Every finding on record at Trinity Home Health Services

Observed in Record Review. In 5 of 16 patient records reviewed, it was noted in review of record for hospice home visits #3 and #4 and RR #1, #4, #9 and #5, the area on the consent for treatment the physician of choice name was not documented. This was discussed with leadership.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted in hospice record review #10 that the MSW did not complete the initial assessment until 15 days following the start of care and there was no documentation related to the reason for the delay in care. This was confirmed by the quality staff member.

Observed in Record Review. In 7 of 16 patient records reviewed, it was noted that the goals stated on the plan of care were not measurable, timed or patient specific. For example, in review of record for hospice home visit #1 the following was stated as a goal for sleep issues, Pt/CG will verbalize/demonstrate knowledge of pharmacologic and non-pharmacologic strategies to improve sleep/rest pattern within episode of care. In another example for constipation the goal was stated as follows, Pt will maintain optima GI/GU status within disease limitation as evidenced by pt/cg will verbalize /demonstrate ability to list sign and symptoms of complications to report to hospice agency by episode of care. In record review for home visit #2, #3 and #4 the following goals were stated, for the problem of nutrition, Pt and family verbalized understanding of nutritional needs, and for edema, Patients edema/excess fluid will be stabilized ongoing throughout the episode of care. In review of record #9 a goal was stated as follows, Final arrangements will be made by end of episode. In review of record #7 it was noted that a goal was stated as follows, T\Pt/CG to verbalize or demonstrate management techniques related to anxiety by the end of the certification period. This was discussed with the hospice director and quality staff member.

Observed in Patient Home. In 7 of 16 patient records reviewed, it was noted that in review of record for hospice home visit #1 the wound care orders were incomplete. For example, the wound care orders stated, cleanse wound with cleanser of choice. Additionally in this record a medication order was stated as Lidocaine patch 4 % apply 1 patch topically if needed for moderate pain to back without a frequency. Lastly in this same record there was no order for a foley catheter to be inserted however a foley catheter was noted while on the visit. In hospice record reviews #5 wound cleanser of choice and skin prep to left heel wound was stated and to be changed daily but there were no dressings ordered. In hospice record review #6 there was no order for a border dressing which was documented in skilled nursing notes as being applied to open areas on neck. In hospice record review #7 the wound care orders stated wound cleanser of choice. In record review #9 and #10 there were no orders for a foley catheter that was documented as being inserted. In HOSDCRR#2 it was noted that there was no discharge order for the patient who was discharged due to no longer meeting hospice criteria. This was discussed with the hospice director and verified by quality staff member. Observed in Record Review. In 5 of 16 patient records reviewed, it was noted that the plan of care was not updated to reflect new issues or problems. For example, in review of record for hospice home visit #1 it was noted that the patient had a new foley catheter inserted with a suspected UTI however this was not reflected in the care plan. In review of record for hospice home visit #2 it was noted that the patient had a new earache and was prescribed antibiotic ear drops however the care plan was not updated to include this new problem. In review of record for hospice home visit #3 it was noted that the patient was a high fall risk with a history of frequent falls and frequent UTI's however neither of these issues were addressed on the plan of care. In review of record for hospice home visit #4 it was noted that the patient had developed a UTI and was treated with antibiotics and had a new order for Kaopectate however the care plan was not updated to reflect these new problems. In hospice record review #8 it was noted that the patient developed a UTI and was treated with antibiotics however the care plan was not updated. This was discussed with the hospice director and quality staff member.

Observed in Record Review. In 6 of 16 patient records reviewed, it was noted that in record review for hospice visits #3 and #4 the plan of care was not followed. For example in record review for visit #3 there was no chaplain visit for the month of March and for visit #4 there was no chaplain visit for the month of January and in both records the visit frequency for chaplain was stated as one time per month. In record review #3 there was a missed hospice aide visit with no documentation of why or who was notified and in record review #4 there were two hospice aide missed visits with no documentation or why or who was notified. In record review #5 there was no chaplain visit for the month of January with a frequency of 1 time monthly and no MSW visit for the month of March with a frequency of twice monthly. In hospice record review #8 there was no chaplain visit made in February with a frequency of one time per month. This was reviewed with hospice leadership.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted in review of hospice record #5 it was noted that the nurse documented during a visit that the patient was currently experiencing a pain level of 7/10 and that in the past 24 hours the worst pain level was 10/10 however there was no documentation that the physician was notified and no new orders for pain management. This was confirmed by the quality staff member.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted that in hospice record review # 5 there was no infection surveillance report documented for a skin infection with a new antibiotic order for Doxycycline prescribed for 13 days. This was confirmed by quality staff member.

Observed in Record Review. In 2 of 12 patient records reviewed, with hospice aide services it was noted that for hospice home visit #1 and #2 the aide care plan did not include any direction of oxygen use during the shower for patients who were on continuous oxygen. This was discussed with the hospice director and quality staff member.

Observed in Document Review. In review of the volunteer program and in discussion with hospice leadership it was noted that for the years, 2023, 2024 and 2025 the level of volunteer activity did not meet the required 5% of the total patient care hours of all paid hospice employees.

Observed in Record Review. In 2 of 16 patient records reviewed, it was noted that the medication profile did not reflect what the patient was actually taking. For example, in review of record for hospice home visit #3 Dulcolax suppository was listed on the hospice medication profile however it was not on the facility medication profile. In the same record, the facility medication profile listed Senna S to be given daily however that medication was not on the hospice medication profile. In review of record for hospice home visit #4 the facility medication profile stated Ativan 0.25 mg every 4 hours PRN and Kaopectate 30 ml every 6 hours PRN however neither of these medications were on the hospice medication profile. This was discussed with hospice director and quality staff member.

Observed in Patient Home. In 1 of 4 home visits conducted, it was noted in home visit #1 that there were two unsecured E tanks standing upright in the corner of the room. The staff member did not attempt to place the tanks on the floor and there was no education to facility staff who entered the room during the visit. This was discussed with hospice director.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 1 of 1 sampled patients (Patient #5) with a pleural catheter (tube inserted into cavity around lung to drain excess fluid).    Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient. --- Findings include:  Review of the hospice policy, titled Hospice – Care Planning Process, dated 4/1/2020, identified the hospice ensures that services are furnished in a safe and effective manner and in accordance with the patient’s plan of care.  Patient #5 had a hospice admission date of 5/28/25, a death date of 6/16/25 and received hospice services while residing in a private residence.  Clinical record review revealed the following:   a. Plan of Care update, dated 6/1/25 to 6/12/25 and 6/13/25 to 6/26/25, included primary diagnosis of endometrial cancer and orders for skilled nursing services three times per week and skilled nurse to drain pleural catheter using aseptic technique every other day.  Patient/caregiver may perform drainage, site care and dressing change when proficient to maintain ordered frequency and comfort.    b. Skilled nurse visit note, dated 6/10/25, included documentation pleural catheter drained with 20-30 milliliters of thick amber fluid.  c. Skilled nurse visit notes, dated 6/11/25, 6/12/25, 6/13/25, 6/14/25 and 6/15/25, lacked documentation pleural catheter was drained by skilled nurse, patient, or caregiver, or a reason why the pleural catheter was not drained as ordered.  During an interview on 8/5/25 at 1:30 PM, Staff B, Quality Management Specialist/Educator, reported unable to find documentation about pleural catheter being drained after 6/10/25.  Skilled nurse failed to drain pleural catheter every other day as ordered or obtain an order to change the frequency to drain the pleural catheter.   The findings were reviewed with the Administrator and Quality Management Specialist/Educator.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 6 sampled patients (Patient #5).  Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. --- Findings include:  Review of the hospice policy, titled Hospice – Care Planning Process, dated 4/1/2020, identified the hospice ensures that services are furnished in a safe and effective manner and in accordance with the patient’s plan of care.  The patient’s response to care is re-evaluated regularly by the IDG that adjusts the plan of care based on changes in the patient’s condition, psychosocial status, achievement or lack of achievement of goals and outcomes.  The IDG makes appropriate decisions such as changes in level of care, interventions and outcomes, visit frequency and continuation of hospice care.  Patient #5 had a hospice admission date of 5/28/25, a death date of 6/16/25 and received hospice services while residing in a private residence.  Clinical record review revealed the following:   a. Plan of Care update, dated 6/1/25 to 6/12/25, included primary diagnosis of endometrial cancer and orders for skilled nursing services three times per week.  b. Skilled nurse visit notes, dated 6/3/25 and 6/6/25, included documentation of a completed nursing visit.  c. IDG update to the plan of care, dated 6/12/25, lacked documentation the IDG was notified of the missed skilled nurse visit for the week of 6/1/25.  The clinical record lacked documentation of a third skilled nursing visit for the week 6/1/25 through 6/7/25, or documentation of a reason for a missed nursing visit.  The hospice failed to provide skilled nurse visits as ordered per the IDG updates to the POC. The findings were reviewed with the Administrator and Quality Management Specialist/Educator.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 13 (Patient #1, #5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: Patient was admitted on 09/28/2022 however, there was no evidence of spiritual assessment until 10/05/2022. Patient #5: Patient was admitted on 10/06/2022 however, there was no evidence of spiritual assessment until 10/13/2022.

Upon patient record review 2 of 13 (Patient #8, #12) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #8: Patient was admitted on 09/06/2022 however, there was no evidence of spiritual assessment completed. Patient #12: Patient was admitted on 09/20/2022 however, there was no evidence of spiritual assessment completed.

Upon patient record review, 5 of 13 (Patient #1, #2, #3, #4, #7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The medication profile included acetaminophen 500-1000mg every 4 hours PRN pain/fever and dipenhydramine 25mg/acetaminophen 500mg 1-2 at bedtime without evidence of a maximum allowable amount. COS Patient #2: The plan of care indicated the patient had oxygen however, there was no evidence of this on the medication profile. COS Patient #3: The medication profile included acetaminophen 500mg 2 tablets every 4 hours PRN pain however, there was no evidence of a maximum allowable amount. The medication profile included Miralax 17gm powder dose however, there was no evidence of directions for mixing. The nurse assessment on 02/28/2023 indicated the facility nurse applied "medicated lotion" to patient legs however, this was not listed on medication profile. COS Patient #4: The medication profile included acetaminophen 500mg 2 tablets twice a day and hydrocodone-acetaminophen 5/325mg 1-2 tablets every 4 hours PRN pain however, there was no evidence of maximum allowable dose. The oxygen 1-5 lpm PRN listed did not have evidence of a route. The Secura xtra protective 30.6% topical cream daily PRN did not have evidence of specific area for application. COS Patient #7: The medication profile included ayr saline gel spray and Visine eyedrops without evidence of use for one or both nostril/eye. In addition, the lidocaine patch did not include directions for location of placement. The Miralax 17gm powder dose did not have evidence of directions for mixing. COS

Upon patient record review, 7 of 13 (Patient #2, #4, #5, #6, #8, #10, #12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: The patient admitted on 05/13/2022 however, the initial bereavement assessment indicated it was completed 09/30/2022. Patient #4: The patient admitted on 09/20/2022 however, the initial bereavement assessment indicated it was completed 03/09/2023. Patient #5: The patient admitted on 10/06/2022 however, the initial bereavement assessment indicated it was completed 11/21/2022. Patient #6: The patient admitted on 08/15/2022 however, the initial bereavement assessment indicated it was completed 10/17/2022. Patient #8: The patient admitted on 09/06/2022 however, the initial bereavement assessment indicated it was completed 01/13/2023. Patient #10: The patient admitted on 09/03/2022 however, the initial bereavement assessment indicated it was completed 09/09/2022. Patient #12: The patient admitted on 09/20/2022 however, the initial bereavement assessment indicated it was completed 11/22/2022.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 13 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: The nurse identified on 03/08/2023 visit that patient had open area on L labia however, there was no evidence of assessment.

Upon patient record review, 2 of 13 (Patient #5, #12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #5: The patient admitted with Alzheimer's however, there was no evidence of neurological problems/interventions/goals. COS Patient #12: The patient admitted with COPD however, there was no evidence of respiratory problems/interventions/goals.

Upon patient record review, 3 of 13 (Patient #1, 8, 9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: Chaplain visits on 01/01/2023 were ordered 2wk, 23 PRN and on 3/2/2023 ordered 3xwk-10m1, 6 PRN however. Social work visits ordered on 12/27/2022 at 13 PRN without a routine visit frequency. Patient #8: The order for visit frequency for nursing on 03/05/2023 was 1W9, 11 PRN. Patient #9: The order for visit frequency for nursing on 03/05/2022 was 1W10, 2W1, 1W1, 70 PRN

Upon patient record review, 5 of 13 (Patient #1, #2, #3, #4, #7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The medication orders for acetaminophen 500-1000mg Q4 hours PRN pain/fever and dipenhydramine 25mg/acetaminophen 500mg 1-2 at bedtime did not include evidence of a maximum allowable amount. COS Patient #2: The plan of care had goals and interventions that indicated the patient had oxygen however, there was no evidence of an order for oxygen. COS Patient #3: The medication order for acetaminophen 500mg 2 tablets every 4 hours PRN pain however, there was no evidence of a maximum allowable amount. The medication order for Miralax 17gm powder dose however, there was no evidence of directions for mixing. The nurse assessment on 02/28/2023 indicated the facility nurse applied "medicated lotion" to patient legs however, there was not an order for this. COS Patient #4: The medication orders included acetaminophen 500mg 2 tablets twice a day and hydrocodone-acetaminophen 5/325mg 1-2 tablets every 4 hours PRN pain however, there was no evidence of maximum allowable dose. The order for oxygen 1-5 lpm PRN listed did not have evidence of a route. The order for Secura xtra protective 30.6% topical cream daily PRN did not have evidence of specific area for application. COS Patient #7: The orders for ayr saline gel spray and Visine eyedrops did not include evidence of directions for use in one or both nostril/eye. In addition, the lidocaine patch order did not include directions for location of placement. The order for Miralax 17gm powder dose did not have evidence of directions for mixing. COS

Upon patient record review, 3 of 13 (Patient #1, #3, #7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: Upon home visit it was observed patient was using hospital and air mattress however, there was no evidence of these on plan of care. COS Patient #3: Upon home visit it was observed patient was using hospital bed, wheelchair, and low air loss mattress however, there was no evidence of these on plan of care. COS Patient #7: The initial assessment and nurse notes indicated patient was using a wheelchair however, there was no evidence this was included in plan of care. COS

Upon patient record review, 1 of 13 (Patient #10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #10: The record indicated upper respiratory infections in January and March, however there was no evidence the plan of care was updated to reflect problems/interventions/goals.

Upon client record review, 8 of 13 (Patient #1, #2, #3, #4, #5, #6, #8, #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: According to plan of care, music therapy was to evaluate and develop plan of care, however there was no evidence of music therapy evaluation. In addition, chaplain visits on 01/01/2023 were ordered 2wk, 23 PRN and on 3/2/2023 ordered 3xwk-10m1, 6 PRN however, there was evidence of January routine visits on 1/24, 1/27, 1/31, February routine visits 2/3, 2/8, 2/10, 2/14, 2/16, 2/21, 2/23, and March routine visits on 3/2, 3/3, 3/6, 3/8, 3/10, 3/13. Social work visits ordered on 12/27/2022 at 13 PRN however, there was evidence of routine visits 1/17, 1/24, 2/22, 2/28, and 3/9. Last nurse visit on 12/27 were ordered 20w1, 28w12, 4w1 however, the week of 3/5 there was only evidence of 15 visits and the week of 2/26 14 visits completed. Patient #2: The order for visit frequency for social work was 1M3, 3 PRN ordered on 01/08/2023 however, there was no evidence of visits in February. Patient #3: According to plan of care, music therapy was to evaluate and develop plan of care, however there was no evidence of music therapy evaluation. COS Patient #4: According to plan of care, music therapy was to evaluate and develop plan of care, however there was no evidence of music therapy evaluation. The orders for nursing visit frequency on 03/05/2023 were 27W1, 1W1, 3 PRN however, the week of 03/05/2023 there was only evidence of 7 visits. Patient #5: The orders for social work on 01/04/2023 were 2M3, 1M1, 2 PRN however there was evidence of visits on 01/05, 01/12, and 01/26 with notes of each as routine. Patient #6: According to plan of care, music therapy was to evaluate and develop plan of care, however there was no evidence of music therapy evaluation. COS Patient #8: The order for visit frequency for nursing on 03/05/2023 was 1W9, 11 PRN and the week of 3/5 there was a routine visit and PRN visit however, the PRN notes reflected routine visit. COS Patient #9: The order for visit frequency for nursing on 03/05/2022 was 1W10, 2W1, 1W1, 70 PRN and the record reflected the week of 03/05 one routine visit performed and 3 PRN visits performed however, notes reflected routine visits. COS

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient #1: The record indicated infection of cellulitis in January, however there was no evidence of reported infection with investigation. Patient #10: The record indicated upper respiratory infections in January and March, however there was no evidence of reported infection with investigation.

Upon patient record review 8 of 13 (Patient #1, #2, #3, #4, #5, #6, #8, #9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The orders for aide on 01/08/2023 were 22w1, 21w10, 3w4 however, the weeks of 3/5 and 2/26 there was only evidence of 18 completed visits. Patient #2: The orders for aide on 01/08/2023 were 2W8, 1W1 however, there was no evidence of visits the week of 02/19 and 02/26. Patient #3: The aide plan of care indicated shower weekly on Wednesdays and bed bath on non shower days-oral care every visit-shampoo every visit however, on home visit 03/15/2023 the aide did not perform these services. In addition, the aide visits on 03/08 and 03/10/2023 services were not performed and marked "not required" as well. Patient #4: The orders for aide on 01/22/2023 were 17W1, 5W7 however, the week of 01/29 through the week of 02/19/2023 there was only evidence of 2-4 visits each week. Patient #5: The aide plan of care indicated bed bath and shampoo every visit however, on 02/20, 02/28, and 03/05 these services were marked "not required". In addition, the orders for aide on 01/04/2023 were 3W1, 5W12, 1W1 however, the week of 01/29 there was only evidence of 4 visits performed. Patient #6: The orders for aide on 02/11/2023 were 5W8, 2W1 however, the week of 02/12/2023 there was only evidence of 3 visits and one missed visit note. In addition, the aide plan of care indicated shower, turn, footcare, and shave every visit however, the notes on 02/13, 02/24, and 03/03/2023 were marked "not required". Patient #8: The orders for aide on 12/05/2022 were 4W13 however, the weeks of 1/29, 2/05, and 02/19 there was only evidence of 2-3 visits per week. Patient #9: The orders for aide on 02/27/2023 were 5W11, 3W1 and no visit frequency orders for homemaker however, the week of 03/05/2023 there were 6 visits performed (5 aide and 1 HM). In addition, the aide plan of care required bed bath every visit however, on 02/27 and 03/06/2023 the aide marked "not required".

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #14: There was no evidence of orientation on hospice philosophy.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #14: There was no evidence of orientation.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #14: There was no evidence of a skills competency in file.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. COS

Upon inpatient contract review, 1 of 4 (SNF/GIP/Respite contract Arbor Springs) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon observation, there is not evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association, NFPA 99 and NFPA 80 for all doors. The Fire doors in the corridor on the east side of the building did not close and self latch as designed when released from the self holding device. The patient rated smoke door labels on patient rooms 1- 6 and the spa room have been painted and the ratings are not visible. NFPA 80 requires the plate door rating to be visible.

Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence that all patient care staff working in the hospice inpatient facility must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion: • Before performing any of the actions specified in this paragraph • As part of orientation • Subsequently on a periodic basis consistent with hospice policy, at a minimum annually Personnel #5: There was not evidence staff member received training on restraints, policies stated restraints could be utilized.

Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence that all direct patient care personnel in the inpatient facility are properly trained and able to demonstrate competency in providing care for a patient in restraint or seclusion including all required content. Personnel #5: There was not evidence staff member received training on restraints, policies stated restraints could be utilized.

Upon client record review, 1 of 13 (Patient #3) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 3 The nurse visit on 03/08/2023 indicated the patient had an open area on L labia however, there was no evidence the plan of care was updated with problems/interventions/goals. COS

Upon patient home visit, 1 of 13 (Patient #3) did not have evidence that the hospice provided the following information to the SNF: • Hospice election form • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #14: There was no evidence of a criminal background.