Every finding on record at The Center for Hospice and Palliative Care Inc

Based on record review and interview, the hospice failed to ensure the Plan of Care and Plan of Care Updates included all care and treatments for 3 of 4 active wound care patients clinical records reviewed (Patient #3, Patient #4, and Patient #5) and in 1 of 1 discharged wound care patient clinical record reviewed (Patient #2).  Findings include: --- 1.A policy dated 06/2023 and titled, “Plan of Care,” indicated the POC would include all services necessary for the management of the terminal illness and conditions. The policy indicated the POC would include but not limited to drugs and treatments to meet the needs of the patient.  The policy indicated the POC would be reviewed and documented as frequently as the patient’s condition warrants, no less frequently than every 15 days, and the Interdisciplinary Team (IDT) would review services being provided, and specific treatment modalities. 2. Procedure with revised date 08/2024, titled “Skin and Wound Care Procedure” indicated all wound care orders would be placed in the electronic medical records system under orders and in the care plan. 3. A revised policy dated 03/2024, titled “Skin and Wound Care,” indicated wound care interventions would be provided per physician’s orders and documented in the POC. 4.A RN 1 Skilled Nursing Visit Note dated 03/02/2026, indicated Patient #3 had moisture related skin damage on their right leg, identified on 3/02/26.  Wound care initiated was a Mepilex (soft, absorbent, foam bandage) dressing and the frequency of dressing change was daily.  An IDT Meeting and Plan of Care Update Note, as identified by the Administrator, indicated a new right leg moisture associated skin damage with onset of 03/03/2026; the POC update failed to evidence wound care orders including frequency of care to be provided.  The clinical record failed to evidence a wound care order. During an interview, on 03/06/2026 beginning at 12:40 PM, case manager RN 1 indicated she notified the physician of the new wound, and she should have entered a wound care order.During an interview, on 03/06/2026, beginning at 4:00 PM, the Administrator indicated the clinical record did not include an order for wound care to the leg and wound care orders should have been entered.   4.A Skilled Nursing Comprehensive Assessment Note, dated 02/26/2026, indicated Patient #4 had a new wound, onset date of 02/26/2026. The note indicated Patient had a stage 2 wound (partial thickness skin loss, damage to middle layer of skin, shallow pink wound bed) to coccyx (buttocks area). The Note indicated physician ordered treatment to the pressure area to coccyx to be cleaned with normal saline, and Calazinc (skin protectant cream) be applied twice a day until healed. An IDT and Plan of Care Update Meeting Note, as identified by the Administrator, dated 03/03/2026, indicated a new wound to the coccyx and failed to evidence wound care orders to include frequency of wound care.  During an interview, on 03/06/2026, beginning at 4:00 PM, the Administrator indicated there were no coccyx wound care orders for Patient #4 on the Updated POC and orders.   5.A Plan of Care for Patient #5 for the benefit period 02/06/2026 to 05/06/2026, evidenced wound care orders for stage IV wound (full thickness tissue loss exposing underlying structures such as bone, muscle and tendons) to coccyx that included clean with normal saline, apply calcium alginate (absorbent wound dressing) to wound bed and triad paste (absorbing wound paste with zinc oxide) to surrounding skin.  The POC failed to evidence the frequency of wound care.  During an interview, on 03/05/2026, beginning at 10:30 AM, Entity C’s wound care nurse indicated the facility changed Patient’s wound dressing to coccyx 2 to 4 times per day due to saturation.    During an interview, on 03/05/2026, beginning at 1:00 PM, the Administrator indicated the frequency of wound care should have been and was not included on the POC.6.A Skilled Nursing Recertification Assessment Visit Note, dated 02/16/2026, indicated Patient #2 had a midline buttocks pressure ulcer with an onset date of 02/16/2026, wound care completed was cleaning with normal saline, applied calcium alginate and Mepilex dressing, and wound care frequency was daily.  An IDT Meeting Notes and Plan of Care Update, as identified by the Administrator, dated 02/17/2026, indicated measurements for the coccyx wound identified at the 02/16/2026 skilled nurse visit and failed to indicate orders for coccyx wound. The Patient Care Written Orders, dated 12/02/2025 to 03/01/2026, failed to evidence orders for wound care to the coccyx area to include frequency. During an interview, on 03/06/2026, beginning at 12:40 PM, case manager RN 1 indicated she would enter new wound orders once received from the hospice physician, but she may have forgotten to write the orders.During an interview, on 03/06/2026, beginning at 4:00 PM, the Administrator indicated there were no wound care orders written for Patient #2’s coccyx wound and should have been entered.

Based on record review and interview, the hospice failed to provide ongoing sharing of information between all disciplines providing care in 1 of 2 active clinical records reviewed of a patient residing in an assisted living facility (Patient #3), and in 1 of 1 discharge clinical record reviewed of a patient residing in an assisted living facility (Patient #2). Findings include: --- 1.A policy, dated 03/2024, titled, “Interdisciplinary Team,” indicated the Interdisciplinary Team (IDT)  would establish the patient POC with the primary physician, and would review and update the POC.  The policy indicated care would be provided or supervised consistent with the established POC, and supervision would be reflected in summaries of patient care conferences in which problems were reviewed by the IDT and interventions would be recommended.  The policy indicated change of condition or situation would be updated in the POC.  The policy indicated the IDT would determine what services were considered reasonable and necessary for the management of the terminal illness and related conditions. 2.A revised policy, date 03/2024, titled, “Hospice Aide, Certified Nurse Aide Assignments and Duties,” indicated duties of the aide would provision of hands on personal care.  The policy indicated aides were to contribute to IDT by discussion with the case manager or attending the meeting.  The policy indicated a RN must make an onsite supervisory hospice aide visit no less frequently than every 14 days, the RN would evaluate that the POC was being provided and patients’ needs were being met. 3.A Hospice Plan of Care, for benefit period 02/08/2026 to 04/08/2026, for Patient #3 indicated hospice aide twice per week for 8 weeks, and Patient resided at Entity B, an assisted living facility.  An Aide Care Plan, start date of 09/11/2025,  indicated bed bath or shower, assist with dressing, shampoo hair, and assist with transfer due to non-weight bearing status to left leg due to left leg fracture at every visit. Aide Visit Notes indicated the following: 02/09/2026 Patient refused shower and a case manager RN was present for visit. 02/12/2026 Patient was called and refused shower and case manager RN 1 would be notified.02/16/2026 case manager RN 1 called Hospice Aide 1 and reported Patient refused shower.02/19/2026 Patient was called and indicated had a bath already and no need for hospice aide visit, would notify case manager RN 102/23/2025 case manager RN 1 notified aide Patient already had a shower, and aide was with another Patient and didn’t make it to the Patient at the time requested02/26/2026 Patient didn’t have good morning, case manager RN 1 present and Patient refused shower03/02/2026 hospice aide completed upper body washing, area on leg open and case manager RN 1 notifiedThe Hospice Aide Notes starting from beginning of benefit period 02/08/2026 to 03/02/2026 indicated 7 of 8 hospice aide visits were refused.  An IDT Meeting and Plan of Care Update Note, as identified by the Administrator, dated 03/03/2026, indicated Patient was struggling with mental health issues, nurse visits would remain 2 times per week, and under care plan indicated patient activities of daily living goal for hospice aide was Patient to be clean, dry, and free from odor after bath with a target date of 04/08/2026, and under progress section was blank. The IDT Meeting Note failed to evidence documentation 7 of 8 hospice aide visits were refused.During an interview, on 03/06/2026, beginning at 12:40 PM, case manager RN 1 indicated Patient often refused hospice aide care at Entity B, an assisted living facility.  RN 1 indicated she did not document in the IDT Meeting notes about Patient refusing care.  During an interview, on 03/06/2026, beginning at 2:05 PM, Hospice Aide 1 indicated she notified nurse of Patient’s refusal of care, and documented notified case manager in visit notes.  Hospice Aide 1 indicated Patient would wash self prior to hospice aide care.  4.A Plan of Care, for benefit period 12/02/2025 to 03/01/2026, indicated Patient #2 was to have an aide visit 1 time per week for 1 week starting 12/02/2025, and 3 times per week starting the week of 12/07/2025.An Aide Care Plan, start date of 12/03/2025, indicated shower or bed bath, assist patient with getting dressed, shampoo twice per week, oral care and nail care was to be performed at every hospice aide visit.An IDT Meeting and Plan of Care Update Note, as identified by the Administrator, dated 01/06/2026, indicated Patient resided in Entity A, an assisted living facility.  Clinical Record Review and Hospice Aide 1 Visit Notes indicated the following:Aide visits completed 12/05/2025, 12/08/2025, 12/10/2025, 12/12/2025, 12/15/2025, 12/19/2025, 12/24/2025, 12/31/2025, 01/07/2026, 01/12/2026,  01/16/2026, 01/23/2026, 01/28/2026, 01/31/2026, 02/04/2026, 02/13/2026. 02/16/2026, 02/18/2026  with patient signature of visit completed by patient, family member or facility staffAide visit 12/15/2025 Patient refused shower, notified facility nurse, and would notify case manager RN 1Aide visit 12/22/2025 Patient refused shower, notified facility nurse, and would notify case managerAide visit 12/26/2025 Patient refused shower, notify facility and case manager RN 1Aide visit 12/29/2025 Patient refused care, hospice supervisor awareAide visit 01/05/2026 Patient refused care, notified facility, nurse would notify RN 1Aide visit 01/09/2026 attempted to shower Patient, Patient having difficulty standing, facility nurse notified, case manager RN 1 notifiedAide visit 01/14/2026 Patient refused shower, Patient indicated leg hurting difficult to make steps, would notify case manager RN 1Aide visit 01/19/2026 Patient refused shower, would notify case manager RN 1Aide visit 01/21/2026 Patient complained of leg pain and swelling, refused shower and bed bath would notify facility nurse and case manager RN 1Aide visit 01/26/2026 Patient refused shower, requested bath next visit, facility nurse and case manager RN 1 notifiedAide visit 02/04/2026 care completed, right foot swollen and toe had open area case manager RN 1 and facility nurse notifiedAide visit 02/06/2026 Patient refused shower, case manager RN 1 notifiedAide Visit 02/09/2026 Patient refused shower due to foot pain, facility nurse notified and case manager RN 1 notifiedAide Visit 02/11/2026 Patient refused shower, facility nurse notified and would notify case manager RN 1  Aide Visit 02/20/2026 Patient refused shower, facility nurse notified and would notify case manager RN 1A clinical record indicated 16 missed aide visits and 17 aide visits completed from start of benefit period 12/02/2025 to date of transfer to another hospice on 02/20/2026.During an interview, on 03/06/2026, beginning at 12:40 PM, case manager RN 1 indicated the hospice aide was to notify the RN of Patient’s refusing care at an ALF, and the RN did not notify the assisted living facility staff of Patient’s refusal.  During an interview, on 03/06/2026, beginning at 2:05 PM, Hospice Aide 1 indicated Patient #2 refused care due to foot ulcer caused pain and Patient did not want to take a shower.  Hospice Aide 1 indicated she would notify the assisted living facility staff of Patient’s pain and notify the hospice case manager of pain and missed visits.  Hospice Aide 1 indicated she would notify the assisted living facility nurse of Patient’s refusal of aide care and if a nurse was not available she would notify the assisted living facility aide.  An IDT Meeting Note, dated 02/17/2026, indicated Patient had a significant change in condition, Patient had increased weakness, 3 new pressure ulcers, several falls, one fall with a pelvic fracture, increased confusion, and required significant help with dressing, bathing, and transfers.  The nurse visits have increased to twice weekly and bath visits remained at 3 times per week.  The IDT Notes failed to evidence discussion of 16 missed visits since hospice election date of 12/02/2025.   During an interview, on 03/06/2026, beginning at 12:40 PM, case manager RN 1 indicated she did not include documentation related to missed aide visits for the IDT meeting.  RN 1 indicated the hospice aide notified the hospice case manager when patients refuse care.  5. During an interview, on 03/06/2026, beginning at 4:00 PM, the Administrator indicated the IDT should be notified of Patient refusing hospice aide care to assess and provide interventions.

Based on record review and interview, the hospice failed to ensure RN documented the hospice aide supervisory visit every 14 days to assess the quality of care provided by the hospice aide to ensure the care ordered by the interdisciplinary team meet the patient's needs in 2 of 2 active clinical records of patients that resided in an assisted living facility reviewed with a hospice aide (Patient #1, Patient #3), and in 1 of 1 discharged clinical records reviewed with a hospice aide (Patient #2).  Findings include: --- 1.A  revised policy, date 03/2024, titled, “Hospice Aide, Certified Nurse Aide Assignments and Duties,” indicated duties of the aide would provision of hands on personal care.  The policy indicated aides were to contribute to IDT by discussion with the case manager or attending the meeting.  The policy indicated a RN must make an onsite supervisory hospice aide visit no less frequently than every 14 days, the RN would evaluate that the POC was being provided and patients’ needs were being met. 2.  A Plan of Care, for benefit period 02/08/2026 to 05/08/2026, for Patient #1, indicated hospice aide 2 times per week for 13 weeks beginning 02/08/2026. Aide Visit Notes, dated 02/12/2026, 02/16/2026, 02/19/2026, 02/23/2026, and 03/02/2026,indicated hospice aide visit care completed included shaving, dressing assistance, showering, recognizing and reporting changes in skin condition and oral care. A Skilled Nursing Comprehensive Assessment Visit Note, dated 02/10/2026, indicated no hospice aide supervisory visit was completed.A RN 1 Skilled Nursing Visit Note, dated 02/13/2026, 02/17/2026, 02/20/2026, 02/27/2026, and 03/03/2026 indicated no hospice aide supervisory visit was completed.   A RN 1 Skilled Nursing Comprehensive Assessment Visit Note, dated 02/24/2026, failed to evidence a hospice aide supervisory visit was completed and indicated under supervision no supervisory visit was completed for hospice aide. During an interview on 03/06/2026, beginning at 3:15 PM, the Administrator indicated there were no hospice aide supervisory visits documented for Patient 02/08/2026 to 03/04/2026.  The Administrator indicated hospice aide supervisory visit by a RN was to be completed every 14 days, documentation would include review of hospice aides’ documentation, review of aide’s plan of care and speaking to patient’s caregivers. During an interview, on 03/05/2026, beginning at 10:30 AM, case manager RN 1 indicated she scheduled supervisory visits every 30 days in the electronic medical record, she would review hospice aide documentation, and evaluate in person care.  3. A Hospice Plan of Care, for benefit period 02/08/2026 to 04/08/2026, for Patient #3 indicated hospice aide twice per week for 8 weeks. An Aide Care Plan, start date of 09/11/2026, indicated report any changes in Patient’s skin condition to the facility nurse and case manager.  The Aide Care Plan indicated bed bath or shower, assist with dressing, shampoo hair,  and assist with transfer due to non-weight bearing status to left leg due to left leg fracture at every visit. Aide Visit Notes indicated the following:02/09/2026 Patient refused shower and a case manager RN was present for visit. 02/12/2026 Patient was called and refused shower and case manager RN 1 would be notified.02/16/2026 case manager RN 1 called Hospice Aide 1 and reported Patient refused shower.02/19/2026 Patient was called and indicated had a bath already and no need for hospice aide visit, would notify case manager RN 102/23/2025 case manager RN 1 notified aide Patient already had a shower, and aide was with another Patient and didn’t make it to the Patient at the time requested02/26/2026 Patient didn’t have good morning, case manager RN 1 present and Patient refused shower03/02/2026 hospice aide completed upper body washing, area on leg open and case manager RN 1 notifiedRN 1 Skilled Nursing Visit Notes, dated 02/12/2026 and 03/02/2026, failed to evidence a hospice aide supervisory visit.A RN 1 Skilled Nursing Comprehensive Assessment Visit Note, dated 02/23/2026, failed to indicate a hospice aide supervisory visit was completed. During an interview, on 03/06/2026, beginning at 12:40 PM, case manager RN 1 indicated she could not find Patient's hospice aide supervisory visit that should have been completed every 30 days.  Request for hospice aide supervisory visit documentation were not met upon exit on 03/06/2026 at 5:20 PM. During an interview, on 03/06/2026, beginning at 4:00 PM, the Administrator indicated there were no hospice aide supervisory visits documented for the current benefit period.   4. A Plan of Care, for benefit period 12/02/2025 to 03/01/2026, indicated Patient #2 was to have an aide visit 1 time per week for 1 week starting 12/02/2025, and 3 times per week starting the week of 12/07/2025. Clinical Record Review and Hospice Aide 1 Visit Notes indicated the following: Aide visits completed 12/05/2025, 12/08/2025, 12/10/2025, 12/12/2025, 12/15/2025, 12/19/2025, 12/24/2025, 12/31/2025, 01/07/2026, 01/12/2026,  01/16/2026, 01/23/2026, 01/28/2026, 01/31/2026, 02/04/2026, 02/13/2026. 02/16/2026, 02/18/2026  with patient signature of visit completed by patient, family member or facility staff Aide visit 12/15/2025 Patient refused shower, notified facility nurse, and would notify case manager RN 1 Aide visit 12/22/2025 Patient refused shower, notified facility nurse, and would notify case manager Aide visit 12/26/2025 Patient refused shower, notify facility and case manager RN 1 Aide visit 12/29/2025 Patient refused care, hospice supervisor aware Aide visit 01/05/2026 Patient refused care, notified facility, nurse would notify RN 1 Aide visit 01/09/2026 attempted to shower Patient, Patient having difficulty standing, facility nurse notified, case manager RN 1 notified Aide visit 01/14/2026 Patient refused shower, Patient indicated leg hurting difficult to make steps, would notify case manager RN 1 Aide visit 01/19/2026 Patient refused shower, would notify case manager RN 1 Aide visit 01/21/2026 Patient complained of leg pain and swelling, refused shower and bed bath would notify facility nurse and case manager RN 1 Aide visit 01/26/2026 Patient refused shower, requested bath next visit, facility nurse and case manager RN 1 notified Aide visit 02/04/2026 care completed, right foot swollen and toe had open area case manager RN 1 and facility nurse notified Aide visit 02/06/2026 Patient refused shower, case manager RN 1 notified Aide Visit 02/09/2026 Patient refused shower due to foot pain, facility nurse notified and case manager RN 1 notified Aide Visit 02/11/2026 Patient refused shower, facility nurse notified and would notify case manager RN 1   Aide Visit 02/20/2026 Patient refused shower, facility nurse notified and would notify case manager RN 1 Clinical record indicated 16 missed aide visits and 17 aide visits completed from start of care benefit period 12/02/2025 to date of transfer to another hospice on 02/20/2026 During an interview, on 03/05/2026, beginning at 4:30 PM, the Administrator indicated case manager RN 1 was not documenting hospice aide supervisory visits, the documentation was embedded in the RN notes and should be completed every 14 days.  During an interview, on 03/06/2026, beginning at 12:40 PM, case manager  RN 1 indicated hospice aide supervisory visits were to be completed every 30 days by the RN case manager, and request for documentation of hospice aide supervisory visits completed was unmet upon exit on 03/06/2026 at 5:20 PM.

Based on record review and interview, the hospice POC failed to identify the care and services that were needed and specifically identify which provider was responsible for performing the respective functions in 1 of 1 active clinical record reviewed of a skilled nursing facility patient (Patient #5). Findings include: --- A policy, dated 03/2024, titled, “Services Provided To A Hospice Patient In A Skilled Nursing Facility,” indicated hospice patients that resided in nursing facilities would receive care according to the hospice POC that was reviewed by the hospice Interdisciplinary Team (IDT) and coordinated with care provided in the nursing facility.  The policy indicated the nursing facility staff was expected to provide care for the hospice patient resident equal to that provided by family and other caregivers for hospice patients that do not reside in a facility. An undated policy, titled, “Skilled Nursing Facility Plan Of Care Coordination,” indicated the interdisciplinary staff and skilled nursing facility interdisciplinary staff would meet to facilitate the coordination of the POC for the patient residing in the skilled nursing facility.  The policy indicated the nurse would initiate a POC during the first comprehensive assessment visit and the skilled nursing facility would be provided with a copy of the POC.  The policy indicated the coordinated POC would be reviewed at each visit and changes in the POC would be communicated to the skilled nursing facility staff and documented in the chart. A Plan of Care, for benefit period 02/06/2026 to 05/06/2026, indicated Patient #5 had wound care orders for stage IV wound (full thickness tissue loss exposing underlying structures such as bone, muscle and tendons) to coccyx that included clean with normal saline, apply calcium alginate to wound bed and triad paste to surrounding skin and measure weekly.   The POC failed to evidence the frequency of wound care.    The POC indicated skilled nursing visits 1 time per week for 1 week, 2 times per week for 11 weeks beginning 02/12/2026.  The POC indicated Patient had a foley catheter (tube into bladder to drain urine) to be changed every 60 days, and percutaneous endoscopic gastrostomy (PEG) tube feedings  (tube into stomach for nutrition) with bolus feedings 5 times per day. The POC indicated hospice aide 1 time per week for 1 week and 2 times per week for 11 weeks beginning 02/12/2026 for bed bath, assist with positioning, oral care, and foley catheter care to include emptying and perineal care  The POC indicated Patient resided at Entity C, a skilled nursing facility.  The POC failed to evidence a delineation of care between the hospice and Entity C of responsibility of wound care, activities of daily living, foley catheter care, and PEG tube care and nutrition administration. The POC failed to indicated the responsibility of Entity C in the absence of hospice staff.  During an interview, on 03/05/2026, beginning at 10:30 AM, Entity C’s wound care nurse indicated the facility changed Patient’s wound dressing to coccyx 2 to 4 times per day due to saturation.   During an interview, on 03/05/2026, beginning at 10:30 AM, Entity C’s Director of Nursing indicated the facility did not have written instructions from the hospice related to the delineation of care, however if hospice does not perform activities of daily living the facility would provide care.   During an interview, on 03/05/2026, beginning at 1:00 PM, the Administrator indicated the frequency of wound care was not included on the POC, and did not indicate what days hospice was responsible for wound care.  The Administrator indicated the POC did not have the delineation of care between hospice and Entity C for foley catheter care nor PEG tube care, nor for activities of daily living. During an interview, on 03/06/2026, beginning at 12:40 PM, case manager RN 1 indicated she does not include a delineation of care between the hospice and a skilled nursing facility on the POC and would discuss verbally with the facility.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 17 of 28 (61%) of clinical records reviewed that accepted spiritual care services revealed that the agency did not ensure the initial and ongoing plans of care included a detailed statement of the scope and frequency of spiritual care services necessary to meet specific patient and family needs. Clinical Record 5 (Election of benefit date 07/03/2024) An initial spiritual care visit was documented on 07/08/2024 with additional spiritual care visits documented on 07/16/2024 and 09/16/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 6 (Election of benefit date 08/31/2024) Spiritual care visits were documented on 09/05/2024, 09/13/2024, 10/10/2024, and 10/17/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 7 (Election of benefit date 06/07/2024) During the certification period dated 09/052024 to 12/03/2024, spiritual care visits were documented on 09/16/2024, 09/18/2024, and 10/03/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 9 (Election of benefit date 06/07/2024) spiritual care visits were documented 06/10/2024 and 08/21/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 10 (Election of benefit date 07/18/2024) A spiritual care visit was documented on 07/31/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 11 (Election of benefit date 02/08/2024) During the certification period dated 05/08/2024 to 08/05/2024, spiritual care visits were documented on 06/13/2024 and 07/25/2024. During the certification period dated 08/06/2024 to 10/04/2024, spiritual care visits were documented 09/04/2024 and 10/04/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 12 (Election of benefit date 08/15/2024) Spiritual care visits were documented on 08/15/2024 and 09/05/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 13 (Election of benefit date 06/24/2024) Initial spiritual care visit was documented on 06/27/2024. During the certification period dated 09/15/2024 to 11/13/2024, spiritual care visits were documented on 09/24/2024 and 10/08/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 14 (Election of benefit date 08/12/2024) Spiritual care visits were documented on 08/15/2024, 08/27/2024, and 09/20/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 15 (Election of benefit date 04/05/2024) During the certification period dated 07/04/2024 to 10/01/2024 spiritual care visits were documented on 08/07/2024, 09/18/2024, and 09/24/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 18 (Election of benefit date 08/08/2023) A spiritual care visit was documented on 08/21/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 20 (Election of benefit date 01/04/2024) During the certification period dated 01/04/2024 to 04/02/2024 spiritual care visits were documented on 01/09/2024 and 03/26/2024. During the certification period dated 04/03/2024 to 07/01/2024 spiritual care visits were documented on 06/20/2024 and 06/27/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 22 (Election of benefit date 02/10/2024) Spiritual care visits were documented on 02/12/2024, 02/28/2024, and 03/19/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 23 (Election of benefit date 05/22/2024) Spiritual care visits were documented on 05/28/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 24 (Election of benefit date 04/20/2024) Spiritual care visits were documented on 04/22/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 27 (Election of benefit date 04/02/2024) Spiritual care visits were documented on 04/05/2025 and 05/14/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. Clinical Record 29 (Election of benefit date 09/17/2024) Spiritual care visits were documented on 09/19/2024, 09/23/2024, and 10/14/2024. The record lacked evidence that the plan of care included the scope and frequency orders for the spiritual care services. In an interview and joint review of clinical records with the Director of Clinical Services, on multiple occasions throughout the site visit, she confirmed that the there were no visit frequency orders for spiritual care services on the initial or ongoing plans of care and stated, "that she didn't think they needed them." A review of all clinical records revealed that the agency did not ensure that all initial and ongoing plans of care (POCs) had ordered frequencies of Spiritual Support visits. Clinical Record (CR) 1 (Benefit Election (BE) date 08/03/2024), CR 5 (BE date 07/03/2024) Initial visit made on 07/08/2024, additional visits made on 07/16/2024 and 09/16/2024. CR 6 (BE date 08/31/2024) Visits made on 09/05/2024, 09/13/2024, 10/10/2024, and 10/17/2024. CR 7 (BE date 06/07/2024) During certification period 09/052024 - 12/03/2024 visits were made on 09/16/2024, 09/18/2024, and 10/03/2024. CR 9 (BE date 06/07/2024) Visits were made on 06/10/2024 and 08/21/2024. CR 10 (BE date 07/18/2024) Visit made on 07/31/2024 CR 11 (BE date 02/08/2024) During certification period 05/08/2024 - 08/05/2024 visits were made on 06/13/2024 and 07/25/2024. During certification period 08/06/2024 - 10/04/2024 visits were made on 09/04/2024 and 10/04/2024. CR 12 (BE date 08/15/2024) Visits were made on 08/15/2024 and 09/05/2024. CR 13 (BE date 06/24/2024) Visits were made on 06/27/2024. During certification period 09/15/2024 - 11/13/2024 visits were made on 09/24/2024 and 10/08/2024. CR 14 (BE date 08/12/2024) Visits were made on 08/15/2024, 08/27/2024, and 09/20/2024. CR 15 (BE date 04/05/2024) During certification period 07/04/2024 - 10/01/2024 visits were made on 08/07/2024, 09/18/2024, and 09/24/2024. CR 18 (BE date 08/08/2023) Visit was made on 08/21/2024. CR 20 (BE date 01/04/2024) During certification period 01/04/2024 - 04/02/2024 visits were made on 01/09/2024 and 03/26/2024, during certification period 04/03/2024 - 07/01/2024 visits were made on 06/20/2024 and 06/27/2024. CR 22 (BE date 02/10/2024) Visits were made on 02/12/2024, 02/28/2024, and 03/19/2024. CR 23 (BE date 05/22/2024) Visit was made on 05/28/2024. CR 24 (BE date 04/20/2024) Visit was made on 04/22/2024. CR 27 (BE date 04/02/2024) Visits were made on 04/05/2025 and 05/14/2024. CR 29 (BE date 09/17/2024) Visits were made on 09/19/2024, 09/23/2024, and 10/14/2024. In an interview and joint review of clinical records with the Director of Clinical Services on multiple occasions, she confirmed that the there was no frequencies of spiritual care on the initial or ongoing plans of care.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by document review and interview that fire drills at the inpatient unit were not documented as completed with each shift. The inpatient unit has 2 shifts. Logs in 2021 documented fire drills completed during the first shift on 02/19/2021, 04/2021, 07/2021, and 10/2021. There was no documentation of any drills completed on the second shift in 2021. During interview on 11/18/2021, the Director of Maintenance provided documentation and stated quarterly drills were completed but only on the day shift.

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; and Ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by review of clinical records, document review, and interview. 2 of 20 (10%) records revealed evidence that visits or treatments were not completed in accordance with orders on patient plans of care. Record #28674: Admitted on 08/20/2021 with an order for nursing to visit 2 times a week. The week beginning 09/05/2021 documented 1 visit only and no reason for the second visit not being provided. Record #23530: Admitted on 09/22/2021 with orders for monthly port flush. During the month of October, from 10/01/2021 - 10/31/2021, there was no documented evidence of a completed port flush or reason why the port note was not flushed. Documentation in the record did confirm that the port did remain patent. Interview with the Director of Quality stated the documentation was not in the record.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; and includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient This standard was not met as evidenced by review of clinical records, document review and interview. 4 of 20 (20%) records contained plans of care that did not include complete orders for interventions, including drugs and treatments, necessary to meet the needs of the patient. Record #17220: Admitted on 09/21/2021 with a subcutaneous infusion delivered via a PCA (patient-controlled analgesia) pump. The plan of care did not include orders for interventions related to the care of the subcutaneous insertion site, dressing change for the site, and frequency of needle change to the site. Record #23530: Admitted on 09/22/2021 with a port-a-catheter in the right chest. The plan of care did not include orders for interventions related to the care of the port, including the specific gauge and length of the Huber needle to be used to access the port during the ordered monthly access. Additionally, there were also no orders for the dressing change at the Aspira Drain site. Record #28674: The initial comprehensive assessment documented on 08/20/2021 stated the patient was receiving antibiotics ordered for a respiratory infection. The plan of care was missing orders for intervention to address the identified respiratory status issues, such as the use of nebulizer treatment and use of inhalers. Record #18269: The initial comprehensive assessment documented on 09/21/2021 stated the patient was using Dapsone for treatment of a skin disorder, however the plan of care did not include documentation of interventions to address the skin disorder. The absence of complete orders on patient plans of care could impact the safety of the patient care provided, however there was no evidence that either patient was negatively impacted at the time of site visit review on 11/18/2021. During interview, the Director of Quality and Director of Education stated that clinical staff are trained annually to include complete orders and this information should have been documented. Also, they stated that a process improvement plan is currently in place to address development of interventions related to identified problems.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: A revised plan of care includes: Information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by review of clinical records, document review and interview which revealed that 2 of 20 (10%) records contained plans of care that were not updated to describe the patients' progress and changes made to document updated goals from information identified during updated comprehensive assessments. Agency policy, (Revised 03/2021) "Plan of Care", stated in part: "Revisions to the plan of care are based on information for the patients updated comprehensive assessment and the patients progress toward outcomes specified in the plan." Record #28674: Admitted on 08/21/2021 with an updated comprehensive assessment dated 09/09/2021, included discontinuation of liquid morphine for pain and change to a pill dosage of MS Contin. This change was made as the patient demonstrated elevated anxiety and taking incorrect dosages of the narcotic medication. The documented pain goals on the plan of care were not updated to describe the lack of progress toward the goal and the need for increased monitoring of this patient. Also, the patient experienced a fall documented on 09/24/2021 with subsequent orders for a dry dressing, and on 10/01/2021 a change to a Mepilex dressing. The plan was not updated to include documentation of a goal related to the patient's skin integrity. Record #23530: Admitted 09/22/2021 with an updated comprehensive assessment dated 10/20/2021 which identified a new area of redness on the abdominal skin surrounding the Aspira Drain site and physician order for a new treatment to the skin. The interdisciplinary plan of care updated on 10/22/2021 did not include documentation of the update and description of the lack of progress toward the identified goal. During interview with the Director of Nursing, Director of Quality, and Director of Education on 11/17/2021, they stated that plans of care are to be updated during the interdisciplinary group meeting.

It is required that medical social services are provided: Based on a psychosocial assessment. The psychosocial assessment addresses: The patient’s and the family’s adjustment to the terminal illness; The presence or absence of adequate coping mechanisms; Family dynamics and communication patterns; Financial resources and any constraints; The caregiver’s ability to function effectively; Obstacles and risk factors that may affect compliance with the plan of care; and Family support systems to facilitate coping. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by review of clinical records and interview. 1 of 20 (5%) records of patients who accepted social work services was missing documented evidence of a fully completed psychosocial assessment. Record #13243: Admitted 09/22/2021. The nursing comprehensive assessment documented 09/22/2021, stated social work services were accepted. The social worker documented a phone call on 09/24/2021 in which the daughter requested a visit the next week. Social work visits were documented on 10/06/2021, 10/22/2021, 11/03/2021 and 11/09/2021, and these visits documented the emotional needs of the patient's daughter but did not include the completion of a comprehensive psychosocial assessment. Agency policy (Revised 03/2021), "Initial Assessment of Patient, Family, Primary Caregiver", stated in part: “The Social Worker is responsible for assessing the psychosocial needs of the patient, family, primary caregiver.” During interview with the Director of Quality on 11/17/2021, they stated, there was no evidence of a comprehensive assessment completed by the social worker.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by review of clinical records, document review and interview that in 5 of 18 (28%) records in which a hospice aide was accepted for care, evidence revealed aide services were not provided in accordance with the aide plan of care. Record #61403: Ordered aide visit frequency was 1 time a week beginning 08/31/2021. The week beginning 09/05/2021 was missing evidence of an aide visit provided and there was no documented reason for the visit not being provided. The aide plan assigned the aide to assist with dressing the patient during each visit, however the aide visit note dated 9/15/2021 did not include documentation that this task was completed. Record #95371: The aide plan assigned the aide to complete catheter care, empty Foley bag, bed bath, foot care, oral care, peri care, and shave. Documentation on the aide visit note dated 11/10/2021 did not state the completion of these duties or a reason why they were not provided. Record #10713: Ordered aide visit frequency was 1 time a week for the first week and then 2 times a week. During the week of 07/18/2021 (week 1), there was no evidence that 1 visit was provided as ordered. During the week of 07/25/2021 (week 2), there was no evidence of 2 visits provided as ordered. Duties were assigned to be completed during each visit included peri care. Documentation on the aide visit note dated 10/19/2021 did not document peri care was completed as assigned. Record #97570: The aide car plan assigned the aide to complete the following duties: assist with dressing, check for no BM (bowel movement) in 3 days, shampoo, skin care, partial bath, peri care and nail care. Documentation on the visit note dated 08/25/2021 did not include completion of assist with dressing, shampoo, peri care, and nail care. Documentation on the visit note dated 09/01/2021 did not include completion of documenting BM, shampoo, skin care, partial bath, and peri care. Documentation on the visit note dated 09/15/2021 did not include assist with dressing, skin care, and peri care, as assigned. Record #18269: Ordered aide visit frequency was 2 times a week, beginning 09/24/2021. The first and second weeks did not include evidence of completed visits, and documentation during the 3rd week revealed only 1 visit was completed. During interview with the Director of Quality they agreed the visits were not provided and the reasons were not documented in the record.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by review of clinical record, document review and interview that 2 of 20 (10%) records failed to document physician orders for care provided to the patient. Record #95371: Admitted 11/06/2021 with wounds. Nursing visit notes documented care to the wound that included cleaning with soap and water and application of a foam dressing. The physician orders dated 11/09/2021 and 11/15/2021 described specific wound care orders including the use of Medihoney and a Mepilex dressing. There was no documented order for the wound care that was provided during the visit on 11/06/2021 until 11/09/2021. Record #18269: Admitted 09/10/2021 and a request was made for volunteer services. Volunteer service was initiated beginning on 10/10/2021 but there was no documented evidence of a written order for volunteer visit frequency as of the site visit review on 11/17/2021. During interview, the Director of Quality stated the orders were not documented.