Every finding on record at Suncrest Hospice, LLC

Based on staff interview, clinical record review, treatment administration record and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary treatments to meet the needs of the patient for 1 of 1 sampled patient with a wound (Patient #5).  Failure to ensure the plan of care included physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms.  Findings include: --- According to the hospice policy, titled Verification of Physician Orders, dated 11/2023, identified signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation.  According to the hospice policy, titled The Plan of Care, dated 11/2023, the written plan of care will contain, but will not be limited to, the following: drugs and treatments, and physician orders.  During an interview on 9/17/25 at 9:15 AM with Staff A, Administrator, staff will contact wound clinic and nursing home to obtain copies of wound care visit note and wound care order.  Staff A provided wound clinic visit note, wound care order and nursing home treatment administration record copies to surveyor on 9/17/25.  Patient #5 had a hospice admission date of 7/23/25, a death date of 8/10/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:  a. Plan of Care, dated 7/23/25 to 10/20/25, included diagnoses of senile degeneration of the brain, unspecified dementia and Type 2 Diabetes Mellitus with hyperglycemia; physician orders for skilled nursing, social work, chaplain and hospice aide services; and sacral/coccyx wound care – cleanse wound with wound cleanser, pat dry, apply hydrogel to wound bed, apply skin prep to surrounding intact skin, cover with foam bordered dressing daily and as needed for wound care.  Facility staff to complete, hospice nurse may complete if present.  b. Skilled nurse visit note, dated 8/5/25, included documentation provider from the wound clinic would make a visit later today.  Coccyx wound with dressing intact.  c. Nursing Home visit note, dated 8/5/25, identified a special visit for wound care evaluation. Patient was initially to come to wound clinic for wound care however quickly declined and subsequently was placed on hospice and deemed no longer able to travel. Patient was admitted from the hospital with wounds present on admission.  Currently has wounds to sacrum which has been documented by previous providers as a Kennedy ulcer as well as wounds to left heel and foot.  Patient moans in discomfort with any sort of manipulation of the body. Apparent Kennedy ulcer to sacrum is foul-smelling, ischemic, palpable/visible bony exposure measuring 6.6 centimeters (cm) by 6 cm by 3 cm, there does not appear to be any tunneling or undermining at this time.  There is necrotic tissue present in the wound base as well as slough.  There is muscle and bone exposure present.  d. Wound care order in nursing home chart, dated 8/5/25, identified to discontinue current dressing, start betadine soaked gauze and cover with dressing of choice, change three times per week and as needed.  Goal of therapy is to improve odor and provide dignity.  This wound will continue to worsen despite wound care therefore, prefer less dressing changes for patient’s comfort/pain.  e. Nursing Home Treatment Administration Record, dated 8/1/25 to 8/31/25, included order for Kennedy Ulcer treatment: betadine soaked gauze, cover with dressing of choice.  Change three times per week and as needed one time a day every 3 days, goal is to improve odor and provide dignity.  Wound will continue to deteriorate despite any wound care.  Prefer less dressing changes for patient comfort. Start date 8/6/25.  Documentation identified care completed on 8/6/25 and 8/9/25.  f. Hospice Skilled nurse visit note, dated 8/7/25, included wound measurements but lacked documentation of wound care or dressings.  g. Hospice Skilled nurse visit notes, dated 8/8/25 and 8/9/25, included documentation skin assessment was completed.  The hospice nurse failed to include the wound care order, dated 8/5/25, in the hospice clinical record.  The above findings were reviewed with the Administrator.

Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure the drug regimen review identified any ineffectiveness of drug therapy, side effects, duplicate drug therapy, actual or potential drug interactions or need for laboratory monitoring associated with all medications taken by the patient for 3 of 5 sampled patients (Patients #1, #3 and #4). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. --- 2. Patient #1 had a hospice admission date of 10/11/24 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. POC, dated 10/11/24 to 12/9/24, included physician orders for Bisacodyl rectal suppositories, Glycerin rectal suppositories, Milk of Magnesia and Fleet enema (bowel medications), Tramadol, Acetaminophen, Gabapentin, Lidocaine topical film and Diclofenac topical gel (pain medications) and Lorazepam and Quetiapine (anxiety medications). b. Start of Care comprehensive assessment visit note, dated 10/11/24, completed by Staff C, Registered Nurse (RN), included documentation a DRR completed of prescription/non-prescription medications for new or changed medications and for issues including: effectiveness of drug therapy, side effects, actual/potential interactions, duplicate drug therapy and drug therapy associated with lab monitoring-no issues identified. The note failed to identify the duplicate bowel medications of Bisacodyl rectal suppositories, Glycerin rectal suppositories, Milk of Magnesia and Fleet enema, duplicate pain medications of Tramadol, Acetaminophen, Gabapentin, Lidocaine topical film and Diclofenac topical gel and duplicate anxiety medications of Lorazepam and Quetiapine. c. The IDG meeting note, dated 10/13/24, included documentation all medications reviewed by medical director for effectiveness of therapy, actual/potential interactions, side effects, duplication and drug therapy associated with lab monitoring. The note failed to identify the duplicate bowel medications of Bisacodyl rectal suppositories, Glycerin rectal suppositories, Milk of Magnesia and Fleet enema, duplicate pain medications of Tramadol, Acetaminophen, Gabapentin, Lidocaine topical film and Diclofenac topical gel and duplicate anxiety medications of Lorazepam and Quetiapine. The hospice failed to accurately complete the drug regimen review and identify the duplicate medications. 3. Patient #4 had a hospice admission date of 8/26/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. POC, dated 8/26/24 to 11/23/24, included physician orders for Albuterol inhalation aerosol and Breo Ellipta inhalation powder (respiratory medications). b. Start of Care comprehensive assessment visit note, dated 8/26/24, completed by Staff D, RN, included documentation a DRR completed of prescription/non-prescription medications for new or changed medications and for issues including: effectiveness of drug therapy, side effects, actual/potential interactions, duplicate drug therapy and drug therapy associated with lab monitoring-no issues identified. The note failed to identify the duplicate respiratory medications of Albuterol inhalation aerosol and Breo Ellipta inhalation powder. c. The IDG meeting note, dated 8/28/24, included documentation all medications reviewed by medical director for effectiveness of therapy, actual/potential interactions, side effects, duplication and drug therapy associated with lab monitoring. The note failed to identify the duplicate respiratory medications of Albuterol inhalation aerosol and Breo Ellipta inhalation powder. The hospice failed to accurately complete the drug regimen review and identify the duplicate medications. The above findings were reviewed with the Administrator. Findings include: According to the hospice policy, titled Comprehensive Assessment, dated 6/2022, review of current and related past medications, including prescription, over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history and other medication information, including but not limited to identification of the following: effectiveness drug therapy, unwanted side and toxic effects, drug interactions (actual or potential), duplicate drug therapy, and drug therapy currently associated with laboratory monitoring. During an interview on 11/19/24 at 1:57 PM, the Administrator, reported the drug regimen review is completed on admission. 1. Patient #3 had a hospice admission date of 9/27/24, and received hospice services while residing in a long-term care facility. Clinical record review revealed: a. Plan of Care (POC), dated 9/27/24 to 12/25/24, included physician orders for Colace and Miralax (bowel medications) and furosemide and hydrochlorothiazide (diuretics). b. Start of Care comprehensive assessment visit note, dated 9/27/24, included documentation a drug regimen review completed of prescription/non-prescription medications for new or changed medications and for issues including: effectiveness of therapy, side effects, actual/potential interactions, duplicate drug therapy, and drug therapy associated with lab monitoring – no issues identified. The note failed to identify the duplicate bowel medications of Colace and Miralax and duplicate diuretic medications of furosemide and hydrochlorothiazide. c. The IDG meeting note, dated 10/7/24, included documentation all medications reviewed by medical director for effectiveness of therapy, actual/potential interactions, side effects, duplication, and drug therapy associated with lab monitoring. The note failed to identify the duplicate bowel medications of Colace and Miralax and duplicate diuretic medications of furosemide and hydrochlorothiazide. The hospice failed to identify the duplicate medication therapy and accurately complete the drug regimen review.

Based on staff interview and clinical record review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group updated the comprehensive assessment with changes to the patient condition regarding wound measurements for 2 of 2 sampled patients with a wound (Patients #2 and #4). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- 2. Patient #4 had a hospice admission date of 8/26/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. Skilled nurse visit notes, dated 9/16/24 and 9/19/24, completed by Staff D, Registered Nurse (RN), identified wound to coccyx had minimal change from prior week although wound bed improved in color and appeared with some granulation tissue. The notes failed to include wound measurements. b. Skilled nurse visit notes, dated 9/24/24 and 9/27/24, completed by Staff E, RN, failed to include documentation of wound assessments/measurements for coccyx wound. The hospice team failed to document weekly wound measurements per hospice agency expectation. The above findings were reviewed with the Administrator. Findings include: During an interview on 11/19/24 at 9:25 AM, the Administrator reported the hospice agency expectation is wounds should to be measured weekly and should include length, width and depth. Wound documentation can be located in the skilled nurse visit note, the wound flow sheet and/or communication notes in the clinical record. When a patient resides in a long-term care facility, hospice nurses collaborate with the facility staff regarding wound care. 1.Patient #2 had a hospice admission date of 10/1/24 and received hospice services while residing in a long-term care facility. Clinical record review revealed: a. Skilled nurse visit note, dated 10/8/24, included documentation of fluid filled pustules clustered near coccyx, the note failed to include wound measurements of the pustules. b. Skilled nurse visit note, dated 10/15/24, included documentation area to coccyx is now open with a second wound developing, approximately 1 inch below. Wound one appears to have yellow green drainage on border foam dressing. A third area on the right side of buttocks appears red and purple, circular in shape. The note failed to include wound measurements. c. IDG meeting note, dated 10/16/24, included documentation new wound to coccyx, started out as what appeared to be pustule. One open area to coccyx started as 2-3 0.3 centimeters pustules, 2nd area has new pustule and 3rd area that appears reddened/purple. The note failed to include wound measurements for the 2nd and 3rd areas identified. d. Skilled nurse visit note, dated 10/18/24, included documentation lesion buttocks, wound one on coccyx, originated as fluid filled pustules, these areas now open creating 1 open area, area has pink wound bed, scant drainage noted on border foam dressing. Wound 2 is approximately 1 inch below area 1 and presents as 2 fluid filled pustules. A new area, wound 3, is stage 2 pressure ulcer to right side of buttocks, pink wound bed, non-draining. Area 4 is circular, intact but has purple/red appearance. The note failed to include wound measurements. e. Skilled nurse visit notes, dated 10/22/24 and 10/28/24, included documentation lesion buttocks, notes failed to include wound descriptions and measurements. f. IDG meeting note, dated 10/30/24, included documentation skin tear to forearm, wound to coccyx has 4 areas total, original wound started as pustule to coccyx. Treatment for buttocks wounds include cleanse with wound cleanser, apply stoma powder and cover with Desitin. The note failed to include wound measurements. g. Skilled nurse visit notes, dated 11/4/24 and 11/11/24, lacked documentation of wounds or if wounds had healed. h. IDG meeting note, dated 11/13/24, included documentation treatment for buttocks wounds include cleanse with wound cleanser, apply stoma powder and cover with Desitin. The note failed to include wound description, measurements or if the wounds had healed. During an interview on 11/19/24 at 1:57 PM, Administrator, reported she had reviewed the clinical record and agreed wound measurements were missing. Administrator had contacted hospice staff to obtain wound measurements and requested staff to annotate visit notes with the appropriate wound measurements. The hospice failed to document weekly wound measurements per hospice agency expectation.

Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview, patient representative interview and hospice staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members and the patient's family or guardian to ensure hospice staff provided treatment and services to the patients according to IDG decisions. The survey identified a concern with 3 of 6 sampled patients (#3, #5 and #6). Failure of the hospice IDG members to communicate and collaborate with family or guardian to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients and family. Findings include: --- Review of the undated policy titled Interdisciplinary Group Coordination of Care, 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 on a communication note, interdisciplinary group meeting form and/or clinical note. The interdisciplinary group will provide ongoing support for patient and family/caregivers. During an interview on 3/12/24 at 4:16 PM the Medical Director stated the hospice does review complaints in IDG meetings. In general the hospice updates the patient's family every week. The hospice routinely attends a death and makes a visit. Staff do call the patient's families at the time of death. During an interview on 3/13/24 at 8:23 AM the Administrator stated the expectation for the nurse to call the primary family member at a minimum of weekly with updates. The family is also updated at the time of patient changes in condition or changes in medications. The expectation of staff is to complete a death visit at the time of death of the patient. 1. Patient #3 had a hospice admission date of 1/4/24 and received routine home care hospice services while residing in a nursing home. The patient received services out of the parent office in West Des Moines. a. The Plan of Care (POC), dated 1/4/24 to 4/2/24, included IDG orders for skilled nursing, social worker, chaplain, music therapy and hospice aide services. b. The skilled nurse visit note, dated 1/11/24 and 1/17/24, included documentation a phone call was made to the primary caregiver. c. The medical record lacked documentation the week 1/21/24 to 1/27/24 and 1/28/24 to 2/1/24 of a phone call by the nurse to the primary caregiver to provide patient updates. d. The skilled nurse visit note, dated 2/15/24, included documentation the primary caregiver requested patient updates to be completed by staff and sent by email. The nurse and social worker were present with the primary caregiver, when the request was made. During interview on 3/12/24 at 8:40 AM, Patient #3's daughter stated at first she did not have updates for the patient status and services provided by the hospice. The hospice did not contact her by phone. She had requested for updates in writing and now receives weekly emails on the patient's status. During an interview on 3/13/24 at 9:25 AM, Staff E, Registered Nurse (RN) stated she was the case manager for Patient #3. She completed family updates at a minimum every week. She stated it is always possible she did not document a call, but did not know of any specific situation, when she did not document a call. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to primary caregiver updates. 2. Patient #5 had a hospice admission date of 7/14/23 and revoked hospice services on 10/2/23 and received routine home care hospice services while residing in a nursing home. The patient received services out of the Ames branch office. a. The POC, dated 7/14/23 to 10/11/23, included IDG orders for skilled nursing, social worker and hospice aide services. b. The skilled nurse visit note, dated 8/14/23, 8/17/23, 8/31/23 and 9/1/23, included documentation a phone call made to the primary caregiver. c. The skilled nurse visit note, dated 9/6/23, included documentation education provided to a family member. d. The medical record lacked documentation the week 9/3/23 to 9/6/23 and 9/24/23 to 9/30/23 of a phone call by the nurse to the primary caregiver to provide patient updates. During an interview on 3/13/24 at 9:47 AM, Staff F, RN stated she had been the case manager for Patient #5. There had been times another family member present during the skilled nurse visit and she did not make a call to the primary caregiver. She further stated she had talked to the primary caregiver and had the okay to just keep the family member present informed. She stated she may not have documented the conversation that the primary caregiver is OK to keep the family member informed, if the primary caregiver wasn't available. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to primary caregiver updates. 3. Patient #6 had a hospice admission date of 11/24/23 and date of death of 11/20/23. The patient received routine home care hospice services while residing in a nursing home. The patient received services out of the Ames multiple location office. a. The Plan of Care (POC), dated 11/24/23 to 2/21/23, included IDG orders for skilled nursing, social worker, chaplain and hospice aide services. b. The skilled nurse visit note, dated 11/30/23, included documentation the patient passed away at the nursing home. A visit refused by the facility nurse as she stated the patient had no family and all tasks and calls were complete. The note included documentation the guardian has been notified. During an interview on 3/13/24 at 12:38 PM Staff G, RN stated she received a call for a report of the death of Patient #6. The nursing home staff denied the need for a nurse visit and reported the patient had no family and the physician and funeral home had been called. Staff G stated she made no phone calls and the patient's guardian was not contacted by herself or the hospice agency about Patient #6 death. The hospice IDG failed to ensure they maintained a system of communication which allowed for the updated notification and hospice's coordination of the patient's death. The Administrator and Regional Administrator received the above findings.

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 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 observation, document review and interview. In 3 of 6 (50%) home visit observations it was revealed that the hospice agency did not ensure that the medication profiles were updated to accurately reflect the patient's current regimen. Document 4: Agency policy #2-004, titled Medication Profile (revised June 2022), sub-section seven (7) stated in part, "A drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication." Home Visit 1: A home visit was conducted at a Skilled Nursing Facility (SNF) for a patient with a hospice benefit election date of 12/01/2023 (record 2) in the presence of the Administrator (staff 6) on 03/05/2024. A medication reconciliation was performed by comparing the hospice agency's medication list to the SNF medication profile. The hospice agency medication profile dated 3/5/2024 stated in part, "Senna Plus fifty (50) milligrams (mg)(-)eight (8) point (.) six (6) (50mg-8.6), starting 12/03/2023, take two (2) tablets two (2) times (X's) daily for constipation. The Skilled Nursing Facility (SNF) medication profile dated 03/05/2024 stated in part, "Senna Plus fifty (50) milligrams (mg)(-)eight (8) point (.) six (6) (50mg-8.6). Take two (2) tablets three (3) times (X's) daily for constipation, effective 02/13/2024. Home Visit 2: A home visit was conducted at a Skilled Nursing Facility (SNF) for a patient with a hospice benefit election date of 09/20/2023 (record 1) in the presence of the Administrator (staff 6) on 03/05/2024. A medication reconciliation was performed by comparing the hospice agency's medication list to the SNF medication profile. The hospice medication profile dated 3/5/2024 stated in part, "Fludrocortisone zero (0) point (.) one (1) (0.1) Take one half (1/2) tablet one (1) time (X) a day for hypotension starting 09/21/2023". The SNF medication profile dated 03/05/2024 stated in part, "Fludrocortisone zero (0) point (.) one (1) (0.1) Take one (1) tablet one (1) time daily for hypotension, effective 01/25/2024". Home Visit 5: A home visit was conducted at a private residence for a patient with a hospice benefit election date of 11/16/2023 (record 5) in the presence of the Administrator (staff 6) on 03/05/2024. A medication reconciliation was performed by comparing the hospice agency's medication list to the patient's current regimen. The hospice medication profile dated 3/5/2024 stated in part, "Aspirin eighty-one (81) milligrams (mg). Take one (1) capsule daily". The patient did not have Aspirin available at the home and reported that they no longer took It. The patient confirmed that they had not taken It since admission to the hospice agency on 11/16/2023. A joint record review, interview, and observation with the Agency Administrator (staff 6) on 03/05/2024 confirmed the hospice agency medication list did not match the patient's current regimen.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 23 (4%) records reviewed it was revealed that the hospice agency did not ensure that all documentation was completed in accordance with its documentation policy. Document 5: Agency policy titled, Human Resources Charting Timeline Policy (revised 04/01/2021, no policy#), stated in part, "Effective February 1, 2014, it is the policy of (Hospice) that all charting is completed within twenty-four (24) hours of the applicable visit." Clinical Record 8: The hospice benefit election date was 10/18/2023. An RN assessment was dated 01/17/2024, but the RN did not complete the documentation until 01/21/2024. In addition, the patient received an RN visit on 02/07/2024, but the RN did not complete the documentation until 02/14/2024. A joint record review and interview with the Regional Administrator (staff 1) on 03/06/2024 confirmed the RN documentation was not completed according to the agency's policy for both the 01/17/2024, and 02/07/2024 visits.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure interdisciplinary group members coordinated and provided care to meet the assessed needs of the patient for 1 of 1 sampled patients (Patient #2) receiving massage therapy services. Failure to ensure hospice IDG coordinated care and services to meet the needs of the patient placed patients at risk for not receiving the care and services necessary to promote quality of life and the patient's highest level of well-being. Findings include: --- Review of the hospice policy, titled Interdisciplinary Group Membership and Responsibilities, dated 6/2022, identified the Interdisciplinary Group (IDG) will collaborate with the patient's physician to develop an individualized written Plan of Care (POC). Review of the hospice policy, titled IDG Coordination of Care, dated 6/2022, identified the IDG retains professional management responsibility to ensure the provision of care and services. The comprehensive and ongoing assessments determine the type and scope of services provided by hospice staff. All IDG members will have access to the POC to ensure coordination and continuity. The IDG will develop, review and update the POC at least once every 15 days. Hospice staff will document the exchange of information in the clinical record. All hospice staff will communicate changes in a timely manner. Hospice staff will document all communication in the communication notes. Patient #2 had a hospice admission date of 10/14/22, received hospice services while residing in a long term care facility (nursing home) and died at the nursing home on 10/30/22. Review of the clinical record revealed the following: a. The initial comprehensive assessment completed by Staff E, Registered Nurse (RN), dated 10/14/22, included documentation Staff E assessed the patient had very deep, pitting edema (fluid retention) with indentations in the leg lasting a long time in the bilateral lower and upper extremities. Staff E, RN, assessed the patient did not have any pain. The assessment identified the patient was cognitively intact with orientation to person, place and time. Staff E, RN, documented the patient requested the services of all disciplines with the exception of chaplain services. b. The POC, dated 10/14/22 to 1/11/23, identified a primary diagnosis of congestive heart failure (disease associated with fluid retention) and included IDG orders for skilled nursing, hospice aide, chaplain, social worker and massage therapy services. The POC included IDG orders for massage therapy to assess and evaluate the patient on 10/19/22, and then 6 as needed visits until the end of the certification period for pain, circulation and overall comfort. The POC lacked a scheduled frequency for massage therapy visits after the initial evaluation. c. The initial chaplain evaluation, completed by Staff H, Chaplain, dated 10/17/22, included documentation which identified the patient expressed a desire to return home rather be in the nursing home. Staff H, Chaplain, documented the patient accepted chaplain services and the patient expressed encouragement when the patient found out the hospice offered massage therapy services. d. The clinical record included documentation of one massage therapy visit, completed by Staff I, Massage Therapist, dated 10/19/22. Staff I, Massage Therapist, documented the patient was very lethargic, denied pain, but accepted the massage. She documented she applied light pressure to massage the feet, legs, hands and arms. The patient's skin tightness loosened and the therapist slowly moved edema with circulation increase. She documented the patient quickly fell back to sleeping and slept off and on throughout session with very little interaction. Staff I, Massage Therapist, documented a plan to continue services for circulation, relaxation and overall comfort. e. A chaplain visit, completed by Staff H, Chaplain, dated 10/21/22, included documentation Staff H asked about any concerns the patient had. Staff H, Chaplain, documented he recalled that when he met with the patient earlier in the week, the patient was anxious about staying in the nursing home. The patient indicated to Staff H, Chaplain, "that it has been ";fine" on this unit, although (the patient) did ask if (the patient) could receive massages." Staff H, Chaplain, documented he let the patient know that the massage therapist had been given the patient's name and would be coming to see the patient soon. f. A skilled nursing visit, completed by Staff E, RN, dated 10/21/22, included documentation Staff E assessed the patient had a 4 plus pitting edema and appeared to be significantly worse than when Staff E admitted the patient to hospice. g. Skilled nursing visits, dated 10/23 and 10/28/22, continued to document the patient's very deep pitting edema in the extremities and that the patient had excessive swelling. h. The IDG meeting, dated 10/26/22, included documentation the massage therapist completed the initial assessment, determined she would do as needed (PRN) visits and circulation and comfort were the only goals. The IDG meeting included documentation the chaplain provided emotional and spiritual support. The IDG lacked any documentation regarding the patient's request for massage therapy services on 10/21/22. i. A chaplain visit, completed by Staff H, Chaplain, dated 10/28/22, included documentation Staff H met with patient, the patient's significant other, and the a family member of the significant other. Staff H, Chaplain, documented how the patient was adjusting to the idea of staying at the nursing home, but also the patient's continued desire to return home. Staff H, Chaplain, documented he encouraged the patient to take advantage of the resources the patient has available, such as the massage therapy the patient has expressed interest in receiving. Staff H, Chaplain, documented he also noted that the massage therapist had been notified about working with the patient. j. The clinical record included documentation of a skilled nursing death visit, dated 10/30/22. On 11/8/22 at 2:51 PM, during an interview, Staff I, Massage Therapist, reported the patient barely spoke with her on 10/19/22. The patient was really sleepy, and the therapist had to repeat her questions to get an answer throughout the visit. The patient did let her give a massage and the patient benefited from an increase in circulation. Staff I reported the reason she chose to have 6 as needed visits was due to not being sure of the patients needs and was not able to gauge her pain. She reported she planned to come back in 10 days to 2 weeks to reassess. She usually sees most patients twice per month. She does as needed visits for patients if the patient is in pain or the patient requests a visit. The nurses and aide know her well and are good about calling to let her know when patients have a need for massage therapy due to increased discomfort or edema. She reported she did get a message 2 days later after her visit asking if she had seen the patient. She did not think the patient was requesting another visit. On 11/8/22 at 3:23 PM, during an interview, Staff H Chaplain, reported he saw the patient for the first time with the hospice social worker. The patient was not overally emotional during the visit. She did not want to stay at the nursing home long term; she wanted to return home. The second time he saw the patient, the significant other was present. The significant other was hesitant about her coming back home and felt the burden of caring for her was a lot. He expressed a lot of guilt. The significant other would not express his concerns in front of the patient. The patient did ask about massage therapy at the initial visit. He was unsure if the massage therapist ever saw the patient. The patient seemed optimistic and happy about having the service. The patient seemed in better spirits. At the third visit, the significant other and the significant other's mother were there. The patient seemed happy to have them visit and displayed no stress indicators. The Chaplain had the sense the patient was looking forward to getting better. The patient did request massage therapy services at his visits. He did not know the therapist had seen the patient due to the patient having some processing and memory issues. He was not sure if it was a communication issue between him and the massage therapist regarding the patient getting more massage therapy visits. On 11/9/22 at 10:24 AM, during an interview, the Clinical Manager reported IDG members communicate in person, by doing joint patient visits, by phone, email and share access to notes in the electronic medical record. IDG members will call if there is an imminent need or concern. The typical nursing frequency is 1-2 times per week and as needed (PRN) as warranted per nurse and IDG member determination. Hospice aide services typically start at 5 times per week unless the patient does not need or want this. The social worker and chaplain base frequency of services on the initial assessment and patients wants/needs. They may increase services as patient needs increase. For music and massage therapy services, the IDG members discuss this in the IDG meeting. If the need for these services comes up between IDG meetings, which occur every other week, the IDG members email each other. The nurse recommends music or massage therapy and lets the therapist know. The therapist does an assessment, determines the frequency for service and discusses the frequency in IDG. Social work, chaplain, music and massage therapy services can be just PRN, but this is rare. Typically this is due to if the patient declined the service, and the hospice has it available if needed. If a service is ordered PRN, typically the nurse will let staff know why it is beneficial for another visit. The delivery of PRN visits is also based on if patient requests the PRN service. The hospice IDG failed to ensure communication and collaboration of massage therapy services per the POC and based on the patient's assessed needs and request for massage therapy services.