Every finding on record at Ur Medicine, Certified Services, Inc.

Observed in Patient Home. In 1 of 23 patient records reviewed, It was noted that a patient (HSPHVRR#4) was receiving a continuous intravenous infusion of hydromorphone for significant pain. On one RN home care visit note, there was no documentation of a pain scale. This lack of documentation was confirmed by the Director of Hospice.

Observed in Record Review. In 1 of 23 patient records reviewed, It was noted in HSPRR#17 that there were two active documented medication orders for oxycodone. One order stated Oxycodone 1mg at bedtime and may have I mg q 1 hour for pain over 24 hours ( no more than 25 in one day ) . The second order stated Oxycodone 1 mg q 1 hour prn for pain( no more that 24 in one day ). These orders were not clarified for 5 days, making it possible for the patient to receive 49 mg of Oxycodone in one day. This was noted by the Director for Hospice Services

Observed in Patient Home. In 1 of 23 patient records reviewed, It was noted that one patient (HSPHVRR#4) was observed to be extremely anxious, agitated, and restless. From record review, these behaviors have been increasing for two weeks, there had been RN visits during the time frame of increasing restlessness and interventions were mentioned for this change in behavior. However there was no mention in the plan of care of goal or plan associated with this change in behavior

Observed in Patient Home. In 1 of 13 patient records reviewed, that patient (HSPHV#3) was on continuous oxygen and the aide care plan read Aide will assist with oxygen nasal canula . There was no specificity for the aide with how to assist with nasal canula when bathing the patient, or any other instruction for the aide that could involve the nasal cannula associated with tasks that the aide might perform. This was confirmed by the Director of Hospice and the Director for the Aide Services.

Observed in Patient Home. In 1 of 13 patient records reviewed, The aide (HSPRR#3) assisted the patient with feeding inclusive of offering food and spoon feeding the patient. However there no mention of feeding or nutritional assist on the aide care plan. This was confirmed the Director of the Hospice and the Director of the Aide Services.

Observed in Tracer Activities. During a review of the volunteer program and an interview with the volunteer coordinator, the hospice pharmacy surveyor noted that the organization had no documentation of their ongoing efforts to recruit volunteers. This omission was validated with the volunteer coordinator and hospice management at the time of the survey.

Observed in Record Review. Due to the electronic medical record system, the aide is not able to document if the RN has been called for the problems of aspiration, falls, and choking. This documentation (HSPRR#7) is listed in one sentence to be answered with a single check box. However there are two actions statements - the first is to check for aspiration, falls, and choking and the second to report these symptoms to the RN - if the aide checks the box there is no way to tell if the aide is checking or reporting the problem. Also the aide can not free text in the electronic medical record - so there is no ability to clarify either reporting or simply checking . This was confirmed by the Director of Aide Services.

Based on review of clinical records, agency policy and procedure, and interviews with agency staff, the hospice failed to ensure in two (2) of three (3) clinical records (Patient #'s 1 and 3), the content of the comprehensive assessment is of sufficient scope to identify all the patient's needs to promote the patient's well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. --- Review of the agency policy and Procedure entitled "Wound Assessment and Documentation" revised 01/11/2024 revealed "The patient's integument and any wounds are addressed at each skilled nursing visit.  Wounds are measured at the start of Hospice care and at recertification.  If standard not met reason for variance and the plan for follow up for wound assessment is documented." Patient #3 – This 90-year-old patient with a terminal diagnosis of alzheimer’s dementia was admitted to the hospice on 09/07/2025.Review of the Skilled Nurse (SN) Hospice Admission Visit dated 09/07/2025 revealed an intervention for sacral erosion wound care to include:- Cleanse wound and peri-wound with wound cleanser/saline/soap and water.- May apply moisture barrier film to peri-wound area.- Apply foam dressing.- Change dressing one (1) time weekly and as needed for soiling, dislodgement, and strikethrough.- Instruct patient/caregiver in wound care/dressing. Review of the SN Hospice Admission Visit dated 09/07/2025 lacks documentation of a wound assessment for the sacral erosion wound. During interview on 10/27/2025 at 03:24 PM, the Nurse Manager stated the clinician that conducted the 09/07/2025 assessment is unavailable for interview.  The Nurse Manager and Director of Hospice both acknowledged there failed to be  an assessment of the sacral wound in the identified documentation. Review of the agency policy and Procedure entitled "Wound Assessment and Documentation" revised 01/11/2024 revealed "The patient's integument and any wounds are addressed at each skilled nursing visit.  Wounds are measured at the start of Hospice care and at recertification.  If standard not met reason for variance and the plan for follow up for wound assessment is documented."Patient #1 – This 83-year-old patient with terminal diagnosis of hepatic encephalopathy was admitted to the hospice on 09/29/2025.Review of the Plan of care 1 from 09/29/2025 to 12/27/2025 included the following wound care orders to the anterior left lower leg, right heel, and right lower leg:-Skilled Nurse (SN) observation of wound(s) at each dressing change.-Cleanse wound and peri-wound with wound cleanser/saline/soap and water.-May apply moisture barrier film to per-wound area.-Apply mepilex foam dressing.-Change dressing twice weekly and as needed for soiling, dislodgement and strikethrough.-Instruct patient/caregiver in wound care dressing.Review of the SN Hospice Admission Visit dated 09/29/2025 lacks documented evidence of wound measurements for the three (3) wounds to the anterior left lower leg, right heel, and the right lower leg.During interview on 10/27/2025 at 3:00 PM, the Registered Nurse (RN) stated the wounds were assessed, wound care was performed but no wound measurements were obtained.

Based on a review of clinical records, agency policy and procedure, and staff interview, for one (1) of three (3) patients (Patient #2), the hospice failed to ensure that patient's comprehensive assessments include changes that had occurred since the initial assessment or were updated every fifteen (15) days or that the hospice nurses are communicating changes in the patient's condition or treatment to the Interdisciplinary Group. Failure to ensure that comprehensive assessments are updated and reflect the patient's status has the potential for unmet patient needs. --- Patient #2 – This 91-year-old patient with a terminal diagnosis of alzheimer’s dementia was admitted to the hospice on 02/10/2025. Review of agency policy and procedure entitled “Wound Assessment and Documentation” revised 01/11/2024 revealed “1.  The patient’s integument and any wounds are addressed at each skilled nursing visit.  Wounds are measured at the start of hospice care and at recertification.  If standard not met reason for variance and the plan for follow up for wound assessment is documented.” Review of the Skilled Nurse (SN) Hospice Visit dated 07/29/2025, the recertification assessment for the third hospice benefit period, revealed the Registered Nurse (RN) documented the patient’s sacral wound is stage 2, peri- wound excoriated, wound with adipose tissue/fat/pink with scant drainage.  The assessment lacks measurements of the patient’s sacral wound or reason for not measuring the wound. During interview on 10/27/2025 at 02:12 PM, the Director of Hospice stated the RN is unavailable for interview.  The Director of Hospice stated the assessment conducted by the SN on 07/29/2025 was the recertification assessment and failed to include the patient’s wound measurements.

Based on review of clinical records and interviews with staff for one (1) of three (3) clinical records (Patient #3) the hospice failed to provide services according to the plan of care.  Failure to provide services in accordance with the plan of care has the potential for unmet patient needs. --- Patient #3 – This 90-year-old patient with a terminal diagnosis of alzheimer’s dementia was admitted to the hospice on 09/07/2025. Review of the Plan of Care 1 from 09/05/2025 to 12/03/2025 revealed the following orders for Skilled Nursing (SN):- one (1) visit daily for one (1) day on 09/05/2025;- one (1) visit daily for one (1) day on 09/07/2025; - one (1) visit every week for thirteen (13) weeks; and- eight (8) visits as needed for symptom management/ end of life needs. Review of the clinical record for the week of 09/21/2025 to 09/27/2025 lacks documentation of any SN visits being conducted. Review of the clinical record for the week of 10/05/2025 to 10/11/2025 lacks documentation of any SN visits being conducted. Review of the clinical record lacks documentation the patient refused SN visits for the weeks of 09/21/2025 to 09/27/2025 and 10/05/2025 to 10/11/2025. During interview of 10/27/2025 at 03:40 PM, the Nurse Manager stated the patient was ordered weekly SN visits and there was no missed visit documentation to explain why visits did not occur for the two (2) identified weeks.

Based on a review of clinical records and interview with agency staff for two (2) of three (3) patients (Patient #’s 1 and 2), the agency failed to ensure the patient and/or caregiver received education and training identified in the Plan of Care. Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. --- Review of agency policy and procedure entitled “Wound Assessment and Documentation” revised 01/11/2024 revealed “5.  When appropriate, the patient, family, and caregiver are instructed and supported in the performance of wound care, including return demonstration." Patient #2 – This 91-year-old patient with a terminal diagnosis of alzheimer’s dementia was admitted to the hospice on 02/10/2025. A.)  Review of the clinical record lacks orders for wound care from 05/21/2025 to 08/12/2025. Review of the Skilled Nurse (SN) Hospice Comprehensive Visit dated 05/21/2025 revealed the patient has a new stage 1 mid-coccyx pressure injury that is excoriated and the Registered Nurse (RN) applied barrier ointment to surrounding skin, triad cream to the stage 1 wound and covered with foam dressing. There is a lack of documentation of instruction to the caregiver and return demonstration to determine independence. Review of the SN Hospice Comprehensive Visit dated 05/29/2025 (the next SN visit) revealed the RN documented the patient has a mid-coccyx stage 1 pressure injury that is excoriated, draining scant serous drainage and the RN applied a barrier ointment to the surrounding skin, triad cream to stage 1 wound and covered with foam dressing.  There is a lack of documentation of instruction to the caregiver and return demonstration to determine independence. Review of the SN Hospice Comprehensive Visit dated 06/05/2025 (the next SN visit) revealed the RN documented the mid-coccyx pressure injury was stage 2, the peri-wound area is excoriated with scant tan drainage and the RN applied “a pharmaceutical agent and foam dressing to stage 2 wound.”  There is a lack of documentation of instruction to the caregiver and return demonstration to determine independence. During interview on 10/27/2025 at 03:14 PM, the RN stated the dressing was being changed three (3) times weekly, the patient’s caregiver was instructed and assisted with the dressing changes during the identified visits but did not demonstrate back the wound care. B.)  Review of the Wound Care Order dated 08/13/2025 revealed the following order for the stage 4 sacral wound:  - Cleanse wound and peri-wound with wound cleanser/saline/soap and water. - May apply moisture barrier film to peri-wound area.  - Apply flagyl sprinkles over wound after cleansing.- Pack undermining and slough areas with exufiber.- Apply foam dressing to secure.- Change dressing daily and as needed (prn) for soiling, dislodgement, and strikethrough.- Instruct patient/caregiver in wound care/dressing. Review of the SN Hospice Comprehensive Visit dated 08/13/2025 revealed the RN documented the mid coccyx (sacral) pressure injury is stage 4 with adipose tissue/fat, bone and slough, foul purulent drainage and cleansed, applied exufiber packing, flagyl sprinkles and foam dressing to the sacral ulcer.  Additionally, the RN documented the dressing to the sacral wound was changed together with the daughter.  There is a lack of documentation of instruction to the caregiver and return demonstration to determine independence. Review of the clinical record revealed the next SN visit occurred on 08/21/2025, eight dressing changes later. During interview on 10/27/2025 at 02:56 PM, the RN stated the patient’s daughter was performing daily wound care to the patient’s sacral wound and was instructed but never demonstrated back the dressing change to the RN. C.)  Review of the SN Hospice Comprehensive Visit dated 10/22/2025 revealed the RN documented a co-visit was conducted with the Wound Nurse Specialist and recommendations for a change in the wound care were made.  The new wound recommendations were demonstrated and written instructions of the new procedure were given to the patient’s caregiver.   Review of the Hospice Care (HC) Co-Visit Note dated 10/22/2025 revealed the Wound Nurse Specialist documented the following: Wound consult: “Wound with excess drainage compromising the peri wound area. "RN suggests daily dressing change to include two (2) layers of skin prep on peri wound, clean with wound cleanser. Hydrofera on high exudate side of wound (right) and flagyl on left side. Thick layer of triad on peri wound. Cover with metra (mextra) high absorbency pad and sacral dressing.” Review of the clinical record lacks documented evidence the RN observed the caregiver's ability to demonstrate proficiency with the dressing change. During interview on 10/27/2025 at 1:35 PM, the patient’s caregiver stated they provide daily wound care to patient’s stage 4 sacral wound. They stated the nurses had conducted a home visit on 10/22/2025 and the nurse performed wound care, and they observed but did not demonstrate the new wound care to the nurse.  During interview on 10/27/2025 at 2:00 PM, the RN stated they performed the new wound care with the caregiver observing but the caregiver did not provide a return demonstration.  Additionally, the RN stated the next planned nursing visit is scheduled for 10/29/2025.    Patient #1 – This 83-year-old patient with terminal diagnosis of hepatic encephalopathy was admitted to the hospice on 09/29/2025.Review of the Plan of Care 1 from 09/29/2025 to 12/27/2025 included the following wound care orders for wounds to the anterior left lower leg, right heel, and right lower leg:-Skilled nurse observation of wound(s) at each dressing change.-Cleanse wound and peri-wound with wound cleanser/saline/soap and water.-May apply moisture barrier film to per-wound area.-Apply mepilex foam dressing.-Change dressing 2x weekly and as needed for soiling, dislodgement and strikethrough.-Instruct patient/caregiver in wound care dressing.Review of the SN Hospice Admission Visit dated 09/29/2025 revealed the RN documented performing the ordered dressing change to the anterior left lower leg, right heel, and right lower leg.  There is a lack of documentation of the caregiver being instructed in the wound care to include a redemonstration of the dressing change to the RN.Review of the clinical record revealed the SN conducted subsequent patient visits on 10/06/2025, seven days later and 10/13/2025, seven days later.Review of the SN Hospice Comprehensive Visits dated 10/06/2025 and 10/13/2025 revealed the RN documented performing the wound care to the anterior left lower leg, right heel, and right lower leg but lack documentation of caregiver instruction to include redemonstration of the wound care to the RN.During interview on 10/27/2025 at 3:00 PM, the RN acknowledged performing the wound care at the identified visits.  The RN stated the family was knowledgeable and instructed in wound care but was not observed redemonstrating the dressing changes.

Based on review of clinical records, agency policy and procedure and staff interviews for one (1) of three (3)  patients (Patient #2), the agency failed to ensure in collaboration with the patient's physician, they reviewed and revised the individualized plan of care (POC) orders correctly. Failure of the agency to develop, review and revise the POC accurately has the potential for unmet patient needs and inadequate care. --- Patient #2 – This 91-year-old patient with terminal diagnosis of alzheimer’s dementia  was admitted to the hospice on 02/10/2025.Review of the Plan of Care 4 from 10/06/2025 to 12/04/2025 included the following wound care orders:- Skilled Nurse (SN) observation of wounds at each dressing change;- Wound 1 stage 4 sacrum;- clean wound and peri-wound with wound cleanser/saline/soap and water;- may apply moisture barrier film to peri-wound area;- apply flagyl sprinkles over wound after cleaning;- pack undermining and slough areas with exufiber;- apply foam dressing to secure;- change dressing daily and as needed for soiling, dislodgment and strikethrough; and-instruct patient/caregiver in wound care/dressing.Review of the Hospice Care (HC) Co-Visit Note dated 10/22/2025 revealed the Wound Nurse Specialist documented the following wound consult: “Wound with excess drainage compromising the peri wound area. Registered Nurse suggests daily dressing change to include two (2) layers of skin prep on peri wound, clean with wound cleanser. Hydrofera on high exudate side of wound (right) and flagyl on left side. Thick layer of triad on peri wound. Cover with metra (mextra) high absorbency pad and sacral dressing.”Review of the SN Hospice Comprehensive Visit dated 10/22/2025 revealed the RN documented making a co-visit with Wound Nurse Specialist and reviewed wound care and received recommendations for managing the wound.  Review of the Physician Order dated 10/22/2025 revealed the RN developed the following supplemental order:- SN observation of wounds at each dressing change;- wound 1 stage 4 sacrum;- clean wound and peri-wound with wound cleanser/saline/soap and water;- may apply moisture barrier film to peri-wound area;- apply flagyl sprinkles over wound after cleaning;- pack undermining with hydrocel (damp with normal saline or sterile water);- apply triad around wound;- apply mextrabsorptive pad and foam dressing to secure;- change dressing daily and as needed for soiling, dislodgement and strikethrough; and- instruct patient/caregiver in wound care/dressing.During interview on 10/27/2025 at 2:00 PM, the RN stated being unaware that the hydrocel written in the supplemental order was a different product than the hydrofera recommended by the Wound Nurse Specialist and acknowledged the supplemental wound order written was incorrect.

Based on review of clinical records and interviews with staff, the hospice failed to ensure in one (1) of three (3) patients (Patient #2) that care and services are provided in accordance with the Plan of Care. Failure to provide care in accordance with the patient's established Plan of Care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. --- Patient #2 – This 91-year-old patient with a terminal diagnosis of alzheimer’s dementia was admitted to the hospice on 02/10/2025. Review of the clinical record revealed the patient received Skilled Nurse (SN) visits with wound care performed on the following dates:  - 05/21/25- The Registered Nurse (RN) applied barrier ointment to surrounding skin, triad cream to stage 1 wound and covered with foam dressing.- 05/29/2025- The RN applied a barrier ointment to the surrounding skin, triad cream to stage 1 wound and covered with foam dressing.  - 06/05/2025- The RN applied “a pharmaceutical agent and foam dressing to stage 2 wound.”   - 06/13/2025- The RN applied zinc oxide paste and a foam dressing to sacral wound.- 06/18/2025- The RN applied zinc oxide paste/ triad cream to wound bed and covered with foam dressing.- 06/26/2025- The RN applied triad cream and foam dressing to sacral wound.- 07/03/2025- The RN applied triad cream and a foam dressing to sacral wound.- 07/10/2025- The RN applied triad cream and a foam dressing to sacral wound.- 07/17/2025- The RN applied zinc oxide paste/triad cream and a foam dressing to sacral wound.- 07/24/2025- The RN applied zinc oxide paste/triad cream and a foam dressing to sacral wound.- 07/29/2025- The RN applied zinc oxide paste/triad cream and a foam dressing to sacral wound.- 08/07/2025- The RN cleansed, performed site care and foam dressing applied to sacral wound. Review of the clinical record from 05/21/2025 through 08/07/2025 lacks orders for the hospice to perform dressing changes to the sacral  wound. During interview on 10/27/2025 at 02:26 PM, the Director of Hospice acknowledged the hospice failed to obtain dressing change orders for the identified time period but could offer no explanation of why this occurred.

Observed in Document Review. Upon review of the organization's hospice admission packet and documents, there was no documentation to validate patient's are informed of their right to receive continuous care as a covered service under the hospice benefit. This was validated in discussion with the hospice leadership team.

Observed in Record Review. In 3 of 16 hospice patient records reviewed, the comprehensive assessment was incomplete. According to organizational policy Documentation No. 724, the assessment should include a head to toe full body assessment. Upon review of HOHV#1, it was noted the patient had a PleurX drain inserted in his right lung with documented shortness of breath; however, on review of the comprehensive assessment, the patient’s lung sounds were not addressed. Upon review of HOHV#2, it was noted the patient had suffered a severe stroke and the nurse documented the patient’s left lower extremity was cool; however, on review of the cardiovascular section of the comprehensive assessment, the pedal pulse section was left blank. The patient’s blood pressure and heart rate were not obtained and there was no documentation to validate why these vital signs were not obtained. Upon review of HORR#12, it was noted the nurse documented rhonchi in the lungs; however, on review of the comprehensive assessment, the section to indicate which lung/lobes in which adventitious lung sounds were auscultated was left blank. The patient had a foley catheter in place; however, the section to describe the urine color, odor, clarity, etc. was left blank. This was reviewed and validated with the QAPI Coordinator and hospice leadership.

Observed in Record Review. In 16 of 16 hospice patient records reviewed, the plan of care did not include goals. According to organizational policy Plan of Care No. 741, the plan of care will include measurable outcomes. Upon review of all records, there were no goals established related to the problems identified on the comprehensive assessment. Examples of problems identified include pain, shortness of breath, anxiety, and constipation. In discussion with leadership, they are aware of the issues related to care planning and have plans to transition to a different documentation system later this year to assist with compliance.

Observed in Record Review. In 16 of 16 hospice patient records reviewed, the plan of care did not include interventions based on the patient’s needs. According to organizational policy Plan of Care No. 741, the plan of care will include interventions to manage pain and symptoms. Upon review of all records, there were no interventions established related to problems identified on the comprehensive assessment. Examples of problems identified include pain, shortness of breath, anxiety, and constipation. In discussion with leadership, they are aware of the care planning issues and have plans to transition to a new documentation system later this year.

Observed in Record Review. In 16 of 16 hospice patient records reviewed, the plan of care did not include visit frequencies specific to the patient’s individualized needs. According to organizational policy Plan of Care No. 741, the plan of care will include a detailed statement of the scope and frequency of services provided. Upon review of all records, the plan of care included a generic, broad range visit frequency for each discipline that was not specific to the patient’s needs. For example, patients receiving in-patient care had a nursing visit frequency of 3-5 visits/week. Patients receiving routine level of care had a nursing visit frequency of 2-8 visits/month, a social worker visit frequency of 1-4/5 visits/month, and a spiritual counselor visit frequency of 1-4 visits/month. On review of aide visit frequencies, a range of visits was ordered. For example, HOHV#1 was receiving aide services 2-3 times/week. This was reviewed and validated with the QAPI Coordinator and hospice leadership.

Observed in Record Review. In 15 of 16 hospice patient records reviewed, medication orders on the plan of care were not complete. According to organizational policy Plan of Care No. 741, the plan of care will include medications necessary to meet the patient's needs. Upon review of HOHV#2, it was noted the patient had orders for oral morphine and subcutaneous morphine; however, the orders did not specify which route would be used first and what indications would necessitate oral or subcutaneous administration. Upon review of HORR#13, it was noted the patient had an order for amoxicillin to be given 1-2 times a day; however, there were no specific instructions provided to indicate when to take 1 dose or when to take 2 doses. Upon review of the comfort kit medications for HOHV#1, HOHV#2, HOHV#3, HOHV#4, HORR#5, HORR#6, HORR#8, HORR#9, HORR#10, HORR#11, HORR#12, HORR#13, HORR#14, HORR#15, and HORR#16, it was noted several medications included a dosage range without specific instructions as to when to take what dosage. For example, orders were as follows: morphine 5-10mg every hour as needed; lorazepam 1-2 tabs every 4 hours as needed; morphine 5-20mg every hour as needed; lorazepam 1-2 tabs every hour as needed. This was reviewed and validated with the QAPI Coordinator and hospice leadership.

Observed in Record Review. The organization had not established goals for the bereavement plans of care in two of two bereavement records reviewed. This was confirmed with the Bereavement Program Manager.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.56 and §418.100.

Observed in Leadership Session. In discussion with hospice leadership, it was noted the organization does not offer/provide continuous care as a level of hospice care for symptom management. Per the Hospice Director and Associate Director, they do not have a process nor staffing in place to provide continuous care in the patient's home setting and they have identified this as a goal for 2023.

Observed in HR File Review. In 1 of 10 HR files reviewed, , the HR specialist confirmed that the background check for the Hospice Medical Director could not be found at the time of survey.

Observed in HR File Review. In 1 of 10 HR files reviewed, the surveyor observed that a criminal background check was not completed or documented for a home health/hospice Aide hired in 1996. Agency policy requires criminal background checks to be completed for all staff. The aide provides care for Home Health and Hospice patients. This observation was verified with the HR Director.