Every finding on record at Traditions Hospice of Crown Point, LLC

Based on record review and interview, the hospice agency failed to have an emergency preparedness communication plan that included alternate means for communicating with facility staff and Federal, State, tribal, regional, and local emergency management agencies. Findings include: --- Record review evidenced an agency policy dated 04/2022, titled, ";Emergency Preparedness Policy," which stated, ";... If communication methods at a hospice site are disrupted, mobile communication systems, email, short-wave radios, walkie-talkies, and/or social media as approved by management, may be sources used by the administrative staff. Local radio and/or television stations may be contacted by the hospice as a method of communicating with the patient population or staff if necessary ...." Record review failed to evidence the hospice agency had an alternate means of communication. During an interview on 08/10/2023, at 10:05 AM, the Administrator indicated the primary means of communication would be through phone and text but did not have an alternate means of communications.

Based on record review and interview, the hospice agencys emergency preparedness plan failed to include a method for sharing information and medical documentation for patients under agencys care with other health care providers to maintain continuity of care, in the event of an evacuation, or a means of releasing patient information and providing general information about the general condition and location of patients. Findings include: --- Record review evidenced an agency policy dated 10/01/2021, titled, ";Emergency Preparedness and Response Plan," which stated, ";The Response and Recovery phases of the Emergency Preparedness and Response Plan will describe: ... A method for sharing information and medical documentation for patients under the Hospices care, as necessary, with other health care providers to maintain the continuity of care ... A means of providing information to the authority having jurisdiction ... about the Hospices needs and its ability to provide assistance...." Review failed to evidence the method that would be implemented for sharing information with other healthcare providers or emergency officials. During an interview on 08/10/2023, at 10:05 AM, the Administrator indicated the patients charts would need to be printed at the hospice agency or another location to provide information to other health care providers. The Administrator indicated the agency would start to download patients information daily to be available if required during an emergency situation.

Based on record review and interview, the agency failed to ensure the comprehensive assessment included a complete physical assessment in 1 of 4 active records with a wound (Patient #1). The findings include: --- Review of an agency policy titled, "Patient Assessment", dated 4/2022, indicated registered nurse will complete an initial comprehensive assessment of the patient including a full physical assessment in order to provide the necessary care and services. Review of the start of care comprehensive assessment, dated 7/19/2023, indicated Patient #1 had a pressure ulcer to the sacrum (tailbone area). The nurse indicated they did not assess the wound. During an interview on 8/11/2023 at 2:45 PM, the administrator indicated wounds should be assessed and measured as part of the comprehensive assessment in order to determine treatment.

Based on record review and interview, the hospice agency failed to provide an initial bereavement assessment upon admission in 2 of 18 active clinical records reviewed (Patient #2, 20). Findings include: --- 1. Record review evidenced an agency policy dated 10/01/2021, titled, ";Bereavement," which stated, ";... The Hospice will perform an initial bereavement assessment of the needs of the patients family ... On admission, a bereavement admission assessment will be made available to the Bereavement Coordinator ...." 2. Clinical record review for patient #2, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 07/22/2023-10/19/2023, which indicated the patients start of care was 07/22/2023. Review failed to evidence a bereavement assessment was performed. 3. Clinical record review for patient #20, evidenced an agency document titled, ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report," for benefit period 05/18/2023-08/02/2023, which indicated the patients start of care was 05/18/2023. Review evidenced an initial bereavement assessment was performed on 05/28/2023. Review failed to evidence the initial bereavement assessment was performed upon admission. 4. During an interview on 08/10/2023, at 12:40 PM, Administrative Staff 2 confirmed patient #2 did not have a bereavement assessment, and patient #20s bereavement assessment was not performed upon admission.

Based on record review and interview, the agency failed to ensure all care and services furnished to the patient followed the plan of care in 1 of 2 active patient records with a feeding tube (#15). The findings include: --- Review of an agency policy titled, ";Plan of Care Process", dated 10/20/2022, indicated all hospice care and services will follow an individualized plan of care established by the hospice. Review of the plan of care for certification period 6/22/2023 to 8/20/2023 evidenced the patient was on fall, aspiration, oxygen, anticoagulation, and seizure precautions. The plan of care failed to evidence using a dressing on the PEG tube site. Review of skilled nurse visit notes and care plan entries with the following dates failed to evidence seizure precautions: 6/23/2023, 6/26/2023, 6/29/2023, 6/30/2023, 7/2/2023, 7/5/2023, 7/7/2023, 7/8/2023, 7/9/2023, 7/10/2023, 7/11/2023, 7/12/2023, 7/13/2023, 7/14/2023, 7/15/2023, 7/16/2023, 7/17/2023, 7/18/2023, 7/19/2023, 7/20/2023, 7/21/2023, 7/22/2023, 7/23/2023, 7/24/2023, 7/25/2023, 7/27/2023, 7/28/2023, 7/30/2023, 7/31/2023, 8/2/2023, 8/4/2023, 8/7/2023 and 8/8/2023. Review of skilled nurse visit notes and care plan entries with the following dates failed to evidence anticoagulation precautions: 6/23/2023, 6/26/2023, 6/29/2023, 6/30/2023, 7/2/2023, 7/5/2023, 7/7/2023, 7/8/2023, 7/9/2023, 7/10/2023, 7/11/2023, 7/12/2023, 7/13/2023, 7/14/2023, 7/15/2023, 7/16/2023, 7/17/2023, 7/18/2023, 7/19/2023, 7/20/2023, 7/21/2023, 7/22/2023, 7/23/2023, 7/24/2023, 7/25/2023, 7/26/2023, 7/27/2023, 7/28/2023, 7/30/2023, 7/31/2023, 8/2/2023, 8/4/2023, 8/7/2023 and 8/8/2023. Review of a skilled nurse visit note dated 2/26/2023 evidenced the nurse used a specialized foam dressing around Patient #15s PEG tube (a feeding tube inserted through the abdomen). During an interview on 8/11/2023 at 3:36 PM, Administrative Staff 2 indicated the patient was on fall, aspiration, oxygen, seizure, and anticoagulation precautions, and the nurse should document safety precautions at each visit either in the visit note or in a care plan entry. During an interview on 8/11/2023 at 3:40 PM, the administrator indicated the nurse should provide PEG tube care as ordered by the physician.

Based on record review and interview, the agency failed to develop an individualized plan of care which included all necessary services and patient-centered goals in 3 of 18 active records reviewed (Patients #1, 10, 12). The findings include: --- 1. Clinical record review for patient #10, evidenced an agency document titled, ";Hospice Recertification Plan of Care Update," for certification period 07/12/2023-10/09/2023, which indicated the patient was on Plavix (blood thinning medication), and had a goal that the patient would have bleeding/hemorrhage identified early for management and will have preventive measures to control. Review of an agency document titled, ";Aide Care Plan Report," for episode 07/12/2023-10/09/2023, failed to evidence bleeding precautions. During an interview on 08/11/2023, at 1:42 PM, the Administrator indicated bleeding precautions should have been on the aide plan of care. 1. Review of an agency policy titled, ";Plan of Care Process", dated 10/20/2022, indicated the hospice will develop an individualized plan of care for each patient which includes all services necessary to meet the patients needs as well as patient and family goals. 2. Review of the plan of care for Patient #1, certification period 7/19/2022 to 10/16/2023, stated, ";Patients anxiety / agitation will be at a 3 or less at eac [sic] SN [skilled nurse] visit by August 2nd". Clinical record review failed to evidence any numeric scale for measuring anxiety / agitation. During an interview on 8/11/2023 at 3:55 PM, Administrative Staff 3 indicated there was no numeric scale for anxiety. 3. Review of skilled nurse visit notes dated 8/3/2023 and 8/10/2023 indicated Patient #12 was at risk for aspiration (breathing in food or liquid). Review of the plan of care for Patient #12, certification period 6/22/2023 to 8/20/2023, indicated the patient had a history of aspiration pneumonitis. The plan of care failed to evidence aspiration precautions. During an interview on 8/11/2023 at 3:02 PM, the administrator indicated Patient #12 was at risk for aspiration and should probably be on aspiration precautions.

Based on record review and interview, the hospice agency failed to include in the plan of care all services necessary for the palliation and management of the terminal illness including drugs and treatments necessary to meet the needs of the patient in 8 of 18 active clinical records reviewed (Patient #1, 2, 4, 6, 7, 13, 15, 17). The findings include: --- 1. Record review evidenced an agency policy dated 10/20/2022, titled, ";Plan of Care Process," which stated, ";... Drug profile, including a review of all of the patients prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy ... The POC [plan of care] includes, but is not limited to: ... Drugs and treatments necessary to meet the needs of the patient ...." 2. Clinical record review for patient #2, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 07/22/2023-10/19/2023, which indicated the patient was on polyethylene glycol (laxative) 17-gram one packet daily. Review of entity 2s document dated 08/09/2023, titled, ";Medication Review Report," which indicated the patient was on polyethylene glycol 17 grams as needed. Review failed to evidence correct medication frequency on the hospice plan of care. During an interview on 08/10/2023, at 11:45 AM, Administrative Staff 3 indicated medication reconciliation with the facilities should be done at every nursing visit. 3. Clinical record review for patient #7, evidenced an agency document titled, ";Hospice Recertification Plan of Care Updated," for certification period 07/26/2023-09/23/2023, which indicated current medication orders included but not limited to: Fentanyl (pain patch) 25 micrograms every 72 hours, Fentanyl 50 micrograms every 72 hours and Fentanyl 100 micrograms every 72 hours (apply one patch in addition to 50 micrograms for a total of 150 micrograms of Fentanyl every 72 hours). Review failed to evidence the dosage of Fentanyl the patient was taking on the hospice plan of care. During an interview on 08/11/2023, at 1:17 PM, Administrative Staff 3 indicated the Fentanyl 25 micrograms should not be on the plan of care medication list and confirmed with the case manager the patient was to take Fentanyl 100 microgram patch and 50 microgram patch every 72 hours for a total of 150 micrograms every 72 hours, and the Fentanyl 25 micrograms should be discontinued on the plan of care medication list. Review of the plan of care indicated the patient had a g-tube (feeding tube into the stomach). Review failed to evidence orders for g-tube site care. 4. Clinical record review for patient #13, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 08/03/2023-10/31/2023, which indicated under orders of discipline and treatments the patient was taking Glucerna (nutritional supplement) 3 times per day via peg tube (feeding tube into stomach) and used oxygen at 2 liters per minute. Review failed to evidence the Glucerna, or the oxygen was on the plan of care medication list. Review evidenced an agency document dated 08/10/2023, titled, ";Client Medication Report," which failed to evidence the Glucerna and the oxygen. Review of the plan of care indicated the patient had a g-tube. Review failed to evidence orders for g-tube site care. During an interview on 08/11/2023, at 1:27 PM, the Administrator indicated the Glucerna, and the oxygen should be an order on the plan of care medication list and added to the medication report. 5. Clinical record review for patient #17, evidenced an agency document titled, ";Hospice Recertification Plan of Care Update," for certification period 07/16/2023-09/13/2023. Review evidenced the patient had a g-tube. Review failed to evidence orders for g-tube site care. 6. During an interview on 08/11/2023, at 12:41 PM, the Administrator indicated the plan of care should include g-tube site care. XX. Review on 8/9/2023 of Skilled Nursing Facility 4s current plan of care for Patient #1, evidenced the using the following medications: Acetaminophen rectal suppository, Aquaphor (a topical skin cream), Lorazepam (an anti-anxiety medication) 0.5 mL (milliliters) by mouth every 2 hours for anxiety / agitation, Lorazepam 0.5 mL by mouth every 4 hours for anxiety, Lorazepam 0.5 mL by mouth every 6 hours for restlessness, Morphine 20 mg (milligrams) / mL, 0.5 mL by mouth every 8 hours as needed for severe pain / shortness of breath, Morphine 20 mg / 5 mL, 0.5 mL by mouth every 2 hours as needed for shortness of breath / pain, Morphine 20 mg / 5mL, 0.5 mL by mouth every 8 hours for restlessness. Review of the plan of care for Patient #1, certification period 7/19/2022 to 10/16/2023, evidenced the following medications not on the facilitys list: Acetaminophen oral (no rectal suppository), Aspirin, Atorvastatin (a cholesterol medication), Citalopram (an anti-depressant), Donepezil (a dementia medication), Famotidine (an acid-reducing medication), Furosemide (a water pill), Haloperidol (an anti-psychotic medication), Memantine (a dementia medication), Metformin (a diabetes medication), Olanzapine (an anti-psychotic), Potassium Chloride, and Trazadone (an anti-depressant). Review failed to evidence Aquaphor. During an interview on 8/11/2023 at 2:51 PM, the administrator indicated the skilled nursing facility and hospice agencys plans of care should include the same current medications. When informed of the findings, the administrator indicated the nurse should have performed a medication reconciliation and clarified the Lorazepam and Morphine orders. XX. Review of the plan of care for Patient #4, certification period 6/23/2023 to 8/21/2023, evidenced the patient was taking Lorazepam (an anti-anxiety medication), Revastigmine (a dementia medication), and Lisinopril (a blood pressure medication). Review of patient medications during a home visit on 8/10/2023 failed to evidence Lorazepam, Revastigmine, and Lisinopril. During an interview on 8/9/2023 at 1:45 PM, Person 6 (caregiver to Patient #4) indicated the patient did not take Lorazepam, Revistigmine, or Lisinopril. During an interview on 8/11/2023 at 2:54 PM, the administrator indicated the nurse should be reviewing the patients medications at each visit. XX. Review of the plan of care for Patient #6, certification period 5/12/2023 to 8/9/2023, evidenced the following medications: Lorazepam (an anxiety medication) 0.5 mg every 8 hours by mouth, and Lorazepam 0.5 mg every 2 hours as needed for breakthrough anxiety. Review of the plan of care failed to evidence Hydroxyzine and Loperamide. Review of Skilled Nursing Facility #7s plan of care evidenced the following: Lorazepam 2 mg / mL, 0.5 mL by mouth every 2 hours as needed for pain, and Lorazepam 2 mg / mL, 0.5 mL by mouth as needed for anxiety. The plan of care also indicated the patient was taking Hydroxyzine (an anti-itch medication) and Loperamide (an anti-diarrheal). During an interview on 8/11/2023 at 2:51 PM, the administrator indicated the skilled nursing facility and hospice agencys plans of care should include the same current medications. When informed of the findings, the administrator indicated the nurse should have performed a medication reconciliation and clarified the Lorazepam orders. XX. Review of the plan of care for Patient #15, certification period 6/22/2023 to 8/20/2023 evidenced the patient had a PEG tube (a feeding tube inserted through the abdomen), but failed to evidence instructions on PEG tube site care. During an interview on 8/11/2023 the administrator indicated the agency did not have a specific policy for PEG tube site care, and specific orders for the patients PEG tube should be in the plan of care.

Based on observation, record review, and interview, the hospice agency failed to follow accepted standards of practice to prevent the transmission of infections, including the use of standard precautions in 2 of 3 home visits observed (Patient #4, 5). The findings include: --- 1. Record review evidenced an agency policy dated 12/15/2022, titled, ";Hand Hygiene," which stated, ";... Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: ... After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressing and used supplies (PPE) [personal protective equipment] if hands are not visibly soiled ... Before moving from a contaminated body site to a clean body site during patient care ...." 2. Review of an agency procedure titled ";Bed Bath", reviewed 5/22/2023, evidenced the following instruction for bathing using water, skin cleanser, and washcloths: wash, rinse and dry the patients neck, shoulders and chest, then the abdomen, groin, and perineum; remove gloves, perform hand hygiene, and don new gloves; wet a clean washcloth with warm water and apply skin cleanser to the washcloth; wash, rinse and dry the legs and feet. 3. Review of the CDC (Center for Disease Control) website on 08/09/2023, evidenced Hand Hygiene Guidance which indicated healthcare personnel should use alcohol-based hand rub or soap and water before moving from work on a soiled body site to a clean body site on the same patient. 4. Observation of a home visit for patient #5, on 08/09/2023, from 11:00 AM-12:05 PM, Registered Nurse (RN) 1 was observed removing wipes out of nursing bag, gloves were applied and perineal care was provided wiping the front perineal area. RN 1 then proceeded to remove the patients diaper and turn the patient to the right side, RN 1 removed the dressing to the patients coccyx and cleansed the wound with wound cleanser, dried the area with gauze, and applied a foam dressing. Observation failed to evidence RN 1 removed gloves or performed hand hygiene after perineal care was performed and prior to wound care being provided. During an interview on 08/10/2023, at 4:55 PM, the Administrator indicated the agency had a hand washing policy and the staff should follow the standard precautions and policy. 5. Home Hospice Aide (HHA) 1 was observed giving Patient #4 a bed bath during a home visit on 8/10/2023 at 12:40 PM. HHA 1 used one basin of water with soap and one washcloth to wash the patients torso, arms, legs, and feet. HHA 1 then removed the patients diaper, and used the same washcloth, rinsed in the same water, to wash the patients genitals. During an interview on 8/11/2023 at 2:56 PM, Administrative Staff 2 indicated they would have to check the policy about bed baths, but they thought one washcloth was to be used separately for the perineal area.

Based on record review and interview, the hospice agency failed to ensure the clinical record contained correct clinical information in 6 of 23 clinical records reviewed (Patient #3, 7, 12, 13, 17, 20). The findings include: --- 1. Record review evidenced an agency policy dated 11/30/2022, titled, ";Medical Record Content," which stated, ";Purpose to ensure each medical record contains complete, correction information ... and accurately describes care provided ... All entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy ... Clinical notes documenting functional and activity limitations, all actions, interventions, and procedures provided by the Hospice, including medication administration, treatments and services, the response to interventions ...." 2. Record review evidenced an agency policy dated 10/01/2021, titled, ";Documentation," which stated, ";... The record must be accurate ... Initial and ongoing assessments and interventions must be documented in the record ... Documentation Tips ... when documenting wound care, be specific regarding: nature of drainage amount of drainage, procedure performed ... any edema, pain, redness, or heat, measurement in centimeters (length, width, depth) and description of wound bed and surrounding area ...." 3. Clinical record review for patient #7, evidenced an agency document titled, ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report," for benefit period 07/26/2023-09/23/2023, evidenced the patient had a g-tube (tube into the stomach for nutrition). Review of agency documents dated 07/31/2023 and 08/04/2023, titled, ";Visit Note Report," failed to evidence documentation of g-tube site assessment. 4. Clinical record review for patient #13, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 08/03/2023-10/31/2023, which indicated the patient had a g-tube. Review of agency documents dated 08/04/2023, 08/05/2023, and 08/09/2023, titled, ";Visit Note Report," failed to evidence documentation of g-tube site assessment. 5. Clinical record review for patient #17, evidenced an agency document titled, ";Hospice Recertification Plan of Care Update," for certification period 07/16/2023-09/13/2023, which indicated the patient had a g-tube. Review of an agency document dated 07/17/2023, titled, ";Visit Note Report," evidenced patient was on Cephalexin (antibiotic) for g-tube infection. Review of an agency document dated 07/19/2023, titled, ";Visit Note Report," failed to evidence documentation of g-tube site assessment. 6. Clinical record review for patient #20, evidenced an agency document titled, ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report," for benefit period 05/18/2023-08/02/2023, which indicated the patient had a g-tube. Review of agency documents dated 06/02/2023, 07/05/2023, and 07/07/2023, titled, ";Visit Note Report," failed to evidence documentation of g-tube site assessment. 7. Clinical record review for patient #3, evidenced an agency document titled, ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report," for benefit period 07/18/2023-09/15/2023, which indicated the patient had wound care orders to the coccyx (tailbone). Review of an agency document dated 07/19/2023, titled, ";Visit Note Report," indicated the patient had a stage II wound (open wounds, skin breaks open and expands into the deeper layers of the skin). Review of agency documents dated 07/19/2023 07/21/2023, 07/24/2023, 07/26/2023, 07/28/2023, 07/31/2023, 08/02/2023, and 08/04/2023, titled, ";Visit Note Report," failed to evidenced documentation of wound measurements. During an interview on 08/10/2023, at 11:57 AM, the Administrator indicated wound documentation should include progression of wound, measurements weekly of wounds greater than stage I (redness to skin), to include depth, and width. 8. During an interview on 08/11/2023, at 12:41 PM, Administrative Staff 3 indicated the g-tube assessment should include documentation of site. XX. Clinical record review for Patient #12, start of care 12/24/2022, failed to evidence any chaplain visit notes before 4/28/2023. During an interview on 8/9/2023 at 11:55 AM, Chaplain 1 indicated the chaplain completes the comprehensive spiritual assessment at the first visit, within 5 days of start of care. During an interview on 8/11/2023 at 3:15 PM, Administrative Staff 2 indicated the patient refused the first chaplain visit, but the chaplain did not write a missed visit note.

Based on record review and interview, the hospice agency failed to forward the patients attending physician a copy of the hospice discharge summary when a patient revokes the election of hospice care in 1 of 1 clinical records reviewed with patients who revoked hospice care (Patient #20). The findings include: --- Record review evidenced an agency policy dated 11/30/2022, titled, ";Medical Record Content," which stated, ";... Documentation of care provided will include: ... notification to the attending physician of patient discharge ...." Clinical record review for patient #20, evidenced an agency document dated 08/02/2023, titled, ";RN [registered nurse] Hospice Discharge From Agency," which indicated the patients family member revoked hospice services so the patient could seek therapy. Review of an agency document titled, ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report," for benefit period 05/18/2023-08/02/2023, indicated the patients hospice physician was hospice personnel physician 1 and the patients physician was physician 3. Review failed to evidence physician 3 was notified or sent the patients discharge from hospice summary. During an interview on 08/11/2023, at 1:07 PM, Administrative Staff 3 indicated there was no documentation physician 3 was notified of the patients discharge from hospice or the summary was sent to physician 3.

Based on record review and interview, the hospice representative failed to ensure continuity between the hospice plan of care and the skilled nursing facility plan of care in 2 of 5 home visits in a skilled nursing facility (Patient #1, 6). The findings include: --- 1. Review of an agency policy titled ";Coordination of Care", dated 10/01/2021, indicated the hospice will ensure the development of an integrated, coordinated plan of care with each provider of care to the patient and the designated RN (registered nurse) will ensure implementation of the plan of care meets the needs of the patient and family. 2. Review of the plan of care for Patient #1, certification period 7/19/2022 to 10/16/2023, indicated the skilled nursing facility staff would provide incontinence checks as well as turn the patient every 2 hours in the absence of hospice. Review on 8/9/2023 of the current plan of care for Patient #1 from Skilled Nursing Facility 4 failed to evidence incontinence checks, and indicated the staff should turn and reposition the patient every shift. During an interview on 8/11/2023 at 2:18 PM, the administrator indicated it was the nurse case managers responsibility to ensure care provided by the facility matched the hospice plan of care. 3. Review of the plan of care for Patient #6, certification period 5/12/2023 to 8/9/2023 indicated the hospice will manage the patients medications, symptom control, and pain. Review on 8/9/2023 of the current plan of care for Patient #6 from Skilled Nursing Facility 7 indicated the nurse shall report pain medication side effects and unsuccessful pain control to the physician. During an interview on 8/9/2023 at 3:25 PM, RN (registered nurse) 2 indicated she did not think the skilled nursing facility had their own care plan. During an interview on 8/11/2023 at 2:59 PM, Administrative Staff 2 indicated the skilled nursing facility should be notifying the hospice agency with any pain medication side effects and unsuccessful pain control.

Based on observation, record review, and interview, the hospice failed to coordinate care with the skilled nursing facility/assisted living facility by providing the facility with the following information: most recent hospice plan of care, hospice election form, advanced directives, physician certification and recertification of terminal illness, hospice medication information specific to each patient, and hospice physician orders in # of # home visits completed in a skilled nursing facility/assisted living facility (Patient #1, 2, 5, 6). The findings include: --- 1. Record reviewed evidenced an agency policy dated 01/01/2021, titled, ";Hospice Care in a SNF/NF [skilled nursing facility/nursing facility] or ICF/IID [Intermediate Care Facility/Intellectual Disabled]," which stated, ";... The Hospice will provide the facility with the following hospice information/documentation on admission and on-going: The most recent hospice plan of care specific to each patient, The Hospice election form and any advanced directives specific to each patient, The physician certification and recertification of the terminal illness specific to each patient, The Hospice medication information specific to each patient, The Hospice Physician and Attending Physician (if any) orders specific to each patient ...." 2. During observation of a home visit for patient #2, on 08/09/2023, from 1:00 PM-2:40 PM, at skilled nursing facility 2, skilled nursing facility staff licensed practical nurse 1, indicated the facility did not have the hospice plan of care, advanced directive, terminal illness certification or hospice election form. 3. During observation of a home visit for patient #5, on 08/09/2023, from 11:00 AM-11:50 AM, at assisted living facility 1, the unit manager failed to have the patients terminal illness certification or the hospice election form. 4. During an interview on 08/10/2023, at 11:14 AM, the Administrator indicated upon admission to a facility the hospice should provide the facility with the hospice plan of care, terminal illness certification and recertification, hospice election form, consents, advanced directives, and delineation of care. XX. Review of Patient #1s clinical record for Skilled Nursing Facility 4 on 8/9/2023 failed to evidence a hospice election form, advanced directives, and physician certification of terminal illness. During an interview on 8/9/2023 at 10:02 AM, Person 5 (staff from Skilled Nursing Facility 4) indicated all information received from the hospice gets entered into the patients electronic record. Person 5 indicated the record failed to evidence a hospice election form, advanced directives, and physician certification of terminal illness. XX Review of Patient #6s clinical record for Skilled Nursing Facility 7 on 8/9/2023 failed to evidence a hospice election form, advanced directives, and physician certification of terminal illness. During an interview on 8/9/2023 at 3:22 PM, Person 8 (nurse from Skilled Nursing Facility 7) indicated all information received from the hospice gets entered into the patients electronic record. Person 8 indicated the record failed to evidence a hospice election form, advanced directives, and physician certification of terminal illness.

Based on record review and interview, the agency failed to ensure skilled nursing facility staff caring for hospice patients were oriented to the hospice philosophy of care. The findings include: --- Review of an agency policy titled ";Hospice Care in a SNF / NF [skilled nursing facility / nursing facility] or ICF / IID [Intermediate Care Facilities for Individuals with Intellectual Disabilities]", dated 10/01/2021, indicated the hospice will ensure the orientation of staff who provides care in the hospice philosophy. During an interview on 08/09/2023 at 1:12 PM Person 9, administrator of Skilled Nursing Facility 2, indicated the facility staff had not received any hospice training from the hospice agency. During an interview on 08/09/2023 at 3:10 PM, Nurse 8 from Skilled Nursing Facility 7 indicated they were caring for Patient #1, and had not received any hospice training from the hospice agency. During an interview on 08/10/2023, at 11:15 AM, the Administrator indicated the marketing team for hospice provided hospice training yearly to skilled nursing facilities. By the time of exit on 08/11/2023, no evidence of hospice training for skilled nursing facility staff was received.

Observed in Record Review. In 2 of 13 patient records reviewed, During RR# 4 and BR# 3's record review it was noted the organization had not ensured the comprehensive assessment was completed no later than five calendar days after the election of hospice care. For example: review of RR# 4's patient record revealed the initial bereavement assessment completed 24 days after the start of care. Review of BR# 3's record revealed the initial bereavement assessment completed 10 days after the start of care. This was reviewed and validated with the Bereavement Coordinator and Branch Director.

Observed in Record Review. In 5 of 9 active patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 6's patient record review it was noted the organization had not ensured it assessed potential medication problems to include duplicate drug therapy. For example: review of RR# 1's medication profile revealed RR# 1 was ordered more than one medication for pain control without direction on when to take the different pain medications. For example: review of RR# 1's medication profile revealed RR# 1 was ordered acetaminophen 325mg 2 tablets every four hours as needed for pain; acetaminophen 650 mg rectal suppository every six hours as needed for pain; and Morphine concentrate 0.25ml every four hours as needed for pain. Further review of RR# 1’s medication profile revealed RR# 1 was ordered more than one medication for constipation without direction on when to take the different constipation medications. RR# 1 was ordered Dulcolax Bisacodyl 10mg rectal suppository every six hours as needed for constipation and MiraLAX 17 grams daily as needed for constipation. Review of RR# 2’s medication profile revealed RR# 2 was ordered more than one medication for pain control. RR# 2 was ordered acetaminophen 500mg tablet every eight hours as needed for pain and Morphine concentrate 0.25 ml every four hours as needed for pain. Review of RR# 3’s mediation profile revealed RR# 3 was ordered Bisacodyl 10 mg rectal suppository daily as needed for constipation and Milk of Magnesia 400mg 30ml daily as needed for constipation without direction on when to take the different constipation medications. Review of RR# 4’s medication profile revealed RR# 4 was ordered Colace 100mg capsule every 12 hours as needed for constipation and Senna Plus 2 tablets daily in the am as needed for constipation without direction on when to take the different constipation medications. Review of RR# 5’s medication profile revealed RR# 5 was ordered acetaminophen 325 mg 2 tablets every 4 hours as needed for pain and Morphine concentrate 0.25ml every four hours as needed for pain without direction on when to take the different pain control medication. Review of RR# 6’s medication profile revealed RR# 6 was ordered Hydromorphone 2ml every six hours as needed for pain and Tylenol 325 mg 2 tablets every four hours as needed for pain without direction on when to take the different pain control medication. This was reviewed and validated with the Branch Director.

Observed in Record Review. In 1 of 9 active patient records reviewed, During RR# 2's patient record it was noted the organization had not ensured the comprehensive assessment was updated based on changes in the patient’s condition. Upon review of RR#2's patient record, it was noted a new wound was identified and new wound care orders were obtained. However, on review of Interdisciplinary Group (IDG)/Plan of Care update documentation and two subsequent IDG/Plan of Care updates documentation, this change was not addressed. This was reviewed and validated with the Branch Director.

Observed in Record Review. In 9 of 9 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, and RR# 6's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals and the time frames, setting, and services required to meet those goals. For example: review of RR# 2's Interdisciplinary Group (IDG)/Plan of Care update documentation revealed a new wound care order. Further review of RR# 2's IDG/Plan of Care update revealed no documentation of a goal for the new wound. In addition, review of the two subsequent IDG/Plan of Care updates documentation revealed no goal for the wound. Review of RR# 1’s IDG/Plan of Care update revealed the goals “Patient's anxiety/agitation will be at a patient/caregiver acceptable level by [24 days after the end of the certification period]”; “Facility staff will demonstrate ability to assist patient with ADLs safety by [71 days after the end of the certification]”; “Facility staff will verbalize/demonstrate appropriate and safe wound care would will be managed without infection and pain will be at patient's acceptable level goal by [71 days after the end of the certification]”. Review of HV# 1’s IDG/Plan of Care update revealed the goal “Patient/family/caregiver will have decreased fear/anxiety/depression regarding death and dying process thru [24 days after the end of the certification period]”. Review of HV# 2’s IDG/Plan of Care update revealed the goals “patient care will be provided by ccv facility nurses and CNAs competent to provide care in absence of hospice by [33 days after the start of care]”; “Patient will have DME needs met by [33 days after the start of care]”; and “Facility staff is knowledgeable and involved in hospice plan of care for continuity of patient care by [33 days after the start of care]”. Review of HV# 3’s IDG/Plan of Care update revealed the goal “Facility staff will have a plan of care established by hospice IDG team to meet all needs by [33 days after the start of the recertification period]”. Review of RR# 3’s recertification plan of care revealed the goal “Patient will have decreased anxiety as evidenced by SW observing patient status and emotions during visits”. However, this goal is not measurable. Review of RR# 3’s IDG/Plan of Care update revealed the goal “Oxygen saturation level will be obtained to determine patient’s acceptable level of oxygen therapy through [15 days after date of IDG/Plan of Care update]. However, review of RR# 3’s patient record revealed RR# 3 was not receiving oxygen therapy. Review of RR# 4’s IDG/Plan of Care update revealed the goals “patient/caregiver/facility staff will have a plan of care established by hospice IDG team to meet all needs by [87 days after the start of care]”; “[Facility] staff will verbalize understanding of dehydration/decreasing nutritional needs in the terminal patient by [87 days after the start of care]”; “Facility staff at [Facility] will verbalize/demonstrate care of skin related to bowel incontinence by [87 days after the start of care]”. Review of RR# 5’s IDG/Plan of Care update revealed the goal “Patient will have DME needs met by [68 days after the date of the IDG/Plan of Care update]”. Review of RR# 6’s start of care plan of care revealed the goal “Patient will have safety needs met through cert by [20 days after the end of the cert]”.

Observed in Record Review. In 1 of 9 active patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the plan care included all services needed for the palliation and management of the terminal illness and related conditions. For example: review of RR# 1's the Interdisciplinary Group (IDG)/Plan of Care update revealed the goal Facility staff will verbalize/demonstrate appropriate and safe wound care would be managed without infection and pain will be at patient's acceptable level by [date]. However, RR# 1’s wound had been healed approximately 43 days prior to the IDG/Plan of Care update. In addition, review of the IDG/Plan of Care update revealed the order for dermal wound cleanser to clean the wound. This was reviewed and validated with the Branch Director.

Observed in Record Review. In 3 of 13 patient records reviewed, During HV# 3, BR# 1, and BR# 2's patient records review it was noted the organization had not ensured it provided care, treatment, or services according to the patient's individualized plan of care. For example: during HV# 3’s home observation the registered nurse was observed providing wound care to HV# 3’s coccyx. The RN cleaned the wound and applied Medi honey to the coccyx and covered with a duoderm. Review of HV# 3’s patient record revealed the wound care provided during the home visit had been discontinued 21 days prior to the home observation and a new wound care order was implemented that included applying collagen powder to wound bed and apply foam dressing. Review of BR# 1's record revealed a bereavement plan of care that included a bereavement visit three months after the day of death and a phone call four months after the day of death. However, there was no documentation of the bereavement visit or phone call. Review of BR# 2’s record revealed a bereavement plan of care that included a bereavement visit four months after the day of death. However, review of BR# 2’s record revealed a phone call with no documentation why a visit was not completed according to the bereavement plan of care. This was reviewed, discussed, and validated with the Bereavement Coordinator and the Branch Director

Observed in Patient Home. In 2 of 2 Home visits conducted with vital sign equipment, During HV# 2 and HV# 3's home observation it was noted the nurse did not adhere to the contact time when cleaning equipment used during the visit. For example: during HV# 2's home observation the nurse was observed cleaning the stethoscope, pulse oximetry, thermometer, and automatic B/P cuff with alcohol wipes and placing each piece of equipment immediately into the bag with no contact time (wet time). During HV# 3's home observation the nurse was observed cleaning the stethoscope, pulse oximetry, thermometer, and automatic B/P cuff with Clorox Bleach wipes and placing each piece of equipment immediately into the bat with no contact time (wet time). This was observed, discussed, and validated with the Clinical Team Lead. Observed in Patient Home. In 2 of 2 Home visits conducted with nurse bag, During HV# 2 and HV# 3's home observation it was noted the organization had not ensured staff followed the organization's policies Hand Hygiene – IC15 and Bag technique – IC.60, that included washing hand for 20 seconds and performing hand hygiene prior to returning cleaned equipment into the bag. For example: during HV# 2's home observation the registered nurse (RN) was observed washing his/her hands multiple times for less than 8 seconds. In addition, during HV# 2’s home observation the RN was observed cleaning the vital sign equipment and placing the items into the nurse bag immediately without performing hand hygiene prior to placing the vs equipment into the nurse bag. In addition, during HV# 2’s home observation the RN was observed applying cream to HV# 2’s buttock and then with the same glove placed the gloved hand on HV# 2’s leg to turn the patient and place the foley bag back in place. During HV# 3's home observation the RN was observed cleaning the vital sign equipment with bleach wipes and placed the equipment immediately into the nurse bag without performing hand hygiene prior to placing the equipment into the bag. This was observed, discussed, and validated with the Clinical Team Lead.

Observed in Record Review. In 3 of 9 active patient records reviewed with hospice aide services, During RR# 3, RR# 4, and RR# 6's patient records review it was noted the organization had not ensured the hospice aide provided services as ordered. For example: review of RR# 3's hospice aide care plan revealed the task of monthly weight during the first week of the month. Review of RR# 3's hospice aide visit notes revealed no documentation of a weight for the current month. Review of RR# 4's hospice aide care plan revealed the task of monthly weight during the first week of the month. Review of RR# 4's hospice aide visit notes revealed no documentation of a weight for the current month or previous month. Review of RR# 6's hospice aide care plan revealed the task of monthly weight during the first week of the month. Review of RR# 6's hospice aide visit notes revealed no documentation of a weight for the current month. This was reviewed and validated with the Branch Director.

Observed in Record Review. The Governing Body/Leadership did not ensure the organization policies and procedures that guide and support patient care, treatment, or services were implemented as evidenced by a pattern of staff failing to follow policies as identified by not meeting the requirements of Initial and Comprehensive Assessment of the Patient (§418.54) and Clinical Records (§418.104) during patient record review and staff interviews.

Observed in Record Review. In 3 of 9 active patient records reviewed, During RR# 5, HV# 1, and HV# 3's patient records it was noted the organization had not ensured it maintained accurate patient records. For example: review of RR# 5's patient record revealed a recertification IDG/Plan of Care update with documentation of added goals dated 16 and 21 days after the date of the recertification IDG/Plan of Care update and documentation of resolved goals dated 69 days after the IDG/Plan of Care update. In addition, the subsequent IDG/Plan of Care update had added goals and resolved goals dated after the IDG/Plan of Care Update. Review of HV# 3’s patient record revealed a recertification IDG/Plan of Care update with documentation of added goals dated 75 days after the recertification IDG/Plan of Care update and documentation of resolved goals dated 81 days after the IDG/Plan of Care update. Further review of HV# 3’s patient record had conflicting documentation regarding wound care. Review of the wound documentation revealed the wound had been inactivated and review of the IDG/Plan of Care update revealed it was still active and the RN was observed completing wound care at the home visit six days after the wound had been inactivated. Review of HV# 1’s patient record revealed HV# 1 had oxygen ordered at 2 lpm as needed. Review of the recertification comprehensive assessment revealed documentation HV#1 did not have oxygen in the home. During the home visit this surveyor observed the oxygen concentrator in HV# 1’s room. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 2 of 9 active patient records reviewed, During HV# 3 and RR# 5's patient records review it was noted the organization had not ensured it maintained the integrity of health information. For example: review of RR# 5's patient record revealed completed and signed recertification IDG/Plan of Care updates with goals added after the recertification IDG/Plan of Care update was signed and completed. Review of the recertification IDG/Plan of Care update revealed documentation of goals added 16 days and 21 days after the IDG/Plan of Care update and documentation of goals that were resolved 69 days after the IDG/Plan of Care update. Further of RR# 5’s patient record revealed the subsequent IDG/Plan of Care update with documentation of goals added two and seven days after the IDG/Plan of Care update and documentation of goals that were resolved 55 days after the IDG/Plan of Care update. Review of HV# 3’s patient record revealed completed and signed recertification IDG/Plan of Care updates with goals added after the recertification IDG/Plan of Care update was signed and completed. Review of HV# 3’s recertification IDG/Plan of Care update revealed documentation of goals added 75 days after the recertification IDG/Plan of Care update. Further review of the recertification IDG/Plan of Care revealed documentation of goals resolved 81 days after the recertification IDG/Plan of Care update. This was reviewed, discussed, and validated with the Administrator and Branch Directors.

Based on record review and interview, the agency failed to identify the physical needs related to the patients terminal diagnosis in the comprehensive assessment in 1 of 2 clinical records reviewed with a fall. (Patient #1) The findings include: --- Review of an agency policy dated 10/20/2022, titled ";Plan of Care Process" stated, ";... The comprehensive assessment will take into consideration the following factors ... Complications and risk factors that affect care planning ... Functional capabilities and status, including the patients ability to understand and participate in his or her own care ... The environmental component for identification of safety issues and/or health hazards ...." Clinical record review on 3/1/2023, for Patient #1, evidenced an agency document titled ";Occurrence Report" dated 1/29/2023, which indicated the patient had a fall on 1/29/2023. Review evidenced agency documents titled ";Visit Note Report" dated 2/8/2023 and 2/20/2023, and identified as registered nurse comprehensive assessment visits. Review evidenced the registered nurse indicated on 2/8/2023 the patient had no recent falls and failed to evidence the comprehensive assessment included the patients recent fall on 1/29/2023. Review failed to evidence the comprehensive assessment included an assessment of the integumentary system (pertaining to the skin, hair, nails) on 2/20/2023. During an interview on 3/2/2023, at 12:20 PM, the family care coordinator indicated the comprehensive assessment should include a skin check for skin integrity. At 1:03 PM, the family care coordinator indicated the comprehensive assessment should have included the assessment of the patients fall on 1/29/2023.

Based on record review and interview, the hospice agency failed to ensure the plan of care specified the hospice care and services necessary to meet the specific needs identified in the comprehensive assessment as related to the terminal illness in 6 of 6 clinical records reviewed receiving care in an assisted living facility (ALF). (Patient #1, #3, #4, #5, #6, #7) Findings include: --- 10. Clinical record review on 3/1/2023, for Patient #1, evidenced an agency document titled ";Visit Note Report" dated 2/8/2023 and identified as a registered nurse comprehensive assessment visit. Review indicated the patients primary diagnosis was senile degeneration of the brain and indicated the patient required assistance for transfers, bathing, dressing, grooming, and toileting. Review indicated the patient lived at an ALF. Review of an agency document titled ";Plan of Care Update" dated 2/27/2023, indicated the hospice aide was to provide assistance 2 times a week for personal care, hygiene, and ADLs. Review indicated the patient was dependent on staff for activities of daily living and facility staff was to anticipate the patients needs. Review failed to evidence who was to provide assistance with transfers, personal care, and hygiene to meet the personal care needs related to the patients terminal illness in the absence of the hospice agency. During an interview on 3/2/2023, at 12:38 PM, the family care coordinator indicated that if the agency indicated the assisted living facility was to provide assistance with toileting and providing medication, then the agency should specify on the plan of care the ALF should do the transfers and personal care. During an interview on 3/2/2023, at 12:38 PM, Administrative Staff #3 indicated the new update for the electronic health record will allow the agency to be more specific on the plan of care related to what care the facility would be responsible for. 1. Record review of an agency policy dated 10/20/2022, titled, ";Plan of Care Process," stated, ";... The POC [plan of care] must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions ...." 2. Clinical record review on 02/28/2023, for patient #3, start of care 12/03/2022, evidenced an agency document dated 02/10/2023, titled, ";Visit Note Report," identified as a comprehensive assessment, indicated the patient lived in assisted living facility 2, had falls within 3 months, was confused, was incontinent, and required assistance with bathing, dressing, grooming, toileting, and used a sit to stand hoyer (patient lift) for assistance. Review evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 12/03/2022-03/02/2023, indicated the primary hospice diagnosis was atherosclerotic heart disease. Review indicated the hospice agency was to provide the patient with skilled nursing services 2 times a week and aide services 2 times per week. Review indicated the patients goals included, but not limited to, safety needs would be met to minimize the risk of falls and the patient would receive assistance with personal care, hygiene, and ADLs (activities of daily living). Review failed to evidence the plan of care included the care that would be provided to meet the patients safety and personal care needs related to the patients terminal illness in the absence of the hospice agency. 3. Clinical record review on 02/28/2023, for patient #4, start of care 11/21/2022, evidenced an agency document dated 02/14/2023, titled, ";Visit Note Report," identified as a comprehensive assessment, indicated the patient resided in assisted living facility 3, had frequent falls, was forgetful, and required assistance with bathing, dressing, grooming, and toileting. Review evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 11/21/2022-02/18/2023, indicated the primary hospice diagnosis was cerebral infarction (stroke). Review indicated the hospice agency was to provide the patient with skilled nursing services 2 times a week and aide services 3 times per week. Review indicated the patients goals included, but not limited, the patient would receive assistance with personal care, hygiene, and ADLs. Review failed to evidence the plan of care included the care that would be provided to meet the patients personal care needs related to the terminal diagnosis in the absence of the hospice agency. 4. Clinical record review on 03/01/2023, for patient #5, start of care 11/18/2022, evidenced an agency document dated 02/21/2023, titled, ";Visit Note Report," identified as a comprehensive assessment, indicated the patients hospice diagnosis was cerebral vascular accident (stroke), lived in assisted living facility 3, was forgetful, had visual impairment, was incontinent, and required assistance with bathing, dressing, grooming and toileting. Review evidenced an agency document titled, ";Plan of Care Update," for certification period 01/17//2023-03/17/2023, indicated the hospice agency was to provide the patient with skilled nursing services 2 times per week and aide services 2 times per week. Review indicated the patients goals included, but not limited to , safety needs would be met, and the patient would receive assistance with personal care, hygiene, and other ADLs. Review failed to evidence the plan of care included the care that would be provided to meet the patients safety and personal care needs related to the patients terminal illness in the absence of the hospice agency. 5. Clinical record review on 02/28/2023, for patient #6, start of care 09/22/2022, evidenced an agency document dated 02/14/2023, titled, ";Visit Note Report," identified as a comprehensive assessment, indicated the patients hospice diagnosis was senile degeneration of the brain (mental deterioration) and lived in assisted living facility 3. Review indicated the patient was confused, incontinent, and required assistance with bathing, dressing, grooming, and toileting. Review evidenced an agency document titled, ";Plan of Care Update," for certification period 12/21/2022-03/20/2023, indicated the hospice agency was to provide the patient with skilled nursing services 2 times per week and aide services 3 times per week. Review indicated the patients goals included, but not limited to, patient will have safety needs met and the patient will receive assistance with personal care, hygiene, and other ADLs. Review failed to evidence the plan of care included the care that would be provided to meet the patients safety and personal care needs related to the patients terminal illness in the absence of the hospice agency. 6. Clinical record review on 02/28/2023, for patient #7, start of care 01/18/2023, evidenced an agency document dated 02/26/2023, titled, ";Visit Note Report," identified as a comprehensive assessment, indicated the patient lived in assisted living facility #4, had a hospice diagnosis of hypertensive heart and chronic kidney disease, was forgetful, and required assistance with bathing, dressing, grooming and toileting. Review evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 01/18/2023-04/17/2023, indicated the hospice agency was to provide the patient with skilled nursing services 2 times per week and aide services 2 times per week. Review indicated the patients goals included, but not limited to, safety needs with fall precautions initiated to minimize the risk of falls, and the patient would receive assistance with personal care and hygiene and ADLs. Review failed to evidence the plan of care included the care that would be provided to meet the patients safety and personal care needs related to the patients terminal illness in the absence of the hospice agency. 7. During an interview on 03/01/2023, at 3:49 PM, the family care coordinator indicated it was presumed the assisted living facility provided care and only assisted facility 3s care was a la carte, the patient/family would choose the care provided by the facility. 8. During an interview on 03/02/2023, at 12:13 PM, the administrator indicated the agency was working to do a plan of care update that would document the care provided in absence of the hospice. 9. During an interview on 03/02/2023, at 1:10 PM, the administrator indicated the delineation of care was outlined in the contract but was not on the plan of care. The administrator indicated assisted living facility #2, and #3 signed the delineation of care contract but assisted living #4 refused to sign.

Based on record review and interview, the interdisciplinary group (IDG) failed to supervise the patient care and ensure the IDG worked together to provide services offered by the hospice to meet the personal and safety needs of the patients in 1 of 2 clinical records reviewed with falls. (Patient #1) The findings include: --- Review of an agency policy dated 10/1/2021, titled ";Interdisciplinary Group Roles [IDG] and Responsibilities" stated, ";... The IDG/IDT [interdisciplinary team], in its entirety, will supervise the care and services including: ... Scope and frequency of all necessary services ... The IDG/IDT will ... note the patients progress toward outcomes and goals specified in the POC [plan of care]. ... Informal verbal and written communication demonstrating coordination of care among all staff members and others providing care is also documented in the medical record...." Clinical record review on 3/1/2023, for Patient #1, evidenced an agency document titled ";Plan of Care Update" dated 1/22/2023. Review indicated the goals included, but were not limited to, fall precautions would be initiated as needs arise to minimize the risk of falls. Review indicated the patient had a fall on 1/29/2023, 2/22/2023, and 2/26/2023. Review failed to evidence any new intervention was initiated since the 1/22/2023, with the implementation of a floor mat. Review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 2/21/2023, failed to evidence the IDG discussed the patients falls and progress to goal related to falls. Review failed to evidence the IDG implemented any additional interventions related to the patients falls. Review of an agency document titled ";Hospice Certification and Plan of Care" for certification period 12/9/2022 – 3/8/2023, indicated the agency was to provide skilled nurse visits 2 times a week and 3 visits as needed (PRN) for symptom management and indicated the agency was to provide hospice aide visits 2 times a week. Review indicated the nurse provided 3 visits during the week of 1/29/2023, due to a (PRN) visit provided on 1/29/2023, due to a fall and the hospice aide provided 1 visit during the week of 2/5/2023, due to a missed visit on 2/9/2023. Review of the IDG notes dated 2/5/2023, indicated the agency did not have any unplanned skilled nurse visits. Review of the IDG notes dated 2/21/2023, indicated the agency did not have any missed hospice aide visits. Review failed to evidence the IDG supervised the frequency of the services. During an interview on 3/2/2023, at 1:01 PM, the administrator indicated the registered nurse should have reviewed the IDG notes prior to the IDG meeting to ensure the accuracy of the information. The administrator indicated each discipline prepared their notes for the IDG prior to the meeting and the IDG reviewed and discussed any new information in addition to each disciplines IDG note. The administrator indicated any new interventions or concerns discussed in the IDG meeting should be documented.

Based on record review and interview the hospice agency failed to provide hospice care and services as directed by the plan of care in 3 of 6 active clinical records reviewed. (Patient #1, #2, #3) Findings include: --- 4. Clinical record review on 3/1/2023, for Patient #1, evidenced an agency document titled ";Plan of Care Update" dated 1/22/2023. Review indicated the goals included, but were not limited to, fall precautions would be initiated as needs arise to minimize the risk of falls. Review indicated the patient had a fall on 1/29/2023, 2/22/2023, and 2/26/2023. Review failed to evidence any new intervention was initiated since the 1/22/2023 with the implementation of a floor mat. During an interview on 3/2/2023, at 12:24 PM, the administrator indicated some possible interventions that could have been implemented after a patients fall were a referral for therapy depending on the patients diagnosis and a medication review. During an interview on 3/2/2023, at 12:24 PM, the family care coordinator indicated if the agency could not prevent the patient from falling, the agency should find interventions to keep the patient safe despite the falls. The family care coordinator indicated there had not been any new interventions initiated since the floor mat on 1/22/2023. 1. Review of an agency policy dated 10/20/2022, titled, ";Plan of Care Process," stated, ";... All hospice care and services furnished to patients and their families will follow an individualized written POC [plan of care] established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with ... the patient or representative, and the primary caregiver, ... and in accordance with the patients needs ...." 2. Clinical record review on 02/28/2023, for patient #2, start of care 01/17/2023, evidenced an agency document dated 02/02/2023, titled, ";Visit Note Report," indicated the patient lived with a family member, the patient is oriented x2, and the patient is alone for about 30 minutes when the family member leaves for work and when the paid caregiver arrived. Review indicated the patient had Life Alert. Review of an agency document titled, ";Hospice Certification and Plan of Care," for certification period 01/17/2023-04/16/2023, indicated the patient had a diagnosis of senile degeneration of brain. Review of the plan of care indicated the hospice nurse was to instruct on applicable safety measures. Review failed to evidence the hospice provided patient/caregiver safety education to include the assessment of patients ability to use Life Alert. During an interview on 03/01/2023, at 4:00 PM, the administrator and family care coordinator indicated a patient that had Life Alert should be on the plan of care and safety education to include the assessment of patients ability to use the Life Alert. 3. Clinical record review on 02/28/2023, for patient #3, start of care 12/03/2022, evidenced an agency document dated, 02/24/2023, titled, ";Visit Note Report," which indicated the patient was alert and oriented to self, confused at times, lived in assisted living facility B, and was dependent for 5/6 activities of daily living. Review of an agency document titled, ";Hospice Certification and Plan of Care," for certification period 12/03/2022-03/02/2023, indicated the hospice nurse to assess patient safety, instruct safety measures as applicable, and fall precautions in place. During an interview on 03/02/2023, at 11:16 AM, the interim director of nursing of assisted living facility B indicated the patient wore a call light pendant around the neck. Review failed to evidence the hospice agency provided patient/caregiver safety education to include the assessment of patients ability to use the call pendant. During an interview on 03/02/2023, at 1:30 PM, the family care coordinator indicated the assessment of a patients ability to use the call pendant should be included on a patients plan of care with confusion.

Based on record review and interview, the hospice agency failed to develop an individualized written plan of care for each patient in 2 of 2 clinical records reviewed with falls. (Patient #1, #4) Findings include: --- 3. Clinical record review on 3/1/2023, for Patient #1, evidenced an agency document titled ";Hospice Certification and Plan of Care" for certification period 12/9/2022-3/8/2023, which indicated the patients primary diagnosis was senile degeneration of the brain (also known as dementia and characterized by a decrease in cognitive abilities and a mental decline). Review indicated the nurse was to instruct on diabetes (a chronic disease that affects the bodys ability to control blood sugar) management, bowel incontinence care, and skin breakdown prevention. Review failed to evidence who the nurse was to instruct given the patients degermation of the brain diagnosis. During an interview on 3/2/2023, at 12:22 PM, the administrator indicated the nurse was to instruct the staff at the assisted living facility. During an interview on 3/2/2023, at 12:22 PM, Administrative Staff #3 indicated the new update to the electronic health record would show who is to be educated. 1. Record review of a policy dated 10/20/2022, titled, ";Plan of Care Process," stated, ";... All hospice care and services furnished to patients and their families will follow an individualized written POC [plan of care] by the Hospice Interdisciplinary Group/Team (IDG/IDT) ... in accordance with the patients needs ... Information will be gathered from the initial assessment and be used by the Hospice to develop the Initial Plan of Care (IPOC)/Physicians Orders and to provide care and services to treat a patients and patients familys immediate care and support needs ...." 2. Clinical record review on 02/28/2023, for patient #4, start of care 11/21/2022, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 11/21/2022-02/18/2023, indicated safety measures included fall precautions. Review of an agency document dated 02/16/2023, titled, ";Visit Note Report," indicated the patient was using a wheelchair at all times for safety with transfers due to 3 falls in January. Review of an agency document dated 02/15/2023, titled, ";Plan of Care Update," indicated the patient and facility staff will verbalize knowledge of potential for bleeding/hemorrhage/bruising and preventative measures, caution with shaving (Hospice Aide Plan of Care). Review of an agency document titled, ";Aide Care Plan Report," for start of episode 02/19/2023 indicated standard precautions. Review failed to evidence the home health aide care plan included bleeding and fall precautions as indicated on the plan of care. During an interview on 03/01/2023, at 4:00 PM, the administrator indicated bleeding and fall risk should be included on the aide plan of care and that standard precautions referred to personal protection equipment.

Deficiency corrected 02/01/2023. --- Deficiency corrected 02/01/2023.

Based on record review and interview, the hospice agency failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings in 1 of 6 clinical records reviewed of patients living in an assisted living facility. (Patient #3) Findings include: --- Record review of an agency policy dated 10/02/2021, titled, ";Coordination of Care," stated, ";... The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and service in all settings ... The Hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care, achieving unduplicated services, and facilitating effective coordination of patient services ...." Clinical record review on 02/28/2023, for patient #3, start of care 12/03/2023, evidenced an agency document dated 02/07/2023, titled, ";Visit Note Report Aide Hospice Visit," which indicated the patient appeared to have a cold, was coughing up mucus, coughing a lot, and the patients shirt and blanket had to be changed because the patient had coughed up mucus. Review failed to evidence the coordination of care between the home health aide and the skilled nurse regarding the patients symptoms. During an interview on 03/01/2023, at 4:02 PM, the administrator indicated the home health aide should have notified the Registered Nurse Coordinator when there was a change in patient condition.

Based on record review and interview, the hospice agency failed to have performance improvement activities track adverse patient events, analyze their causes, and implement preventive actions in 1 of 1 clinical record reviewed with injury (Patient #2) and in 1 of 2 clinical records reviewed with falls (Patient #1). Findings include: --- 3. Clinical record review on 3/1/2023, for Patient #1, evidenced an agency document titled ";Visit Note Report" dated 2/22/2023, which indicated the assisted living facility (ALF) reported to the hospice nurse the patient had a fall earlier in the morning. Review failed to evidence the agency completed an incident report. During an interview on 3/2/2023, at 12:13 PM, the administrator indicated there was not an incident report completed. 1. Record review evidenced an agency policy dated 10/01/2021, titled, ";Occurrence/Incident Reporting," stated, ";... The Hospice will document and report all occurrences/incidents (accidents, injuries, safety hazards, employee unprofessional and misconduct) that deviate from routine Hospice operations and may result in injury or potential harm to a patient and/or caregiver or Hospice staff ... An Occurrence/Incident Report will be completed on all occurrences or incidents, as defined in policy, by the staff member involved or the first person to become aware of the incident. The report will be submitted to the immediate supervisor ... The Occurrence/Incident Report will be forwarded to Management and the QAPI [quality assessment performance improvement} Committee for the purposes of reviewing, analyzing, aggregating, trending, and making performance improvement recommendations ...." 2. Clinical record review on 02/28/2023, for patient #2, start of care 01/17/2023, evidenced an agency document dated 02/23/2023, titled, ";Visit Note Report," which indicated the patient got weak trying to get inside the house and patient hit shin on the step when daughter was trying to help her. The Visit Note indicated the patient had a skin tear to left lower leg, and daughter called fire department to assist. Review failed to evidence an occurrence/incident report was completed. Review on 03/02/2023, evidenced an agency document dated 03/02/2023, titled, ";Client Coordination Note Report," which indicated the document was an addendum to 02/23/2023 visit. The document indicated the patient was too weak to climb the stairs into the house and the patient got a skin tear. During an interview on 03/01/2023, at 3:50PM, the clinical manager indicated she would need to check into the incident. During an interview on 03/02/2023, at 1:20 PM, the clinical manager indicated the nurse did an addendum to the 02/23/2023 nurse visit note. The clinical manager indicated a fall did not occur, so an occurrence report was not completed. When queried about occurrence/incident policy indicating an occurrence/incident report should be completed when an injury occurs the clinical manager indicated she would need to clarify with the nurse about the addendum to the note regarding when the injury occurred. Upon exit on 03/02/2023, no further information was provided.

Based on record review and interview, the hospice agency failed to ensure the patients received effective pain management and symptom control from the hospice for conditions related to the terminal illness in 3 of 5 clinical records reviewed. (#2, #4, #5) --- 1. Record review evidenced an agency policy dated 10/20/2022, titled, ";Pain and Symptom Management," which stated, ";... The Hospice will respect the patients right to receive effective pain management and symptom control for conditions related to the terminal illness ...." 2. Record review evidenced an agency policy dated 10/01/2021, titled, ";Patients Rights and Responsibilities," which stated, ";... the patient has the right: ... to receive effective pain management and symptom control from the Hospice for conditions related to the terminal illness ...." 3. Clinical record review on 01/03/2023, for patient #2, start of care 09/22/2022, evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, which indicated the primary diagnosis of senile degeneration of brain (mental deterioration known as dementia) and had a secondary diagnosis of anxiety. Review indicated the patient's medications included, but were not limited to, Ativan (a medication used to treat anxiety) twice a day. Review evidenced an agency document dated 11/03/2022, titled, ";Visit Note Report SN [skilled nurse] Hospice Subsequent Visit Report," which indicated the patient did not have scheduled Ativan tablets. The visit note indicated the ALF (assisted living facility) nurse did not know that the patient was out of Ativan and indicated the hospice nurse ordered Ativan tablets for delivery on 11/04/2022. Review evidenced the patient was assessed to be forgetful and confused. Review failed to evidence the hospice provided symptom control related to the terminal diagnosis by ensuring the administration of the Ativan. Review of an agency document dated 11/17/2022, titled, ";Visit Note Report SN Hospice Subsequent Visit," indicated the hospice nurse counted the Ativan tablets and stated, "count was the same as last count done by RNCM [registered nurse case manager]," which was completed on 11/15/2022. Review indicated the patient had not received scheduled Ativan 11/15/2022-11/17/2022. Review indicated ALF #2 nurse informed the hospice nurse the patient had been having "more behaviors." Review indicated the patient was assessed to be confused, forgetful, and anxious. Review failed to evidence the hospice provided symptom control related to the terminal diagnosis by ensuring the administration of Ativan. During an interview on 01/04/2023, at 12:40 PM, ALF #2 nurse indicated the patient received medication reminders from the residential aides and the residential aide got medications out of patients cabinet and handed to patient to take medication. The ALF #2 nurse indicated hospice fills the patients medication box. During an interview on 01/05/2023, at 4:04 PM, the hospice family care coordinator indicated hospice could set up medications for patients at assisted living facilities and it should be included on the plan of care. During an interview on 01/05/2023, at 4:20 PM, the hospice family care coordinator indicated ALF #2 nurse did not put medications in the patients medication box, and ALF #2 nurse forgot to notify the hospice agency to order the Ativan tablets. 4. Clinical record review on 01/04/2023, for patient #4, start of care 09/17/2022, evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 09/17/2022-10/09/2022, which indicated the hospice diagnosis was senile degeneration of brain. Review indicated the patient's medications included, but were not limited to Zofran (a medication used to treat nausea and vomiting) as needed and Tramadol (a medication used to treat pain) twice a day. Review evidenced an agency document dated 11/06/2022, titled, ";RN [registered nurse] Hospice PRN [as needed] Visit," which indicated ALF #2 staff informed hospice the patient had two episodes of vomiting. The visit note indicated the aides did not have access to comfort medications. The visit note indicated ALF #2 aide attempted to call ALF #2 nurse at home to gain access to Zofran for the patient. The visit note indicated the hospice nurse would reorder the Zofran. Review failed to evidence the hospice had methods in place to ensure the management of symptoms related to the terminal diagnosis. Review evidenced an agency document dated 12/29/2022, titled, ";Visit Note Report RN Hospice Subsequent Visit," which indicated the patient had not received scheduled Tramadol for 2 weeks. Review indicated the hospice nurse on 12/21/2022, assessed the patient to have increased agitation. Review failed to evidence the hospice managed symptoms related to the terminal diagnosis. During an interview on 01/06/2023, at 2:40 PM, the family care coordinator indicated she was aware the tramadol count remained the same. 5. Clinical record review for patient #5 on 01/03/2023, start of care 12/22/2022, evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 12/22/2022-03/21/2023, which indicated the patient's diagnosis was interstitial pulmonary disease (scarring of the lungs). Review indicated the patient's medications included, but were not limited to, Morphine (a narcotic pain medication) and Ipratropium/Albuterol (a medication used to treat shortness of breath) via nebulizer (an inhaled medication delivered through mist) as needed. Review evidenced an agency document dated 12/30/2022, titled, ";Visit Note Report SN Hospice PRN Visit," which indicated the patient was confused, lethargic and had labored breathing. The visit note indicated the hospice triage nurse instructed ALF #1 aide to administer morphine and a nebulizer treatment; however, ALF #1 aide was unable to administer medication due to the facility policy that the patient needed to self-administer. Hospice nurse visit was made to administer nebulizer and morphine. The visit note indicated the patient was able to self-administer medication prior to the change in condition. Review indicated the ALF executive director had concerns on how the patient was to take medications on his own due to the new change in condition. Hospice failed to manage the patient's symptoms related to terminal diagnosis by a delay in medication administration and failing to have methods in place for when the patient's ability to self-administer medications was no longer possible. During an interview on 01/06/2023, at 3:25 PM, the administrator indicated hospice should coordinate care with ALF #1 and the family to instruct on medication administration if the patient was unable to take medications independently.

Based on record review and interview, the hospice agency failed to ensure: the physical and safety needs related to the patients terminal diagnosis were identified and included in the comprehensive assessment (See tag L524) and the comprehensive assessment was updated to consider the changes that have taken place since the initial assessment (See tag L0533). --- The cumulative effect of these systemic problems has resulted in the hospice agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 418.54 Initial and Comprehensive Assessment of the Patient.

Based on record review and interview, the agency failed to identify the physical needs related to the patients terminal diagnosis in the comprehensive assessment in 2 of 5 clinical records reviewed. (#1, 2) The findings include: --- Clinical record review for patient #2, on 01/03/2023, start of care 09/22/2022, evidenced an agency document dated 09/22/2022, titled, ";Visit Note Report RN [registered nurse] Hospice Start of Care," identified as the start of care comprehensive assessment. Review indicated the patient resided in an assisted living facility, was alert, confused, had hallucinations, sundowners, was combative at times, seemed anxious and tense, spoke nonsensically, was alert to self only, paced in the room, had panic attacks, and was ambulatory without assist. Review indicated the patients primary diagnosis was senile degeneration of the brain (mental deterioration identified as dementia). The comprehensive assessment indicated no abnormal environmental/safety issues identified. Review failed to evidence the comprehensive assessment included the patients safety needs related to the terminal illness. During an interview on 01/06/2023, at 3:30 PM, the hospice family care coordinator indicated the comprehensive assessment should be done at each visit to identify patient safety needs. Review of an agency policy dated 10/20/2022, titled ";Plan of Care Process" stated, ";... The comprehensive assessment will take into consideration the following factors ... Complications and risk factors that affect care planning ... Functional capabilities and status, including the patients ability to understand and participate in his or her own care ... The environmental component for identification of safety issues and/or health hazards ...." Clinical record review on 1/3/2023, for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Visit Note Report" dated 11/30/2022 and identified as the start of care assessment. Review indicated the patients primary hospice diagnosis was senile degeneration of the brain (also known as dementia and characterized by a decrease in cognitive abilities and a mental decline) and indicated the patient was minimally responsive. Review indicated the patient lived in an assisted living facility (ALF), was wheelchair dependent, dependent for 5 of 6 activities of daily living (ADLs), had a history of falls with injury, and was a fall risk. During an interview on 1/4/2023, at 3:29 PM, Registered Nurse (RN) #1 indicated the patient wore a call pendant necklace to call for assistance provided by the ALF prior to hospice admission. Review failed to evidence the comprehensive assessment included the patients ability to use the call pendant. During an interview on 1/6/2023, at 1:25 PM, the administrator indicated the agency needed to assess the appropriateness of the call pendant given to the patient given the patients mental capacity.

Based on record review and interview the hospice agency failed to ensure the interdisciplinary group updated the comprehensive assessment to consider changes that have taken place since the initial assessment in 2 of 5 clinical records reviewed. (#2,#3) The findings include: --- 1. Record review of an undated agency policy received on 01/05/2023, titled, ";Patient Assessment," stated, ";... The update to the comprehensive assessment will be completed as frequently as the condition of the patient requires ... updates to the comprehensive health assessment will be accomplished by the IDG [interdisciplinary group] ... to include ... changes that have taken place since the initial assessment ... reassessing a patients needs when there is a significant health status change in the patients condition ...." 2. Clinical record review for patient #2, on 01/03/2023, start of care 09/22/2022, evidenced an agency document dated 09/27/2022, titled, ";Visit Note Report: SN [skilled nurse] Hospice Subsequent Visit," identified as the comprehensive assessment. This document indicated the patient walked to the restaurant next door on Saturday without staff notification. The comprehensive assessment failed to evidence updated goals or interventions related to the patients elopement risk after becoming aware of the elopement on 09/27/2022. During an interview on 01/06/2023, at 3:30 PM, the hospice family care coordinator indicated the comprehensive assessment should be updated at each patient visit to identify patient safety needs. 3. Clinical record review for patient #3 on 01/04/2023, start of care 11/10/2022, evidenced an agency document dated 11/11/2022, titled, "Visit Note Report RN [registered nurse] Hospice Subsequent Visit," identified as the comprehensive assessment. This document indicated the director of nursing of the assisted living facility requested medications to be discontinued due to patient not swallowing. The comprehensive assessment failed to evidence updated goals, interventions, or assessment related to the patient's difficulty swallowing after becoming aware of the concern on 11/11/2022. During an interview on 01/06/2023, at 3:00 PM, the hospice administrator and family care coordinator indicated they were unsure of the outcome of the patient's difficulty swallowing, and upon exit from the facility no new information was provided. During an interview on 01/06/2023, at 3:30 PM, the hospice family care coordinator indicated the comprehensive assessment should be updated at each patient visit.

Based on record review and interview, the hospice agency failed to ensure: the plan of care specified the hospice care and services necessary to meet the specific patient needs identified in the comprehensive assessment as related to the terminal illness (See tag L0538); the interdisciplinary group (IDG) worked together to provide services offered by the hospice to meet the personal care and safety needs of the patients (See tag L0539); hospice care and services were provided as directed by the plan of care (See tag L0543); the patient and primary caregiver received education and training appropriate for their responsibilities for the care and services identified in the plan of care (See tag L0544); an individualized, patient specific plan of care was developed that reflected patient goals and interventions based on the problems identified in the initial and updated comprehensive assessment (See tag L0545); the plan of care was revised to include information from the updated comprehensive assessment (See tag L0553); care was coordinated between all disciplines providing care (See tag L0557); and care was coordinated with the assisted living facility (See tag L0558). --- 2. Clinical record review for patient #2 on 01/03/2023, start of care 09/22/2022, evidenced an agency document dated 09/22/2022, titled, ";Visit Note Report, RN [registered nurse] Hospice Start of Care," which indicated patient resided in an assisted living facility, is alert, confused, and had hallucinations, patient had sundowners (sic) and was combative at times, patient did seem anxious and tense, patient spoke nonsensically and was alert to self only, patient paced in the room and had panic attacks, patient was ambulatory without assist, and patient was started on buspirone (anxiety medication) and lorazepam (anxiety medication) for anxiety on 09/22/2022. This comprehensive assessment indicated under assessment no abnormal environmental/safety issues identified. Review of an agency document dated 09/27/2022, titled, ";Visit Note Report: SN [skilled nurse] Hospice Subsequent Visit," which indicated the patient walked to the restaurant next door on Saturday 09/24/2022, without staff notification. This comprehensive assessment subsection ";Interventions Provided," and ";Goals Met," failed to evidence goals or interventions related to safety. Review of an agency document dated 10/11/2022, titled, ";Visit Note Report: RN Hospice Subsequent Visit," which indicated patient was walking the halls upon the nurses arrival, patient was pleasantly confused, and the patient was able to ambulate independently. Review evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, which stated, ";... Diagnoses: Senile Degeneration of Brain, Not Elsewhere Classified, Unspecified Dementia With Behavioral Disturbance, and Other Mixed Anxiety Disorders ... Safety Measures: Adequate Lighting, Clean Technique, Fall Precautions, Standard Precautions ...." The plan of care subsection titled, ";Orders of Disciplines and Treatments," failed to evidence hospice nurse orders for assessment, monitoring or instruction related to safety. The plan of care subsection titled, ";Goals," failed to evidence safety measure goals related to the terminal illness. The plan of care failed to include any active interventions or goals to ensure patient safety related to the terminal illness. Review of an agency document dated 09/28/2022, titled, ";Hospice POC [plan of care] Report," which indicated medical social worker to assess the safety of the patients environment, and to have safety needs met. This plan of care failed to evidence patient specific needs identified in the comprehensive assessment related to the terminal illness. Review on 01/03/2022, evidenced an agency document dated 09/28/2022, titled, ";Visit Note Report, Visit Type: MSW [social worker] Hospice PRN [as needed] Visit," which indicated the patient had memory deficit memory loss, impaired decision-making, inability to appropriately stop activities, and jeopardized safety through actions; the patient is alert oriented to person, confused, lethargic and disoriented. This visit note indicated the visit was made to discuss safety concerns for the patient as she paced and ambulated outside of her assisted living facility, usually onto patio but potential is there for elopement, the social worker indicated the director at the assisted living facility indicated patient had history of sundowners (sic) with anxiety, agitation and paranoia and the director requested medication intervention. The social worker also discussed safety protocols such as a tracking device for patient, so the family knows if the patient leaves the building. The social worker contacted a family member that saw the same behavior and she was open to medication intervention and also a tracking type device. The social worker indicated the family member would discuss further with the director of the assisted living facility. The social worker visits were to continue monthly. The social worker indicated interventions provided were instructing the caregiver regarding a tracking device. The goals indicated by the social worker were for the patient to have the safety needs met. Review of an agency document dated 10/17/2022, titled, ";Visit Note Report, Visit Type MSW Hospice Subsequent Visit," which indicated the patient feels others are trying to control her and she is anxious and doesnt know what to do or where to go. Patient does multiple circles around building every hour but struggled with a goal for her time; the patient has shown no recent desire to walk off facility grounds and has generally been staying indoors due to change in weather. Interventions provided indicated assess the safety of the patient environment by reinforcing instructions given by nurse regarding safety, staying on facility grounds and goals to have safety needs met. This visit note failed to follow up with family and facility regarding tracking device and/or medication interventions discussed at 09/28/2022 visit. This visit note failed to note education with assisted living facility staff regarding safety measures to prevent elopement. During an interview on 01/05/2023, at 3:50 PM, the family care coordinator indicated there was no follow up with family or assisted living staff regarding tracking device for the patient. The family care coordinator indicated there is a sign on the assisted living facility door that the doors lock at 8:00 PM and there are more staff at the facility during the day to watch the patient. Review of an untitled agency document, identified by the family care coordinator as a plan of care order update, dated 12/06/2022, indicated goals will be to have patient safety needs met as evidenced by no new falls through the end of the certification period. This plan of care update failed to evidence individualized patient safety goals related to the terminal diagnosis or elopement. During an observation on 01/04/2023, at 12:30 PM, evidenced an ambulatory, pleasantly confused patient carrying stuffed dogs with her. The hospice aide indicated the patient became combative at times. During an interview on 01/05/2023, at 4:37 PM, the family care coordinator indicated safety precautions should be included on the plan of care. During an interview on 01/06/2023, at 11:18 AM, the wellness nurse of assisted living facility #2 indicated the patient would periodically leave the assisted living facility and go to the restaurant nearby. The restaurant would call the facility to notify the patient was at the restaurant. Review evidenced an agency document dated 09/28/2022, titled, ";Visit Note Report MSW [social worker] Hospice PRN [as needed] Visit," which indicated safety concerns due to potential for elopement; the director of the assisted living facility indicated the patient had anxiety, agitation and paranoia, and requested medication intervention. The social worker discussed tracking device and medication intervention with family member, and the family member would discuss the tracking device with the director of assisted living facility #2. Review of the interdisciplinary group meetings on 01/05/2023, which evidenced social worker #1indicated at 09/28/2022 interdisciplinary group meeting there are no safety concerns; at a 10/12/2022 interdisciplinary group meeting social worker #2 noted safety concerns due to behaviors and a potential for elopement; 10/26/2022 social worker #1 noted emotional support and comfort provided by social work; 11/08/2022 interdisciplinary group meeting did not address safety information; 11/21/2022 meeting the social worker noted patient confusion and provided emotional support; 11/23/2022 meeting indicated no safety information was addressed by social worker #1, 01/04/2023 social worker #1 noted there are no safety concerns. The clinical record failed to evidence the interdisciplinary group supervised the care and services offered by hospice related to safety and the patients terminal diagnosis. The clinical record failed to evidence documentation regarding tracking device or medication interventions at the interdisciplinary group meeting. Review failed to evidence documentation of safety coordination, interventions or follow up related to safety concerns with assisted living facility #2 or family member related to elopement risk. During an interview on 01/05/2023, at 1:10 PM, the family care coordinator indicated the interdisciplinary group meetings notes are unable to be printed. During an interview on 01/05/2023, at 3:50 PM, the family care coordinator indicated there was no incident report done regarding patient elopement on 9/24/2022. During an interview on 01/05/2023, at 4:00 PM, the family care coordinator indicated there was no documentation of follow up regarding the patients tracking device or medication interventions related to safety or elopement risk. During an interview on 01/05/2023, at 4:10 PM, the family care coordinator indicated the interdisciplinary group should address safety concerns and if more care is required for the patient. Review on 01/03/2023, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, which indicated hospice nurse to coordinate plan of care with facility staff and facility staff is knowledgeable and involved in hospice plan of care. During an interview on 01/05/2023, at 4:00 PM, the administrator indicated the hospice agency work to coordinate with facilities, but due to staffing issues at facilities it was difficult to coordinate patient care and safety. Review of an agency document received 01/06/2023, date implemented 09/26/2022, titled, ";Hospice POC [plan of care] Report," the family care coordinator indicated this document is the patients safety plan. This Hospice POC Report indicated the intervention was for assessment of the safety of the patient environment and the goals is patient had safety needs met. This plan of care failed to evidence individualized safety measures regarding elopement risk. Review of an agency document received 01/06/2023, titled, ";Indiana HOS Consents," for start of care 09/22/2022, indicated the primary care giver was Assisted Facility Living #2. During an interview on 01/05/2023, at 4:37 PM, the family care coordinator indicated there was no care plan meeting to discuss patients elopement with the family. During an interview on 01/05/23, at 4:37 PM, the family care coordinator indicated the plan of care should have safety precautions and indicated there is no documentation of the patients elopement safety measures on the patients plan of care. During an interview on 01/06/2023, at 2:06 PM, administrative staff #2 indicated an assisted living facility should not be listed as the primary caregiver. Review of an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, indicated hospice nurse to coordinate plan of care with facility staff. This plan of care failed to evidence education and training related to the terminal diagnosis that would be provided to the primary caregiver. Review of an agency document titled, ";Visit Note Report MSW Hospice PRN Visit," dated 10/17/2022, indicated routine visit to encourage safety protocols of patient remaining on the facility grounds and patient was walking the hallway and indicated the patient felt others are trying to control here and she was anxious and does multiple circles around building every hour; patient had shown no recent desire to walk off facility grounds and has generally been staying indoors due to change in weather. This visit note failed to evidence documentation of safety education or training with assisted living facility #2 or patients family member. Review of an agency document titled, ";Visit Note Report MSW Hospice PRN Visit," dated 10/24/2022, indicated patient had behaviors related to impaired decision making, inability to appropriately stop activities and jeopardizes safety through actions. This visit note indicated patient was agitated, disoriented, and arguing with staff and residents. This visit note indicated interventions provided were assessment of the safety of the patient environment and goal to have safety needs met. This visit note failed to evidence documentation of education and training with assisted living facility #2 staff or family member regarding safety concerns related to the patients terminal diagnosis. During an interview on 01/05/2023, at 11:18 AM, the wellness nurse at assisted living facility B indicated education related to individual patient elopement risk is done verbally with the assisted living facility staff and there is no documentation of education. The wellness nurse indicated she will have meeting on education regarding wandering patients. During an interview on 01/05/2023, at 3:50 PM, the family care coordinator indicated there is no documentation of follow up education regarding the tracking device or medication intervention related to elopement safety risk with the family or assisted living facility #2. During an interview on 01/05/2023, at 4:34 PM, the family care coordinator indicated the hospice agency needed more documentation of education with assisted living facility. Review evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, which indicated safety measures to include adequate lighting, clean technique, fall precautions, standard precautions. This document failed to evidence safety goals, and safety related to the patients terminal diagnosis. Review of an agency document dated 09/28/2022, titled, ";Visit Note Report: MSW [social worker] Hospice PRN [as needed] Visit," indicated potential is there for elopement. The plan of care and updated plan of care failed to evidence revisions regarding elopement risk. Review on 01/03/2023, evidenced an agency document dated 10/11/2022, titled, ";Visit Note Report, RN [registered nurse] Hospice Subsequent Visit," indicated communication with facility nurse and all safety measures in place upon departure. This comprehensive assessment failed to evidence safety assessment were included in the interventions provided and failed to evidence safety measures were coordinated with assisted living facility #2 wellness nurse. Review of assisted living facility B received on 01/04/2023, identified by the executive director as a ";task sheet," evidenced patient #2 does receive incontinent care every 2 hours. The document evidenced two other assisted living facility #2 residents that have 2-hour checks noted but patient #2 was not listed. Review of an agency document on 01/03/2023, titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, updated 12/06/2022, indicated hospice nurse for assessment of patient safety, and to instruct safety measures. Review of an agency document dated 12/08/2022, titled, ";RN [registered nurse] Hospice Subsequent Visit," indicated education provided were medication management, fall prevention, skin breakdown preventions and ways to decrease anxiety. This comprehensive assessment failed to evidence instruction of safety measures with assisted living facility #2. During an interview with the wellness nurse assisted living facility B on 1/06/2023, at 11:18 AM, the wellness nurse indicated the patient does not have a tracking device and education to staff regarding a wandering patient was done verbally by assisted living facility #2 and does not have documentation of education. The wellness nurse indicated she assumed the patient had 2-hour checks done with every 2-hour incontinent care. During an interview on 01/06/2023, at 1:10 PM, the administrator indicated coordination between hospice and an assisted living facility is done through the care plan and education with the facility. During an interview on 01/06/2023, at 3:00 PM, the administrator indicated hospice received a medication list and a history and physical form from assisted living facility #2, but hospice did not receive the assisted living facility task sheet. 1. Review of an agency policy obtained 1/10/2023 and dated 10/20/2022, titled ";Plan of Care Process" stated, ";... All hospice care and services furnished to patients and their families will follow an individualized written POC [plan of care] established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with ... the patient or representative, the primary caregiver, ... and in accordance with the patients needs. ... The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions ... The Hospice will ensure that each patient and primary caregiver receive education and training as appropriate to their responsibilities for the care and services identified in the POC ... The Hospice IDG/IDT ... will review, revise, and document the individualized plan as frequently as the patients condition requires ... Documentation will support that the patient receives the appropriate level of care and services as indicated by the interdisciplinary assessments...." 2. Review of an agency policy obtained 1/10/2023 and dated 10/1/2021, titled ";Interdisciplinary Group Roles and Responsibilities" stated, ";... the IDG/IDT will: ... Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings ... Provide for the ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions...." 3. Review of an agency policy obtained 1/10/2023 and dated 10/1/2021, titled ";Coordination of Care" stated, ";... Upon referral and/or during the initial assessment, Hospice staff will determine if the patient is receiving care from other providers. ... An IDG/IDT member will contact the outside entities and determine the care that is being provided for the patient. ... The IDG/IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities. ... The IDG/IDT will designate a staff member(s) to communicate and coordinate with outside entities to determine any duplication of service and to educate the entity of the role of the Hospice in the patients care. ... All communications and coordination of care is documented in the clinical record...." 4. Review of an agency policy obtained 1/10/2023 and dated 10/1/2021, titled ";Patient Care Site and Patient Safety Education" stated, ";... The educational needs will be prioritized and incorporated into the patients Plan of Care. ... The educational information will be presented, and patient and/or caregiver response assessed and documented in the patients medical record. ... After instruction has been provided by the Hospice staff, if the patient and/or caregiver is unwilling to implement the measures to correct or improve the identified hazard, the Interdisciplinary Group/Team (IDG/IDT) will further evaluate each case for ongoing risk and impact for patient and staff safety to determine if further action is needed. ... All communication with the patient and/or family regarding safety concerns will be documented in the patients medical record...." 5. Clinical record review on 1/3/2023 for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Visit Note Report" dated 11/30/2022 and identified as the start of care assessment. Review indicated the patients primary hospice diagnosis was senile degeneration of the brain (also known as dementia and characterized by a decrease in cognitive abilities and a mental decline) and indicated the patient was minimally responsive. Review indicated the patient lived in an assisted living facility (ALF), was wheelchair dependent, and was dependent for care in 5 of 6 activities of daily living (ADLs). During an interview on 1/4/2023, at 3:29 PM, RN #1 indicated the patient wore a call pendant necklace to call for assistance provided by the ALF prior to hospice admission. Review evidenced an agency document titled ";Hospice Certification and Plan of Care" for certification period 11/30/2022-2/27/2023 indicated the agency was to provide the patient with skilled nursing services 3 times a week and aide services 2 times a week to include skilled nursing visits as needed for symptom management. Review indicated the patients goals included, but were not limited to, safety needs would be met to minimize the risk of falls and the patient will receive assistance with personal care, hygiene, and ADLs. Review failed to evidence the plan of care included the care that would be provided to meet the patients safety and personal care needs related to the patients terminal illness in the absence of the hospice agency. Review evidenced the hospice nurse was to instruct the patient/caregiver on safety measures. Review failed to evidence the hospice provided patient/caregiver education on the use of the call pendant as a safety measure. During an interview on 1/6/2023, at 1:48 PM, the Mishawaka branch director indicated the agency should have provided patient/caregiver safety education to include the use of the call light. Review of the IDG notes dated 12/6/2022 and 12/20/2022, failed to evidence the IDG discussed and provided care to meet the safety needs of the patient as identified in the initial assessment. Review failed to evidence the IDG identified the safety needs and interventions of the patient in the absence of the hospice. During an interview on 1/5/2023, at 4:52 PM, the administrator indicated different levels of care were provided to the patients at different ALFs. The administrator indicated the hospice was to determine what services should be provided to the patient by completely assessing the patients needs and then determine what care the facility will provide. At 4:54 PM, the administrator indicated patients needs should be discussed during IDG meetings and documented. The administrator indicated there was not documentation in the IDG meeting notes that the agency identified safety needs and interventions other than the patients risk of falls. The administrator indicated the IDG notes did not specify the personal care needs related to the patients dependent status in the absence of hospice and family. During an interview on 1/6/2023, at 1:34 PM, the Mishawaka branch director indicated the ALF provided room and board, food services, and other services purchased by the patient/family. The Mishawaka branch director indicated the services provided by the ALF were not clearly documented on the plan of care. At 1:48 PM, the Mishawaka branch director indicated the patient probably needed a higher level of care with either a private caregiver or increased care provided by the family in the absence of hospice caregivers. During an interview on 1/6/2023, at 1:34 PM, the administrator indicated there was a lack of documentation to show the agency talked with the ALF about the patients needs. Review of an agency document titled ";Client Coordination Note Report" dated 12/21/2022, indicated the hospice on-call was notified of patients change in condition by the ALF staff to include patient had tremors, difficulty speaking, increased confusion, and a change in breathing pattern. Review failed to evidence the hospice provided a skilled nursing visit to manage symptoms as directed in the plan of care. During an interview on 1/4/2023, at 4:14 PM, RN #2 indicated no skilled nursing visit was provided related to the report of the change in status because the ALF nurse told her the family did not need the hospice nurse to make a visit to the patient and wanted the patient to go to bed. RN #2 indicated she was aware the ALF nurse was not present at the ALF at the time of the reported change in patients condition. RN #2 indicated she was surprised when she was informed the patient passed away the next morning and stated, ";I was thinking did I miss something?" During an interview on 1/5/2023, at 11:11 AM, Person #3, ALF wellness nurse, indicated the patient was not assessed by a nurse at the ALF on 12/21/2022 because there was no nurse at the ALF when the patients change in condition was reported by the ALF aide. Person #3 indicated she called the patients family to notify them the ALF aide reported the patient was more confused. Person #3 indicated the family expressed the hospice nurse did not need to make a visit if the patient would just go to bed and indicated she relayed the familys message to the hospice nurse. Person #3 indicated the patient was wheelchair dependent, weak, required a maximum assist with transfers from the bed to the wheelchair. Person #3 indicated the patients family would need to hire a private caregiver or have routine family care if the patient required more than assistive care. Person #3 indicated the ALF was not informed by hospice the patient required additional care or had care needs that were not met. During an interview on 1/5/2023, at 9:37 AM, Person #4, the patients family member, indicated Person #3 called her on 12/21/2022 to report the patient was tired and more confused than usual. Person #4 indicated she informed Person #3 the hospice nurse did not need to make a visit if the patient would go to bed. Person #4 indicated she was not informed the patient had difficulty speaking and altered breathing. Person #4 stated, ";[Patient] wasnt going to stay in that bed unless you tied her down." Person #4 indicated there was no way the patient was able to get out of bed on her own. Person #4 indicated the patient had frequent recent falls which resulted in a fractured pelvis prior to the hospice admission. Person #4 indicated she was not informed the patient required more care than the ALF could provide.

Based on record review and interview, the agency failed to ensure the plan of care specified the hospice care and services necessary to meet the specific patient needs identified in the comprehensive assessment as related to the terminal illness in 5 of 5 clinical records reviewed. (#1, #2, #3, #4, #5) The findings include: --- 1. Clinical record review for patient #2, on 01/03/2023, start of care 09/22/2022, evidenced an agency document dated 09/22/2022, titled, ";Visit Note Report, RN [registered nurse] Hospice Start of Care," which indicated patient resided in an assisted living facility, was confused, had hallucinations, and was ambulatory without assistance. Review evidenced an agency document dated 09/27/2022, titled, ";Visit Note Report: SN [skilled nurse] Hospice Subsequent Visit," which indicated the patient walked to the restaurant next door on Saturday without staff notification. Review evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, indicated the primary diagnosis of senile degeneration of the brain (mental deterioration known as dementia). The plan of care indicated the agency was to provide skilled nurse 3 times per week and aide services 5 times a week. Review indicated the patient's goals included the patient would receive assistance with personal care, hygiene and ADL's (activities of daily living). Review failed to evidence the plan of care included the care that would be provided to meet the patient's safety, and personal care needs related to the patient's terminal illness in the absence of the hospice agency. During an interview on 01/05/2023, at 4:37 PM, the family care coordinator indicated safety precautions should be included on the plan of care. 2. Clinical record review on 01/04/2023, for patient #3, start of care 11/10/2022, evidenced an agency document dated 11/10/2022, titled, "Visit Note Report, RN [registered nurse] Hospice Start of Care," which indicated the patient lived in an assisted living facility, was incontinent, fed by staff, wheelchair bound, and dependent for 6/6 ADL's (activities of daily living). Review evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 11/10/2022-02/07/2023, indicated a diagnosis of senile degeneration of the brain (mental deterioration known as dementia). The plan of care indicated the agency was to provide the patient with skilled nursing services 2 times a week. Review indicated the patient's goals included safety needs would be met to minimize the risk of falls. Review failed to evidence the plan of care included the care that would be provided to meet the patient's safety and personal care needs related to the patient's terminal illness in the absence of the hospice agency. 3. Clinical record review on 01/04/2023, for patient #4, start of care 09/17/2022, evidenced an agency document dated 09/17/2022, titled, "Visit Note Report RN [registered nurse] Hospice Start of Care," which indicated the patient resided in an assisted living facility, was bedbound, and dependent for all ADL's (activities of daily living). Review evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 09/17/2022-10/09/2022, indicated a diagnosis of senile degeneration of the brain (mental deterioration known as dementia). The plan of care indicated the agency was to provide the patient with skilled nursing services 2 times a week and aide services 3 times per week. Review indicated the patient's goals included the patient would receive assistance with personal care, hygiene and other ADL's. Review failed to evidence the plan of care included the care that would be provided to meet the patient's safety and personal care needs related to the patient's terminal illness in the absence of the hospice agency. 4. Clinical record review on 01/03/2023, for patient #5, start of care 12/22/2022, evidenced an agency document dated 12/22/2022, titled, "Visit Note Report RN [registered nurse] Start of Care," which indicated the patient resided in an assisted living facility, was short of breath at rest, and was unable to shower self due to poor endurance. Review evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 12/22/2022-03/21/2023, indicated a diagnosis of interstitial pulmonary disease (scarring of the lungs). The plan of care indicated the agency was to provide the patient with skilled nursing services 2 times per week and aide services 2 times per week. Review indicated the patient's goals included safety needs would be met with fall precautions and the patient would receive assistance with personal care, hygiene and ADL's (activities of daily living). Review failed to evidence the plan of care included the care that would be provided to meet the patient's safety and personal care needs related to the patient's terminal illness in the absence of the hospice agency. 1. Review of an agency policy obtained 1/10/2023 and dated 10/20/2022, titled ";Plan of Care Process" stated, ";... The POC [plan of care] must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions...." 2. Clinical record review on 1/3/2023 for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Visit Note Report" dated 11/30/2022 and identified as the start of care assessment. Review indicated the patients primary hospice diagnosis was senile degeneration of the brain (also known as dementia and characterized by a decrease in cognitive abilities and a mental decline) and indicated the patient was minimally responsive. Review indicated the patient lived in an assisted living facility (ALF), was wheelchair dependent, and was dependent for care in 5 of 6 activities of daily living (ADLs). Review evidenced an agency document titled ";Hospice Certification and Plan of Care" for certification period 11/30/2022-2/27/2023 indicated the agency was to provide the patient with skilled nursing services 3 times a week and aide services 2 times a week. Review indicated the patients goals included, but were not limited to, safety needs would be met to minimize the risk of falls and the patient will receive assistance with personal care, hygiene, and ADLs. Review failed to evidence the plan of care included the care that would be provided to meet the patients safety and personal care needs related to the patients terminal illness in the absence of the hospice agency. During an interview on 1/5/2023, at 4:52 PM, the administrator indicated different levels of care were provided to the patients at different ALFs. The administrator indicated the hospice was to determine what services should be provided to the patient by completely assessing the patients needs and then determine what care the facility will provide. During an interview on 1/6/2023, at 1:34 PM, the Mishawaka branch director indicated the ALF provided room and board, food services, and other services purchased by the patient/family. The Mishawaka branch director indicated the services provided by the ALF were not clearly documented on the plan of care. During an interview on 1/6/2023, at 1:34 PM, the administrator indicated there was a lack of documentation to show the agency talked with the ALF about the patients needs.

Based on record review and interview, the agency failed to ensure the interdisciplinary group (IDG) worked together to provide services offered by the hospice to meet the personal care and safety needs of the patients in 3 of 5 clinical records reviewed. (#1, 2, 4) The findings include: --- 1. Record review evidenced an agency policy dated 10/01/2021, titled, ";Interdisciplinary Group Roles and Responsibilities," which stated, ";...the IDG [interdisciplinary group] ... will prepare a written POC [plan of care] for each patient and family, which specifies the care and services necessary to meet the patient and/or familys specific needs identified in the comprehensive assessment, as those needs relate to the terminal illness and related conditions. The IDG ... will supervise the care and services including: ... informal verbal and written communication demonstrating coordination of care among all staff members and others providing care ...." 2. Clinical record review for patient #2, on 01/03/2023, start of care 09/22/2022, evidenced an agency document dated 09/27/2022, titled, ";Visit Note Report SN [skilled nurse] Hospice Subsequent Visit," which indicated patient had left the assisted living facility on Saturday without letting the staff know. Review evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022 which indicated the primary diagnosis was senile degeneration of the brain (mental deterioration known as dementia). Review evidenced an agency document dated 09/28/2022, titled, ";Visit Note Report MSW [medical social worker] Hospice PRN [as needed] Visit," which indicated safety concerns due to potential for elopement; the director of assisted living facility #2 indicated the patient had anxiety, agitation and paranoia, and requested medication intervention. The visit note indicated the social worker discussed tracking device and medication intervention with patients family member. Record review on 01/05/2023, of the (IDG) interdisciplinary group meeting notes for 09/22/2022, 09/28/2022, 10/12/2022, 10/26/2022, 11/08/2022, 11/21/2022, 11/23/2022, and 01/04/2023 failed to evidence the IDG supervised the care and services offered by hospice related to patients safety, elopement risk and the terminal diagnosis. During an interview on 01/05/2023, at 3:50 PM, the hospice family care coordinator indicated there was no incident report done regarding patient elopement on 9/24/2022. During an interview on 01/05/2023, at 4:10 PM, the hospice family care coordinator indicated there was not documentation of follow up regarding the patient's tracking device or medication interventions related to the elopement risk. During an interview on 01/05/2023, at 4:10 PM, the hospice family care coordinator indicated the interdisciplinary group should address safety concerns and if more care is required for the patient. 3. Clinical record review on 01/04/2023, for patient #4, start of care 09/17/2022, evidenced an agency document dated 09/17/2022, titled, "Visit Note Report RN [registered nurse] Hospice Start of Care," which indicated the patient resided in an assisted living facility, was bedbound, and dependent for all ADL's (activities of daily living). Review evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 09/17/2022-10/09/2022, indicated a diagnosis of senile degeneration of the brain (mental deterioration known as dementia). Review evidenced an agency document dated, 12/29/2022, titled, "Visit Note Report RN Hospice Subsequent Visit," which indicated the patient had not received the scheduled Tramadol (pain medication) for 2 weeks. Review of the IDG (interdisciplinary group) notes dated 12/21/2022, the RN noted patient had increased agitation with care. Review of the IDG notes dated 12/21/2022, failed to evidence the IDG provided care to manage the patient's pain needs as identified in the initial plan of care. During an interview on 01/05/2023, at 4:10 PM, the hospice family care coordinator indicated the interdisciplinary group should address safety concerns and if more care is required for the patient. 1. Review of an agency policy dated 10/01/2021, titled, ";Interdisciplinary Group Roles and Responsibilities" stated, ";...the IDG ... will prepare a written POC [plan of care] for each patient and family, which specifies the care and services necessary to meet the patient and/or familys specific needs identified in the comprehensive assessment, as those needs relate to the terminal illness and related conditions. The IDG ... will supervise the care and services including: ... informal verbal and written communication demonstrating coordination of care among all staff members and others providing care ...." 2. Clinical record review on 1/3/2023 for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Visit Note Report" dated 11/30/2022 and identified as the start of care assessment. Review indicated the patients primary hospice diagnosis was senile degeneration of the brain (also known as dementia and characterized by a decrease in cognitive abilities and a mental decline) and indicated the patient was minimally responsive. Review indicated the patient lived in an assisted living facility (ALF), was wheelchair dependent, and was dependent for care in 5 of 6 activities of daily living (ADLs). During an interview on 1/4/2023, at 3:29 PM, Registered Nurse (RN) #1 indicated the patient wore a call pendant necklace to call for assistance provided by the ALF prior to hospice admission. Review of the IDG notes dated 12/6/2022 and 12/20/2022, failed to evidence the IDG discussed and provided care to meet the safety needs of the patient as identified in the initial assessment. Review failed to evidence the IDG identified the safety needs and interventions of the patient in the absence of the hospice. During an interview on 1/5/2023, at 4:54 PM, the administrator indicated patients needs should be discussed during IDG meetings and documented. The administrator indicated there was not documentation in the IDG meeting notes that the agency identified safety needs and interventions other than the patients risk of falls. The administrator indicated the IDG notes did not specify the personal care needs related to the patients dependent status in the absence of hospice and family. During an interview on 1/6/2023, at 1:34 PM, the Mishawaka branch director indicated the services provided by the ALF were not clearly documented. During an interview on 1/6/2023, at 1:30 PM, the administrator indicated the call pendant should be included in the plan of care as a safety precaution. At 1:34 PM, the administrator indicated there was a lack of documentation to show the agency talked with the ALF about the patients needs.

Based on record review and interview, the agency failed to provide hospice care and services as directed by the plan of care in 2 of 5 clinical records reviewed. (#1, 3) The findings include: --- 3. Clinical record review on 01/03/2023, for patient #2, start of care 09/22/2022, evidenced an agency document dated 09/22/2022, titled, "Visit Note Report RN [registered nurse] Hospice Start of Care." Review indicated the patient lived in an assisted living facility, was ambulatory without assistance, and was confused and hallucinated. During an interview on 01/04/2023, at 12:40 PM, assisted living facility #2 nurse indicated the patient wore a call pendant to call for assistance provided by the assisted living facility. Review evidenced an agency document titled, "Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, which indicated the hospice safety measures would include fall precautions and standard precautions. Review failed to evidence the hospice provided the patient/caregiver safety education to include the use of the call pendant. During an interview on 01/06/23, at 3:10 PM, the Mishawaka branch director indicated the agency should have assessed and provided patient/caregiver safety education to include the use of the call pendant at the start of care. 4. Clinical record review on 01/04/2023, for patient #3, start of care 11/10/2022, evidenced an agency document dated 11/10/2022, titled, "Visit Note Report RN [registered nurse] Hospice Start of Care." Review indicated the patient lived in an assisted living facility, and was dependent for care in 6/6 activities of daily living. During an interview on 01/04/2023, at 12:40 PM, assisted living facility #2 nurse indicated the patient wore a call pendant to call for assistance provided by the assisted living facility. Review of an agency document titled, "Hospice Certification and Plan of Care," for certification period 11/10/2022-02/07/2023 which indicated the hospice agency was to provide nurse for assessment of patient safety, instruct safety measures, and fall precautions. Review failed to evidence the hospice provided patient/caregiver education to include the use of the call pendant. During an interview on 01/06/2023, at 3:10 PM, the Mishawaka branch director indicated the agency should have assessed and provided patient/caregiver safety education to include the use of the call pendant at the start of care. Review of an agency policy obtained 1/10/2023 and dated 10/20/2022, titled ";Plan of Care Process" stated, ";... All hospice care and services furnished to patients and their families will follow an individualized written POC [plan of care] established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with ... the patient or representative, the primary caregiver, ... and in accordance with the patients needs...." Clinical record review on 1/3/2023 for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Visit Note Report" dated 11/30/2022 and identified as the start of care assessment. Review indicated the patient lived in an assisted living facility (ALF), was wheelchair dependent, and was dependent for care in 5 of 6 activities of daily living (ADLs). During an interview on 1/4/2023, at 3:29 PM, Registered Nurse (RN) #1 indicated the patient wore a call pendant necklace to call for assistance provided by the ALF prior to hospice admission. Review evidenced an agency document titled ";Hospice Certification and Plan of Care" for certification period 11/30/2022-2/27/2023 which indicated the agency was to provide skilled nursing visits as needed for symptom management. Review indicated the hospice nurse was to instruct on applicable safety measures. Review failed to evidence the hospice provided patient/caregiver safety education to include the use of the call pendant. During an interview on 1/6/2023, at 1:48 PM, the Mishawaka branch director indicated the agency should have provided patient/caregiver safety education to include the use of the call light. Review of an agency document titled ";Client Coordination Note Report" dated 12/21/2022, indicated the hospice on-call was notified of patients change in condition by the ALF staff to include patient had tremors, difficulty speaking, increased confusion, and a change in breathing pattern. Review failed to evidence the hospice provided a skilled nursing visit to manage symptoms as directed in the plan of care. During an interview on 1/4/2023, at 4:14 PM, RN #2 indicated no skilled nursing visit was provided related to the report of the change in status because the ALF nurse told her the family did not need the hospice nurse to make a visit to the patient and wanted the patient to go to bed. RN #2 indicated she was aware the ALF nurse was not present at the ALF at the time of the reported change in patients condition. RN #2 indicated she was surprised when she was informed the patient passed away the next morning and stated, ";I was thinking did I miss something?" During an interview on 1/5/2023, at 11:11 AM, Person #3, ALF wellness nurse, indicated the patient was not assessed by a nurse at the ALF on 12/21/2022 because there was no nurse at the ALF when the patients change in condition was reported by the ALF aide. Person #3 indicated she called the patients family to notify them the ALF aide reported the patient was more confused. Person #3 indicated the family expressed the hospice nurse did not need to make a visit if the patient would just go to bed and indicated she relayed the familys message to the hospice nurse. During an interview on 1/5/2023, at 9:37 AM, Person #4, the patients family member, indicated Person #3 called her on 12/21/2022 to report the patient was tired and more confused than usual. Person #4 indicated she informed Person #3 the hospice nurse did not need to make a visit if the patient would go to bed. Person #4 indicated she was not informed the patient had difficulty speaking and altered breathing.

Based on record review and interview, the agency failed to ensure the patient and primary caregiver received education and training appropriate for their responsibilities for the care and services identified in the plan of care in 2 of 5 clinical records reviewed. (#1, 2) The findings include: --- 1. Clinical record review on 1/06/2023, for patient #2, start of care 09/22/2022, evidenced an agency document titled, ";Indiana HOS Consents," this document indicated the primary caregiver to be assisted living facility #2. Review of an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, indicated hospice nurse to coordinate plan of care with facility staff. This plan of care failed to evidence safety education and training related to the terminal diagnosis that would be provided to the primary caregiver. Review of an agency document titled, ";Visit Note Report MSW [medical social worker] Hospice PRN [as needed] Visit," dated 10/24/2022, indicated patient had behaviors related to impaired decision making, inability to appropriately stop activities and jeopardized safety through actions. The visit note indicated patient was agitated, disoriented, and arguing with staff and residents. The visit note indicated interventions provided were assessment of the safety of the patient environment and goal to have safety needs met. The visit note failed to evidence documentation of education and training with assisted living facility #2 staff or family member regarding safety concerns related to the patients terminal diagnosis. During an interview on 01/05/2023, at 11:18 AM, the wellness nurse at assisted living facility #2 indicated education related to individual patient elopement risk is done verbally with the assisted living facility staff and there is no documentation of education. During an interview on 01/05/2023, at 2:06 PM, administrative staff #2 indicated the assisted living facility should not be listed as the primary caregiver. During an interview on 01/05/2023, at 3:50 PM, the family care coordinator indicated there is no documentation of follow up education regarding the tracking device or medication intervention related to elopement safety risk with the family or assisted living facility #2. During an interview on 01/05/2023, at 4:00 PM, the administrator indicated hospice agency works to coordinate care with the assisted living facilities; however due to staffing issues at the facilities difficult to coordinate patient care and safety with facilities. During an interview on 01/05/2023, at 4:34 PM, the family care coordinator indicated the hospice agency needed more documentation of education with assisted living facility. 1. Review of an agency policy dated 10/20/2022, titled ";Plan of Care Process" stated, ";... The Hospice will ensure that each patient and primary caregiver receive education and training as appropriate to their responsibilities for the care and services identified in the POC ...." 2. Review of an agency policy dated 10/1/2021, titled, ";Patient Care Site and Patient Safety Education," stated, ";... the hospice will provide the needed education in response to specific identified needs in the following areas ... home safety ... medications ... symptom management ... the educational information will be presented, and the patient and/or caregiver response assessed and documented in the patients medical record ...." 3. Clinical record review on 1/3/2023 for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Hospice Certification and Plan of Care" for certification period 11/30/2022-2/27/2023. Review indicated the patient resided at an assisted living facility (ALF) and indicated the agency was to provide assistance with personal care, hygiene, and activities of daily living (ADLs) and was to assess patients safety. During an interview on 1/4/2023, at 3:29 PM, Registered Nurse (RN) #1 indicated the patient wore a call pendant necklace to call for assistance provided by the ALF prior to hospice admission. Review evidenced agency documents titled ";Visit Note Report" indicated the patients primary hospice diagnosis was senile degeneration of the brain (also known as dementia and characterized by a decrease in cognitive abilities and a mental decline) and indicated the patient was wheelchair dependent, dependent for 5 of 6 ADLs, had a history of falls with injury, and was a fall risk. Review of document dated 12/7/2022, indicated the patient was disoriented, forgetful, confused, and restless. Review failed to evidence the hospice educated the ALF on the patients safety precautions related to the patients dependent status, disorientation, and the appropriateness of the call pendant. During an interview on 1/6/2023, at 1:48 PM, the Mishawaka Branch Director indicated there was no documentation the agency educated the ALF on the patients dependent status with ADLs and appropriateness of the call pendant.

Based on record review and interview, the hospice agency failed to ensure development of an individualized, patient specific plan of care that reflected patient goals and interventions based on the problems identified in the initial and updated comprehensive assessment in 1 of 2 active clinical records reviewed. (#2) The findings include: --- Record review evidenced an agency policy dated 10/20/2022, titled, ";Plan of Care Process," which stated, ";... all hospice care and services furnished to the patients and their families will follow an individualized written POC [plan of care] established by the Hospice Interdisciplinary Group/Team in collaboration with the Attending Physician, the patient or representative, and the primary caregiver ... in accordance with the patients needs ...." Clinical record review for patient #2 on 01/03/2023, start of care 09/22/2022, evidenced an agency document, identified as the comprehensive assessment, dated 09/27/2022, titled, "Visit Note SN [skilled nurse] Hospice Subsequent Visit," which indicated the patient experienced sun downing and the patient did walk to the restaurant next door on 09/24/2022, without assisted living facility #2 staff's knowledge. Review evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, updated on 12/06/2022, which indicated patient's primary diagnosis was senile degeneration of the brain (mental deterioration known as dementia). The plan of care stated, ";... hospice nurse for assessment of patient safety, instruct safety measures as applicable ... patient will have safety needs met AEB [as evidenced by] no new falls through the end of the certification period ...." The plan of care failed to evidence individualized safety goals or interventions related to the terminal diagnosis regarding elopement risk. Review of an agency document received 01/06/2023, date implemented 09/26/2022, titled, ";Hospice POC [plan of care] Report," identified as the safety plan of care. The Hospice POC Report indicated the intervention was for assessment of the safety of the patient environment and the goals was patient had safety needs met. The plan of care failed to evidence individualized safety measures regarding elopement risk. During an interview on 01/05/23, at 4:37 PM, the family care coordinator indicated the plan of care should have safety precautions and indicated there was no documentation of the patients elopement safety measures on the patients plan of care.

Based on record review and interview, the hospice agency failed to ensure they included information from the updated comprehensive assessment in the revised plan of care in 1 of 2 active clinical records reviewed. (#2) The findings include: --- Record review of an agency policy dated 10/20/2022, titled, ";Plan of Care Process," stated, ";... All hospice care and services furnished to patients and their families will follow an individualized written POC [plan of care] ... in accordance with the patients needs ... the Hospice interdisciplinary group will review, revise, and document the individualized plan as frequently as the patients condition requires ..." Record review of an agency policy dated 10/01/2021, titled, ";Review and Revision of Patient Care," stated, ";... The Hospice will review and revise patient care in accordance with changes in the patients condition ... changes that have occurred regarding diagnosis, treatment, medications, precautions, and limitations ... Upon identifying that patient care needs have changed ... adjustments to the are planning documents will be made as follows: ... IDT (interdisciplinary team) Plan of Care ... Each change will be accompanied by specific interventions ... All written changes to the Plan of Care will be incorporated into the patients medical record as changes occur ...." Record review of an agency policy last reviewed 10/01/2021, titled ";Interdisciplinary Group Roles and Responsibilities," stated, ";... A revised interdisciplinary POC [plan of care] will include information from the patients updated Comprehensive Assessment and will note the patients progress toward outcomes and goals specified in the POC ...." Clinical record review for patient #2, on 01/03/2023, start of care 09/22/2022, evidenced an agency document dated, 09/27/2022, titled, ";Visit Note Report: SN [skilled nurse] Hospice Subsequent Visit," which indicated the patient left assisted living facility #2 without staff knowledge on 09/24/2022. Review of an untitled agency document, identified as a plan of care update, dated 12/06/2022, indicated goals were to have patient safety needs met as evidenced by no new falls through the end of the certification period. The plan of care failed to evidence patient safety goals related to elopement. During an interview on 01/05/2023, at 4:37 PM, the family care coordinator indicated the plan of care should include safety precautions, and there was no documentation of precautions for patient elopement risk.

Based on record review and interview, the agency failed to ensure they shared information between all staff proving care to the patient in 1 of 1 clinical record reviewed utilizing on-call services. (#1) The findings include: --- Review of an agency policy dated 10/1/2021, titled ";Coordination of Care" stated, ";... The Hospice will provide for and ensure the ongoing of sharing of information between disciplines providing care and services in all settings ... All communications and coordination of care is documented in the clinical record." Clinical record review on 1/3/2023, for Patient #1, start of care 11/30/2022, evidenced an agency document titled ";Hospice Certification and Plan of Care" for certification period 11/30/2022-2/27/2023, which indicated the agency was to provide the patient with skilled nursing services 3 times a week and as needed for symptom management. Review of an agency document titled ";Client Coordination Note Report" dated 12/21/2022, indicated the hospice on-call was notified of patients change in condition by the assisted living facility (ALF) staff to include patient had tremors, difficulty speaking, increased confusion, and a change in breathing pattern. During an interview on 1/4/2023, at 4:14 PM, registered nurse (RN) #2 indicated no skilled nursing visit was provided related to the report of the change in status because the ALF nurse told her the family did not need the hospice nurse to make a visit to the patient and wanted the patient to go to bed. Review of an agency document titled ";Client Coordination Note Report" dated 12/22/2022, indicated RN #1 checked on the patient at the request of the ALF nurse while she was at the ALF to see another hospice patient. Review indicated the nurse found the patient on the floor next to the bed with the patients head stuck between the mattress and the side rail and with the call pendant wrapped tightly around the patients neck and wrist. Review indicated the patient was cold to the touch and the patient did not have a pulse and had expired. Review failed to evidence the agency coordinated care with RN #1, who was typically assigned to the patient, of the patients change in status as reported the night prior. During an interview on 1/4/2023, at 3:29 PM, RN #1 indicated she was not scheduled to visit the patient this day and had not been informed by the agency of the report of the change in status made to on-call the night prior. During an interview on 1/6/2023, at 2:19 PM, the Mishawaka branch director indicated all staff assigned to a patient should be notified of change in condition and any issues from on-call.

Based on record review and interview, the agency failed to coordinate care with the assisted living facility (ALF) in 5 of 5 clinical records reviewed. (#1, 2, 3, 4, 5) The findings include: --- 1. Record review evidenced an agency policy dated 10/01/2021, titled, ";Coordination of Care," which stated, ";... The hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the Hospice, or by other providers. The hospice will provide for an ongoing sharing of information with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. The hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care ... and facilitating effective coordination of patient services ... the IDG [interdisciplinary group] will ... communicate and coordinate with outside entities to ... educate the entity of the role of the Hospice in the patients care ... The IDG will ensure that the care and services provided are based on all assessments of the patients and familys needs and are provided in accordance with the POC [plan of care]. All communications and coordination of care is documented in the clinical record...." 2. Record review evidenced an agency policy dated 10/01/2021, titled, ";Advanced Directives," which stated, ";... The patients Advanced Directive (a written statement of a persons wishes regarding medical treatment) status will be communicated to all staff involved in the patients care in one of the following ways: identifying the chart, list in the on-call book, and verbal and written communication ...." 3. Clinical record review on 01/03/2023, for patient #2, start of care 09/22/2022, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022, which indicated the patients Advanced Directive is Do Not Resuscitate (a person does not want to be revived if their heart stopped beating and/or stopped breathing). Review of assisted living facility #2 document, received on 01/04/2023, identified as the assisted living facility Task Sheet, indicated the patient is a Full Code (if a persons heart stopped beating and/or stopped breathing, all resuscitation procedures will be provided to keep them alive). Review failed to evidence coordination with the assisted living facility regarding the patients Advanced Directive. During an interview on 01/05/2023, at 4:10 PM, the hospice family care coordinator indicated that advanced directives should be discussed with the assisted living facility and reviewed at the hospice tuck-ins (described as hospice nurse check with assisted living facility to coordinate care). The family care coordinator indicated the hospice would like to come up with a checklist to educate staff at hospice tuck-ins. The family care coordinator indicated the Advanced Directive orders are sent to the assisted living facility after it is signed by family. The family care coordinator indicated there is no documentation the Do Not Resuscitate orders were sent to the assisted living facility. During an interview on 01/06/2023, at 3:00 PM, the administrator indicated hospice received a medication list and history and physical from the assisted living facility but did not receive the assisted living facility task sheet. Review of an agency document dated 12/06/2022, titled, "Current Ordered Medications," indicated patient is on Ativan (antianxiety medication) tablets twice a day and Ativan oral concentrate every 2 hours PRN (as needed). Review of an agency document dated 11/03/2023, titled, ";Visit Note Report SN [skilled nurse] Hospice Subsequent Visit," which indicated the patients medications were set up by assisted living facility #2 nurse. The visit note indicated there were no Ativan tablets in the cabinet and the facility nurse did not know the patient was out of Ativan. Review evidenced assisted living facility #2 medication list dated 12/26/2022, which failed to evidence the Ativan PRN oral concentrate. The review failed to evidence coordination between the hospice and assisted living facility regarding responsibility for set up of medications box and PRN medication administration. During an interview on 01/04/2023, at 12:40 PM, assisted living facility #2 nurse indicated patient received medication reminders where the hospice fills the medications box, and the residential aides will hand medications to patient. The nurse indicated Ativan PRN is signed out by the residential aides. The nurse indicated she is the only nurse available at the facility but is available by phone 24 hours a day. During an interview on 01/05/2023, at 4:04 PM, the hospice family care coordinator indicated hospice will set up medications for certain patients at the assisted living facility. During an interview on 01/05/2023, at 4:22 PM, the hospice family care coordinator indicated assisted living facility #2 nurse was giving the patient medications. The hospice family care coordinator indicated the assisted living facility had the hospices plan of care to know when to administer PRN medications. During an interview on 01/05/2023, at 4:00 PM, the administrator indicated hospice worked to coordinate care with facilities, however due to staffing issues at the facilities it was difficult to coordinate patient care. During an interview on 01/06/2023, at 1:10 PM, the administrator indicated the hospice will have the social worker and register nurse increase documentation of coordination between hospice and the assisted living facility regarding responsibilities. 4. Clinical record review on 01/04/2023, for patient #3, start of care 11/10/2022, evidenced an agency document dated 11/11/2022, titled, ";Visit Note Report RN [registered nurse] Hospice Subsequent Visit," which indicated the director of nursing at assisted living facility #1 requested for medications to be discontinued due to patient not swallowing. The review failed to evidence further coordination between the assisted living facility and hospice regarding medications being discontinued due to patients difficulty swallowing. During an interview on 01/06/2022, at 3:10 PM, the hospice family care coordinator, administrator, and administrative staff #2 indicated they were unsure of outcome of the director of nursing request regarding the discontinuing of medications. At the time of exit no further information was given. 5. Clinical record review on 01/04/2023, for patient #4, start of care date 09/17/2022, evidenced an agency document dated 12/29/2022, titled, ";Visit Note Report RN [registered nurse] Hospice Subsequent Visit," which indicated the hospice nurse educated the aide regarding the patients Tramadol (pain medication) needed to be added to medication box due to the assisted living facilitys nurse not being on the facility premises to reeducate. Review failed to evidence sharing of information regarding the entity responsible for set up of the patients medication box. During an interview on 01/04/2023, at 12:40 PM, assisted living facility #2 nurse indicated patient receives medication reminders where the hospice fills the medications box, and the residential aides will hand medications to patient. The nurse indicated she is the only nurse available at the facility but is available by phone 24 hours a day. During an interview on 01/05/2023, at 4:04 PM, the hospice family care coordinator indicated hospice will fill medication box for certain patients at the assisted living facility. During an interview on 01/05/2023, at 4:00 PM, the administrator indicated hospice worked to coordinate care with assisted living facilities, however due to staffing issues at the facilities it was difficult to coordinate patient care. 6. Clinical record review on 01/03/2023, for patient #5, start of care 12/22/2022, evidenced an agency document titled, ";Visit Note SN [skilled nurse] Hospice PRN [as needed] Visit," which indicated the patient was lethargic, confused and had labored breathing. The visit note indicated the hospice nurse instructed the facility CNA (certified nursing assistant) to administer morphine (pain medication) and a nebulizer (inhaled breathing medication) treatment, however the CNA is unable to administer medications due to the facility policy, the patient would have to give medications himself and the patient was unable to understand the directions to do so. The visit note indicated assisted living facility #1 executive director was concerned about the patients ability to take medications on own and requested medication reminders where the staff will be able to give the patient his medications when its time for him to take them. The visit note indicated the hospice nurse administered morphine and the nebulizer. Review of an agency document dated 12/31/2022, titled, ";Visit Note Report RN Hospice PRN Visit," which indicated the patient did not receive relief from PRN Morphine or Lorazepam (anxiety medication). Roxanol (pain medication) was given by the hospice nurse. The visit note indicated the staff and daughter were to continue to utilize comfort medications. Review failed to evidence the coordination of care with assisted living facility #1 staff and hospice regarding the facility staffs ability to administer PRN medications. During an interview on 01/06/2023, at 3:30 PM, the hospice family care coordinator indicated hospice should meet with the family and assisted living staff to coordinate care to determine when PRN medications are to be given and who will be giving the medications. During an interview on 01/06/2023, at 3:40 PM, the administrator indicated the hospice should coordinate with the assisted living facility and family when patient is requiring transitional care. 1. Review of an agency policy obtained 1/10/2023 and dated 10/1/2021, titled ";Coordination of Care" stated, ";... Upon referral and/or during the initial assessment, Hospice staff will determine if the patient is receiving care from other providers. ... An IDG/IDT member will contact the outside entities and determine the care that is being provided for the patient. ... The IDG/IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities. ... The IDG/IDT will designate a staff member(s) to communicate and coordinate with outside entities to determine any duplication of service and to educate the entity of the role of the Hospice in the patients care. ... All communications and coordination of care is documented in the clinical record...." 2. Clinical record review on 1/3/2023 for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Visit Note Report" dated 11/30/2022 and identified as the start of care assessment. Review indicated the patient lived in an ALF, was wheelchair dependent, and was dependent for care in 5 of 6 activities of daily living (ADLs). Review failed to evidence the hospice agency coordinated care with the ALF to include what were the needs of the patient and what care was being provided by the ALF. During an interview on 1/5/2023, at 4:52 PM, the administrator indicated different levels of care were provided to the patients at different ALFs. The administrator indicated the hospice was to determine what services should be provided to the patient by completely assessing the patients needs and then determine what care the facility will provide. During an interview on 1/6/2023, at 1:34 PM, the Mishawaka branch director indicated the ALF provided room and board, food services, and other services purchased by the patient/family. The Mishawaka branch director indicated the services provided by the ALF were not clearly documented on the plan of care. During an interview on 1/6/2023, at 1:34 PM, the administrator indicated there was a lack of documentation to show the agency talked with the ALF about the patients needs. Review of agency documents titled ";Visit Note Report" indicated on 12/7/2022 and 12/9/2022 indicated the patient was constipated. Review failed to evidence the agency coordinated care with the ALF regarding the patients constipation. During an interview on 1/6/2023, at 2:02 PM, the Mishawaka Branch Director indicated hospice should have discussed the patients constipation with the ALF in an effort to bring the patient relief.

Based on record review and interview, the agency failed to ensure performance improvement activities tracked adverse events, analyzed their causes, and implement preventative actions in 3 of 3 clinical records reviewed with adverse events. (#1, 2, 4) The findings include: --- 1. Record review evidenced a reviewed agency policy dated 10/01/2021, titled, ";Occurrence/Incident Reporting," which stated, ";... The hospice will document and report all occurrences/incidents that deviate from routine Hospice operations and may result in injury or potential harm to a patient ... an occurrence/incident report will be completed on all occurrences or incidents ...the report will be submitted to the immediate supervisor. The supervisor will review the Occurrence/Incident report and will document awareness of the occurrence/incident. The Occurrence/Incident Report will be forward to Management and the QAPI [quality assessment performance improvement] Committee for the purposes of reviewing, analyzing, aggregating, trending, and making performance improvement recommendations ...." 2. Record review evidenced a reviewed agency policy dated 10/01/2021, titled, ";Reporting/Follow-up of Medication Incidents," which stated, ";... The hospice recognizes that two types of medication incidents are possible. Medication errors related to an error in the administration of the medication by staff and/or by the patient and/or caregiver; and adverse reactions ... The hospice considers medication errors that warrant reporting and possible follow-up as: ... any error involving omission of medication for three or more consecutive doses by the patient ... The Registered Nurse [RN] case manager will be notified ... internal reporting includes completing an ";Occurrence Report" ... All occurrences will be reviewed as part of the performance improvement function ...." 3. Clinical record review on 01/03/2023, for patient #2, start of care 09/22/2022, evidenced an agency document dated 09/27/2022, titled, ";Visit Note Report SN [skilled nurse] Hospice Subsequent Visit," which indicated the patient had walked to the restaurant next door to the facility on Saturday without letting the facility staff know. During an interview on 01/05/2023, at 3:50 PM, the hospice family care coordinator indicated the hospice did not complete an incident report regarding the patient elopement. 4. Clinical record review on 01/04/2023 for patient #4, start of care 09/17/2022, evidenced an agency document dated 12/29/2022, titled, ";Visit Note Report RN Hospice Subsequent Visit," which indicated the patient had not been given scheduled Tramadol (pain medication) for 2 weeks and the RNCN (registered nurse clinical manager) was aware. During an interview on 01/06/2023, at 3:00 PM, the hospice family care coordinator indicated ALF #2 nurse did not fill tramadol medication into patients medication box and would need to review further. Upon exit of the facility on 01/06/2023 no further information was provided regarding patient not receiving Tramadol for 2 weeks. 1. Review of an agency policy dated 10/1/2021, titled ";Occurrence/Incident Reporting" stated, ";... The Hospice will document and report all occurrences/incidents ... that deviate from routine Hospice operations and may result in injury or potential harm to a patient ... Adverse Events include ... Safety hazards that endanger staff and/or patients ... Serious Adverse Events include ... Unexpected death not resulting from the patients medical condition ... An Occurrence/Incident Report will be completed on all occurrences or incidents ... The Occurrence/Incident Report will be forwarded to Management and the QAPI [Quality Assessment Performance Improvement] Committee for the purposes of reviewing, analyzing, aggregating, trending, and making performance improvement recommendations...." 2. Review of an agency policy dated 10/01/2021, titled, ";Reporting/Follow-up of Medication Incidents," stated, ";... The hospice recognizes that two types of medication incidents are possible ... The hospice considers medication errors that warrant reporting and possible follow-up as: ... any error involving omission of medication for three or more consecutive doses by the patient ... internal reporting includes completing an ";Occurrence Report" ... All occurrences will be reviewed as part of the performance improvement function ...." 3. Clinical record review on 1/3/2023 for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Visit Note Report" dated 11/30/2022 and identified as the start of care assessment. Review indicated the patient lived in an assisted living facility (ALF), was wheelchair dependent, and was dependent for care in 5 of 6 activities of daily living (ADLs). During an interview on 1/4/2023, at 3:29 PM, Registered Nurse (RN) #1 indicated the patient wore a call pendant necklace to call for assistance provided by the ALF prior to hospice admission. Review of an agency document titled ";Client Coordination Note Report" dated 12/22/2022, indicated registered nurse (RN) #1 checked on the patient at the request of the ALF nurse. Review indicated the nurse found the patient on the floor next to the bed with the patients head stuck between the mattress and the side rail and with the call pendant wrapped tightly around the patients neck and wrist. Review indicated the patient was cold to the touch, and the buttocks, upper and lower extremities, and neck were purple. Review indicated the patient did not have a pulse and had passed away. Review failed to evidence an incident report was completed surrounding the patients death. During an interview on 1/6/2023, at 1:18 PM, the Mishawaka Branch Manager stated the circumstances surrounding the patients death were ";certainly an occurrence and I didnt think to say to [RN #1] to do an incident."

Based on record review and interview, the administrator failed to be responsible for the day-to-day operations of the hospice and failed to ensure the agency followed its policies. The findings include: --- 1. Review of an agency policy dated 10/1/2021, titled ";Expected Patient Death" stated, ";... If a patients death results from an injury, accident or other possible unnatural causes, the Hospice will notify all applicable accrediting federal, local and state authorities...." 2. Review of an agency policy dated 10/1/2021, titled ";Responsibilities of the Administrator" stated, ";... The Hospice Administrator will assume overall responsibility and authority for the administrative and leadership functions, supervision of the established organizational plan, and responsibility for ongoing communication with the Governing Body, as well as the Hospice staff...." 3. Clinical record review on 1/3/2023, for Patient 1, start of care 11/30/2022, evidenced an agency document titled ";Client Coordination Note Report" dated 12/22/2022, which indicated registered nurse (RN) #1 checked on the patient at the request of the assisted living facility (ALF) nurse. Review indicated the nurse found the patient on the floor next to the bed with the patients head stuck between the mattress and the side rail and with the call pendant wrapped tightly around the patients neck and wrist. Review indicated the patient was cold to the touch, and the buttocks, upper and lower extremities, and neck were purple. Review indicated the patient did not have a pulse and had passed away. Review failed to evidence local authorities were notified per agency policy. During an interview on 1/5/2023, at 11:11 AM, Person #3, wellness nurse at ALF #1, indicated the manner in which the patient was found at time of death was unusual and traumatic. Person #3 indicated if a non-hospice ALF patient had been found in the same manner, the ALF would have called 911. During an interview on 1/6/2023, at 2:09 PM, the Mishawaka Branch Director indicated the patients death was an unusual circumstance and indicated she thought the coroner would notify the police if the police were needed to be notified. 4. The administrator failed to ensure the physical needs related to the patients terminal diagnosis were identified in the comprehensive assessment. Please see tag L0524. 5. The administrator failed to ensure the comprehensive assessment was updated to reflect patient changes. Please see tag L0533. 6. The administrator failed to ensure the plan of care specified the hospice care and services necessary to meet the specific patient needs identified in the comprehensive assessment as related to the terminal illness, failed to ensure the interdisciplinary group (IDG) worked together to provide services offered by the hospice to meet the safety needs of the patients, failed to provide the care and services per the plan of care, failed to provide education and training to the caregiver appropriate to their responsibilities for the care and services identified in the plan of care, failed to revise the plan of care as necessary, and failed to coordinate services with the IDG and assisted living facility. Please see tags associated with federal regulation 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services. 7. The administrator failed to ensure performance improvement activities tracked adverse events, analyzed their causes, and implement preventative actions. Please see tag L0569. 8. During an interview on 1/6/2023, at 1:10 PM, the administrator indicated the hospice care provided by the agency was supplemental care. When queried who was responsible for the health and safety of the patient, the administrator indicated it was a coordination between the ALF, hospice, and family. The administrator indicated the agency could have increased the hospice visit frequencies at ALF #1 and ALF #2 because the ALF company was new and had caused the agency problems.

Based on record review and interview, the hospice agency failed to determine the ability of the patient and/or family to safely self-administer drugs in the home as part of the plan of care in 1 of 2 active clinical records reviewed. (#2) The findings include: --- Record review evidenced an agency policy dated 10/20/2022, titled, ";Plan of Care Process," which stated, ";... drug profile ... identification of the following: ... determine the ability of the patient and/or family to safely self-administer drugs ...." Clinical record review on 01/03/2023, for patient #2, start of care 09/22/2022, evidenced an agency document titled, ";Hospice Certification and Plan of Care," for certification period 09/22/2022-12/20/2022. The plan of care failed to evidence if the patient had the ability to self-administration medications. Review of an agency document dated 09/23/2022, titled, "Visit Note Report RN [registered nurse] Hospice Subsequent Visit," indicated the assisted living facility nurse was setting up patient's medication in her pill dispenser. Review of assisted living facility #2 document, received on 01/04/2023, identified as a task sheet, indicated the patient had scheduled medication reminders. During an interview on 01/04/2023, at 12:40 PM, assisted living facility #2 nurse indicated the patient received medications reminders described as the residential aides get the medications out of the cabinet and hands to the patient. During an interview on 01/05/2023, at 4:04 PM, the family care coordinator indicated hospice sets up medication for certain patients at an assisted living facility and it should be indicated on the plan of care if the hospice agency sets up medication.