indicated Person 8 (owner of group home, nurse practitioner, authorized that change. RN 3 indicated she was not aware the change was made, or who made it. RN 3 indicated the patient developed dysphagia (difficulty swallowing) after admission to hospice, there had been no referral to dietician or SLP made for assessment/management of dysphagia or diet recommendations, and the patient couldn't take a trip outside the home for the evaluation. The clinical record for Patient #13 Election date 7/26/2022 included the initial plan of care for benefit period 7/26/2022 - 10/23/2022, which evidenced diet as tolerated. The updated plan of care dated 8/08/2022 indicated a regular diet with thin liquids. A coordination note dated and entered by Registered Nurse (RN) 3 on 9/27/2023, evidenced patient was observed eating mechanical soft lunch, but then began coughing very loudly (sign of aspiration/ingestion of food into lungs). The updated POC dated 10/02/2023, for certification period 9/19/2023 - 11/17/2023, evidenced a nursing summary entry which indicated the patient continued to decline, coughed hard with mechanical soft (chopped foods) diet/nectar thick liquids, and recommended alteration of diet to prevent aspiration (ingestion of food into lungs). The POC failed to evidence dietician or SLP was ordered. A coordination note dated and entered by RN 3 on 10/04/2023, evidenced patient still experienced cough with meals. A coordination note dated and entered by RN 3 on 10/17/2023, evidenced RN 3 sent a message to Person 8 to request a change in diet to pureed (pudding/blended consistency), and was awaiting a response. A coordination note dated and entered by RN 3 on 10/24/2023, evidenced RN 3 observed patient consume a mechanical soft meal, the patient coughed repeatedly during, and well after meal was completed. An undated comprehensive care plan report received on 11/20/2023 evidenced the patient's diet was changed to puree with nectar thick liquids on 10/24/2023 (27 days after documented sign of aspiration). 4. A home visit was observed on 11/15/2023 at 12:00 PM with Patient #15 and RN 2. Family indicated she was very overwhelmed with everything, and she has been since the whole hospice process started; the patient never had any type of therapy after the stroke, patient developed trouble swallowing well over a month ago, and patient's diarrhea was ongoing and very hard to deal with; family was never offered SLP services, but would like patient to have it; family wanted to see the MSW more often, and were very overwhelmed; RN 2 asked family about the difficulty swallowing. During a confidential interview after the home visit, at 2:27 PM, family indicated they had to hire a private nurse who came twice weekly for 5 hours each visit, so family could go to dentist, get a massage, and "stuff like that". Family indicated RN 2 was aware of the hiring and indicated MSW 1 could help, but that was the end of that. The clinical record for Patient #15 (EOB date 8/24/2023) included an initial comprehensive assessment, which indicated family was open to volunteer visits. The clinical record failed to evidence volunteer service visits occurred. A "Coordination Notes Report" for date range 8/25/2023 - 11/22/2023 evidenced the following entries: 8/31/2023: RN visit made and family very anxious in regard to many issues. 9/22/2023: MSW visit made and family not feeling well because he/she was somewhat overwhelmed with caregiving, and was not sleeping well. 9/25/2023: Licensed Practical Nurse (LPN) visit made and family indicated they were anxious about several things. 9/30/2023: Family indicated patient just sustained a fall, and emergency medical services (EMS) came to help get the patient up. 10/03/2023: RN visit made, and family informed RN about recent fall, patient was walking and right leg went out from under her. Family thought patient had a transient ischemic attack (TIA, or mini-stroke), and speech was garbled for several minutes, but returned to normal after several hours. 10/11/2023: RN visit made, and family reported patient had signs of pain in right leg while walking, reported increased difficulty swallowing, and reported she was thickening liquids. The clinical record failed to evidence SLP was ordered. 10/18/2023: RN made visit, and family reported they were fatigued, had questions about respite care, and RN made referral for MSW to follow up with respite and volunteer to provide caregiver with some free time. The clinical record failed to evidence respite or volunteer services was provided. 10/25/2023: RN visit made, and patient experienced coughing with eating regular diet. The clinical record failed to evidence SLP was ordered. 10/27/2023: MSW made, family tearful upon arrival, family will be in from out of town, many going out to dinner, but family just too overwhelmed to go out with them. Family reported they hired a private pay nurse ten hours per week starting next week to give family relief. The clinical record failed to evidence respite or volunteer services was provided. 11/01/2023: RN visit made, family reported patient continued to have diarrhea most days, and having trouble swallowing foods. RN suggested to give soft foods. The clinical record failed to evidence SLP was ordered. 11/09/2023 RN visit made, patient had 2 falls since admission to hospice, and has difficulty swallowing. The clinical record failed to evidence SLP was ordered. 11/22/2023: RN visit made, family reports increased difficulty swallowing medications and is crushing most medications at this time. The clinical record failed to evidence SLP was ordered. During an interview on 11/15/2023 at 2:36 PM, RN 2 indicated family just mentioned the patient's trouble swallowing during the past couple visits, he/she guessed if it continued, he/she could talk to the supervisor for a dietary consult, and didn't know if they could do that or not; services provided included but not limited to SLP and dietician; he/she thought family crushed medications and gave with something soft, and wasn't sure if the patient's issues were discussed in IDG. 5. A review of the clinical record for Patient #5 included a triage note dated 11/18/2023. The note indicated a nurse from Patient #5s nursing home called to report the patients urine was dark brown. The triage note continued indicated ";... nurse visit advised for change in condition." A note from the on-call nurse also dated 11/18/2023, indicated they called the nursing home and spoke to a nurse. The on-call nurse advised Patient #5s urine was dark as they were not drinking enough fluids, and they should encourage the patient to drink more fluids. The next nursing visit with Patient #5 occurred on 11/20/2023, two days after the triage call. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated a visit should occur if recommended by triage to address the concerns. A review of the clinical record for Patient #11, benefit election date 9/28/2023, identified diagnoses which included, but not limited to, lung cancer with metastasis to the bones. The record identified triage coordination notes for problems after hours. A nurse visit note for 10/4/2023 at 8:54 PM, completed by licensed practical nurse (LPN) 5, indicated Patient #11 had a bloody nose that continued to bleed. According to the note, Patient #11 removed the cotton ball the nurse used to staunch the blood flow. LPN 5 then inserted a tampon into Patient 11s nostril and told patient to keep it there until morning. The LPN left 3 additional tampons to be used if nose continued to bleed. A triage note dated 10/5/2023 at 1:33 AM, indicated Patient #11s nose continued to bleed. The caller indicated they had used a total of 6 tampons in approximately 4 hours and Patient #11s nose continued to bleed. The triage note indicated a visit was advised. The clinical record failed to evidence a note for a nursing visit on 10/5/2023. 6. A triage note dated 10/8/2023 at 11:20 AM indicated Patient #11 was short of breath and had already taken all the routine and PRN (taken as needed) medications. The triage note indicated a visit was advised. The clinical record failed to evidence a note for a nursing visit on 10/8/2023. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated visits should have occurred since the triage nurse advised it. A review of an agency policy on nursing care indicated the registered nurse case manager (RNCM) was responsible to determine the care needs of the patient and / or caregivers needs. The policy also indicates the RN was responsible to facilitate changes to the level of care based on the patient and / or caregiver's needs. A review of the clinical record for Patient #11 evidenced a nursing visit note dated 10/6/2023 indicated Patient #11s spouse was interested in respite care ";... for better pain management and time to locate additional paid PCG [patient care giver] ..." A nursing visit note for 10/20/2023 indicated Patient #11 was in a facility for a respite stay. Respite stay began 10/19/2023, 13 days after the spouse requested respite. During an interview on 11/28/2023 at 1:30 PM, the Administrator indicated there is no specific time frame required to put someone into respite. When asked, the Administrator indicated they do not place patients in respite for pain management. When documentation of a discussion of general inpatient care (used for pain and symptom management), the Administrator was unable to provide any. When documentation of social work involvement to assist with finding caregiver options was requested, the Administrator indicated the family had declined social work services at the time of admission. When asked if the family was educated about the assistance a social worker could provide, at the time the family expressed the need, the Administrator indicated there was no documentation of the education.

Based on record review and interview, the hospice failed to ensure information was shared between all disciplines caring for the patient in 1 of 1 patient reviewed that received physical therapy services (Patient #17), and 1 of 1 active clinical records reviewed where a patient requested a post-fall nursing visit (Patient #15). The findings include: --- A home visit was observed on 11/15/2023 at 12:00 PM with Patient #15 and RN 2. Family indicated patient fell on 9/29/2023, family called and received non-emergency lift assist, and non-emergency personnel instructed family to call hospice for follow up. Family called hospice at that time, indicated they spoke to office staff 5, office staff 5 indicated they'd let the nurse know. Family indicated it was early enough in the afternoon for a nurse to be notified and provide a visit. Family indicated patient wasn't seen for 5 days, and this was the time period when patient was transitioning from RN 1 to RN 2 to provide care. RN 2 apologized to family and indicated no one told her about the fall. The clinical record for Patient #15 evidenced the patient's hospice diagnosis was stroke, a nursing visit occurred on 9/28/2023 by RN 1, and failed to evidence communication occurred from office staff 5 to RN 1 or RN 2 on 9/29/2023. A coordination note dated 9/30/2023 evidenced HHA 2 was told by family that patient had fallen, and failed to evidence RN 1 or RN 2 was notified. A coordination note dated 10/03/2023 evidenced a home visit was made by RN 2, family reported fall occurred 9/29/2023, and thought patient might have had a transient ischemic attack (TIA/mini-stroke), which caused the fall. During an interview on 11/15/2023 at 3:10 PM, the Administrator indicated office staff 5's job duties were medical records and answering incoming calls. The plan of care for benefit period 0/17/2023 to 1/14/2023 evidenced Patient #17 was receiving physical therapy and the nurse was to collaborate care with the physical therapist to meet the patients needs. The patients record failed to evidence any coordination of care with the contracted physical therapist. During an interview on 11/15/2023 at 1:22, RN (Registered Nurse) 9 indicated Patient #17 had received physical therapy for a few weeks, and she never communicated with the physical therapist. During an interview on 11/16/2023 at 12:23 PM, Administrative Staff 2 indicated care communication was conducted by the physical therapist when they sent their documentation to the agency office, and by staff talking to Patients family about how therapy was going.

Based on record review and interview, the hospice agency failed to ensure its Quality Assessment and Performance Improvement (QAPI) program demonstrated measurable improvement in indicators related to improved palliative outcomes; measured, analyzed, and/or track quality indicators; identified agency-specific quality indicator data elements; used data collected to monitor effectiveness of care or identified opportunities and priorities for improvement; performance improvement (PI) activities focused on high risk, high volume, and/or problem-prone areas; considered incidence, prevalence, and/or severity of problems identified; program activities positively affected palliative outcomes, patient safety, and/or quality of care; analysis of cause(s) and implementation of preventative actions related to adverse patient events; took actions aimed at performance improvement, implemented actions, measured for success or tracked performance; developed, implemented, and/or evaluated performance improvement projects (PIPs). The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate care and services, which could result in the agency not providing quality health care, thus being out of compliance with the Condition of Participation 42 CFR §418.58: Quality Assessment and Performance Improvement (QAPI). The findings include: --- An agency policy dated 7/24/2023, titled "Gentiva - Hospice Division Quality Assessment Performance Improvement (QAPI) Plan 2023", evidenced program objectives included but were not limited to measuring, analyzing, and tracking quality indicators including adverse events, incidents including medication errors, falls, safety issues, and others; responsibilities of the Administrator included but not limited to maintaining a systematic review of indicators related to adverse events; program activities included but not limited to identifying trends per location identified needs, such as pain and symptom management, and provision of services appropriate to patient needs; the plan involved 2 primary activities: measuring and assessing performance of clinical services via collection and analysis of data, and conducting quality improvement initiatives and taking action where indicated, including improvement of services; program performance measurement activities included selection of performance indicators based on high volume, problem-prone, or high risk areas; program activities included to show measurable improvement in palliative outcomes (improvement of quality of life), improvement of quality of care, and patient safety, and program improvement initiatives included a Performance Improvement Plan which focused on preventing problems and improving current systems and services, measure, analyze and track quality indicators, and monitor the effectiveness. QAPI meeting minutes for the first quarter (January - March) of 2023 evidenced 12 complaints were received (from one or more patients, caregivers, and/or employees), complaints were "down" from the previous quarter, and failed to evidence percentage of each complaint made by patient, caregiver, or employee, type/analysis of complaint(s)/concern(s), or threshold for success; the minutes evidenced 283 incidents were reported for the quarter, all incidents involved patients, incidents included falls with/without injury, medication errors, wounds, and "other" (not further specified), failed to evidence analysis included which incidents were identified as adverse events (patient harm occurred), cause(s) of events, or implementation of preventative actions, the percentage of incidents/adverse events with patients in a home setting, long term care setting, or assisted living/group home setting to identify potential trends, and failed to evidence a threshold for success was analyzed. The plan also failed to evidence effectiveness and safety were analyzed based on the data, or that it identified a plan to improve negative outcomes. QAPI meeting minutes for the second quarter (April - June) of 2023 evidenced 17 complaints were received (15 from patient/caregiver, and 2 from contracted facility/facilities) compared to 11 complaints (an increase of 6) from the previous quarter, and failed to evidence type/analysis of complaints, or threshold for success; the minutes evidenced 392 occurrences (391 patient/caregiver, 1 employee) were reported for the quarter versus 299 the previous quarter (increase of 93), failed to evidence the types/ percentages/ analysis of occurrences, or threshold for success, and failed to evidence analysis included which incidents were identified as potential adverse events, cause(s) of events, or implementation of preventative actions. The plan also failed to evidence effectiveness and safety were analyzed based on the data, or that it identified a plan to improve negative outcomes. Complaint, Infection, and incident logs for parent and all multiple site locations for the date range June 2023 - 11/14/2023, received on 11/14/2023, revealed: of 298 current patients, 28 complaints, 356 infections, 103 falls with injury, and 259 new wounds occurred. A random patient sample (Patient #25) developed 5 new wounds between 5/03/2023 – 6/29/2023. The logs all failed to evidence the types, percentages, and/or analysis of occurrences, or threshold for success. Quarterly QAPI meeting minutes for the first (January - March), second (April - June), and third (July - September) quarters of 2023 all failed to evidence activities improved palliative outcomes, patient safety, or quality of care. During an interview on 11/13/2023 at 2:47 PM, the Medical Director indicated they were involved with QAPI all the time, and didn't know what agency-specific data elements the agency used to determine measurable progress to goals. During an interview on 11/14/2023 at 10:00 AM, the Administrator indicated she did not have complaints, incidents, or infection logs from the multiple site locations. During an interview on 11/17/2023 at 11:38 AM, the Administrator indicated the standardized data elements the agency used to allow for measurement of outcomes was their QAPI program, nothing stood out that there were any significant trends recently, and the 3rd quarter template was still in progress. The Administrator indicated nothing in the QAPI program identified any recent trends, and the QAPI program was created at the corporate level for all owned hospice agencies. The Administrator indicated examples of data elements assessed during the comprehensive assessment including but not limited to fall risk assessment and the Braden scale for risk of skin breakdown skin, they presented the information during the interdisciplinary group (IDG) meetings, and at the time of admission it was presented to the physician, and they reviewed QI logs each month and tracked to see if there were any trends. They reviewed incident logs each month to identify any trends, and the data wasn't broken down to identify the prevalence of falls that occurred in home versus long-term care or assisted living facilities (to identify potential trends in a particular home setting). The Administrator indicated they tracked quality improvement reports, complaints, incidents, and infections, and indicated those reports were analyzed to see if there were any trends or things like that; when there was an occurrence, they would assess the environment, see if additional education was needed, provide community resources, and provide education. The Administrator indicated they would like to find out the root cause of live discharges, several of them (live discharges) were extended prognosis, by no longer meeting hospice criteria, and actions taken were being reviewed at their business development operations meetings to be able to provide community education to refer at appropriate times. During an interview on 11/17/2023 at 3:10 PM, the Administrator indicated high-risk patients weren't addressed in the QAPI program, and they didn't track data elements from the comprehensive assessments. The Administrator indicated they didn't think high-risk data was noted in QAPI, and they didn't track risks or problems identified on the comprehensive assessments. During an interview on 11/27/2023 at 11:15 AM, the Administrator indicated between 11/22/2023 - 11/24/2023 (as a result of an Immediate Jeopardy and part of the removal plan), they completed audits on all wound records, reassessed all current patients for the presence of wounds, and indicated analysis of data collected revealed a "few" new wounds. The Administrator indicated they didn't have data on the total number, type(s), or any potential trends identified. During an interview on 11/27/2023 at 2:07 PM, the Administrator indicated, they assessed/identified 50 new wounds that were previously undocumented, and had no further data on the total number, type(s), or any potential trends identified.

Based on observation, record review and interview, the agency failed to ensure standard precautions were followed to reduce the risk of infection in 2 of 2 (Patients #13 and 18) home visit observations for wound care, with the potential to affect all wound care patients. Findings include: --- 3. A home visit was observed on 11/16/2023 at 11:00 AM - 12:20 PM with Patient #13, RN 3, and Person 9 (group home caregiver). RN 3 removed a soiled dressing, cleansed the wound, and failed to remove dirty gloves, perform hand hygiene, and don clean gloves prior to applying a clean dressing to the wound. RN 3 then indicated she should have changed her gloves after cleansing the wound, and before touching clean dressings to apply to the patient. A review of an agency infection prevention policy indicated gloves should be changed and hand hygiene (hand wash or use of hand sanitizer) completed after touching patient belongings and prior to applying a clean dressing to a wound. An observation occurred on 11/22/2023 at 11 AM with Patient #18 and registered nurse (RN) 21. RN 21 washed hands after removing the old wound dressing. RN 21 put on clean gloves. While person 1 rolled patient on the side, RN 21 adjusted Patient 18s blanket. RN 21 failed to complete hand hygiene and apply new gloves after touching Patient #18s blanket and before they applied a new wound dressing. During an interview following the observation, RN 21 indicated hand hygiene and new gloves were required prior to applying clean wound dressings. RN 21 indicated they were not aware they adjusted the patients blanket prior to the application of the new wound dressing.

Based on record review and interview, the agency failed to ensure a licensed practical nurse documented an accurate assessment for 1 of 1 clinical record of a patient (Patient #1) with a broken wrist following a fall, in a sample of 21. Findings include: --- A review of an agency policy on nursing services indicated the registered nurse (RN) supervised care provided by a licensed practical nurse (LPN) and nursing care followed accepted standards of nursing care and per the agency treatment protocols. A review of an agency policy on wound assessment indicated the details of the wound must be completed in the Integumentary Command Center (ICC), was used to track the number and status of wounds. A review of the clinical record for Patient #1 included a nursing visit note for 11/7/2023 by LPN 6, which indicated Patient #1 returned from the emergency department after a fall. A review of the nursing visit note for 11/9/1013, completed by RN 7, indicated Patient #1 suffered a broken wrist and a skin tear from the fall on 11/7/2023. The 11/7/23 LPN visit note failed to indicate Patient #1 suffered a broken wrist and a skin tear. During an interview on 11/15/2023 at 2 PM, the Administrator indicated the LPN documentation should have mentioned the injuries and the RN and IDG should have been notified immediately.

Based on record review and interview, the agency failed to oversee services provided under arrangement in 1 of 1 active patient records reviewed receiving physical therapy (Patient #17) in a sample of 21. The findings include: --- A clinical record review for the certification period 10/17/2023 to 1/14/2023 evidenced (Physical Therapist) 1 was providing care for Patient #17, starting 11/1/2023. The patients record failed to evidence any communication with the contracted physical therapist. A review of the Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of Care Update Reports dated 11/2/2023 and 11/16/2023 failed to include input from PT 1 or any information about the patients therapy. During an interview on 11/16/2023 at 12:23 PM, Administrative Staff 2 indicated care communication was conducted by the physical therapist sending in their documentation to the agency office, and by the staff talking to the patients family about how therapy is going. Administrative Staff 2 indicated patient care collaboration and updating of the plan of care to meet patient needs was done by the IDG meetings and documented in the Comprehensive Assessment and Plan of Care Update Reports.

Based on record review and interview, the agency failed to ensure each patient's record included responses to treatment in 1 of 1 patients with a foley catheter (Patient #17) in a sample of 21. The findings include: --- In an ";on call note" dated 10/21/2023, RN (Registered Nurse) 10 indicated they inserted a foley catheter (a tube inserted through the urethra to drain the bladder) into Patient #17. The note failed to evidence how the patient tolerated the procedure and a patient assessment. During an interview on 11/16/2023 at 1:01 PM, Administrative Staff 2 indicated RN 10 should have completed a full visit note including a patient assessment instead of only the ";on call note".

Upon patient record review 3 of 23 (Patient #9, #10, #12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #9: The patient admitted 08/19/2023 however, the spiritual comprehensive assessment was performed 08/28/2023. Patient #10: The patient admitted 06/08/2023 however, the spiritual comprehensive assessment was performed 09/07/2023. Patient #12: The patient admitted 03/29/2023 however, the spiritual comprehensive assessment was performed 09/27/2023.

Upon patient record review, 7 of 23 (Patient #1, #3, #5, #6, #8, #12, #15) 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 #1: The medication profile listed diclofenec 1% topical gel to affected joint without evidence of specific joint(s). In addition, listed oxygen at 3lpm via nasal cannula however, the nurse noted on 08/31 patient was using at 1lpm and on 09/19 patient was using at 4lpm. corrected on site Patient #3: The medication profile listed remedyphytoplex z-guard PRN for stage 2 on buttocks however, wound was no longer active. corrected on site Patient #5: The medication profile listed oxygen at 2lpm via nasal cannula continuous however, the nurse noted on 09/21 that patient was using oxygen 2-4lpm. corrected on site Patient #6: The medication profile listed oral anesthetic 20%, apply small pea size over gums and affected area without evidence of specifics on specific area(s). corrected on site Patient #8: The medication profile listed oxygen/CPAP with oxygen at 2lpm infused t/cpap at HS however, there was no evidence of CPAP settings. In addition, on 09/07 nurse noted she encourage patient to used nebulizer however, there was no evidence of an inhalation medication on profile. corrected on site Patient #12: The nurse documented patient was using pulmicort on 09/09, 09/16, and 09/23 however, this was not included on medication profile. corrected on site Patient #15: The medication profile listed oxygen 2lpm PRN by mouth which was not an appropriate route. corrected on site

Upon patient record review, 1 of 23 (Patient #9) 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 #9: The patient admitted 08/19/2023 however, the bereavement assessment was not complete until 08/28/2023

Upon patient record review, 7 of 23 (Patient #1, #3, #5, #6, #8, #12, #15) 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 order for diclofenec 1% topical gel to affected joint did not contain evidence of specific joint(s). In addition, oxygen at 3lpm via nasal cannula was ordered however, the nurse noted on 08/31 patient was using at 1lpm and on 09/19 patient was using at 4lpm. corrected on site Patient #3: The order for remedyphytoplex z-guard PRN for stage 2 on buttocks however, wound was no longer active and order was still active. corrected on site Patient #5: The oxygen at 2lpm via nasal cannula continuous was ordered however, the nurse noted on 09/21 that patient was using oxygen 2-4lpm. corrected on site Patient #6: The order for oral anesthetic 20%, apply small pea size over gums and affected area did not contain evidence of specifics on specific area(s). corrected on site Patient #8: The order for oxygen/CPAP with oxygen at 2lpm infused t/CPAP at HS did not contain evidence of CPAP settings. In addition, on 09/07 nurse noted she encourage patient to used nebulizer however, there was no evidence of an inhalation medication order. corrected on site Patient #12: The nurse documented patient was using pulmicort on 09/09, 09/16, and 09/23 however, there was no evidence of an order for this medication. corrected on site Patient #15: The order for oxygen 2lpm PRN by mouth which was not an appropriate route. corrected on site

Upon patient record review, 3 of 23 (Patient #1, #8, #9) 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 #1: The nurse note on 09/11 documents patient using a wheelchair however, this was not listed on the plan of care. corrected on site Patient #8: Upon home visit it was noted the patient was using an electric scooter however, this was not listed on the plan of care. In addition, it was noted on nurse note she encourage patient to use nebulizer however, there was no evidence of nebulizer DME on plan of care. corrected on site Patient #9: Upon home visit it was noted the patient was using a shower chair however, this was not listed on the plan of care. corrected on site

Upon client record review, 9 of 23 (Patient #3, #4, #5, #7, #10, #13, #14, #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: The nurse documented on 08/29 and 08/26 a border dressing was applied as preventative care however, there was no evidence of an order for this treatment. corrected on site Patient #4: The social work visit frequency 08/10 was 1M1, 2M2, 2 PRN however, the month of August there was evidence of two visits on 08/14 and 08/30. Patient #5: The social work visit frequency 06/16 was 1M1, 4M1, 2M1, 2 PRN and chaplain 06/16 was 1M3, 2 PRN however, there was only evidence of three visit for social worker in July on the 7th, 18th, 25th, and one visit in August on the 3rd and there was no evidence of visits in July for the chaplain. Patient #7: The nurse visit frequency 08/06 was 2W8, 1W1, 4 PRN however,the week of 08/06 there was evidence of one visit 08/11. Patient #10: The social work visit frequency 07/01 was 1M3, 2 PRN however, there was no evidence of any visits in August. Music therapy evaluation ordered on 07/10/2023 however, there was not indication this had been completed. Patient #13: The spiritual care visit frequency 08/19 was 2M1, 4M1, 3M1 2 PRN however, there was no evidence of any visits and evidence of one missed visit note for 08/22. In addition, the nurse visit frequency 09/17 was 3W2, 2W2, 1W1, 4 PRN however, the week of 09/17 there was evidence of four routine visits 18th, 19th, 22nd, and 23rd and one PRN on the 21st. Patient #14: The nurse visit frequency 07/26 was 1W1, 2W8, 4 PRN however, the week of 09/17 there was only evidence of one visit on 09/19. Patient #16: The spiritual care visit frequency 06/22 was 2M2, 1M1, 2 PRN however, there was only evidence of one visit in June on 06/26 and two visits in August on the 23rd and 26th. Patient #18: The nurse visit frequency 08/13 was 2W7, 1W1 however, the week of 09/03 there was only evidence of one visit on 09/06.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 4: Observed clinician perform patient assessment to assess lungs and abdomen and did not witness handwashing prior to patient assessment policy 6-006, #3 Hand decontamination using an alcohol-based hand rub should be performed: a. before having direct contact with patients. Patient 7: Observed clinician perform peri care and during procedure, remove gloves and replace with new gloves without handwashing per policy 6-006, #3 Hand decontamination using an alcohol-based hand rub should be performed: g. after removing gloves.

Upon personnel record review, 1 of 17 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #7: The skills checklist did not indicate skills were completed on patient and/or pseudo patient.

Upon patient record review 5 of 23 (Patient #2, #4, #5, #13, #16) 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 #2: The aide plan of care ordered hair care weekly however, the aide performed this on 09/12, 09/15, 09/19, and 09/22. Patient #4: The aide visit frequency 08/13 was 2W12, 1W1 however, the week of 09/03 there was only evidence of one visit on 09/06. Patient #5: The aide visit frequency 06/18 was 2W8 however, the week of 07/02 there was no evidence of a visit. Patient #13: The aide visit frequency 07/16 was 3W1, 2W4 and 08/20 2W8, 1W1 however, the week of 08/06 and 08/27 there was only evidence of one visit each week on 08/09 and 08/31. Patient #16: The aide visit frequency 06/25 was 2W12, 1W1 however, the week of 07/30 there was only evidence of one visit on 08/03.

Upon patient client record review, 2 of 23 (Patient #2, #15) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: The election statement contained a section for patient/caregiver to ELECT or DECLINE notice of non-covered items however, this was not completed. Patient #15: The patient/caregiver elected to receive the notice of non-covered items however, there was no evidence this was provided.

Upon patient client record review, 1 of 23 (Patient #10) did not have evidence that each patient record contains Advance Directives. Patient #10: Patient Advance Directive was DNR however, there was not evidence of a copy of POST. corrected on site

Upon patient client record review, 2 of 23 (Patient #4, #5) 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 nurse documented on 09/19 "WSKED OT JA SHENHAD ANY PAIN PT APPEAARS TO HAVE NO NOTICEABLE..." and on 08/29 "education on fall prevention and stand BG assistance for transfer and RR". Documentation was unclear and used unapproved abbreviations. Patient #5: The nurse documented "family planning trips out of SA...let hospice know ASAP so TSA can be arranged. Randy VU" using unapproved abbreviations.

Upon personnel record review, 1 of 17 (Personnel #9) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #9: The social worker file did not have evidence of 1 year of social work experience as the employee recently graduated MSW program in 2022 and resume does not contain evidence of prior work experience in social work field.

An Immediate Jeopardy related to 42 CFR §418.52 Patient's Rights was identified and announced on 9/27/22 at 1:51 PM. The Immediate Jeopardy began on 9/21/22, when clinical record review evidenced Patient #9 (terminal Diagnosis cerebrovascular disease [an area of the brain is temporarily or permanently damaged by obstruction of blood flow or bleeding], other diagnosis Dementia) was oriented to self only, and was confused. On 9/06/22, The patient's in-home private duty caregiver (PDCG) informed the hospice agency of an incident of abuse that occurred on 9/05/22, and requested a nurse visit. The PDCG witnessed a family member yell, physically grab and yank the patient, and told her to stop talking, to which the patient responded by hitting and kicking out toward the family member. The hospice nurse performed a visit on 9/06/22. She documented assessed bruising on the patients right arm. On 9/15/22, a social worker visit was made, and the social worked documented the PDCG observed family member ";being rough" with patient, and it upset the PDCG, patient was disoriented, family instructed PDCGs to have patient upstairs in her room before he/she got home from work at 4:00 PM, PDCG was concerned about patients safety, as she ";scooted" up and down the stairs, and the house smelled very strongly of cat urine. On 9/16/22, a nursing visit was made, which documented bruising noted to left lower back and left distal forearm, environmental issues included strong cat urine odor in home with fleas, patient fell on 9/11/22, and had difficulty going up/down the stairs. On 9/21/22 a clinical record document indicated the social worker received a call from the PDCG agency, who indicated they would no longer provide services to the patient due to the circumstances between the family member and the patient, PDCG felt it was unsafe for the patient, they were going to let Adult Protective Services (APS) know they were ";backing out" of the case, and fleas remained in the home. During an interview on 9/26/22 at 12:23 PM, when queried about alleged abuse, PDCG staff indicated he/she had concern with family/patient interaction, and he/she notified APS. When queried if there was any outcome, PDCG staff indicated he/she didnt know, he/she informed the hospice agency to make them aware of the concern for abuse on 9/06/22, and APS was called again (by PDCG staff) on 9/12/22. Due to the actions taken by the agency, the Immediate Jeopardy was abated prior to the conclusion of the survey on 9/28/22, at 11:37 AM. Additionally, the hospice agency failed to immediately investigate and take immediate action to prevent further potential abuse while an allegation was being verified (See tag L509); failed to report a witnessed physical/verbal incident to the Indiana Department of Health (IDOH) and Adult Protective Services (APS) within 5 working days of becoming aware of the violation (See tag L511); failed to ensure the patient was free from mistreatment, verbal, and/or physical abuse, which also included injuries of unknown source (See tag L517); The cumulative effect of these systemic problems resulted in the hospice agency's failure to ensure the provision of quality health care in a safe environment at 42 CFR §418.52 Patient's Rights. Other unrelated conditions of participation and findings will be cited. A standard citation was evidenced at this level. Based on record review and interview, the hospice agency failed to ensure it took appropriate corrective action, and ensured that a verified violation of abuse was reported to IDOH and APS within 5 working days of becoming aware of the violation, for 1 of 1 clinical record reviewed where a hospice agency patient experienced physical and verbal abuse by a family member (#9). This practice had the potential to affect all agency patients. The findings include: --- Review of an agency policy dated 11/2020, titled ";Assessment of Possible Abuse/Neglect" stated, ";... Hospice ... will report all suspected cases of abuse, neglect ... Occurrences may include but are not limited to ... Physical Abuse ... [examples] ... bruise ... Neglect ... Acceptable environment ... Verbal Abuse ... Verbal humiliation ... Upon receiving a report of a potential patient violation [sic] the hospice must ... Ensure patient is protected from further potential violations during the investigational period ... Report any verified violations to State ... within 5 working days ... The hospice will maintain evidence that all allegations ... have been thoroughly investigated and that further potential abuse has been prevented ...." Review of an agency policy dated 5/22, titled ";Patient Rights" stated, ";... Patients Have the Right ... To be free from mistreatment, neglect, or verbal, mental ... emotional, and physical abuse, including injuries of unknown source ... Hospice Has the Responsibility ... To ensure that all alleged violations ... are reported immediately ... immediately take action to prevent further potential violations while the alleged violation is being verified ...." Review of the agencys incident/complaint log on 9/21/22, evidenced a document dated 9/06/22, titled ";Client Occurrence Report", which indicated entity #3 (a non-medical provider for private duty caregiver [PDCG] services) staff requested a hospice nurse visit because she witnessed a verbal/physical altercation between the patient and a family member on 9/05/22; family yelled, grabbed, and yanked the patients right arm, and told the patient to be quiet and stop talking. In response, the patient hit and kicked out toward the family member. The documented stated ";... [the nurse assessed] ... right posterior [back] forearm old bruising yellowish in color and round circular dime sized old purplish in color bruise to anterior [front] right forearm ...." The document also included an update added by Administrator #1 on 9/06/22, which indicated a call was placed to entity #3, the Administrator spoke with entity #3s manager (person #5), who indicated he was going to place a call to APS to report the incident. The document failed to evidence the hospice agency conducted its own investigation, ensured the patient was safe, or reported the incident to IDOH or APS. Clinical record review on 9/21/22, for patient #9, election of benefit/hospice admission date 4/19/22, primary diagnosis cerebrovascular disease (an area of the brain is temporarily or permanently damaged by obstruction of blood flow or bleeding) and other diagnosis Dementia, evidenced a document dated 9/06/22, titled ";Visit Note Report", which indicated a nursing visit was made due to allegations of abuse by family, and Administrator #1 ";was made aware". Review of a document dated 9/15/22, titled ";Visit Note Report", indicated a social worker visit was made, and documented entity #3 staff observed family member ";being rough" with patient, it upset entity #3 staff, patient was disoriented, family instructed entity #3 staff to have patient upstairs in her room before he/she got home from work at 4:00 PM, entity #3 staff was concerned about patients safety, as she ";scooted" up and down the stairs, and the house smelled very strongly of cat urine. Review of a document dated 9/16/22, titled ";Visit Note Report", indicated a nursing visit was made, which documented bruising noted to left lower back and left distal forearm, environmental issues included strong cat urine odor in home with fleas, patient fell on 9/11/22, and had difficulty going up/down the stairs. A document dated 9/19/22, titled ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report", evidenced social worker #1 received phone calls from entity #3 with concerns that patient had bruises and witnessed family being rough with the patient. The document failed to indicate the hospice IDG took any immediate action to ensure the patients safety. Review of a document dated 9/21/22, titled ";Client Coordination Note Report", indicated the social worker received a call from the PDCG agency, who indicated they would no longer provide services to the patient due to the circumstances between the family member and the patient, entity #3 felt it was unsafe for the patient, they were going to let Adult Protective Services (APS) know they were ";backing out" of the case, and fleas remained in the home. During an interview on 9/21/22 at 5:18 PM, Administrator #1 indicated the agency did send a nurse out (after being notified of alleged abuse), collaborated with entity #3, the hospice agency didn't find the evidence, entity #3 did, so they (entity #3) actually contacted APS to put in a complaint to do further investigation. When queried if the hospice agency followed up on the APS complaint, Administrator #1 stated ";Yes, and there were no significant findings ... The caregiver is still in the home ...." During an interview on 9/26/22 at 12:23 PM, when queried about alleged abuse, entity #3s manager (person #5) indicated he had concern with family/patient interaction, and he notified APS. When queried if there was any outcome, person #5 indicated he didnt know, he/she informed the hospice agency to make them aware of the concern for abuse on 9/06/22, and APS was called again (by entity #3) on 9/12/22.

Based on record review and interview, the hospice agency failed to report a witnessed physical/verbal incident to the Indiana Department of Health (IDOH) and Adult Protective Services (APS) within 5 working days of becoming aware of the violation, for 1 of 1 clinical record reviewed where the patient experienced verbal/physical abuse by a family member (#9). Findings include: --- Review of an agency policy dated 11/2020, titled ";Assessment of Possible Abuse/Neglect" stated, ";... Hospice ... will report all suspected cases of abuse, neglect ... Report any verified violations to State ... within 5 working days ...." Review of an agency policy dated 5/22, titled ";Patient Rights" stated, ";... Hospice Has the Responsibility ... To ensure that all alleged violations ... are reported immediately ... to State and local bodies ... including ... [IDOH] ... within 5 working days of becoming aware ...." Review of the agencys incident/complaint log on 9/21/22, evidenced a document dated 9/06/22, titled ";Client Occurrence Report", which indicated entity 3 (a non-medical provider for PDCG services) staff requested a hospice nurse visit because she witnessed a verbal/physical altercation between the patient and a family member on 9/05/22; family yelled, grabbed, and yanked the patients right arm, and told the patient to be quiet and stop talking. In response, the patient hit and kicked out toward the family member. The documented stated ";... [the nurse assessed] ... right posterior [back] forearm old bruising yellowish in color and round circular dime sized old purplish in color bruise to anterior [front] right forearm ...." The document also included an update added by Administrator #1 on 9/06/22, which indicated a call was placed to entity #3, the Administrator spoke with entity #3s manager (other person #5), who indicated he was going to place a call to APS to report the incident. The document failed to evidence the hospice agency reported the incident to IDOH or APS. During an interview on 9/21/22 at 5:18 PM, Administrator #1 indicated the agency collaborated with entity #3, entity #3 staff witnessed the incident, not the hospice agency, so they (entity #3) actually contacted APS to put in a complaint to do further investigation. When queried if the hospice agency followed up on the APS complaint, Administrator #1 stated ";Yes, and there were no significant findings ... The caregiver is still in the home ...." During an interview on 9/26/22 at 12:23 PM, when queried about alleged abuse, entity #3s manager (other person #5) indicated he had concern with family/patient interaction, and he notified APS. When queried if there was any outcome, person #5 indicated he didnt know, he informed the hospice agency to make them aware of the concern for abuse on 9/06/22, and APS was called again (by entity #3) on 9/12/22. During an interview on 9/26/22 at 1:05 PM, when queried if the hospice agency notified IDOH, Administrator #1 stated ";No." When queried if there was any agency documentation about follow up with APS, or if it was confirmed that entity #3 contacted APS, Administrator #1 indicated there was not.

Based on record review and interview, the hospice agency failed to ensure the patient was free from mistreatment, verbal, and/or physical abuse, which also included injuries of unknown source, for 1 of 1 clinical record reviewed where the patient experienced verbal/physical abuse by a family member (#9). The findings include: --- Review of an agency policy dated 11/2020, titled ";Assessment of Possible Abuse/Neglect" stated, ";... Occurrences may include but are not limited to ... Physical Abuse ... [examples] ... bruise ... Neglect/Failure to Provide ... Acceptable environment ... Verbal Abuse ... Verbal humiliation ... Upon receiving a report of a potential patient violation [sic] the hospice must ... Ensure patient is protected from further potential violations during the investigational period ... [ensure] further potential abuse has been prevented ...." Review of an agency policy dated 5/22, titled ";Patient Rights" stated, ";... Patients Have the Right ... To be free from mistreatment, neglect, or verbal, mental ... emotional, and physical abuse, including injuries of unknown source ...." Review of the agencys incident/complaint log on 9/21/22, evidenced a document dated 9/06/22, titled ";Client Occurrence Report", which indicated entity 3 (a non-medical provider for private duty caregiver services) staff requested a hospice nurse visit because entity #3 witnessed a verbal/physical altercation between the patient and a family member on 9/05/22; family yelled, grabbed, and yanked the patients right arm, and told the patient to be quiet and stop talking. The documented stated ";... [the nurse assessed] ... right posterior [back] forearm old bruising yellowish in color and round circular dime sized old purplish in color bruise to anterior [front] right forearm ...." The document failed to evidence the hospice agency conducted its own investigation, ensured the patient was safe, or attempted to determine the cause of the "old" bruises. Clinical record review on 9/21/22, for patient #9, election of benefit/hospice admission date 4/19/22, primary diagnosis cerebrovascular disease (an area of the brain is temporarily or permanently damaged by obstruction of blood flow or bleeding) and other diagnosis Dementia, evidenced a document dated 9/06/22, titled ";Visit Note Report", which indicated a nursing visit was made due to allegations of abuse by family, and Administrator #1 ";was made aware". Review of a document dated 9/15/22, titled ";Visit Note Report", indicated a social worker visit was made, and documented entity #3 staff observed family member ";being rough" with patient, it upset entity #3 staff, patient was disoriented, family instructed entity #3 staff to have patient upstairs in her room before he/she got home from work at 4:00 PM, entity #3 staff was concerned about patients safety, as she ";scooted" up and down the stairs, and the house smelled very strongly of cat urine. The document failed to evidence the hospice agency provided any intervention for the patient's safety/prevention of abuse, safety while using stairs, or to ensure an acceptable home environment. Review of a document dated 9/16/22, titled ";Visit Note Report", indicated a nursing visit was made, which documented bruising noted to left lower back and left distal forearm, environmental issues included strong cat urine odor in home with fleas, patient fell on 9/11/22, and had difficulty going up/down the stairs. The document failed to evidence the hospice agency provided any intervention for safety while using stairs, why/how the patient fell, or to ensure an acceptable home environment. A document dated 9/19/22, titled ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report", evidenced social worker #1 received phone calls from entity #3 with concerns that patient had bruises and witnessed family being rough with the patient. The document failed to indicate the hospice IDG took any immediate action to ensure the patients safety or prevention of further abuse. Review of a document dated 9/21/22, titled ";Client Coordination Note Report", indicated the social worker received a call from entity #3, who indicated they would no longer provide services to the patient due to the circumstances between the family member and the patient, entity #3 felt it was unsafe for the patient, they were going to let Adult Protective Services (APS) know they were ";backing out" of the case, and fleas remained in the home. During an interview on 9/26/22 at 12:23 PM, when queried about alleged abuse, entity #3s manager (person #5) indicated he/she had concern with family/patient interaction, and he/she notified APS. When queried if there was any outcome, person #5 indicated he/she didnt know, he/she informed the hospice agency to make them aware of the concern for abuse on 9/06/22, and APS was called again (by entity #3) on 9/12/22. During an interview on 9/26/22 at 1:05 PM, when queried what steps were taken when the agency was made aware of the witnessed verbal/physical abuse, Administrator #1 indicated a nurse went out to assess the patient, the social worker and chaplain always checked while they visited, and family was rarely present during hospice agency visits. When queried if physical therapy (PT) was referred for the concern with the patient's ability to safely negotiate stairs, Administrator #1 indicated there was not a PT referral made.

An Immediate Jeopardy related to 42 CFR §418.56 Interdisciplinary Group, Care Planning, and Coordination of Services was identified and announced on 9/26/22 at 12:46 PM. The Immediate Jeopardy began on 9/21/22, when clinical record review evidenced Patient #8 (admitted 5/6/22, terminal diagnosis osteomyelitis [infection in bone], other diagnosis paraplegia [paralysis of legs and lower body]), had a Stage 4 pressure injury (PI) (wound caused by unrelieved pressure, with muscle, tendon, and/or bone exposed) to coccyx (tailbone area) identified 5/6/22, and Stage 4 PIs to left and right buttocks, also identified on 5/6/22. On 8/9/22, the EMR indicated the buttocks ulcers had ";morphed into one bigger wound", to include area of gluteal cleft (vertical crease between buttocks) and rectal area, with ";extensive" depth, and purulent (indicative of infection) drainage, tunneling (a wound that's progressed to form passageways underneath the surface of the skin). Antibiotics werent ordered until 9/2/22 for wound infection, newly prescribed Morphine for increased pain, and also indicated extensive patient non-compliance with treatment orders and medications. Interdisciplinary Group (IDG)/plan of care (POC) documents failed to include the patients ongoing non-compliance with treatment/medications; wound assessments, which would include all wounds, location(s), and measurements; or wound treatments. The EMR also indicated the wounds were not assessed by the hospice nurse(s) since 8/09/22. During a home visit on 9/23/22, surveyor observed presence of wounds not included in the EMR (greater than 2), and worsening of wound(s) as compared to most recent documentation reviewed in the EMR. Patient #11 was admitted to hospice 11/23/20, with terminal diagnosis hypertensive heart disease with heart failure (inability to effectively pump blood throughout the body, caused by high blood pressure). The EMR indicated a wound was present on the left lower leg, and the last wound care order was 7/22/22. The EMR failed to evidence any assessment of the wound on or after 7/22/22. When interviewed, registered nurse (RN) #1 indicated she knew the patient had a wound, but couldnt remember which leg, shed never assessed or seen the wound herself, she saw a picture of it ";at least 3 or 4 weeks ago"; and Entity #1 (an extended care facility [ECF]) where the patient resided, had a wound care nurse, and they did the wound care. Review of Entity #1 documentation indicated the patient actually had 2 ongoing wounds to the left lower leg. Entity #1 staff interview revealed last picture taken of wound(s) was 4/28/22, and the hospice nurse(s) were aware the wound physician rounded (saw patients) on Tuesdays, and were always welcome to attend and participate in wound assessments. The hospice IDG meeting notes failed to evidence accurate number of wounds, location(s), measurements, or treatment; and failed to include care coordination between Entity #1 and the hospice agency. Patient #5 (admitted to hospice 7/11/22, revoked 8/08/22, terminal diagnosis chronic obstructive pulmonary disease [COPD] [long-term lung disease]). The RN admission document indicated the patient had abdominal surgery ";2 days ago (7/9/22)" with presence of incisions. No assessments of incisions were made during the visit. During this visit, the patients oxygen saturation (O2 sat) was 88% (95-100% is normal range). No further indication O2 sat was checked at any subsequent nursing visit. Interview with the admitting RN indicated checking O2 saturation was ";not part of hospice vital signs". A skilled nursing note dated 7/12/22 indicated the patient asked nurse to assess the surgical sites, as the dressings had not been removed since surgery (7/9/22), an incision had a large amount of drainage, but no documentation of an assessment made, or measurements taken. A nursing note dated 7/20/22, indicated the patient only had 1 lung, and stated she was unable to breathe. No O2 sat was assessed. The patient used oxygen 2LPM (2 liters per minute), and reported minor pain to abdomen. A skilled nursing visit note dated 8/05/22 indicated the patient complained of shortness of breath, and used oxygen 2 LPM. The note failed to evidence the nurse increased quantity of oxygen administration or assessed O2 sat. The patients medication list indicated the patient could use O2 at 2-3 LPM. A patient coordination note dated 8/08/22 indicated the patient stated she felt like she was being smothered, and revoked services. IDG document dated 7/13/22 failed to evidence the presence of surgical incisions, assessment, or treatment. Due to the actions taken by the agency, the Immediate Jeopardy was abated prior to the conclusion of the survey on 9/28/22, at 11:37 AM. The cumulative effect of these systemic problems resulted in the hospice agency's failure to ensure the provision of quality health care in a safe environment at 42 CFR §418.56 Interdisciplinary Group, Care Planning, and Coordination of Services. Other unrelated conditions of participation and findings will be cited. Additionally, the hospice agency failed to ensure the patients plan of care included measurable outcomes (See tag L548); failed to ensure the patients plan of care included all drugs and/or treatments (See tag L549); failed to review/revise, and document the patient's plan of care as often as needed (See tag L552); and failed to ensure it directed, supervised, and coordinated/shared information to meet the patients needs (See tag L554). This practice had the potential to affect all agency patients. A standard level citation was evidenced as follows: Based on observation, record review, and interview, the hospice agency failed to ensure all patients' plans of care contained patient-specific treatment/care needs, it supervised the care provided, ensured continuous assessments that met the patients' needs, or coordinated care to ensure needs were met, all which led to wound infection(s), emergent hospitalization, and/or likelihood of new/worsening wounds for 3 patients (#5, 8, 11). This practice had the potential to affect all agency patients. The findings include: --- 7. The clinical record of Patient #8 was reviewed on 09/22/2022 and 09/27/2022. The record included a skilled nursing visit completed on 08/09/2022 by RN #1. The visit note indicated Patient #8 had one extensive Stage 4 pressure ulcer to their left and right buttocks, gluteal cleft (groove between buttocks), and rectum. The nurse measured the wound to be 11 cm in length by 17.8 cm in width by 2.4 cm in depth with undermining of 2.1 cm from 12 – 3 oclock, 2.8 cm from 3 -6 oclock, 4.2 cm from 6 - 9 oclock, and 4 cm from 9- 12 oclock, and tunneling of 4.8 cm from 6 -9 oclock. An interview was conducted on 09/23/2022 at 9:40 AM with LPN #1. During the interview, the LPN confirmed Patient #8 refused any wound care or treatment to their Stage 4 bilateral (both right and left sides of the body) gluteal cleft wound. The nurse indicated the patient would typically allow her to assess the wound but refused wound care treatment. LPN #1 reported she felt the patient was depressed and had ";given up." A home visit observation with Patient #8 occurred on 09/23/2022 at 10:00 AM with RN #1 and LPN #1. Upon entry to the home, Patient #8 was noted to be lying on a hospital bed however no specialty mattress was observed. During the home visit, RN #1 assessed Patient #8s right leg and foot. The patient had two closed wounds on their right anterior toes, one to the 3rd toe and one to the 5th toe. The patient also had pencil-sized dark purple bruising to their anterior right 4th toe. The patient reported the wounds had been present for ";a few" weeks. RN #1 indicated she had completed the assessment of the patients right leg and foot and began to put the patients clothing back on their foot but had failed to assess or measure the right toe wounds. After prompting from the surveyor, the nurse assessed and measured the right toe wounds. RN #1 then moved to assessing the patients Stage 4 bilateral gluteal cleft wound. The surveyor observed a Stage 2 pressure ulcer to the patients midline lower back above the Stage 4 bilateral gluteal cleft wound. After the nurse assessed and measured the Stage 4 gluteal cleft wound, she indicated the patient could reposition back onto their back despite the nurse failing to assess the midline Stage 3 coccyx wound. The surveyor asked RN #1 if wound to coccyx was new and the nurse reported she had not seen the wound prior to it being pointed out by the surveyor. The nurse then assessed and measured wound but failed to offer wound care for the midline coccyx wound. Later in the visit, the nurse confirmed she had completed her assessment of the patient but had failed to assess the patients left leg and foot. After prompting by the surveyor, the nurse assessed the left leg and foot. A closed wound to the 2nd left anterior toe was noted. An interview was conducted on 09/23/2022 at 10:53 AM with Patient #8. The patient confirmed they routinely declined wound care to their extensive coccyx/gluteal wound due to the wound having copious amounts of drainage and the wound dressing would get saturated and fall off within 1 hour of applying. Patient #8 indicated they had been declining a wound dressing to the extensive coccyx/gluteal wound for several years. The patient stated they preferred no dressing to be applied to the area and only have reusable pads placed underneath them. An interview was conducted on 09/23/2022 at 11:00 AM with RN #1. During the interview, the nurse confirmed they were the nurse case manager for Patient #8 and attended the patients IDG meetings. The nurse reported the patients primary concern discussed during IDG was pain control. RN #1 reported the visit completed on 09/23/2022 was the first visit ";in a long time" where the patient allowed her to measure their wounds. The nurse indicated the patient typically allowed her during visits to assess the wound but declined wound measurements. RN #1 could not remember the last time the wound was measured. RN #1 indicated Patient #8 had refused wound care or treatment since she began caring for the patient. The clinical note from the visit completed on 09/23/2022 was reviewed on 09/27/2022. RN #1 documented two new ";unstageable" wounds to the patients right 5th toe, the first measuring 1 cm in length by 1 cm in width with no depth and the second measuring 1 cm in length by 1.5 cm in width with no depth. The visit note documentation indicated one new ";unstageable" wound to the left 5th toe measuring 1 cm in length by 0.75 cm in width with no depth and one new Stage 3 pressure ulcer to the midline lower back measuring 3 cm in length by 2 cm in width by 0.25 cm in depth. The visit note documentation also indicated the Stage 4 pressure ulcer wound to the left and right gluteal clefts measured 23 cm in length by 18 cm in width by 2 cm in depth with undermining of 1.75 cm from 12 – 3 oclock, 2.5 cm from 3-6 oclock, 2.5 cm from 6 -9 oclock, and 2 cm from 9 -12 oclock. No tunneling was noted. The documentation indicated there was no change in the wound despite the increase of 5.2 cm in length compared to the 08/09/2022 assessment. The assessment failed to reflect the wounds observed on Patient #8s right 3rd toe and left 2nd toe. 1. A Joint Commission web-based reference reviewed 9/21/22, https://www.jointcommission.org/standards/standard-faqs/home-care/provision-of-care-treatment-and-services-pc/000001744/?p=1, titled ";Topic: Pulse Oximetry [O2 sat] - Order by Physician/Licensed Independent Practitioner ... Is a Physician/Licensed Independent Practitioner's order required for the use of a pulse oximeter?" stated, ";... CMS does not have any requirements which prohibit the use of pulse oximetry without a physician's order ... The use of pulse oximetry on a PRN [as needed] basis may be viewed as a part of vital signs [temperature, heartbeats per minute, breaths per minute, blood pressure] ...." 2. Review of an agency policy dated 11/2020, titled ";Ongoing Assessment" stated, ";... During each home visit, the Case Manager [nurse] ... will evaluate the patient according to the problems ... assess each patient on each visit for ... Vital signs appropriate to the patients condition ... skin integrity ...." 3. Review of an agency policy dated 8/05/22, titled ";Wound Assessment, Documentation and Clinical Oversight" stated, ";... Physician orders will be obtained for all wound treatments ... Wound assessments will be performed ... no less than once weekly ... will include wound measurements ... Location ... Wound bed characteristics ... Condition of surrounding skin ... Patients Who Reside in Facilities ... information applies to all patients, including those who reside in a facility ... If facility staff are performing wounds care, the hospice nurse must assess the wound at least once per week, documenting a full assessment. This is not optional ... The patient/caregiver has the right to refuse treatment ... When a patient/caregiver refuses wound assessment or wound care, the following must be completed ... Educate patient ... on importance of wound assessment and wound care ... potential consequences ... Notify the attending physician ... Report refusals to the ... members of the IDG ... include specifics regarding the refusal ... Document the report, the plan to address refusals, and collaboration in the IDG note ...." 4. Review of an agency policy dated 6/27/22, titled ";Hospice Nursing Care" stated, ";... The hospice nurse will ... Initiate appropriate preventative ... nursing procedures ... Assure communication ... between the hospice and other non-hospice health care providers ...." 5. Review of an agency policy dated 1/2022, titled ";Interdisciplinary Group Membership and Responsibilities" stated, ";... responsibilities include but are not limited to ... establishment of the plan of care ... periodic review and updating of the plan of care ... to evidence specific treatments, goals and outcomes ... Coordination of care ... to include ... non-hospice care providers ...." 6. Clinical record review on 9/21/22, for patient #8, election of benefit/hospice admission date 5/6/22, terminal diagnosis osteomyelitis [infection in bone], other diagnosis paraplegia [paralysis of legs and lower body]), evidenced a document titled ";Visit Note Report" (skilled nurse home visit), dated 8/04/22. The document indicated presence of a stage 4 PI on the patients coccyx, with onset date 5/06/22; a stage 4 PI on the patients right buttock; and a stage 4 PI on the patients right buttock; and the patient refused wound assessment or treatment. A document titled ";Visit Note Report" (skilled nurse home visit), dated 8/09/22, indicated the patient was non-compliant with taking medications, following treatment orders on the plan of care, and this was reported to the RN Case Manager, and IDG team coordination was needed; and the stage 4 PIs to the left and right buttocks became 1 large wound, which now included both buttocks, gluteal cleft, and rectal area, with purulent drainage, extensive wound depth, and signs of infection present. A document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 8/10/22, indicated skilled nurse visits were ordered 2 times weekly, wound care was ordered daily, wounds continued to get worse, and patient was non-compliant with medications and wound care; and listed diagnoses included only 1 wound- ";pressure ulcer [injury] of unspecified site, unspecified stage". The document failed to include who did wound care on days the hospice nurse was not present, or a plan to improve compliance with medications and wound care; an actual number of, locations, assessments, or measurements of all wounds the patient had. Documents titled ";Visit Note Report" (skilled nurse home visit), dated 8/04/22, 8/16/22, 8/18/22, 8/23/22, 8/30/22, and 9/13/22, all indicated the patient refused wound assessment/treatment. Documents titled ";Visit Note Report", dated 8/18/22, 8/30/22, 9/01/22, 9/08/22, 9/13/22, and 9/15/22, all indicated wound care was already completed, and no wound care/assessment was performed by the hospice nurse. A document titled ";Visit Note Report", dated 09/02/22, indicated the visit occurred at the request of family, due to the patients complaint of pain level 10 (0= no pain at all, with 10= worst pain ever, unbearable) to tailbone area, hips, and lower back and family report of change in wound appearance. Review evidenced the nurse failed to assess wounds or provide wound care. A new antibiotic and morphine was ordered. No further nursing visit was made until 9/08/22. A document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 9/07/22, indicated skilled nurse visits were ordered 2 times weekly, antibiotics were ordered 9/02/22 (daily for 10 days) for wound infection, morphine was ordered 9/02/22 for pain, presence of ";multiple wounds", wounds have increased in size, and problems to be addressed over the next 2 weeks included the primary caregiver (family, who patient resided with) had failing health, the patient experienced depression, and need for facility placement. The document failed to include wound care orders, efficacy of antibiotic treatment, level of pain relief from morphine, or an actual number of, locations, assessments, or measurements of all wounds the patient had; the failure of hospice nurses to assess wounds since 8/09/22 with a plan for immediate completion of wound assessment/treatment plan; or a plan to prevent further deterioration of wounds. A document titled ";Visit Note Report", dated 09/08/22, failed to evidence the nurse assessed or provided wound treatment for efficacy of antibiotic treatment, or assessed compliance with taking all antibiotics as ordered. A document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 9/21/22, indicated the patient had multiple wounds which were getting larger, recently prescribed morphine, and new infection in wound and placed on antibiotics. The document failed to include update on caregivers failing health, the patients depression, or current need for facility placement; wound care orders, efficacy of antibiotic treatment, level of pain relief from morphine, or an actual number of, locations, assessments, or measurements of all wounds the patient had; the failure of hospice nurses to assess wounds since 8/09/22 with a plan for immediate completion of wound assessment/treatment plan; or a plan to prevent further deterioration of wounds. A document titled ";Visit Note Report", dated 09/08/22, indicated 4 new wounds were identified, the wound to the buttocks, gluteal cleft, and rectum area was significantly worse/larger; and no wound care was being performed per the patient, as the patient wanted the incontinence pads to absorb wound drainage. During an interview on 9/21/22 at 3:57 PM, Administrator #1 indicated the patients clinical record didn't show any wound measurements after 8/09/22. During an interview on 9/23/22 at 4:18 PM, Administrator #1 indicated the patient had the right to refuse (treatments), but IDG should be discussing it, and the first goal was to keep the patient comfortable, and she would expect to see that included on IDG meeting notes. When queried if a full head to toe assessment was appropriate every visit for this patient, Area Director of Education #5 stated ";Yes we would expect a full head to toe assessment." Area Director of Education #5 also indicated the patients depression and non-compliance should be discussed and documented in IDG meeting notes. 7. Clinical record review on 9/21/22, for Patient #11, election of benefit/hospice admission date 11/23/20, terminal diagnosis of hypertensive heart disease with heart failure (inability to effectively pump blood throughout the body, caused by high blood pressure), evidenced an undated (cumulative report) document received on 9/22/22, titled ";Wound Record Report". The document evidenced the patient had one stage 2 (partial thickness, involving no more than the layers of the skin) PI to the left lower leg, with onset date 7/20/2020, a nurse visit date 7/22/22, and an order for wound care to be performed by the hospice nurse each visit. The document failed to evidence the wound was assessed, measured, or wound care was performed on or any time after 7/22/22. A document titled ";Visit Note Report", dated and signed by RN #1 on 09/12/22, indicated the patient had ";wound(s)". The document failed include assessment of the wound, or wound care was performed. A document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 9/14/22, indicated the patient resided at an extended care facility (ECF) (no further information provided), and had wounds on leg (not further specified). The document failed to specify the type, location, assessment, or measurements of the wound(s), wound treatment orders, what ECF the patient resided at, or who performed wound care for the patient; and failed to include care coordination between Entity #1 and the hospice agency. During an interview on 9/22/22 at 2:21 PM, RN #1 indicated she knew the patient had a wound, but couldnt remember which leg, shed never assessed or seen the wound herself, she saw a picture of it ";at least 3 or 4 weeks ago"; and Entity #1 (ECF) (where the patient resided) had a wound care nurse, and they did the wound care. When queried if the patient had more than 1 wound, RN #1 stated, ";No." During an interview on 9/22/22 at 1:35 PM, the Administrative RN #4 (Area Vice President of Operations) indicated she was the agencys Clinical Supervisor, the patient resided at a facility, and ";they" typically had a wound care nurse. When queried where the wound was documented in the clinical record, Administrator #1 indicated she didnt see anything. Administrative RN #4 indicated she saw an order for wound care on 5/18/22. When queried if all wound assessments performed during visits would be included on the ";Wound Record Report", Administrative RN #4 indicated the report showed a wound to the left lower leg on the report, and she assumed all wound assessments would be on the report. At 1:44 PM, Administrator #1 indicated there were no wound care orders after 7/22/22, or wounds assessments on or after 7/22/22. Review of Entity #1 documentation received on 9/23/22, dated 9/16/22 and 9/20/22, both titled ";Wound Evaluation and Management Summary" indicated the patient had 2 current, chronic/ongoing wounds greater than 1 year old to the left lower leg, and wound care was ordered 3 times weekly. During an interview on 9/23/22 at 11:50 AM, Staff #2 (at Entity #1) indicated the last picture taken of wound(s) was 4/28/22, they didnt do that anymore, the hospice nurse(s) were aware that the wound physician rounded (saw patients) on Tuesdays, and were always welcome to attend and participate in wound assessments. 8. Clinical record review on 9/21/22, for Patient #5, election of benefit/hospice admission 7/11/22, revoked 8/08/22, terminal diagnosis chronic obstructive pulmonary disease (COPD) (long-term lung disease), evidenced a document dated 7/11/22, titled ";Hospice RN Start of Care". The document indicated the patient had difficulty breathing at rest, used continuous supplemental oxygen at 2 LPM, had abdominal surgery ";2 days ago (7/9/22)" with presence of incisions. No assessments of incisions were made during the visit. Also during this visit, the patients oxygen saturation (O2 sat) was 88% (95-100% is normal range). No further indication O2 sat was re-checked, or checked during any subsequent nursing visit. A document titled ";Visit Note Report", dated 7/12/22, indicated the patient asked the nurse to assess the surgical sites, as the dressings had not been removed since surgery (7/9/22), an incision had a large amount of drainage, and wound care was performed with a dressing change; and failed to evidence documentation that an assessment was made, or measurements taken. A document titled ";Visit Note Report", dated 7/20/22, indicated the patient only had 1 lung, stated she was unable to breathe, and reported minor pain to her abdomen. The nurse failed to assess O2 sat or abdominal incision(s). A document titled ";Visit Note Report", dated 8/05/22, indicated the patient complained of shortness of breath, and used oxygen 2 LPM. The note failed to evidence the nurse increased quantity of oxygen administration or assessed O2 sat. A document received 9/20/22, titled ";Client Medication Report" indicated the patient could use O2 at 2-3 LPM, with an effective date of 7/11/22. A document dated 8/08/22, titled ";Client Coordination Note Report", indicated the patient stated she felt like she was being smothered, and revoked services to seek aggressive treatment. A document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 7/13/22 failed to evidence the presence of surgical incisions, assessments made, or wound/incision care orders. A document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 7/27/22, failed to evidence the presence of surgical incisions, assessments made, wound/incision care orders, plan to mitigate shortness of breath, or abdominal pain. During an interview on 9/20/22 at 2:39 PM, Administrator #1 indicated she was unaware there was no regulation which required a physicians order to obtain O2 sat, the clinical record failed to include incision/wound care orders, or detailed assessment of incision(s), wounds and treatment; orders should be on the plan of care; and the ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" was the plan of care and comprehensive assessment. During an interview on 9/21/22 at 10:20 AM, RN #2 indicated she performed the start of care visit for patient #5. When queried the procedure for charting on incisions/wounds, RN #2 stated, ";You would assess upon admission ... [the patient] had the dressing on it [incision(s)] ... and they [patient/family] had said it was just put on in the hospital ... and I didn't have supplies because I didn't know what was going on ... I called the doctor on admission, to make sure he didn't want to change the orders for treatment ... The patient and [family] wanted it changed the next day ...." When queried if that information was documented in the start of care visit note, RN #2 stated ";I probably didn't ... I'm trying to enter a late note ... I did not get those details in there appropriately ...." When queried how often the incision(s) should be assessed, RN #2 stated ";They [no further specific identifier] instructed daily dressing change, so I added that [late visit note] ... I want to say we would check it 2 or 3 times a week ...." When queried about O2 sats, RN #2 stated ";... It looks like I have 88% in the note ... But the patient said my O2 sat was wrong, and she never runs that low ...." When queried if she checked the patients O2 sat every visit, RN #2 stated ";... Usually just a baseline ... I usually check each visit ... I know its not a vital sign for hospice ...."

Based on observation, record review, and interview, the hospice agency failed to ensure the patients plan of care included measurable outcomes for 6 of 6 active clinical records reviewed (#1, 3, 8, 9, 10, 11). The findings include: --- 1. Review of an agency policy dated 01/22, titled ";Interdisciplinary Group [IDG] Membership and Responsibilities" stated ";... responsibilities include ... updating of the plan of care for each patient ... to evidence specific ... outcomes ...." 2. Review of an agency policy received 9/26/22, dated ";February" (no year identified), titled ";The Plan of Care", stated ";... The individualized plan of care will be reviewed by the interdisciplinary group ... Each patient will be monitored for ... response to care or services provided against ... goals ... and patient outcomes to evaluate progress ... written plan of care will contain ... Measurable outcomes ...." 3. Review of an agency policy dated 11/2020, titled ";Ongoing Assessments", stated, ";... the plan of care-including ... goals, and outcomes ... will be reviewed and updated by the interdisciplinary group [IDG] members ...." 4. A home visit was observed with patient #1 and registered nurse (RN) #3 on 9/22/22 at 3:00 PM. The patient indicated she decreased use of acetaminophen (non-narcotic pain relief) to twice daily, and family indicated she only took 1 today so far. Clinical record review on 9/21/22, for patient #1, election of benefit/hospice admission date 6/14/22, evidenced a document dated 9/12/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report". The document stated ";... Current Problem List ... Declining Status ... Altered Comfort ... The patient is now using [acetaminophen] for pain and norco [a narcotic pain reliever] at times ... has had increased fatigue and will often sleep 12-16 hours at a time ...." The plan of care failed to include measurable outcomes for pain to include the patients acceptable pain level, previous pain level, current pain level, or specific amount of medication used to attain/maintain desired pain relief; or previous hours slept to determine the patients increased fatigue. During an interview on 9/23/22 at 3:35, Administrator #1 indicated the plan of care did not include measurable outcomes. 5. Clinical record review on 9/21/22, for patient #3, election of benefit/hospice admission date 5/25/22, evidenced a document dated 9/19/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report". The document indicated progress toward goals included ";skin condition worsened". During an interview on 9/23/22 at 10:10 AM, RN #4 indicated she didnt read ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report[s]" very often. When queried if ";wound worsened" was a measurable outcome, RN #4 indicated it should be explained in more detail, and it was not a measurable outcome. During an interview on 9/23/22 at 3:29 PM, Administrator #1 indicated wound measurements would be specific and measurable outcomes on the plan of care. 6. Clinical record review on 9/21/22, for patient #8, election of benefit/hospice admission date 5/6/22, evidenced a document dated 8/10/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report". The document indicated the patient was bedbound, his wounds continued to get worse, was non-compliant with wound care, and stated ";... what has occurred in the past 2 weeks to include progress toward goals ... [wounds] on lower buttocks have become 1 large wound ... [skilled nurse] plan, goals ... for next 2 weeks ... goals to be measurable and patient specific ...." The document failed to include any wound measurements to determine a measurable outcome, measurable outcome for non-compliance with wound care, or any measurable and patient specific skilled nursing goals for the next 2 weeks to determine outcome. Review of a document dated 9/21/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", indicated the patient had ";multiple wounds" which were getting larger, increased pain and recently prescribed morphine (a narcotic medication for severe pain), had new wound infection, and was prescribed antibiotics. The document stated ";... Progress to goals ... NA [not applicable] ...." The document failed to include the number of wounds, or any wound measurements to determine a measurable outcome; and failed to include measurable outcomes for pain to include the patients acceptable pain level, previous pain level, current pain level, or specific amount of medication used to attain/maintain desired pain relief. During an interview on 9/23/22 at 4:18 PM, Administrator #1 indicated the patient had the right to refuse treatment, but IDG should be discussing it, the first goal was to keep the patient comfortable, and she expected to see this documented on the plan of care. When queried about the IDG plan of care dated 9/21/22, which indicated the wound was bigger, Area Director of Education #5 indicated the plan of care should include the wound assessment measurements. 7. Clinical record review on 9/21/22, for patient #9, election of benefit/hospice admission date 4/19/22, primary diagnosis cerebrovascular disease (an area of the brain is temporarily or permanently damaged by obstruction of blood flow or bleeding) and other diagnosis Dementia, evidenced a document dated 9/06/22, titled ";Visit Note Report", which indicated a nursing visit was made due to allegations of abuse from family, and Administrator #1 ";was made aware". Review of a document dated 9/15/22, titled ";Visit Note Report", indicated a social worker visit was made, and documented entity #3 (non-medical private duty caregiver agency) staff observed family member ";being rough" with patient, it upset the entity #3 staff, patient was disoriented, family instructed entity #3 staff to have patient upstairs in her room before he/she got home from work at 4:00 PM, entity #3 staff was concerned about patients safety, as she ";scooted" up and down the stairs, and the house smelled very strongly of cat urine. Review of a document dated 9/16/22, titled ";Visit Note Report", indicated a nursing visit was made, which documented bruising noted to left lower back and left distal forearm, environmental issues included strong cat urine odor in home with fleas, patient fell on 9/11/22, and had difficulty going up/down the stairs. Review of a document dated 9/19/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", evidenced social worker #1 received phone calls from entity #3 with concerns that patient had bruises and witnessed family being rough with the patient. The document failed to include development of measurable goals/outcomes for home safety related to patient ability to go up/downstairs, home environment related to cat urine odor and fleas, falls, or alleged abuse. During an interview on 9/21/22 at 5:18 PM, when queried if there was evidence the IDG addressed abuse, home safety, inadequate home environment, falls, and inability to safely negotiate stairs in the clinical record, Regional Director of Clinical Operation #2 indicated there was documentation, but it wasnt part of the clinical record. During an interview on 9/26/22 at 1:05 PM, when queried if the clinical record evidenced the IDG or plan of care addressed home safety related to patient ability to go up/downstairs, home environment related to cat urine odor and fleas, falls, or alleged abuse, Administrator #1 indicated they did not. 8. Clinical record review on 9/21/22, for patient #10, election of benefit/hospice admission date 3/2/22, evidenced a document dated 9/07/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", which stated ";... Any new problems identified: wound to heel ...." The document failed to include development of measurable outcomes for the new wound. Review of a document dated 9/21/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", failed to include any documentation of presence or status of a wound. During an interview on 9/28/22 at 12:04 PM, when queried if there were any wound treatment orders on the plan of care, measurements, or outcomes addressed on the plan of care, Administrator #1 stated ";No." During this time, Regional Director of Clinical Operation #2 indicated this patient was on the list to be audited as part of the Immediate Jeopardy plan for removal, the audits were due to be completed by 5:00 PM on 9/30/22, and this record was not yet audited. 9. Clinical record review on 9/22/22, for patient #11, election of benefit/hospice admission date 11/23/2020, evidenced a document dated 9/14/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", which indicated the patient had wounds on her leg, and new problems included increased fatigue. The document failed to include development of measurable outcomes for the increased fatigue, or measurable outcomes for the wounds. During an interview on 9/23/22 at 3:43 PM, Administrator #1 indicated she would expect basic wound information to be in the plan of care, they didnt usually include a lot of specific information, and that would be included in the wound care report. During this time, Area Director of Education #5 indicated wound review of better or worse should be in IDG (plan of care document), and should be described as far as progress, and include new interventions if worse. 10. During an interview on 9/22/22 at 1:44 PM, when queried what the agency has implemented to protect patients from negative outcomes, Administrator #1 indicated they developed a performance improvement project (PIP) on 9/01/22, and Area Vice President of Operations #4 indicated this problem was identified in July and August (2022), but no immediate action was taken yet to protect patients from negative outcomes.

Based on observation, record review, and interview, the hospice agency failed to ensure the patients plan of care included all drugs and/or treatments for 4 of 6 active clinical records reviewed (#1, 3, 10, 11). The findings include: --- 1. Review of an agency policy received 9/26/22, dated ";February" (no year identified), titled ";The Plan of Care", stated ";... written plan of care will contain ... Medications and treatments ... including drugs and treatments necessary to meet the needs of the patient ...." 2. Review of an agency policy dated 11/2020, titled ";Ongoing Assessments", stated, ";... change/verbal orders will be generated ... and incorporated into the plan of care ... The physician will be notified to verify any changes in medications, including drugs and treatments to meet the needs of the patient, over-the-counter medications ... will be included in the plan of care by the interdisciplinary group ...." 3. A home visit was observed with patient #1 and registered nurse (RN) #3 on 9/22/22 at 3:00 PM. Observed the patient had an indwelling urinary catheter (a tube inserted into the bladder to drain urine), RN #3 indicated she just changed it about a week ago, and it was changed every 30 days. Observed the patients buttocks were reddened/inflamed, and RN #3 applied ";Coloplast Hydrophilic Wound Dressing Paste" (wound/skin treatment to provide a protective seal over the skin, while absorbing excess fluid, to reduce inflammation/skin redness) to the buttocks after personal care was provided (due to incontinence of bowel). RN #3 indicated the patient had previous open wounds on the buttocks, which were now healed, and the paste was routinely used for prevention of skin breakdown due to bowel incontinence and bedbound status. Clinical record review on 9/21/22, for patient #1, election of benefit/hospice admission date 6/14/22, evidenced a document dated 9/12/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report". The plan of care failed to include Coloplast Hydrophilic Wound Dressing Paste was used as a routine treatment (per RN #3 statement), or was listed as an over-the-counter (OTC) remedy on the medication list; and failed to include treatment orders for the care/maintenance of the indwelling urinary catheter. An agency document received and reviewed on 9/23/22, dated 9/22/22, titled ";Visit Note Report" indicated the patient had a stage 1 (a wound without skin breaks or tears, appears reddened and does not blanch [lose color briefly when you press your finger on it and then remove your finger]) pressure injury (injury caused by unrelieved pressure) to the left buttock, and barrier cream was applied. . During an interview on 9/23/22 at 3:35, Administrator #1 indicated no order was needed for barrier cream if it wasnt an actual treatment, but just used as a preventative. 4. A home visit was observed with patient #3 and registered nurse (RN) #4 on 9/22/22 at 3:00 PM, at entity #6 (an assisted living facility [ALF]). Observed RN #4, who applied hydrocolloid dressings to both buttocks, and applied lotion to a reddened area on the patients spine, just below the shoulder blades, where pressure was consistent while the patient sat in the recliner. RN #4 indicated the area on the spine was an old pressure injury, she kept lotion on the area to keep the skin supple, and she wasnt ";doing anything official" with it. Clinical record review on 9/21/22, for patient #3, election of benefit/hospice admission date 5/25/22, evidenced a document dated 8/26/22, titled ";Visit Note Report", which indicated a nursing visit was made, the nurse re-applied a hydrocolloid dressing (provides a moist and insulating healing environment which protects uninfected wounds while allowing the body's own enzymes to help heal wounds) to the patients buttocks, and applied lotion to a reddened area on the patients spine. The clinical record failed to evidence an order for the use of hydrocolloid, or use of lotion to treat the reddened area on the patients spine on 8/26/22. Review of a document dated 8/29/22, titled ";Visit Note Report", indicated a nursing visit was made, and the nurse applied a hydrocolloid dressing to the buttocks. The clinical record failed to evidence an order for the use of hydrocolloid on 8/29/22. Review of a document dated 9/02/22, titled ";Visit Note Report", indicated a nursing visit was made, the nurse applied antifungal cream (location not specified). The clinical record failed to evidence an order for the use of antifungal cream on 8/29/22. Review of a document dated 9/12/22, titled ";Visit Note Report", indicated a nursing visit was made, the nurse applied antifungal cream (location not specified), and indicated staff at entity #6 (an assisted living facility [ALF]) was aware hydrocolloid dressings were available if patient had increased discomfort or skin worsened. The clinical record failed to evidence an order for the use of hydrocolloid to be used if needed. Review of a document dated 9/16/22, titled ";Visit Note Report", indicated a nursing visit was made, the patient had a new shearing (caused by friction) wound to the left buttock, and an order was received to apply hydrocolloid dressing during skilled nursing visits. Review of a document dated 9/06/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report". The document stated ";... Buttocks remain red and chaffed. We are now using antifungal barrier cream ...." The section of the document for inclusion of orders received since last IDG meeting failed to evidence an order for the antifungal cream, or frequency of use. Review of a document dated 9/16/22, titled ";Hospice Physician Order", indicated wound orders to apply hydrocolloid dressing to the left buttock. The order failed to indicate hydrocolloid was ordered to be applied to the right buttock. During an interview on 9/28/22 at 11:42 AM, Administrator #1 indicated she would expect to see a treatment order for the antifungal, but wouldnt expect to see an order for barrier cream. When queried if there should be an order, and should it be on the plan of care, for the hydrocolloid documented in the skilled nurse note dated 9/12/22, which stated, ";... Staff aware hydrocolloid available if patient has increased to discomfort or skin condition worsens ....", Administrator #1 stated, ";... Well I think it wasnt being used yet ... she [hospice nurse] was just letting them [entity #6 staff] know it was available if it was needed ...." When queried if there was an order to apply hydrocolloid to both buttocks, Administrator #1 stated, ";... maybe she [hospice nurse] was being proactive with the hydrocolloid ....", and indicated there should be an order for the hydrocolloid, and it should be on the plan of care. 5. Clinical record review on 9/21/22, for patient #10, election of benefit/hospice admission date 3/2/22, evidenced a document dated 9/07/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", which stated ";... Any new problems identified: wound to heel ...." The document failed to include wound treatment orders. Review of a document dated 9/21/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", failed to include any documentation of presence or status of a wound. During an interview on 9/28/22 at 12:04 PM, when queried if there were any wound treatment orders on the plan of care, Administrator #1 stated ";No." During this time, Regional Director of Clinical Operation #2 indicated this patient was on the list to be audited as part of the Immediate Jeopardy plan for removal, the audits were due to be completed by 5:00 PM on 9/30/22, and this record was not yet audited. 6. Clinical record review on 9/22/22, for patient #11, election of benefit/hospice admission date 11/23/2020, evidenced a document dated 9/14/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", which indicated the patient had wounds on her leg, and failed to include any wound treatment orders. During an interview on 9/22/22 at 2:21 PM, RN #1 indicated she knew the patient had a wound, but couldnt remember which leg, shed never assessed or seen the wound herself, she saw a picture of it ";at least 3 or 4 weeks ago"; entity #1 (an extended care facility [ECF]) (where the patient resided) had a wound care nurse, and they did the wound care. When queried if the patient had more than 1 wound, RN #1 stated, ";No." During an interview on 9/22/22 at 1:35 PM, Administrative RN #4 (Area Vice President of Operations) indicated she was the agencys Clinical Supervisor, the patient resided at a facility, and ";they" typically had a wound care nurse. Administrative RN #4 indicated she saw an order for wound care on 5/18/22. At 1:44 PM, Administrator #1 indicated there were no wound care orders after 7/22/22. Review of a document dated 7/22/22, titled ";Hospice Physician Order", stated, ";... Wound care leg ... clean with wound cleaners ... rinse with NS [sterile salt water] ... apply silver alginate [dressing made of natural fibers derived from seaweed, with silver as an antimicrobial property] ... cover with dressing ... wound care to be performed ... [during hospice nurse visits] ...." Review of Entity #1 documentation received on 9/23/22, dated 7/28/22, 8/4/22, 8/11/22, 8/15/22, 8/23/22, 8/30/22, 9/16/22 and 9/20/22, all titled ";Wound Evaluation and Management Summary" indicated the patient had 2 current, chronic/ongoing wounds greater than 1 year old to the left lower leg; and wound care was ordered 3 times weekly to both wounds: apply iodosorb (iodine impregnated gauze), cover with Vaseline impregnated gauze, and wrap leg with rolled gauze.

Based on record review and interview, the hospice interdisciplinary group (IDG) failed to review/revise, and document the patient's plan of care as often as needed, for 1 of 1 clinical record reviewed for a patient who required immediate intervention (#9). The findings include: --- Review of an agency policy dated 01/22, titled ";Interdisciplinary Group [IDG] Membership and Responsibilities" stated ";... responsibilities include ... Review of any ... caregiver complaints ... and takes remedial action as appropriate ...." Review of an agency policy received 9/26/22, dated ";February" (no year identified), titled ";The Plan of Care", stated ";... The plan of care will be reviewed and revised as often as frequently as deemed necessary ... Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care ... Any change in the patient's condition must result in a change in the plan of care, prior to the implementation of the new service ...." Review of the agencys incident/complaint log on 9/21/22, evidenced a document dated 9/06/22, titled ";Client Occurrence Report", which indicated entity #3 (a non-medical provider for private duty caregiver services) staff requested a hospice nurse visit because its staff member (other person #4) witnessed a verbal/physical encounter between the patient and a family member on 9/05/22; family yelled, grabbed, and yanked the patients right arm, and told the patient to be quiet and stop talking. Clinical record review on 9/21/22, for patient #9, election of benefit/hospice admission date 4/19/22, primary diagnosis cerebrovascular disease (an area of the brain is temporarily or permanently damaged by obstruction of blood flow or bleeding) and other diagnosis Dementia, evidenced a document dated 9/06/22, titled ";Visit Note Report", which indicated a nursing visit was made due to allegations of abuse by family, bruising was noted, and Administrator #1 ";was made aware". A document dated 9/06/22, titled ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to include information related to allegations of abuse. The clinical record failed to evidence another IDG meeting was conducted "as needed" to revise/update the plan of care due to the need for immediate hospice agency intervention(s) for alleged patient abuse. A document dated 9/19/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", evidenced social worker #1 received phone calls from entity #3 on 9/15/22 with concerns that patient had bruises and witnessed family being rough with the patient. The document failed to indicate the hospice IDG conducted a meeting to update the plan of care prior to 9/19/22. During an interview on 9/21/22 at 5:18 PM, Administrator #1 indicated the agency did send a nurse out (after being notified of alleged abuse). During an interview on 9/26/22 at 12:23 PM, when queried about alleged abuse, entity #3s manager (other person #5) indicated he had concern with family/patient interaction, and he informed the hospice agency on 9/06/22, to make them aware of the concern for abuse. During an interview on 9/26/22 at 1:05 PM, when queried what steps were taken when the agency was made aware of the witnessed verbal/physical abuse, Administrator #1 indicated a nurse went out to assess the patient, the social worker and chaplain always checked while they visited, and family was rarely present during hospice agency visits.

Based on record review and interview, the interdisciplinary group (IDG) failed to ensure it directed, supervised, and coordinated/shared information to meet the patients needs, for 6 of 6 active clinical records reviewed (#1, 3, 8, 9, 10, 11). The findings include: --- 1. Review of an agency policy dated 01/22, titled ";Interdisciplinary Group [IDG] Membership and Responsibilities" stated ";... responsibilities include ... supervision of hospice care and services ... Coordination of care and sharing of information among IDG members and non-hospice care providers ...." 2. A home visit was observed with patient #1 and registered nurse (RN) #3 on 9/22/22 at 3:00 PM. The patient indicated she wanted to receive a COVID-19 booster shot and a seasonal flu shot, and she previously asked hospice staff about this. RN #3 indicated she previously talked to the social worker about it, and the social worker was looking into who might be able to come to the home to administer the vaccines. Clinical record review on 9/21/22, for patient #1, election of benefit/hospice admission date 6/14/22, evidenced a document dated 9/22/22, titled ";Visit Note Report", failed to evidence care coordination/sharing of information to the IDG about the patients request to receive vaccinations. Review of a document dated 9/12/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", failed to evidence care coordination/sharing of information to the IDG about the patients request to receive vaccinations. During an interview on 9/23/22 at 3:35 PM, Administrator #1 indicated they (the agency) just needed an order from the physician, and then they could administer the vaccines. When queried if the clinical record contained information about the patients request for vaccines, no further information was provided or submitted. 3. A home visit was observed with patient #3 and registered nurse (RN) #4 on 9/22/22 at 3:00 PM, at entity #6 (an assisted living facility [ALF]). The patient did not have a wound dressing in place on the buttocks upon removal of clothing. Observed RN #4, who applied hydrocolloid dressings to both buttocks. When queried why there was no dressing on the patients buttocks, RN #3 stated, ";... It must have fallen off ...." At 10:10 AM, person #7 (staff at entity #6) indicated they (staff at entity #6) did not do wound care for this patient, they werent allowed, and the hospice did it. Clinical record review on 9/21/22, for patient #3, election of benefit/hospice admission date 5/25/22, evidenced a document dated 9/19/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report". The document included wound care orders, which indicated the ";facility" (entity #6) nurse would change the dressing as needed if soiled or loosened. During an interview on 9/28/22 at 11:47 AM, Administrator #1 indicated she was unaware entity #6 staff did not perform wound care, and she would have to get clarification. No further information was provided. 4. Clinical record review on 9/21/22, for patient #8, election of benefit/hospice admission date 5/6/22, evidenced a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 8/10/22, indicated skilled nurse visits were ordered 2 times weekly, wound care was ordered daily, wounds continued to get worse, and patient was non-compliant with medications and wound care; and listed diagnoses included only 1 wound- ";pressure ulcer [injury] of unspecified site, unspecified stage". The document failed to include who did wound care on days the hospice nurse was not present, or a plan to improve compliance with medications and wound care. Review of documents titled ";Visit Note Report" (skilled nurse home visit), dated 8/04/22, 8/16/22, 8/18/22, 8/23/22, 8/30/22, and 9/13/22, all indicated the patient refused wound assessment/treatment. Review of documents titled ";Visit Note Report", dated 8/18/22, 8/30/22, 9/01/22, 9/08/22, 9/13/22, and 9/15/22, all indicated wound care was already completed, and no wound care/assessment was performed by the hospice nurse. Review of a document dated 9/21/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", indicated the patient had ";multiple wounds" which were getting larger, increased pain and recently prescribed morphine (a narcotic medication for severe pain), had new wound infection, and was prescribed antibiotics. The document failed to evidence the IDG supervised the care provided and was aware no wound care or assessments were made since 8/09/22. During an interview on 9/23/22 at 4:18 PM, Administrator #1 indicated the patient had the right to refuse treatment, but IDG should be discussing it, the first goal was to keep the patient comfortable, and she expected to see this documented on the plan of care. When queried about the IDG plan of care dated 9/21/22, which indicated the wound was bigger, Area Director of Education #5 indicated the plan of care should include wound assessment/measurements. 5. Clinical record review on 9/21/22, for patient #9, election of benefit/hospice admission date 4/19/22, primary diagnosis cerebrovascular disease (an area of the brain is temporarily or permanently damaged by obstruction of blood flow or bleeding) and other diagnosis Dementia, evidenced a document dated 9/06/22, titled ";Visit Note Report", which indicated a nursing visit was made due to allegations of abuse by family, and Administrator #1 ";was made aware". Review of the agencys incident/complaint log on 9/21/22, evidenced a document dated 9/06/22, titled ";Client Occurrence Report", which indicated entity #3 (a non-medical provider for private duty caregiver services) staff requested a hospice nurse visit because its staff member (other person #4) witnessed a verbal/physical encounter between the patient and a family member on 9/05/22; family yelled, grabbed, and yanked the patients right arm, and told the patient to be quiet and stop talking. The documented stated ";... [the nurse assessed] ... right posterior [back] forearm old bruising yellowish in color and round circular dime sized old purplish in color bruise to anterior [front] right forearm ...." The document also included an update added by Administrator #1 on 9/06/22, which indicated a call was placed to entity #3, Administrator #1 spoke with entity #3s manager (other person #5), who indicated he was going to place a call to APS to report the incident. The document failed to evidence the hospice IDG conducted its own investigation, contacted/coordinated with Adult Protective Services (APS) or Indiana Department of Health (IDOH), or immediately took action to ensure the patients safety. Review of a document dated 9/06/22, titled ";Client Coordination Note Report" indicated the hospice agency was unsuccessful with attempt to contact family, and a voicemail was left. The clinical record failed to evidence any further attempt to coordinate with family. Review of a document dated 9/19/22, titled ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report", evidenced social worker #1 received phone calls from entity #3 with concerns that patient had bruises and witnessed family being rough with the patient. The document failed to indicate the hospice IDG conducted its own investigation or took any immediate action to ensure the patients safety. During an interview on 9/21/22 at 5:18 PM, Administrator #1 indicated the agency did send a nurse out (after being notified of alleged abuse), collaborated with entity #3, entity #3 witnessed the incident, not the hospice agency, so they (entity #3) actually contacted APS to put in a complaint to do further investigation. During an interview on 9/26/22 at 12:23 PM, when queried about alleged abuse, entity #3s manager (other person #5) indicated he had concern with family/patient interaction, and he informed the hospice agency to make them aware of the concern for abuse on 9/06/22. During an interview on 9/26/22 at 1:05 PM, when queried what steps were taken when the agency was made aware of the witnessed verbal/physical abuse, Administrator #1 indicated a nurse went out to assess the patient, the social worker and chaplain always checked while they visited, and family was rarely present during hospice agency visits. 6. Clinical record review on 9/21/22, for patient #10, election of benefit/hospice admission date 3/2/22, evidenced a document dated 9/07/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", which indicated the patient resided at entity #8, a long-term care facility, and had a new wound to the heel. The document failed to evidence coordination with entity #8, which heel the wound was located, or who performed wound care. Review of a document dated 9/21/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", failed to include any documentation of presence or status of a wound. During an interview on 9/28/22 at 12:04 PM, Administrator #1 indicated the IDG meeting note/plan of care dated 9/07/22, failed to include the wound was addressed by the IDG. During this time, Regional Director of Clinical Operation #2 indicated this patient was on the list to be audited as part of the Immediate Jeopardy plan for removal, the audits were due to be completed by 5:00 PM on 9/30/22, and this record was not yet audited. 7. Clinical record review on 9/22/22, for patient #11, election of benefit/hospice admission date 11/23/2020, evidenced a document dated 9/14/22, titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report", which indicated the patient had wounds on her leg, and failed to include the IDG addressed the wound(s), or coordinated care with entity #1(an extended care facility [ECF]) (where the patient resided). During an interview on 9/22/22 at 2:21 PM, RN #1 indicated she knew the patient had a wound, couldnt remember which leg, shed never assessed or seen the wound herself, she saw a picture of it ";at least 3 or 4 weeks ago"; and entity #1 had a wound care nurse, who did the wound care. When queried if the patient had more than 1 wound, RN #1 stated, ";No." During an interview on 9/22/22 at 1:35 PM, Administrative RN #4 (Area Vice President of Operations) indicated she was the agencys Clinical Supervisor, the patient resided at a facility, and ";they" typically had a wound care nurse. Administrative RN #4 indicated she saw an order for wound care on 5/18/22. At 1:44 PM, Administrator #1 indicated there were no wound care orders after 7/22/22. During an interview on 9/23/22 at 11:50 PM, person #2 (staff at entity #1) indicated the hospice was aware the facility wound physician saw wound patients every Tuesday, and they were welcome to attend. Review of a document dated 7/22/22, titled ";Hospice Physician Order", stated, ";... Wound care leg ... clean with wound cleaners ... rinse with NS [sterile salt water] ... apply silver alginate [dressing made of natural fibers derived from seaweed, with silver as an antimicrobial property] ... cover with dressing ... wound care to be performed ... [during hospice nurse visits] ...." No further wound treatment orders were evidenced in the clinical record. Review of Entity #1 documentation received on 9/23/22, dated 7/28/22, 8/4/22, 8/11/22, 8/15/22, 8/23/22, 8/30/22, 9/16/22 and 9/20/22, all titled ";Wound Evaluation and Management Summary" indicated the patient had 2 current, chronic/ongoing wounds greater than 1 year old to the left lower leg; and wound care was ordered 3 times weekly to both wounds: apply iodosorb (iodine impregnated gauze), cover with Vaseline impregnated gauze, and wrap leg with rolled gauze. The clinical record failed to evidence coordination with entity #1 for current wound care orders. During an interview on 9/23/22 at 3:43 PM, Administrator #1 indicated she would expect weekly coordination with the facility to schedule a time to attend while the facility performed wound care/assessments. 8. During an interview on 9/23/22 at 4:02 PM, Administrator #1 indicated whatever was included on the IDG/plan of care document was what was discussed during the meeting.

Based on record review and interview, the agency failed to provide a means for patients to voice grievances to the state hotline by having provided an incorrect Indiana Department of Health toll-free number for reporting complaints for 6 (Patients #5, 6, 10, 13, 14, and 24) of 6 active patients patients whose records were reviewed, with a potential to affect all 139 active patients. The Findings Included: 1. A review of a policy titled "PATIENT BILL OF RIGHTS POLICY NO. 2-002," dated November 2020, received from the administrator on 5-25-22 AT 3:15 PM, revealed the patients' right to "Receive in writing prior to start of care, the telephone numbers for the State specified Hotline ... to receive complaints ... about the hospice." 2. A review of the clinical record for Patient #5, on 05-24-2022, evidenced the clinical record contained a document titled, "SOUTHERNCARE HOSPICE SERVICES ...DISCLOSURE STATEMENT: INDIANA," approved 05/2017, signed by Patient #5, that revealed an incorrect telephone number, 1-800-277-6334, for the Indiana Department of Health toll-free phone number to make complaints. On 05-26-22 at 10:36 AM, the Administrator was informed the complaint/incident toll-free number for the Indiana Department of Health was listed incorrectly on the signed consent forms in their patient home packets. She confirmed that the number was incorrect and that all patients at all Southerncare Hospice branches had this incorrect toll-free on their forms titled, ... "DISCLOSURE STATEMENT: INDIANA. " 3. A review of the clinical record for Patient #6, on 05-24-2022, evidenced the clinical record contained a document titled, "SOUTHERNCARE HOSPICE SERVICES ...DISCLOSURE STATEMENT: INDIANA," approved 05/2017, signed by Patient #6's representative, that revealed an incorrect telephone number, 1-800-277-6334, for the Indiana Department of Health toll-free phone number to make complaints. On 05-26-22 at 10:36 AM, the Administrator was informed the complaint/incident toll-free number for the Indiana Department of Health was listed incorrectly on the signed consent forms in their patient home packets. She confirmed that the number was incorrect and that all patients at all Southerncare Hospice branches had this incorrect toll-free on their forms titled, ... "DISCLOSURE STATEMENT: INDIANA. " 4. A review of clinical record review for Patient #10, on 5-24-22 at 10:15 AM, evidenced the clinical record contained a document titled, "SOUTHERNCARE HOSPICE SERVICES ...DISCLOSURE STATEMENT: INDIANA," approved 05/2017, signed by Patient #10's representative, that revealed an incorrect telephone number for the Indiana Department of Health toll-free phone number to make complaints. On 5-25-22 at 10:36 AM, the Administrator was informed the complaint/incident toll-free number for the Indiana Department of Health was listed incorrectly on the signed consent forms in their patient home packets. She confirmed that the number was incorrect and that all patients at all Southerncare Hospice branches had this incorrect toll-free on their forms titled, ... "DISCLOSURE STATEMENT: INDIANA. " 5. Clinical record review for patient #13, on 5-24-22, evidenced the clinical record contained a document titled, "SOUTHERNCARE HOSPICE SERVICES ...DISCLOSURE STATEMENT: INDIANA," approved 05/2017, signed by Patient #13, that revealed an incorrect telephone number for the Indiana Department of Health toll-free phone number to make complaints. On 5-25-22 at 10:36 AM, the Administrator was informed the complaint/incident toll-free number for the Indiana Department of Health was listed incorrectly on the signed consent forms in their patient home packets. She confirmed that the number was incorrect and that all patients at all Southerncare Hospice branches had this incorrect toll-free on their forms titled, ... "DISCLOSURE STATEMENT: INDIANA. " 6. A review of the clinical record for Patient #14, on 5-25-22 at 10:15 AM, evidenced the clinical record contained a document titled, "SOUTHERNCARE HOSPICE SERVICES ...DISCLOSURE STATEMENT: INDIANA," approved 05/2017, signed by Patient #14's representative, that revealed an incorrect telephone number for the Indiana Department of Health toll-free phone number to make complaints. On 5-25-22 at 10:36 AM, the Administrator was informed the complaint/incident toll-free number for the Indiana Department of Health was listed incorrectly on the signed consent forms in their patient home packets. She confirmed that the number was incorrect and that all patients at all Southerncare Hospice branches had this incorrect toll-free on their forms titled, ... "DISCLOSURE STATEMENT: INDIANA. " During an interview on 5-23-22 at 3:35 PM, with Patient #14's representative, they reported having attempted to contact the Indiana Department of Health Hot-line to lodge a complaint. Patient #14's representative used the information provided by SouthernCare Hospice, and discovered they had been given an incorrect phone number. 7. A review of the clinical record for Patient #24, on 05-24-2022, evidenced the clinical record contained a document titled, "SOUTHERNCARE HOSPICE SERVICES ...DISCLOSURE STATEMENT: INDIANA," approved 05/2017, signed by Patient #24, that revealed an incorrect telephone number, 1-800-277-6334, for the Indiana Department of Health toll-free phone number to make complaints. 8. On 05-26-22 at 10:36 AM, the Administrator was informed the complaint/incident toll-free number for the Indiana Department of Health was listed incorrectly on the signed consent forms in their patient home packets . The administrator indicated these were the only signed consents for Patients #5, 6, 10, 13, 14, and 24. The administrator confirmed that the number was incorrect and that all patients at all Southerncare Hospice branches had this incorrect toll-free on their forms titled, ... "DISCLOSURE STATEMENT: INDIANA. "