Every finding on record at St Croix Hospice LLC

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 4 of 18 (22%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse(s) provided specific written instructions for the hospice aide(s). CLINICAL RECORD 4: The patient elected the hospice benefit on 02/07/2025. The HA care plan was updated 07/09/2025 to include the following: "Assist to toilet, oral care, dressing-first visit of week and as needed, prepare snack, offer snack, bathing (bed)-first visit of week, provide incontinence care, shampoo-last visit of week, skin care, transfer assist, change linens-last visit of week, socialization-last visit of week, provide vigil, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions." All tasks were to be completed every visit unless specified. The HA visit frequency was two times weekly. The hospice aide care plan was updated on 11/18/2025 to include the following: "Assist to toilet, oral care, provide incontinence care, skin care, transfer assist, change linens-last visit of week, bathing (shower)-first visit of week, offer fluids, prepare snack, socialization-last visit of week, provide vigil, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions." All tasks were to be completed every visit unless specified. The HA visit frequency was two times weekly. A nursing visit dated 11/01/2025 noted the patient to have "bilateral kerlix wrapped legs for edema." The HA care plan did not provide the aide with notification of the dressings or with specific instructions for the legs during assigned tasks. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/15/2025. The HA care plan dated 08/15/2025 assigned the following relevant tasks: "Bathing (shower)-assist of two for transfers first visit of every week, dressing, nail care-clean and file only-last visit of the week, oral care-toothettes, incontinence care, skin care-full body lotion, transfer assist-hoyer lift, turn and position in bed, change linens-first visit of the week, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions. All tasks were to be completed every visit unless otherwise specified. The HA visit frequency was twice weekly. The initial nursing admission note dated 08/16/2025 noted the patient had a "J/G tube. and the medication list documented six (6) medications for seizures (Amantadine, Baclofen, Diazepam, Lacosamide, Levetiracetam, Zonisamide). The HA care plan did not provide the aide with notification of the patient's feeding tube nor seizure precautions. CLINICAL RECORD 11: The patient elected the hospice benefit on 06/07/2025. The HA care plan dated 07/09/2025 assigned the following relevant tasks: "Bathing (Shower) first visit of week and Bathing (Tub Bath) first visit of week, Bathing (Bed) last visit of week. The care plan was updated on 08/22/2025 however the assigned tasks remained the same with an HA visit frequency of twice weekly. The HA care plan did not provide the aide with a specific bath type for the first visit of the week; what was assigned was both a shower and tub bath for that first visit of the week. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/19/2025. The HA care plan dated 08/20/2025 assigned the following relevant tasks: "Oral care, incontinence care, shampoo, skin care-apply lotion after shower, transfer assist, turn and position in bed, provide vigil, report pain to nurse, report skin changes to nurse, nurse to orient aide to care plan, safety precautions." The HA care plan was updated on 09/04/2025 to add "use Hoyer lift for transfers." The HA care plan was updated 09/07/2025 to add "Bathing-shower." All tasks were to be completed every visit with the exception of the shower which was weekly. The HA visit frequency was twice weekly. A physician's order dated 08/22/2025 documented the following: "Clean area with wound cleanser, pat dry with gauze, apply calcium alginate to wound bed, cover with sacral Optiview dressing. Clean area with wound cleanser, pat dry with gauze, apply Xerofoam, cover with gauze, Kerlix and posey sleeve." A physician's order dated 08/26/2025 documented the following: "Posterior medial vertebrae wound: Clean area with wound cleanser, pat dry with gauze, apply calcium alginate to wound bed, cover with sacral Optiview dressing. Left forearm wound: Clean area with wound cleanser, pat dry with gauze, apply Xerofoam, cover with gauze, Kerlix and posey sleeve." A physician's order dated 10/14/2025 documented the following: "Stage III pressure ulcer to medial spine.......cover with foam bordered dressing." A physician's order dated 10/18/2025 documented the following: "Wound to right second toe: Cover with gauze to keep dry. Lamb's wool between toes on bilateral feet." The HA care plans did not notify the aide(s) of the wounds nor provide specific instructions for the aide to notify the nurse if the dressing(s) became soiled, dislodged or wet. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/21/2025. The HA care plan dated 07/30/2025 assigned the following relevant tasks: "Bathing- shower, dressing, oral care, incontinence care, skin care, report pain to nurses, report skin changes to nurses, nurse to orient aide to care plan, provide vigil, safety." All tasks were to be completed every visit. The HA visit frequency was twice weekly. A nursing visit note dated 08/03/2025 documented a "Pleurex drain was placed." The HA care plan did not notify the aide(s) of the drain nor provide specific instructions for the drain during assigned tasks. A joint clinical record review and interview was conducted with the Statewide Clinical Director on 12/04/2025 during which it was agreed the HA care plans should have included instructions 'for the seizures, wounds, only 1 bath type and any drains or tubes."

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. This standard was not met as evidenced by document review and interview. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided 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. Review of the hospice volunteer program revealed the volunteer percentage for October 2024 through November 2025 equaled 0.64% and included administrative and patient care services. During a joint document review and interview with the Manager of Volunteer Services and Regional Volunteer Coordinator on 12/03/2025, the volunteer percentage of 0.64% was confirmed. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided 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. An interview and document review was conducted with the Manager of Volunteer Services and Regional Volunteer Coordinator on 12/03/2025, and the volunteer percentage for the past year (October 2024 to November 2025) in either an administrative or patient care role equaled 0.64%.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. 2 of 11 (18%) personnel records reviewed revealed the agency did not ensure that the skills and competencies of all individuals providing care, including volunteers, were assessed.   The agency policy GF 101 7.9, titled "Employee Records" dated January 2024, stated in relevant parts: "The MCS (Manager of Clinical Services) is responsible for completing initial and annual skills checklists for RN, aides, chaplains, social workers, music therapists, massage therapists. They will retain a copy at the branch office...After completion, the MSC will email a copy of the completed document to..." PERSONNEL RECORD 3: A personnel record review was conducted on 12/03/2025, which revealed that there were no documented annual skills checklists in 2023 for this Clinical Manager/Registered Nurse, hired on 05/24/2021. PERSONNEL RECORD 8: A personnel record review was conducted on 12/03/2025, which revealed that there were no documented annual skills checklists in 2023 for this Music Therapist, hired on 10/16/2013. The personnel record review and interview were conducted on 12/03/2025 with the Human Resources Manager (HRM) who was unable to locate the skills competency assessments for 2023 for the above employees (Personnel records 3 and 8). The HRM stated that the checklists "had not been scanned to Human Resources" and would have the local office(s) check. A check at the local office was performed by the Statewide Clinical Director (SCD) on 12/03/2025 who stated: "They contacted the employees who believe the competencies had been completed but were unable to locate the forms." The HRM and SCD stated, "These (checklists) should have been completed and sent to Human Resources by the previous manager."

Based on record review and interview, the Interdisciplinary Group (IDG) failed to review and revise the Plan of Care (POC) as the patient required in 10 of 10 patients (Patients #1-10) and failed to provide coordination of services for patients that reside in an Assisted Living Facility (ALF) / Skilled Nursing Facility (SNF) in 9 out of 10 patient records reviewed (Patients #1, #2, #4, #5, #6, #7, #8, #9, #10). --- Findings include: The agency's IDG failed to maintain direction and coordination of care provided. See Tag L0554. The cumulative effect of this systemic problem resulted in the agency's inability to ensure the provision of quality care.

Based on record review and interview, agency staff failed to ensure that the IDG (Interdisciplinary Group) maintained responsibility for directing and coordinating the care provided to 10 of 10 patient records reviewed (Patients #1-10) and failed to provide coordination of services for patients that reside in an Assisted Living Facility (ALF) / Skilled Nursing Facility (SNF) in 9 out of 10 patient records reviewed (Patients #1, #2, #4, #5, #6, #7, #8, #9, #10). --- Findings include: Review of policy ";Interdisciplinary Group Coordination of Care" No. 1-035 last revised 2/20/2024 revealed in part, ";4. [Hospice] personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication." Further review revealed, ";6. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record and will involve the patients attending physician." Review of Patient #1s medical record revealed Patient #1 was admitted to hospice service on 12/1/2023 with a primary diagnosis of coronary artery disease. Secondary diagnoses included dementia and atrial fibrillation. Patient #1 resided in a memory care unit in an ALF (Assisted Living Facility.) Patient #1 was ambulatory with an unsteady gait and transferred with the assist of one and a walker. Patient #1 had a history of frequent falls prior to hospice admission. Review of Patient #1s medical record revealed Patient #1s dementia progressed through February 2024 with episodes of aggression, agitation, increased confusion, and exit-seeking. Patient #1 also became less steady and more impulsive. In March 2024, Patient #1 experienced 5 falls; April 2024 8 falls; May 2024 4 falls; June 2024 1 fall; July 2024 5 falls; August 1 through August 13, 2024, 1 fall. Further review of Patient #1s medical record revealed there were no medication changes after 2/29/2024. Further review of Patient #1s record revealed no documentation within the IDG (Interdisciplinary Group) meeting reports of discussions within the IDG regarding the frequent falls and possible further intervention to assist in preventing them, throughout this time period. There was also no documentation in Patient #1s record of collaboration/discussions with facility staff regarding the frequent falls and possible intervention that may assist in decreasing them. There was no documentation of collaboration with Patient #1s PCP (Primary Care Provider) regarding the frequent falls. Review of Patient #2's medical record revealed Patient #2 was admitted to hospice service on 6/22/2023 with a primary diagnosis of Alzheimer's Disease. Patient #2 resided in a SNF (Skilled Nursing Facility). Further review revealed no documentation within the IDG meeting reports of discussions within the IDG of review of the care plans and what may need to be changed based on the patient's current status and no documentation of discussion regarding collaboration with the SNF. Review of Patient #3's medical record revealed Patient #3 was admitted to hospice service on 7/5/2024 with a primary diagnosis of congestive heart failure. Patient #3 resided in a private home. Further review revealed no documentation within the IDG meeting reports of discussions within the IDG of review of the care plans and what may need to be changed based on the patient's current status. Review of Patient #4's medical record revealed Patient #4 was admitted to hospice service on 9/20/2024 with a primary diagnosis of Alzheimer's Disease. Patient #4 resided in an ALF (Assisted Living Facility) There was no documentation within the IDG meeting report of discussion regarding the formulation of an initial plan of care and no documentation of discussion regarding collaboration with the ALF. Review Of Patient #5's medical record revealed Patient #5 was admitted to hospice service on 8/28/2024 with a primary diagnosis of heart disease. Patient #5 resided in an ALF. Further review revealed no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plans and what may need to be changed based on the patient's current status and no documentation of discussion regarding collaboration with the ALF. Review of Patient #6's medical record revealed Patient #6 was admitted to hospice service on 5/15/2024 with a primary diagnosis of dementia. Patient #6 resided in an ALD. Further review of Patient #6's record revealed 2 falls: one on 8/28/2024 and another on 9/7/2024. A Patient Safety Analysis was documented after both falls. Root causes for both falls was increasing weakness and confusion. There was no documentation within the IDG meeting reports of discussions within the IDG regarding the falls or what may need to be changed based on the patient's current status and no documentation of discussion regarding collaboration with the ALF. Review of Patient #7's medical record revealed Patient #7 was admitted to hospice service on 9/6/2024 with a primary diagnosis of sepsis (systemic infection). Patient #7 resided in an ALF. There was no documentation within the IDG meeting report regarding discussion of the formulation of an initial plan of care. There was no documentation of discussion regarding collaboration with the ALF. Review of Patient #8's medical record revealed Patient #8 was admitted to hospice service on 9/24/2022 with a primary diagnosis of vascular dementia. Patient #8 resided in an ALF. There was no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plans and what may need to be changed based on the patient's current status and no documentation discussion regarding collaboration with the ALF. Review of Patient #9's medical record revealed Patient #9 was admitted to hospice service on 7/31/2024 with a primary diagnosis of congestive heart failure. Patient #9 resided in SNF. There was no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plans and what may need to be changed based on the patient's current status and no documentation of discussion regarding collaboration with the SNF. Review of Patient #10's medical record revealed Patient #10 was admitted to hospice service on 9/13/2024 with a primary diagnosis of Alzheimer's Disease. Patient #10 resided in an ALF. There was no documentation within the IDG meeting reports of discussions within the IDG of the review of the care plan and what may need to be changed based on the patient's current status and no documentation of discussion regarding collaboration with the SNF. During an interview with Regional Director B on 10/1/2024 at 11:20 a.m., Regional Director B was asked if the IDG meeting reports should indicate what was discussed in the IDG meeting, including collaboration with ALF/SNF. Regional Director B stated yes.

It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 6 (33%) clinical records reviewed, the agency did not ensure that the patients received effective symptom management based on needs identified through triage assessments and/or reported by patients and families. Document 1: (No. 9-005) 1. The Bill of Rights statement defines the right of the patient to: "C. Receive effective pain management and symptom control from the hospice for conditions related to terminal illness." Clinical Record 4: On 3/1/23 the patient's family placed an initial call to triage at 0134 because the patient was experiencing shortness of breath. At 0208 the family was informed that the on-call nurse was notified, and a visit was requested. At 0310, 0335, 0441, and 0619 the family had spoken to triage nurse reporting symptoms had not resolved and continued to request a nurse visit. At 0702 the daughter called to report that they called 911 because they were unable to manage the symptoms. Clinical Record 7: On 3/22/23 at 1720 the patient called to report discomfort due to inability to urinate and was made aware the nurse was currently at a visit but would come out. Patient made return calls at 1930 and 1956 expressing frustration because he was uncomfortable and needed assistance. The on-call nursing visit initiated at 2051. During an interview on 8/3/23, the Clinical Director and Administrator confirmed the findings and stated that neither of these events reflect the type of care they strive to provide. It was further confirmed through interview and contract review that the agency did have the ability to initiate GIP (General In-Patient) care to assist with symptom management, but documentation did not reflect that this had been considered or offered.

t 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, document review and interview. The Agency policy, No. 1-012 stated in a relevant part, "The on-call nurse/triage will provide follow-up appropriate to the call: A. Call the patient/family/caregiver. B. Visit the patient, if necessary. C. Obtain physician orders, as needed. D. Arrange for other hospice services, as needed. 6. The on-call/triage will document each patient/family interaction in a clinical note in the EMR for availability to all assigned team members. 7. On-call staff will respond to a patient within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the call.) In 2 of 7 (29%) clinical records reviewed, the agency did not ensure that nursing services met the needs of the patient as identified through nursing assessments and/or symptoms reported to a Registered Nurse, nor adherence to agency policy for timeliness of on-call nursing visits. Clinical Record 4: Election of benefit 12/8/22 with terminal diagnosis of Congestive Heart Failure. Clinical record on-call nurse/triage documentation summarized for March 1, 2023: At 0134 "Son in-law called to report patient was having difficulty breathing and oxygen levels were decreasing. He had given one dose of Morphine (0.25ml) 10 minutes ago." On-call nurse “advised it can take 30 minutes to work and advised Lorazepam can also be given for SOB (shortness of breath).” It was further documented, “writer advised to call back should medication not be effective within the next hour and writer can send a nurse out.” At 0208 the son in-law called to report patient continued to have shortness of breath and requested nurse visit. “Writer advised (nurse) currently in visit and may take some time to arrive offered to call physician.” Physician was notified with new orders written to "increase Morphine to 0.5ml every 2 hours and Lorazepam 0.5mg give 2 tablets every 2 hours PRN (as needed) SOB. Writer returned call to son in-law with order changes and informed nurse would visit when available. On call nurse notified of visit need.” 0310 “Writer called to check in, spoke with son in-law and informed him that RN had been called to an emergency and Estimated Time of Arrival (ETA) is roughly 2 hours. Son in-law said patient was doing better now that he has received medication, but they still want a visit.” 0335 “Son in-law calls back to ask about ETA and writer advised that specific ETA is unknown but will visit when able. Son in-law stated, "well we need to get something figured out since this is a service, we are paying for we need someone out here." The writer apologized and assured him staff was working with the on-call supervisor to find a quicker solution. The son in-law reported "patient was taking newly increased doses and next due at 0400.” 0441 Son-in-law calls "still laboring to breathe, really agitated. RN was supposed to come but haven't heard back or seen anyone. Writer called on-call nurse who reported she is at death visit and cannot leave the bedside even to call son-in-law. Writer forwarded message to on call manager.” 0619 "Son in-law calls back to report patient continues to have difficulty breathing and states, "what is going on here we were supposed to have someone out." Writer apologized offering to call doctor while patient waited for nurse visit. Son in-law hesitantly agreed." 0702 “Daughter calls that patient has SOB and increased anxiety. Has given morphine and lorazepam several times and nothing is helping. Daughter says patient has been struggling for 5 hours and family is not waiting any longer and called 911. Explained to daughter that if patient is admitted he will have to come off services, daughter verbalized understanding.” During the phone interview conducted on 8/3/23, the son in-law recounted what he described as a "traumatic experience" watching his father in-law struggle to breathe. He voiced that he made multiple calls requesting a nursing visit and stated, "kept being told the nurse was at an emergency, but I felt this was an emergency too." He stated, "that night, when we needed them the most, they were not there for us." Clinical Record 7: Election of benefit 12/17/21 with terminal diagnosis of Congestive Heart Failure. Clinical record from on-call nurse/triage documentation summarized for March 22, 2023: At 1720 "Patient calls unable to urinate, he is only able to go a few drops and he is uncomfortable. He is aware nurse is at visit will call back with changes." 1930 "Patient called flustered that the nurse still has not arrived. He knows she is at another visit, but he is uncomfortable and does not want to take another dose of morphine. He does not want to take Ativan to help relax but he will think about it. Aware nurse will come as soon as she is done with current visit." At 1956 Patient called to question how much longer for the nurse visit. He is flustered that he called earlier and that the nurse has been with another patient and feels there should be a backup plan for him. He is aware that the nurse is driving and is 45 min away. He wants feedback given and complaint filed." At 2051 the RN initiated the PRN visit. During an interview and a joint review of the documentation on 8/3/23, the statewide Clinical Director and Administrator confirmed that the patient's did not receive timely on-call nursing response. The Clinical Director reported that a "deep dive" was done for Record 4 and said that on-call processes were "changed to include additional nurses to call if first nurse is busy."

It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by clinical record review, document review, and interview. The Agency policy, No. 1-012 stated in a relevant part, "The on-call nurse/triage will provide follow-up appropriate to the call: A. Call the patient/family/caregiver. B. Visit the patient, if necessary. C. Obtain physician orders, as needed. D. Arrange for other hospice services, as needed. 6. The on-call/triage will document each patient/family interaction in a clinical note in the EMR for availability to all assigned team members. 7. On-call staff will respond to a patient within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the call.) In 2 of 7 (29%) clinical records reviewed, the agency did not ensure that nursing services were made available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. Clinical Record 4: Election of benefit 12/8/22 with terminal diagnosis of Congestive Heart Failure. Clinical record on-call nurse/triage documentation summarized for March 1, 2023: At 0134 "Son in-law called to report patient was having difficulty breathing and oxygen levels were decreasing. He had given one dose of Morphine (0.25ml) 10 minutes ago." On-call nurse “advised it can take 30 minutes to work and advised Lorazepam can also be given for SOB (shortness of breath).” It was further documented, “writer advised to call back should medication not be effective within the next hour and writer can send a nurse out.” At 0208 the son in-law called to report patient continued to have shortness of breath and requested nurse visit. “Writer advised (nurse) currently in visit and may take some time to arrive offered to call physician.” Physician was notified with new orders written to "increase Morphine to 0.5ml every 2 hours and Lorazepam 0.5mg give 2 tablets every 2 hours PRN (as needed) SOB. Writer returned call to son in-law with order changes and informed nurse would visit when available. On call nurse notified of visit need.” 0310 “Writer called to check in, spoke with son in-law and informed him that RN had been called to an emergency and Estimated Time of Arrival (ETA) is roughly 2 hours. Son in-law said patient was doing better now that he has received medication, but they still want a visit.” 0335 “Son in-law calls back to ask about ETA and writer advised that specific ETA is unknown but will visit when able. Son in-law stated, "well we need to get something figured out since this is a service, we are paying for we need someone out here." The writer apologized and assured him staff was working with the on-call supervisor to find a quicker solution. The son in-law reported "patient was taking newly increased doses and next due at 0400.” 0441 Son-in-law calls "still laboring to breathe, really agitated. RN was supposed to come but haven't heard back or seen anyone. Writer called on-call nurse who reported she is at death visit and cannot leave the bedside even to call son-in-law. Writer forwarded message to on call manager.” 0619 "Son in-law calls back to report patient continues to have difficulty breathing and states, "what is going on here we were supposed to have someone out." Writer apologized offering to call doctor while patient waited for nurse visit. Son in-law hesitantly agreed." 0702 “Daughter calls that patient has SOB and increased anxiety. Has given morphine and lorazepam several times and nothing is helping. Daughter says patient has been struggling for 5 hours and family is not waiting any longer and called 911. Explained to daughter that if patient is admitted he will have to come off services, daughter verbalized understanding.” During the phone interview conducted on 8/3/23, the son in-law recounted what he described as a "traumatic experience" watching his father in-law struggle to breathe. He voiced that he made multiple calls requesting a nursing visit and stated, "kept being told the nurse was at an emergency, but I felt this was an emergency too." He stated, "that night, when we needed them the most, they were not there for us." Clinical Record 7: Election of benefit 12/17/21 with terminal diagnosis of Congestive Heart Failure. Clinical record from on-call nurse/triage documentation summarized for March 22, 2023: At 1720 "Patient calls unable to urinate, he is only able to go a few drops and he is uncomfortable. He is aware nurse is at visit will call back with changes." 1930 "Patient called flustered that the nurse still has not arrived. He knows she is at another visit, but he is uncomfortable and does not want to take another dose of morphine. He does not want to take Ativan to help relax but he will think about it. Aware nurse will come as soon as she is done with current visit." At 1956 Patient called to question how much longer for the nurse visit. He is flustered that he called earlier and that the nurse has been with another patient and feels there should be a backup plan for him. He is aware that the nurse is driving and is 45 min away. He wants feedback given and complaint filed." At 2051 the RN initiated the PRN visit. During an interview and a joint review of the documentation on 8/3/23, the statewide Clinical Director and Administrator confirmed that the patients did not receive timely on-call nursing response. The Clinical Director reported that a "deep dive" was done for Record 4 and said that on-call processes were "changed to include additional nurses to call if first nurse is busy."

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 medical supplies and appliances necessary to meet the patient's needs. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 6 of 16 (38%) clinical records reviewed, the patient's durable medical equipment was not listed on the plan of care. Agency policy 9-017, The Plan of Care, states in part that "A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The written plan of care will contain, but will not be limited to, the following: DME and medical supplies necessary to meet patient needs." Clinical Record 6: The initial admission assessment was completed on 5/27/2022, it was documented that the hospice ordered a mattress for the patient that resided in an Assisted Living Facility. There was no documented evidence of this item on the initial plan of care. Clinical Record 13: The initial admission assessment was completed on 11/2/2021, the RN documented that the patient required a pressure pad, hospital bed, Hoyer lift, over-bed table, and Broda chair. The equipment was ordered and provided to the patient, however, there was no documented evidence of the equipment on the patient's initial plan of care. Clinical Record 2: The initial admission assessment was completed on 5/20/2021 it was documented that the agency provided an alternating pressure mattress, bedrails, hospital bed, and Broda chair to meet the patient's needs. There was no documented evidence of these items on the initial plan of care or updated plans of care, Clinical Record 1: The initial admission assessment was completed on 12/27/2021, the RN documented that the hospice provided the patient with a hospital bed, wheelchair, over-bed table, and an oxygen concentrator. There was no documented evidence of durable medical equipment provided by hospice found in the patient's initial plan of care or updated plan of care. Clinical Record 7: The initial admission assessment was completed on 4/23/20 the RN documented that a hospital bed, alternating pressure pad, wheelchair cushion, and fall were ordered by the hospice. The agency failed to list durable medical equipment provided by the hospice on the initial patient plan of care. Clinical Record 8: The initial admission assessment was completed on 6/7/2021 the RN documented that the patient required a Hoyer lift for transfers. The equipment was ordered, however, the agency did not list the equipment on the patient's initial plan of care. In an interview with the Administrator, she stated it is the agency's standard practice to list durable medical equipment on the plan of care and update that list as needed. Agency policy 9-017 The Plan of Care, states in part that, "A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The written plan of care will contain, but will not be limited to, the following: DME and medical supplies necessary to meet patient needs." In an interview with the Administrator, she stated it is the agency's normal practice to list durable medical equipment on the plan of the care and update that list as needed.