Every finding on record at St. Croix Hospice, LLC

It is required that the patient’s pain is assessed as part of a comprehensive assessment. Assessment of pain in children and adolescents is conducted with consideration of age and neurocognitive development. The documented assessment of the patient’s pain includes: history of pain and its treatment, both pharmacological and non-pharmacological; use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including: location, frequency, and intensity; and how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. 3 of 23 (13%) clinical records reviewed revealed that the agency did not ensure that a comprehensive pain assessment was completed upon admission. CLINICAL RECORD 7: The patient's date of election was 09/02/2025. The RN [registered nurse] Hospice Start of Care visit note dated 09/02/2025 documented in part, "Was the patient screened for pain? Yes ... Pain score (0-10) 0 - Patient has no pain. Was a comprehensive pain assessment done? No..." The coordination admission note stated in part, "Patient was seen at (State) Specialty Hospital (City/State) on 08/04/2025 due to steady abdominal pain that radiated to back... CT scan of abdomen and pelvis performed and revealed a nodular mass in the ascending colon and cecum. Mild adjacent pericolonic inflammatory changes. Suspected carcinoma. Patient was given script for tramadol for pain." The medication profile reviewed revealed tramadol 50 mg tablet, take 1-2 tablets by mouth every 6 hours for pain, dated 09/02/2025. The record lacked a comprehensive pain assessment that would have included history of pain and its treatment, both pharmacological and non-pharmacological; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function; and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. CLINICAL RECORD 8: The patient's date of election was 10/16/2025. The RN Hospice Start of Care visit note dated 10/16/2025 documented in part, "Was the patient screened for pain? Yes ... Pain score (0-10) 0 None...Was a comprehensive pain assessment done? No..." The coordination admission note stated in part, "Pain: patient has some mild pain that is being managed with prn (as needed) and scheduled Tylenol." The medication profile reviewed revealed acetaminophen 325 mg tablet, take 1 tablet every 4 hours as needed for pain or fever, dated 10/16/2025; and acetaminophen 325 mg tablet, take 2 tablets every 8 hours for pain, dated 10/16/2025. The record lacked a comprehensive pain assessment that would have included history of pain and its treatment, both pharmacological and non-pharmacological; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function; and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. CLINICAL RECORD 22: The patient's date of election was 11/28/2025. The RN Hospice Start of Care visit note dated 11/28/2025 documented in part, "Was the patient screened for pain? Yes ... Pain score (0-10) 0 - Patient has no pain...Was a comprehensive pain assessment done? No..." The coordination admission note stated in part, "Pt (patient) indicates (patient) has no pain at this time. Staff stated (patient) continues with Tylenol 3x a day scheduled for chronic pain. They feel (patient) is comfortable at this time." The medication profile reviewed revealed acetaminophen 500 mg tablet, 1 tablet three times a day orally for chronic pain, dated 11/28/2025. The record lacked a comprehensive pain assessment that would have included history of pain and its treatment, both pharmacological and non-pharmacological; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function; and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. During a joint clinical record review and interview on 04/17/2026, the Regional Director of Clinical Operations confirmed that the records lacked evidence that comprehensive pain assessments were conducted upon admission.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation showed volunteer hours of 467.92 and direct patient care hours of 45,608.29, resulting in a combined volunteer-to-patient-care ratio of 1.03% for 2025. The agency had a Performance Improvement Project (Document 1) identified and initiated on 01/01/2025. The project contained quarterly data for each branch through Quarter 1, January 2026. Agency Performance Improvement Project: Volunteer Cost Savings, dated 01/01/2025, documented: Date Identified: 01/01/2025. Revaluation Date: 03/30/2026. List of indicators: (State) Branches not at or above 5% cost savings. Measurable goals for each indicator: Successful achieved 5% cost savings; volunteer recruitment growth; improvement in volunteer service hours. Root Cause Analysis: 04/2020-12/31/2023, PHE-1135 Volunteer Services Waiver in place; Waiver lifted on 01/2024. Metric Scores/Location(s) as Applicable: The following Branches in (State); Pre-Intervention Score: Q4-2024: 0.46%. Remeasurement Scores are sectioned out by Branch and quarter. The PIP remeasurement data: Q2-April 2025: Parent (P): 0.49%, ADS1: 0.79%, ADS2: 0%; Q3-July 2025: P:0.94%, ADS1: 1.85%, 0.71%; Q4-October 2025: P: 1.13%, ADS1: 1.30%, ADS2: 0.65%; Q1-January 2026: P: 1.02%, ADS1: 0.80%, ADS2: 0.92%. Task Related to Desirable Outcome: RVC's (Regional Volunteer Coordinators) to re-evaluate and enhance recruitment strategy; enhance the recruitment network with the community; and engage with current volunteers to maximize volunteer activity. All tasks were assigned to team members. All tasks had a start date of 01/15/2025 and a revaluation date of 03/30/2026. During a joint document review and interview on 04/15/2026, the Director of Human Resources Operations and the previous Manager of Volunteer Services (Corporate) provided an overview of the Volunteer Program. This position was in the process of being transitioned to the current Manager of Volunteer Services (Personnel Record 13). The discussion covered recruitment and retention efforts, as well as recent attempts to recruit more volunteers and processes for retaining them. During a joint document review and interview on 04/16/2026, the Regional Volunteer Coordinator discussed efforts to increase the number of volunteers and volunteer hours at the parent and two alternate delivery sites. During a joint document review and interview on 04/16/2026, the Regional Director of Clinical Operations discussed the Performance Improvement Project that began in January 2025 and the progress of interventions aimed at improving volunteer hours. A discussion was held regarding the volume of direct patient care hours, including multiple monthly visits for Music Therapy and Massage Therapy, and the volume of end-of-life visits, which resulted in a higher total number of direct patient care hours and a lower percentage for the volunteer hours. Upon reviewing the volunteer program, the documentation showed volunteer hours of 467.92 and direct patient care hours of 45,608.29, resulting in a combined volunteer-to-patient-care ratio of 1.03% for 2025. The agency had a Performance Improvement Project (Document 1) identified and initiated on 01/01/2025. The project contained quarterly data for each Branch through Quarter 1, January 2026.

Based on observations, staff interviews, patient/caregiver interviews, policy review and clinical record review the agency failed: to maintain a system of communication and integration in accordance with the hospices own policies and procedures to ensure the interdisciplinary group maintained responsibility for directing, coordinating, and supervising the care and services provided (L554). --- The cumulative effects of these systemic practices resulted in placing patients at risk of not receiving safe, individualized and consistent care designed to meet each patients health needs.

Based on home observations, staff and family interviews, record reviews, and policy review, the agency failed to maintain and develop a system of communication and integration in accordance with the hospices own policy to ensure the interdisciplinary group maintains responsibility for directing coordination and supervising the care and services provided for 1 of 4 sampled patients. (Patient #3) Failure of the interdisciplinary team to collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. --- Findings include: In the policy titled Interdisciplinary Group Coordination of Care, dated 2/20/2024, the hospice interdisciplinary group will retain professional management responsibilities/ for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner. The hospice agency will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and families/caregivers serviced by the hospice. The Registered Nurse Case manager will be responsible for the coordination of services with the interdisciplinary group from referral to discharge and know the scope of care which can be provided by the different members of the interdisciplinary team. Patient #3 had a start of care date of 8/19/24. Interview 10/8/24 at 3:35 pm, Staff A, Manager of Clinical Services with the Cedar Falls Branch, stated, on 9/24/24, the agency became aware at approximately 4:00PM, that Staff B, Registered Nurse (RN) Case Manager did not complete a scheduled visit for patient #3 on 9/23/24. Staff A reported that she received a call from Staff C, Home Health Aide, who reported the family member of Patient #3 was concerned that Patient #3 did not receive the scheduled skilled nurse visit on 9/23/24. Staff A reported she called and spoke with the family member of Patient #3. Patient #3's family member stated the nurse did not make the visit on 9/23/24, based on the private caregivers report. Staff A reported the family did not want Staff B, RN back into the home. Staff A, reported she called Staff B, RN, immediately after speaking with Patient #3's family member. Staff A reported initially Staff B stated she made the visit, but then Staff B RN, recanted and stated she was confused and she had not made the visit. Staff A reported the family of Patient #3 was offered an additional skilled nurse visit on 9/24/24, but the visit was declined. Staff A reported the next scheduled skilled nursing visit, 9/26/24, was completed by Staff D, Licensed Practical Nurse (LPN), who identified a new pressure area that was red and non blanchable to Patient #3s right hip. Staff F, Nurse Practitioner was notified at the time of the LPN visit and order obtained for mepilex (foam) dressing to be placed over the area. Staff A acknowledged a Registered Nurse did not complete an assessment following the missed visit on 9/23/24, until 10/1/24. Staff A reported that Staff E, RN, noted a second pressure area to the left hip on 10/1/24 and noted the pressure area on the right hip was open with minimal drainage. Staff E, notified Staff F, Nurse Practitioner, and received order to cover area with mepilex, change two times per week and as needed. Staff A reported on 10/1/24, agency offered daily nursing visits for Patient #3 family member, until the skin areas healed, the family member declined. Record review indicated no Registered Nurse (RN) completed a comprehensive assessment on 9/24/24. Patient #3's record review identified the agency did not have a RN complete an assessment visit until 10/1/24. Interview 10/9/24 at 8:23 AM, with Staff C, Home Health Aide (HHA), stated when Staff C placed a call to Patient #3's family member for an update, following her visit on 9/24/24, the family member reported she was concerned, the RN did not make the scheduled visit on 9/23/24. Staff C, HHA reported she called Staff A, Manager of Clinical Services and reported Patient 3's family member's concern. Interview 10/9/24 at 10 AM, with Staff B, RN Case Manager, reported she made a mistake and became confused on dates, and indicated the visit scheduled for 9/23/24 for Patient #3 was not missed on purpose. Staff B reported when she realized the visit was missed, she did document a missed visit and notified the physician via fax on 9/24/24. Interview 10/09/24 at 10:AM, with Staff F, Nurse Practitioner (NP) stated on 9/26/24, the missed RN visit and the stage 1 pressure area to the right hip was reported to her during the visit by Staff D, LPN, and again on 10/1/24, when Staff E, RN notified Staff F, NP, of a second pressure area over the left hip. Staff F reported on 10/1/24, Patient 3's family was offered daily nursing visits for monitoring of skin breakdown, until skin areas could heal and the family declined. Interview 10/9/24 at 3:00 PM, with Patient #3s family member stated, Patient #3 is a centurion, and resided in the home alone monitored by live cameras approximately every 2 hours. The family member reported she and a private caregiver provided cares for Patient #3 for the last three years. She reported Patient #3 was bedbound and fatigued easily, sleeping about 16 out of 24 hours a day. The family member reported the private caregiver came Monday through Friday in the morning about 8:00 AM to get Patient #3 out of bed, complete a sponge bath, change the incontinency briefs, prepare a meal and help Patient #3 back to bed, placing a cup with water or juice by the bedside and filling a bowl with snacks. The family member reported the hospice agency agreed to send a nurse twice a week on Monday and Thursday and a home health aide on Tuesday and Friday to complete the same routine at about 3pm, and the family provided cares on the weekend. The family member reported, hospice staff agreed to call or text her after every visit to give an update on Patient #3. On Monday, 9/23/24, she realized at 11:30 PM, no communication from the hospice agency had been received. The family member stated she checked the camera and noted Patient #3 was sleeping, and waited for the private caregiver to arrive the next day at 9 am for a report. The family member stated she placed a call to the on call nurse, Staff G, RN on Sunday, 9/29/24 to report a new reddened area over the right hip. Stated Staff G instructed her to put a foam dressing over that area as well, and stated she would pass the information on to Staff E, RN Case Manager. Clinical record revealed the following. a. The Plan of Care (POC), dated 8/19/24 to 11/16/24 diagnoses of senile degeneration of brain, malignant neoplasm of rectum and urinary incontinence. The POC included physician orders for skilled nurse visits 2x a week. The skilled nurse visit included assess medication response, provide instructions related to prevention/management of skin breakdown. b. Clinical record review revealed a missed visit notification on 9/24/24. c. The Interdisciplinary Group Note (IDG) dated 9/25/24, noted the missed visit and identified concerns that Patient #3 was completely bedbound and unable to transfer out of bed without max assist. IDG documentation noted the IDG team was concerned that Patient #3 needed 24-hour care in the home and documented the agency would be providing resources. d. The skilled nurse visit dated 9/26/24 by Staff D, LPN identified a stage 1 pressure ulcer measuring 1 cm x 1cm, non blanchable, over the right hip. The Nurse Practitioner (NP) was notified of the stage 1 pressure ulcer by the LPN and a physician order obtained to apply Mepilex (foam dressing) over the area, change 2x week and as needed and continue to monitor until healed. e. Care coordination note, dated 9/29/24, revealed the family member of Patient #3 placed a call to Staff G, RN Triage Nurse to report a newly identified red area on the right hip and asked if Mepilex could be applied to that area also. Staff G, RN instructed Patient #3's family member to cover that area with Mepilex and noted it was passed on to the RN Case Manager, Staff E, to update. The documentation lacked a physicians order for Mepilex to area reported by family member. f. A skilled nursing visit completed by Staff E, RN Case Manager on 10/1/24, identified a new stage 1 pressure area over the left hip measuring 5.4 cm x 4cm, non blanchable. Staff F, NP was notified and a new physicians order obtained to cover the area with Mepilex and continue to monitor. Staff E, also documented a deterioration to the stage 1 pressure ulcer to the right hip and documented the area as dark red and open with minimal drainage. Documentation revealed the third wound area to the right hip , was a 3cm by 3cm bruise, non blanchable with Mepilex foam dressing. The clinical record lacked a physicians order noted for the third wound on the right hip to be covered by Mepilex dressing. Documentation from Staff E, RN noted a wound care nurse would be notified to assist in recommendations for Patient #3. The clinical record lacked any documentation of assessment of wounds by a wound care nurse. g. The IDG note dated, 10/9/24, lacked discussion of the call family member placed to Staff G , RN triage nurse on 9/29/24, for new reddened area over the right hip, and no order in the IDG notes for Mepilex to be applied to third wound located on right hip. h. Clinical progress note, dated 10/9/24, Staff F, NP, identified Patient #3 was bedbound and completely dependent, for all personal care needs. Staff F, NP, documented a skin assessment and identified all three areas as stage 1 pressure ulcers, two areas on the right hip, and one area on the left hip. Physician orders to continue Mepilex to all three areas. The IDG team failed to maintain responsibility for coordinating and supervising the care and services provided to meet the individualized needs of the patient.

It is required that the comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (11%) clinical records reviewed, the hospice did not ensure the comprehensive assessment identified the physical needs related to the patient's terminal illness that must be addressed to promote the patient's well-being and comfort. Clinical Record 3: The patient elected hospice care on 3/16/2022. The comprehensive assessment completed by the Registered Nurse (RN) dated 3/16/2022 documented no problems identified for endocrine. The patient had a history of diabetes, and the hospice medication profile listed Lantus 100 units/ML 81 units subcutaneously every morning. The Lantus was decreased on 4/5/2022 to 15 Units subcutaneously every morning and then later to 8 Units on 6/14/2022. The coordination note completed by RN on 6/14/2022 documented the "patient's son has concerns with cognition" and stated the patient had increased confusion the last two evenings. The comprehensive assessment did not identify the patient's physical needs related to diabetes. During the joint record review, the Manager of Accreditation confirmed that the assessed identified needs in the clinical records were not updated on their individual plans of care.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. 4 of 4 (100%) home visit observations, the hospice did not ensure that the comprehensive assessment included a complete review of the patient's current prescription medications. Home Visit 1/Clinical Record 17: During the home visit on 5/3/2023 with the Registered Nurse (RN) [Personnel Record 4], a medication reconciliation was performed comparing the hospice drug profile dated 5/2/2023 with the facility drug profile. The medications Lasix and Potassium were not documented on the facility drug profile. The facility nurse stated that the attending Nurse Practitioner (NP) discontinued the medications on 3/20/2023. The discontinuation of the medications by the NP was confirmed during a joint review of the facility's electronic medical record. The hospice RN was not aware of the discontinued medications. The skilled nursing frequency was two times a week since the patient’s election of hospice care on 1/30/2023. The findings were reviewed with the Administrator and Branch Director on 5/3/2023, confirming the hospice medication profile was inaccurate. Home Visit 2/Clinical Record 15: During the home visit on 5/3/2023 with the hospice aide, a medication reconciliation was performed, comparing the hospice drug profile with the patient's medication bottles. The patient provided the medication bottles for all current medications and verbalized the current medication regimen. The patient reported taking “Bayer Back and Body” daily and Naproxen as needed. The medications were not documented on the hospice drug profile. The medication Lorazepam Intensol documented on the hospice drug profile with a start date of 11/17/2022 was not located in the home. The patient did not recall the medication. The skilled nursing frequency was two times a week since the patient’s election of hospice care on 11/17/2022. Later that day, the findings were reviewed with the Administrator and the Manager of Accreditation. Both confirmed the inaccurate medication profile. Home Visit 3/ Clinical Record 19: The patient elected hospice care on 4/13/2023 and received hospice services at an assisted living facility. During the home visit on 5/4/2023 with the Medical Social Worker (MSW) on 5/4/2023, a medication reconciliation was performed comparing the hospice drug profile dated 5/2/2023 with the facility drug profile dated 5/4/2023 and the patient's medication bottles. The patient was alert and oriented and managed and administered his medications. The patient provided his medication bottles. The hospice drug profile documented “acetaminophen 500mg by mouth twice daily with a start date of 4/14/2023.” The facility drug profile did not include acetaminophen. The patient reported taking "acetaminophen two tablets by mouth three times daily for pain." The patient’s acetaminophen bottle dosage per tablet read 650mg, not 500mg, as the hospice’s drug profile documented. The patient reported taking daily: Ferrous Sulfate Fish oil, Calcium/D3, Multivitamins, Vitamin E, and Odorless Garlic. The OTC medications were not documented on the hospice or facility drug profiles. In addition, the patient stated he does not take Senna as listed on the hospice’s drug profile but takes Docusate Sodium and Miralax for constipation; neither medication was documented on the hospice or facility drug profile. The skilled nurse frequency was two times a week since the patient’s election of hospice care on 4/13/2023. Home Visit 4/Clinical Record 18: The patient elected hospice care on 7/29/2022 and received hospice services at a nursing facility. During the home visit on 5/4/2023 with the Registered Nurse [Personnel Record 3], a medication reconciliation was performed comparing the hospice drug profile dated 5/2/2023 with the facility's drug profile dated 5/4/2023. The hospice's drug profile documented “Protonix 40mg by mouth daily” with a start date of 7/29/2022 and “120mL of water to flush the (percutaneous endoscopic gastrostomy) PEG tube twice daily” with a start date of 9/15/2022. The facility's drug profile documented “omeprazole 20mg by mouth two times a day” with a start date of 9/8/2022 and “240mL of water to flush the PEG tube two times per day” with a start date of 10/11/2022. Additionally, the facility's drug profile documented “Senokot S tablet 8.6-50mg by mouth two times a day,” with a start date of 10/16/2022. The hospice's drug profile documented “Senekot” as discontinued on 4/26/2023. After the visit on 5/4/2023, the findings were reviewed with the Administrator and Manager of Accreditation, and both confirmed that the drug profiles were inaccurate.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care [HCPC.19.I/L540]; Failed to ensure that all hospice care and services furnished to patients followed an individualized written plan of care [HCPC.91.I/L543]; Failed to ensure an individualized written plan of care was prepared for each patient based on the comprehensive assessment [HCPC.21.I/L545]; Failed to ensure that the plan of care included the medical supplies and appliances necessary to meet the needs of the patient [HCPC.21.I/L550]; and Failed to ensure that the Interdisciplinary Group reviewed, revised, and documented the individualized care plan as frequently as the patient's condition required, but no less frequently than every 15 calendar days [HCPC.22.I/L552]. 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 for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, interview, and observation. 2 of 19 (11%) clinical records reviewed, the hospice did not ensure the registered nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care. Clinical Record 15: The patient elected hospice care on 11/17/2022. The coordination note completed by the hospice aide on 1/11/2023 documented "pt right 2nd, and 3rd toes starting to breakdown. Applied lotion...Open area also still present on bottom. Applied cream." On 1/17/2023, the hospice aide documented, "Sore looks to be worsening, applied zinc cream...RNCM updated... Asked about possibly ordering different cushion or covering with Mepilex." Additionally, on 1/20/2023 hospice aide documented, "Patient bottom still open, coccyx looks more red as well...Patient also complaining of needing to have a BM. RNCM updated." There was no documented evidence that the RN followed up with the hospice aide to address the aide's concerns. The RN visit note dated 1/23/2023 documented "Redness to Coccyx." The RN visit note dated 1/27/2023 did not include documentation or assessment of the coccyx. There was no evidence of physician orders for barrier cream or zinc cream documented in the plan of care or medication profile, and no evidence the plan of care was updated to include interventions and goals for wound care. Clinical Record 16: The patient elected hospice care on 2/9/2023. The coordination note completed by the on-call RN dated 2/12/2023 documented that the facility called to report that the patient had an unwitnessed fall, had stood up from bed and fell, and complained of right hip and head pain. The triage nurse dispatched a nurse to complete the visit. On 2/12/2023, the physician ordered, "Facility to obtain PA and Lateral Views of Right Hip." A clinical record review revealed that the X-ray results dated 2/16/2023 documented " right hip with no fracture or dislocation, including degenerative changes without bone destruction." There was no documentation of the results being reported to the physician or the interdisciplinary team. The Manager of Accreditation confirmed the findings during the interview and a joint record review on 5/5/2023.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by clinical record review and observation. 1 of 1 (100%) home visit observed of a patient receiving wound care, the organization did not ensure that wound care was provided as per the written plan of care. Home Visit 1/Clinical Record 17: During the home visit to the patient receiving hospice services in a nursing facility on 5/3/2023, the Registered Nurse (RN) [Personnel Record 4] performed wound care to the patient's left leg wound. The facility's wound order dated 4/29/2023 documented, "Per Hospice: Cover wound with ABD pad and roll gauze after cleansing with soap and water. Change two times per day (BID). Use Dimethicone ointment around wound to protect surrounding skin." The hospice RN cleansed the wound with wound cleanser, not soap and water, per the physician's order. In addition, the RN did not document Dimethicone ointment around the wound applied per the wound care order.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed, the hospice did not ensure that the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient elected hospice care on 3/16/2022, with a primary diagnosis of multiple myeloma and a history of diabetes. The comprehensive assessment dated 3/16/2022 documented no problems identified for endocrine; however, the patient had a history of diabetes, and the medication profile listed "Lantus 100 units/ML 81 units subcutaneously every morning." The medication profile documented the Lantus decreased on 4/5/2022 to 15 units subcutaneously every morning and then later to 8 units on 6/14/2022. On 6/9/2022, the blood glucose was 47; on 6/10/2022, the blood glucose was 48. The coordination note completed by the RN dated 6/14/2022 documented the "patient's son has concerns with cognition" and stated the patient had increased confusion the last two evenings. The RN continued to make follow-up visits to monitor the patient's blood glucose without updating the needs of the patient in the plan of care. The patient expired on 6/19/2022. During the joint record reviews of records with the Manager of Accreditation, it was confirmed that the blood test monitoring orders were missing for the assessed identified needs in the clinical records and were not updated on their respective plans of care. Clinical Record 9: The patient elected hospice care on 3/1/2023. For the benefit period of 3/1/2023 through 4/29/2023, the plan of care dated 3/1/2023 orders for Foley catheter and wound care were left blank, incomplete, and read in part: "Hospice Nurse to Insert/Maintain indwelling catheter (blank) FR/(blank) cc balloon, may irrigate with (blank). Change catheter every (blank) or as needed...Hospice Nurse to perform wound care to (blank) on (blank). Utilizing the clean technique-cleanse with (blank), apply (blank), Cover with (blank), and change every (blank) and PRN. Instruct caregiver in wound care." The plan of care did not specify the hospice care necessary to meet the needs of the patient. During the joint record review on 5/5/2023 with the Manager of Accreditation, it was confirmed that the physician orders needed to be revised.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. 5 of 19 (26%) clinical records reviewed of patients with durable medical equipment (DME), the hospice did not ensure that the individualized written plan of care included medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 1: The patient elected hospice care on 4/26/2022. For the benefit period dated 4/26/2022 through 6/24/2022, the plan of care dated 4/26/2022 documented "none" for DME and Supplies. The certification of terminal illness signed by the Medical Director on 5/10/2022 documented "incontinent of bowel and bladder...patient had two falls in the last two weeks." During the joint record review on 5/5/2023, the Manager of Accreditation confirmed the hospice agency provided the patient with a wheelchair, walker, wheelchair cushion, and incontinence supplies. Clinical Record 5: The patient elected hospice care on 9/23/2022. The coordination note dated 9/28/2022 documented, "Wife called hospice to report fall.. Using the Hoyer lift …." The plan of care dated 9/23/2023 did not include documentation of the Hoyer lift with the patient's DME. Clinical Record 15/Home Visit 2: The patient elected hospice care on 11/17/2022. The plan of care dated 11/17/2022 for the benefit period from 11/17/2022 through 2/14/2023 and the current plan of care for the benefit period from 2/15/2023 through 5/15/2023 listed the patient's DME/supplies: "Lotion, Soothe & Cool, 8OZ Wipe, Aloe Touch." During the home visit on 5/3/2023, the patient stated she used the wheelchair to get around the home. It was observed that the patient had a wheelchair, a walker, and a shower transfer bench chair, in the home. The patient's plan of care did not include documentation of the wheelchair, walker, and transfer bench. Clinical Record 17/Home Visit 1: The patient elected hospice care on 1/30/2023. The plan of care dated 3/16/2023 for the benefit period dated 3/31/2023 through 5/29/2023 documented oral swabs and wipes under the DME and Supplies section. During the home visit on 5/3/2023 with the registered nurse, the patient sat in a bariatric Broda wheelchair and used a Hoyer lift for transfers. An oxygen concentrator was in the patient's room. The patient's plan of care did not include documentation of the Broda wheelchair, Hoyer lift, and oxygen concentrator. Clinical Record 18/Home Visit 4: The patient elected hospice care on 7/29/2022. The certification of terminal illness narrative dated 7/29/2022 documented that "... He is a Hoyer transfer." The initial comprehensive assessment completed by the Registered Nurse on 7/29/2023 documented the patient owned a wheelchair. However, the hospice agency ordered a Broda chair. The coordination note dated 7/29/2023 documented, ".... is an assist x2 with a Hoyer Lift for transfers from bed to wheelchair. He receives his nutrition via G Tube and orally... has a Foley catheter in place and needs an assist x2 for incontinence care...Patient wears an immobilization device to left hand due to contracture...wears protective booties to bilateral feet." During the home visit on 5/4/2023 with the Registered Nurse, the patient sat in a Broda chair. Additionally, the patient had a hospital bed. The patient's plan of care did not include documentation of the Hoyer lift, Broda wheelchair, hospital bed, Foley supplies, and incontinence supplies. During the record review on 5/5/2023, the Manager of Accreditation confirmed the hospice agency provided a hospital bed and the Hoyer lift, which were missing from the Plan of Care.

It is required that the hospice interdisciplinary group (in collaboration with the individual's attending physician, (if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, interview, and observation. 1 of 19 (5%) clinical records reviewed, the organization did not ensure that the individualized plan was revised as frequently as the patient's condition required. Clinical Record 18/Home Visit 4: The patient elected hospice care on 7/29/2022 with a primary diagnosis of cerebral infarction with residual effects. The initial comprehensive assessment completed by the Registered Nurse (RN) on 7/29/2022 documented the patient had a percutaneous endoscopic gastrostomy tube (PEG tube) for feeding and a Foley catheter. The patient was observed without a Foley catheter during the home visit on 5/4/2023 with the RN [Personnel Record 3]. Reviewing the facility's record revealed documentation that the Foley was discontinued on 3/20/2023. Additionally, the facility physician's order for maintenance of the PEG tube dated 9/9/2022 documented "Dressing change to G-tube site daily; wash with warm water, pat dry, apply gauze 4x4 secure with Medipore tape if needed every shift" and facility's physician's order dated 12/9/2022 documented "Change Mepilex dressing to the coccyx area on bath days, every day shift every Tuesday, Friday for Mepilex placed to bony prominence on the coccyx and as needed (PRN)." The RN [Personnel Record 3] confirmed the findings and entered a clarification order for discontinuing the Foley catheter, PEG tube maintenance, and coccyx area skin treatment to update the hospice plan of care. During the joint record review on 5/5/2023 with the Manager of Accreditation, it was confirmed that the physician orders needed to be revised.

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and observation. I of 4 (25%) home visit observations of patients receiving hospice aide services, the hospice did not ensure that the hospice aide provided services included in the plan of care. Home Visit 2/Clinical Record 15: During the home visit on 5/3/2023 with the hospice aide, the hospice aide stated that the patient's coccyx had healed, and barrier cream was applied to the area. The application of barrier cream to the patient's coccyx was not included in the hospice aide care plan.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed, the organization did not ensure that the patient's record included physician orders for care and services provided. Clinical Record 6: The patient elected hospice care on 11/6/2022. On 11/14/2022, the physician ordered, "Insert 16 French catheter, 10cc balloon change monthly, and PRN for irrigation and skin preservation. No flushing order. Caregiver to manage and hospice RN to assess every visit." The coordination note completed by the Skilled Nurse (SN) dated 3/6/2023 documented "changed catheter using sterile technique." The aide care plan dated 4/4/2023 removed the catheter care from the assigned tasks. During the joint record review with the Manager of Accreditation, it was confirmed the patient's Foley catheter was discontinued. There was no evidence of a physician's order to discontinue the Foley catheter.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. All hospice care is provided in the facility in accordance with the hospice plan of care. Any changes to the hospice plan of care are discussed with the patient or representative and SNF/NF or ICF/IDF representatives and are approved by the hospice before implementation. This standard was not met as evidenced by clinical record review and interview. 3 of 9 (33%) clinical records reviewed of patients residing in a Skilled Nursing Facility/Nursing Facility (SNF/NF), the agency did not ensure that the written plans of care with the SNF/NF specified which provider was responsible for performing the functions that were agreed upon and included in the plans of care. Clinical Record 8: The patient elected hospice care on 1/18/2023 and resided in a SNF. There was no written plan of care with the facility identifying who was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 10: The patient elected hospice care on 2/1/2023 and resided in a SNF. There was no written plan of care with the facility identifying who was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 17: The patient elected hospice care on 1/30/2023 and resided in a SNF. There was no written plan of care with the facility identifying who was responsible for performing the functions that were agreed upon and included in the plan of care. During an interview and a joint record review on 5/5/2023, the Manager of Accreditation stated the Registered Nurses documented the details of the hospice and facility plan of care in the visit notes, not directly onto the written plan of care. During the review of the records of the patients that received hospice services in nursing facilities, the agency documented on the Hospice POC Report a generic problem (pathway), interventions, and goals, that did not specify on the Plan of Care the identified treatments and services of the patient. Furthermore, the plan of care did not delineate each provider's responsibilities. "NDP: Need for Facility Staff Care Coordination-Hospice. (I) Interventions: Review hospice plan of care with facility staff; Instructed caregiver/patient on what items hospice is responsible for; Instructed patient/caregiver on what items the facility is responsible for; GOALS (G): Facility staff is knowledgeable and involved in the hospice plan of care for the patient; Continuity of care among providers is achieved; Facility and hospice staff will continue to collaborate at each visit. An interview with the Manager of Accreditation during the joint record reviews on 5/5/2023 stated the registered nurses documented the details of the hospice and facility plan of care in the nurses' visit notes, not directly onto the written plan of care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by document review, interview, and observation. 1 of 2 (50%) home visits observed of patients residing at a SNF, the hospice did not provide the facility with the patient's information, including the physician certification and recertification narratives. Home Visit 1: During the home visit on 5/3/2023 with the Registered Nurse (RN) [Personnel Record 4], the hospice facility binder was reviewed. The binder did not include the physician certification and recertification narratives. During a joint review of the binder and interview, the RN [Personnel Record 4] present for the visit confirmed the documents were missing.