Every finding on record at Takecare Insurance Company, Inc.

Based on a review of the facility's Emergency Preparedness Plan (EPP) and staff interview, the Hospice agency failed to establish a current comprehensive Emergency Preparedness Program that complies with all applicable Federal Emergency Preparedness requirements that was based off the facility's all hazard risk assessment and patient population it serves. This deficient practice has the potential to put the current seven patients who are provided care by the facility and facility staff from the agency at risk in the event of an emergent event.Findings include:During a review of the facility Emergency Preparedness plan on 08/01/25 at 1:40 PM, the Home Health and Hospice Manager and the Healthcare Delivery Administrator revealed the all- hazards risk assessment and the EPP, based on that assessment, had not been updated since 2017; in conjunction with other requirements of the EPP that were not included. Cross Reference: E0006, E0013, E0019, E0029, E0030, E0031, E0032, and E0036.

Based on interview and review of the agency's Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP policies were based on a current all hazards-based agency and/or community risk assessment. This failure had the potential to affect the current seven patients receiving care from the agency and employed staff.Findings include:During a review of the agency's Emergency Preparedness plan on 08/01/25 at 1:40 PM, the Home Health and Hospice Manager and the Healthcare Delivery Administrator revealed the all- hazards risk assessment, the basis for the agency's EPP, had not been updated since 2017.Review of the all-hazards assessment showed it included "epidemic" and "swine flu" but did not include pandemic/emerging infectious diseases.During an interview on 08/01/25 at 1:59 PM, the Healthcare Delivery Administrator stated, "This is something we have to update since we moved to this building in 2023."

Based on interview and review of the agency's Emergency Preparedness Plan (EPP), the agency failed to develop and implement emergency preparedness policies and procedures based on a current facility and community based all-hazards risk assessment that included emerging infectious diseases and failed to review and update their policies on an annual basis. This failure had the potential to affect the seven patients served by the hospice and hindered the agency's ability to provide care and services to keep patients and staff safe during an emergency. Findings include: Review of the agency's EPP on 08/01/25 at 1:40 PM with the Home Health and Hospice Department Manager (HDM) and Healthcare Delivery Administrator (HDA) did not reveal policies and procedures that had been updated every two years.  During an interview on 08/01/25 at 1:42 PM stated the last documented update was in 2017.At 1:55 PM, the HDA stated he/she thought there was an update in 2019 but no evidence was provided.

Based on interview and review of the agency's Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP addressed a procedure to inform the State and Local Emergency Preparedness Officials of homebound patients in need of evacuation. This failure had the potential to affect any of the seven patients currently receiving care from the agency.Findings include:Review of the agency's EPP, last updated on 07/11/17, with the Home Health and Hospice Department Manager (HDM) revealed no policy or procedure that identified the procedure the agency would use to notify the local or state emergency officials of homebound patients that required evacuation in an emergency event.During an interview on 08/01/25 at 2:28 PM, the HDM stated, "We don't have that. It would probably be each case manager, but it's not written."

Based on interview and review of the agency's Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to develop and maintain an Emergency Preparedness Communication Plan that was reviewed and updated at least bi-annually (every two years). This failure had the potential to affect the seven current patients receiving care from the agency, potentially hindered the agency's ability to continue care and services to patients during an emergency event and keep patients and staff safe during an emergency.Findings Include:Review of the agency's EPP with the Home Health and Hospice Department Manager (HDM) on 08/01/25 at 1:40 PM did not reveal any evidence the Communication Plan had been updated in the last two years.During an interview on 08/01/25 at 2:51 PM, the HDM stated he/she had nothing to show it had been reviewed or updated every two years, stating, "The one in the book is 2017."

Based on interview and review of the agency's Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the Hospice failed to maintain a current list of names and contact information in the "Emergency Preparedness Communication Plan" that included other hospice agencies. This failure had the potential to affect the seven patients receiving care from the organization and could delay the agency's ability to respond to an emergency.Findings include:Review of the agency's EPP Communication Plan, with a last reviewed date of 07/11/2017, with the Home Health and Hospice Department Manager (HDM), revealed no inclusion of other hospice agencies.During an interview on 08/01/25 at 2:56 PM, the HDM confirmed that other hospices were "not in there."

Based on interview and review of the agency's Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to maintain a current list of contact information that included the Federal Emergency Preparedness staff and/or agencies in their Emergency Preparedness Communication Plan. This failure had the potential to affect any of the seven patients receiving care from the agency and could delay the agency's ability to respond to an emergency and had the potential to prevent first responders and other sources of assistance from providing care and services to the agency and its' patients or staff during an emergency event.Findings include:Review of the agency's EPP Communication Plan with the Home Health and Hospice Department Manager (HDM) and Healthcare Delivery Administrator (HDA) on 08/01/25 at 1:40 PM revealed no inclusion of emergency contact information for the Federal emergency staff/agency.During an interview on 08/01/25 at 3:01 PM, the HDA confirmed that the Federal Emergency Management Agency (FEMA) was on the island but not included in the EPP Communications Plan.

Based on interview and review of the agency's Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP Communication Plan identified a means of primary and/or alternate form of communication with staff, federal and state emergency management agencies. This failure had the potential to affect the current seven patients receiving care from the agency and hinder the agency's ability to prepare for/respond to potential emergency situations.Findings include:Review of the agency's EPP Communications Plan on 08/01/25 at 1:40 PM with the Healthcare Delivery Administrator (HDA) did not reveal specified primary and alternate methods of communication with the federal and state emergency management agencies.During an interview on 08/01/25 at 3:05 PM, the HDA stated, "We don't have that."

Based on interview and review of the agency's documentation, the agency failed to ensure the Emergency Management Plan, also known as the Emergency Preparedness Plan (EPP), documented an updated training program every two years. This failure had the potential to affect the seven current patients receiving care and services from the hospice due to the lack of staff or volunteer preparedness in the case of an emergent event.Findings include:Review of the EPP on 08/01/25 at 1:40 PM with the Home Health and Hospice Department Manager (HDM) revealed no documentation regarding an updated/reviewed training program in the last two years.During an interview on 08/01/25 at 3:32 PM, the HDM confirmed the last training program update was in 2017.

Based on record review and interview, the facility failed to ensure the initial Interdisciplinary Group (IDG) assessments were completed within five days of Hospice admission for two of 14 patients (Patient (P) 1 and P2) reviewed out of a total sample of 14. This failure could affect the care the patient and/or family received due to inaccurate assessment of needs.Findings include:1. P1 was admitted to Hospice services on 07/19/25.During P1's record review, no Social Worker or Spiritual assessments were found.During an interview on 08/01/25 at 4:16 PM, the Billing Associate (BA, operating the electronic medical record) stated, "I don't think [he/she, Social Worker] completed it before [he/she] left. It's not completed."2. P2 was admitted to Hospice services on 07/08/25.During P2's record review, no Social Worker assessment was found.During an interview on 08/04/25 at 4:37 PM, BA stated "[He/She] hasn't visited yet." The Hospice Manager commented that P2 was "Gov.Guam" and they did not cover a Hospice Social Worker.Review of the facility's policy titled, "Patient Record Content," revised 06/2018, did not address the requirement of the IDG assessment completion within five days of admission.

Based on record review, interviews, and policy review, it was determined that the Governing Body did not ensure the Quality Assurance program maintained an effective performance improvement program with evidentiary documentation. This failure had the potential to affect the quality of care for the current seven patients receiving services from the agency.Findings include:1. There was no documented evidence that the hospice agency had Governing Body meetings according to agency policy to monitor the Quality Assurance and Performance program. Cross Reference: L562.2. The agency failed to document performance improvement plans being conducted, the reason for the project, and measurable progress. Cros Reference: L573.3. The Governing Body failed to ensure the Quality Assurance Performance Improvement process was defined, implemented, maintained, and evaluated annually. Cross Reference L574.

Based on record review and interview, the facility failed to ensure the Quality Assurance Performance Improvement and/or Governing Body had evidence of at least one measurable improvement in hospice services or palliative outcomes. This failure had the potential to affect the quality of life of any of the seven current hospice patients.Findings include:Review of the facility provided minutes of the last Quality Assurance Performance Improvement meeting, held without the Medical Director in attendance on 05/07/25, revealed the "Attendance Sheet" had a handwritten topic of "Home Health & Hospice Care Conference," had the following attachments:"PT [Physical Therapy] – RN [Registered Nurse] Case Management Checklist""FHP Hospice Strategic and Improvement Plan for 2024 – 2026," with"Strategic Goal and Initiatives:1. Quality Improvement and Quality of Care2. Regulatory Compliance and Readiness3. Workforce Development4. Referral Growth and Community Engagement5. Financial Sustainability" and"Activates [sic] and implementation timelines:Q1 [Quarter 1] 2024  5 Day Assessment RulePartnership Building and Education CampaignQ2 2024Partnership BuildingReferral Growth and Community EngagementQ3 2024Build and maintain communicationsWorkforce developmentQ4 2024Financial SustainabilityQ1 2025Revenue enhancement and Cost ManagementQ2 2025Staff Training and educationQ3 2025Staff Training and educationWorkforce developmentRegulatory Compliance and ReadinessQ4 2025Quality Improvement and Quality of CareImplementation of HOPE [Hospice Outcomes & Patient Evaluation] tool."During an interview on 08/04/25 at 7:50 PM, the Healthcare Delivery Administrator (HDA) stated that the items they had been looking at for improvement were physical therapy / Registered Nurse communication for patient functionality and alleviating pain to increase quality of life. The HDA stated performance improvement issues were not in a written format and were discussed at the Interdisciplinary Group (IDG) meetings every two weeks. The HDA stated QAPI did not meet regularly. The HDA stated, "We met in May and the one before that, the only one was in November of 2024."The facility provided the last documented Governing Body meeting minutes, and they were dated 09/28/22.No policy regarding Quality Assurance Performance Improvement was provided.

Based on interview, policy review, and attempted record review, the agency failed to ensure there was evidence of the Performance Improvement Plans/Projects (PIP) being conducted, the reason for the project undertaking, and/or measurable progress from the improvement plan. This failure had the potential to affect the quality of life for any of the current seven patients or the practices of the Hospice agency staff.Findings include:During an interview on 08/04/25 at 7:50 PM, in response to a request for PIPs in the past year, the Healthcare Delivery Administrator (HDA) stated that the items they had been looking at for improvement were physical therapy / Registered Nurse communication for patient functionality and alleviating pain to increase quality of life. The HDA stated performance improvement issues were not in a written format and were discussed at the Interdisciplinary Group (IDG) meetings every two weeks but QAPI did not meet regularly. The HDA stated, "We met in May and the one before that, the only one was in November of 2024."Review of the facility policy titled, "Leadership Assessment of Contributions to Quality Assessment/Performance Improvement (QAPI) and Safety Improvement Activities," revised March 2013, revealed, ". . . 1. At lease annually Hospice leaders and the Governing Body will perform an analysis/assessment of their contributions to Hospice's QAPI program. 2. Hospice leaders and Governing Body members will establish expectations for using data and information for improving safety and quality of care . . ."

Based on record review and interview, the agency's Governing Body failed to ensure the Quality Assurance Performance Improvement activities were evaluated annually. This failure had the potential to affect the quality of life during the palliative care process for any of the current seven patients and the ability of staff to effectively care for those patients.Findings include:In response to a request for the Governing Body meeting minutes, the facility provided a sign-in sheet and agenda from a meeting dated 09/28/22.During an interview on 08/04/25 at 7:50 PM, the Healthcare Delivery Administrator (HDA) stated, "The policy says they are to meet annually. They have not had a meeting since 2022." The HDA provided an attendance sheet from that meeting dated 09/28/22.Review of the facility policy titled, "Leadership Assessment of Contributions to Quality Assessment/Performance Improvement (QAPI) and Safety Improvement Activities," revised March 2013, revealed, ". . . 1. At least annually Hospice leaders and the Governing Body will perform an analysis/assessment of their contributions to Hospice's QAPI program. 2. Hospice leaders and Governing Body members will establish expectations for using data and information for improving safety and quality of care."Review of the facility policy titled, "Governing Body," revised 06/2018, revealed, ". . . Responsibilities . . . The Governing Body annually evaluates Hospice's performance in relation to its vision, mission and goals . . . The Governing Body meets at least annually to review the operation of Hospice and documents all meetings by minutes . . ."

Based on personnel file review, staff interview, and review of agency policy, the agency failed to offer Hepatitis B vaccines to one of six direct care staff whose personnel files were reviewed. This had the potential for the potential transmission of Hepatitis B to patients and other staff employed by the agency.  Findings include:  Review of Registered Nurse (RN)3's personnel file revealed a hire date of 02/22/99. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by the employee since the date of hire.  During an interview on 08/04/25 at 1:20 PM, the Home Health and Hospice Department Manager (HDM) confirmed there was no evidence the Hepatitis B Vaccine (HBV) was offered to or declined by RN3  During an interview on 08/04/25 at 7:03 PM regarding a HBV policy, the Healthcare Delivery Administrator (HDA) stated the agency did not have a policy regarding the HBV, "It's in our general Human Resources policy that we offer the vaccine for free, but not a Hospice policy."

Based on record review, interview, and agency policy review, the facility failed to ensure bereavement services were provided per policy for two of 14 sampled patients (Patient (P) 4 and P5). This failure had the potential to affect the ability of patient family members to process the loss and grief of death.Findings include:1. Review of P4's record revealed a hospice admission date of 06/12/24 with a terminal diagnosis of brain cancer. P4 passed away on 08/18/24. The record revealed the first bereavement condolence call was on 08/25/24; the first mailing was 08/18/24; the next mailing was at six months on 02/18/25; the next mailing was at 12 months on 08/18/25 During an interview on 08/04/25 at 3:44 PM, the Home Health and Hospice Department Manager (HDM) stated, "The third and ninth months were missed." 2. Review of P5's record revealed a hospice admission date 04/16/24 with a terminal diagnosis of prostate cancer. P5 passed away on 07/05/24. The record revealed the first bereavement condolence call was on 07/12/24; the first mailing was a card on 08/05/24; the next contact was at six months on 01/05/25 then at 12 months on 07/05/25, and the record was scheduled to be closed on 08/05/25.  During an interview on 08/04/25 at 3:49 PM, the Home Health and Hospice Department Manager (HDM) stated, "The third and ninth months were missed." Review of the facility policy titled "Bereavement Services," revised 2014, revealed, ". . . Procedure . . . 3. Within two weeks of the patient death, a condolence card will be mailed to the family. Within a month of death, a twelve-month bereavement mailing program will be initiated for designated family members . . ."

Based on interview and personnel file review, the facility failed to ensure one of one Certified Nurse Aide / Home Health Aide (CNA/HHA) had twelve hours of annual in-service training. This failure had the potential to affect any of the current seven patients that may require aide services.Findings include:Review of CNA1's personnel file showed a facility hire date of 01/08/24.During an interview on 08/04/25 at 12:52 PM, the Hospice Manager confirmed CNA1 did not have the twelve in-service hours required. At 2:45 PM, the Hospice Manager provided a few online certificates, two without dates, and the others were dated 07/08/24 and 07/10/24, with a total of eight in-service hours. The Hospice Manager stated the facility year was September to September and confirmed these were outside the past twelve months and the facility did not have a policy regarding in-services.Review of the facility policy titled, "Hospice Aide Services and Training Program," revised 2014, revealed no reference to the provision of in-service training hours.

Based on interview, patient packet review, and policy review, the facility failed to ensure written controlled medication disposal policies were provided to one of three patients/family members (Patient (P) 3) out of a total sample of 14. This failure had the potential for unused or discontinued medications to be mishandled, diverted, or left undestroyed.Findings include:During an interview on 08/04/25 at 11:45 AM, the Responsible Party (RP3) for P3 was asked if he/she had received instruction on medication destruction. RP3 stated, "No." RP3 confirmed during the interview that the Hospice had provided a comfort pack that included controlled substances. Registered Nurse (RN) 2 reminded RP3 about destroying medications in used coffee grounds or cat litter, RP3 stated, "Oh yes." The Hospice paper packet provided to P3 and RP3 was reviewed, and there were no documents regarding medication destruction. RN2 confirmed there were no documents related to medication destruction.During an interview on 08/04/25 at 3:06 PM, the Administrator stated the written medication destruction information had not been included in the sample admission packet provided to the surveyor and "probably was not in the packet the patient received."Review of the facility policy titled "Medication Disposal," revised 06/2018, revealed, ". . . 1. At the time when controlled drugs are first ordered, Hospice will: Provide a copy of the Hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family . . ."

Based on interview and record review the facility did not assure that Interdisciplinary Group (IDG) met to review, revise and document the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days for six of 11 patients (1, 2, 3, 4, 6, and 8). The other five sampled patients were not on service long enough to have an IDG meeting. The cumulative effect of this deficient practice put patients at potential risk of not receiving care and services that met the patients needs. (Cross reference L552). --- Findings: On 9/22-23/2022 when asked where the surveyors would find the IDG notes, the Director of Patient Care Services (DPCS) provided a binder for the IDG meetings that occurred during 2021. The binder was divided by month and included form with the date the meeting was held and a list of attendees. The IDG form titled ";Interdisciplinary Team Meeting Note" had information recorded for each of the patients the team discussed during the meeting. Review of each month showed no patient records except for 10/20/2021. The following IDG attendee lists were in the2021 binder: January - 1/20/21- this was a screenshot of a ZOOM® meeting, 1/27/21 signed list. No Team Meeting Notes February – 2/3/21, 2/10/21, 2/17/21 and 2/24/21 March – 3/3/21, 3/10/21 and 3/17/21. April- NONE May- 5/2/21 and 5/26/21 June - September – NONE October – 10/20/21 November – 11/3/21- No Team Meeting Notes December- 12/15/21- No Team Meeting Notes For 2020 and 2022 the DPCS stated they did not have binders for these; however, they would find the documents for the sampled patients. Patient 1 was admitted on 10/18/2021 The following IDGs were missed for each certification period below: Second certification period: 1/17/22 -4/16/22- missed one in January, one in March and one in April. IDGs were done on 2/2/22; 2/16/22; 3/16/22. Third certification period: 4/17/22 – 6/15/22- missed one in April, one in May and one in June. IDGs were done on 5/4/22 and 6/15/22. Fourth certification period: 6/18/22 – 8/14/22- missed one in June, two in July and one in August. IDGs were done on 7/20/22 and 8/11/22. Fifth certification period: 8/15/22 – 11/13/22- missed one August and one in September. IDGs done 9/19/22. Patient 2 was admitted on 8/22/2022 with certification period 8/22/2022 – 11/19/2022. IDGs missed for this certification period were one in August and one in September. One was conducted on 9/19/2022. Patient 3 was admitted on 8/12/2022 with certification period 8/12/2022 – 11/9/2022. IDGs missed for this certification period were two in September. One was conducted on 8/24/2022. Patient 4 was admitted on 7/22/2021 with certification period 7/22/21-10/19/2021 IDGs missed for this certification period were as follows: First certification period 7/22/21 – 10/19/2022- one late in September, the previous IDG was held on 8/18/21 and the next one was 21 days later on 9/8/21. Third certification period – 1/18/2022 – 3/18/2022 missed two in January. Patient 6 was admitted on 8/5/2019 and passed away 10/27/2021. IDGs review for year 2021 only: The patient had five certification periods in 2021. There were IDGs for two of the five certification periods as follows: 7/25/2021 – 9/22/2021 – IDG done 8/11/2021, 8/25/21, 9/8/21 and 9/22/21 9/23/2021 – 11/21/2021- IDG done 10/6/21, 10/2021. There should have 12 other IDG notes completed for the year 2021; however, no other IDG notes were provided by the agency. Patient 8 was admitted 5/3/2022 and died on 8/19/2022 with certification period 5/3/2022 -7/2/22 and 7/3/2022 – 9/2/2022. I DGs reviewed included 5/4/2022, 6/16/2022, 7/20/2022 and 8/11/2022 There should have been eight IDG notes for these two certification periods; however, four were missing. During an interview on 9/23/2022 at 2 PM, the Administrator and DPCS stated they have had difficulty returning to their routines after the pandemic; however, acknowledged they missed many of the meetings. Cross reference L552

Based on interview and record review the agency did not assure that the Interdisciplinary Group (IDG) review, revise and document the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days for six of 11 patients (1, 2, 3, 4, 6, and 8). This deficient practice had the potential for the patients not to received necessary updated care and services and the treatment team from knowing the aspects of the patients care and progress toward goals. --- Findings: During an interview and concurrent record review during the survey between 9/22-23/2022, the IDG binder was reviewed with the Director of Patient Care Services (DPCS). There was one binder with the notes for the IDG meetings for 2022. Although there was a sign in sheet for each of the IDG meetings held twice per month, there were not corresponding notes for each of the patients they reviewed. There was no binder for the 2021 IDG meetings. Reviewed the Electronic Health Record (EHR) for each of the sampled patients and there were notes missing for the following patients: 1. Patient 1 (Pt 1) was admitted on 10/18/2021 with diagnosis including but not limited to Lewy Body Dementia. The patients functional limitations included needing assistance with feeding (puree diet), unable to walk, needed assistance with transfer from surface to surface, was incontinent of bowel and bladder, had contractures (a fixed shortening of the muscles) and limited endurance. Activities permitted were complete bed rest, transfer bed to chair and wheelchair. Mental status was lethargic. Services provided were Skilled Nurse (SN) visits were 2 time per week for 13 weeks written as SN 2W13. SN to provide supportive care including pain management. The following IDGs were missed for each certification period below: Second certification period: 1/17/22 -4/16/22- missed one in January, one in March and one in April. IDGs were done on 2/2/22; 2/16/22; 3/16/22. Third certification period: 4/17/22 – 6/15/22- missed one in April, one in May and one in June. IDGs were done on 5/4/22 and 6/15/22. Fourth certification period: 6/18/22 – 8/14/22- missed one in June, two in July and one in August. IDGs were done on 7/20/22 and 8/11/22. Fifth certification period: 8/15/22 – 11/13/22- missed one August and one in September. IDGs done 9/19/22. 2. Patient 2 was admitted on 8/22/2022 with certification period 8/22/2022 – 11/19/2022. Diagnoses included but not limited to malignant lung cancer with metastases to the left adrenal and thyroid glands and brain. Functional limitations included amputation, bowel and bladder incontinence, dyspnea (difficulty breathing) with minimal exertion and limited endurance. Activities permitted included up as tolerated, transfer bed/chair using a cane. The patient was alert and oriented. Services provided were medical social work (MSW) visits were 1-3 time per month for 3 months to provide supportive care. Skilled Nurse (SN) visits were 1 time per week for 13 weeks written as SN 1W13. SN to provide supportive care including pain management. IDGs missed for this certification period were one in August and one in September. One was conducted on 9/19/2022. 3. Patient 3 was admitted on 8/12/2022 with certification period 8/12/2022 – 11/9/2022. Diagnoses included but not limited to End Stage Renal Disease and bilateral below the knee amputations and History of type 2 diabetes, high blood pressure and stroke. Functional limitations included amputations, ambulation, bowel and bladder incontinence and endurance. Activities permitted included complete bed rest. Patient was alert and oriented but sometimes confused. Services provided were SN 1W13 plus as needed visits. SN to provide supportive care including pain management. IDGs missed for this certification period were two in September. One was conducted on 8/24/2022. 4. Patient 4 was admitted on 7/22/2021 with certification period 7/22/21-10/19/2021 diagnoses including but not limited to vascular dementia and history of stroke with left sided paralysis, dementia without behavioral disturbance, weakness and dysphagia (difficulty swallowing). Services provided were SN 1w13 to provide supportive care including disease and pain management; HHA 1w13; VS each visit, assist w ADLs, bed bath each visit; teach cg how to provide grooming needs and ADLs safely. IDGs missed for this certification period were as follows: First certification period 7/22/21 – 10/19/2022- one late in September, the previous IDG was held on 8/18/21 and the next one was 21 days later on 9/8/21. Third certification period – 1/18/2022 – 3/18/2022 missed two in January. 5. Patient 6 was admitted on 8/5/2019 and passed away 10/27/2021. Diagnoses included but not limited to dementia without behavioral disturbance, Parkinsons disease and abnormal weight loss. There were no changes to the patients diagnoses. Functional limitations included bowel and bladder incontinence, ambulation, hearing, speech and endurance. Activities permitted went from walker to transfer bed to chair and up in wheelchair as tolerated. Patient went from forgetful and disoriented to confused and disoriented to agitated and disoriented. Services provided were SN 1w 9 to provide supportive care including disease and pain management; HHA 2w8 to provide and assist with personal care and assistance with activities of daily living. The services and care plans were the same each certification period with minor changes in visitation schedule. IDGs review for year 2021 only: The patient had five certification periods in 2021. There were IDGs for two of the five certification periods as follows: 7/25/2021 – 9/22/2021 – IDG done 8/11/2021, 8/25/21, 9/8/21 and 9/22/21 9/23/2021 – 11/21/2021- IDG done 10/6/21, 10/2021. There should have 12 other IDG notes completed for the year 2021; however, no other IDG notes were provided by the agency. 6. Patient 8 was admitted 5/3/2022 with diagnoses including but not limited to adult failure to thrive and died on 8/19/2022 with certification period 5/3/2022 -7/2/22 and 7/3/2022 – 9/2/2022. Services provided were SN 2w9 to provide supportive care including disease and pain management, HHA 2w9 to provide and assist with personal care and assistance with activities of daily living, and MSW 1-3 times per month to provide supportive care and community resources. IDGs reviewed included 5/4/2022, 6/16/2022, 7/20/2022 and 8/11/2022 There should have been eight IDG notes for these two certification periods; however, four were missing. On 9/23/2022 at approximately 3 PM, during an interview when asked about the missing IDG meeting notes listed above, the DPCS stated they looked for them; however, they could not find any other IDG notes. Some of the meetings were missed or done late. Review of the facilitys Policies and Procedures Manual for Hospice©2009 PED-PASS, Inc. (Revised June 2018) 9/12/1 titled, ";IDG Care Planning Process" read in pertinent part as follows: ";Policy; In order to assure that care provided is appropriately planned to meet each patients specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessments and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with the patients needs and goals as a priority....Procedure...9 The IDG...reviews, revises and documents the individualized plan as frequently as the patients conditions requires but no less frequently than ever 15 calendar days..."

Based on interview and record review the agency did not ensure that care and services were provided according the physicians orders for one of 11 sampled patients (Pt 4). This deficient practice had the potential for patients not getting needed treatment. --- Findings: Patient 4 was admitted on 7/22/2021 with diagnoses including but not limited to vascular dementia and history of stroke with left sided paralysis, dementia without behavioral disturbance, weakness and dysphagia (difficulty swallowing). For certification period 7/22/21-10/19/2021 Pertinent Medications included: Gabapentin Oral Tablet 100 MG- 1 -Tab(s) -2 Times a day (seizure medication) Quetiapine Fumarate Oral Tablet 50 MG - 1- Tab(s) - 2 Times a day (antipsychotic) Nifedipine CR Oral Tablet Extended Release 24 Hour 30 MG - 1 - Tab(s) ( Heart medication) Bumetanide 1 mg -1- tab daily (Diuretic) Clopidogrel Bisulfate 75 mg-1- tab once a day (antiplatelet) Metoprolol Succinate oral capsule ER 24 hours -2-capsules once a day (for high blood pressure) Pertinent services provided were Skilled Nurse to visit twice per week for nine weeks, written as SN 2w9 to assess and evaluate: Vital Signs, Cardiovascular/Pulmonary Status, Signs and symptoms to observe and report to nurse or MD, Skilled nursing to teach and instruct: Disease process and potential complications for disease management; Medications compliance and response. A. PARAMETERS to Notify physician were: Temperature: (greater than) > 100.5 or (less than) < 95; Respirations> 24 < 12; Blood Pressure> 160/80 < 80/60; Pulse Rate> 100 < 60 Review of the visit notes on the following days indicated the vital sign parameters were out of range and the SN or HHA did not notify the hospice or physician. 8/10//2021 SN visit note indicated the residents blood pressure (BP) was 164/78 – there was no note indicating the SN had call the hospice or the physician. There was no instruction regarding BP management. 9/28/2021 SN visit note indicated the residents BP was 200/70- there was no note indicating the SN had call the hospice or the physician. There was no instruction regarding BP management. 10/26/2021 SN visit note indicated the residents BP was 190/78- there was no note indicating the SN had call the hospice or the physician. There was no instruction regarding BP management. 11/16/2021 SN visit note indicated the residents BP was 179/78- there was no note indicating the SN had call the hospice or the physician. There was no instruction regarding BP management. 12/14/21 SN visit note indicated the residents BP was 174/70- there was no note indicating the SN had call the hospice or the physician. There was no instruction regarding BP management. B. MISSED VISITS: For the following certification periods: 1st Certification Period 8/5/19 – 11/3/19 visit orders were HHA 1w1; 2w12 The HHA canceled visits on the following days and did no make up the days or notify the agency or physician: 8/16/2019, 9/6/2019; 2nd Certification Period 11/3/2019 – 1/31/2020 visit orders were HHA 2w13. There were no HHA visits between 11/10/2019 and 11/30/2019; that is six missed visits. 7th Certification Period 9/28/2020- 11/26/2020 visit orders were SN 1w9. On 10/20/2020 and 11/22/2020 the SN missed visits due to patient cancelling; however, the agency did not notify the physician until 5/17/2021 about seven months later. During an interview 9/23/2022 at 2 PM, the DPCS stated some of the patients were afraid to have visit due to the pandemic; however, they should have documented their attempts to reschedule the visits and to notify the physicians.

Based on interview the agency did not provide for short term inpatient treatment for for pain control, symptom management, and respite purposes. This deficient practice resulted in all patient not being given the opportunity for extra pain control and symptom management if needed or respite care for all families. --- Findings: During home visits revealed the following: 1. Patient (Pt) 1 was admitted on 10/18/2021 with diagnosis including but not limited to Lewy Body Dementia. The patients functional limitations included needing assistance with feeding (puree diet), unable to walk, needed assistance with transfer from surface to surface, was incontinent of bowel and bladder, had contractures (a fixed shortening of the muscles) and limited endurance. Activities permitted were complete bed rest, transfer bed to chair and wheelchair. Mental status was lethargic. On 9/15/2022 beginning at 9 AM, when asked Family1 (FM1) if there were times the patients symptoms became unmanageable, FM1 stated that she had been through this before with other family members and the agency managed any symptoms that came up. When asked if she or the other family members who cared for Pt. 1 needed respite care, FM1 stated they did not. They helped each other and they had a hired care giver to help out. 2. Patient (Pt) 2 was admitted on 8/22/2022 with certification period 8/22/2022 – 11/19/2022. Diagnoses included but not limited to malignant lung cancer with metastases to the left adrenal and thyroid glands and brain. Functional limitations included amputation, bowel and bladder incontinence, dyspnea (difficulty breathing) with minimal exertion and limited endurance. Activities permitted included up as tolerated, transfer bed/chair using a cane. The patient was alert and oriented. On 9/15/2022 beginning at 12 noon, when asked Pt 2 if there were times the her symptoms became unmanageable, Pt 1stated that so far she had been able to manager with her sisters help and the agency were always available when she needed them. 3. Patient (Pt) 3 was admitted on 8/12/2022 with certification period 8/12/2022 – 11/9/2022. Diagnoses included but not limited to End Stage Renal Disease and bilateral below the knee amputations and Hx of type 2 diabetes, high blood pressure and stroke. Functional limitations included amputations, ambulation, bowel and bladder incontinence and endurance. Activities permitted included complete bed rest. Patient was alert and oriented but sometimes confused. On 9/19/2022 beginning at 7:20 AM, Pt 3 was observed in bed and was not very responsive. His family was all around him and one of them (FM3) spoke English. When asked FM3 if there were times the patients symptoms became unmanageable, FM3 stated that the agency skilled nurse (SN) had instructed the family very well how to managed any symptoms that came up. When asked if she or the other family members who cared for Pt 3 needed respite care, FM3 stated they did not. They helped each other and people from the church to help if needed. During an interview on 9/23/2022 at 2:25 PM, when asked about the agencys contract with a hospital or Skilled Nursing Facility (SNF), the Administrator (ADM) and Director of Patient Care Services (DPCS) stated they had a contract with the hospital; however, upon review of the contract, it was not a contract specifically with the hospice to provide specific general inpatient services (GIP) services for hospice patients. The ADM stated they thought the general contract to provide care for patients as any other patient would be enough.