Every finding on record at Texas County Memorial Hospital

Based on policy review, record review, and interview the hospice provider failed to ensure an accurate/updated medication profile was maintained in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Observation and interview on 11/18/2025 showed the following discrepancies between the provider’s current medication profile and the patient’s home medication bottles:-The provider’s medication profile showed cefdinir (used to treat bacterial infections in several parts of the body) 300 milligrams (mg). Take one capsule by mouth every 12 hours for eight days. The patient stated that he/she was no longer taking this medication;-The provider’s medication profile showed doxycycline (an antibiotic used to treat a wide range of infections) 100 mg. Take one capsule by mouth every day for eight days. The patient stated that he/she was no longer taking this medication;-The provider’s medication profile showed triple antibiotic ointment. Apply a small amount topically to the right ankle. The patient stated that he/she was no longer using this medication since her ankle wound healed;-The patient was taking MiraFAST chews (magnesium hydroxide 1200 mg). The patient stated that he/she was taking this for constipation for “a while”. The provider’s medication list did not include this medication;-The patient was taking acetaminophen 325 mg 1-2 tablets every 8 hours as needed for pain. The provider’s medication list did not include this medication; and-The patient was taking Aleve 220 mg. Take one tablet every 8-12 hours as needed for mild pain/fever. The provider’s medication list did not include this medication.During an interview on 11/20 at 10:20 AM, the hospice administrator stated that he/she would expect the medication list to reflect what the patient is taking in the home. Findings included:RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abnormal aortic aneurysm (a bulge in the wall of the aorta), systolic congestive heart failure (the left ventricle is weakened and cannot pump blood effectively) and AFib (irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers. Observation and interview on 11/18/2025 beginning at 11:25 AM, showed the following discrepancies:- The patient was taking Ropinirole (Parkinson's disease and restless leg syndrome medication) .25 milligrams (mg) tablet by mouth once a day. The caregiver (adult child) stated he/she had been taking this prior to hospice admission. The hospice providers Chronological List of Medications, Labs and Equipment printed on 11/17/2025 failed to include Ropinirole;- The patient was taking Jardiance (extended release medication to treat high blood sugars) 10 mg tablet by mouth once a day. The caregiver stated he/she had been taking the dosage prior to hospice admission. The hospice provider's Client Medication Report printed on 11/17/2025 failed to include Jardiance;- The patient was taking Tussin (over the counter cough syrup) 20 milliliters (ml) by mouth every 6 hours as needed. The caregiver stated he/she had been taking this since the hospice admission. The hospice providers Client Medication Report printed on 11/17/2025 failed to include Tussin;- The patient was taking Acetaminophen (over the counter pain reliever) 650 mg tablet by mouth every 8 hours as need for pain. The caregiver stated he/she had been taking this prior to hospice admission. The hospice providers Client Medication Report printed on 11/17/2025 failed to include Acetaminophen;- The patient was taking Relaxium Sleep supplement (over the counter sleep aid) 10 mg tablet by mouth once a day. The caregiver stated he/she had been taking this since hospice admission. The hospice providers Client Medication Report printed on 11/17/2025 failed to include Relaxium Sleep supplement;- The patient was using Benadryl Itch Cream (over the counter itch relief) as need for itching. The caregiver stated he/she had been using this prior to hospice admission. The hospice providers Client Medication Report printed on 11/17/2025 failed to include Benadryl Itch Cream;- The hospice provider's Client Medication Report printed on 11/17/2025 showed Oxycodone IR (immediate-release analgesic for pain) 5 mg tablet (q) four hours as needed (PRN). The caregiver stated the patient had all medications on the dresser in the bedroom;- The hospice provider's Client Medication Report printed on 11/17/2025 showed Lorazepam intensol oral concentrate (nonsteroidal anti-inflammatory drug and blood thinner) 2 mg/ml by mouth PRN, q4h (four times daily). The caregiver stated the patient had all medications on the dresser in the bedroom;- The hospice provider's Client Medication Report printed on 11/17/2025, showed Nystatin powder (topical fungal infection caused by yeast) 15 grams (GM) BID (two times daily). The caregiver stated the patient had all medications on the dresser in the bedroom. the hospice administrator stated the treatment had completed for this medication;-  The hospice provider's Client Medication Report printed on 11/17/2025, showed Morphine (sedative) 20 mg/ml liquid by mouth as needed q4h for air hunger. The caregiver stated the patient had all medications on the dresser in the bedroom; and- The hospice provider's Client Medication Report printed on 11/17/2025, showed Xanax (steroid) .25 mg tablet by mouth q4h for anxiety PRN. The caregiver stated the patient had all medications on the dresser in the bedroom.The hospice provider failed to maintain an accurate drug profile.  During an interview on 11/18/2025 at 2:00 PM, the administrator stated the medication list for the facility had not been updated. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided at skilled nursing facility (SNF) as the primary caregivers. Observation and interview on 11/19/2025 beginning at 10:07 AM, showed the following discrepancies:- The hospice provider's Client Medication Report printed on 11/17/2025 showed Lorazepam intensol oral concentrate (nonsteroidal anti-inflammatory drug and blood thinner) 2 mg/ .5-1ml by mouth QD (one time daily). The SNF did not list this medication on the facility medication administration record (MAR); and- The hospice provider's Client Medication Report printed on 11/17/2025, showed Morphine sulfate (oral opioid analgesic used for pain and advanced air hunger) 20mg/ .5-1 ml as needed (PRN) q2h (every two hours). The SNF did not list this medication on the facility medication administration record (MAR).The hospice provider failed to maintain an accurate drug profile for pain management in partnership with the SNF.  Findings included:Review of the provider’s policy titled, “Medication Management – Patient Information,” effective 10/2009, showed, in part, that the patient’s medications are reviewed and assessed during each skilled visit. Any changes to the medications or changes in the patient’s response to the medications are conveyed to the ordering physician.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abdominal aortic aneurysm (AAA; a ballooning of the wall in the abdominal aorta), systolic congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers. Observation and interview on 11/18/2025 beginning at 11:25 AM, showed the following discrepancies:- The patient was taking ropinirole (Parkinson's disease and restless leg syndrome medication) 0.25 milligrams (mg) tablet by mouth (PO) once a day. The caregiver (adult child) stated that the patient took this prior to hospice admission. The hospice providers chronological list of medications, labs and equipment, printed on 11/17/2025, failed to include ropinirole;- The patient was taking Jardiance (extended-release medication to treat high blood sugars) 10 mg tablet PO once a day. The caregiver stated that the patient took the dosage prior to hospice admission. The hospice provider's client medication report, printed on 11/17/2025, failed to include Jardiance;- The patient was taking Tussin (over the counter cough syrup) 20 milliliters (ml) PO every six hours as needed (PRN). The caregiver stated that the patient had been taking this since the hospice admission. The hospice provider’s client medication report, printed on 11/17/2025, failed to include Tussin;- The patient was taking acetaminophen (over the counter pain reliever) 650 mg tablet PO every eight hours PRN for pain. The caregiver stated that the patient took this prior to hospice admission. The hospice provider’s client medication report, printed on 11/17/2025, failed to include acetaminophen;- The patient was taking Relaxium Sleep supplement (over the counter sleep aid) 10 mg tablet PO once a day. The caregiver stated that the patient had been taking this since hospice admission. The hospice provider’s client medication report, printed on 11/17/2025, failed to include Relaxium Sleep supplement;- The patient was using Benadryl Itch Cream (over the counter itch relief) PRN for itching. The caregiver stated that the patient used this prior to hospice admission. The hospice provider’s client medication report, printed on 11/17/2025, failed to include Benadryl Itch Cream;- The hospice provider's client medication report, printed on 11/17/2025, showed oxycodone IR (immediate-release analgesic for pain) 5 mg tablet every four hours PRN. The caregiver stated that all of the patient's medications were on the dresser in the bedroom. The oxycodone IR was not in the home;- The hospice provider's client medication report, printed on 11/17/2025, showed Lorazepam Intensol oral concentrate (an antianxiety medication) 2 mg/ml PO PRN, q4h (every four hours). The caregiver stated that all of the patient's medications were on the dresser in the bedroom. The Lorazepam Intensol was not in the home;- The hospice provider's client medication report, printed on 11/17/2025, showed Nystatin powder (topical fungal infection caused by yeast) 15 grams (GM) BID (two times daily). The caregiver stated that all of the patient's medications were on the dresser in the bedroom. The Nystatin powder was not in the home;-  The hospice provider's client medication report, printed on 11/17/2025, showed morphine (opioid analgesic used for pain and air hunger) 20 mg/ml liquid PO PRN q4h for air hunger. The caregiver stated that all of the patient's medications were on the dresser in the bedroom. The morphine was not in the home; and- The hospice provider's client medication report, printed on 11/17/2025, showed Xanax (an antianxiety medication) 0.25 mg tablet PO q4h for anxiety PRN. The caregiver stated that all of the patient's medications were on the dresser in the bedroom. The Xanax was not in the home.The hospice provider failed to maintain an accurate drug profile. During an interview on 11/18/2025 at 2:00 PM, the administrator stated that the patient had completed the Nystatin treatment but the provider's medication list had not been updated. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided at skilled nursing facility (SNF) and the SNF staff were the primary caregivers. Observation and interview on 11/19/2025 beginning at 10:07 AM, showed the following discrepancies:- The hospice provider's client medication report, printed on 11/17/2025, showed Lorazepam Intensol oral concentrate 2 mg/ml 0.5-1ml PO QD (one time daily). The SNF's medication administration record (MAR) did not include the Lorazepam Intensol; and- The hospice provider's client medication report, printed on 11/17/2025, showed morphine sulfate 20mg/ 0.5 -1 ml PRN q2h (every two hours). The SNF's MAR did not include the morphine.The hospice provider failed to maintain an accurate drug profile for pain management in partnership with the SNF. RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Observation and interview on 11/18/2025 showed the following discrepancies between the provider’s current medication profile and the patient’s home medication bottles:-The provider’s medication profile showed cefdinir (used to treat bacterial infections in several parts of the body) 300mg. Take one capsule by PO every 12 hours for eight days. The patient stated that he/she was no longer taking this medication;-The provider’s medication profile showed doxycycline (an antibiotic used to treat a wide range of infections) 100 mg. Take one capsule PO every day for eight days. The patient stated that he/she was no longer taking this medication;-The provider’s medication profile showed triple antibiotic ointment. Apply a small amount topically to the right ankle. The patient stated that he/she was no longer using this medication since his/her ankle wound healed;-The patient was taking MiraFAST chews (magnesium hydroxide 1200 mg). The patient stated that he/she was taking this for constipation for “a while”. The provider’s medication profile failed to include this medication;-The patient was taking acetaminophen 325 mg, one to two tablets every eight hours PRN for pain. The provider’s medication profile failed to include this medication; and-The patient was taking Aleve 220 mg. Take one tablet every eight to12 hours PRN for mild pain/fever. The provider’s medication profile failed to include this medication.During an interview on 11/20/2025 at 10:20 AM, the hospice administrator stated that he/she would expect the medication profile to reflect what the patient was taking in the home.

Based on policy review, record review, and interview the hospice provider failed to ensure: - The plan of care (POC) contained:   * Individualized goals and interventions based on the problems identified (L0545);   * The scope and frequency of services needed (L0547);   * Measurable outcomes (L0548);   * The drugs and treatments necessary to meet the needs of the patient (L0549); and- The provider failed to maintain the responsibility for directing, coordinating, and supervising the care and services provided (L0554). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to ensure that each patient received an individualized initial or revised plan of care (POC) in four of five full records reviewed (Records/Patients #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the provider's policy titled, "Interdisciplinary Team Plan of Care," dated 10/09, showed the POC is based on identified problems, goals, and interventions. --- RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses of asthma (inflammation and swelling in the airways), dyspnea (shortness of breath), weakness, depression. The patient resided in his/her home with the assistance of his/her spouse. Review of the initial POC dated 04/01/2025 showed, in part, that the patient needed nursing services for dressings/wound care, catheter/ostomy care, medication administration, approved treatments, and homemaker/aide services. Review of the initial comprehensive nursing assessment dated 04/01/2025 showed, in part, that the patient did not have wounds or need for dressing changes, a catheter or ostomy, a need for nursing to administer medications or treatments, and the patient and spouse had declined homemaker/aide services. During an interview on 11/20/2025 at 9:15 AM, the administrator stated that:- They would expect the initial POC to reflect the patient’s condition at the time of the initial comprehensive assessment; and- The patient’s POC did contain elements that were not applicable to the patient’s POC.   RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the skilled nurse (SN) notes dated 09/07/2025 – 11/17/2025 showed, the following:-Patient continues to smoke and drink alcohol daily. The plan of care (POC) failed to include interventions regarding the patient’s smoking and alcohol consumption;-Patient has a history of falls. The POC failed to include interventions regarding falls;-Patient reports high pain levels but refuses to take prescribed morphine. The POC failed to include interventions regarding the patient’s thoughts about not taking morphine; and-Patient reports high pain levels but states he/she will take pain medication “when needed”.  The POC failed to include interventions regarding the patient’s acceptable level of pain. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided at skilled nursing facility (SNF) as the primary caregivers.Review of the initial plan of care (POC), dated 09/16/2025, showed a list of nursing services that could be selected for the patient. The nurse selected/check marked every service on the list, and marked catheter/ostomy care (a sterile tube placed in the bladder to drain urine/artificial opening in a organ of the body), and dressings/wound care as needed (PRN). Review of the Initial and Comprehensive Admission Assessment form, dated 09/16/2025, showed the patient had occasional incontinence (loss of bladder control). The skin assessment showed the patient's skin was red with scabbing on the coccyx (tail bone). The assessment failed to include documentation of wound dressings, or a catheter/ostomy.The facility failed to show consistent and accurate care provided to the patient.    RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse and daughter as his/her caregivers. Review of the POC, dated 11/14/2025, showed a list of nursing services that could be selected for the patient. The nurse selected/check marked every service on the list including catheter/ostomy care (a sterile tube placed in the bladder to drain urine/artificial opening in a organ of the body), and dressings/wound care. Review of the Initial and Comprehensive Admission Assessment form, dated 11/14/2025, showed the patient had occasional incontinence (loss of bladder control) and wore Depends (absorbent undergarment used for loss of bladder control). The skin assessment showed the patient's skin was normal, warm, dry, and intact. The assessment failed to include documentation of a wound/dressings, or a catheter/ostomy.During an interview on 11/20/2025 at 10:25 AM, the hospice administrator stated that the patient’s POC should only include the care needed for that patient.  RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided in a skilled nursing facility and the SNF staff were the primary caregivers. Review of the initial plan of care (POC), dated 09/16/2025, showed a list of nursing services that could be selected for the patient. The nurse selected/check marked every service on the list, and marked catheter/ostomy care (a sterile tube placed in the bladder to drain urine/artificial opening in a organ of the body), and dressings/wound care as needed (PRN). The facility failed to show consistent and accurate care provided to the patient.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse and daughter as his/her caregivers. Review of the POC, dated 11/14/2025, showed a list of nursing services that could be selected for the patient. The nurse selected/check marked every service on the list including catheter/ostomy care (a sterile tube placed in the bladder to drain urine/artificial opening in a organ of the body), and dressings/wound care. Review of the admission assessment  dated 11/14/2025, showed the patient had occasional incontinence (loss of bladder control) and wore Depends (absorbent undergarment used for loss of bladder control). The skin assessment showed the patient's skin was normal, warm, dry, and intact. The assessment failed to include documentation of a wound/dressings, or a catheter/ostomy.During an interview on 11/20/2025 at 10:25 AM, the hospice administrator stated that the patient’s POC should only include the care needed for that patient. RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the skilled nurse (SN) notes dated 09/07/2025 – 11/17/2025 showed, the following:-Patient continued to smoke and drink alcohol daily. The plan of care (POC) failed to include interventions regarding the patient’s smoking and alcohol consumption;-Patient has a history of falls. The POC failed to include interventions regarding falls;-Patient reports high pain levels but refuses to take prescribed morphine. The POC failed to include interventions regarding the patient’s thoughts about not taking morphine; and-Patient reports high pain levels but states he/she will take pain medication “when needed”.  The POC failed to include interventions regarding the patient’s acceptable level of pain.RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses of asthma (inflammation and swelling in the airways), dyspnea (shortness of breath), weakness, depression. The patient resided in his/her home with the assistance of his/her spouse. Review of the initial POC dated 04/01/2025 showed, in part, that the patient needed nursing services for dressings/wound care, catheter/ostomy care, medication administration, approved treatments, and homemaker/aide services. Review of the initial comprehensive nursing assessment dated 04/01/2025 showed, in part, that the patient did not have wounds or need for dressing changes, a catheter or ostomy, a need for nursing to administer medications or treatments, and the patient and spouse had declined homemaker/aide services. During an interview on 11/20/2025 at 9:15 AM, the administrator stated that:- They would expect the initial POC to reflect the patient’s condition at the time of the initial comprehensive assessment; and- The patient’s POC did contain elements that were not applicable to the patient’s POC.

Based on policy review, record review, and interview, the hospice provider failed to ensure a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs in three of five records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the hospice provider. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure (CHF- a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse and daughter as his/her caregivers. Review of the Social Work Note, dated 11/17/2025, showed the social worker planned to visit the patient one time per week.Review of the Interdisciplinary Team (IDT) Conference Summary Continuing Plan of Care (POC) form, dated 11/18/2025, showed the social worker planned to visit the patient two times per month.During an interview on 11/20/2025 at 10:25 AM, the hospice administrator stated that he/she would expect the visit frequency to match. Findings included:RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abnormal aortic aneurysm (a bulge in the wall of the aorta), systolic congestive heart failure (the left ventricle is weakened and cannot pump blood effectively) and AFib (irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers.Review of the Social Work POC, dated 06/05/2025, showed the social worker planned to visit the patient two times per month.Review of the Social Worker Note, dated 10/28/2025. showed the social worker planned to visit the patient one time per month. Review of the Interdisciplinary Team (IDT) Conference Summary Continuing Plan of Care (POC) form, dated 11/18/2025, showed the social worker planned to visit the patient one time per month. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided at skilled nursing facility (SNF) as the primary caregivers.Review of the Social Work Note assessment, dated 09/18/2025, showed the social worker did not specify a number of visits to the patient.Review of the Interdisciplinary Team (IDT) Conference initial Plan of Care (POC) form, dated 09/18/2025, showed the social worker was declined.Review of the IDT continuing POC, from 11/18/2025, showed the social worker planned to increase visits to the patient to four times per month.  Findings included:Review of the provider’s policy titled, “Physician Orders/Plans of Care,” effective 10/2009, showed in part that the policy failed to contain the verbiage that the plan of care (POC) would include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abnormal aortic aneurysm (a bulge in the wall of the aorta), systolic congestive heart failure (the left ventricle is weakened and cannot pump blood effectively) and atrial fibrillation (irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers.Review of the social work POC, dated 06/05/2025, showed, in part, the social worker planned to visit the patient two times per month.Review of the social worker visit documentation, dated 10/28/2025. showed the social worker planned to visit the patient one time per month. Review of the interdisciplinary team (IDT) conference summary and continuing POC dated 11/18/2025, showed the social worker planned to visit the patient one time per month. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided at skilled nursing facility (SNF) as the primary caregivers.Review of the social work assessment, dated 09/18/2025, showed the social worker did not specify a number of visits to the patient.Review of the interdisciplinary team (IDT) conference summary and continuing POC dated 09/18/2025, showed the social worker was declined.Review of the IDT continuing POC, from 11/18/2025, showed the social worker planned to increase visits to the patient to four times per month. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure (a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse and daughter as his/her caregivers. Review of the Social Work Note, dated 11/17/2025, showed the social worker planned to visit the patient one time per week.Review of the interdisciplinary team (IDT) conference summary and continuing POC dated 11/18/2025, showed the social worker planned to visit the patient two times per month.During an interview on 11/20/2025 at 10:25 AM, the hospice administrator stated that he/she would expect the visit frequency to match. Findings included:Review of the provider’s policy titled, “Physician Orders/Plans of Care,” effective 10/2009, showed, in part, that the policy failed to contain the regulatory requirement that the plan of care (POC) would include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abdominal aortic aneurysm (AAA; a ballooning of the wall in the abdominal aorta), systolic congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers.Review of the social work POC, dated 06/05/2025, showed the social worker planned to visit the patient two times per month.Review of the social worker visit documentation, dated 10/28/2025, showed the social worker planned to visit the patient one time per month (The POC showed two visits per month). RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure (a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse and daughter as his/her caregivers. Review of the social work note, dated 11/17/2025, showed the social worker determined the patient needed visits one time a week.Review of the interdisciplinary group (IDG) conference summary and continuing POC dated 11/18/2025, showed social worker visits were ordered two times a month.During an interview on 11/20/2025 at 10:25 AM, the hospice administrator stated that he/she would expect the visit frequency to match.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the plan of care (POC) contained measurable goals and outcomes in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses of asthma (inflammation and swelling in the airways), dyspnea (shortness of breath), weakness, depression. The patient resided in his/her home with the assistance of his/her spouse. Review of the nursing plan of care initiated 04/01/2025, and last updated 05/29/2025, showed in part that the patient had an identified problem of:- Nutrition:  * Goal: The patient’s nutritional status would remain at baseline; and  * The goal failed to contain measurable elements to define ‘baseline’;- Respiratory:  * Goal: The patient would not have stressing respiratory symptoms within the limits of his/her disease process; and  * The goal failed to contain measurable elements to define ‘stressing; - Pain:   * Goal: The patient would have pain control with optimal quality of life within limits of disease process; and  * The goal failed to contain measurable elements to define ‘control’ and ‘optimal’; - Elimination:  * Goal: The patient would have adequate elimination of urine within limits of disease process and no urine retention; and  * The goals failed to contain measurable elements to define ‘adequate’ and ‘retention’; - Anxiety:   * Goal: The patient’s anxiety will be relieved within two hours of report; and  * The goals failed to contain measurable elements to define ‘relieved’; - Family coping:   * Goal: The patient’s family will voice concerns and develop a plan to relieve stress while caring for the patient; and   * The goal failed to contain the desired outcome. During an interview on 11/20/2025 at 9:30 AM, the administrator stated that:- They expect the goals and outcomes to be measurable and objective; and- The goals and outcomes for the patient were not measurable and subjective. Findings included:Review of the provider’s policy titled, “Physician Orders/Plans of Care,” dated 10/2009 showed, the following:-The content of the orders (plan of care) will include:*Assessment of the patient’s needs;*A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency and duration; and*A description of any medical, physical, psychosocial or environmental precautions or limitations that affect the implementation of the plan of care.RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the Nursing Plan of Care dated 09/07/2025 showed the following goals:-Patient’s nutritional status will remain at patient’s baseline. The provider failed to include what the patient’s baseline was at the time of admission;-Patient will have pain control with optimal quality of life within limits of disease process. The provider failed to specify the patient’s acceptable level of pain; and-Patient will not have stressing respiratory symptoms within limits of disease process. The provider failed to include a baseline of the patient’s respiratory status.During an interview on 11/20/2025 at 9:20 AM, the hospice administrator stated that care plans will be looked at and changed. They are currently not measurable. The goals should be objective rather than subjective. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abnormal aortic aneurysm (a bulge in the wall of the aorta), systolic congestive heart failure (the left ventricle is weakened and cannot pump blood effectively) and AFib (irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers.Review of the Nursing Plan of Care dated 06/05/2025 showed the following goals:-Patient’s nutritional status will remain at patient’s baseline. The provider failed to include what the patient’s baseline was at the time of admission;-Patient will have pain control with optimal quality of life within limits of disease process. The provider failed to specify the patient’s acceptable level of pain; and-Patient will not have stressing respiratory symptoms within limits of disease process. The provider failed to include a baseline of the patient’s respiratory status. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided at skilled nursing facility (SNF) as the primary caregivers.Review of the Nursing Plan of Care dated 09/16/2025 showed the following goals:-Patient’s nutritional status will remain at patient’s baseline. The provider failed to include what the patient’s baseline was at the time of admission;-Patient will have pain control with optimal quality of life within limits of disease process. The provider failed to specify the patient’s acceptable level of pain; and-Patient will not have stressing respiratory symptoms within limits of disease process. The provider failed to include a baseline of the patient’s respiratory status. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure (CHF- a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse and daughter as his/her caregivers. Review of the nursing plan of care initiated 11/14/2025 showed in part that the patient had an identified problem of:- Respiratory:  * Goal: Any shortness of breath will be relieved within one hour of report; and  * The goal failed to contain measurable elements to define relieved; - Pain:   * Goal: Any pain will be relieved within one hour of report; and  * The goal failed to contain measurable elements to define relieved; - Patient coping:   * Goal: Any anxiety will be relieved within one hour of report; and  * The goals failed to contain measurable elements to define relieved.Review of the Initial and Comprehensive Admission Assessment dated 11/14/2025 showed the patient’s pain was 0 on admission and patient’s reported acceptable level of pain was 4-5 on a scale of 0-10 (numeric rating scale where 0 is no pain and 10 is the worst possible pain).   Findings included:Review of the provider’s policy titled, “Physician Orders/Plans of Care,” dated 10/2009 showed, in part, the following:- The content of the orders (POC, plan of care) will include:  * Assessment of the patient’s needs;  * A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency and duration; and  * A description of any medical, physical, psychosocial or environmental precautions or limitations that affect the implementation of the POC.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abdominal aortic aneurysm (AAA; a ballooning of the wall in the abdominal aorta), systolic congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers.Review of the nursing POC dated 06/05/2025, showed the following goals:- Patient’s nutritional status will remain at patient’s baseline. The provider failed to include what the patient’s baseline was at the time of admission;- Patient will have pain control with optimal quality of life within limits of disease process. The provider failed to specify the patient’s acceptable level of pain; and- Patient will not have stressing respiratory symptoms within limits of disease process. The provider failed to include a baseline of the patient’s respiratory status. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/16/2025 with the terminal diagnosis of end stage renal disease. The patient resided at skilled nursing facility (SNF) and the SNF staff were the primary caregivers. Review of the nursing POC dated 09/16/2025, showed the following goals:- Patient’s nutritional status will remain at patient’s baseline. The provider failed to include what the patient’s baseline was at the time of admission;- Patient will have pain control with optimal quality of life within limits of disease process. The provider failed to specify the patient’s acceptable level of pain; and- Patient will not have stressing respiratory symptoms within limits of disease process. The provider failed to include a baseline of the patient’s respiratory status.RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure. The patient resided at home with a spouse and daughter as his/her caregivers. Review of the nursing POC initiated 11/14/2025 showed that the patient had an identified problem of:- Respiratory:  * Goal: Any shortness of breath will be relieved within one hour of report; and  * The goal failed to contain measurable elements to define relieved; - Pain:   * Goal: Any pain will be relieved within one hour of report; and  * The goal failed to contain measurable elements to define relieved; - Patient coping:   * Goal: Any anxiety will be relieved within one hour of report; and  * The goals failed to contain measurable elements to define relieved.Review of the initial and comprehensive admission assessment, dated 11/14/2025, showed the patient’s pain was 0 on admission and patient’s reported acceptable level of pain was 4-5 (four to five) on a scale of zero (0) to 10 (numeric rating scale where 0 is no pain and 10 is the worst possible pain). RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the nursing POC dated 09/07/2025 showed the following goals:- Patient’s nutritional status will remain at patient’s baseline. The provider failed to include what the patient’s baseline was at the time of admission;- Patient will have pain control with optimal quality of life within limits of disease process. The provider failed to specify the patient’s acceptable level of pain; and- Patient will not have stressing respiratory symptoms within limits of disease process. The provider failed to include a baseline of the patient’s respiratory status. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses of asthma (inflammation and swelling in the airways), dyspnea (shortness of breath), weakness, depression. The patient resided in his/her home with the assistance of his/her spouse. Review of the nursing POC initiated 04/01/2025, and last updated 05/29/2025, showed in part that the patient had an identified problem of:- Nutrition:  * Goal: The patient’s nutritional status would remain at baseline; and  * The goal failed to contain measurable elements to define ‘baseline’;- Respiratory:  * Goal: The patient would not have stressing respiratory symptoms within the limits of his/her disease process; and  * The goal failed to contain measurable elements to define ‘stressing’; - Pain:   * Goal: The patient would have pain control with optimal quality of life within limits of disease process; and  * The goal failed to contain measurable elements to define ‘control’ and ‘optimal’; - Elimination:  * Goal: The patient would have adequate elimination of urine within limits of disease process and no urine retention; and  * The goals failed to contain measurable elements to define ‘adequate’ and ‘retention’; - Anxiety:   * Goal: The patient’s anxiety will be relieved within two hours of report; and  * The goals failed to contain measurable elements to define ‘relieved’; - Family coping:   * Goal: The patient’s family will voice concerns and develop a plan to relieve stress while caring for the patient; and   * The goal failed to contain the desired outcome. During an interview on 11/20/2025 at 9:30 AM, the administrator stated that:- They expect the goals and outcomes to be measurable and objective; and- The goals and outcomes for the patient were not measurable and subjective.

Based on policy review, record review, and interview the hospice provider failed to ensure the plan of care (POC) contained the drugs and treatment necessary to meet the needs of the patient in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect the care of all patients served by the provider. Findings included: --- Review of the provider’s policy titled, “Physician Orders/Plans of Care,” effective 10/2009, showed, in part, that the contents of the POC will include: - A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency, and duration; and- A description of current medication, including name, dose, frequency , and route of each medication.  RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses of asthma (inflammation and swelling in the airways), dyspnea (shortness of breath), weakness and depression. The patient resided in his/her home with the assistance of his/her spouse. Review of the clinical documentation showed:- On 04/11/2025, the patient was experiencing bladder pain, and the physician gave an order for AZO (a medication used to treat urinary bladder pain); - The updated POC, dated 04/16/2025, showed that the document failed to contain an update for the AZO prescribed on 04/11/2025;- On 05/30/2025, the patient’s left eye was draining, and he/she had a greenish buildup in the corner of the eye; - On 06/02/2025, a new medication was prescribed for the treatment of the patient’s left eye drainage; and - The POC failed to contain an update identifying the medication used to treat the patient’s left eye drainage. During an interview on 11/20/2025 at 9:20 AM, the administrator stated that: - They would expect clinicians to update the plan of care with changes; and- They were unable to locate updates to the plan of care for the AZO or treatment for the patient’s left eye drainage.

Based on policy review, record review, and interview, the hospice provider failed to ensure a system of communication was developed and maintained in two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of provider’s policy titled, “Interdisciplinary Team Coordination of Care,” dated 10/2009 showed the team will initiate changes as the patient, family and caregiver needs evolve during the terminal illness. It is the responsibility of the of the team to facilitate communication about changes in the patient’s status among all assigned staff.RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the skilled nurse (SN) note, dated 09/22/2025, showed patient stated that his/her tramadol is no longer controlling his/her pain.Review of the nursing documentation, dated 09/22/2025, showed the nurse called the patient’s primary physician and left a voicemail regarding pain medication.Review of the nursing documentation, dated 09/25/2025, showed the nurse called the hospice medical director regarding the patient’s pain medication as no return call was received from the patient’s primary physician. The medical director ordered a change from tramadol to oxycodone.Review of the nursing documentation, dated 09/25/2025, showed the nurse called the patient’s spouse to inform him/her of the new pain medication order and he/she stated that it was okay to wait until 09/26/2025 for delivery of new pain medication.The provider failed to document any contact with the patient/family between 09/22/2025 and 09/25/2025.During an interview on 11/20/2025 at 10:20 AM, the hospice administrator stated that he/she was there when the patient was called during the time period of 09/22/2025 and 09/25/2025 but there was not documentation of the phone call to check on the patient. He/she stated that they would expect the patient contact to all be documented in the clinical record. Findings included:Review of provider’s policy titled, “Interdisciplinary Team Coordination of Care,” dated 10/2009 showed that the team will initiate changes as the patient, family and caregiver needs evolve during the terminal illness. It is the responsibility of the team to facilitate communication about changes in the patient’s status among all assigned staff.RECORD/PATIENT #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the skilled nurse (SN) note, dated 09/22/2025, showed patient stated that his/her tramadol is no longer controlling his/her pain.Review of the nursing documentation, dated 09/22/2025, showed the nurse called the patient’s primary physician and left a voicemail regarding pain medication.Review of the nursing documentation, dated 09/25/2025, showed the nurse called the hospice medical director regarding the patient’s pain medication as no return call was received from the patient’s primary physician. The medical director ordered a change from tramadol to oxycodone.Review of the nursing documentation, dated 09/25/2025, showed the nurse called the patient’s spouse to inform him/her of the new pain medication order and he/she stated that it was okay to wait until 09/26/2025 for delivery of new pain medication.The provider failed to document any contact with the patient/family between 09/22/2025 and 09/25/2025.During an interview on 11/20/2025 at 10:20 AM, the hospice administrator stated that he/she was there when the patient was called during the time period of 09/22/2025 and 09/25/2025 but there was not documentation of the phone call to check on the patient. He/she stated that they would expect the patient contact to all be documented in the clinical record.RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses of asthma (inflammation and swelling in the airways), dyspnea (shortness of breath), weakness, depression. The patient resided in his/her home with the assistance of his/her spouse. Review of the clinical documentation showed, in part, that:- On 04/30/2025, the IDT summary showed that the patient was having more weak days; - On 05/09/2025, the spouse stated that he/she was feeling fatigued being the patient’s caregiver and the skilled nurse (SN) discussed respite services with the spouse, and the spouse declined services; and- The clinical record failed to contain documentation that the SN notified the IDT of the spouse reporting increased fatigue or the discussion of the need for respite services. Review of the clinical documentation showed, in part, that: - On 05/16/2025 the spouse reported that:  * The patient had exhibited strange behavior that included taking a shower (when he/she did not), and mining for gold; and  * He/she would like the nurse to prefill a medication planner for him/her; - The clinical record failed to contain documentation that the SN notified the IDT of the spouse reporting strange behavior or the request for a medication planner. During an interview on 11/20/25 at 09:12 AM, the administrator stated that:- They would expect the nurse to notify the IDT of changes in the patient’s condition, behavior, and the spouse’s fatigue; and- That nurse no longer worked for the provider.

Based on policy review, record review, home visit observation, and interview the hospice provider failed to ensure the registered nurse (RN) prepared written patient care instructions for the aide that was individualized and consistent with the needs of the patient in one of four full records reviewed with aide services (Record/Patient #3). This deficient practice has the potential to affect all the provider's patients with aide services. --- Findings included:Review of the provider’s policy titled, “Home Health Aide Services,” dated 10/2009, showed the purpose was to specify the role of the hospice home health aide, and further stated that written instructions for the aide are prepared by the RN.RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 11/14/2025 with a terminal diagnosis of combined congestive heart failure (CHF- a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse and daughter as his/her caregivers.Review of the initial and comprehensive admission assessment, dated 11/14/2025, showed the RN documented that the patient used Depends (brand; absorbent undergarment used for loss of bladder control).The patient did not have a urinary catheter.  The box for Foley (indwelling urinary catheter- a sterile tube placed in the bladder to drain urine) and catheter was not marked on the paper assessment.  Review of the home health aide assignment sheet, dated 11/14/2025, showed the RN documented/instructed the aide to provide:- A tub bath/shower with a stool; - Provide a bed bath, as needed; and- Catheter care two times per week (the patient did not have a catheter).Observation on 11/19/2025 at 11:55 AM, showed the aide gave the patient a bed bath and the patient did not have a catheter. During the observation, an interview with the patient's daughter was conducted related to the patient's need for a bed bath and the daughter stated the tub and shower in the home were not accessible for the patient. During an interview on 11/20/2025 at 10:25 AM, the administrator stated that the RN should assign appropriate tasks.

Based on policy review, employee file review, and interview, the hospice provider failed to complete an initial and annual skills competency for the chaplain and the social worker disciplines in two of four employee files reviewed (Chaplain-A and Social Worker A). This deficient practice has the potential to affect the provision of competent services for all the provider’s patients. Findings included: --- Review of the provider’s policy titled, “Position Description and Standards of Performance Hospice Medical Social Worker,” effective 10/2009, showed that the policy failed to contain the verbiage that the social worker would complete initial and annual skills competency evaluation. Review of the provider’s employee education files showed that the provider failed to provide initial and annual competency evaluations for Chaplain A and Social Worker A. During an interview on 11/19/2025 at 1:30 PM, the administrator stated that they had not performed skill competencies with the chaplains or social workers in the past and would initiate the process in the future.

Based on policy review, record review, and interview, the hospice provider failed to ensure the accuracy of documentation in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Entries into Clinical Records,” dated 10/2009 showed, in part, the following:-Documentation in the clinical record will be timely, detailed, accurate and reflect the care or services provided; and-All entries shall be legible and complete. Record/Patient #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the physician’s orders showed the following:-An order dated 09/07/2025 for tramadol (an opioid pain medication used to treat moderate to moderately severe pain) 50 milligrams (mg) take one tablet by mouth every four hours as needed for pain;-An order dated 09/07/2025 for morphine sulfate (an opioid analgesic used to treat moderate to severe pain that is not adequately managed by other medications) 20 mg/mL (milliliter) 0.5-1 mL by mouth every four hours as needed for pain/air hunger; and-An order dated 09/25/2025 for oxycodone (a potent semisynthetic opioid analgesic used to treat moderate to severe pain) 5 mg immediate release (IR) 1-2 tablets by mouth every six hours as needed for pain.Review of the skilled nurse (SN) note, dated 09/29/2025, showed medications used for pain control:-Oxycodone 50 mg (the patient’s order was for 5 mg);Review of the SN note, dated 10/06/2025, showed medications used for pain control:-Oxycodone 50 mg (the patient’s order was for 5 mg);Review of the SN note, dated 10/21/2025, showed medications used for pain control:-Hydrocodone IR 5 mg (the patient was prescribed oxycodone IR 5 mg. The patient was not taking hydrocodone); andReview of the SN note, dated 10/22/2025, showed medications used for pain control:-Hydrocodone IR 5 mg (the patient was prescribed oxycodone IR 5 mg. The patient was not taking hydrocodone).During an interview on 11/20/2025 at 10:20 AM, the hospice administrator stated that the nurse miswrote the medication orders on the 09/29 and the 10/21 nursing visit notes. The 10/06 and the 10/22 notes were copied from the previous notes. He/she stated that they would expect the documentation to match what the patient was prescribed and taking. Record/Patient #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abnormal aortic aneurysm (a bulge in the wall of the aorta), systolic congestive heart failure (the left ventricle is weakened and cannot pump blood effectively) and AFib (irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers.Review of the physician’s orders showed the following:-An order dated 10/25/2025 for Jardiance (a medication used to treat diabetes) 10 milligrams (mg) take one tablet by mouth one time per day;-An order dated 10/25/2025 for morphine sulfate (an opioid analgesic used to treat moderate to severe pain that is not adequately managed by other medications) 20 mg/mL (milliliter) 0.5-1 mL by mouth every four hours as needed for pain/air hunger; and-An order dated 10/25/2025 for Lorazepam (a benzodiazepine used to produce a calming effect) 2 mg/ml immediate release (IR) 1-2 tablets by mouth every two hours as needed for anxiety.Review of the chronological list of Medication, showed medications used for pain control and comfort:-Oxycodone IR 5 mg;-Nystatin 15 mg topical powder (for fungal infections on the skin); and-Lorazepam 2 mg/ml (produces a calming effect).Observation of the patient's medication in his/her home failed to locate the medications in the patient's room with his medication.The facility failed to ensure the active prescribed medications were available in the home.  Findings included:Review of the provider’s policy titled, “Entries into Clinical Records,” dated 10/2009 showed, in part, the following:-Documentation in the clinical record will be timely, detailed, accurate and reflect the care or services provided; and-All entries shall be legible and complete.Record/Patient #1:Review of the clinical record showed the patient was admitted to hospice services on 06/05/2025 with the terminal diagnosis of abnormal aortic aneurysm (a bulge in the wall of the aorta), systolic congestive heart failure (the left ventricle is weakened and cannot pump blood effectively) and atrial fibrillation (irregular heartbeat). The patient resided at home with his/her adult child and their spouse as the primary caregivers.Review of the physician’s orders showed the following:- An order dated 10/25/2025 for Jardiance (a medication used to treat diabetes) 10 milligrams (mg) take one tablet by mouth one time per day;- An order dated 10/25/2025 for morphine sulfate (an opioid analgesic used to treat moderate to severe pain that is not adequately managed by other medications) 20 mg/mL (milliliter) 0.5-1 mL by mouth every four hours as needed for pain/air hunger; and- An order dated 10/25/2025 for Lorazepam (a benzodiazepine used to produce a calming effect) 2 mg/ml immediate release (IR) 1-2 tablets by mouth every two hours as needed for anxiety.Review of the chronological list of medications, showed medications used for pain control and comfort:-Oxycodone (an opioid analgesic used to treat moderate to severe pain) IR 5 mg;-Nystatin 15 mg topical powder (for fungal infections on the skin); and-Lorazepam 2 mg/ml (produces a calming effect).Observation of the patient's medication in his/her home failed to locate the medications in the patient's room with his medication.The provider failed to ensure the active prescribed medications were available in the home.  Record/Patient #4:Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of end stage emphysema (a chronic lung condition where the air sacs in the lungs are damaged, causing them to lose their elasticity and break down). The patient lived at home with his/her spouse.Review of the physician’s orders showed the following:- An order dated 09/07/2025 for tramadol (an opioid pain medication used to treat moderate to moderately severe pain) 50 milligrams (mg) take one tablet by mouth every four hours as needed for pain;- An order dated 09/07/2025 for morphine sulfate  20 mg/mL (milliliter) 0.5-1 mL by mouth every four hours as needed for pain/air hunger; and- An order dated 09/25/2025 for oxycodone 5 mg immediate release (IR) 1-2 tablets by mouth every six hours as needed for pain.Review of the skilled nurse (SN) notes showed: - On 09/29/2025, the patient was to take oxycodone 50 mg (the patient’s order was for 5 mg);- On 10/06/2025, oxycodone 50 mg (the patient’s order was for 5 mg);- On 10/21/2025, hydrocodone IR 5 mg (the patient was prescribed oxycodone IR 5 mg. The patient was not taking hydrocodone); and- On 10/22/2025, hydrocodone IR 5 mg (the patient was prescribed oxycodone IR 5 mg. The patient was not taking hydrocodone).During an interview on 11/20/2025 at 10:20 AM, the hospice administrator stated that the nurse miswrote the medication orders on the 09/29 and the 10/21 nursing visit notes. The 10/06 and the 10/22 notes were copied from the previous notes. He/she stated that they would expect the documentation to match what the patient was prescribed and taking.

Based on policy review, record review, and interview the agency failed to use the comprehensive assessment to adequately assess patient comfort in, but not limited to, three (Records/Patients #1, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Comprehensive and Ongoing Assessment," dated 10/2009, showed in part, that the comprehensive assessment shall take into account the following: pain - including origin, location, duration, severity, and relief measures. RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted to services on 12/01/2021 with a diagnosis of Squamous Cell Lung Cancer in the left lung (a cancer that typically begins in the tissues that line the air passages of the lung); - The comprehensive admission assessment dated 12/01/2021 showed the following for pain assessment: * Patient and family's expectations and preferences for pain management: "want pain controlled as much as possible"; and * Amount of pain mediation doses taken in last 24Hours: "3 scheduled and patch, 3 PRN" [pro re nata - as needed]. - The comprehensive assessment failed to include: * History of pain; * Intensity of pain; * Descriptors of pain; * Pattern of pain; * Location and radiation of pain; * Frequency, timing and duration of pain; * Impact of pain on quality of life; * Factors such as activities, care, or treatment that precipitate or exacerbate pain; * Strategies and factors that reduce pain; and * Additional symptoms associated with pain. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to services on 08/30/2022 with a diagnosis of End Stage Alzheimer's Disease (a brain condition that causes progressive decline in cognitive abilities); - The comprehensive admission assessment dated 08/30/2022 showed for pain assessment the following: * Circle the words that describe the patient's pain: "unable to describe- hurts"; * Describe any previous or ongoing instances of pain: "occasional pain voiced"; * What previous methods of pain control have been helpful: "Acetaminophen 500 milligrams"; * What previous methods of pain control have not been helpful: "none"; * Patient's and family's expectations and preferences for pain management: "want patient kept comfortable"; and * Amount of pain medication doses taken in the last 24Hours: "0" - The comprehensive assessment failed to include: * History of pain; * Intensity of pain; * Location and radiation of pain; * Frequency, timing and duration of pain; * Impact of pain on quality of life; * Factors such as activities, care, or treatment that precipitate or exacerbate pain; and * Additional symptoms associated with pain. RECORD/PATIENT #5: Review of the clinical record showed: - The patient was admitted to services on 12/26/2022 for Metastatic Lung Cancer (a cancer that begins in the lungs and spreads to other areas); - The comprehensive admission assessment dated 12/26/2022 showed for pain assessment the following: * Patient and family's expectations and preferences for pain management: "wants pain managed as much as possible"; and * Amount of pain medication doses taken in last 24Hours: "2 oil, 1 gummies" - The comprehensive assessment failed to include: * History of pain; * Intensity of pain; * Descriptors of pain; * Pattern of pain; * Location and radiation of pain; * Frequency, timing and duration of pain; * Impact of pain on quality of life; * Factors such as activities, care, or treatment that precipitate or exacerbate pain; * Strategies and factors that reduce pain; and * Additional symptoms associated with pain. During an interview on 01/05/2023 beginning at 9:45 AM the administrator stated that he/she would expect a full pain review to be done on the comprehensive assessment.

Based on policy review, record review, and interview the agency failed to ensure that each patient's medication regimen review on the comprehensive assessment was completed in, but not limited to, two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Comprehensive and Ongoing Assessment," dated 10/2009 showed in part: - Drug profile: a review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: * Effectiveness of drug therapy; * Drug side effects; * Actual or potential drug interactions; * Duplicate drug therapy; * Drug therapy currently associated with laboratory monitoring; and * Compliance with treatments and medication regimen. RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted to services on 12/01/2021 with a diagnosis of Squamous Cell Lung Cancer in the left lung (a cancer that typically begins in the tissues that line the air passages of the lung); - The comprehensive admission assessment dated 12/01/2022 failed to show a drug regimen review; - The admission orders dated 12/01/2021 had a list of medications, however, failed to show a drug regimen review; and - A pharmacist visit log was completed on 12/01/2021 and stated, "none at this time," under recommended changes, however, the log failed to include any information that medications or treatments were checked. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to services on 08/30/2022 with a diagnosis of End Stage Alzheimer's Disease (a brain condition that causes progressive decline in cognitive abilities); - The comprehensive admission assessment dated 08/30/2022 failed to show a drug regimen review; - The admission orders dated 08/30/2022 had a list of medications, however, failed to show a drug regimen review; and - A pharmacist visit log was completed on 08/31/2022 and stated, "none at this time," under recommended changes, however, the log failed to include any information that medications or treatments were checked for. During an interview on 01/05/2023 beginning at 9:45 AM, the administrator stated that he/she would expect drug reviews to be completed according to the specific guidelines required.

Based on policy review, record review, and interview, the agency failed to ensure that the hospice care and services were following the individualized written plan of care established by the interdisciplinary team in, but not limited to, four (Records/Patients #1, #2, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #1: - Review of the document titled, "Continuing Plan of Care," dated 12/07/2022, showed that the social worker had a visit frequency of one time per week; - Review of the social worker visit note dated 12/20/2022, showed that the next visit was scheduled for 01/02/2023 or as needed and the social worker would be available by phone; - There was no visit made during the week of 12/25/2022 through 12/31/2022; and - The agency could not produce an order for the missed visit. RECORD/PATIENT #3: - Review of the document titled, "Continuing Plan of Care," dated 11/23/2022, showed that the social worker had a visit frequency of one time per week; - Review of the social worker visit note dated 12/20/2022, showed that the next visit was scheduled for 01/02/2023 or as needed and the social worker would be available by phone; - There was no visit made during the week of 12/25/2022 through 12/31/2022; and - The agency could not produce an order for the missed visit. Findings included: Review of the policy titled "Physician Orders/Plans of Care," dated 10/2009, showed: -The contents of the orders (plan of care) will include: *a description of the treatment/procedure to be done, including, when appropriate, the type, frequency, and duration RECORD/PATIENT #2: -Review of the document titled, "Continuing Plan of Care", dated 11/23/2022, showed that the Social Worker had a visit frequency of one time a week; -Review of the Social Worker visit note from 12/19/2022 showed that the next visit was scheduled for 01/02/2023 and the social worker would be available by phone if required the week of 12/25/2022 through 12/31/2022; -There was no visit made during the week of 12/25/2022 through 12/31/2022; and -The agency could not produce an order for the missed visit. RECORD/PATIENT #4: -Review of the document titled, "Social Work Plan of Care", dated 12/02/2022, showed that the Social Worker had a visit frequency of two times a week; -Review of the Social Worker visit note from 12/21/2022 showed that the social worker would be available by phone if required the week of 12/25/2022 through 12/31/2022; -There was no visits made during the week of 12/25/2022 through 12/31/2022; and -The agency could not produce an order for the missed visits. During an interview on 01/05/2023 at 9:30 AM, the administrator stated that he/she could not find a policy pertaining to missed visits but the expectation is to document missed visits in the patient's chart.

Based on nationally-recognized standards, policy review, observation, and interview the agency failed to ensure that accepted standards of practice to prevent transmission of infections and communicable diseases were followed, in three (Records/Patients #1, #4, and #5) of three home visit observations conducted. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #4: Observation on 01/03/2023 at 2:30 PM, during the patient's home visit, showed: -Employee A entered the patient's room and set his/her clipboard on the patient's bedside table- no barrier present; -Employee A completed the home visit and picked up his/her clipboard; -Employee A exited facility, entered his/her car, and left facility; and -Employee A failed to sanitize the clipboard prior to leaving the facility. Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the agency's undated policy titled, "Hand Hygiene- CDC Guidelines," showed in part, hand hygiene should be done: - Before each patient encounter; - After coming in contact with patient's intact skin, i.e., taking a patient's blood pressure, pulse, lifting/moving the patient; - After working on a contaminated body site and then moving to a clean body site on the same patient; - After coming in contact with bodily fluids, dressings, mucous membranes, etc., and hands are not visibly soiled (i.e., handling sputum containers, bedpans, urinals, catheters); - After contact with medical equipment/supplies in patient areas; and - Always after removing gloves. Review of the agency's undated policy titled, "Home Health Aide Bag Technique," showed in part, the following: - When the visit is completed, reusable equipment will be cleaned, hands will be cleansed, and equipment and supplies will be returned to the bag. RECORD/PATIENT #1: Observation on 01/03/2023 beginning at 2:25 PM, during the patient's long term care facility home visit, showed the following: - Employee B entered the room and placed his/her clipboard on the bedside table with no barrier; - Patient was lying in bed with a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall) to the left abdomen leaking stool from the wafer (a skin barrier that protects the skin around a colostomy opening); - Employee B cleaned stool from the stoma (an opening in the body) and failed to change gloves and perform hand hygiene; - Employee B touched scissors, new wafer, new colostomy bag, patient's gown and cleaned more stool from the patient's left leg prior to removing gloves and performing hand hygiene; - Employee B removed patient's dirty gown and towel with stool noted from patient's bed without donning gloves; and - Employee B failed to disinfect the clipboard that had been on the bedside table prior to leaving patient room. RECORD/PATIENT #5: Observation on 01/03/2023 beginning at 1:15 PM, during the patient's home visit, showed the following: - Employee C failed to perform hand hygiene prior to entering the patient's home; - Employee C completed visit and exited the home at approximately 1:40 PM; and - Employee C failed to complete hand hygiene prior to leaving the home or when he/she returned to his/her vehicle. During an interview on 01/05/2023 beginning at 9:45 AM, the administrator stated that he/she would expect gloves to be changed per policy, hand hygiene to be completed per policy, and all equipment to be disinfected per policy.

Based on contract review and interview, the agency failed to ensure that the written contract between the agency and the skilled nursing facilities (SNFs) contained the verbiage that services will be furnished in a safe and effective manner by qualified personnel in , but not limited to, two (Contracts #1 & #2) of two contracts reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: CONTRACT #1: -Review of the contract with the SNF failed to show the verbiage that the services performed will be furnished in a safe and effective manner by qualified personnel. CONTRACT #2: -Review of the contract with the SNF failed to show the verbiage that the services performed will be furnished in a safe and effective manner by qualified personnel. During an interview on 01/05/2023 at 09:30 AM, the administrator stated that he/she would expect this verbiage to be contained within the contracts with the SNFs.

Based on policy review and interview, the agency failed to complete a written agreement for the coordination of care with the hospital, to provide short-term inpatient care. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Coordination of Care, Treatment and Services with Contracts/Agreements," showed, in part, the following: -The hospice provides services to meet the physical, psychosocial and spiritual needs of patients, families or caregivers admitted; -Hospice provides education and training regarding Hospice care to inpatient staff at [named hospital] at least annually; -Hospice evaluates [named hospital] staff needs for education and training at least annually; and -Hospice retains quality improvement responsibility for evaluating services, maintaining professional management responsibility and ensuring continuity of care in all settings. During an interview on 01/04/2023 at 10:50 AM, the administrator stated that they did not have a written agreement [as required] with [named hospital] because the hospital owns the hospice agency.

Based on contract review and interview, the agency failed to ensure that the contracts with the skilled nursing facility (SNF) contained the verbiage that there would be a manner in which the facility and the hospice are to communicate with each other, and document to ensure that the needs of the patient are met 24/7 in, but not limited to, two (Contracts #1 and #2) of two SNF contracts reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: CONTRACT #1: -Review of the contract with the SNF failed to showed the verbiage that contained a manner in which the facility and hospice are to communicate with each other and document to ensure the needs of the patient are met 24/7. CONTRACT #2: -Review of the contract with the SNF failed to showed the verbiage that contained a manner in which the facility and hospice are to communicate with each other and document to ensure the needs of the patient are met 24/7. During an interview on 01/05/2023 at 9:30 AM, the administrator stated that he/she would expect their SNF contracts to contain the required elements.